Critical Practice and Perspectives in Health Promotion

Introduction

Diabetes is defined as those people having a fasting blood glucose value of greater than or equal to 7.0 mmol/L or on medication for diabetes/raised blood glucose. Since the last 30 years there has been an epidemic rise in the number of people between ages 20 to 60 with diabetes especially in Asia. The purpose of this essay is to debate who the experts in health promotion are. The aim of this essay is to investigate the literature regarding the high incidence and causes of Diabetes Mellitus in Asians, and to develop a health promotion campaign for empowering people to tackle the problem locally. WHO defines empowerment as “a process through which people gain greater control over decisions and actions affecting their health”. People’s empowerment is a process of developing understanding, knowledge, and skills to perform a task in an environment that recognises community and cultural differences and encourages patient participation.

Background

WHO estimates that, globally, 422 million people over 18 years had diabetes in 2014, the highest numbers living in South-East Asia and Western Pacific Regions. Prevalence of diabetes has risen from 4.7% in 1980 to an average of 8.5% globally in 2014. 7.1% were found in Africa, 8.3% in the Americas, 13.7% in the Eastern Mediterranean Region, 7.3% in Europe, 8.6% in the South-East Asia Region, and 8.4% in the Western Pacific Region (currently 13.7%). Since the last 10 years, it has risen four times in developing countries from 108 million to around four times higher. (Ref 1 Global Report on Diabetes, WHO 2016)

In the UK, about 1.3 million suffer with diabetes Type 2 and has increased in all groups of people, especially in black and other ethnic groups. The UK National Service Framework (NSF) for Diabetes has set out 12 standards to drive up service quality and primary care. Each NSF sets national standards, identifies the interventions that will help meet those standards and the milestones against which NHS performance will be measured. (Ref. 2 National Service Framework for Diabetes; Standards).

Discussion

Worldwide, and especially in Asia, increased fast food consumption, increased use of cars, and urbanisation has increased the BMI (Basal Metabolic Rate) and diabetes risk factors. In China, diabetes has increased from approximately 1% in 1980 to currently 9.7%. South Asians are 6 times more likely to develop diabetes than Europeans according to a

study published in the August 2011 edition of the Journal of Nature Genetics (Ref.3). Scientists from Glasgow University discovered that South Asians have skeletal muscles which do not metabolise fat as well as Europeans, and during exercise burn 40% less fat than Europeans due to insulin resistance. Also, nearly 50% of adult men in Asian countries smoke regularly, which is linked with higher abdominal fat and increased risk of men developing diabetes. Experts believe that diet, a reduced sensitivity to insulin and lifestyle have resulted in the storage fat in different ways in the body, while genetically south Asians are susceptible to diabetes and heart disease more than any other group of people and have poorer diabetes management (Ref. 4. NHS 17 Nov. 2016). Also, Asian countries have their own treatment regimes. (Ref. 5 Diabetes in Asians (Eun-Jung Rhee, Endocrinology and Metabolism, 2015). Lawton et al (Ref. 6. Diabetic Medicine. 2010) points out that South Asian people blame external factors for their diabetes. South Asian food has also been blamed by them

Asians mostly do not know the risks of complications, and especially for heart disease. The relationship between fatalistic beliefs and diabetes treatment is inconclusive and needs further study. (Ref. 7 The Role of Illness Beliefs and Social Networks in South Asian People with Diabetes: Rankin and Bhopal, 2001; Misra et al, 2009).

Other studies have shown that men develop the disease by gaining much less weight than women at lower Basal Metabolic Rate (Ref. 8. NHS. Men 'develop diabetes more easily'. 2011). It is also theorised that men store fat around their organs rather than under the skin like women do. A new report shows that due to different lifestyles, men between 35-54 years are twice more prone to diabetes (Ref. 9. Public Health England. 2014)

Currently, only 7 of 11 countries in South-East Asia have policies for diabetes, either stand-alone or integrated with other policies. Lack of staff training, people’s knowledge belief and attitudes, bias towards generic drugs, poor logistics of medicines, and weak referral systems are all to blame. Also, the political economy of a country determines how health services are structured and delivered, while public health and health promotion are social and political issues. (Ref. 10 Salvatore B (2009). They override health promotion efforts that prop up the health system. To be effective there is need for integration within social and political contexts and require specific responsibility and behaviour of people through joint efforts and coordination.

I would plan a campaign within a specific Asian population seeking to change their current behaviour. Health Promoters increase the confidence of people, informing them that knowledge is available. When promoting a message it is important to use medical practitioners to communicate the correct message. (Ref. 11 Strategies for Developing a Health Promotion Campaign. Loti Popescscu et al, Common Health, 2000)

Debate

Health promoters may however be people from different backgrounds. They are ideally people trained in the basic provision of health care services, in the prevention of disease, and in the promotion of health in their communities (e.g. In Malaysia). However, they are mostly trained in a number of diverse health topics, whereas knowledge of health is becoming more complex and the balance between individual, community, and government responsibility appears to be continual tilting. So who should be the ‘expert’ in a health promotion campaign? It is important to consider the bigger picture as many factors influence health (environmental, social, political, and economic) that do not fall within the domain of the health sector and the control of the people who work for it. (Ref. 12 Journal of medical ethics 2004: Debates and Dilemmas in Promoting Health. J Clarkson). Social marketing skills are also required. Ralph Lefebvre argues that social marketing is misunderstood and has frequently been under used by health promoters. Peter Townsend encourages us to “think globally, act locally”. Taking the above limitations and statements into consideration, the skills required by Health Promoters are exhaustive and they require ongoing education and training in their communities. I would consider the ‘experts’ to be local health practitioners who will take ownership of the program on a longer term. They have a wide range of knowledge and skills which can be upgraded. This could be myself as a Health Promoter if I meet all the requirements to qualify as an ‘expert’.

Behavioural economists say that people have a bias towards the present and choose things that will provide immediate benefits rather than benefits in the future (better health). So they are not so motivated towards future benefits. During pre planning, I would design a health promotion campaign for preventing diabetes within a specific population taking all above considerations into account to guide me. . I must manage a number of elements at each stage including participation of key stakeholders, time frames, money and resources, data-gathering and interpretation.

A specific strategy will be developed selecting two elements from the Ottawa Charter for Health Promotion, namely strengthening community action and creating supportive environment. I have selected these two because they provide the communities with self empowerment and the best chance of a cost effective result and long last effect regarding behaviour change. They address the core issues that need to be changed, not only the structural changes. Building healthy public policy, reorienting health services and/or developing personal skills can be expensive and by themselves may not guarantee a long lasting change in behaviour of individuals and communities.

Strategy A. Strengthening community action to become an integral part of health promotion practice. Grace Spencer (Ref. 13. 2013) has postulated that there are 6 distinct forms of empowerment, namely impositional, dispositional, concessional, oppositional, normative and transformative which define the different elements of power that determines people’s empowerment. Our actions will be guided by these theories in order to better enforce empowerment. Focus group discussions will be conducted to share knowledge on the dangers of diabetes and to understand, how diabetes impacts people’s health and society. They will be informed about the methods of prevention, treatment, and long term management of the disease to prevent complications. Advocacy will focus on political, economic, social, cultural, environmental, behavioural and biological factors affecting health. A comprehensive health communication campaign will be developed to use a combination of media, interpersonal and community events involving an organised set of communication activities. Mediation will ensure that different people are involved.

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Strategy B. Creating a supportive environment

It is important to involve key community members, especially those that are most knowledgeable about the affected people, the environment, cultural habits, and which health communication messages are effective. Individuals and organisations with an interest in diabetes should be involved in all stages of health promotion. It is important to know who supports it, who can sabotage it, and who has good knowledge about it. Individuals should not be seen representing a particular form of culture (Csordas, 2002), and family units, groups of people and communities as a whole will be targeted. Enablement of communities will develop a supporting environment, flow of information, and the life skills and opportunities for empowering people in making healthy choices. 'Expert' is someone who has local experience and knowledge of the problems in the community.

Target population: I have selected Belabo sub district of Narsingdi District in Bangladesh. Belabo has a population of 145,708 (1991 census). 98% are Bengali and remaining are Biharis or other groups; Perceptions about diabetes include perceptions about food, linking together sugar, bone marrow and semen as causes of diabetes (Choudhury et al, 2009). The lack of sweating and difficult labour was also attributed to diabetes (Greenhalgh et al, 1998). Eating bitter gourd is said to be a treatment for diabetes (Choudhury et al, 2009). These beliefs may cause people not to seek treatment or delay starting it (Choudhury et al, 2009).

I would like to change these perceptions of the population for better health seeking behaviour. I will consider the fact that in South Asia the dynamics of managing type 2 diabetes is family oriented and to bring about lifestyle changes it was expressed that it would be helpful to educate the family unit instead, as expressed by Madhur, from Bangladesh. I will identify the specific audience (adults aged 20-60 years old), estimate the required resources, and prepare a budget.

Specific indicators of performance will be developed that can be monitored and evaluated at each step of the process. Then specific activities will be developed. (Ref.14 Public Health Ontario 2012). Program timeframe: 2 weeks planning, 3 months for developing materials and implementation of the campaign, and one year for monitoring and evaluating the community’s ability to become an integral part of health promotion practice.

Goal: To change the health seeking behaviour of adults aged 20-60 years old within

Belabo subdistrict of Narsingdi District in Bangladesh

Specific objectives will then be developed that will be specific, measureable, achievable, replicable and time bound (SMART).

Activities. Specific activities will be developed:

1. Conduct a situational analysis: A systematic collection and evaluation of economical, political, social, and technological data, aimed at (a). identification of internal and external forces that may influence the choice of my strategy (b) assessment of the community’s strengths and weakness by doing a Strengths, Weaknesses, Opportunities & Threats analysis (SWOT). In consultation with my team and key stakeholders, I will gather, analyse, synthesise and. communicate data to inform planning decisions. I will recruit the participation of the ‘experts’ i.e. local health practitioners who have knowledge about local disease patterns and incidence and peoples health seeking behaviour. These experts will be given the opportunity to independently address different sources of uncertainty (Ref. 15 Ferson and Ginzburg 1996) & (Ref. 16 Regan et al. 2002). They will be the key implementers of the campaign and will ensure continuity of the health promotion activities after project closure. I will conduct a stakeholder workshop or informal meetings to ensure their ownership. I will look at political agendas of individuals and parties. I will investigate the political, economic, environmental, social and technological factors that could potentially affect the project (PEEST analysis). The risk factors (killer assumptions) will then be monitored at every step.
2. Analyse and segment the audience: Segmenting audiences will enable me to focus on those people who are most essential to reach and also to design the most effective and efficient strategy for helping each audience with specific needs and preferences to adopt new behaviours.
3. Select channels of communication: Various channels to be considered alone or combined will include:

• a. Interpersonal channels- one to one communication, home visits, and group discussions.
• b. Broadcast channels, such as radio and television to provide local coverage.
• c. Print channels, like pamphlets, flyers, and posters, are generally considered best for providing reminders of important communication messages

I will use also use Doctor-patient communication, focus-group discussions, self-help groups, mass media campaign and events. An initial big event will build up to a grand finale.

Design campaign messages and produce the materials

Behaviour change requirements for development of the messages will include current behaviour, benefits of behaviour change, acceptance of change, social or medical consequences, skill level, knowledge, attitudes, practices, behaviour etc. Effective messages will be designed which are attractive, eye-catching, appropriate and logical. The experts to be used for project implementation will have excellent communication skill, are mature, non-judgemental, confident and culture-sensitive. They will be able to interact well with diverse groups of people and should have good problem solving skills.

Messages will be context-specific and sensitive and will be technically correct.

Pilot and implement the campaign

All materials will be pre-tested on the target population before use. I will allocate resources according to needs and time frame. The health communication process will utilise learning processes. Wherever possible, I will use expert medical opinion to communicate facts.

Evaluate and maintain the campaign

I will then make an impact assessment, followed by an outcome assessment which will define the result and tell me if the goals and objectives have been achieved, especially specific behaviour changes. This will be done by ongoing monitoring and enforcement of the critical messages about behaviour change.

Conclusion

There is huge increase in the incidence of diabetes mellitus worldwide since the last decade. The difference in increase is greatest in Asia where modernisation and changing lifestyle have caused this increase. Each region of the world has its unique culture and belief system which determines what causes diabetes. It is highly affected by existing political, environmental and social factors. I discussed the relationship between political economy, public health, and health promotion. Government, community, and individual awareness, commitment and effort are required to halt this ‘tsunami of diabetes’. Health promotion efforts needs to be accelerated and health systems strengthened at all levels. An example of how health promotion within a specific population can be conducted is outlined in this essay and I identified that local health practitioners at community level are the real ‘experts’.