Multi professional / disciplinary working is essential in public health, since it draws on theatrical perspectives from a wide range of fields (Naidoo & Wills 2001). It is the intention of this essay to demonstrate the importance of this, by evaluating some opposing disciplines that contribute to the field. I would like to explore the diversities of perspectives such as Epidemiology, Social Sciences and the contribution of the public/lay perspectives, to illustrate how ideas from different disciplines contribute to an understanding of public health. By evaluating some of the opposing approaches to public health and highlighting how these diverse disciplines often come from different academic and organisational cultures, it should demonstrate what different perspectives offer to the public health debate and why is a necessity for then to work together. It also offers an analysis of the challenges to public health being a truly multi disciplinary profession.
Epidemiology is defined as “the study of patterns of disease occurrence in human populations and the factors that influence these patterns” (Lilienfeld & Lilienfeld, 1980 as cited in moon, 2000 p1). However public health entails far more that bio-physiological factors and requires investigation of the social context and public/lay perspectives. Sociology examines the social dimensions of health, illness and health care and what accounts for the socio-economic inequalities in public health. It looks at how the social structures, institutions and processes affect health and what is the relation between the professional disciplines and the public (Daykin as cited in Naidoo 2001 p102). Social science is used in the same context as (Williams G & Popay J 1997) referring to researchers/disciplines that look at the “ influence of the economic and political context of Britain and other western countries mainly in the late 20 century over the heath of the populations”.
Naidoo & Wills (2001 p2) offer a reminder that the notion of multi professional working is not a new concept in the study of health. (WHO 1946 cited in Naidoo & Wills 2001p2) was one of the first to look at health holistically describing it as a state of complete will being and although this may be considered utopia today, it still highlights the multi dimensional aspects of health and offers arguments as to why disciplines must work in a multi disciplinary way.
The most recent government is pressing the idea that public health should be a multi disciplinary profession and wants to bring in more integrated and partnership working with these disciplines. It sees it as one of the ways forward to rid health of the internal market philosophies of the previous Government (Partnership in Action D of H 1998). (The New NHS: Modern and Dependable D of H.1997; Making a Difference: A Strategy for Nursing, Midwifery and Health Visiting D of H.1999; NHS Plan D of H. 2000) jointly pledge to introduce new ways of partnership working and among their concurrent objectives, to raise the profile of public health. Working across boundaries is seen as vital in working with the most vulnerable in society that previously have been missed (D of H 1997). It builds devices around the needs of those whose are most in need and avoids duplication (D of H 1998) and if professionals do not work together then will find themselves in no mans land. (D of H 1998). This document is trying to give different agencies more power to work together by pooling budgets, having lead commissioners, integrating provision and incentives.
It could be a challenge for public health to be a truely multi-displinary profession when medicine has dominated in public health in the past. Modern epidemiological studies have however, contributed greatly and influenced public health work and policies, in trying to change individual’s lifestyles (D of H 1992). However, persistent limitations of this approach has led to the acknowledgement for the wider influences that effect public health, mainly that of health inequalities (D of H, 1999), (D of H, 2001a). These documents recognise that to achieve a comprehensive understanding of public health it is necessary to look beyond “malfunctioning of the physical body” and investigate, “societal and cultural factors along side”(Naidoo et al 2001) This essay argues that more credence must be given to social science research, if public health is to be effective. It is clear that if we are going to work effectively on public health then professions must not only work together in a multi disciplinary way but must also listen to what the public say about their own health needs (Williams G & Popay J (1997). Recent documents such as the expert patient (D of H, 2001b) and “Shifting the balance of power” (D of H 200a) offer a basis for involving the public, however it remains a challenge about how to work in conjunction with everyone with our current, diverse and multi cultural society. More innovative research is needed, including both epidemiological and social perspectives.
To understand the constraints of multi- professional working within public health, it is necessary to look at the history behind public health, especially the contributions of Epidemiology, which has focused on the causes of disease at population level and continues to be considered one of the most important sciences contributing to it. (Beaglehole & Bonita, 1997). By the end of the Victorian era, public health had moved into two very distinct areas that were quite separate. The first was involved in the general improvements of social conditions and the second concentrated on the development of specific preventative and curative health services ( Baggott 2000) Epidemiology since the nineteenth century has had an enormous impact on public health with wide ranging achievements (susser &susser, 1996) starting with improvements in drainage and sewerage, initiating statistical evidence, recognising and tackling environmental and social factors that have effected health. Work was also done on eradicating infectious diseases though the development of vaccinations. Effects on public health by this discipline have not all been seen as beneficial and the insights gained previously into environmental factors and poverty were somewhat lost with this dominant but narrow biomedical approach (Baggett R 2000). Mc known 1976 even observed that health improvements have less to do with immunisations and more to do with improving socio economic factors.
From a social perspective (Williams G & pope, 1997) go further than this and claim that this medical led power may have led to people not focusing on social reform as much and that in fact in the recent decades as historically, the poor have continued to be blamed for illness and the disease. They feel that to much credence has been given to data collecting and the epidemiological model, so to stifle public health work. They also claim that the public and lay views are just as valid and that general feelings and perceptions are equally as important.Those from a medical health background to give less credence to socilogocal perspectives especially the lay involvement in health matters(Heller T 2001) claims that to ensure that medicine continues to be the lead in many public health issues there needs to be more evicence base and it is the lack of this has caused problems in dilemmas around the medical perceptions of important health issues and those of the public i.e. MMR vaccination debate. This is particularly significant in today’s climate of clinical governance and evidence –based practise (D of H, 1997 and 1998) These ideologies have had a major impact on Epidemiology where there have been criticisms regarding the standards of research and data collection and yet in contrast ,there appears to be a complex confusion of views between the various disciplines with the government saying they want more evidence based practise from the scientific disciplines and equally a desire for the public to be listed to and involved . whilst Black (2001) claims there needs to be a more sustained drive to collect and use evidence as an underpinning of health policies at all levels and that despite the rhetoric and criticism around their own discipline , health policy makers equally develop their policies largely in an evidence-free zone (Black 2001).
Povey (1998) states very strongly that Lay people need to be much more involved in order to include the social and cultural context of public health This term “lay” refers to people who are not health care professionals or researchers but may have a specialist knowledge related to health including the general public and consumer advocates. (Entwistle et al 1998). This essay would also like to argue that the lay perspective should be included in any debate around multi- professional working, Even though they are not health professionals but are very much needed for the social and cultural context (povey 1998)
It has also been claimed that duee to the way medicine it constructed, it contributes to contribute to a loss of individual autonomy for example medicine has encroached on normal things such as life and death (mckeown, 1976) and that public health research, especially that of Epidemiology ,has increasingly excluded from its ‘microscope attention’ the voices of the people (Williams et al 1997). Whilst Epidemiology has indeed done great things in the development of the fight against infection., the power that Epidemiology was then consequently afforded in public health meant that they focused on these areas somewhat to the exclusion of the political need to look at social inequalities and injustices. Historically all disciplines come from differing perspectives with different concepts models highlighting why it must be necessarily multi disciplinary but it is relatively recently that people have really started to link the different perspectives to health (stansfield 1999 cited in Naidoo 2001) and therefore highlighting the need for them to collaborate and make connections when working together for the improvement of the public’s health.
It would appear that reflecting on this review of public Health history, that Epidemiology has had significant successes and the knowledge and influence that it has gained have influenced many public health policies and campaigns such as “Health of the Nation”, (D of H, 1992). But despite the measures by Epidemiology to demonstrate strong associations of risk factors Emslie et al (2001 a p25) suggest that the current “evidence on the effectiveness of health advice to modify behavioural risk factors, is discouraging” and propose that an “urgent need to understand the public perceptions of the causes and consequences is needed”. (Parsons 1951) first developed the concept that ill health should be viewed in relation to the society as a whole and not just as the individual, which very much forms the basis of public health work today . This backs up all the recent social science research of health being strongly patterned by social factors. People do not have equal chance of enjoying health or living to old age and deprived groups experience poorer health, higher levels of mortality and there are differences in class gender sexuality and ethnicity. When looking at why these inequalities persist it offers a view of how the medical perspective of health can be at odds with sociological and public perception (Naidoo page social science)
(Williams G et al1997) recorded some interesting research done in Salford, which has some of the poorest population in Great Britain within the ward. This research claimed that the public were able to present a sophisticated understanding of the network of factors which may structure perceptions of ill health and related risks i.e smoking through despair is an obvious well researched example (Graham, 1987 and 1993)This research indicated that the traditional health education messages alone do not work .people in these poorest wards well know the health related risks that they faced i.e. the effects of smoking, drinking, drugs poor diet and exercise etc but most of the respondents cited structural and socio- economic factors as the most powerful influences on their health such as living in high rise flats and the stresses of bringing up young children in this environment that caused depression and isolation . Unemployment, poverty, economic decline and fear of crime were all put down as the most signifant cause of their poor health. Heat education alone may have increased knowledge, but have failed to address the real issues of public health and have possibly caused an era of victim blaming. Epidemiology has been criticised for its methodological individualism (Diex- Roux, 1998 p 216) and as with (William g & povey), (Schwartz &Carpenter 1999) and (Pearce, 1996) they all criticise modern Epidemiology for its disregard of wider socio-cultural, temporal issues. It is suggested that contextual or multilevel analyses to investigate individual and multi-level variables would bring context back to Epidemiology Diex-Rusx 1992 p216)
It is clear therefore that “public health has to be multi disciplinary because social factors such as income, housing, and employment have been shown to have greatest impact on health status than health care” (Modernising Health and Social Services 1998) Multi disciplinary working is recognised in health improvement guidance (D of H, 1997) where the shared responsibility for health between local authorities, NHS and their partners is highlighted. There have bewen many changes in public health, in recent years and we are now more likely to hear that the pattern of health inequality is about where you live and whether you are rich or poor, rather that you own lifestyle decisions. (Mitchell R et al 2000). This report on the Inequalities in Life and Death claims that all health changes can be manipulated though radical social policy changes.
The new approaches to Epidemiology also sound promising with a suggestion of a new era of eco-Epidemiology addressing health at population, societal and individual levels. However without a multi disciplinary approach to epidemiological research, it will fail to investigate context and will continue to provide invalid conclusions and recommendations for public health. Diez- roux (1998) acknowledges that defining and measuring contextual variables is problematic and Epidemiology must create methods of research that incorporate both qualitative and quantitative approaches. This can only happen with collaboration with different disciplines. Especially social and cultural methodologies.
Much of the work done around involving the public derives from a sociological perspective and this has also helped to produce useful models for health promotion. Public health disciplines must continue to adopt socially aware and multi disciplinary approaches. They must continue to liase with and involve the public who are empowering themselves often by gathering information over the internet (Hardy 1999).
If health promotion is to be truly multi disciplinary then disciplines shoulimitations when standing alone which leads to the need for them not to stand alone but be a part of the debate Naidoo page2 the value of people working in a multi disciplinary way is that by drawing on many different expertise, a fuller account of public health can begin to challenge existing boundaries of knowledge that lead to only a partial understanding of health. In this assignment, I hope to have also argued that whilst inter professional working is vital in public health and indeed there are barriers too it. It is also equally as important to ensure that the public or consumers of the professionals have a greater say in the quality and nature of the provision. . There will always be intellectual tensions between disciplines but this should provide the basis for invigorating debate rather than mutual hostility (Williams 1997) Naidoo By working in a multi. Public Health is far too complex to be interpreted in a single discipline.