CHAPTER 3 CONCEPTUAL FRAMEWORK
The previous chapter dealt with the review of existing literature with pertinence to health promotion and the extent to which all eye health promotion priority areas can affect individuals from a public health perspective. The literature provided adequate insight into the challenges of eye health promotion in South Africa. Subsequently, this chapter discusses the theoretical frame work which applies to this study. According to Polit and Hungler (1999:107), conceptual frameworks are constructed mechanisms for developing or organising structures along which information, knowledge and data could be assembled. A conceptual framework further delineates the units to be analyzed into various perspectives, and in accordance with the themes under which the variables have been constructed or organized (Miles, 1994:18).
The concept of health promotion as a vital component of public health is elaborated in numerous texts (WHO 1986; Glasgow, Vogt Boles 1999:1322). Collectively they call for comprehensive approaches to health development and ensure sustainability. For eye health this means reducing the eye disease burden in ways that improve eye health outcomes in an equitable manner and promote healthy lifestyles by reducing socio-economic and environmental risk factors to eye health care. By implication this requires a common risk factor approach to health promotion to control risk factors to eye health and preferably embraces population-wide intervention strategies (Sheiham & Watt 2000:399). This provides the rationale behind attempts to integrate eye health promotion elements into all other areas of health policy and health-related policy. These concepts and the guidelines of the Ottawa charter (WHO 1986), provide the basis for the conceptual framework used.
In this chapter, an ecological framework (Milio 1988:263), which is in line with guidelines of the Ottawa Charter, has been used to delineate the social climate, key players, and strategic action to be taken in policy-making, making healthy public policy a political reality and knowing how this can be carried out. This framework has been used because public health sees human health in an ecological relationship with all in our natural and human made habitats (Milio 1988:263). Also, the framework is relevant to both high and low income countries (Patel 1986:37). This view derives from growing evidence that health and illness are embedded in the household, workplace, school, community and larger environments in which we live and evolve our social and individual, public and private, informal and organized ways of living.
From an ecological perspective, people’s health affairs cannot be neatly grouped into diagnoses, symptoms and risk factors to be targeted and eliminated or altered (Milio 1988:263). Health problems, having multiple origins, are themselves interrelated. The people, for example, who have one major problem are more likely to have additional problems (Kokkte 1986:2). The earlier in life people experience illness, the more likely they are to become ill, and more severely ill (Millio 1988:263). This snowballing process continues into old age, for those who survive. Similarly, disadvantaged groups are likely to be socially vulnerable in more than one way (Kasi et al 2004:e44). On the more positive side, the groups of people favoured with the lifelong conditions for healthy living carry a robust biological and social capacity into later decades of life (Bambra, Joyce & Maryon-Davies 2010:48).
Upon reflection, an ecological view of health leads to an awareness that the many contexts in which people live and the ways that people relate to them are profoundly influenced by the most powerful collective means to shape human living: public policy (Stokols 1996:282). Simply put, public policy – the guide to government action – sets the range of possibilities for the choices made by public and private organizations, commercial and voluntary enterprises, and individuals (Millio 1988:264). In virtually every facet of living, the creation and use of goods, services, information, and environments are affected by government policies– fiscal, regulatory, service provision, research and education (Sallis, Cervero, Ascher, Henderson, Kraft & Kerr 2006:297).
Public policy then becomes a prime approach to creating the conditions and relations that can nurture health. Public health thus asserts that all public policies should take into account the health interests of the public (Sallis et al 2006:298). It advocates that policies should make healthful choices easy (less costly in various ways) and damaging choices difficult (high in monetory or other costs) to the chooser, whether a corporate body or individual (Sallis et al 2006:298). It is of course encouraging that the South African government has been over the past few years imposing higher taxes on both tobacco and alcohol, which obviously have detrimental health effects.
To be effective, this approach must be multisectoral in scope – not confined to the conventional sphere of health policy – and collaborative in strategy, involving not only sectors of national policy, such as employment and income maintenance, agriculture, housing, education and health services, but also other levels of government, and voluntary, economic, and community groups (WHO 1986).
Having outlined the various guiding principles that led to the use of the ecological framework in the study, this section further defines the various elements of the conceptual model, their interrelationship and the assumptions made for empirical analysis. The use of theory was thus an important aspect in developing the conceptual framework. The theory provides the analytical framework through which to form logical interpretations of the facts collected in the study and guides the search for new information (Wan 1995:31). The research used the theory that eye health promotion efforts could be better supported at an implementation level if these activities were adequately expressed in other strategic health policy documents.
The conceptual framework consisted of the following components:
- Theoretical foundation to policy analysis;
- Policy document;
- Eye health promotion-related decision-making at national and provincial levels and;
- An examination of the external and internal influences on eye health promotion policy. External influences refer to issues such as infrastructure, health inequities and resources. Internal influences refer to decision-makers’ attitudes and perceptions towards eye health promotion policy.
The conceptual framework for eye health promotion policy analysis is shown in Figure 3.1. Each component of the framework is discussed briefly using theoretical considerations and supporting evidence from the literature section
COMPONENTS OF THE CONCEPTUAL FRAMEWORK
Policy document analysis
The strategy for policy analysis referred to by Myburgh, Owen, Hobdell, Chikte, Matsinhe and Thorpe (2005:233) advocates a systemic approach to the identification and selection of evidence-based oral health policy priorities and interventions appropriate to local community settings. A similar strategy has been used to identify and select evidence-based eye health policy priorities and interventions in the general health promotion policy of South Africa. The research used the assumption that eye health promotion activities would thus not be uniformly expressed in all of the identified health programmes. Health promotion focal persons in the provinces would be in a better position to comment on the intricate details of the programme strategies, perceptions and expectations on eye health promotion.
Content analysis is defined as a systematic method to identify specific characters or themes and to draw logical conclusions from the presentation (Taylor, Haglund & Tillgren 2000:185). Content analysis of health policy documents would be important to characterise organizational changes, identify priorities and strategies for implementation and potential alliances and resources (Taylor et al 2000:185). Content analysis could also identify policy aspects that are important for eye health development but are not included in policy. Thus this analysis focused on the underlying philosophical approach that each policy document adopted. The inclusion of broad-based philosophical statements provided evidence for whether these statements were preventive or curative driven. Alternatively health policy statements could also indicate whether health policies focused on health integration or vertical programme delivery.
Eye health promotion-related decision-making
The research used strategic mapping to identify health decision-makers involved in health policy development (Kerr, Taylor & Heard 1998:555). The research also used the assumption that health policy development has the potential to mobilise and support health action. The research built on the assumption that while there may be interest groups that have an explicit interest in eye health activities, there may also be decision makers in health management that will not have an explicit interest in eye health promotion but that they could prove to be very influential in determining the delivery and sustainability of eye health promotion services. The research used the theory that the leadership structure within the health system in South Africa may support change in response to changing external and internal conditions (Bracht 1990:53). These changes would include the generation of evidence based developments in eye health practices.
Decision makers in Health Promotion; Chronic Diseases, Disabilities and Geriatrics; Maternal, Child and Women’s Health; Integrated Nutrition; HIV/AIDS and Youth Health cannot by definition be referred to as direct stakeholders in eye health promotion but they could be regarded as implicit stakeholders where they do not have an outright interest in eye health promotion but their influence could impact on the delivery and sustainability of eye health promotion services in South Africa. The research took into account that health policy studies are context specific and that it would not be feasible to generalise the findings (Brugha & Varvasovszky 2000:239; Badura & Kickbusch 1991:60).
Key criteria to address health decision-making
The following key criteria were used to examine the eye health decision-making process in South Africa. The study needed to determine the extent to which eye health promotion is recognized as a priority and programmatic efforts at all levels of the health system. This required an examination of the extent to which eye health promotion efforts are included in other health policies and programmes at district level. The extent to which lifestyle induced risk factors to health are included in policy and programmes was also seen as an important factor for eye health promotion programmatic compatibility with district health activities. The study examined possible opportunities to include eye health promotion efforts in integrated district health service delivery. It was also important to identify specific strategies that could support and facilitate the inclusion of eye health promotion efforts onto the other identified health policy agendas.
The study also focused on any eye health promotion programmes and strategies that were available and further looked on the epidemiological basis of their selection and strategies (Box 3.1). The study attempted to determine the impact and availability of appropriate human resources on service provision. The study needed to determine the extent to which the current eye health promotion programmes have contributed to improved community health and to identify the possible barriers in this process.
The study examined possible influences on the eye health policy process. These included provisions on stakeholder involvement and the impact of budgetary allocations at provincial and district levels. Considerations were also given to the fact that eye health promotion activities could be in competition with other health issues on the policy agenda. Economic, socio-political and cultural influences were taken into account. The roles of any possible lobbies or special interest groups on eye health issues such as eye protection against radiation exposure were also considered.
CHAPTER 1 ORIENTATION TO THE STUDY
1.2 CONTEXT OF THE PROBLEM
1.3 STATEMENT OF THE PROBLEM
1.4 RESEARCH OBJECTIVES
1.5 SIGNIFICANCE OF THE STUDY
1.6 RESEARCH QUESTION
CHAPTER 2 LITERATURE REVIEW
2.2 THE CONTEXTUALIZATION OF THE LITERATURE REVIEW
2.3 EVIDENCE IN EYE HEALTH PROMOTION
2.4 COMPONENTS OF EYE HEALTH PROMOTION
CHAPTER 3 CONCEPTUAL FRAMEWORK
3.2 COMPONENTS OF THE CONCEPTUAL FRAMEWORK
CHAPTER 4 RESEARCH DESIGN AND METHODOLOGY
4.2 RESEARCH DESIGN
4.3 RESEARCH METHODOLOGY
4.4 EXTERNAL AND INTERNAL VALIDITY OF DATA
4.5 DISSEMINATION OF RESULTS
CHAPTER 5 ANALYSIS, PRESENTATION AND DESCRIPTION OF THE RESEARCH FINDINGS
CHAPTER 6 DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS
6.2 RESEARCH DESIGN AND METHOD
6.3 SUMMARY AND INTERPRETATION OF THE RESEARCH FINDINGS
6.6 CONTRIBUTIONS OF THE STUDY
6.7 LIMITATIONS OF THE STUDY
6.8 CONCLUDING REMARKS
LIST OF REFERENCES
LIST OF APPENDICES
GET THE COMPLETE PROJECT
A CRITICAL ANALYSIS OF THE SOUTH AFRICAN HEALTH POLICIES AND PROGRAMMES WITH REGARD TO EYE HEALTH PROMOTION