The as what Habermas referred to as human activity

The
system

In contrast to lifeworld, the
system is oriented to “sedimented structures and established patterns” of
strategic action (Finlayson, 2005, p. 54). As such, the administration of the
system is characterized by a strategic action that is aligned more towards
result than mutual understanding. It is concerned with how the economy and the
state are coordinated. This, according to Habermas, does not promote the
interests of communicative action, and the system is driven by the two
subsystems of money and power (Bohman, 2014; Finlayson, 2005). Thus, money and
power “form the steering media of the capitalist economy” by directing both the
state administration (for example, the civil service) as well as the activities
of the political parties (Finlayson, 2005, p. 54).

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Critique of the Individualistic
Approach to Health Promotion

The health promotion practice can
be viewed as what Habermas referred to as human activity taking place within a
social context. Within the framework of Habermas’s TCA, I argue that the individualized
approach is oriented to strategic action. According to Habermas, strategic
action is goal-oriented whereby interventions are used to achieve personal
desires in an oppressive manner. Thus, I contend that the individualistic
approach to health promotion is oriented to modification of individual
behaviour with the assumption that “…personal behaviour is the most important
determinant of health…” (Williams, 1989, p. 19). Furthermore, in nursing
practice, several theories of behavioural change are employed to explain the
health and health behaviours of individuals. These theories are oriented
towards motivating individuals to adopt healthier behaviours rather than taking
into account the ways in which socioeconomic factors and environmental
determinants of health influence peoples’ health and health outcomes. Although
some behavioural theories do consider the wider context of socioeconomic
factors, their main focus is directed toward individual activities and their
ability to make healthy choices (Baum, & Fisher, 2014).

Indeed, the emphasis on the
individualistic approach is also evident in the manner in which WHO (1985)
defines health promotion. WHO defined health promotion as “the process of
enabling people to increase control over and to improve their health” (p. 5).
This statement further reinforces the idea that individuals are responsible for
their health status Arguably, people seems not to be aware of the assumption
underlying this approach including  its
associated oppression. Habermas refers to this situation as systematically
distorted communication. As a result of peoples’ inability to react to this
oppression (Cody, 1998) at this is a form of oppression and nursing contributes
to this oppression by concentrating on individuals are held responsible for the
failure of health promotion in changing behaviours. For example, people are
held responsible for continuing to smoke or remaining physically inactive
(Laverack, 2017).

Viewing the individualistic
approach to health promotion from the lens of the lifeworld and the system, it
could be argued that nursing is in an equivocal position. As such, nurses can
be seen as being of the lifeworld as advocates and by virtue of being part of
the oppressed group, while they are of the system as professionals working and
interacting with the capitalist model and its principles. To adopt the
perspective of Habermas’s communicative action as a framework for health
promotion, nursing scholars must work to embody these two positions
simultaneously. Lack of success in acting out the roles of both system and
lifeworld might lead to systematically distracted communication. This is what
Habermas’s TCA seek to expose with regard to health promotion practice. This
being said, from my perspective, the analysis of Habermas’s ideas presented in
this paper suggests not only that it might be impossible to achieve the
intended emancipatory practice for health promotion in nursing, but that they
seem to be inherently unachievable as a result of system constraints that do
not support communicative action. Habermas contends that the success of all
activities or actions in the real world depends on the capacity to reach meet
the conditions of the TCA (Finlayson, 2005).

Why Individualistic Approach Exists

Several nurse scholars have noted
that people, including nurses, tend to view health promotion from the
individualistic standpoint as a result of identifying with ideologies that are
predominant in their environment despite that that dominant ideologies may not
have the capacity to serve individual interests (Lather, 1991; Williams, 1989).
The dominant neoliberalist ideologies that operate in nursing and health care
invariably dictate the knowledge that shapes nursing health promotion practice
(Browne, 2000). It could be argued that lack of criticism with regard to the
knowledge that informs nursing health promotion contributes to a reinforcement
of the individualistic approach to health promotion. Some health scholars
clearly identified with the individualistic approach to health promotion. For
example, Schank (1999) supports the individualistic approach to nursing health
promotion practice and claims that in view of the increasing emphasis on
preventive health care, it “will require the individual to possess the
necessary cognitive and psychomotor skills to provide for their health and the
health of their families” (Schank, 1999, p. 10). This statement further
reinforces the assumption that the individual is the most important determinant
of health.

 

Despite that the individualistic
approach to nursing health promotion and practice seems inadequate with regard
to serving individual interests, its use is still being promoted in nursing
practice. Browne (2001) suggests that the manner in which nursing scholars
promulgate theories and models grounded in the individualistic approach might
be relevant to the existence of this approach to health promotion. Following
this line of reasoning, it could be argued that the ideologies of neoliberalism
operating in nursing and health care as the basis for nursing knowledge
development and nursing inquiry shape nursing health promotion practice. Thus,
I will discuss the assumptions underlying the neoliberal ideologies with regard
to how it has impacted the individualistic approach to health promotion theory
and practice in nursing, as well as its influence regarding public health
policy.

Assumptions of
Neoliberal Ideology

In the mid-eighteenth century, the
term liberalism (meaning, removal of government intervention in the market
economy) originated from the ideas of Adam Smith, who advocated for a
minimization of the role of government in the market economy to increase
profit. Later, in the late nineteenth century, neoliberalism or new liberalism
replaced liberalism with the assumption that the free functioning of market
forces would produce higher profits and development (McGregor, 2001). Ayo
(2014) argues that reducing government intervention in the market economy
equally prevents government from investing in the fundamentals of health, such
as income, housing, and food. Consequently, “health promotion policy and
practice…” (p. 102) seems to ignore these fundamentals of health, paving the
way for poor health outcomes. Thus, it could be argued that the liberal
ideology is at the root of the unequal distribution of the “educational,
economic, and motivational resources” needed to change unhealthy behaviours
(Williams, 1989, p. 20).

Furthermore, Foucault substantiates
the individualistic nature of neoliberalism with respect to the ways in which
the state controls the market. He states that neoliberalism involves extending
the economic model of supply and demand and of investment-costs-profit so as to
make it a model of social relations, and of existence itself. As such, it
speaks to the type of relationship the individual has to himself, time, those
around him, the group, and the family (Foucault 2004/2008, p. 242). Therefore,
as one of the central tenets of neoliberalism, neoliberal individualism does
not support the perspective “that health is primarily created by the structures
which powerfully shape peoples’ lives, including the dominant economic
structure” (Baum, & Fisher, 2014, p. 3).