Domains of Core Competency in Health Promotion

[Maurice Mittelmark]

Gabriel, I think your idea of rearranging the domains in order of procession is quite sensible... I understand your rationale for eliminating catalyzing change, as all the other domains should add up to that. Catalyzing change is in a sense an outcome, not a competency...

[Hasse68]

I’d like to take the opportunity to thank those initiating and contributing to the VHPO initiative, and for inviting to dialog on (among other subjects) the “Galway Consensus Conference Statement” (GCCS) on domains of core competencies in health promotion.

It’s always exciting to read recommendations of a consensus group. Identifying common denominators in a vast and diverse subject matter is a daunting task indeed. GCCS identifies eight competence domains for health promotion practice (Catalyzing change, Leadership, Assessment, Planning, Implementation, Evaluation, Advocacy, and Partnerships). I find them highly interesting, but also somewhat problematic. Interesting because the eight domains combined portray the competent health promotion practitioner akin to a competent project manager, or perhaps more precisely: Akin to Schön’s “reflective practitioner”, i.e. someone capable of continuously adjusting plans, perspectives and means based on assessment of ongoing experience, so as to stimulate change in the direction of desired objectives. Seen like this the eight competence domains provide a bridge to other areas of expertise. Health promotion can learn from experiences in practically all fields of inquiry, like education, nursing and engineering, or economy, carpentry and transport for that matter (they all produce valuable insights on the eight domains). There is clearly a lot to learn from others concerning “what constitutes competent practice?”, and emphasising overlapping domains is a promising strategy. In passing I would also like to note that the eight domains are very much in line with what we in our masters program in health promotion refer to as “practical competence”.

On the other hand, it is somewhat problematic that GCCS is less specific on what is unique for health promotion, i.e. what separates it from other fields of inquiry. Somewhat simplified; the GCCS tells us a lot about HOW TO promote, but little on WHAT TO promote. We all know “health” is what we’re supposed to promote – and nobody in their right mind would criticise a consensus conference for not reaching agreement on what health is – but what could (probably should) be addressed is how we can identify core competencies given different understandings of health. GCCS does not address this issue, but takes as point of departure “urgent health needs”, concretely “the global epidemic of cardiovascular diseases, diabetes and other chronic diseases; infectious diseases, such as HIV/AIDS, malaria, and tuberculosis; environmental threats; and injuries”. Consequently, GCCS highlights health understood as absence of disease. Concerning prevention of specific risks and diseases it certainly might be a good idea – as stated in “Recommendations and Key Actions” – to move “towards global consensus regarding competencies, standards, and quality assurance”.

However, with understandings of health as presence – like well-being, or as a positive state or resource, or based in theories of salutogenesis, etc – aiming for global consensus and standards seems self-defeating. The variation in “health as presence” in settings, cultures or individuals is overwhelming. If one is to take ideals of participation and empowerment seriously it is impossible to anticipate what competence is needed. One could perhaps opt for standardising competence in how to assess variation in health, but not how to promote it in practice (which is the challenge GCCS is addressing).

Still, engaging in dialog on the eight competence domains for health promotion practice may be highly useful for all walks of health promotion. It would help us deepen our understanding of what is particular for health promotion. The engine driving this process would partly be comparison between different practices within health promotion, and partly comparison with other practices relating to the eight domains. Whether or not such a debate would take us closer to or further away from professionalizing health promotion is another debate…

Regards,

Hans A. Hauge
Research Centre for Health Promotion in Settings
Vestfold University College, Norway

[Torill.Bull]

Dear Hans,

I really appreciated your thought-provocative inputs here! You catch my interest, and I start by agreeing with what you say. Next, I go back to the Consensus statement (GCCS), change my mind a bit, but still I do agree with especially one of your observations:

-the Core Competencies (CC) read as key words are so general that they do not become very interesting - reading them out of context there is nothing that would give away they are health promotion competencies.

You describe the challenge of diverse understandings of health, pointing out that the GCCS preamble hightlights health as absence of disease. Reading the preamble, I get a sense of a sentence missing, stating the understanding of health as a positive presence. To me, this understanding seems to be saturating the document, but it is not stated explicitly. I miss that. A consensus like this should definitely have a point of departure in a positive understanding of health, given the statements of the Ottawa charter.

Now about the uniqueness to health promotion of the CCs: The key words are not hp specific, but if I define the FULL SENTENCES of the CCs, I find I get to a description that captures hp 'quite well'. And I think that might be the closest we can get if the CCs shall be globally acceptable? That is one of my core questions regarding documents like this - the balance between specificity and global acceptability, and what is lost in the negotion between these...

Now, the GCCS also states that 'Finally, what is unique about health promotion is the combined application of the domains of core competency and their integration with knowledge from other disciplines in health promotion practice.' This sentence is a bit foggy to me, but from discussions with colleagues I take this to mean: Health promotion practitioners may have backgrounds in different disciplines (let me cite, 'education, nursing and engineering, or economy, carpentry and transport for that matter'), - we are a community of professions, not a single profession. What makes us health promoters, is to which aims and by which means (e.g., the full-sentence CCs) we perform our professions.

Well, these were some early morning musings from the Research Centre for Health Promotion in Bergen, Norway. I really did not have the time to do this musing, but nevertheless - here it is!

Torill Bull

[Torill.Bull]

By the way, I would like to add one comment to my 'musings' above:

I am not very happy with the opening sentence of the GCCS: 'Health is necessary to achieving the global agenda for social progress.' I did not see any other statement on the value of health, for instance its value to the individuals - not at the aggregate level. Is our view of health really that instrumental, and only at a global level? Maybe some sentences are missing here?

Torill Bull

[Hasse68]

Thank you for your response Torill!

One of the most interesting characteristics of health promotion is that it provides a global "meeting place" across cultures, disciplines, sectors, scientific theories of knowledge, etc, etc. This is probably both our greatest strength and weakness. To some extent there is a tendency to polarization, perhaps most neatly formulated by Lawrence Green (in his foreword to Raeburn and Rootman's "People-Centred Health Promotion"):

"The practitioners of health promotion (find) themselves in a withering crossfire between the more-rigorous-than-thou rhetoric from the radically reductionist, scientific wing of health promotion on one side and the more-equitable-than-thou rhetoric of the politically correct wing on the other."

Many of the key contributors to health promotion have launched their ideas on how to bridge the gap between these wings, for instance Raeburn, Rootman, Tones and (perhaps most persistantly) Mittelmark. They and many others have given us interesting suggestions on how to find a "third way", avoiding the trenches. Such initiatives are clearly contributing to developing health promotion as a discipline.

On the other hand, the GCCS as well as other policy documents with global aspirations (like the Bangkok Charter) take another route. Read literally they seem to presuppose that bridging the gap is unproblematic, and that differences can be leveled by imposing super-standards applicable to all. The "lingua franca" so to speak of policy documents these days is the instrumental rhetoric of new public management. The twin brother (sister?) of this rhetoric is "the more-rigorous-than-thou rhetoric from the radically reductionist, scientific wing of health promotion". And perhaps this is to be expected? The statements/ policies are not written for health promotion practitioners, but for funding agencies particularly at government levels.

I believe it's important to remember that GCCS is written on behalf of health promotion practitioners, not by them. Such benevolent paternalism is fine as long as one doesn't forget that in practice health promotion is oftentimes more complicated than implementing solutions for those with health deficiencies. In conclusion; it would be nice if statements like GCCS acknowledged that health promotion practice is diverse, depending to a large degree on how health is understood, making different sets of competencies necessary. We cannot talk as if we can implement well-being, quality of life (or more generally health as presence) by applying a fixed set of core competencies.

Regards,

Hans

[Maurice Mittelmark]

I appreciate and enjoyed reading the exchange between Hans and Torill. I think the 'word smithing' they both propose would strengthen the statement, and I know the managers of the statement drafting process are hoping for input just like this.

However, this exchange reminds me that in many minds, the distinction between competencies and domains of competence is not very clear. In my view the value of the domains approach is that is tries to set an agenda for us, to get working on developing agreement about core competencies. Seen this way the domains should be both specific and vague. Specific, in that each domain is sufficiently distinct and understandable so that teams can use them in the work of writing specific competencies. Vague, so that the various contexts of practice that Hans mentions can be taken into account when trying to write core competencies.

Even in homogeneous Norway, I expect that the master's level core competencies in the Bergen research centre and the Vestfold research centre will have some overlap and some uniqueness. However it would be nice if the domains were about the same.

[Hasse68]

Maurice, as you know "word smithing" is the middle name of most social scientists...

The difference between "core competencies" and "domanis of competence" was precisely what I tried to address. As I concluded in a previous reply: "...engaging in dialog on the eight competence domains for health promotion practice may be highly useful for all walks of health promotion. It would help us deepen our understanding of what is particular for health promotion. The engine driving this process would partly be comparison between different practices within health promotion, and partly comparison with other practices relating to the eight domains." So I fully support the notion of it being worthwhile -irrespective of differences in understandings of health, objectives, target groups, etc. - to try and relate to the same competence domains.

When it comes to "core competencies" (or just "comeptencies") they will have to be specified in relation to the practical challenges faced in various contexts, e.g. compentent "Leadership" will (although to some extent overlapping) not be the same in say a smoke-cessation intervention and a community development program. If I understood your reply correctly, I believe we agree on this.

In my reading of the GCCS in its present form it is not very clear in separating "competence domains" and "core competencies", i.e. being less than crystal clear on the fact that within each domain a large array of competencies may be needed depending on the task at hand/ what dimension of health is sought promoted. Instead "health" in GCCS is a means for achieving social progress and combatting disease. As I stated in a previous reply: "Concerning prevention of specific risks and diseases it certainly might be a good idea – as stated in “Recommendations and Key Actions” – to move “towards global consensus regarding competencies, standards, and quality assurance”.

Consensus and standards are worthwhile objectives when faced with technical/ instrumental challenges (the "system world" of positivism and new public management), but highly problematic for instance when engaging in moral/ ethical challenges. And most health challenges activate moral tensions and dilemmas, for instance concerning distribution of resources/ political engagement in general, trying to alter structures and practices in settings, balancing employers' need for healthy employees with employees' self-determination over own health, the relationship between cultural practices and risks for disease, etc, etc, etc. Such practical "values-infested" challenges cannot be addressed adequately by applying a consensus-based standard regarding competencies (which GCCS in in present form calls for in its "Recommendations and Key Actions"), simply because there is no absolute right or wrong irrespective of individual or group interests.

This does not mean that we cannot develop competencies, learn from experience, and learn from others inside and outside of health promotion. It just means that we should think of other ways to organise our competence than "consensus-based standards" within those realms of health promotion that are "values-infested/ moral" (as opposed to instrumental/ technical).

We should probably be equally concerned with how we set up meeting places for dialog on how to develop our competencies, as with how to develop consensus-based standards. My point is that the eight competence domains are brilliant for setting up meeting places; some of the competencies we agree on may be useful in competence standards, and some will not. Both (all) types of competencies are necessary for health promotion practice, depending on objective and context. Again, it would be nice if the GCCS more clearly reflected competence challenges in all walks of health promotion, and insisted on the usefulness of bringing all together in dialog on competence challenges in health promotion practice.

Regards,

Hans

[glenn.laverack]

Well done to the participants of the Galway conference on putting together this statement. Some comments below:

Specific points: 1. p. 6 1st sentence. Does the Ottawa Charter use the term 'determinants' in its definition or are the participants thinking of the Bangkok Charter? 2. 3rd para line 2. 'the habits of mind' is a strange phrase and sounds as though it is coming from psychology - an individual focus which we are trying to move away from. Suggest you delete this.

General points: Reading the competencies they offer a combination of the Ottawa Charter (Catalyzing (enabling), advocacy, partnerships (mediating) and influencing public policy) and health promotion programming (domains 3, 4, 5, and 6). Although there is no discussion about programming in the introduction as the core business of HP. Its a bit like old wine in a new bottle. However, the use of language such as catalyzing and leadership is helpful and personally I think a focus on programming is helpful to practitioners. So why not be more explicit about this approach?

Alternative domains:

Programme design, management, implementation and evaluation.
The ability to plan effective health promotion programmes, including the management of resources and personnel. This involves an understanding of programme cycles, budgeting, the planning and evaluation of bottom-up approaches in top-down programming.

The planning and delivery of effective communication strategies.
Communication strategies are an integral part of many health promotion programmes to increase knowledge levels and to raise awareness. A high level of competence is needed for the development of programmes that target individuals, groups and communities including one to one communication, the design of print materials and the use of the mass media.

Research skills.
Health promotion programme design and evaluation is based on sound research including the use of participatory techniques, qualitative and quantitative methods and systematic reviews.

Community capacity building skills.
Community empowerment is central to health promotion. This is a process of capacity building and health promoters must be competent in a range of strategies that they can use to help individuals, groups and communities to gain more power.

Ability to influence policy and practice (catalyzing).
Health promoters have the opportunity to influence policy and practice in their everyday work, for example, through technical advisory groups and through helping communities to mobilise and organise themselves towards gaining power. Health promoters must develop competence in the use of strategies to influence policy, developing partnerships and sound working relationships.

Leadership. As stated.

Places where not relevant. Any country in which HP (rather than IEC, health communication, health education etc) is not recognised as a concept and/or where concepts such as empowerment are not accepted. I can think of a number of such countries where I have worked.

[margaretbarry]

I have been following this discussion with much interest and thank you for sharing your views. We are currently collating responses and feedback to the Consensus Statement and I hope that we can incorporate your comments into this process.

[ksrini]

I would like to thank those who started this initiative. It is an important area of health which requires more inputs from various disciplines.
I quickly gone through the "June 2008 Galway Consensus Conference Statement". In page 7 under the competencies required, 8 points(domains ?) are mentioned. I see this similar to the following;
(1) Catalyzing the change
(2) Leadership
(3) Assesment
(4) Planning
(5) Implementation
(6) Evaluation
(7) Advocacy
(8) Partnerships

This looks similar to the Program Management in ICT implementations.

(1) Project location and intervention design
(2) Partnership and Management
(3) Unforeseen technical limitations
(4) Planning
(5) Participatory process(capacity building)
(6) Research
(7) A model or pattern to follow
(8) Financial stability
(9) Lasting impact, continuity and scaling-up(sustainability)

From the 9 mentioned items by me all items except the 9th one seems to be appearing in the consensus statement. I think, the sustainability or scaling-up have to be included. I see Health promotion and ICT implementations are closely related. Both are information goods and have common features. Cost-wise both are similar. Even the deliverables are similar in nature. One can also improve a health promotion campaign over the period. One can have versions for the campaigns. Use of ICT in Health promotion is increasing day by day. This makes one to look in as a ICT product. The capacity required similar to ICT.

K.Srinivasan
Associate Professor- Health Management,
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Triandrum, India