Chapter 1 Defining health and public health
Defining health and ill-health
Reflection
Most public health workers, or educators who work in public health, see ‘health’ as central to their work, and believe that the majority of people also hold health to be an important part of their lives. We clearly know that this is not the case. Much research (Baum 2002; Blaxter 1990, 2007; Fleming & Parker 2007) has been undertaken regarding the way in which people define health within the context of their daily lives.
Health and illness
Illness can be culturally specific and may also be influenced by social, spiritual, supernatural and psychological aspects (Maher 1999). An individual lifestyle perspective has also been seen as an important dimension of health. Introduced initially by the document A New Perspective on the Health of Canadians (Lalonde 1974) the individual lifestyle perspective had as its focus individual behaviours. The World Health Organization (WHO, defined later in this chapter) subsequently redefined ‘lifestyle’ to mean behavioural choices made from alternatives that are available to people according to their socioeconomic circumstances (Kickbusch 1986). A social view of health considers issues such as the impact of social and economic factors on health, but these dimensions have often been overshadowed by the biomedical view of health. A biomedical model of health predominately had as its focus diagnosing diseases. The model’s focus does not take into account the role of social factors and it also overlooks the fact that prevention of disease is not included.
In the 1940s, the WHO defined health as ‘a state of complete physical, social and emotional wellbeing and not merely the absence of disease or infirmity’ (WHO 1948). Some authors have argued that a state of health delineated by this definition is too difficult to achieve (Bircher 2005; Waltner-Toews 2000), but it certainly moved the debate about health away from an exclusive biomedical perspective.
‘Health’ itself is difficult to measure because it is a dynamic concept rather than something that is always the same. ‘… [H]ealth cannot be defined without reference to some goals …’ (Waltner-Toews 2000 p 657) and it is a ‘dynamic state of wellbeing characterised by a physical, mental and social potential …’ (Bircher 2005 p 335). It is much easier to measure disease or an absence of disease than it is to measure health or wellbeing.
Lay definitions of health
Lay concepts of health and illness have been extensively researched and discussed. Blaxter (2007), quoting Kleinman, describes three ways in which health and illness have been discussed; these include professional, alternative and lay. Contemporary scholars prefer to consider lay beliefs about health and illness to be defined as ‘commonsense understandings and personal experience, imbued with professional rationalization’ (Blaxter 2007 p 26). In a seminal study in 1990 Blaxter, while exploring lay definitions of health and illness, found that people define health in a variety of different ways. In her research, she suggests that health is defined by people as not being ill or diseased or as being a reserve against illness. Others define health as a ‘healthy life’, as physical fitness or as having energy or vitality. Still others take health to mean social relationships, that is, relationships with other people or as a function of the ability to do things. For others health has meaning as psychosocial wellbeing.
Collectively, health can be seen to represent the social, cultural and economic context of people’s lives – a status, socially recognised and admired. Others believe their health is dominated by religious or supernatural forces (Durie 2004). For some, the centrality of people’s relationships to the land, family and community are the central foci for health and wellbeing (Durie 2004; Thompson & Gifford 2000). For Aboriginal and Torres Strait Islander Australians ‘health’ is about the totality of their environment.
‘ “Health” to Aboriginal peoples is a matter of determining all aspects of their life, including control over their physical environment, of dignity, of community self-esteem, and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines or the absence of disease and incapacity’ (National Aboriginal Health Strategy Working Party 1989 p ix). These issues are discussed further in Chapter 15.
A critical perspective
While lay definitions of health have focused on the ways in which health is defined in the day-to-day lives of people, Baum (2008), for example, examines how health is defined by looking at the purposes that are achieved through particular ways of defining health. Table 1.1 summarises some of the ways in which a number of authors say health is defined (Baum 2008; Brown et al. 2005; Morris 2010), according to how the term might be used by different people.
TABLE 1.1 Contemporary definitions of health
| Definitional focus | Application |
|---|---|
| Health defined by capitalist society | Defining and controlling mechanism where a person’s health is defined primarily through illness. |
Health is defined by inequities in health status and influenced by environment, housing and occupational conditions. Defined as ‘a change in the health of an individual, a group of people or population which is attributable to an intervention or series of interventions’ (Baum 2002 p. 12). Often neglects the notion that the demonstration of health outcomes is complex. | |
| Ecosystem health (Baum 2008, Brown et al. 2005) | Consideration of the environment and the interdependence of systems within the overall ecosystem in order to achieve long-term sustainability of our planet. |
(Summarised from Baum 2008; Brown et al. 2005; Morris 2010)
Defining public health: an art and a science?
Public health is based on scientific principles and it uses a range of disciplines such as epidemiology, biostatistics, biology and biomedical sciences in its analysis of public health problems (Lawson & Bauman 2001; Lin et al. 2007; Schneider 2006). Public health relies heavily on environmental sciences and the social and behavioural sciences. Public health is also an art in that it involves applying this scientific knowledge to a range of practical settings that require attention to issues such as selecting intervention strategies and approaches that communities need. Furthermore, public health deals with social, cultural, political and economic issues, as well as health issues.
Winslow (1920), an American public health leader in the early twentieth century, defined public health as a science and an art:
… of preventing disease, prolonging life, and promoting physical health and efficiency through organised community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. (Winslow 1920 p 24)
What are some of these emerging threats? Environmental factors such as the effects of greenhouse gases and global warming, HIV/AIDS, avian influenza, SARS (severe acute respiratory syndrome) and H1N1 (swine flu) are significant public health issues (McMichael & Butler 2007; US Department of Health and Human Services website 2011). These twenty-first-century challenges require public health to return to its roots to control infectious diseases, as well as be a part of a global effort to sustain the planet and its environment for generations to come (Gostin 2010; McMichael & Butler 2007).
Public health today is recognised as being integral to promoting and sustaining the health of the population. The following definition of public health by Last (2001) supports this approach:
… the efforts organised by society to protect, promote, and restore the people’s health. It is the combination of sciences, skills and beliefs that is directed to the maintenance and improvement of the health of all the people through collective or social actions. (Last 2001 p 145)
In Australia, similar definitions are used to describe the art and the science of public health. The Public Health Association of Australia (PHAA) defines public health as ‘a combination of science, practical skills and beliefs that is directed to the maintenance and improvement of the health of all people. It is one of the efforts organised by society to protect, promote and restore the people’s health through collective or social actions’ (PHAA website). Recent debates in the literature (Goldberg 2009; Rothstein 2009) about definitions of public health have focused on how broad and all encompassing, or narrow, definitions of public health should be. What is common about most of these definitions is the notion that there is an organised desire to improve the health of the population as a whole, a sense of general public interest and a focus on the broader determinants of health (Beaglehole et al. 2004). It is worthwhile stopping here to consider the meaning of the term ‘determinant’. Determinants are discussed in Section Two (Chapters 4, 5 & 6) as both the causes of and risk factors for health events. A wide range of determinants, including physiological, psychosocial, behavioural and risk conditions, ‘can work together to influence quality of life, wellbeing, illness and disability. However, the ways in which these determinants manifest themselves in each society would depend on history, culture and politics’ (Lin et al. 2007 p 76).
The concepts of public health should become a little clearer to you as we further discuss its vital role in our day-to-day lives. Consider the following scenario to help you think about the contribution of public health to daily life and to enable you to begin to broaden your understanding of public health (Case Study 1.1).
Reflection
Reflect on the issues you have listed above. Did you consider any of the following issues:
There are a number of activities that we take part in every day that affect our health and the public’s health collectively. Public health has developed systematic ways of thinking about health issues (Schneider 2006). This systematic approach enables public health workers to tackle a health issue in a considered and deliberate fashion. However, unless public health has a collective action domain it will lack a focus on social and economic issues that are so central to supporting and maintaining changes that enhance the public’s health.
If you were asked to think about how you might tackle a public health problem, you might think about it in terms of levels of prevention – primary, secondary and tertiary (see Chapter 13 for more detail on these concepts). Primary prevention focuses on maintaining health, for example, school health programmes, seat belts in motor vehicles, anti-smoking campaigns, and physical activity and nutrition programmes. Secondary prevention aims to minimise the extent of a health problem by focusing on early intervention, such as, prostate, bowel and breast screening. Tertiary intervention aims to minimise disability and provide rehabilitation services, such as cardiac rehabilitation.
Another way of dealing with a public health problem is to consider a chain of causation (see Chapter 10 for further consideration of this concept) involving an agent, a host and the environment. In this case, prevention is accomplished by interrupting the chain of causation, for example, by providing immunisation, using antibiotics or purifying water.
Public health vision and values
Having a vision of where you think public health might be placed in the next 5 to 10 years is important for the discipline and for you in your practice. There are a range of factors that impact on health and public health that will have a profound effect on the nature and scope of the discipline in the next decade. Globalisation is one of those issues (as discussed in Chapter 14); other issues include the emergence of new virulent infectious diseases, an increase in chronic disease such as diabetes, the ageing population and the ever-increasing cost and the expanding technological sophistication of health care. In Chapters 10 to 13 we examine the role of health protection and health promotion in advancing the health of the population, and in Chapter 14 we explore the notion of globalisation and its impact on health.
