Health promotion as multi-professional and multi-disciplinary work

Abstract

A health promoter is the name given to all those experts who are intended to prevent disease and ill health and to increase well-being at the community level. That seems to be a very good and useful idea in general, but can it be achieved by individuals alone? Review to what extend team work and the concept of team development are a pre-requisite for effective health promotion. That is the central objective of this article and the answer will be explored through an analysis of the international literature. The first part will set out to define the notions of both health promotion and health promotion specialists, in order to provide a framework for the multi-professional and multi-disciplinary nature of health promotion. The second part will try to establish the meaning of collaboration for health promotion, starting with definitions of the concepts: group, team and teamwork. The benefits of collaborative work in health promotion will be discussed alongside the common barriers that can arise during the process. The article will conclude by proposing the characteristics of a successful team-working health promotion group.

Headnote

ABSTRACT

Background: A health promoter is the name given to all those experts who are intended to prevent disease and ill health and to increase well-being at the community level. That seems to be a very good and useful idea in general, but can it be achieved by individuals alone?

Objective: Review to what extend team work and the concept of team development are a pre-requisite for effective health promotion. That is the central objective of this article and the answer will be explored through an analysis of the international literature.

Discussion: The first part will set out to define the notions of both health promotion and health promotion specialists, in order to provide a framework for the multi-professional and multi-disciplinary nature of health promotion. The second part will try to establish the meaning of collaboration for health promotion, starting with definitions of the concepts: group, team and teamwork. The benefits of collaborative work in health promotion will be discussed alongside the common barriers that can arise during the process.

Conclusions: The article will conclude by proposing the characteristics of a successful team-working health promotion group.

Keywords: Health promotion, multi-professional, multi-disciplinary, team work.

Introduction

The term health promotion is used in a number of different ways often without any clarity of meaning. Until the 1980 most health promotion interventions were referred to as health education and the practice of those interventions was almost exclusively located within preventive medicine and education. According to Naidoo and Wills (2001) the origins of health promotion lie in the 19th century when epidemic disease eventually led to pressure for sanitary reform for the overcrowded industrial towns. This public health movement contained the principal idea of education for the good of people's own health and against contagion (Somervaille, Knight &Cornish 2007). Thus, a variety of medical officers of health were appointed in each town under public health legislation of 1848 and many others followed, such as London Statistical Society, the Health of Town Association and the Sanitary institute. During the 20th century the development of health promotion in Britain was rapid with a number of important movements, giving Britain a deservedly high reputation for its health promotion achievements (Naidoo and Wills, 2001).

There has been increasing recognition that health policy in recent years could not continue to be confined to clinical and medical services, and that health depends also on individuals' lifestyle and physical environment (Davies & Macdowall 2005). These debates and arguments led to the health promotion movement through the Ottawa Charter for health promotion which provided the definition of health promotion commonly used today. This definition according to Katz, Peberdy and Douglas (2000) is very broad, incorporating health education, public policy change as well as environmentalism and community action. A more precise definition is offered by the World Health Organization: "Health promotion is the process of enabling people to increase control over, and to improve their health. Health promotion represents a comprehensive social and political process, in not only embraces actions directed at strengthening the skills and capabilities of individuals but also action directed toward changing social, environmental and economic conditions so as to alleviate their impact on public and individual health" (W.H.O, 1998)

This definition reveals the purpose of health promotion in society as well as the intentions of health promoters. But in practical terms, exactly what are health promoters? Sheps (1994) cited in Scriven and Orme (2001) suggests that health promotion specialists are advisors, consultants, researchers, trainers, project leaders, coordinators, policy development officers, enablers, mediators and advocates. All those people through their own roles intend to help thousands of health professionals such as doctors, nurses, teachers, police officers, local authorities, company directors and community representatives in order to carry out health promotion interventions within their own environments and settings (Kapelus, Karim, Pimento, Ferrara & Ross 2009).

Multi-professional and Multi-disciplinary Health Promotion.

There is a great variety of terms used in order to reflect the cooperative work of the different health professional groups (Finn, Lear month & Reeedy 2010). According to Payne (2000; p9) "words with a multi prefix several different professional groups working together". The word professional suggests "a concern for different professional groups and functions and activities which associated with those groups" (Payne, 2002; p9). The word disciplinary suggests "a concern with the knowledge and skills underlying particular roles" (Payne, 2000; p9). Multiprofessional and multi-disciplinary health promotion work demonstrate that a wide range of health professional groups, with various knowledge, qualifications and skills are drawn together within a structure in order to provide health promotion services (Solheim, Memory & Kimm 2007).

Many individual health care providers, health professionals and many organizations feel that they have role, even a leading role, in promoting and improving the health of the population. According to the former Health Education Authority (now the Health development Agency) there are many organizations, agencies and individuals that have a stake in improving public health. However, "the nature and the quality of the relationships between them will be significant factor in the development of effective and appropriate Health Improvement Programs" (H.E.A, 2000; p16). This view is supported by the fact that the nature of health promotion is that it draws on professionals from a wide range of settings, including doctors, great number of nurses, midwives, health visitors, teachers, dieticians, psychotherapists, dental health workers, health and fitness workers, community workers and many other relative to physical and emotional-mental health professionals (Whitehead 2004).

Building a supportive physical, cultural and socio-economic environment in which the population can live and work, in other words the task of promoting health, does not belong to one professional group or sector of health services. What is essential for effective health promotion is the intersectional collaboration across different health care professionals and public or private sectors (Bergquist 2004). The many factors that influence peoples health are well known and often discussed. The plurality of these makes clear that health does not depend only on health services or nurses and doctors. The great variety of activities which constitute health promotion, needs a correspondingly wide range of skills from many professions and health sectors (Yeager 2005). Health promotion has to be a team activity, and health professionals as health promoters have to work within many other disciplines. "No single profession has a monopoly of health promotion wisdom or is equipped to perform all the necessary tasks" (Kemm and Close, 1995; p15)

Collaboration: Defining the Notions of Group and Team.

Although the terms "group and team" are used interchangeably, it is useful to distinguish between the two. According to Martin and Henderson (2001; p93) "a group is any collection of people who interact with one another because they perceive themselves to have a similar purpose or similar interests". A team is something more complex than group (Weaver 2008).

"Team is a group with a sense of common goal or task, the pursuit of which requires collaboration and the coordinations of the activities of its members, who have regular and frequent interactions with one another" (Martin and Henderson, 2001; p93). Payne (2000; p5) adds that "the meaning of team and team work is controversial and is a useful part of any team development activity that participants review what they mean, and understand differences in meaning which exist within their group".

Groups and teams present a variation on size and complexity. There are groups and teams composed either by several people or by thousands. However, participants in a team need to make decisions, take actions and agree with resolutions which they would not have had the intention to do as individuals (Paice 2007). So, the presence of a participant in a team has an important effect on their behavior. A group of people is labeled as a team because their manager, leader or even themselves expect to work efficiently together towards cooperation, collaboration and good coordination. Those people from different organizations and professional backgrounds share a common endeavor and act in different ways according to different knowledge bases, cultural traditions and objectives(Payne, 2000).

Team work in Health Promotion- Healthy Alliance.

A team may be defined as a small group of people who interact with each other and contribute together to a common goal (Paice 2007). Today, health promotion through health care services and through local, national and worldwide policies depends on effective decisionmaking by relevant groups and teams (Gottwald 2006). However, it is not a very easy task to develop and maintain a team work within the boundaries of health promotion. This task requires conscious and continuous efforts. Apart from the qualities of the individuals what makes teamwork really successful is the way that team members work together (Mittelmark, Kickbusch, Rootman, Scriven &Tones 2008). According to Pike and Forster (1997; p102) "the potential for new ways of delivering primary health care, for instance, has never been grater and teamwork is the key to effective health promotion within primary health care". Martin and Henderson (2001) suggest that in health promotion and social care teams have very frequently to struggle with issues that dramatically affect people's lives, and many times at some personal cost to the members of the teams. That happens because they are usually part of very large organizations which require lots of efforts to be organized and controlled, as well as great sums of money to be accounted for.

Naidoo and Wills (1999) state that The Department of Health introduced the term "healthy alliance" in order to define the way agencies can work together to promote health emphasizing on the concepts of co-operation and partnership. So, a healthy alliance is in effect a partnership of individuals and organizations formed to enable people to increase their influence over the factors that affect their health and well-being (DoH, 1993 cited in Naidoo and Wills, 1999). Health alliances foster the involvement and sense of ownership and commitment, of all those with an interest on health. If health promotion policies are keen to improve the health and the well-being of the population, then inter-agency collaboration is essential. All those factors in the community which have an impact on people's health must be coordinated to achieve the health goals identified (Orme, Viggiani, Naidoo & Knight 2007).

Dines and Cribb (1995) support that health promoters should attempt to influence each other at the same way they aim to influence the politicians through reasons and evidences. They add that "such collaboration is essential for open and informed health care terms who understand the goals of health promotion" (Dines and Cribb, 1995; p200). However, team work and collaboration should be built on respect of individuals' feelings and autonomy, even if it is a very difficult task for the team. Otherwise, is very hard and almost impossible to work in an environment which does not reflect on the above concepts (Praga 2006). The Benefits of Collaborative Work in Health Promotion

Team work is a useful skill which can be learned, and once a productive working relationship is established, then the benefits are very important. There is a reasonable body of evidence which indicates the importance of team work to the level of performance in many different health settings (Clark, Dunbar, Aycock, Blanton & Wolf 2009). Collaboration is a very meaningful challenge for health promoters because it brings together strengths from many people, organizations, sectors or agencies and lead to better decisions which are made by people working together (Jansen 2008). Team working in health promotion is able to bring together public or private organizations and groups who would not normally see them selves as heaving a role in promoting health alone. "Teamwork increases these organizations knowledge and understanding of each other, helping to clarify roles and overcome rivalry" (Naidoo and Wills, 2001; p162). Through this process collaboration provides a wider spectrum of knowledge and experience which comes from all those experts. Resources are increased and can be used more effectively by joint commissioning services from health promoters in order to improve people's health (Jansen, DeVries, Kok & VanOers 2008).

Working together provides another important advantage. It develops more significant achievements than by agencies working separately, because amongst others increases access to networks. That is also reinforced by the fact that joint working and collaborative service planning is based on comprehensive picture of local needs and helps to eliminate gaps (Naidoo and Wills, 2001). A multi-professional job: "achieve to bring together a range of professional skills;it shares information; achieves the continuity of care; apportioning and ensuring responsibility and accountability; coordinates in planning resources; coordinates in delivering resources for professionals to apply for the benefit of service users"(Payne, 2000).

Improvements to standards of care for clients and patients is another advantage of joint working in health promotion. It offers higher levels of job satisfaction for health promotion staffbecause it increases morale for the team as a whole and provides mutual support for the team members in their work (Hosman 2000).

Barriers in Collaborative Work

Collaboration can fail if the stakeholders as well as the participants do not take into account some barriers that can arise. Individuals and groups who work together will have perceptions of each other's role and may not understand the ways in which their organizations work. That could lead to "lack of understanding of different organizational cultures and the constraints of other organization" (Naidoo and Wills, 2001;p 163). In a health promotion team work, where a range of health professionals try to cooperate in order to achieve a common goal, there may be competing professional rationales about values and ways of working (Dhavan & Reddy 2008). According to Health Education Authority (2000 ) collaborative work in a health promotion project is sometimes like trying to mix oil and water together.

Barriers that can arise in a collaborative project, include "lack of commitment at a senior level; differences in outlook; professional rivalry, especially in those with differences in status; imbalance in the contributions to reassuring the alliance; exclusion of new partners; lack of appropriate skills; lack of shared achievable goals. (Naidoo and Wills, 2001; pp162-163). The different geographical boundaries between authorities, sectors or agencies can influence the success or the failure of a collaborative health promotion project, for example between a local authority and a health authority because they are not co-terminus - do not cover the same populations (Heitkemper, McGrath, Killien, Jarret, Landis, Lentz, Woods & Hayward 2008). Another potential barrier is the competition between the public and private sectors. Evidently, private companies are financial businesses interested in expanding their market shares in a competitive market. Conversely, the public sector has limited resources for health. Thus, competition between large organizations of care and health promotion either private or public can complicate the work of a collaboration whose partners are competing against each other (Scriven & Orme 1996) .

The great challenge of sharing data among participants in a multi-sectoral coalition is also a significant barrier that healthy teams should try to overcome. In a so highly competitive market managed health professionals reveal many concerns about presenting the content of their proprietary data systems.

Kingsbury (1999) supports the above theory, adding that "there are issues of truth and concerns about relinquishing control of data and I may be virtually impossible to integrate data systems composed of non standardized data elements, coded in many different ways and in incompatible formats".

Despite the above barriers collaborative work can and is practiced within the boundaries of health promotion. On the contrary, health promotion requires good quality team work and coordination both with colleagues in the same department, but also with other disciplines and professions (Omer, Mhatre, Ansari, Laucirica &Anderson 2008; Wagemakers, Vaandrager, Koelen, Saan & Leeuwis 2010). In order to tackle issues such as competition in coalitions between the private and the public sector, health promoters need to foster creative linkages and re-assess traditional and old fashioned perceptions.

Characteristics of Successful Collaborative Working

Basic reason for the creation of teams in areas such as health promotion is the expectation that those coalitions will carry out tasks more effectively than individuals. Teams are composed by members from a great range of emotional, social, professional and educational background (Begley 2009). Pearson and Spencer (1997) in their research about promoting teamwork in primary care indicate that team members should actively focus upon their objectives, regularly reviewing ways of achieving them, in order to function effectively. The purpose of this process is to provide steps to change the teams ways of working, if that is necessary, in order to promote effectiveness.

The most significant purpose of multidisciplinary teams is to bring together a range of different perspectives on people's care and to maximize a range of strengths and knowledge from many professionals and sectors. The differences between members perspectives need to be explored, not hidden. Those differences, if they are managed well have the potential to become a source of strength not weakness for the team (Misra, Harvey, Stokols, Pine, Fuqua, Shocair & Whiteley 2009). An ideal team has certain essential characteristics "a common task or purpose; members are selected because they have specific expertise; members know their own roles and those of other members; members support each other on the task; members complement ach other in their skills and personalities; members have a commitment to accomplishing the task; there is a leader who will coordinate and take responsibility; the team may have a base" (Naidoo and Wills, 2001; p164)

The development of a clear purpose is an essential step for a successful partnership. When a clear purpose is defined and agreed between the team members, then all those people joint their forces in the same direction. The ability to stay on focus comes from the clarity about the purpose of the team and sticking to the same purpose (ElAnsari, Russell & Wills 2003). Conversely, unclear priorities demotivate collaboration because the task appears too big. Meads and Ashcroft(2000;p17) in their research about relationships in the NHS claim that "where real goals (as opposed to stated goals) and strategies are not shared, collaborative relationships can become a focus for conflict". Instead of conflicts, developing relationships amongst the members of a team is a very important element for efficient collaboration. Real human relationships based on respect of other members can lead to higher levels of trust and more respectful treatment toward each other. Some groups have found it helpful to engage trained facilitators at strategic points in order to promote relationships between the team members, (Kingsboury, 1999).

The achievement of success is a very important subject for the team as well as for the individual (Whitehead 2007). During the meetings of a team there must be reflective discussion in what is going very well and what is going to fail. On that point it is suggested when short term objectives are achieved, to be recognized by the participants. Celebration and recognition of group success will help to develop greater pride. That happens in many aspects of people's life and it consists an important characteristic for constructive collaborations. Naidoo and Wills (2001) assert that it is very important to demonstrate achievements within the team and "this may include monitoring the process of the alliance including levels of commitment and participation, levels of activity and it may also measure outcomes as well as the achievement of original objectives".

The involvement of a team leader who will coordinate and who will take the teams accountabilities is essential for collaboration success. "Leadership is not a matter of indefinable attributes or of inspiring followers in the heroic style. Rather, it is a matter of influencing people to do things that must be done by the way he or she things as a leader" (Martin and Henderson, 2001; pp42-43). Using the word leadership is to describe the way in which leaders set out a strategy for the work of a team. Leaders have to lead their teams, to motivate them and to plan and co-ordinate the area of work. The appropriate qualifications for appointment as a team leader are very significant and are often connected with experience and expertise (MacSherry and Pearce, 2002). A conscientious team leader should take into account all the previous steps on building a strong collaboration in order to achieve success on their task(Hubbard 2006). Both the leaders and the members of the team have to combine general skills and characteristics of cooperating and working with other people. Those are communication skills, participation skills in meetings, managing paperwork, managing time, and being and working in a group (Naidoo and Wills, 2001).

Conclusion

Health promotion specialists are an identified workforce whose potential purpose is to promote health through the whole range of activities which are introduced by the health promotion authorities and advocated by the World Health Organization. Their priorities are to empower the individual, to promote social responsibility for health and to create supportive environments developing personal skills and strengthening community action. In health promotion there is an established consensus around features of successful collaboration, and experiences as well as impressions of professionals are supported by research studies. Teamwork and the concept of team development is a pre-requisite for effective health promotion achievements. Health promoters have long recognized the potential role of working together despite the barriers that can arise. The logic is indisputable: if health is more than the absence or treatment of disease, then its promotion and maintance lie beyond the remit of any one professional group or sector. Intersectoral and inter-professional collaboration have become very familiar and useful terms within the boundaries of health promotion.

References

References

Begley C (2009). "Developing inter-professional learning: Tactics, teamwork and talk". Nurse Education Today, 29(3): 276-283

Bergquist R (2004). "Improving public health through collaboration in research". International Congress Series, 1267: 7-16

Clark P, Dunbar S, Aycock D, Blanton S, Wolf S (2009). "Pros and Woes of Interdisciplinary Collaboration With a National Clinical Trial". Journal of Professional Nursing, 25(2):93-100

Davies M, Macdowall W (2005). "Health Promotion Theory". Open University Press, London

Dhavan P, Reddy K(2008). "Public Health Professionals". International Encyclopedia of Public Health,432-439

Dines A, Cribb A (1995)."Health Promotion Concepts and Practice". Blackwell Science. Chapter 13, 195-204

El Ansari W, Russell J, Wills J (2003)."Education for health: case studies of two multidisciplinary MPH/MSc public health programmes in the UK".Public Health, 117(5): 366-376

Finn R, Learmonth M, Reedy P (2010). "Some unintended effects of teamwork in healthcare". Social Science & Medicine, 70(8): 1148-1154

Gottwald M (2006). "Health Promotion Models". Rehabilitation, 131-146

Heitkemper M, McGrath B, Killien M, Jarrett M, Landis C, Lentz M, Woods N, Hayward K (2008). "The role of centers in fostering interdisciplinary research".Nursing Outlook, 56(3): 115-122

Hosman C (2000). "Prevention and health promotion on the international scene: The need for a more effective and comprehensive approach". Addictive Behaviors, 25(6): 943-954

Hubbard H (2006). "Interdisciplinary Research: The Role of Nursing Education".Journal of Professional Nursing, 22(5): 266-269

Jansen L (2008). "Collaborative and Interdisciplinary Health Care Teams: Ready or Not?".Journal of Professional Nursing, 24( 4):218-227

Jansen M, De Vries N, Kok G, Van Oers H (2008). "Collaboration between practice, policy and research in local public health in the Netherlands". Health Policy, 86(2-3): 295-307

Kapelus G, Karim R, Pimento B, Ferrara G, Ross C (2009). "Interprofessional health promotion field placement: Applied learning through the collaborative practice of health promotion''. Journal of Interprofessional Care, 23(4): 410-413

Katz J, Peberdy A, Douglas J (2000). " Promoting Health". Open University Press. Chapter 1, 2-17

Kemm J, Closse A (1995)."Health Promotion/ Theory and Practice". Macmillan. Chapter 1, 3-20

Kingsbury L (1999). "Health Promotion at the Community Level 2". Sage. Chapter 12, 219-228

Martin V, Henderson E (2001). "Managing Health and Social Care". Routledge, The Open University. Chapter 3, 39-56 and Chapter 6, 93-112

McSherry R, Pearce P (2002). "Clinical Governance". Blackwell Science. Chapter 5, 89-114

Meads G, Killoran A, AshcroftJ, Cornish Y (2000). "Mixing oil and water". Health Education Authority

Misra S, Harvey R, Stokols D, Pine K, Fuqua J, Shokair S, Whiteley J (2009). "Evaluating an Interdisciplinary Undergraduate Training Program in Health Promotion Research".American Journal of Preventive Medicine, 36 (4): 358-365

Mittelmark M, Kickbusch I, Rootman I, Scriven A, Tones K (2008).

"Health Promotion". International Encyclopedia of Public Health, 225-240

Naidoo J, Wills J (1999). "Practicing Health Promotion/ Dilemmas and Challenges". Bailliere Tindalll, Royal College of Nursing. Chapter 8, 161-184

Naidoo J, Wills J (2001). "Health Promotion/ Foundations for Practice". Bailliere Tindall, Royal College of Nursing. Chapter 4, 71-90

Omer K, Mhatre S, Ansari N, Laucirica J, Andersson N (2008). "Evidence-based training of frontline health workers for door-to-door health promotion: A pilot randomized controlled cluster trial with lady health workers in Sindh Province, Pakistan". Patient Education and Counseling, 72(2): 178-185

Orme J, Viggiani N, Naidoo J, Knight T (2007). "Missed opportunities? Locating health promotion within multidisciplinary public health". Public Health, 121(6):414-419

Paice J (2007). "The Interdisciplinary Team". Palliative Care,473-486

Payne M (2000). "Teamwork in Multi-professional Care". Palgrave. Chapter 1, 1-24 and Chapter 8, 157-180

Pearson P, Spencer J (1997). "Promoting Teamwork in Primary Care". Arnold. Chapter 2, 12-26

Pike S, Forster D (1997). "Health Promotion for All". Churchill Livingstone. Chapter 8, 95-108

Prada G (2006). "Lighting the way to interdisciplinary primary health care".Healthcare Management Forum, 19(4):6-10

Scriven A, Orme J (1996). "Health Promotion Processional Perspectives". The Open University, Macmillan. Chapter 2, 22-32

Scriven A, Orme J (2001). "Health Promotion Professional Perspectives". Palgrave, The Open University. Chapter 6, 65-70

Solheim K, McElmurry B, Kim M (2007). "Multidisciplinary teamwork in US primary health care". Social Science & Medicine, 65(3): 622-634

Somervaille L, Knight T, Cornish Y (2007). "A short history of the Multidisciplinary Public Health Forum". Public Health, Volume 121, Issue 6, June 2007, Pages 409-413

Wagemakers A, Vaandrager L, Koelen M, Saan H, Leeuwis C (2010). "Community health promotion: A framework to facilitate and evaluate supportive social environments for health". Evaluation and Program Planning, 33(4): 428-435

Weaver T (208). "Enhancing multiple disciplinary teamwork". Nursing Outlook, 56(3):108-114

Whitehead D (2004). "The Health Promoting University (HPU): the role and function of nursing". Nurse Education Today, 24(6):466-472

Whitehead D (2007). "Reviewing health promotion in nursing education".Nurse Education Today, 27(3):225- 237

World Health Organization (1998) The Ottawa Charter. Geneva: WHO

Yeager S (2005). "Interdisciplinary Collaboration: The Heart and Soul of Health Care".Critical Care Nursing Clinics of North America, 17(2):143-148