What is Relational Health?
‘If we wanted a unicorn we would have asked for a unicorn, what we wanted was a dentist’
This is a quote from a community partner on what it felt like to be told what the problems were for your community and then being given a solution to something that wasn’t a problem for them.
There is an increasing body of evidence demonstrating the association between positive relationships and health and wellbeing . Moreover, positive relationships can also mitigate some of the negative impacts of adverse conditions and experiences [2,3]. There is also an increased understanding of schools, communities, workplaces etc, as complex adaptive systems, and that health is an emergent property arising from the system’s complex nature [4,5]. Health, as an emergent behaviour of a complex system, is therefore a consequence of the nature of the relations that comprise such systems. These relations can be the relations that subsist within the system, as well as relations that exist between the system and its environment .
Hence, in order to understand how health is constituted in complex systems, we need to understand the relational nature of these systems and their distinctive “relationalities”.
Relational Health is therefore concerned with understanding the relationality of social systems to understand how the conditions are created for health/ ill health in and of the system. This focus on relationships within the system and its wider environment as determinants of health/ ill health takes the focus away from trying to affect individuals at risk of ill health or individual behaviours in isolation.
A Relational Health approach means the focus is on understanding the nature and the qualities of the relations which support the system to self-organise towards a more health creating ‘state’.
Taking a relational approach is a challenge to much of the dominant discourses of public health and public approaches. In particular, a relational health approach to understanding the nature of population health challenges is a radical departure from the way that health ‘problems’ are currently conceptualised and addressed. For the most part, population health problems are identified and determined externally, ie from outside of the system and then programmes or policies developed to address the problem, which is usually aimed at targeting unhealthy behaviours or populations deemed to be more at risk. Such programmes tend to be evaluated on individual outcomes (and with a ’logic of coherence’ which renders context as static). For example, research to prevent/ address childhood obesity has focussed on developing school based programmes as a means of affecting weight outcomes. The ‘problem’ ie preventing or addressing overweight and obesity is ‘imposed’ upon schools and subsequent programmes to address the problem target altering the behaviours of the children and sometimes their families. Whilst this approach might have some effect in the short term, there is evidence suggesting that programmes aimed at supporting health can actually widen rather than reduce inequalities . Moreover, schools are unlikely to be sustain the programmes unless having preventing or addressing obesity is deemed to be a ‘problem’ for that school . Rather, we suggest, that unless the relations within the system change sufficiently, the system will tend to revert back to prior ways of ‘being’ once the programme has ended.
By comparison, a relational health approach insists that a necessary condition for systems to self-organise into becoming health creating environments is for the school or neighbourhood or workplace to identify and recognise the nature of the issues.
Addressing poor health and health inequalities by creating the conditions to identify the barriers to health is a fundamentally different starting point to most stakeholder engagement processes; whereby stakeholders are brought into conversations about the externally determined problem to understand what it means to them and what would be feasible and acceptable ways of addressing it. What is significant here is that the problem is still externally determined.
A relational approach starts with the recognition that more of the same can not deliver change on the scale that is needed and that new ways of delivering services are needed in response to what people identify as the barriers to a health promoting environment.
These new ways of working /delivering services start by understanding the current behaviour of the system by actively listening to understand the nature of the lived realities for people living and working in particular neighbourhoods or organisations. This approach requires practitioners, researchers and commissioners to engage people living and working in these areas to hear what the ‘problems’ are for the service or school or neighbourhood and to develop new ways of working with the residents/ workforce to respond to these issues. The local partnerships which then form become a sustainable means for the identification of local problems and responding to them. The new relationality of the system becomes the process by which the system self-organises to a more health creating ‘state’ and becomes a sustainable way for the system to adapt and respond to changes in the environment.
- Holt-Lunstad J, Smith TB, Layton JB (2010) Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 7(7): e1000316. https://doi.org/10.1371/journal.pmed.1000316
- ACE, W.A.C.E., 2018. Sources of resilience and their moderating relationships with harms from adverse childhood experiences. https://www.wales.nhs.uk/sitesplus/documents/888/ACE%20&%20Resilience%20Report%20(Eng_final2).pdf [Accessed Jan 2021]
- Beckmann, K.A., 2017. Mitigating adverse childhood experiences through investments in early childhood programs. Academic Pediatrics, 17(7), pp.S28-S29.
- Davies SC, Winpenny E, Ball S, Fowler T, Rubin J, Nolte E. For debate: a new wave in public health improvement. Lancet. 2014 Nov 22;384(9957):1889-1895. https://doi.org/10.1016/S0140-6736(13)62341-7. Epub 2014 Apr 3. PMID: 24703631.
- Harry Rutter, Natalie Savona, Ketevan Glonti, Jo Bibby, Steven Cummins, Diane T Finegood, Felix Greaves, Laura Harper, Penelope Hawe, Laurence Moore, Mark Petticrew, Eva Rehfuess, Alan Shiell, James Thomas, Martin White. The need for a complex systems model of evidence for public health, The Lancet, Volume 390, Issue 10112, 2017,Pages 2602-2604, https://doi.org/10.1016/S0140-6736(17)31267-9.
- Goodwin, Brian. How the Leopard Changed Its Spots: The Evolution of Complexity. Princeton, New Jersey: Princeton University Press, 2001. https://doi.org/10.2307/j.ctv14163sj
- Lorenc T, Petticrew M, Welch V, Tugwell P. What types of interventions generate inequalities? Evidence from systematic reviews. J Epidemiol Community Health. 2013;67(2):190-3.
- Pearson M, Chilton R, Wyatt KM, Abraham C, Ford T, Buckley Woods H and Anderson R. Implementing health promotion programmes in schools: A realist systematic review of research and experience in the United Kingdom. Implementation Science 2015 10:149 https://doi.org/10.1186/s13012-015-0338-6