The invisibilization of health promotion in Australian public health initiatives

The invisibilization of health promotion in Australian public health initiatives Abstract The field of health promotion has arguably shifted over the past thirty years from being socially proactive to biomedically defensive. In many countries this has been accompanied by a gradual decline, or in some cases the almost complete removal of health promotion designated positions within Government health departments. The language or discourse used to describe the practice and discipline of health promotion is reflective of such changes. In this study, critical discourse analysis was used to determine the representation of health promotion as a practice and a discipline within 10 Australian Government weight-related public health initiatives. The analysis revealed the invisibilization of critical health promotion in favour of an agenda described as ‘preventive health’. This was achieved primarily through the textual practices of overlexicalization and lexical suppression. Excluding document titles, there were 437 uses of the terms health promotion, illness prevention, disease prevention, preventive health, preventative health in the documents analysed. The term ‘health promotion’ was used sparingly (16% of total terms), and in many instances was coupled with the term ‘illness prevention’. Conversely, the terms ‘preventive health’ and ‘preventative health’ were used extensively, and primarily used alone. The progressive invisibilization of critical health promotion has implications for the perceptions and practice of those identifying as health promotion professionals and for people with whom we work to address the social and structural determinants of health and wellbeing. Language matters, and the language and intent of critical health promotion will struggle to survive if its speakers are professionally unidentifiable or invisible. health promotion discourse, critical perspectives, evaluation methodology, health policy BACKGROUND ‘The way we name things shapes our feelings, judgements, choices and actions’ (Glendon, 1991) (p. 11). In Porter’s critical analysis of the changing discourse in health promotion from the 1986 Ottawa Charter for Health Promotion to the 2005 Bangkok Charter for Health Promotion in a Globalized World, she noted ‘a move from socially proactive to biomedically defensive health promotion’ (Porter, 2007) (p. 77). The purpose of the health promotion espoused in the Ottawa Charter was to enhance the positive concepts of health, wellbeing and resilience, whereas the purpose of the more limited form of health promotion presented in the Bangkok Charter was to prevent the negative state of disease (Porter, 2007). The contrasting foci of health promotion in these documents are consistent with critical and traditional health promotion respectively (Gregg and O’Hara, 2007; O’Hara et al., 2015). Critical health promotion (Ferreira and Castiel, 2009; Simpson and Freeman, 2004; Taylor et al., 2014) is ‘underpinned by values and principles of social justice, equity, holistic and ecological conceptions of health, empowerment, participation, salutogenesis, and evidence-based practice’ (Tretheway et al., 2015) (p. 1). Traditional health promotion is underpinned by biomedical and behavioural models of health and health improvement (Baum, 2008; Robison and Carrier, 2004). The shift from critical to traditional health promotion that was identified by Porter in the Ottawa and Bangkok Charters has been echoed by a shift in the language used to describe the discipline and practice of health promotion within public health policy and programming in a number of countries. In Canada the term ‘population health’ has gained ascendancy over the term ‘health promotion’ because, it is argued, it provides a depoliticized discourse consistent with the retreat of the welfare state in that country (Raphael, 2008; Robertson, 1998). Since 1997, when ‘New’ Labour was elected to government in England, the hegemonic language shifted inexorably towards ‘public health’ or ‘health improvement’ (Scott-Samuel and Springett, 2007; Scott-Samuel and Wills, 2007). Although the new commitment to public health was regarded as a largely positive development, it signalled the start of the decline in health promotion discourse (Scott-Samuel and Springett, 2007). The disappearance of the discourse and professional recognition of the discipline of health promotion prompted one editorial to ask if health promotion in England was a corpse or just a sleeping beauty (Scott-Samuel and Wills, 2007)? In Australia, the biomedical and individualized behavioural approach to health promotion has been historically dominant in public health policy (Fisher et al., 2016). Although this traditional approach to health promotion is regarded as narrow and ineffective, particularly with respect to addressing the social determinants of health and health inequities (Fisher et al., 2016), it nonetheless signifies some level of commitment to health promotion, albeit in a less than ideal form. However events in recent years in Australia, such as the almost complete obliteration of health promotion positions in Queensland and large scale changes in South Australia (though not in New South Wales and Victoria) suggest that health promotion may be disappearing from the government public health landscape, prompting the question, health promotion, health promotion, wherefore art thou health promotion? Discourses on health and health promotion change over time and reflect the prevailing social, political and economic contexts and ideologies in which they are produced and maintained (Fisher et al., 2016; Robertson, 1998). One of the major health topics attracting the attention of the media, industry and Governments in the last decade is that of body weight. Given the considerable emphasis on body weight in public health initiatives, this issue will be used to explore the position of health promotion within such initiatives. The prevalence of people with a body mass index (BMI) (an index of the relationship between height and body mass) that are categorized as ‘overweight’ or ‘obese’ is reported to have increased rapidly throughout the world on a population wide basis (Anand and Yusuf, 2011; Campos et al., 2006), and that everyone everywhere is at risk of becoming ‘overweight’ or ‘obese’ (Campos, 2004). The use of such terms such as ‘global’, ‘epidemic’, ‘pandemic’ and ‘globesity’ have contributed to the notion that body weight is increasing exponentially and that these changes are sweeping through the populations of developed and developing countries alike (Caballero, 2007; Swinburn et al., 2011; World Health Organization, 2003). Despite evidence that the prevalence of children, adolescents and adults in the ‘obese’ category stabilized around the turn of the 21st Century in many parts of the world (Olds et al., 2011; Rokholm et al., 2010), the World Health Organization (WHO) and national governments of Australia and many other countries around the world continue to respond to the perceived ‘obesity epidemic’ with weight-related public health initiatives (World Health Organization, 2004). The placement of body weight at the focal point of discourse about health is referred to as the ‘weight-centred health paradigm’ (O’Hara et al., 2015). This paradigm has become dominant in public health policy and programmes in the developed English speaking world. Most weight-related public health policies and programmes are enacted through the discipline of health promotion. However such policies and programmes have received little critique through a health promotion lens. Further to de Leeuw’s lament that ‘Rhetoric is a field of scholarship and study in the health promotion field that has received too little attention’ (de Leeuw, 2010) (p. 142), in this study we sought to critically analyse the rhetoric and discourses in Australian Government weight-related public health initiatives (WR-PHI) to determine the representation of health promotion as a practice and a discipline within such initiatives. RESEARCH DESIGN Methodology Critical discourse analysis (CDA) (Jacobs, 2006) was the methodology used in the study. CDA focuses on identifying the practices used by text producers to legitimize their knowledge claims and support their ideology (Sproule, 2006). CDA assumes that power and ideology are transmitted through discourse, and therefore aims for a detailed critique of text to highlight the connection of text to ideology and the exercise of power. Such connections are often hidden, or appear neutral on the surface, but shape the representation of the content for particular ends. As a method, CDA has a structured three dimensional approach involving textual practice analysis (for lexicon) at the core, within the context of discursive practice analysis (for rhetorical and lexical strategies particularly with respect to claims-making), which falls within the context of social practice analysis (Jacobs, 2006). Social practice analysis explores the role played by power and ideology in supporting or disturbing the discourse. Analysis explores how power is maintained in the text, how hegemonic is the discourse, and whether there is any evidence of inconsistency in the discourse (Jacobs, 2006; Machin and Mayr, 2012). Analytic attention must therefore be paid to each of these dimensions. Given that texts may have meaning in all three dimensions, analysis across the dimensions was conducted simultaneously rather than in isolation or in a sequence from textual to discursive to social practice analysis. Data collection The texts chosen for analysis were documents describing weight-related public health initiatives from Australia. A web search was conducted for documents that met the following six inclusion criteria: (i) report, policy, programme, strategy or action plan; (ii) commissioned or produced by the Australian federal government or parliament; (iii) published between 2003 and February 2013; (iv). name, description or rationale of the document is explicitly focused on body weight as the primary or major issue; (v) population level focus; and (vi) freely available on the internet. The start date of 2003 was selected as this was the date when the Commonwealth, State and Territory Health Ministers first declared that ‘overweight and obesity are significant public health problems that threaten the health gains made by Australians in the last century’ (Australian Government, 2003) (p. i). References and links in documents that met the inclusion criteria were also searched. Searching continued until data saturation was reached and no new documents were found. Documents were excluded if they reported on the progress or evaluation of a weight-related public health policy or program. Ten documents were retrieved that metal of the inclusion criteria. Data analysis This study used the eight stage analytical procedure outlined by Marshall and Rossman (1989): organizing the data, immersion in the data, generating categories and themes, coding the data, writing analytical memos, offering interpretations, searching for alternative understanding, and writing the report. All documents were entered into NVivo data analysis software (QSR International Pty Ltd. Version 10, 2012). Using Machin and Mayr’s framework (2012), analysis of documents involved examining the vocabulary, grammar, sentence structure, visuals and overall structure of the text for textual practices, discursive practices and social practices. Documents were examined for evidence of word connotations, overlexicalization, lexical suppression and lexical absence (Machin and Mayr, 2012) as well as other discourse strategies related to health promotion as a discipline and practice. Word connotations refer to the choice of words that place the events into a particular framework of reference or discourse. Overlexicalization refers to the use of a surfeit of repetitious, quasi-synonymous terms, over-persuasion or excessive description. Lexical suppression refers to the suppression of important terms, activities, elements or participants. Lexical absence refers to the absence of important terms, activities, elements or participants. Where the practices of overlexicalization and lexical suppression or absence were identified, the data were examined to determine if quantitative analysis of the usage of terms would yield a meaningful result. Statistical analysis involved calculating descriptive results of the number of times specific terms were used, and where appropriate, the proportion of the total. No statistical tests were conducted on the data. The discourse practices and strategies used within the documents related to health promotion as a practice and a discipline are identified and discussed. A series of questions is then presented as a heuristic for developing the critical competence of health promotion practitioners and the general public with respect to the results presented. The heuristic for developing critical competence uses the 4Rs Model for Critical Reflection: recall, relive, reinterpret and respond (McKenzie, 2000). This study did not involve data collection from humans, therefore approval from the Human Research Ethics Committee was not required. All documents used in the study were available online to the public or through the university databases. RESULTS AND DISCUSSION Ten documents were retrieved for analysis (Table 1). All of the Australia: The Healthiest Country by 2020 (hereafter referred to as AHC2020) documents except the AHC2020 Technical Report No 1 Obesity in Australia: a need for urgent action (hereafter referred to as the AHC2020 Obesity Technical Report) addressed three issues: obesity, tobacco use and alcohol use. The sections of each document specifically related to tobacco and alcohol use were not included in the analysis. All other sections were included. Table 1: Weight-related public health initiatives included in analysis Document  Year  Document modalities  Healthy Weight 2008—Australia’s Future: the National Action Agenda for Children and Young People and their Families (Australian Government, 2003)  2003  26 page written policy  Measure Up Social Marketing Campaign (Australian Government Department of Health and Ageing, 2011a)  2006  Brochures, booklet, posters, tape measure, 12-week planner, community guide, print, radio, television, outdoor and online advertisements, websites  Australia: The Healthiest Country by 2020: A discussion paper (Australian Government National Preventative Health Taskforce, 2008)  2008  80 page written discussion paper  Australia: The Healthiest Country by 2020 Technical Report No. 1 Obesity in Australia: a need for urgent action (Australian Government National Preventative Health Taskforce, 2009c)  2009  138 page written technical report  Australia: The Healthiest Country by 2020—National Preventative Health Strategy—Overview (Australian Government National Preventative Health Taskforce, 2009a)  2009  60 page written report  Australia: The Healthiest Country by 2020—National Preventative Health Strategy—the roadmap for action (Australian Government National Preventative Health Taskforce, 2009b)  2009  316 page written report  Weighing it up: Obesity in Australia Report (House of Representatives Standing Committee on Health and Ageing, 2009)  2009  223 page written report  Taking Preventative Action—A Response to Australia: The Healthiest Country by 2020—The Report of the National Preventative Health Taskforce (Australian Government, 2010)  2010  125 page written report  Swap It (Measure Up phase 2) Social Marketing Campaign (Australian Government Department of Health and Ageing, 2011b)  2011  Brochures, posters, cards, fact sheets, recipe collections, print, radio, television, outdoor and online advertisements, website  Australian Government Response to Weighing it up: Obesity in Australia Report (Australian Government, 2013)  2013  22 page written report  Document  Year  Document modalities  Healthy Weight 2008—Australia’s Future: the National Action Agenda for Children and Young People and their Families (Australian Government, 2003)  2003  26 page written policy  Measure Up Social Marketing Campaign (Australian Government Department of Health and Ageing, 2011a)  2006  Brochures, booklet, posters, tape measure, 12-week planner, community guide, print, radio, television, outdoor and online advertisements, websites  Australia: The Healthiest Country by 2020: A discussion paper (Australian Government National Preventative Health Taskforce, 2008)  2008  80 page written discussion paper  Australia: The Healthiest Country by 2020 Technical Report No. 1 Obesity in Australia: a need for urgent action (Australian Government National Preventative Health Taskforce, 2009c)  2009  138 page written technical report  Australia: The Healthiest Country by 2020—National Preventative Health Strategy—Overview (Australian Government National Preventative Health Taskforce, 2009a)  2009  60 page written report  Australia: The Healthiest Country by 2020—National Preventative Health Strategy—the roadmap for action (Australian Government National Preventative Health Taskforce, 2009b)  2009  316 page written report  Weighing it up: Obesity in Australia Report (House of Representatives Standing Committee on Health and Ageing, 2009)  2009  223 page written report  Taking Preventative Action—A Response to Australia: The Healthiest Country by 2020—The Report of the National Preventative Health Taskforce (Australian Government, 2010)  2010  125 page written report  Swap It (Measure Up phase 2) Social Marketing Campaign (Australian Government Department of Health and Ageing, 2011b)  2011  Brochures, posters, cards, fact sheets, recipe collections, print, radio, television, outdoor and online advertisements, website  Australian Government Response to Weighing it up: Obesity in Australia Report (Australian Government, 2013)  2013  22 page written report  From Healthy Weight 2008 forward, the textual practices of overlexicalization and lexical suppression were evident. Firstly, the term ‘health promotion’ was used sparingly, and in many instances it was coupled with the term ‘illness prevention’. Neither term was used in the social marketing campaigns Measure Up or Swap It, Don’t Stop It and therefore these documents were therefore excluded from further analysis. Secondly, terms relating to ‘prevention’ were used extensively throughout the documents. Excluding the use of prevention-related terms in the titles of the documents, there were 437 uses of the terms health promotion, illness prevention, disease prevention, preventive health and preventative health. Where used, each term was most likely to be used alone. Health promotion was used alone 51 times (12% of the total), and coupled with a prevention-oriented term 16 times (4% of the total). Half of these uses were in the AHC2020 Discussion paper, where the term health promotion/illness prevention was used throughout the document. For example: Among its tasks, a national agency would ensure the delivery of a minimum set of evidence-based, illness prevention/health promotion programs that are accessible to all Australians (AHC2020 Discussion paper p. xiv) Subsequent AHC2020 documents including the AHC2020 National Preventative Health Strategy Overview (AHC2020 NPHS Overview) and the AHC2020 National Preventative Health Strategy Roadmap (AHC2020 NPHS Roadmap) saw a rapid decline in the use of this joint term, and a concomitant rise in the use of prevention-oriented terms alone. For example: Action and leadership on preventative health is urgent and long overdue in Australia. (AHC2020 NPHS Roadmap p. 6) Health promotion was used alone 40% of the time in the AHC2020 Obesity Technical Report. This is the highest rate of use of the term health promotion in any of the policy documents. The AHC2020 Obesity Technical Report included a detailed literature review of strategies designed to address the issue of obesity, and therefore included many studies that used the term health promotion. With the publication of the AHC2020 NPHS Overview and then the AHC2020 NPHS Roadmap, references to health promotion alone decreased to 15 and 11% respectively, demonstrating further lexical suppression. The hegemonic power of the prevention discourse grew further with the Government’s response Taking Preventative Action, in which the term health promotion was used alone only 6% of the time and a prevention-focused term was used alone 92% of the time (Figure 1). Fig. 1: View largeDownload slide Relative proportion of use of terms within selected Australian Government weight-related public health initiatives. Excluding terms in the document titles and references to the National Preventative Health Taskforce. AHC2020, Australia the Healthiest Country by 2020; NPHS, National Preventative Health Strategy. Fig. 1: View largeDownload slide Relative proportion of use of terms within selected Australian Government weight-related public health initiatives. Excluding terms in the document titles and references to the National Preventative Health Taskforce. AHC2020, Australia the Healthiest Country by 2020; NPHS, National Preventative Health Strategy. A striking finding from this analysis was the dominance of use of the term ‘preventive health’ or ‘preventative health’, which draws on the biomedical concept of prevention but attempts to remove the disease connotation by coupling it with the term ‘health’. The resulting term is nonsensical, as the goal of preventive health is not to prevent health, but to prevent illness, injury, disease and death. Thus, despite the attempt to present prevention as a positive concept by coupling it with the word health, it cannot escape its root meaning of avoidance of poor health. Notwithstanding the absolute dominance of the term preventive/preventative health in these Australian Government policy documents, perhaps the proximity of the term to oxymora has resulted in it gaining little traction elsewhere. That is not to say that prevention-related terms are not in use, but they are not the truncated version seen here, and hence make more literal sense. Prevention-related terms that are widely used in the fields of clinical practice, public health and health promotion include preventive health behaviours/practices (behaviours or practices that contribute to prevention of health problems) (Chapman and Coups, 2006); preventative health education (specific process used to prevent health problems) (Whitehead et al., 2004); preventative health model (processes used to prevent health problems) (Kazak, 2006); preventive medicine (processes used to prevent health problems) (Rose, 2008); and preventive health care/services (services provided for the prevention of health problems) (Sabates and Feinstein, 2006). But the scaled-back term ‘preventive/preventative health’ is unused almost anywhere else. The nonsensical nature of the term and the cognitive dissonance required to use it may account for its notable absence from health related policies or programs elsewhere, and confinement to Australian Government initiatives including those examined here, and the Preventative Health Research Flagship of the Commonwealth Scientific and Industrial Research Organization (CSIRO), Australia's national science agency (CSIRO, no date). The textual practices of foregrounding the term prevention through overlexicalization, and backgrounding the term health promotion through lexical suppression served to invisibilize or remove recognition from health promotion as a discipline and practice, replace it with the reductionist biomedical health paradigm concept of disease (health) prevention, and characterize its professionals as the preventative health workforce. For example: There are many very large tertiary institutions across Australia that act as educators of the preventative health workforce of the future (AHC2020 NPHS Overview p. 33) The Commonwealth Government has provided $500,000 for an audit of the preventative health workforce (Taking Preventative Action p. 33) Is health promotion on its way to becoming a corpse or is it a sleeping beauty? (Scott-Samuel and Wills, 2007). If health promotion discourse is indeed just sleeping, at least in Australian Government weight-related policies and programs, analysis of the textual practice of word connotations in the documents provided some ideas about the source of its life-sustaining breath. Word connotations placed the term health promotion most frequently within the context of programs, strategies and activities. Indeed, of the 51 uses of health promotion alone, 37 of these (73%) occurred within this context. For example: Through the Healthy Children Initiative, the Commonwealth Government will make $325.5 million available for states and territories to implement health promotion programs and activities in pre-schools, schools and child care settings. (Taking Preventative Action p. 13) The remaining 27% of uses related to health promotion practitioners, foundations, associations and investment, the WHO definition of health promotion and mental health promotion. Within the context of programs, strategies and activities, the textual practice of word connotations placed the term health promotion most frequently within the specific context of the workplace. Of the 37 uses of the terms related to programs, strategies and activities, 20 of these refer to workplace health promotion. This represented 39% of the total uses of the term health promotion, which was by far the most common specific use of the term. In Weighing it up, there were four mentions of term health promotion, all of which were within the context of health promotion programs, strategies and activities. In the Weighing it up Government Response, there were also four mentions of the term health promotion, three of which were workplace health promotion, and one related to health promotion practitioners. In the three phases of action on ‘obesity’ in the AHC2020 NHPS Overview, the term health promotion appears twice, and both times as workplace health promotion: Establish a national action research project to strengthen evidence of effective workplace health promotion programs in the Australian context (AHC2020 NPHS Overview p. 13) Learn from best practice and promote effective workplace health promotion programs throughout Australia (AHC2020 NPHS Overview p. 15) The identification of various settings for ‘preventative health’ action was common across many of the documents. For example Healthy Weight 2008 identified a range of settings in which health promotion action would need to take place, including child care, schools, primary care services, family and community care services, neighbourhoods and community organizations, workplaces, food supply, and media and marketing. A similar range of settings was identified in the AHC2020 documents. However the specific language used to describe these health promoting settings was inconsistent. In fact workplace health promotion was the only settings-based term that was used, and other specific. settings-based terms such as health promoting schools, health promoting universities, health promoting health care services and healthy cities were completely absent. For example, when referring to the capacity of schools, instead of referring to the Health Promoting Schools approach, the AHC2020 NPHS Overview stated: We need to create school environments that are supportive of good health, and in particular promote healthy eating and adequate physical activity, by providing programs and services that build skills and knowledge, and reach people in need. (AHC2020 NPHS Overview p. 32) Workplace health promotion has a WHO programme to support it, a model of practice, national and international associations and professional journals dedicated to it. But likewise, there are WHO supported initiatives for health promoting schools, health promoting health care services and healthy cities. For example the health promoting schools program has an established model of practice, robust support structures, and national and local support in Australia provided by the Health Promoting Schools Association. So why was the term ‘workplace health promotion’ mentioned so frequently in the policy documents, and health promoting schools, or any other health promoting setting term was completely absent? One possible explanation may be drawn from the examination of the role of economic power as a social practice operating within the documents. For-profit companies ‘providing’ workplace health promotion programs are prevalent in the Australian health promotion landscape, with many companies now claiming to provide health promotion programs to workplaces (PricewaterhouseCoopers, 2010). These programs often consist of individual employee health risk assessment and health education, and therefore do not reflect the comprehensive workplace health promotion model of practice (Torp et al., 2011). For-profit companies selling ‘weight-loss’ programmes are also tapping into workplaces as a major customer source (Will, 2013) and also focus their strategies on individuals and their behaviours. For example Weight Watchers has developed a weight loss programme for implementation in workplaces titled Health Solutions (Weight Watchers, 2013), and has partnered with numerous health insurance providers in the USA to deliver weight loss programs within workplaces (Will, 2013). There is powerful economic incentive for a range of for-profit organizations to sell their ‘health promotion’ programmes to workplaces, and equally powerful economic, moral and social incentives for workplaces to institute workplace health promotion programmes (PricewaterhouseCoopers, 2010). Other settings have the same economic, moral and social incentives to institute health promoting schools, health promoting health services and health promoting cities programs (World Health Organization, 2013), but there is little opportunity for profit-making ‘health promotion providers’ within these largely not-for-profit sectors, compared with the vast opportunity within the workplace sector. In the section of the AHC2020 NPHS Overview on developing strategic partnerships, workplace health promotion providers were the only settings-based providers specifically mentioned: New partnerships can develop to improve the health of 10 million Australians in the workplace. These can be between private and public sector employers, insurers, health insurers, unions and workplace health promotion providers. (AHC2020 NPHS Overview p. 28) In a neoliberal capitalist environment where the free market is valued, it would be expected that advocacy for workplace health promotion programmes from those with the greatest potential to make profit from such programmes would be stronger than advocacy for health promoting settings programs in schools, hospitals and cities, where there is less opportunity for profit-making. Baum and Fisher (2011, 2014) highlight the need to examine the ‘increasing efforts of large corporations to influence health promotion policies of governments’ (Baum and Fisher, 2011) (p. 323) and although they are referring more specifically to tobacco and food companies, the dominance of workplace health promotion to the exclusion of any other settings-based approaches may also reflect corporate efforts to influence government policy. From the documents analysed it was apparent that a number of for-profit organizations operating in workplaces took the opportunity to make submissions and/or appear before the hearings examined in this study. For example, Weight Watchers Australia made a written submission to the Parliamentary Inquiry on Obesity, appeared before the hearings, and was quoted in Weighing it up. The Weight Management Council, a peak body representing four of the largest weight loss companies in Australia, made a submission to the AHC2020 process. Although it was beyond the scope of this study to examine the content of these submissions, let alone determine the relative contribution that these organizations made to advocating specifically for workplace health promotion versus other settings based health promotion, other studies have identified the power of industry to influence government policy. For example, Jenkin et al. (2011) examined the framing of submissions to the New Zealand inquiry into obesity and found that those from the marketing and food industries argued more strongly for health education strategies focused on individual behaviours, compared with submissions from the public health sector. Furthermore, Jenkin (2010) found that the strategies proposed in the industry submissions were disproportionately represented in subsequent Government food policy. To our knowledge, no studies have examined the role of the ‘weight management’ sector in influencing government policy and this is an area that requires further attention. Through critical discourse analysis we identified the backgrounding of any health promotion discourse, be it critical or traditional, and the foregrounding of the prevention discourse that excluded any reference to health promotion. Prevention discourse was ascribed merit or value and was privileged at the expense of globally recognized health promotion discourse. This has significant implications for those on the receiving end of these policies and programs. For health promotion practitioners expected to work on preventive health initiatives, and for members of the public involved in or impacted by such initiatives, the preventive health discourse prompts a number of critical questions. Responding to Baum’s call for all health promotion research to have a critical or change oriented focus (Baum, 2008), as an output of this study we developed a set of reflective questions using the 4Rs Model for Critical Reflection (McKenzie, 2000) to assist in the development of critical competence about the preventive health discourse (Table 2). The 4Rs Model includes four categories of questions: (i) Recall: What is your assessment of the current situation?; (ii) Relive: How do these recollections make you feel?; (iii) Reinterpret: What meaning do you make of the current situation and your feelings about it?; and (iv) Respond: What can/will you do now? The purpose of these questions is to provoke conversation and critical reflection on the utility, desirability, implications and consequences of the preventive health discourse. Table 2: Reflection questions to assist in the development of critical competence related to the preventive health discourse Reflection phase  Health promotion professionals  People in the community  Recall  In what ways are you required to reframe your role as a ‘preventive health’ practitioner?  How does the preventive health discourse relate to the strategies that you use in everyday life to enhance or optimize health and wellbeing?  Recall  How do you feel about the invisibilization of the health promotion discipline and practice in these documents?  How consistent is the preventive health discourse with your lived experiences of health and wellbeing?  Recall  Do you perceive your role to be valued differently (more or less) because health promotion discourse has been overtaken by the preventive health discourse?  What is gained or lost in the preventive health discourse that is important to you?  Relive  How do these reflections make you feel?  How do these reflections make you feel?  Reinterpret  Why do you think you feel that way?  Why do you think you feel that way?  Respond  How might you translate the preventive health discourse into everyday language that resonates with people in the community?  How might you convey your views to the health promotion practitioners and government representatives responsible for implementing policies and programs using the preventive health discourse?  Respond  What potential risks and benefits are there for you to undertake such a process?  What potential risks and benefits are there for you to do so?  Respond  How might you mitigate the potential risks and optimize the potential benefits?  How might you mitigate the potential risks and optimize the potential benefits?  Reflection phase  Health promotion professionals  People in the community  Recall  In what ways are you required to reframe your role as a ‘preventive health’ practitioner?  How does the preventive health discourse relate to the strategies that you use in everyday life to enhance or optimize health and wellbeing?  Recall  How do you feel about the invisibilization of the health promotion discipline and practice in these documents?  How consistent is the preventive health discourse with your lived experiences of health and wellbeing?  Recall  Do you perceive your role to be valued differently (more or less) because health promotion discourse has been overtaken by the preventive health discourse?  What is gained or lost in the preventive health discourse that is important to you?  Relive  How do these reflections make you feel?  How do these reflections make you feel?  Reinterpret  Why do you think you feel that way?  Why do you think you feel that way?  Respond  How might you translate the preventive health discourse into everyday language that resonates with people in the community?  How might you convey your views to the health promotion practitioners and government representatives responsible for implementing policies and programs using the preventive health discourse?  Respond  What potential risks and benefits are there for you to undertake such a process?  What potential risks and benefits are there for you to do so?  Respond  How might you mitigate the potential risks and optimize the potential benefits?  How might you mitigate the potential risks and optimize the potential benefits?  Health promotion strategies would be expected to comprise the majority of the strategies in any major public health initiative. However, through the analysis we identified that the discipline of health promotion and the health promotion professionals that practice that discipline were backgrounded through the preventive health discourse. Even the broader term ‘public health’ was minimally represented in the documents. So who is it that is expected to do the work described in the initiatives? Judging from the description of the strategies, health promotion practitioners are expected to do much of the work, but are not given the professional courtesy of being named as such, and instead must be assumed to exist in the amorphous ‘preventative health workforce’. There was no obvious rationale for the shift away from the internationally recognized health promotion terms, and de Leeuw (2010) suggests that the preventive health discourse may simply be the ‘political craze of the day’ in a general political environment that is swinging more toward liberal and neo-corporatist perspectives. This is consistent with Raphael’s proposal that a similar shift from health promotion discourse to population health discourse in Canada provided a depoliticized discourse consistent with the retreat of the welfare state (Raphael, 2008), and Fisher and Baum’s analysis of Australian health policy as dominated by ‘politically easier’ individualized behavioural approaches for neoliberal governments (Fisher et al., 2016). The origin of the term ‘preventative health’ is unclear—it simply appeared in announcement of the National Preventative Health Taskforce commissioned to develop the AHC2020 National Preventative Health Strategy. No explanation for the use of the term appeared in any of the documents, and it was presented as a given that this term was the most appropriate term to use. Baum and Fisher (2011) argue that the narrow terms of reference set for the National Preventative Health Taskforce meant that the National Preventative Health Strategy was inevitably focused on promoting individual behaviour change to address so-called ‘lifestyle’ risk factors, but this does not explain the limited use of the term ‘health promotion’ in the documents. Traditional health promotion is underpinned by the biomedical and behavioural models, but the term ‘health promotion’ is still used to describe this approach. Critical health promotion however, is concerned with inequity and access to the determinants of health, requiring strategies that are inherently political, and the backgrounding of health promotion and even public health discourse in favour of the more nebulous apolitical preventive health discourse may well have been a deliberate attempt to depoliticize the (unavoidably political) discipline of critical health promotion (Baum, 2008). Whatever the reason, the documents analysed took up the preventive health baton with gusto, with barely a sideways glance at the health promotion and public health disciplines and practitioners that were marginalized in the process. Although the form of health promotion presented in the Bangkok Charter reflected this negative biomedical orientation, subsequent Charters such as the Nairobi Call to Action and the Adelaide Statement on Health in All Policies showed that ‘a strong commitment from politicians and practitioners to a powerful positive health approach in all sectors and levels of society is possible and worth pursuing’ (de Leeuw, 2010) (p. 142). However there was little evidence in Australian Government weight-related public health initiatives of a political agenda consistent with the positive concept of critical health promotion first espoused 30 years ago in the Ottawa Charter for Health Promotion and returned to in the Charters following Bangkok. The study had a number of strengths and limitations. The study covered a decade from 2003 to 2013 in which weight-related public health initiatives were initiated by the Australian Government, and produced a set of reflective questions for critical competence for use by health promotion professionals and the general public. The study did not include other documents such as program evaluation reports or submissions to the consultative processes, which may have provided additional insights. Additionally, the study did not include initiatives undertaken by other levels of Government or the non-Government sector and so the results cannot be generalized. The study results were constructed by us and are limited to our interpretation. CONCLUSION Through critical discourse analysis we identified the invisibilization of health promotion in favour of the biomedically defensive preventive health agenda in Australian Government weight-related public health initiatives. Further research is required on the extent of such changes in discourse in other sectors. The implications of such a shift in discourse on the perceptions and practice of those identifying as health promotion professionals and other people in the community need to be explored. REFERENCES Anand S. S., Yusuf S. ( 2011). Stemming the global tsunami of cardiovascular disease. The Lancet , 377, 529– 532. Google Scholar CrossRef Search ADS   Australian Government. ( 2003) Healthy Weight 2008: Australia’s Future - The National Action Agenda for Children and Young People and their Families. Retrieved from Canberra. http://www.healthyactive.gov.au/docs/healthy_weight08.pdf (1 April 2010, date last accessed). Australian Government. ( 2010) Taking Preventative Action – A Response to Australia: The Healthiest Country by 2020 – The Report of the National Preventative Health Taskforce. Australian Government. ( 2013) Australian Government response to the House of Representatives Standing Committee on Health and Ageing report: Weighing it up: Obesity in Australia. Australian Government Department of Health and Ageing. ( 2011a) Measure Up. https://web.archive.org/web/20110817065823/ http://www.measureup.gov.au/internet/abhi/publishing.nsf/Content/About+the+campaign-lp (7 August 2011, date last accessed). Australian Government Department of Health and Ageing. ( 2011b) Swap It, Don't Stop It. https://web.archive.org/web/20110830084149/ http://swapit.gov.au (30 August 2011, date last accessed). Australian Government National Preventative Health Taskforce. ( 2008) Australia: The Healthiest Country by 2020 - A discussion paper. Australian Government National Preventative Health Taskforce. ( 2009a) Australia: The Healthiest Country by 2020 – National Preventative Health Strategy – Overview. Australian Government National Preventative Health Taskforce. ( 2009b) Australia: The Healthiest Country by 2020 – National Preventative Health Strategy – the roadmap for action. Australian Government National Preventative Health Taskforce. ( 2009c) Australia: the healthiest country by 2020. Technical Report No 1 Obesity in Australia: a need for urgent action, Including addendum for October 2008 to June 2009. Baum F. ( 2008) The New Public Health , 3rd edn. Oxford University Press, Melbourne. Baum F., Fisher M. ( 2011) Are the national preventive health initiatives likely to reduce health inequities? Australian Journal of Primary Health , 17, 320– 326. Google Scholar CrossRef Search ADS PubMed  Baum F., Fisher M. ( 2014) Why behavioural health promotion endures despite its failure to reduce health inequities. Sociology of Health and Illness , 36, 213– 225. Google Scholar CrossRef Search ADS PubMed  Caballero B. ( 2007) The global epidemic of obesity: an overview. Epidemiologic Reviews  29 , 1– 5. Google Scholar CrossRef Search ADS PubMed  Campos P. ( 2004) The Obesity Myth.  Gotham Books, New York. Campos P., Saguy A., Ernsberger P., Oliver E., Gaesser G. ( 2006) The epidemiology of overweight and obesity: public health crisis or moral panic? International Journal of Epidemiology , 35, 55– 60. Google Scholar CrossRef Search ADS PubMed  Chapman G. B., Coups E. J. ( 2006) Emotions and preventive health behavior: worry, regret, and influenza vaccination. Health Psychology , 25, 82. Google Scholar CrossRef Search ADS PubMed  CSIRO. (no date) Preventative Health. http://www.csiro.au/Organisation-Structure/Flagships/Preventative-Health-Flagship.aspx (2 September 2011, date last accessed) de Leeuw E. ( 2010) Warning! Changing rhetoric ahead! Health Promotion International , 25, 141– 142. Google Scholar CrossRef Search ADS PubMed  Ferreira M. S., Castiel L. D. ( 2009) Which empowerment, which Health Promotion? Conceptual convergences and divergences in preventive health practices. Cadernos de Saúde Pública , 25, 68– 76. Google Scholar CrossRef Search ADS PubMed  Fisher M., Baum F., MacDougall C., Newman L., McDermott D. ( 2016) To what Extent do Australian Health Policy Documents address Social Determinants of Health and Health Equity? Journal of Social Policy , 45, 545– 564. Google Scholar CrossRef Search ADS   Glendon M. A. ( 1991) Rights Talk: The Impoverishment of Political Discourse . The Free Press, New York. Gregg J., O’Hara L. ( 2007) Values and principles evident in current health promotion practice. Health Promotion Journal of Australia , 18, 7– 11. Google Scholar CrossRef Search ADS PubMed  House of Representatives Standing Committee on Health and Ageing. ( 2009) Weighing it up: Obesity in Australia. Jacobs K. ( 2006) Discourse analysis. In Walter M. (ed), Social Research Methods: An Australian perspective . Oxford University Press, South Melbourne, VIC, AUS. Jenkin G. ( 2010) Individuals, the Environment or Inequalities: Industry and Public Health Framing of Obesity and its Presence in New Zealand Government Policy on Food and Nutrition. (PhD), University of Otago Dunedin, New Zealand. http://www.otago.ac.nz/wellington/otago042929.pdf (28 December 2012, date last accessed). Jenkin G., Signal L., Thomson G. ( 2011) Framing obesity: the framing contest between industry and public health at the New Zealand inquiry into obesity. Obesity Reviews , 12, 1022– 1030. Google Scholar CrossRef Search ADS PubMed  Kazak A. E. ( 2006) Pediatric Psychosocial Preventative Health Model (PPPHM): Research, practice, and collaboration in pediatric family systems medicine. Families, Systems, and Health , 24, 381. Google Scholar CrossRef Search ADS   Machin D., Mayr A. ( 2012) How to Do Critical Discourse Analysis: A Multimodal Introduction . Sage Publications, London, UK Marshall C., Rossman G. ( 1989) Designing Qualitative Research . Sage, Newbury Park, CA. McKenzie B. ( 2000) Phase 1 Workbook: Strategic leadership development program. Retrieved from Sydney, NSW, AUS. http://www.systemics.com.au/intro.html (19 July 2009, date last accessed). O'Hara L., Taylor J., Barnes M. ( 2015) The extent to which the public health ‘war on obesity’ reflects the ethical values and principles of critical health promotion: a multimedia critical discourse analysis. Health Promotion Journal of Australia , 26, 246– 254. Google Scholar CrossRef Search ADS PubMed  Olds T. S., Maher C., Zumin S., Péneau S., Lioret S., Castetbon K. et al.   ( 2011) Evidence that the prevalence of childhood overweight is plateauing: data from nine countries. International Journal of Pediatric Obesity , 6, 342– 360. Google Scholar CrossRef Search ADS PubMed  Porter C. ( 2007) Ottawa to Bangkok: changing health promotion discourse. Health Promotion International , 22, 72– 79. Google Scholar CrossRef Search ADS PubMed  PricewaterhouseCoopers ( 2010) Workplace Wellness in Australia: Aligning Action with Aims: Optimising the Benefits of Workplace Wellness . PricewaterhouseCoopers, Melbourne, VIC, AUS. Raphael D. ( 2008) Grasping at straws: a recent history of health promotion in Canada. Critical Public Health , 18, 483– 495. Google Scholar CrossRef Search ADS   Robertson A. ( 1998) Shifting discourses on health in Canada: from health promotion to population health. Health Promotion International , 13, 155– 166. Google Scholar CrossRef Search ADS   Robison J., Carrier K. ( 2004) The Spirit and Science of Holistic Health . Authorhouse, Bloomington, IN. Rokholm B., Baker J. L., Sørensen T. I. A. ( 2010) The levelling off of the obesity epidemic since the year 1999 – a review of evidence and perspectives. Obesity Reviews , 11, 835– 846. Google Scholar CrossRef Search ADS PubMed  Rose G. ( 2008) Rose’s Strategy of Preventive Medicine . Oxford University Press, Oxford, UK. Google Scholar CrossRef Search ADS   Sabates R., Feinstein L. ( 2006) The role of education in the uptake of preventative health care: the case of cervical screening in Britain. Social Science and Medicine , 62, 2998– 3010. Google Scholar CrossRef Search ADS PubMed  Scott-Samuel A., Springett J. ( 2007) Hegemony or health promotion? Prospects for reviving England's lost discipline. The Journal of the Royal Society for the Promotion of Health , 127, 211– 214. Google Scholar CrossRef Search ADS PubMed  Scott-Samuel A., Wills J. ( 2007) Health promotion in England: sleeping beauty or corpse? Health Education Journal , 66, 115– 119. Google Scholar CrossRef Search ADS   Simpson K., Freeman R. ( 2004) Critical health promotion and education—a new research challenge. Health Education Research , 19, 340– 348. Google Scholar CrossRef Search ADS PubMed  Sproule W. ( 2006) Content analysis. In Walter M (ed), Social Research Methods: An Australian Perspective . Oxford University Press, South Melbourne, VIC, AUS. Swinburn B., Sacks G., Hall K. D., McPherson K., Finegood D. T., Moodie M. L. et al.   ( 2011) The global obesity pandemic: shaped by global drivers and local environments. The Lancet , 378, 804– 814. Google Scholar CrossRef Search ADS   Taylor J., O’Hara L., Barnes M. ( 2014) Health promotion: a critical salutogenic science. International Journal of Social Work and Human Services Practice , 2, 283– 290. Torp S., Eklund L., Thorpenberg S. ( 2011) Research on workplace health promotion in the Nordic countries: a literature review, 1986-2008. Global Health Promotion , 18, 15– 22. Google Scholar CrossRef Search ADS PubMed  Tretheway R., Taylor J., O’Hara L., Percival N. ( 2015) A missing ethical competency? A review of critical reflection in health promotion. Health Promotion Journal of Australia , 26, 216– 221. Google Scholar CrossRef Search ADS PubMed  Weight Watchers. ( 2013) Weight Watchers Health Solutions. http://www.weightwatchers.com/templates/marketing/marketing_utool_1col.aspx?pageid=1307891 (17 November 2011, date last accessed) Whitehead D., Keast J., Montgomery V., Hayman S. ( 2004) A preventative health education programme for osteoporosis. Journal of Advanced Nursing , 47, 15– 24. Google Scholar CrossRef Search ADS PubMed  Will M. ( 2013) Weight watchers sets its eyes on employers. http://www.huffingtonpost.com/2013/08/09/weight-watchers-employers-_n_3730850.html (27 November 2013, date last accessed) World Health Organization. ( 2003) Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation, Geneva, 28 January - 1 February 2002. World Health Organization and the Food and Agriculture Organization of the United Nations, Geneva. World Health Organization. ( 2004) Global Strategy on Diet, Physical Activity and Health . World Health Assembly, Geneva. World Health Organization. ( 2013) Healthy Settings. http://www.who.int/healthy_settings/en/ (16 September 2014, date last accessed) © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Promotion International Oxford University Press

The invisibilization of health promotion in Australian public health initiatives

Loading next page...
 
/lp/ou_press/the-invisibilization-of-health-promotion-in-australian-public-health-fVdQX9dYEF
Publisher
Oxford University Press
Copyright
© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
ISSN
0957-4824
eISSN
1460-2245
D.O.I.
10.1093/heapro/daw051
Publisher site
See Article on Publisher Site

Abstract

Abstract The field of health promotion has arguably shifted over the past thirty years from being socially proactive to biomedically defensive. In many countries this has been accompanied by a gradual decline, or in some cases the almost complete removal of health promotion designated positions within Government health departments. The language or discourse used to describe the practice and discipline of health promotion is reflective of such changes. In this study, critical discourse analysis was used to determine the representation of health promotion as a practice and a discipline within 10 Australian Government weight-related public health initiatives. The analysis revealed the invisibilization of critical health promotion in favour of an agenda described as ‘preventive health’. This was achieved primarily through the textual practices of overlexicalization and lexical suppression. Excluding document titles, there were 437 uses of the terms health promotion, illness prevention, disease prevention, preventive health, preventative health in the documents analysed. The term ‘health promotion’ was used sparingly (16% of total terms), and in many instances was coupled with the term ‘illness prevention’. Conversely, the terms ‘preventive health’ and ‘preventative health’ were used extensively, and primarily used alone. The progressive invisibilization of critical health promotion has implications for the perceptions and practice of those identifying as health promotion professionals and for people with whom we work to address the social and structural determinants of health and wellbeing. Language matters, and the language and intent of critical health promotion will struggle to survive if its speakers are professionally unidentifiable or invisible. health promotion discourse, critical perspectives, evaluation methodology, health policy BACKGROUND ‘The way we name things shapes our feelings, judgements, choices and actions’ (Glendon, 1991) (p. 11). In Porter’s critical analysis of the changing discourse in health promotion from the 1986 Ottawa Charter for Health Promotion to the 2005 Bangkok Charter for Health Promotion in a Globalized World, she noted ‘a move from socially proactive to biomedically defensive health promotion’ (Porter, 2007) (p. 77). The purpose of the health promotion espoused in the Ottawa Charter was to enhance the positive concepts of health, wellbeing and resilience, whereas the purpose of the more limited form of health promotion presented in the Bangkok Charter was to prevent the negative state of disease (Porter, 2007). The contrasting foci of health promotion in these documents are consistent with critical and traditional health promotion respectively (Gregg and O’Hara, 2007; O’Hara et al., 2015). Critical health promotion (Ferreira and Castiel, 2009; Simpson and Freeman, 2004; Taylor et al., 2014) is ‘underpinned by values and principles of social justice, equity, holistic and ecological conceptions of health, empowerment, participation, salutogenesis, and evidence-based practice’ (Tretheway et al., 2015) (p. 1). Traditional health promotion is underpinned by biomedical and behavioural models of health and health improvement (Baum, 2008; Robison and Carrier, 2004). The shift from critical to traditional health promotion that was identified by Porter in the Ottawa and Bangkok Charters has been echoed by a shift in the language used to describe the discipline and practice of health promotion within public health policy and programming in a number of countries. In Canada the term ‘population health’ has gained ascendancy over the term ‘health promotion’ because, it is argued, it provides a depoliticized discourse consistent with the retreat of the welfare state in that country (Raphael, 2008; Robertson, 1998). Since 1997, when ‘New’ Labour was elected to government in England, the hegemonic language shifted inexorably towards ‘public health’ or ‘health improvement’ (Scott-Samuel and Springett, 2007; Scott-Samuel and Wills, 2007). Although the new commitment to public health was regarded as a largely positive development, it signalled the start of the decline in health promotion discourse (Scott-Samuel and Springett, 2007). The disappearance of the discourse and professional recognition of the discipline of health promotion prompted one editorial to ask if health promotion in England was a corpse or just a sleeping beauty (Scott-Samuel and Wills, 2007)? In Australia, the biomedical and individualized behavioural approach to health promotion has been historically dominant in public health policy (Fisher et al., 2016). Although this traditional approach to health promotion is regarded as narrow and ineffective, particularly with respect to addressing the social determinants of health and health inequities (Fisher et al., 2016), it nonetheless signifies some level of commitment to health promotion, albeit in a less than ideal form. However events in recent years in Australia, such as the almost complete obliteration of health promotion positions in Queensland and large scale changes in South Australia (though not in New South Wales and Victoria) suggest that health promotion may be disappearing from the government public health landscape, prompting the question, health promotion, health promotion, wherefore art thou health promotion? Discourses on health and health promotion change over time and reflect the prevailing social, political and economic contexts and ideologies in which they are produced and maintained (Fisher et al., 2016; Robertson, 1998). One of the major health topics attracting the attention of the media, industry and Governments in the last decade is that of body weight. Given the considerable emphasis on body weight in public health initiatives, this issue will be used to explore the position of health promotion within such initiatives. The prevalence of people with a body mass index (BMI) (an index of the relationship between height and body mass) that are categorized as ‘overweight’ or ‘obese’ is reported to have increased rapidly throughout the world on a population wide basis (Anand and Yusuf, 2011; Campos et al., 2006), and that everyone everywhere is at risk of becoming ‘overweight’ or ‘obese’ (Campos, 2004). The use of such terms such as ‘global’, ‘epidemic’, ‘pandemic’ and ‘globesity’ have contributed to the notion that body weight is increasing exponentially and that these changes are sweeping through the populations of developed and developing countries alike (Caballero, 2007; Swinburn et al., 2011; World Health Organization, 2003). Despite evidence that the prevalence of children, adolescents and adults in the ‘obese’ category stabilized around the turn of the 21st Century in many parts of the world (Olds et al., 2011; Rokholm et al., 2010), the World Health Organization (WHO) and national governments of Australia and many other countries around the world continue to respond to the perceived ‘obesity epidemic’ with weight-related public health initiatives (World Health Organization, 2004). The placement of body weight at the focal point of discourse about health is referred to as the ‘weight-centred health paradigm’ (O’Hara et al., 2015). This paradigm has become dominant in public health policy and programmes in the developed English speaking world. Most weight-related public health policies and programmes are enacted through the discipline of health promotion. However such policies and programmes have received little critique through a health promotion lens. Further to de Leeuw’s lament that ‘Rhetoric is a field of scholarship and study in the health promotion field that has received too little attention’ (de Leeuw, 2010) (p. 142), in this study we sought to critically analyse the rhetoric and discourses in Australian Government weight-related public health initiatives (WR-PHI) to determine the representation of health promotion as a practice and a discipline within such initiatives. RESEARCH DESIGN Methodology Critical discourse analysis (CDA) (Jacobs, 2006) was the methodology used in the study. CDA focuses on identifying the practices used by text producers to legitimize their knowledge claims and support their ideology (Sproule, 2006). CDA assumes that power and ideology are transmitted through discourse, and therefore aims for a detailed critique of text to highlight the connection of text to ideology and the exercise of power. Such connections are often hidden, or appear neutral on the surface, but shape the representation of the content for particular ends. As a method, CDA has a structured three dimensional approach involving textual practice analysis (for lexicon) at the core, within the context of discursive practice analysis (for rhetorical and lexical strategies particularly with respect to claims-making), which falls within the context of social practice analysis (Jacobs, 2006). Social practice analysis explores the role played by power and ideology in supporting or disturbing the discourse. Analysis explores how power is maintained in the text, how hegemonic is the discourse, and whether there is any evidence of inconsistency in the discourse (Jacobs, 2006; Machin and Mayr, 2012). Analytic attention must therefore be paid to each of these dimensions. Given that texts may have meaning in all three dimensions, analysis across the dimensions was conducted simultaneously rather than in isolation or in a sequence from textual to discursive to social practice analysis. Data collection The texts chosen for analysis were documents describing weight-related public health initiatives from Australia. A web search was conducted for documents that met the following six inclusion criteria: (i) report, policy, programme, strategy or action plan; (ii) commissioned or produced by the Australian federal government or parliament; (iii) published between 2003 and February 2013; (iv). name, description or rationale of the document is explicitly focused on body weight as the primary or major issue; (v) population level focus; and (vi) freely available on the internet. The start date of 2003 was selected as this was the date when the Commonwealth, State and Territory Health Ministers first declared that ‘overweight and obesity are significant public health problems that threaten the health gains made by Australians in the last century’ (Australian Government, 2003) (p. i). References and links in documents that met the inclusion criteria were also searched. Searching continued until data saturation was reached and no new documents were found. Documents were excluded if they reported on the progress or evaluation of a weight-related public health policy or program. Ten documents were retrieved that metal of the inclusion criteria. Data analysis This study used the eight stage analytical procedure outlined by Marshall and Rossman (1989): organizing the data, immersion in the data, generating categories and themes, coding the data, writing analytical memos, offering interpretations, searching for alternative understanding, and writing the report. All documents were entered into NVivo data analysis software (QSR International Pty Ltd. Version 10, 2012). Using Machin and Mayr’s framework (2012), analysis of documents involved examining the vocabulary, grammar, sentence structure, visuals and overall structure of the text for textual practices, discursive practices and social practices. Documents were examined for evidence of word connotations, overlexicalization, lexical suppression and lexical absence (Machin and Mayr, 2012) as well as other discourse strategies related to health promotion as a discipline and practice. Word connotations refer to the choice of words that place the events into a particular framework of reference or discourse. Overlexicalization refers to the use of a surfeit of repetitious, quasi-synonymous terms, over-persuasion or excessive description. Lexical suppression refers to the suppression of important terms, activities, elements or participants. Lexical absence refers to the absence of important terms, activities, elements or participants. Where the practices of overlexicalization and lexical suppression or absence were identified, the data were examined to determine if quantitative analysis of the usage of terms would yield a meaningful result. Statistical analysis involved calculating descriptive results of the number of times specific terms were used, and where appropriate, the proportion of the total. No statistical tests were conducted on the data. The discourse practices and strategies used within the documents related to health promotion as a practice and a discipline are identified and discussed. A series of questions is then presented as a heuristic for developing the critical competence of health promotion practitioners and the general public with respect to the results presented. The heuristic for developing critical competence uses the 4Rs Model for Critical Reflection: recall, relive, reinterpret and respond (McKenzie, 2000). This study did not involve data collection from humans, therefore approval from the Human Research Ethics Committee was not required. All documents used in the study were available online to the public or through the university databases. RESULTS AND DISCUSSION Ten documents were retrieved for analysis (Table 1). All of the Australia: The Healthiest Country by 2020 (hereafter referred to as AHC2020) documents except the AHC2020 Technical Report No 1 Obesity in Australia: a need for urgent action (hereafter referred to as the AHC2020 Obesity Technical Report) addressed three issues: obesity, tobacco use and alcohol use. The sections of each document specifically related to tobacco and alcohol use were not included in the analysis. All other sections were included. Table 1: Weight-related public health initiatives included in analysis Document  Year  Document modalities  Healthy Weight 2008—Australia’s Future: the National Action Agenda for Children and Young People and their Families (Australian Government, 2003)  2003  26 page written policy  Measure Up Social Marketing Campaign (Australian Government Department of Health and Ageing, 2011a)  2006  Brochures, booklet, posters, tape measure, 12-week planner, community guide, print, radio, television, outdoor and online advertisements, websites  Australia: The Healthiest Country by 2020: A discussion paper (Australian Government National Preventative Health Taskforce, 2008)  2008  80 page written discussion paper  Australia: The Healthiest Country by 2020 Technical Report No. 1 Obesity in Australia: a need for urgent action (Australian Government National Preventative Health Taskforce, 2009c)  2009  138 page written technical report  Australia: The Healthiest Country by 2020—National Preventative Health Strategy—Overview (Australian Government National Preventative Health Taskforce, 2009a)  2009  60 page written report  Australia: The Healthiest Country by 2020—National Preventative Health Strategy—the roadmap for action (Australian Government National Preventative Health Taskforce, 2009b)  2009  316 page written report  Weighing it up: Obesity in Australia Report (House of Representatives Standing Committee on Health and Ageing, 2009)  2009  223 page written report  Taking Preventative Action—A Response to Australia: The Healthiest Country by 2020—The Report of the National Preventative Health Taskforce (Australian Government, 2010)  2010  125 page written report  Swap It (Measure Up phase 2) Social Marketing Campaign (Australian Government Department of Health and Ageing, 2011b)  2011  Brochures, posters, cards, fact sheets, recipe collections, print, radio, television, outdoor and online advertisements, website  Australian Government Response to Weighing it up: Obesity in Australia Report (Australian Government, 2013)  2013  22 page written report  Document  Year  Document modalities  Healthy Weight 2008—Australia’s Future: the National Action Agenda for Children and Young People and their Families (Australian Government, 2003)  2003  26 page written policy  Measure Up Social Marketing Campaign (Australian Government Department of Health and Ageing, 2011a)  2006  Brochures, booklet, posters, tape measure, 12-week planner, community guide, print, radio, television, outdoor and online advertisements, websites  Australia: The Healthiest Country by 2020: A discussion paper (Australian Government National Preventative Health Taskforce, 2008)  2008  80 page written discussion paper  Australia: The Healthiest Country by 2020 Technical Report No. 1 Obesity in Australia: a need for urgent action (Australian Government National Preventative Health Taskforce, 2009c)  2009  138 page written technical report  Australia: The Healthiest Country by 2020—National Preventative Health Strategy—Overview (Australian Government National Preventative Health Taskforce, 2009a)  2009  60 page written report  Australia: The Healthiest Country by 2020—National Preventative Health Strategy—the roadmap for action (Australian Government National Preventative Health Taskforce, 2009b)  2009  316 page written report  Weighing it up: Obesity in Australia Report (House of Representatives Standing Committee on Health and Ageing, 2009)  2009  223 page written report  Taking Preventative Action—A Response to Australia: The Healthiest Country by 2020—The Report of the National Preventative Health Taskforce (Australian Government, 2010)  2010  125 page written report  Swap It (Measure Up phase 2) Social Marketing Campaign (Australian Government Department of Health and Ageing, 2011b)  2011  Brochures, posters, cards, fact sheets, recipe collections, print, radio, television, outdoor and online advertisements, website  Australian Government Response to Weighing it up: Obesity in Australia Report (Australian Government, 2013)  2013  22 page written report  From Healthy Weight 2008 forward, the textual practices of overlexicalization and lexical suppression were evident. Firstly, the term ‘health promotion’ was used sparingly, and in many instances it was coupled with the term ‘illness prevention’. Neither term was used in the social marketing campaigns Measure Up or Swap It, Don’t Stop It and therefore these documents were therefore excluded from further analysis. Secondly, terms relating to ‘prevention’ were used extensively throughout the documents. Excluding the use of prevention-related terms in the titles of the documents, there were 437 uses of the terms health promotion, illness prevention, disease prevention, preventive health and preventative health. Where used, each term was most likely to be used alone. Health promotion was used alone 51 times (12% of the total), and coupled with a prevention-oriented term 16 times (4% of the total). Half of these uses were in the AHC2020 Discussion paper, where the term health promotion/illness prevention was used throughout the document. For example: Among its tasks, a national agency would ensure the delivery of a minimum set of evidence-based, illness prevention/health promotion programs that are accessible to all Australians (AHC2020 Discussion paper p. xiv) Subsequent AHC2020 documents including the AHC2020 National Preventative Health Strategy Overview (AHC2020 NPHS Overview) and the AHC2020 National Preventative Health Strategy Roadmap (AHC2020 NPHS Roadmap) saw a rapid decline in the use of this joint term, and a concomitant rise in the use of prevention-oriented terms alone. For example: Action and leadership on preventative health is urgent and long overdue in Australia. (AHC2020 NPHS Roadmap p. 6) Health promotion was used alone 40% of the time in the AHC2020 Obesity Technical Report. This is the highest rate of use of the term health promotion in any of the policy documents. The AHC2020 Obesity Technical Report included a detailed literature review of strategies designed to address the issue of obesity, and therefore included many studies that used the term health promotion. With the publication of the AHC2020 NPHS Overview and then the AHC2020 NPHS Roadmap, references to health promotion alone decreased to 15 and 11% respectively, demonstrating further lexical suppression. The hegemonic power of the prevention discourse grew further with the Government’s response Taking Preventative Action, in which the term health promotion was used alone only 6% of the time and a prevention-focused term was used alone 92% of the time (Figure 1). Fig. 1: View largeDownload slide Relative proportion of use of terms within selected Australian Government weight-related public health initiatives. Excluding terms in the document titles and references to the National Preventative Health Taskforce. AHC2020, Australia the Healthiest Country by 2020; NPHS, National Preventative Health Strategy. Fig. 1: View largeDownload slide Relative proportion of use of terms within selected Australian Government weight-related public health initiatives. Excluding terms in the document titles and references to the National Preventative Health Taskforce. AHC2020, Australia the Healthiest Country by 2020; NPHS, National Preventative Health Strategy. A striking finding from this analysis was the dominance of use of the term ‘preventive health’ or ‘preventative health’, which draws on the biomedical concept of prevention but attempts to remove the disease connotation by coupling it with the term ‘health’. The resulting term is nonsensical, as the goal of preventive health is not to prevent health, but to prevent illness, injury, disease and death. Thus, despite the attempt to present prevention as a positive concept by coupling it with the word health, it cannot escape its root meaning of avoidance of poor health. Notwithstanding the absolute dominance of the term preventive/preventative health in these Australian Government policy documents, perhaps the proximity of the term to oxymora has resulted in it gaining little traction elsewhere. That is not to say that prevention-related terms are not in use, but they are not the truncated version seen here, and hence make more literal sense. Prevention-related terms that are widely used in the fields of clinical practice, public health and health promotion include preventive health behaviours/practices (behaviours or practices that contribute to prevention of health problems) (Chapman and Coups, 2006); preventative health education (specific process used to prevent health problems) (Whitehead et al., 2004); preventative health model (processes used to prevent health problems) (Kazak, 2006); preventive medicine (processes used to prevent health problems) (Rose, 2008); and preventive health care/services (services provided for the prevention of health problems) (Sabates and Feinstein, 2006). But the scaled-back term ‘preventive/preventative health’ is unused almost anywhere else. The nonsensical nature of the term and the cognitive dissonance required to use it may account for its notable absence from health related policies or programs elsewhere, and confinement to Australian Government initiatives including those examined here, and the Preventative Health Research Flagship of the Commonwealth Scientific and Industrial Research Organization (CSIRO), Australia's national science agency (CSIRO, no date). The textual practices of foregrounding the term prevention through overlexicalization, and backgrounding the term health promotion through lexical suppression served to invisibilize or remove recognition from health promotion as a discipline and practice, replace it with the reductionist biomedical health paradigm concept of disease (health) prevention, and characterize its professionals as the preventative health workforce. For example: There are many very large tertiary institutions across Australia that act as educators of the preventative health workforce of the future (AHC2020 NPHS Overview p. 33) The Commonwealth Government has provided $500,000 for an audit of the preventative health workforce (Taking Preventative Action p. 33) Is health promotion on its way to becoming a corpse or is it a sleeping beauty? (Scott-Samuel and Wills, 2007). If health promotion discourse is indeed just sleeping, at least in Australian Government weight-related policies and programs, analysis of the textual practice of word connotations in the documents provided some ideas about the source of its life-sustaining breath. Word connotations placed the term health promotion most frequently within the context of programs, strategies and activities. Indeed, of the 51 uses of health promotion alone, 37 of these (73%) occurred within this context. For example: Through the Healthy Children Initiative, the Commonwealth Government will make $325.5 million available for states and territories to implement health promotion programs and activities in pre-schools, schools and child care settings. (Taking Preventative Action p. 13) The remaining 27% of uses related to health promotion practitioners, foundations, associations and investment, the WHO definition of health promotion and mental health promotion. Within the context of programs, strategies and activities, the textual practice of word connotations placed the term health promotion most frequently within the specific context of the workplace. Of the 37 uses of the terms related to programs, strategies and activities, 20 of these refer to workplace health promotion. This represented 39% of the total uses of the term health promotion, which was by far the most common specific use of the term. In Weighing it up, there were four mentions of term health promotion, all of which were within the context of health promotion programs, strategies and activities. In the Weighing it up Government Response, there were also four mentions of the term health promotion, three of which were workplace health promotion, and one related to health promotion practitioners. In the three phases of action on ‘obesity’ in the AHC2020 NHPS Overview, the term health promotion appears twice, and both times as workplace health promotion: Establish a national action research project to strengthen evidence of effective workplace health promotion programs in the Australian context (AHC2020 NPHS Overview p. 13) Learn from best practice and promote effective workplace health promotion programs throughout Australia (AHC2020 NPHS Overview p. 15) The identification of various settings for ‘preventative health’ action was common across many of the documents. For example Healthy Weight 2008 identified a range of settings in which health promotion action would need to take place, including child care, schools, primary care services, family and community care services, neighbourhoods and community organizations, workplaces, food supply, and media and marketing. A similar range of settings was identified in the AHC2020 documents. However the specific language used to describe these health promoting settings was inconsistent. In fact workplace health promotion was the only settings-based term that was used, and other specific. settings-based terms such as health promoting schools, health promoting universities, health promoting health care services and healthy cities were completely absent. For example, when referring to the capacity of schools, instead of referring to the Health Promoting Schools approach, the AHC2020 NPHS Overview stated: We need to create school environments that are supportive of good health, and in particular promote healthy eating and adequate physical activity, by providing programs and services that build skills and knowledge, and reach people in need. (AHC2020 NPHS Overview p. 32) Workplace health promotion has a WHO programme to support it, a model of practice, national and international associations and professional journals dedicated to it. But likewise, there are WHO supported initiatives for health promoting schools, health promoting health care services and healthy cities. For example the health promoting schools program has an established model of practice, robust support structures, and national and local support in Australia provided by the Health Promoting Schools Association. So why was the term ‘workplace health promotion’ mentioned so frequently in the policy documents, and health promoting schools, or any other health promoting setting term was completely absent? One possible explanation may be drawn from the examination of the role of economic power as a social practice operating within the documents. For-profit companies ‘providing’ workplace health promotion programs are prevalent in the Australian health promotion landscape, with many companies now claiming to provide health promotion programs to workplaces (PricewaterhouseCoopers, 2010). These programs often consist of individual employee health risk assessment and health education, and therefore do not reflect the comprehensive workplace health promotion model of practice (Torp et al., 2011). For-profit companies selling ‘weight-loss’ programmes are also tapping into workplaces as a major customer source (Will, 2013) and also focus their strategies on individuals and their behaviours. For example Weight Watchers has developed a weight loss programme for implementation in workplaces titled Health Solutions (Weight Watchers, 2013), and has partnered with numerous health insurance providers in the USA to deliver weight loss programs within workplaces (Will, 2013). There is powerful economic incentive for a range of for-profit organizations to sell their ‘health promotion’ programmes to workplaces, and equally powerful economic, moral and social incentives for workplaces to institute workplace health promotion programmes (PricewaterhouseCoopers, 2010). Other settings have the same economic, moral and social incentives to institute health promoting schools, health promoting health services and health promoting cities programs (World Health Organization, 2013), but there is little opportunity for profit-making ‘health promotion providers’ within these largely not-for-profit sectors, compared with the vast opportunity within the workplace sector. In the section of the AHC2020 NPHS Overview on developing strategic partnerships, workplace health promotion providers were the only settings-based providers specifically mentioned: New partnerships can develop to improve the health of 10 million Australians in the workplace. These can be between private and public sector employers, insurers, health insurers, unions and workplace health promotion providers. (AHC2020 NPHS Overview p. 28) In a neoliberal capitalist environment where the free market is valued, it would be expected that advocacy for workplace health promotion programmes from those with the greatest potential to make profit from such programmes would be stronger than advocacy for health promoting settings programs in schools, hospitals and cities, where there is less opportunity for profit-making. Baum and Fisher (2011, 2014) highlight the need to examine the ‘increasing efforts of large corporations to influence health promotion policies of governments’ (Baum and Fisher, 2011) (p. 323) and although they are referring more specifically to tobacco and food companies, the dominance of workplace health promotion to the exclusion of any other settings-based approaches may also reflect corporate efforts to influence government policy. From the documents analysed it was apparent that a number of for-profit organizations operating in workplaces took the opportunity to make submissions and/or appear before the hearings examined in this study. For example, Weight Watchers Australia made a written submission to the Parliamentary Inquiry on Obesity, appeared before the hearings, and was quoted in Weighing it up. The Weight Management Council, a peak body representing four of the largest weight loss companies in Australia, made a submission to the AHC2020 process. Although it was beyond the scope of this study to examine the content of these submissions, let alone determine the relative contribution that these organizations made to advocating specifically for workplace health promotion versus other settings based health promotion, other studies have identified the power of industry to influence government policy. For example, Jenkin et al. (2011) examined the framing of submissions to the New Zealand inquiry into obesity and found that those from the marketing and food industries argued more strongly for health education strategies focused on individual behaviours, compared with submissions from the public health sector. Furthermore, Jenkin (2010) found that the strategies proposed in the industry submissions were disproportionately represented in subsequent Government food policy. To our knowledge, no studies have examined the role of the ‘weight management’ sector in influencing government policy and this is an area that requires further attention. Through critical discourse analysis we identified the backgrounding of any health promotion discourse, be it critical or traditional, and the foregrounding of the prevention discourse that excluded any reference to health promotion. Prevention discourse was ascribed merit or value and was privileged at the expense of globally recognized health promotion discourse. This has significant implications for those on the receiving end of these policies and programs. For health promotion practitioners expected to work on preventive health initiatives, and for members of the public involved in or impacted by such initiatives, the preventive health discourse prompts a number of critical questions. Responding to Baum’s call for all health promotion research to have a critical or change oriented focus (Baum, 2008), as an output of this study we developed a set of reflective questions using the 4Rs Model for Critical Reflection (McKenzie, 2000) to assist in the development of critical competence about the preventive health discourse (Table 2). The 4Rs Model includes four categories of questions: (i) Recall: What is your assessment of the current situation?; (ii) Relive: How do these recollections make you feel?; (iii) Reinterpret: What meaning do you make of the current situation and your feelings about it?; and (iv) Respond: What can/will you do now? The purpose of these questions is to provoke conversation and critical reflection on the utility, desirability, implications and consequences of the preventive health discourse. Table 2: Reflection questions to assist in the development of critical competence related to the preventive health discourse Reflection phase  Health promotion professionals  People in the community  Recall  In what ways are you required to reframe your role as a ‘preventive health’ practitioner?  How does the preventive health discourse relate to the strategies that you use in everyday life to enhance or optimize health and wellbeing?  Recall  How do you feel about the invisibilization of the health promotion discipline and practice in these documents?  How consistent is the preventive health discourse with your lived experiences of health and wellbeing?  Recall  Do you perceive your role to be valued differently (more or less) because health promotion discourse has been overtaken by the preventive health discourse?  What is gained or lost in the preventive health discourse that is important to you?  Relive  How do these reflections make you feel?  How do these reflections make you feel?  Reinterpret  Why do you think you feel that way?  Why do you think you feel that way?  Respond  How might you translate the preventive health discourse into everyday language that resonates with people in the community?  How might you convey your views to the health promotion practitioners and government representatives responsible for implementing policies and programs using the preventive health discourse?  Respond  What potential risks and benefits are there for you to undertake such a process?  What potential risks and benefits are there for you to do so?  Respond  How might you mitigate the potential risks and optimize the potential benefits?  How might you mitigate the potential risks and optimize the potential benefits?  Reflection phase  Health promotion professionals  People in the community  Recall  In what ways are you required to reframe your role as a ‘preventive health’ practitioner?  How does the preventive health discourse relate to the strategies that you use in everyday life to enhance or optimize health and wellbeing?  Recall  How do you feel about the invisibilization of the health promotion discipline and practice in these documents?  How consistent is the preventive health discourse with your lived experiences of health and wellbeing?  Recall  Do you perceive your role to be valued differently (more or less) because health promotion discourse has been overtaken by the preventive health discourse?  What is gained or lost in the preventive health discourse that is important to you?  Relive  How do these reflections make you feel?  How do these reflections make you feel?  Reinterpret  Why do you think you feel that way?  Why do you think you feel that way?  Respond  How might you translate the preventive health discourse into everyday language that resonates with people in the community?  How might you convey your views to the health promotion practitioners and government representatives responsible for implementing policies and programs using the preventive health discourse?  Respond  What potential risks and benefits are there for you to undertake such a process?  What potential risks and benefits are there for you to do so?  Respond  How might you mitigate the potential risks and optimize the potential benefits?  How might you mitigate the potential risks and optimize the potential benefits?  Health promotion strategies would be expected to comprise the majority of the strategies in any major public health initiative. However, through the analysis we identified that the discipline of health promotion and the health promotion professionals that practice that discipline were backgrounded through the preventive health discourse. Even the broader term ‘public health’ was minimally represented in the documents. So who is it that is expected to do the work described in the initiatives? Judging from the description of the strategies, health promotion practitioners are expected to do much of the work, but are not given the professional courtesy of being named as such, and instead must be assumed to exist in the amorphous ‘preventative health workforce’. There was no obvious rationale for the shift away from the internationally recognized health promotion terms, and de Leeuw (2010) suggests that the preventive health discourse may simply be the ‘political craze of the day’ in a general political environment that is swinging more toward liberal and neo-corporatist perspectives. This is consistent with Raphael’s proposal that a similar shift from health promotion discourse to population health discourse in Canada provided a depoliticized discourse consistent with the retreat of the welfare state (Raphael, 2008), and Fisher and Baum’s analysis of Australian health policy as dominated by ‘politically easier’ individualized behavioural approaches for neoliberal governments (Fisher et al., 2016). The origin of the term ‘preventative health’ is unclear—it simply appeared in announcement of the National Preventative Health Taskforce commissioned to develop the AHC2020 National Preventative Health Strategy. No explanation for the use of the term appeared in any of the documents, and it was presented as a given that this term was the most appropriate term to use. Baum and Fisher (2011) argue that the narrow terms of reference set for the National Preventative Health Taskforce meant that the National Preventative Health Strategy was inevitably focused on promoting individual behaviour change to address so-called ‘lifestyle’ risk factors, but this does not explain the limited use of the term ‘health promotion’ in the documents. Traditional health promotion is underpinned by the biomedical and behavioural models, but the term ‘health promotion’ is still used to describe this approach. Critical health promotion however, is concerned with inequity and access to the determinants of health, requiring strategies that are inherently political, and the backgrounding of health promotion and even public health discourse in favour of the more nebulous apolitical preventive health discourse may well have been a deliberate attempt to depoliticize the (unavoidably political) discipline of critical health promotion (Baum, 2008). Whatever the reason, the documents analysed took up the preventive health baton with gusto, with barely a sideways glance at the health promotion and public health disciplines and practitioners that were marginalized in the process. Although the form of health promotion presented in the Bangkok Charter reflected this negative biomedical orientation, subsequent Charters such as the Nairobi Call to Action and the Adelaide Statement on Health in All Policies showed that ‘a strong commitment from politicians and practitioners to a powerful positive health approach in all sectors and levels of society is possible and worth pursuing’ (de Leeuw, 2010) (p. 142). However there was little evidence in Australian Government weight-related public health initiatives of a political agenda consistent with the positive concept of critical health promotion first espoused 30 years ago in the Ottawa Charter for Health Promotion and returned to in the Charters following Bangkok. The study had a number of strengths and limitations. The study covered a decade from 2003 to 2013 in which weight-related public health initiatives were initiated by the Australian Government, and produced a set of reflective questions for critical competence for use by health promotion professionals and the general public. The study did not include other documents such as program evaluation reports or submissions to the consultative processes, which may have provided additional insights. Additionally, the study did not include initiatives undertaken by other levels of Government or the non-Government sector and so the results cannot be generalized. The study results were constructed by us and are limited to our interpretation. CONCLUSION Through critical discourse analysis we identified the invisibilization of health promotion in favour of the biomedically defensive preventive health agenda in Australian Government weight-related public health initiatives. Further research is required on the extent of such changes in discourse in other sectors. The implications of such a shift in discourse on the perceptions and practice of those identifying as health promotion professionals and other people in the community need to be explored. REFERENCES Anand S. S., Yusuf S. ( 2011). Stemming the global tsunami of cardiovascular disease. The Lancet , 377, 529– 532. Google Scholar CrossRef Search ADS   Australian Government. ( 2003) Healthy Weight 2008: Australia’s Future - The National Action Agenda for Children and Young People and their Families. Retrieved from Canberra. http://www.healthyactive.gov.au/docs/healthy_weight08.pdf (1 April 2010, date last accessed). Australian Government. ( 2010) Taking Preventative Action – A Response to Australia: The Healthiest Country by 2020 – The Report of the National Preventative Health Taskforce. Australian Government. ( 2013) Australian Government response to the House of Representatives Standing Committee on Health and Ageing report: Weighing it up: Obesity in Australia. Australian Government Department of Health and Ageing. ( 2011a) Measure Up. https://web.archive.org/web/20110817065823/ http://www.measureup.gov.au/internet/abhi/publishing.nsf/Content/About+the+campaign-lp (7 August 2011, date last accessed). Australian Government Department of Health and Ageing. ( 2011b) Swap It, Don't Stop It. https://web.archive.org/web/20110830084149/ http://swapit.gov.au (30 August 2011, date last accessed). Australian Government National Preventative Health Taskforce. ( 2008) Australia: The Healthiest Country by 2020 - A discussion paper. Australian Government National Preventative Health Taskforce. ( 2009a) Australia: The Healthiest Country by 2020 – National Preventative Health Strategy – Overview. Australian Government National Preventative Health Taskforce. ( 2009b) Australia: The Healthiest Country by 2020 – National Preventative Health Strategy – the roadmap for action. Australian Government National Preventative Health Taskforce. ( 2009c) Australia: the healthiest country by 2020. Technical Report No 1 Obesity in Australia: a need for urgent action, Including addendum for October 2008 to June 2009. Baum F. ( 2008) The New Public Health , 3rd edn. Oxford University Press, Melbourne. Baum F., Fisher M. ( 2011) Are the national preventive health initiatives likely to reduce health inequities? Australian Journal of Primary Health , 17, 320– 326. Google Scholar CrossRef Search ADS PubMed  Baum F., Fisher M. ( 2014) Why behavioural health promotion endures despite its failure to reduce health inequities. Sociology of Health and Illness , 36, 213– 225. Google Scholar CrossRef Search ADS PubMed  Caballero B. ( 2007) The global epidemic of obesity: an overview. Epidemiologic Reviews  29 , 1– 5. Google Scholar CrossRef Search ADS PubMed  Campos P. ( 2004) The Obesity Myth.  Gotham Books, New York. Campos P., Saguy A., Ernsberger P., Oliver E., Gaesser G. ( 2006) The epidemiology of overweight and obesity: public health crisis or moral panic? International Journal of Epidemiology , 35, 55– 60. Google Scholar CrossRef Search ADS PubMed  Chapman G. B., Coups E. J. ( 2006) Emotions and preventive health behavior: worry, regret, and influenza vaccination. Health Psychology , 25, 82. Google Scholar CrossRef Search ADS PubMed  CSIRO. (no date) Preventative Health. http://www.csiro.au/Organisation-Structure/Flagships/Preventative-Health-Flagship.aspx (2 September 2011, date last accessed) de Leeuw E. ( 2010) Warning! Changing rhetoric ahead! Health Promotion International , 25, 141– 142. Google Scholar CrossRef Search ADS PubMed  Ferreira M. S., Castiel L. D. ( 2009) Which empowerment, which Health Promotion? Conceptual convergences and divergences in preventive health practices. Cadernos de Saúde Pública , 25, 68– 76. Google Scholar CrossRef Search ADS PubMed  Fisher M., Baum F., MacDougall C., Newman L., McDermott D. ( 2016) To what Extent do Australian Health Policy Documents address Social Determinants of Health and Health Equity? Journal of Social Policy , 45, 545– 564. Google Scholar CrossRef Search ADS   Glendon M. A. ( 1991) Rights Talk: The Impoverishment of Political Discourse . The Free Press, New York. Gregg J., O’Hara L. ( 2007) Values and principles evident in current health promotion practice. Health Promotion Journal of Australia , 18, 7– 11. Google Scholar CrossRef Search ADS PubMed  House of Representatives Standing Committee on Health and Ageing. ( 2009) Weighing it up: Obesity in Australia. Jacobs K. ( 2006) Discourse analysis. In Walter M. (ed), Social Research Methods: An Australian perspective . Oxford University Press, South Melbourne, VIC, AUS. Jenkin G. ( 2010) Individuals, the Environment or Inequalities: Industry and Public Health Framing of Obesity and its Presence in New Zealand Government Policy on Food and Nutrition. (PhD), University of Otago Dunedin, New Zealand. http://www.otago.ac.nz/wellington/otago042929.pdf (28 December 2012, date last accessed). Jenkin G., Signal L., Thomson G. ( 2011) Framing obesity: the framing contest between industry and public health at the New Zealand inquiry into obesity. Obesity Reviews , 12, 1022– 1030. Google Scholar CrossRef Search ADS PubMed  Kazak A. E. ( 2006) Pediatric Psychosocial Preventative Health Model (PPPHM): Research, practice, and collaboration in pediatric family systems medicine. Families, Systems, and Health , 24, 381. Google Scholar CrossRef Search ADS   Machin D., Mayr A. ( 2012) How to Do Critical Discourse Analysis: A Multimodal Introduction . Sage Publications, London, UK Marshall C., Rossman G. ( 1989) Designing Qualitative Research . Sage, Newbury Park, CA. McKenzie B. ( 2000) Phase 1 Workbook: Strategic leadership development program. Retrieved from Sydney, NSW, AUS. http://www.systemics.com.au/intro.html (19 July 2009, date last accessed). O'Hara L., Taylor J., Barnes M. ( 2015) The extent to which the public health ‘war on obesity’ reflects the ethical values and principles of critical health promotion: a multimedia critical discourse analysis. Health Promotion Journal of Australia , 26, 246– 254. Google Scholar CrossRef Search ADS PubMed  Olds T. S., Maher C., Zumin S., Péneau S., Lioret S., Castetbon K. et al.   ( 2011) Evidence that the prevalence of childhood overweight is plateauing: data from nine countries. International Journal of Pediatric Obesity , 6, 342– 360. Google Scholar CrossRef Search ADS PubMed  Porter C. ( 2007) Ottawa to Bangkok: changing health promotion discourse. Health Promotion International , 22, 72– 79. Google Scholar CrossRef Search ADS PubMed  PricewaterhouseCoopers ( 2010) Workplace Wellness in Australia: Aligning Action with Aims: Optimising the Benefits of Workplace Wellness . PricewaterhouseCoopers, Melbourne, VIC, AUS. Raphael D. ( 2008) Grasping at straws: a recent history of health promotion in Canada. Critical Public Health , 18, 483– 495. Google Scholar CrossRef Search ADS   Robertson A. ( 1998) Shifting discourses on health in Canada: from health promotion to population health. Health Promotion International , 13, 155– 166. Google Scholar CrossRef Search ADS   Robison J., Carrier K. ( 2004) The Spirit and Science of Holistic Health . Authorhouse, Bloomington, IN. Rokholm B., Baker J. L., Sørensen T. I. A. ( 2010) The levelling off of the obesity epidemic since the year 1999 – a review of evidence and perspectives. Obesity Reviews , 11, 835– 846. Google Scholar CrossRef Search ADS PubMed  Rose G. ( 2008) Rose’s Strategy of Preventive Medicine . Oxford University Press, Oxford, UK. Google Scholar CrossRef Search ADS   Sabates R., Feinstein L. ( 2006) The role of education in the uptake of preventative health care: the case of cervical screening in Britain. Social Science and Medicine , 62, 2998– 3010. Google Scholar CrossRef Search ADS PubMed  Scott-Samuel A., Springett J. ( 2007) Hegemony or health promotion? Prospects for reviving England's lost discipline. The Journal of the Royal Society for the Promotion of Health , 127, 211– 214. Google Scholar CrossRef Search ADS PubMed  Scott-Samuel A., Wills J. ( 2007) Health promotion in England: sleeping beauty or corpse? Health Education Journal , 66, 115– 119. Google Scholar CrossRef Search ADS   Simpson K., Freeman R. ( 2004) Critical health promotion and education—a new research challenge. Health Education Research , 19, 340– 348. Google Scholar CrossRef Search ADS PubMed  Sproule W. ( 2006) Content analysis. In Walter M (ed), Social Research Methods: An Australian Perspective . Oxford University Press, South Melbourne, VIC, AUS. Swinburn B., Sacks G., Hall K. D., McPherson K., Finegood D. T., Moodie M. L. et al.   ( 2011) The global obesity pandemic: shaped by global drivers and local environments. The Lancet , 378, 804– 814. Google Scholar CrossRef Search ADS   Taylor J., O’Hara L., Barnes M. ( 2014) Health promotion: a critical salutogenic science. International Journal of Social Work and Human Services Practice , 2, 283– 290. Torp S., Eklund L., Thorpenberg S. ( 2011) Research on workplace health promotion in the Nordic countries: a literature review, 1986-2008. Global Health Promotion , 18, 15– 22. Google Scholar CrossRef Search ADS PubMed  Tretheway R., Taylor J., O’Hara L., Percival N. ( 2015) A missing ethical competency? A review of critical reflection in health promotion. Health Promotion Journal of Australia , 26, 216– 221. Google Scholar CrossRef Search ADS PubMed  Weight Watchers. ( 2013) Weight Watchers Health Solutions. http://www.weightwatchers.com/templates/marketing/marketing_utool_1col.aspx?pageid=1307891 (17 November 2011, date last accessed) Whitehead D., Keast J., Montgomery V., Hayman S. ( 2004) A preventative health education programme for osteoporosis. Journal of Advanced Nursing , 47, 15– 24. Google Scholar CrossRef Search ADS PubMed  Will M. ( 2013) Weight watchers sets its eyes on employers. http://www.huffingtonpost.com/2013/08/09/weight-watchers-employers-_n_3730850.html (27 November 2013, date last accessed) World Health Organization. ( 2003) Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation, Geneva, 28 January - 1 February 2002. World Health Organization and the Food and Agriculture Organization of the United Nations, Geneva. World Health Organization. ( 2004) Global Strategy on Diet, Physical Activity and Health . World Health Assembly, Geneva. World Health Organization. ( 2013) Healthy Settings. http://www.who.int/healthy_settings/en/ (16 September 2014, date last accessed) © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Journal

Health Promotion InternationalOxford University Press

Published: Feb 1, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 12 million articles from more than
10,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Unlimited reading

Read as many articles as you need. Full articles with original layout, charts and figures. Read online, from anywhere.

Stay up to date

Keep up with your field with Personalized Recommendations and Follow Journals to get automatic updates.

Organize your research

It’s easy to organize your research with our built-in tools.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

Monthly Plan

  • Read unlimited articles
  • Personalized recommendations
  • No expiration
  • Print 20 pages per month
  • 20% off on PDF purchases
  • Organize your research
  • Get updates on your journals and topic searches

$49/month

Start Free Trial

14-day Free Trial

Best Deal — 39% off

Annual Plan

  • All the features of the Professional Plan, but for 39% off!
  • Billed annually
  • No expiration
  • For the normal price of 10 articles elsewhere, you get one full year of unlimited access to articles.

$588

$360/year

billed annually
Start Free Trial

14-day Free Trial