TY - JOUR
AU - Houghton,, Frank
AB - Abstract The vast majority of public health students exhibit the kind of ‘clean living’ that is routinely advocated as highly desirable by health promoters. However, this social and cultural distance from many of the most important health issues faced in our society creates a barrier for understanding and working with other population groups. Insider status, knowledge and understanding is essential in developing true insight in developing culturally appropriate interventions. Referencing Rose's influential prevention paradox, a revision is suggested stating that prevention measures are often developed by individuals outside the population in question and may offer little actual benefit to that population. Diversity is public health is essential. This diversity needs to encompass not just traditional foci such as race and ethnicity, but also socio-economic status and numerous other demographic variables. diversity, medical dominance, prevention paradox, public health workforce ‘Choose life. Choose a job. Choose a career. Choose a family. Choose a fucking big television, choose washing machines, cars, compact disc players and electrical tin openers. Choose good health, low cholesterol, and dental insurance. Choose fixed interest mortgage repayments. Choose a starter home. Choose your friends. Choose leisurewear and matching luggage. Choose a three-piece suit on hire purchase in a range of fucking fabrics. Choose DIY … Choose your future. Choose life.. But why would I want to do a thing like that? I chose not to choose life. I chose somethin’ else. And the reasons? There are no reasons. Who needs reasons when you've got heroin?1 As a public health academic, I am increasingly struck by the disjoint between the threats to the health of the majority of the population and the attitudes, experiences and behaviours of public health students who will go on to be the public health practitioners and leaders of the future. The question needs to be asked, what will our increasingly conformist and ‘clean living’ students really understand about alternative logics and ways of living, being and meaning that are beyond their experience, knowledge and comprehension? The infamous quotation from the movie Trainspotting above, references heroin. However, even taking the more prevalent example of smoking, most public health students that I teach do not smoke, and perhaps more interestingly, never have. This is an obvious issue given that smoking is the largest preventable cause of mortality in many countries. Such wholesome living is surely a success you might suggest? Testimony to the triumph of health promotion efforts perhaps? However, even putting aside concerns over the moral and ideological overtones of ‘healthism’, this distance, or perhaps more correctly this social and cultural distance, from such issues creates its own problems. The current focus in the fifth wave of public health, which aims to create a culture for health,2 would appear more than ever to create the need for a culturally competent public health workforce from diverse communities, including those from the full spectrum of socio-economic circumstances.3,4 It will probably not surprise many readers to learn that recent evidence suggests that entry to medicine in the UK remains as class privileged as ever.5,6 Public Health functions, in part at least, to help counter-balance the dominance of bio-medical approaches in the health arena. It must be acknowledged, however, that as Public Health continues to professionalize and a university education becomes ever more expensive, so the socio-economic profile of Public Health practitioners may become ever more of an outlier from many of the populations they serve. Social gradients in obtaining a university education are, although somewhat stable at present, very marked,7 especially in more prestigious universities.8 Such gradients are often more apparent at postgraduate level,9 and this has obvious implications for training to achieve the standard qualification in the field, the Masters in Public Health (MPH). Looking into the future, recruitment of a much needed diverse and non-standard applicant pool into Public Health may be threatened by both a removal of the cap on university fees and potential qualification inflation in the field of Public Health.10 Examining the public health workforce is notoriously difficult.11 Attempts have been made to examine the issue of diversity in this workforce in many countries, including the USA.12,13 In a UK context, it seems somewhat bizarre that even the civil service has a recent report by the Comptroller and Auditor General addressing diversity and inclusion within its ranks,14 whereas discussions of the UK Public Health workforce appear to take no such focus.15,16 Health inequities are mirrored in workforce composition, with dire consequences for minority groups.4 Traditional positivist approaches within Public Health may struggle with the obvious subjectivity of this argument. However, the case for the importance of such insider perspectives is well established in the social sciences, particularly within the disciplines of ‘qualitative’ sociology and interpretive anthropology.17 A shared and subjective cultural understanding of phenomena (termed ‘verstehen’) is a foundational element of Weberian sociology.18,19 Similarly, a rejection of so-called ‘objective knowledge’ is equally well established in the schools of ethnomethodology20 and phenomenology,21,22 where insider status, knowledge and understanding is seen as a virtue and often a pre-requisite in achieving true insight. Geoffrey Rose introduced the term the prevention paradox to describe the apparent contradiction that ‘a preventive measure which brings much benefit to the population offers little to each participating individual’.23–25 Given the need for cultural competency and insider knowledge in the latest wave of Public Health, perhaps it is time for a second prevention paradox: prevention measures are often developed by individuals outside the population in question and may offer little actual benefit to that population. Public Health will remain distant, fractured and impoverished until it can successfully recruit and retain a more diverse cross-section of non-standard applicants. Growing professionalization within Public Health is a two-edged sword. It may aid status, pay and influence. However, the ‘Cloak of Professionalism’ may also serve to distance practitioners from communities.26 The professionalization project in Public Health may also move the cost and appeal of entry beyond the capacity or interest of the very individuals and communities that it needs in order to be successful. Involving client groups in projects and on advisory, steering and governance boards is not enough. It is imperative that the composition of the Public Health workforce attains and retains a diversity across the full range of demographic variables that allows it to engage successfully with all communities. Developing a culture of health in disparate communities will require a level of diversity, as yet unseen in public health. References 1 Quote from the character Mark “Rent-boy” Renton in the 1996 movie Trainspotting by Irvine Welsh. 2 Public Health England . Fit for the Future—Public Health People. A Review of the Public Health Workforce . London : Public Health England , 2016 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 3 Jackson CS , Gracia JN. Addressing health and health-care disparities: the role of a diverse workforce and the social determinants of health . Public Health Rep 2014 ; 129 ( Supplement 2 ): 57 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 4 US Department of Health and Human Services . Health Resources and Service Administration Bureau of Health Professions. The Rationale for Diversity in the Health Professions: A Review of the Evidence . Washington, DC : US Department of Health and Human Services , 2006 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 5 Steven K , Dowell J, Jackson C et al. . Fair access to medicine? Retrospective analysis of UK medical schools application data 2009-2012 using three measures of socioeconomic status . BMC Med Educ 2016 ; 16 : 11 . DOI:10.1186/s12909-016-0536-1. Google Scholar Crossref Search ADS PubMed WorldCat 6 Carrell S. Students from wealthy backgrounds dominate medical schools . The Guardian , 22nd January 2016 . https://www.theguardian.com/society/2016/jan/22/medical-school-students-wealthy-backgrounds (18 November 2016, date last accessed). 7 Croxford L , Raffe D. Differentiation and social segregation of UK higher education, 1996-2010 . Oxf Rev Edu 2013 ; 39 ( 2 ): 172 – 92 . Google Scholar Crossref Search ADS WorldCat 8 Hemsley-Brown J. Getting into a Russell Group university: high scores and private schooling . Br Educ Res J 2015 ; 41 ( 3 ): 398 – 422 . Google Scholar Crossref Search ADS WorldCat 9 Wakeling P. La noblesse d’état anglaise? Social class and progression to postgraduate study . Br J Sociol Educ 2005 ; 26 ( 4 ): 505 – 22 . Google Scholar Crossref Search ADS WorldCat 10 Lee JM , Furner SE, Yager J et al. . A review of the status of the Doctor of Public Health Degree and identification of future issues . Public Health Rep 2009 ; 124 : 177 – 183 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Sumatra CV . Enumeration and composition of the public health workforce: challenges and strategies . Am J Public Health 2012 ; 102 ( 3 ): 469 – 474 . Google Scholar Crossref Search ADS PubMed WorldCat 12 US Department of Health and Human Services, Health Resources and Services Administration Bureau of Health Workforce National Center for Health Workforce Analysis Sex, Race, and Ethnic Diversity of US Health Occupations (2010-2012) . Washington, DC : US Department of Health and Human Services , 2015 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 13 Mays D , Klaiman T, Kumanyika S et al. . A call to action to address diversity in public health professional preparation . Divers Health Soc Care 2008 ; 5 : 207 – 14 . OpenURL Placeholder Text WorldCat 14 Comptroller and Auditor General Equality, Diversity and Inclusion in the Civil Service . London : National Audit Office , 2015 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 15 Department of Health . Healthy Lives, Healthy People: A Review of the 2013 Public Health Workforce Strategy . London : Public Health Policy and Strategy Unit, Department of Health , 2013 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 16 Department of Health . Healthy Lives, Healthy People: An Update on the Public Health Workforce Strategy . London : Public Health Policy and Strategy Unit, Department of Health , 2016 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 17 Geertz C. The Interpretation of Cultures . New York : Basic Books , 1973 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 18 Gerth HH , Wright Mills C. From Max Weber: Essays in Sociology . New York : Oxford University Press , 1946 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 19 Tucker WT. Max Weber's “Verstehen” . Sociol Q 1965 ; 6 ( 2 ): 157 – 65 . Google Scholar Crossref Search ADS WorldCat 20 Garfinkel H. Studies in Ethnomethodology . Cambridge : Polity Press , 1984 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 21 Zahavi D. Husserl's Phenomenology . Stanford : Stanford University Press , 2003 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 22 Berger P , Kellner H. Marriage and the construction of reality: an exercise in the microsociology of knowledge . Diogenes 1964 ; 12 ( 46 ): 1 – 24 . Google Scholar Crossref Search ADS WorldCat 23 Rose G. Strategy of prevention: lessons from cardiovascular disease . Br Med J 1981 ; 282 : 1847 – 51 . Google Scholar Crossref Search ADS WorldCat 24 Rose G. Sick individuals and sick population . Int J Epidemiol 1985 ; 14 : 32 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Rose G. The Strategy of Preventive Medicine . Oxford : Oxford University Press , 1992 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 26 Davies C. The cloak of professionalism. In: M Robb, M Allott (eds). Understanding Health and Social Care: An Introductory Reader . London : Sage Publications , 1998 : 190 – 7 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC © The Author 2016. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
TI - The Prevention Paradox Mark II: an appeal for diversity in public health
JF - Journal of Public Health
DO - 10.1093/pubmed/fdw133
DA - 2017-12-01
UR - https://www.deepdyve.com/lp/oxford-university-press/the-prevention-paradox-mark-ii-an-appeal-for-diversity-in-public-0HeM2ZT6v5
SP - e142
VL - 39
IS - 4
DP - DeepDyve
ER -