What makes health promotion research distinct?

Application to real-world contexts

The first element of distinctiveness is that health promotion research should be on the development of practice and on developing appropriate strategies for action on health [6,11]. While not a truly unique characteristic, as other disciplines would hold this attribute, this understanding that health promotion research should be applied to real-world contexts and inform action is a widely held principle. In short, ‘blue sky’ research [12] in health promotion that does not have direct application to understanding health or tackling health determinants is relatively rare. Whitehead et al. [13] have suggested how the tenets of action research, i.e. research designed explicitly to feed into and inform practice, resonates strongly with health promotion research. The community-driven, rather than expert-driven, nature of action research and its focus on participatory learning are some of the features that align with health promotion:

researchers in the field of health promotion need to conduct studies that are relevant and useful to the communities involved. This necessarily requires some degree of community participation, in identifying research problems and questions and in helping to articulate the implications and application of the research. [14: 339]

The focus on developing practice through health promotion research has, however, been problematic and some have argued that health promotion research has not fully embraced action research principles:

Most health promotion research employs conventional approaches in which the subjects of research function principally as sources of data. This role neither contributes directly to the subjects’ empowerment nor encourages action by those experiencing the problems studied. [15: 189]

Perhaps more significantly, commentators have suggested a gulf between those practising and those researching health promotion [16]. Some have noted difficulties in practitioners physically accessing peer-reviewed research literature [17], but we anticipate such challenges becoming historical given the rise of open-access publications. Notwithstanding this, practitioners have noted how much health promotion research is difficult to apply in practice and fails to adequately inform the strategies to tackle health issues in communities [16]. Glasgow et al. have attempted to outline in detail why such a research−practice gap exists and why there has been a ‘slow and uneven translation of research findings into practice’ [18: 1266] – this includes a lack of consideration on the part of the research community to explore issues of generalisability of findings from one context to another, thus inhibiting substantial theory generation. So, while in principle the notion of research leading to action is a distinctive feature, it is apparent that much is to be done to ensure this happens. The growth of academic and practice research collaborations and initiatives within health promotion, including research–practice partnerships and mentoring is, however, a promising development [17,19].

Research values

The second area of distinction is in the application of health promotion values to the research process. Health promotion’s value base, derived from the Ottawa Charter [20], is clear in espousing ways of working that are enabling and empowering and which support individuals and communities to gain control over their own health. Some claim that health promotion research should reflect this and have an emphasis on control-enhancing action with ‘values related to inclusion and participation’ explicitly woven into the research design [6]. Community participation, as an example, is regarded as a basic principle of health promotion and, by extension, should be of health promotion research [14]. Practitioners of health promotion too have challenged the research community to ensure that their design and method takes care to ‘to ensure that there is an adequate fit with health promotion principles and practice’ [21: 12–13]. There is a clear tension, for example, when programmes intended to enable and empower are evaluated or deploy research methods that are antithetical or undermining to such principles [22].

A closer recognition of power in the research endeavour is perhaps in sharper focus in health promotion research, given the broader goals to reduce health inequalities and frequently because health promotion research engages with marginalised groups in society [23]. Indeed, ‘the power imbalance between researcher and researched is inescapable’ [24: 8] and is perhaps exemplified by experimental approaches that are often predicated on the researchers having complete control of all aspects of the design, implementation and dissemination of the study. Commentary by Eakin et al. [25] outlines how power is a salient issue for health promotion research, with the inclusivity and participation of individuals and the community in health promotion research processes as important. Indeed, this philosophy of research with, not on, communities has been suggested to have contributed to the generation of new data, more sensitive and knowledgeable stakeholders, increased advocacy, and more meaningful, sustainable policy change [23]. From our own research practice, the use of storyboards, as a creative research method, was used to neutralise power relations. The storyboard approach was used in this case with young, vulnerable women to understand their social context and to reflect on their engagement with a service designed to support their health and social needs. The approach was contingent on building rapport and relationships with the young women in order to increase trust and eradicate any perceived power relationships. Participants were supported to develop a storyboard of their lives before and during their engagement with the service and to envisage what life may be like in the future. Participants were encouraged to use creative and artistic ways to do this and this formed the basis of further discussion – such an approach was designed to put participants at ease. While not without challenges, the participatory approach used was concluded to have provided rich data, promoted engagement and empowerment and enabled individuals to have more power over the research process [24]. This example usefully demonstrates how values of equality and respect can mitigate uneven power imbalances within the research process.

Relinquishing professional control

The process of health promotion researchers as ‘co-researchers with the participants in the co-production of knowledge’ [24: 9] is a distinctive feature of health promotion research. Such participatory approaches in health promotion research and the evidence that they derive, asks people to adopt different epistemological attitudes to knowledge production and to reject traditional models of evidence or evidence hierarchy [13]. Indeed, relinquishing professional control over the research process through the participation of individuals and communities does pose questions over the ‘scientific’ rigour of health promotion research carried out in this way. MacDonald [26] observes that health promotion researchers frequently find themselves balancing research processes that resonate with health promotion’s intrinsic values of participation and empowerment and ensuring that these are acceptable to academics and funders. We would support comments by others [14: 338] who have noted that ‘a participative model does result in less control available to the researcher over the content and process of research’ but this does not necessarily equate to a loss of rigour. Indeed, non-participative research strategies do not in themselves guarantee scientific rigour. As noted previously, participatory approaches do often increase the quality and richness of data and the ultimate utility of it to affect practice and policy.

Health promotion research has shown that it can be empowering and emancipatory for individuals and communities and in itself the process can produce positive, even transformative, effects when professional researchers relinquish control and enable others to be involved in the research endeavour. To what extent though should health promotion research be transformative for individuals and communities? Authors have encouraged the research community to be clearer about this and, of course, pragmatic requirements such as time and funding constraints can, and often do, determine this [27]. As a further illustrative example from our research practice, we were involved in the training of lay people as peer researchers – in this case, individuals experiencing severe and multiple levels of deprivation were trained to interview others in similar situations [28]. As health promotion researchers, our rationale for such a research design was twofold. First, evidence consistently demonstrates that such an approach often provides richer and more detailed data about lived experience. People who understand and share common experiences, coupled with being trained in research skills and competencies, potentially offer a much more viable way of really understanding people’s views and thoughts [29]. Second, training people with lived experience of multiple needs proved empowering for those involved and provided opportunities for confidence building, raising self-esteem as well as acquiring skills that can be transferred to other contexts (like applying for employment etc.). The peer research process derived rich and meaningful data that, arguably, would be inaccessible to obtain from ‘outsiders’ or professional researchers. Moreover, those trained as researchers derived practical as well as emotional benefits from their engagement and participation in the process [28].

Expansive methodological toolkit

The fourth area of distinctiveness is the expansive methodological toolkit that health promotion researchers can and should draw upon in their practice. Inherently interdisciplinary and not dogmatically tied to research paradigms, views or perspectives, health promotion research should be flexible and diverse to address the issue being explored or investigated. It is our view that such a position is upheld, especially given the range and types of work carried out under the health promotion banner. Ecological models of health promotion, for example, operate on the premise that health and determinants of health are produced by intrapersonal factors, interpersonal processes and primary groups, institutional factors, community factors and public policy [30]. To reflect this, Watson and Platt [21] suggest that health promotion research must reflect this broad-ranging approach. That said, we hope that the research ‘paradigm war’ debate that frequently overshadowed health promotion research and which often pitted positivism against interpretivism in a very stark way is in the past [23]. In its place, we are thankfully seeing the proliferation of more pluralistic and synthesising approaches that are demonstrated to be both feasible and desirable [21]. The continued challenge, it seems, is to develop pluralistic frameworks of health promotion research that bridge tensions, but accommodate epistemological difference.

The future of health promotion research

Our final thought on health promotion research is one of optimism. Health promotion research in many respects is in good health, with the volume of published research rising steadily [6]. A number of academic journals dedicated to showcasing international research and expertise in health promotion is one indicator of this success [8]. Flagship journals for those researching within health promotion, for example, report that they receive a considerable volume of manuscripts each year from around the world [8,31]. Moreover, health promotion journals’ impact factors are increasing year on year which is a crude measure of the usefulness and utility of the research being produced. Other evidence suggesting the prosperity of health promotion research includes the evolution of a vibrant health promotion research community – recognised most tangibly by the formation and sustainability of academic health promotion research centres and growth in the numbers of individuals studying health promotion at PhD level supervised by academic chairs devoted to the discipline [8]. This paper afforded us the opportunity to lay out how we conceptualise and practise health promotion research, which we would encourage others to do. Acknowledging that other views on this topic exist, we hope that this acts as a way to ignite further debate. Health promotion as a field of practice is still in its infancy and therefore it is perhaps unsurprising that discussions on health promotion research have lagged behind. We recognise that we have only ‘scratched the surface’ but hope that subsequent discussions continue on the nature of health promotion research to ensure its future sustainability.

Conclusion

This paper set out to clarify and stimulate debate on health promotion research and to state why health promotion research is distinctive. Our experience of running a workshop on the topic at the 8^th Nordic Health Promotion Conference suggests that practitioners and researchers are enthusiastic in engaging in this debate and do believe that health promotion research has something distinct to offer. The paper suggests four areas that make health promotion research distinct. This includes: the notion that health promotion research should have real-world application; the distinct value base of health promotion research which encompasses respect and participation; relinquishing professional control to support the co-production of knowledge; and finally, the expansive methodological toolkit that health promotion researchers can draw upon.