the social context of public health

The social context of public healthDistrict Health Management

Community Research and Health Promotion

Session 2015-2016

Assoc Prof Dr Halyna Lugova

Content

1. Definitions of health: models of health

2. Evolution of public health

3. Approaches to health promotion

4. Health needs assessment

Definitions of Health(a) The medical model of health

‘Health is defined as the absence of disease’

(has dominated since Middle Ages in Western societies)

Human body like an intricate machine

Curative model, undermines prevention

Fails to accommodate social causes of diseases

(sanitation, overcrowding)

Subjective perceptions of ill-health disregarded by

health professionals

Medicine is a social enterprise closely linked with

exercise of professional power

Health is measured in terms of its absence:

o incidence, death rates

By studying and mastering the workings

(Physiology) of the parts (Anatomy), we

can understand the operation of the

whole. Simple.

When the parts start to malfunction

(Pathology), we can address them…cure

them…through medicines

(Pharmacology) and/or removal

(Surgery)

Definitions of Health

(b) The holistic model of health

‘Health is a state of complete physical, mental

and social well-being and not merely the

absence of disease of infirmity’ (WHO, 1946)


(c) The wellness model of health

‘Health is 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’ (1986, Ottawa Charter for Health Promotion)

Moving from viewing health as a state to a dynamic model

(d) Salutogenesis and Quality of Life

Salutogenetic model:

‘Health is viewed in terms of resilience as the capability of individuals and

communities to cope successfully in the case of significant adversity or risk’

(A. Antonovsky, 1996)

Quality of Life model:

‘Health is not a condition that one introspectively feels in oneself. Rather, it

is condition of being involved, of being in the world, of being together with

one‘s fellow human beings, of active and rewarding engagement in one‘s

everyday tasks’ (Gadamer, 1986)


Adopted from: Lindstrom &

Ericsson, 2011

Adopted from: Nurse

& Edmondson-Jones,

2006

Evolution of Public Health

1) Health Protection

Antiquity – 1830

• Enforced regulation of

human behaviour

• Religious practices,

customs and

quarantine


2) Miasma Control

1840 – 1870

• Addressing unsanitary

environmental

conditions

• Potable water and

sanitation programs


3) Contagion Control

1880 – 1930

• Germ theory:

infectious origins of

diseases

• Vaccination,

Chemotherapy


4) Preventive Medicine

1940 – 1960

• Focus on “high-risk”

groups

• Medical dominance

• Treatment of

communicable diseases


5) Primary Health Care

1970 – 1980

• Health for All

• Preventive approach

• Emphasis on equity

• Social determinants of

health


6) Health Promotion

1990 – present

• Educational, economic

and political actions

enabling (empowering)

individuals and

communities to increase

control over, or improve,

their health

Health PromotionIt is widely considered that health promotion is the

cornerstone of primary health care and is therefore a core

function of public health.

Factors amenable to HP include:

• Individual lifestyle factors

• Social and community networks

• Living and working conditions

• General socio-economic, cultural, and environmental conditions

Social determinants of health

Social gradient:

a reflection of

social structure

on health of the

population which

indicates the

differences in

health across the

society in a graded manner

1) The medical approach

Preventive services

Aims to reduce morbidity & mortality

Three levels of prevention

Expert-led, top-down

2) Behavior change

Encourage individuals to

adopt healthy behaviors

One-to-one counselling

Seek to ensure

compliance

Expert-led, top-down

3) Educational approach

Does not set out to

persuade change

Provide knowledge

so that people can

make an informed

choice

Health education

4) Empowerment

• Empowerment is the

practice-based knowledge

that people have or gain if

they realize that they can

control and master their

lives

• Identifying concerns and

working with individuals

(communities) to plan a

program of action to address

these concerns

5) Social change

• Focus at the policy

• Environmental level

• Broader socio-economic

determinants of health

• ‘To make the healthy

choice the easier choice’

• Lobbying, policy

planning, advocacy

Critique of approaches directed towards individual or lifestyle determinants of health

It involves considerable effort for a person to change his or her

habits or routines.

People adopt a certain behaviour or lifestyle for various reasons.

Health is not always a salient issue in people’s lives.

People are sometimes prevented from making lifestyle

changes for reasons outside their personal control. Not

everyone has the same choices.

Health needs assessment

Normative needs

Felt needs

Expressed needs

Comparative needs

Maslow hierarchy

of basic needs

Health needs assessment

What information is needed?

How can I find out this information?

What am I going to do with the information?

What scope is there to act on the information?

What information is needed?

A community profile:

Age profile, social networks

Extent of economic activity and unemployment, housing, transport links, green areas, air pollution

Availability of health service provision

Health improvement programs

Indicators of the state of health:

Self-reported health

Life expectancy

Mortality rates and cause

Morbidity

A community profile:

Age profile, social networks

Extent of economic activity and unemployment, housing, transport links, green areas, air pollution

Availability of health service provision

Health improvement programs

Indicators of the state of health:

Self-reported health

Life expectancy

Mortality rates and cause

Morbidity

Gathering information

Routine information (e.g. census,

local authority data)

Public meetings and forums

Interviews with users

Focus groups

Use local media

Rapid appraisals, ethnographic

studies

Whose needs count?

There will be disadvantaged individuals

who do not have opportunities for

expression: harder to reach groups:

Homeless

Unemployed

Residing in a remote area

Ethnic minorities

Illegal immigrants

Getting cross-section of a community,

comparing information between different

population groups will help to identify

health needs of the disadvantaged

One can clearly see that

for a common outcome,

means to get it may

imply unequal services

provision within a given

population.

Setting priorities

The issue should be a major cause of premature death or

avoidable ill health in the population as a whole or amongst specific

groups

There are marked inequalities in those who suffer ill health or

premature death

Effective intervention should be possible

Locally determined priorities, e.g. diabetes, elderly people’s health

Summary1) We discussed the principles of health promotion: definitions and models

of health, approaches to health promotion, social determinants of health.

2) We discussed how health needs are to be defined and how this should

inform program planning and development.

3) Health Promotion is a concept and a strategy for reducing health

inequalities and closing the health gap between the rich and the poor, and

the socially advantaged and disadvantaged groups.

4) Action at all levels is required: empowering individuals and

communities, building community capacity, advocacy, building healthy

public policy to create environments that support and sustain health and

well-being.

References:Antonovsky, A. (1996) ‘The salutogenic model as a theory to guide health promotion’, Health Promotion

International, 11 (1), pp. 11–18.

Awofeso, N. (2004) ‘What’s new about the “new public health” ?’ American Journal of Public Health, 94 (5),

pp. 705–709.

Dahlgren, G, Whitehead, M. (1991): Policies and Strategies to Promote Social Equity in Health.

Dahlgren, G. & Whitehead, M. (2006) Levelling up (part 2): European strategies for tackling social inequities in

health. Studies on social and economic determinants of population health, no. 3. (pp. 1–34) Copenhagen,

Denmark: World Health Organization, Regional Office for Europe.

Lindström, B. & Eriksson, M. (2005) ‘Salutogenesis’, Journal of Epidemiology and Community Health, 59 (6),

pp. 440–442.

Naidoo, J. & Wills, J. (2009) Foundations for health promotion. 3rd ed. Edinburgh: Baillière Tindall Elsevier.

Nurse, J. & Edmondson-Jones, P. (2007) ‘A framework for the delivery of public health: an ecological

approach’, Journal of Epidemiology and Community Health, 61 (6), pp. 555 -558.

the social context of public health

Health & Medicine