How does health promotion differ from disease prevention in theory and practice?
The past century and a half has seen a series of shifts in our definitions of health and disease and, as a result, also in the approaches taken by governments and health professionals. After an initial focus on sanitation and public health in the late nineteenth century, health policy moved towards formal health care after the 1930s. With escalating costs of welfare, the 1970s saw a greater emphasis on individual responsibility for health and behaviour change and since then the concept of health promotion has come increasingly to the fore. I will examine the reasons for this change and its implications in theory and practice, as well as considering some of the criticisms that have been voiced against the health promotion approach. Finally I will turn to disease prevention, looking at its implementation and how it fits into this revised model of health care. Visit coursework ae in ae fo ae for ae more work ae Do ae not ae redistribute
During the latter half of the nineteenth century, approaches to decreasing the prevalence of disease centred on reducing population exposure to causes of disease. This ‘sanitary phase’ (Rees Jones 2003) in public health was initiated in Britain following Chadwick’s 1842 report on the problems of industrialised cities. Implemented through the Public Health Act of 1848, it involved measures such as the provision of clean drinking water and the safe disposal of sewage. From the 1930s onwards, the advances of medical science encouraged a medical approach to disease and governments were concerned with increasing the provision of, and ensuring access to, the formal health care system (Locker 1997). In the UK this resulted in the formation of the National Health Service, with the aim to reduce population health-care costs in the longterm. When this failed to happen and the 1970s brought with them the oil crisis and economic recession, the focus shifted towards a behavioural approach to health care. Since the middle of the century epidemiological studies linking lifestyle factors with the rising prevalence of chronic disease had been accumulating (Breslow 1999) and policies began to emphasise health education and disease prevention through behaviour changes at the individual level. Criticising these for failing to recognize social, economic and environmental factors affecting health, others advocated a more socioenvironmental approach (McKinlay 1974, cited in Locker 1997). Out of these shifts in thinking, drawing on both the behavioural and socioenvironmental perspectives, arose a revised approach with a changed emphasis from disease prevention to health promotion.
The movement towards health promotion also had its roots in a shift in thinking about the meaning of ‘health’. With the near eradication of communicable diseases and the improvement in treatment of chronic non-communicable disease, people in developed countries were on the whole living longer, healthier lives. As a result, there was a revision of the traditional view of health as ‘lack of disease’ (Breslow 1999). As early as 1948 the World Health Organisation defined health as ‘a complete state of physical, mental and social well-being and not merely the absence of disease and infirmity’. This has since been extended and elaborated on and the 1987 definition emphasised health as ‘a resource for everyday life ... social and personal resources, as well as physical capabilities’ (ICHP, cited in Tudor 1999). Labonte (1993, cited in Lacker 1997) listed the components of good health as energy, good social relationships, a sense of control over one’s life, being able to do enjoyable things, having a sense of purpose in life and feeling part of a community. Achieving this rather extensive list of health objectives clearly involves more than disease prevention and medical treatment and health promotion sought to bridge this gap. Sometimes referred to as the ‘new public health’ approach (Locker 1997), it began to take hold after the publication of the 1974 Lalonde Report, which maintained that all morbidity and mortality could be explained through deficiencies in four factors - health care provisions, lifestyle and behaviour, environment or human biology. The World Health Organisation launched its health promotion programme in 1981 (Rees Jones 2003) and 1986 saw the first International Conference on Health Promotion in Ottawa, resulting in the publication of the Ottawa Charter. This defined health promotion as ‘a process of enabling people to increase control over, and to improve, their health ... health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well-being’ (cited in Tudor 1999).
In practice, the WHO emphasised, this was to involve ‘diverse but complementary approaches including legislation, fiscal measures, taxation and organisational change’ (1984, cited in Locker 1997) and with health care professionals nonetheless playing an important part through a reorientation of health services. The focus was to be on the population as a whole rather than targeting those who have, or are at risk for, specific diseases and action should be directed towards the determinants of health, not illness. (WHO 1986, cited in Tudor 1999). Locker (1997) summarises further components of the approach, including the creation of supportive environments to facilitate ‘healthy choices’, the necessity for all organisations to take into account the potential health effects of their strategies in order to develop a ‘healthy public policy’. Public participation in identifying priorities for, planning, and implementing community action is to be encouraged through the provision of education and information. The objective of increasing awareness both about health risks and about what can be done to counter them is to empower communities and individuals by transferring the responsibility for, and control over health from professionals to the general public. This has its basis in studies showing that powerlessness is a major risk factor for disease and ill-health (Wallerstein 1992, cited in Locker 1997). Breslow (1999) offers more specific ways in which health professionals can be involved in ‘building health reserves’. He suggests that rather than looking for indications of risk factors for coronary heart disease, GPs should actively encourage a lowering of cholesterol even in those with relatively healthy levels, that even in the absence of osteoporosis radiologists should advise patients on strengthening their bones. In Breslow’s world, geneticists ought to study chromosomal deviations associated with better health rather than specific diseases, while social workers should aim to work towards strengthening families in general instead of helping dysfunctional families. from coursewrok work info
Though lauded by many, the health promotion approach has also been criticised and Tudor (1996) reviews the main points that have been made. Though claiming to take into considerartion socioenvironmental factors, it does seem to have a tendency to place the responsibility, and thus the blame for deficiencies in, personal behaviour entirely on the individual and at the expense of also accounting for social and environmental aspects of lifestyle, illness and ill-health. A related point is made by Scambler and Scambler (1995, cited in Rees Jones 2003) who argue that health promotion work is mainly limited to change at the level of operational work, failing to address factors at the political and structural level. The focus on the individual can have a deleterious effects on mental health, for example through reduced self-esteem from excessive focus on weight-reduction. Unrealistic health promotion campaigns focusing on healthy eating and exercise may not seem achievable by people on low income and this too can lead to stress and anxiety. Becker (1986, cited in Locker 1997) warns of the ‘tyranny of health promotion’, excessive proscription in the name of health, McCormick calls for ‘modified hedonism’ instead and Reinharz (2001) complains that the never-ending health warnings take the joy out of life. Indeed, Schofield (1996) notes that proselytising promotion of behaviour change has been largely discredited, citing a 1989 HEA document acknowledging that ‘people need to be able to understand and accept the need for change before they are willing or able to modify their personal behaviour’. Tudor further points to the risk of contradictory advice being given due to the uncertainties surrounding the link between specific behaviours and health due to the changing nature of research. I would add, especially in view of Breslow’s (1999) specific suggestions, that though a focus on health rather than disease, though commendable in theory, seems a somewhat unrealistic demand to place on the already overworked NHS.
Though aiming to go beyond disease prevention, health promotion clearly also needs to incorporate this dimension into health care. The two approaches are closely linked, as some of the behaviours targeted by health promotion also help to prevent specific diseases. The concepts are often conflated; Tudor 1996 find that though advocating the need for health promotion, eleven out of the fourteen objectives of the the Department of Health’s 1991 ‘Health of the Nation’ document in fact fall into the realm of disease prevention. Having extensively examined the concept of health promotion, a closer look at the definition and practical approaches to prevention is warranted. Traditional approaches to prevention are based on intervention at three levels (Locker 1997). Primary prevention seeks to avoid the onset of disease, for example through immunisation or individual changes in behaviour. Secondary prevention consists of early detection and treatment of disease or states likely to lead to disease and includes screening for diseases or risk factors. Tertiary prevention, lastly, intends to minimise the disability from a disease state that cannot be cured or leaves the individual with some loss of function. The workings and limitations of disease prevention are best illustrated using two examples, namely mass screening and targeted individual intervention.
Screening is the active early diagnosis of a disease or risk factors with the aim to intervene to prevent the onset or progression of disease (Locker 1997) and thus, as mentioned, forms part of secondary prevention. It can take the form of mass screening offered to the population on a voluntary basis, such as that for breast and cervical cancer. Alternatively, it may form part of routine health care, such as the screening of newborns for congenital abnormalities. Although reducing morbidity and mortality by identifying and treating individuals at the earliest possible stage in the disease process, screening is not without its problems. Stewart-Brown (1997) calls for a greater consideration of the social and psychological costs of screening. In studies of screening for hypertension, patients receiving false positive results reported more depression and a lower state of general health than the control group (Bloom and Monterossa 1981). Skrabanek (1988) points out that this is especially problematic in breast cancer screening, as a Canadian breast screening study found screening to have only 5-10% positive predictive value and a Swedish study reported 30-40% overdiagnosis, entailing unnecessary and psychologically damaging biopsies and mastectomies. The ‘certificate of health’ effect (Tjimstra and Bieleman 1987) is another problematic issue, as an absence of risk factors may reinforce unhealthy lifestyles. In order for screening to be ethically defensible, Cochrane and Holland argue (1971, cited in McCormick 1994), there must be ‘conclusive evidence that screening can alter the natural history of disease in a significant proportion of those screened’. McCormick (1994) stresses that in the case of coronary heart disease, there is no such evidence, pointing to studies such as that of McCormick and Skrabanek (1988), whose meta-analysis of multiple risk factor intervention trials failed to find any benefits despite over 800,000 man-years of observation. McCormick dismisses screening for CHD risk factors in a symptomless population as a waste of resources, an ‘unmandated intervention in people’s lives’ which merely serves to contribute to hypochondriasis. cobf bfr sebfbfw orbf bfk inbf fobf bf!
Schofield (1996) looks at how targeted individual intervention is best approached in practice. He highlights studies such as Pill and Stott (1990) which indicate that unwarranted advice is not well-received by patients and that it diverts time and resources from the other activities of primary care, and proposes that lifestyle changes should only be suggested to high-risk individuals. Further, he maintains that a great deal of attention must be paid to how advice is presented. Considering the factors influencing the motivation and ability of individuals to change their behaviour, he points to perceptions about susceptibility and severity of disease (health beliefs), beliefs about personal ability to change behaviour (self efficacy) and the crucial notion of ‘empowerment’. He cites studies indicating that in order for interventions to be effective, counselling must have relevance to the patient, be individualised (the needs and characteristics of the patient must be taken into consideration in order to arrive at specific goals). In addition there is the need for reinforcement through encouragement and facilitation through the provision of support throughout (Simons-Morton et al 1992). Schofield highlights the need for these considerations at each stage of the consultation process. Initial exploration should focus not only on the health problem but also on the patient’s beliefs and expectations, while explanations, rather than being generalised statements, should reinforce positive attitudes and counter negative ideas. When negotiating future actions, opportunities and potential barriers should be taken into account and achievable goals should be selected by the patient rather than suggested by the health professional. Once these goals are chosen, support is crucial, including both feedback on progress and positive reinforcement.
Both health promotion and disease prevention form important and complementary parts of contemporary health care. In order for each to make a positive contribution towards the health of individuals and populations, the problems facing each must be taken into careful consideration before any specific policy is proposed. While an active promotion of behaviour change and mass screening may instinctively appeal, for instance, reality is complex and there may be problems that outweigh the good done by such schemes. The costs and benefits of all measures need to be evaluated in order to arrive at a realistically achievable, constructive approach to health care.
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Breslow (1999) ‘From disease prevention to health promotion’ Journal of the American Medical Association 281 p.1030cobf bfr sebfbfw orbf bfk inbf fobf bf!
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Locker (1997) ‘Prevention and Health Promotion’ in Scambler (ed) Sociology as Applied to Medicine, 4th editioncoca car secacaw orca cak inca foca ca.
McCormick (1994) ‘Health promotion: The ethical dimension’ Lancet 344 p.390
Rees Jones (2003) ‘Health Promotion and the New Public Health’ in Scambler (ed) Sociology as Applied to Medicine, 5th edition
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