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- 1. Foundations for HealthPromotion 4th Edition Jennie Naidoo - eBook PDF install download https://ebookluna.com/download/foundations-for-health-promotion- ebook-pdf/ Download more ebook instantly today - Get yours now at ebookluna.com
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- 6. Foundations for HealthPromotion FOURTH EDITION Jennie Naidoo Principal Lecturer, Health Promotion and Public Health, University of the West of England, Bristol, UK Jane Wills Professor of Health Promotion, London South Bank University, London, UK
- 7. Table of Contents Coverimage Title page Copyright Preface Acknowledgements Part One. The theory of health promotion Introduction Chapter One. Concepts of health Importance of the Topic Defining health, well-being, disease, illness and ill health Well-being The Western scientific medical model of health A critique of the medical model Lay concepts of health
- 8. Cultural views ofhealth A unified view of health Conclusion Summary Chapter Two. Influences on health Importance of the Topic Determinants of health Social class and health Income and health Housing and health Employment and health Gender and health Health of ethnic minorities Place and health Explaining health inequalities Tackling inequalities in health Conclusion Summary Chapter Three. Measuring health Importance of the Topic Why measure health?
- 9. Ways of measuringhealth Measuring health as a negative variable (e.g. health is not being diseased or ill) Mortality statistics Morbidity statistics Measuring health and disease in populations Measures of health as an objective attribute Measuring deprivation Subjective health measures Physical well-being, functional ability and health status Psychological well-being Social capital and social cohesion Quality of life Conclusion Summary Chapter Four. Defining health promotion Importance of the Topic Foundations of health promotion Origins of health promotion in the UK Public health The World Health Organization and health promotion Defining health promotion
- 10. Critiques of healthpromotion The argument for health promotion Advocacy Enablement Mediation Conclusion Summary Chapter Five. Models and approaches to health promotion Importance of the Topic The medical approach Behaviour change The educational approach Empowerment Social change Models of health promotion Theories in health promotion Conclusion Summary Chapter Six. Ethical issues in health promotion Importance of the Topic The need for a philosophy of health promotion
- 11. Duty and codesof practice Consequentialism and utilitarianism: The individual and the common good Ethical principles Conclusion Summary Chapter Seven. The politics of health promotion Importance of the Topic What is politics? Political ideologies Globalization Health as political The politics of health promotion structures and organization The politics of health promotion methods Being political Conclusion Summary Part Two. Strategies and methods Introduction Chapter Eight. Reorienting health services Importance of the Topic
- 12. Introduction Promoting health inand through the health sector Primary healthcare and health promotion Primary healthcare principles Primary healthcare: strategies Primary healthcare: service provision Participation Equity Collaboration Who promotes health? Public health and health promotion workforce Specialist community public health nurses Mental health nurses School nurses Midwives General practitioners Practice nurses Dentists Pharmacists Environmental health workers Allied health workers Care workers
- 13. Specialists Conclusion Summary Chapter Nine. Developingpersonal skills Importance of the Topic Definitions The health belief model Theory of reasoned action and theory of planned behaviour The stages of change model The prerequisites of change Conclusion Summary Chapter Ten. Strengthening community action Importance of the Topic Defining community Why work with communities? Approaches to strengthening community action Defining community development Community development and health promotion Working with a community-centred approach Types of activities involved in strengthening community action
- 14. Dilemmas and challengesin community-centred practice Conclusion Summary Chapter Eleven. Developing healthy public policy Importance of the Topic Defining HPP Health in all policies (HiAP) Health impact assessment (HIA) The history of HPP Key characteristics of HPP: advantages and barriers The practitioner’s role in HPP Evaluating an HPP approach Conclusion Summary Chapter Twelve. Using media in health promotion Importance of the Topic Introduction The nature of media effects The role of mass media Planned campaigns Unpaid media coverage
- 15. Media advocacy Social marketing Whatthe mass media can and cannot do Communication tools Conclusion Summary Part Three. Settings for health promotion Introduction Chapter Thirteen. Health promoting schools Importance of the Topic Why the school is a key setting for health promotion Health promotion in schools The health promoting school Policies and practices Links with the community Effective interventions Conclusion Summary Chapter Fourteen. Health promoting workplaces Importance of the Topic
- 16. Why is theworkplace a key setting for health promotion? The relationship between work and health Responsibility for workplace health Health promotion in the workplace Conclusion Summary Chapter Fifteen. Health promoting neighbourhoods Importance of the Topic Defining neighbourhoods Why neighbourhoods are a key setting for health promotion Conclusion Summary Chapter Sixteen. Health promoting health services Importance of the Topic Defining a health promoting hospital Why hospitals are a key setting for health promotion Promoting the health of patients Promoting the health of staff The hospital and the community Organizational health promotion The HPH movement
- 17. Health promoting pharmacies Conclusion Summary ChapterSeventeen. Health promoting prisons Importance of the Topic Why prisons have been identified as a setting for health promotion Barriers to prisons as health promoting settings Health promoting prisons Examples of effective interventions Conclusion Summary Part Four. Implementing health promotion Introduction Chapter Eighteen. Assessing health needs Importance of the Topic Defining health needs The purpose of assessing health needs Health needs assessment Setting priorities Conclusion
- 18. Summary Chapter Nineteen. Planninghealth promotion interventions Importance of the Topic Reasons for planning Health promotion planning cycle Strategic planning Project planning Planning models Stage 1: What is the nature of the problem? Stage 2: What needs to be done? Set aims and objectives Stage 3: Identify appropriate methods for achieving the objectives Stage 4: Identify resources and inputs Stage 5: Plan evaluation methods Stage 6: Set an action plan Stage 7: Action, or implementation of the plan Planning models PRECEDE-PROCEED model Quality and audit Conclusion Summary Chapter Twenty. Evaluating health promotion interventions
- 19. Importance of theTopic Defining evaluation Why evaluate? What to evaluate Process, impact and outcome evaluation Evaluation research methodologies How to evaluate: The process of evaluation How to evaluate: Gathering and analysing data Building an evidence base for health promotion What to do with the evaluation: Putting the findings into practice Conclusion Summary Glossary Index
- 20. Copyright © 2016, ElsevierLtd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). First edition 1994 Second edition 2000 Third edition 2009 ISBN 978-0-7020-5442-6 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress
- 21. Notices Knowledge and bestpractice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
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- 23. Preface Health promotion isa core aspect of the work of a wide range of healthcare workers and those engaged in education and social welfare. It is an emerging area of practice and study, still defining its boundaries and building its own theoretical base and principles. This book aims to provide a theoretical framework for health promotion, as this is vital to clarify practitioners’ intentions and desired outcomes. It offers a foundation for practice which encourages practitioners to see the potential for health promotion in their work, to be aware of the implications of choosing from a range of strategies and to be able to evaluate their health promotion interventions in an appropriate and useful manner. This fourth edition of Health Promotion: Foundations for Practice has been comprehensively updated and expanded to reflect recent research findings and major organizational and policy changes over the last decade. Our companion volume, Public Health and Health Promotion: Developing Practice (Naidoo and Wills, 2010), discusses in more detail some of the challenges and dilemmas raised in this book, e.g. partnership working, tackling inequalities and engaging the public. The book is divided into four main parts. The first part provides a theoretical background, exploring the concepts of health, health education and health promotion. Part One concludes that health promotion is working towards positive health and well-being of individuals, groups and communities. Health promotion includes health education but also acknowledges the social, economic and environmental factors which determine health status. Ethical and political values inform practice, and it is important for practitioners to reflect upon these values and their implications. Part One embraces the shift towards well-being rather than a narrow interpretation of health, and the move away from a simple focus on lifestyle changes as the goal of health promotion. Its aim is to enable readers to
- 24. understand and reflectupon these theoretical drivers of health promotion practice within the context of their own work. Part Two explores strategies to promote health, and some of the dilemmas they pose. Using the Ottawa Charter (World Health Organization, 1986) framework to identify the range of strategies, the potential, benefits and challenges of adopting each strategy are discussed. Examples of interventions using the different strategies are presented. What is reflected here is how health services have not moved towards prioritizing prevention, although there is much greater acceptance and support for empowerment approaches in work with individuals and communities. While policies that impact on health still get developed in isolation from each other, there is a recognition of the need for health in all policies, and for deliberative democracy and working methods that engage with communities as the ways forward. Part Three focuses on the provision of supportive environments for health, identified as a key strategy in the Ottawa Charter. Part Three explores how a range of different settings in which health promotion interventions take place can be oriented towards positive health and well-being. The settings discussed in this part – schools, workplaces, neighbourhoods, health services and prisons – have all been targeted by national and international policies as key for health promotion. Reaching specific target groups, such as young people, adults or older people, within these settings is also covered in Part Three. There is much debate about the need for systems thinking and seeing such settings more broadly as environments where physical, social and economic drivers come together, and not just as places in which to carry out health education and lifestyle behaviour interventions. Part Four focuses on the implementation of health promotion interventions. Each chapter in this part discusses a different stage in the implementation process, from needs assessment through planning to the final stage of evaluation. This part is designed to help practitioners to reflect on their practice through examining what drives their choice of practical implementation strategies. A range of
- 25. real-life examples helpsto illustrate the options available and the criteria that inform the practitioner’s choice of approach. This book is suitable for a wide range of professional groups, and this is reflected in the choice of examples and illustrative case studies, which have been completely updated for this edition. In response to reader feedback about the ways to engage with a textbook, we have changed the format for this edition. Each chapter has between 6 and 15 learning activities which encourage readers to engage with the text and extend their learning. Indicative feedback about the points that a reader or student might wish to consider is provided at the end of the chapter. Each chapter also includes at least one case study and research example to provide the reader with examples of application and encourage a focus on topics. Further questions at the end of each chapter encourage readers to reflect on their practice, values and experience, and to debate the issues. To reflect the huge changes in information management since this book was first published in 1994, website addresses are given for resources and further reading where possible. The book is targeted at a range of students, including those in basic and post-basic training and qualified professionals. By combining an academic critique with a readable and accessible style, this book will inform, stimulate and encourage readers to engage in ongoing enquiry and reflection regarding their health promotion practice. The intention, as always, is to encourage readers to develop their practice through considering its foundation in theory, policy and clear principles. Jennie Naidoo Jane Wills, Bristol and London
- 26. References Naidoo J, WillsJ. Public Health and Health Promotion: Developing Practice. third ed. London: Baillière Tindall; 2010. World Health Organization. Ottawa Charter for Health Promotion. Geneva: WHO; 1986.
- 27. Acknowledgements It is 21years since the publication of the first edition of this book, which was initially prompted by our teaching on the first postgraduate specialist courses in health promotion. Students and colleagues at the University of the West of England and London South Bank University have, as always, contributed to this edition through their ideas, debates and practice examples. We continue to be committed to the development of health promotion as a discipline. We dedicate this fourth edition to our children, Declan, Jessica, Kate and Alice.
- 28. PART ONE The theoryof health promotion OUTLINE Introduction Chapter One. Concepts of health Chapter Two. Influences on health Chapter Three. Measuring health Chapter Four. Defining health promotion Chapter Five. Models and approaches to health promotion Chapter Six. Ethical issues in health promotion Chapter Seven. The politics of health promotion
- 29. Introduction Part One exploresthe concepts of health, health education and health promotion. Health promotion draws upon many different disciplines, ranging from the scientific (e.g. epidemiology) and the social sciences (e.g. sociology and psychology) to the humanities (e.g. ethics). This provides a wealth of theoretical underpinnings for health promotion, ranging from the scientific to the moralistic. This in turn means that health promotion in practice may range from a scientific medical exercise (e.g. vaccination) or an educational exercise (e.g. sex and relationships education in schools) to a moral query (e.g. end-of-life options). An important first step for health promoters is to clarify for themselves where they stand in relation to these various different strategies and goals. Are they educators, politicians or scientists? In part this will be determined by their background and initial education, but health promotion is an umbrella which encompasses all these activities and more. Working together, practitioners can bring their varied bodies of knowledge and skills to focus on promoting the health of the population, and achieve more significant and sustainable results than if they were operating on their own. This first part of the book explores different understandings of the concept of health and well-being, and the ways in which health can be enhanced or promoted. The effect on health of structural factors such as income, gender, sexuality and ethnicity and the way in which social factors are important predictors of health status are explored in Chapter 2. The different ways in which health is measured reflect different views on health, from the absence of disease to holistic concepts of well-being, and these are discussed in Chapter 3. Chapters 4 and 5 debate what health promotion is, adopting an ecological model in which change in health is said to be influenced by the interaction of individual, social and physical environmental variables.
- 30. Chapters 6 and7 will help those who promote health to be clear about their intentions and how they perceive the purpose of health promotion. Is it to encourage healthy lifestyles? Or is it to redress health inequalities and empower people to take control over their lives?
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- 32. Concepts of health LEARNINGOUTCOMES By the end of this chapter you will be able to: • define the concepts of health, well-being, disease, illness and ill health, and understand the differences between them • discuss the nature of health and well-being, and how culture and populism influence our definitions • understand the elements of the medical model of health and how it influences healthcare practice. KEY CONCEPTS AND DEFINITIONS Biomedicine Focuses on the causes of ill health and disease within the physical body. It is associated with the practice of medicine, and contrasts with a social model of health. Disease Is the medical term for a disorder, illness or condition that prevents an individual from achieving the full functioning of all his or her bodily parts. Health Is the state of complete mental and physical well-being of an individual, not merely the absence of disease or illness. Ill health Is a state of poor health when there is some disease or impairment, but not usually serious enough to curtail all activities. Illness Is a disease or period of sickness that affects an individual’s body or mind and prevents the individual achieving his or her optimal outputs.
- 33. Well-being Is thepositive feeling that accompanies a lack of ill health and illness, and is associated with the achievement of personal goals and a sense of being well and feeling good.
- 34. Importance of theTopic Everyone engaged in the task of promoting health starts with a view of what health is. However, these views, or concepts, of health vary widely. It is important at the outset to be clear about the concepts of health to which you personally adhere, and recognize where these differ from those of your colleagues and clients. Otherwise, you may find yourself drawn into conflicts about appropriate strategies and advice that are actually due to different ideas concerning the end goal of health. This chapter introduces different concepts of health and traces the origin of these views. The Western scientific medical model of health is dominant, but is challenged by social and holistic models. Working your way through this chapter will enable you to clarify your own views on the definition of health and locate these views within a conceptual framework.
- 35. Defining health, well-being,disease, illness and ill health Health Health is a broad concept which can embody a huge range of meanings, from the narrowly technical to the all-embracing moral or philosophical. The word ‘health’ is derived from the Old English word for heal (hael) which means ‘whole’, signalling that health concerns the whole person and his or her integrity, soundness or well-being. There are ‘common-sense’ views of health which are passed through generations as part of a common cultural heritage. These are termed ‘lay’ concepts of health, and everyone acquires a knowledge of them through socialization into society. Different societies and different groups within one society have different views on what constitutes their ‘common-sense’ notions about health. Learning Activity 1.1 What does health mean to you? What are your answers to the following? • I feel healthy when… • I am healthy because… • To stay healthy I need… • I become unhealthy when… • My health improves when… • (An event) affected my health by… • (A situation) affected my health by… • …is responsible for my health. Health has two common meanings in everyday use, one negative and one positive. The negative definition is the absence of disease or illness. This is the meaning of health within the Western scientific medical model, which is explored in greater detail later in this
- 36. chapter. The positivedefinition of health is a state of well-being, interpreted by the World Health Organization in its constitution as ‘a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity’ (World Health Organization, 1946). Health is holistic and includes different dimensions, each of which needs to be considered. Holistic health means taking account of the separate influences and interaction of these dimensions. Figure 1.1 shows a diagrammatic representation of the dimensions of health. The inner circle represents individual dimensions of health. • Physical health concerns the body, e.g. fitness, not being ill. • Mental health refers to a positive sense of purpose and an underlying belief in one’s own worth, e.g. feeling good, feeling able to cope. • Emotional health concerns the ability to feel, recognize and give a voice to feelings, and to develop and sustain relationships, e.g. feeling loved. • Social health concerns the sense of having support available from family and friends, e.g. having friends to talk to, being involved in activities with other people. • Spiritual health is the recognition and ability to put into practice moral or religious principles or beliefs, and the feeling of having a ‘higher’ purpose in life. • Sexual health is the acceptance and ability to achieve a satisfactory expression of one’s sexuality.
- 37. FIG. 1.1 Dimensionsof health. The three outer circles are broader dimensions of health which affect the individual. Societal health refers to the link between health and the way a society is structured. This includes the basic infrastructure necessary for health (such as shelter, peace, food, income), and the degree of integration or division within society. We shall see in Chapter 2 how the existence of patterned inequalities between groups of people harms the health of everyone. Environmental health refers to the physical environment in which people live, and the importance of good-quality housing, transport, sanitation and pure-water facilities. Global health involves caring for the planet and ensuring its sustainability for the future.
- 38. Learning Activity 1.2Holistic model of health What are the implications of a holistic model of health for the professional practice of health workers?
- 39. Well-being ‘Well-being’ is aterm widely used to describe ‘what makes a good life’. It is also used in healthcare discourse to broaden views on what health means beyond the absence of illness. Feeling good and functioning well are seen as important components of mental well- being. This, in turn, leads to better physical health, improved productivity, less crime and more participation in community life (DH, 2010). The New Economics Foundation has developed the Happy Planet Index (New Economics Foundation, 2012) as a headline indicator of how nations compare in enabling long and happy lives for their citizens. In 2012: • eight of the nine countries that are achieving high and sustainable well-being are in Latin America and the Caribbean • the highest-ranking Western European nation is Norway in 29th place, just behind New Zealand in 28th place. • the USA is in 105th position out of 151 countries. Similarly, the UNICEF index of child well-being (UNICEF, 2013) shows that well-being is greater in more egalitarian countries, such as Norway and other Scandinavian countries. Evidence (Government Office for Science, 2008) suggests that there are five methods or steps that individuals can take to enable themselves to achieve well-being: • connect • be active • take notice • give • keep learning. More recently, ‘Care (about the planet)’ has been added to this list. Learning Activity 1.3 Five steps to well-being What evidence is there for each of the steps to well-being?
- 40. Disease, illness andill health Disease, illness and ill health are often used interchangeably, although they have very different meanings. Disease derives from desaise, meaning uneasiness or discomfort. Nowadays, disease implies an objective state of ill health, which may be verified by accepted canons of proof. In our modern society these accepted canons are couched in the language of scientific medicine. For example, microscopic analysis may yield evidence of changes in cell structure, which may in turn lead to a diagnosis of cancer. Disease is the existence of some pathology or abnormality of the body which is capable of detection. Disease can be due to exogenous (outside the body, e.g. viral infection) or endogenous (inside the body, e.g. inadequate thyroid function) factors. Illness is the subjective experience of loss of health. This is couched in terms of symptoms, for example the reporting of aches or pains, or loss of function. One way that illness is given meaning is through the narratives we construct about how we fall sick. The process of making sense of illness is a task most sick people engage in to answer the question ‘why me?’ Illness and disease are not the same, although there is a large degree of coexistence. For example, a person may be diagnosed as having cancer through screening, even when there have been no reported symptoms; thus a disease may be diagnosed in someone who has not reported any illness. When someone reports symptoms, and further investigations such as blood tests prove a disease process, the two concepts of disease and illness coincide. In these instances, the term ill health is used. Ill health is therefore an umbrella term used to refer to the experience of disease plus illness. Health is the normal functioning of the body as a biological entity. Health is both not being ill and the absence of symptoms. Social scientists view health and disease as socially constructed entities. Health and disease are not states of objective reality waiting to be uncovered and investigated by scientific medicine; rather, they are actively produced and negotiated by ordinary people. Cornwell’s (1984) study of London’s Eastenders used three categories of health problems.
- 41. 1. Normal illness,e.g. childhood infections. 2. Real illness, e.g. cancer. 3. Health problems, e.g. ageing, allergies. Illness has often been conceptualized as deviance – as a different state from the healthy norm and a source of stigma. Goffman (1968) identified three sources of stigma. 1. Abominations of the body, e.g. psoriasis. 2. Blemishes of character, e.g. human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). 3. Tribal stigma of race, nation or religion, e.g. apartheid. The subjective experience of feeling ill is not always corroborated by an objective diagnosis of disease. When this lack of corroboration happens, doctors and health workers may label sufferers ‘malingerers’, denying the validity of subjective illness. This can have important consequences. For example, a sick certificate, and therefore sick pay, may be withheld if a doctor is not convinced that someone’s reported illness is genuine. The acceptance of reported symptoms as signs of an illness leads to a debate about how to manage the illness. Several conditions, such as chronic fatigue syndrome and repetitive strain injury, have taken a long time to be recognized as legitimate illnesses. Learning Activity 1.4 The medicalization of health What examples are there of a condition or behaviour where its medicalization has led to its acceptance or otherwise? It is also possible for an individual to experience no symptoms or signs of disease, but to be labelled sick as a result of medical examination or screening. Hypertension and pre-cancerous changes to cell structures are two examples where screening may identify a disease even though the person concerned may feel perfectly healthy. Figure 1.2 gives a visual representation of these discrepancies. The central point is that subjective perceptions cannot be overruled, or
- 42. invalidated, by scientificmedicine.
- 43. The Western scientificmedical model of health In modern Western societies, and in many other societies as well, the dominant professional view of health adopted by most healthcare workers during their training and practice is labelled Western scientific medicine. Western scientific medicine operates within a medical model using a narrow view of health, which is often taken to mean the absence of disease and/or illness. In this sense, health is a negative term, defined more by what it is not than by what it is. FIG. 1.2 The relationship between disease and illness. This view of health is extremely influential, as it underpins much of the training and ethos of a wide variety of health workers. Its definitions become powerful because they are used in a variety of contexts, not just in professional circles. For example, the media often present this view of health, disease and illness in dramas set in hospitals or documentaries about health issues. By these means, professional definitions become known and accepted in society at large.
- 44. The scientific medicalmodel arose in Western Europe at the time of the Enlightenment, with the rise of rationality and science as forms of knowledge. In earlier times, religion provided a way of knowing and understanding the world. The Enlightenment changed the old order, and substituted science for religion as the dominant means of knowledge and understanding. This was accompanied by a proliferation of equipment and techniques for studying the world. The invention of the microscope and telescope revealed whole worlds which had previously been invisible. Observation, calculation and classification became the means of increasing knowledge. Such knowledge was put to practical purposes, and applied science was one of the forces which accompanied the Industrial Revolution. In an atmosphere when everything was deemed knowable through the proper application of scientific method, the human body became a key object for the pursuit of scientific knowledge. What could be seen, and measured and catalogued was ‘true’ in an objective and universal sense. This view of health is characterized as: • biomedical – health is assumed to be a property of biological beings • reductionist – states of being such as health and disease may be reduced to smaller and smaller constitutive components of the biological body • mechanistic – this conceptualizes the body as if it were a machine, in which all the parts are interconnected but capable of being separated and treated separately • allopathic – this works by a system of opposites; if something is wrong with a body, treatment consists of applying an opposite force to correct the sickness, e.g. pharmacological drugs which combat the sickness • pathogenic – this focuses on why people become ill • dualistic – the mind and the body can be treated as separate entities. Health is predominantly viewed as the absence of disease. This view sees health and disease as linked, as if on a continuum, so that the more disease a person has, the further away he or she is from health and ‘normality’.
- 45. The pathogenic focuson finding the causes for ill health has led to an emphasis on risk factors, whether these are health behaviours or social circumstances. Antonovsky (1993) called for a salutogenic approach which looks instead at why some people remain healthy. He identifies coping mechanisms which enable some people to remain healthy despite adverse circumstances, change and stress. An important factor for health, which Antonovsky labels a ‘sense of coherence’, involves the three aspects of understanding, managing and making sense of change. These are human abilities which are in turn nurtured or obstructed by the wider environment. The medical model focuses on etiology, and the belief that disease originates from specific and identifiable causes. The causes of contemporary long-term chronic diseases in developed countries are often ‘social’. Medicine and medical practice thus recognize that disease and the diseased body must be placed in a social context. Nevertheless, the professional training of many healthcare workers provides an exaggerated view of the benefits of treatment and pays little attention to prevention. In part this is due to the dominant concern of the biomedical model with the organic appearance of disease and malfunction as the causes of ill health. Research Example 1.1 Carers’ health An ageing population means that caring for the elderly will become a more common experience for younger adults or even children. This has significant implications for the health of the population as a whole. Research studies have reported a clear association between caring and care givers’ poor mental and physical health, emotional distress and increased mortality. A more intense caring role (e.g. having to provide 24-hour cover, or caring for someone with both mental and physical ill health) is associated with poorer health outcomes on the part of the carer. Yet evidence also shows that not all carers report poor health. Indeed, caring has the opposite effect on some carers, conferring positive benefits through feelings of altruism, fulfilment of familial obligations and personal growth. It is
- 46. likely that theimpact of caring on the health of carers will be to some extent dependent on the existence, or lack, of a supportive environment, including, for example, community activities and respite opportunities. It also seems likely that the existence of personal religious and faith beliefs is associated with improved health and caring, as religion provides an overarching rationale for existence, even if this is compromised by poor health. Religious centres often provide supportive and caring activities for members of their faith, enabling carers to cope better with their burden of care, and providing some respite care for people with disabilities. See for example Awad et al., 2008; Rigby et al., 2009; Vellone et al., 2008. Table 1.1 contrasts the traditional views of a medical model with those of a social model of health.
- 47. A critique ofthe medical model The role of medicine in determining health The view that health is the absence of disease and illness, and that medical treatment can restore the body to good health, has been criticized. The distribution of health and ill health has been analysed from a historical and social science perspective. It has been argued that medicine is not as effective as is often claimed. The medical writer Thomas McKeown (McKeown, 1976) showed that most of the fatal diseases of the nineteenth century had disappeared before the arrival of antibiotics or immunization programmes. McKeown concluded that social advances in general living conditions, such as improved sanitation and better nutrition made available by rising real wages, have been responsible for most of the reduction in mortality achieved during the last century. Although his thesis has been disputed, there is little disagreement that the contribution of medicine to reduced mortality has been minor when compared with the major impact of improved environmental conditions. Table 1.1 The medical and social model of health Learning Activity 1.5 The impact of medicine • What effects do medical advances in knowledge have on death rates? • What other reasons could account for declining death rates? The rise of the evidence-based practice movement (see Chapter 20)
- 48. is attributed toArchie Cochrane (1972). His concern was that medical interventions were not trialled to demonstrate effectiveness prior to their widespread adoption. Instead, many procedures rest on habit, custom and tradition rather than rationality. Cochrane advocated greater use of the randomized controlled trial as a means to gain scientific knowledge and the key to progress. The role of social factors in determining health Most countries are characterized by profound inequalities in income and wealth, and these in turn are associated with persistent inequalities in health (see www.who.int/social_determinants/sdh_definition/en/). The impact of scientific medicine on health is marginal when compared to major structural features such as the distribution of wealth, income, housing and employment. Tarlov (1996) claimed that medical services contributed only 17 percent to the gain in life expectancy in the twentieth century. As Chapter 2 shows, the distribution of health mirrors the distribution of material resources within society. In general, the more equal a society is in its distribution of resources, the more equal, and better, is the health status of its citizens (Wilkinson and Pickett, 2009). Medicine as a means of social control Social scientists argue that medicine is a social enterprise closely linked with the exercise of professional power. Foucault (1977) argues that power is embedded in social organizations, expressed through hierarchies and determined through discourses. Medical power derives from its role in legitimizing health and illness in society, and the socially exclusive and autonomous nature of the profession. The medical profession has long been regarded as an institution for securing occupational and social authority. Access to such power is controlled by professional associations that have their own vested interests to protect (Freidson, 1986). The 1858 Medical Act established the General Medical Council, which was authorized to regulate
- 49. doctors, oversee medicaleducation and keep a register of qualified practitioners. The Faculty of Public Health Medicine opened membership to non-medically qualified specialists in 2003, becoming the Faculty of Public Health. Medicine is a powerful means of social control, whereby the categories of disease, illness, madness and deviancy are used to maintain a status quo in society. Doctors who make the diagnoses are in a powerful position. The role of the patient during sickness as conceptualized by Parsons (1951) is illustrated in Table 1.2. Increasingly, too, doctors are involved in decisions relating to the beginning and ending of life (terminations, assisted reproduction, neonatal care, euthanasia). The encroachment of medical decisions into these stages of life subverts human autonomy and, it is argued, gives to medicine an authority beyond its legitimate area of operation (Illich, 1975). Table 1.2 The sick role Medicine as surveillance Public health medicine has been concerned with the regulation and control of disease. Historically this included the containment of bodies, such as those infected with the plague, tuberculosis or venereal disease. Mass-screening programmes have given rise to what has been called medical surveillance. The wish to identify the ‘abnormal’ few with ‘invisible’ disease justifies monitoring the entire target population. Another critique of the pervasive power of medicine suggests the mapping of disease and identification of risk have subtly handed responsibility of health to individuals. This may invite new forms of control in the name of health, e.g. random drug testing or linking deservingness for surgery to lifestyle factors. The
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