EHJ December 2004, pages 382-384

How can you tell whether public health initiatives are effective? Jill Stewart and Suri Thomas explain the government's overall health strategy and shows how the health initiative you are working on fits into the big picture using the Beattie health model

Public health is complex. Thousands of people are delivering the public health agenda, but it is not always clear that everyone is working towards the same goals. Some are working from a clinical background, while others, like EHPs, take a much wider, social and economic view of health.

Being a public health practitioner is sometimes a job where it is not always easy to see the wood for the trees. Health projects proliferate and partnerships abound to the point where we can lose ourselves in a soup of acronyms, agencies and initiatives. It is an unusual EHP who does not sometimes lose sight of the role he or she is playing in helping to drive down health inequality across the UK.

It is during these moments of doubt that it may be useful to turn to a model of public health delivery that we teach our students at Greenwich University. The Beattie model first appeared on the scene in the early 1980s, but it is only recently that it is finding favour among academics as a tool for making sense of the current government's approach to public health.

THE NEW LABOUR DREAM

Since 1997 the government has increasingly placed health at the core of its policy. It has recognised that it can only hope to end health inequality by providing joined-up solutions to solve complex social and economic problems. Ministers also recognise that health initiatives are only any good if they actually work. What they want to see is hard evidence that health policies are effective and sustainable.

At the heart of New Labour's health policies lies a political philosophy, dubbed the third way. New Labour sees its role as providing a social and economic framework in which increasingly active communities enter into a social contract with government. This led to the launching of a plethora of initiatives, sure start, the social exclusion unit, the new deal for communities, to name a few. The idea is that communities become empowered to help bring about sustainable changes in reducing health inequalities. In short, real improvements in health and lifestyles come about when communities take the lead, rather than when government agencies impose their will. There needs to be a bottom up approach to developing communities, especially where health inequality is at its greatest.

It is over this approach to community development that New Labour has been criticised for moving away from traditional Labour ideology and aligning itself with European social democratic politics along with the United States' emphasis on communitarianism during the Clinton era.

THE BEATTIE MODEL

So how does the Beattie model help the EHP understand where a particular initiative fits into this political philosophy? Back in the early 1980s the World Health Organisation told us that health promotion is not just about delivering improvements in diet, housing, income and skills, but it is also about creating environments where personal and community empowerment is allowed to flourish. EHPs have roles to play in both these aspects of health promotion.

The WHO also told us that health promotion is an area where personal choice, for example choosing to give up smoking, synthesises with the idea of social responsibility, in this case reducing environmental tobacco smoke and decreasing hospital costs. Taking these ideas, which New Labour has adopted, Beattie allows the health professional to understand the role of health promotion and to analyse its likely success.

The beauty of the Beattie model is that it fits so well with current government policy on health promotion. The model shows the importance of sound partnership working, with government setting the legislative, resource and policy framework, with individuals and communities also playing an active role. If activities do not occur across each of the boxes (above), they are unlikely to yield sustainable health promotion, particularly since it places the person or community whose health is affected or likely to be affected at the heart of policy, now seen as the best way to ensure sustainable health promotion for those experiencing the most acute health inequalities.

THE FOUR DIMENSIONS OF THE MODEL (SEE ABOVE)

"Legislative action for health" attempts to redirect behaviour towards healthiness at a macro level and is a top down method attempting to improve health, but which is unlikely to work alone (eg application of current housing standards without wider community regeneration, enforcement of food hygiene standards without advice, a move toward legislation which more closely aligns environmental condition with health impact - housing health and safety rating system etc).

"Community development for health" enables those in similar need to work together to seek changes in their environment as part of a bottom up rather than top down approach to regeneration. There is a recognition of the need for EHP training in this key area to optimise health outcomes of area regeneration strategies.

"Persuasion for health" deals with researched-based health risk factors and requires the user to change from damaging to safe health behaviours and this approach is useful to a consolidated short-term effort, but is unlikely to be effective in itself. For example, persuasion alone is unlikely to stop people smoking, and it is necessary to ask who smokes in the first place and to understand the reasons why people smoke before embarking on a local strategy that fails to grasp the point.

"Personal counselling for health" is a process of active listening and reflection to empower the individual - based on their current knowledge and behaviour - to become more capable of making genuine choices. Again, this is unlikely to be successful alone, if for example, a woman fleeing domestic violence is forced to return to B&B accommodation which may aggravate poor health in another way.

The advantage of the Beattie model is that it allows the health professional to question what actions are really useful in delivering change and where a particular initiative fits into the overall strategy. It also shows us that a coordinated approach is needed to achieve health gains.

In practice, this is represented by a shift in emphasis from local government to local governance as part of the modernisation agenda with increasingly innovative partnership arrangements at the core of public health delivery. It relies on new administrative structures and services which more closely reflect community-based organisations, networking, trust and a revival of social capital to meet need in new ways. It is about community-based responsibilities and participation, not just the continued provision of existing top down services with the "professional" in control, with government, communities and individuals mutually responsible for improving health.

RELEVANCE FOR THE EHP

For EHPs, local partnerships, local delivery planning, community strategies, public service agreements and so on, help tackle health inequalities by highlighting the environmental determinants of health. Strategies have emerged around community issues, such as those tackling tuberculosis, food poverty, homelessness and suitability of B&B accommodation for families. New partnership-based strategies should look at health needs, be evidence based and focus on health impact assessments to maximise health gain.

However, it would be na•ve to assume that the current situation is working perfectly. Many EHPs are demoralised by being forced to meet stringent performance indicators that have little to do with health promotion. In addition, the extent to which community development is just being seen as a bolt on to regeneration rather than genuinely taking the lead in health promotion is questionable.

There is still a need for EHPs to rigorously challenge the work they are doing and to question if it really results in health promotion. EHPs have a crucial and unique role in maintaining health rather than curing illness and need more legislative and policy support from the government to be able to fulfil their potential. Given the right policy and legislative basis, EHPs can be key players in public health, reducing health inequalities through their relationship with the public. The profession can also apply expertise to tackle the wider health determinants by identifying, controlling and preventing current and future risks, as well as leading in integrated strategies to contribute to the public health agenda.

Beattie A (1991) Knowledge and control in health promotion: a test case for social policy and social theory in J Gabe, M Calnan and M Bury (eds) (1994). The sociology of the health service, London. Routledge

Jill Stewart, senior lecturer in public health and housing, University of Greenwich, j.l.stewart@greenwich.ac.uk. Suri Thomas, programme leader, public health, University of Greenwich, r.k.thomas@greenwich.ac.uk