As part of the introductions for my current PhD module, we were all asked to introduce our job roles through the lens of the ‘three domains of public health’.  We all did so – but it was only when I was chatting to another student, that I dared to say that I didn’t really like them and was pleased when she agreed.  But before rejecting something outright on the basis of an emotional reaction – it is perhaps best to look where they originally came from and what they were originally for…and explore the thoughts behind my emotional reaction.

What are the three domains?

They aren’t always named in exactly the same way, but they are listed on the Faculty of Public Health website as health improvement; health protection; and improving services.  They are sometimes represented through a series of three headings – with a list of topics underneath that belongs in each of these domains.  The Faculty of Public Health website is a case in point.

However, more usefully for those that always see overlaps they are often represented as three interlocking circles – such as this example and others hidden in non-open access journal articles such as Griffiths et al (2005),

Who introduced them?

The articles I have looked at all seem to attribute the introduction of the three domains of public health to the UK Faculty of Public Health.  Although I am sure the particular FPH members who proposed them were steeped in public health experience there doesn’t seem to be any particular research project involving concept mapping etc that led to them.  The Faculty of Public Health includes them in a list as part of their page on ‘What is public health‘ – but I can’t seem to find any history e.g. date they were adopted, the process that led to them.  So it seems as if they just appeared!

Griffiths et al (2005) explain “Their origins lie in the historic importance of the control of communicable disease, health education and the role of hospital and community services over the last 150 years” (page 910).  That sentence is what inspired the title for this blog – the things that were of historic importance may not be as vital moving forward – especially in high income countries.  It could be that the conceptual tool that seemed right for the past are blocking our view of the future.

Why they were introduced?

Again, I can’t find anything specific on this on the Faculty’s website itself.  Griffiths et al (2005) draw on a Faculty of Public Health 2004 report on the role of the Director of Public health (I can’t find this) to explain that “breadth of public health becomes more manageable if conceptualized within the model of three domains of practice” (page 910).  Whilst, Hunter et al (2007) also highlight that it was “an attempt to make sense of the wide range of activities which go to make up public health” (page 14).

Once again I find this interesting – all too often now, I hear statements using these three domains that are very ‘definitional’ – a statement of what is.  I think it would be helpful if people went back to talking in terms of using them to make better sense of all the things involved in public health or the type of things public health professionals focus on.  Let’s face it – like any conceptual model – they reveal some things and hide others – presenting the domains in a definitional way doesn’t allow for much debate of what they may hide.  It doesn’t allow for the three domains to be contested when perhaps they should be.

How do they seem to be used?

They predominantly seem to inform professional development and competency frameworks and curricula (e.g. for Masters in Public Health).  UK Faculty of Public Health use them alongside a number of core values to underpin standards of training and practice.  They seem therefore to create the boundaries of the profession – what is in, and what is out – as well as who is in and who is out.  I’m not sure how inspirational they are then for those people/professions who are ‘out’ but are told health is everyone’s business.

Thorpe et al (2008) used the framework to analyse the curricula of 35 Masters of Public Health offered in the UK.  Whilst there does appear to be modules offered across the domains, the breadth of cover within each domain appeared variable.  I thought it was particularly interesting that within the health improvement domain modules largely focussed on theory and lifestyle issues – thus restricting the view away from the all important ‘health inequalities’ that is listed in this area.  The authors end by encouraging universities to use the full breadth of the three domains to inform their curricula.

Given their use by the Faculty of Public Health,  it is not surprising that the three domains are also enshrined in guidance relating to the role of the Director of Public Health who has “a leadership role spanning all three domains of public health – health improvement, health protection and healthcare public health.” (DH, 2013, page 5).  That seems a mighty brief.

Am I the only one critiquing the domains?

I haven’t got too much time so this wasn’t a systematic literature search by any stretch of the imagination.  But my very quick search led me to a  report by Hunter et al (2007) where they include a short discussion (on pages 14/15) of the domains including a summary of how they have been criticised.

Key points are:

• particularly intense debate with respect to the ‘health improvement’ domain touching on the “nature of the public health function and the boundaries of formal (and informal) public health systems” (page 15).
• that they do not help get over what Lewis (1986) referred to as the philosophical lacuna in public health – which is that public health is defined in terms of the activities it does with a rather ‘fuzzy’ view of the idea behind it
• questions about whether it is helpful to split public health across three domains when most problems cross all three and require a mix of skills
• they seem to concentrate ‘downstream’ and feel NHS focussed

Hunter et al (2007, page 15) conclude “In the light of these difficulties, it may be that in future topic based specialisation will occur, with a consequent blurring of the three domains”

So what of my own discomfort?

The majority of my own public health practice falls into the ‘health improvement’ domain – so I can’t speak about the other two domains from experience.  But my discomfort seems to come down to…

• health improvement domain has too much richness to be characterised by just one heading
• health improvement has become too associated with individual and population health education and individual behaviour change work on lifestyles
• health improvement domain seems to overlook the ‘wellbeing’ angle and seems too much about prevention – it overlooks the ‘protective’ element of positive wellbeing and good health itself.
• somehow we need to highlight that ‘health improvement’ entails population interventions (such as legislation, regulation, policy); community interventions (such as community development); and, individual interventions.  (Bentley, 2008, page 7)
• that it would all be more inspirational if informed by the concept of health promotion – which the Ottawa charter describes as

Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.

Source: http://www.who.int/healthpromotion/conferences/previous/ottawa/en/index.html

• that the Ottawa Charter’s key areas of action seem a more productive way of looking at public health practice, than the domains
  • healthy public policy
  • create supportive environments
  • strengthen community actions
  • develop personal skills
  • reorient health services

And I also wonder whether any Masters curriculum or set of training standards can really help someone to be able to work well and lead across all of these domains.  To be able to lead action on the social determinants of health, you’ll need to be an economist, an urban planner, a community activist, a politician, a social marketeer, a policy specialist; a change agent etc etc. – there are many different masters degrees in that list.  If health truly is everyone’s business, then it would be better to focus on making sure health is built into other curricula too – and that the ‘specialist’ public health community trusts those colleagues to get on with doing what they do.

In order to succeed at improving health it seems to me that the ‘public health community’ needs to be able to let go – and it seems the three domains create a tight professional boundary to defend, rather than blur.

And that is as far as my rambling thoughts have got.  Happy for discussions with others.

References

Bentley, C. (2008) Systematically addressing health inequalities, Department of Health.  Available at http://www.cwsportspartnership.org/files/addressing_hi.pdf [Accessed 26 October 2013]

Griffiths, S., Jewell T., and Donnelly, P. (2005) Public health in practice: the three domains of public health, Public Health, Volume 119, Issue 10, Pages 907-913, Abstract at http://www.sciencedirect.com/science/article/pii/S0033350605000570

Thorpe, A., Griffiths, S. Jewell, T., Adshead, F. (2008) The three domains of public health: An internationally relevant basis for public health education?, Public Health, Volume 122, Issue 2, Pages 201-210, Abstract at http://www.sciencedirect.com/science/article/pii/S0033350607001862

Hunter, D.J., Marks, L., Smith, K. (2007) The Public Health System in England: a scoping study, University of Durham.  Available at http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1618-150_V01.pdf  [accessed 26 Oct 2013].  It seems this is an earlier text for this book