University of Applied Sciences , Utrecht, The Netherlands
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Health and health problems are affected by health determinants. Health determinants are groups of factors that may provide a way for analyzing health and health problems. Health determinants are: endogenous determinants, lifestyle and behavior, the physical and social environment, and medical care and prevention. Each health determinant has a specific impact on a health problem. Health determinants may be a guide for optimizing health problems, for the understanding of health risks, and for improving (people’s) health. We start with Health Concept of Lalonde, and also describe the Conceptual Model of Public Health and the VTV-model (Sect. 2.1). In Sect. 2.2., endogenous, personal health determinants are described. In Sect. 2.3, the health determinants lifestyle and behavior are dealt with; in Sect. 2.4 the health determinant physical environment and in Sect. 2.5 social environment are described. In Sect. 2.6, medical care and prevention are the focus.
2.1 Lalonde Report
The Lalonde Report consists of a model for exploring health, and the central concept is to promote health (Lalonde was the Minister of Public Health in Canada, 1974) (Lalonde 1974). In the Report, health is the central theme rather than disease or sickness.
What is the core of the Report? An inventory was made of all kinds of factors that affect health and disease, and a classification devised of the internal environment, external environment, behavior, and health care. Each of these areas, all equally as important, are called health determinants. Using the Lalonde Report (Fig. 2.1), but also in other conceptual models of public health (Figs. 2.2 and 2.3), we are able to look at the health determinants that affect health at the group level. The models are not developed to analyze individual health of a patient or client, but are suitable for looking at health at the population or group level.
Health Concept Lalonde
Health concept, health determinants:
Endogenous, personal health determinants, internal environment or human biology
Health determinants behavior and lifestyle
External environment: health determinant physical environment
External environment: health determinant social environment
Health determinant healthcare organization and prevention
Before the health concept was common, we used to think about health from the perspective of endogenous determinants of health, and medical care was the way to handle health problems. The innovation in the health concept was above all the exogenous health determinants lifestyle and behavior, in addition to more attention being paid to the health determinants physical and social environment. Now, it is a common understanding that lifestyle and behavior affect health and play a role in health problems, and that lifestyle and behavior should be taken as entry points for health promotion. However, taking health as the starting point for nursing care and not disease, remains an issue in health care.
The determinants of health, how can they be described in brief? The endogenous, personal health determinant is about the factors that play a role in the human body and affect health. The endogenous health determinant is subdivided into genetic factors and acquired properties. The endogenous health determinant is also referred to by the terms individual factors, internal environment, or human biology.
The health determinants lifestyle and behavior are the influence that lifestyle and people’s behavior have on their health and on the onset or worsening of health problems. These health determinants concern both one’s rationale to behave in a certain way, as the actual behavior of a people.
The health determinant external environment can be divided into the physical and the social environment. These health determinants are also called exogenous determinants of health. The physical environment factors affect health outside the human body and can have an influence on the onset or worsening of health problems. For the people themselves, the physical environment and the impact on their health is often difficult to control.
The social environment is the health determinant that reflects the place of people within society. Their place in society has an important influence on health and on people’s sense of well-being.
The health determinants healthcare organizations and prevention include all kinds of health care facilities. These facilities are delivered with the aim of curing people, of preventing the worsening of the health situation or of ensuring that people stay healthy.
Health for all by the year 2000. The WHO’s aim is optimal health for all people in the world, and those people should be enabled to live a socially and economically productive life. The innovative strategy of global health for all by the year 2000 is that this strategy was the departure point for health policy in 34 countries, regardless of the public health situation and the level of health care facilities. Primary health care is the means of achieving optimal health. The main goals of the health-for-all strategy wholibdoc.who.int/publications/9241800038.pdf was to reduce health inequalities between countries and groups in countries and to improve the health of individuals and reduce health problems. This was to be achieved by promoting equality in health, improving the quality of life, adding health to life by reducing health problems, and prolonging the life span (reducing premature and maternal mortality).
Health (problems) are central to the health concept, but do health determinants mutually affect each other? The health concept takes health as the starting point, and the model may be used to analyze a health problem. In what way do health determinants affect health or the health problem? Health determinants have a mutual, sometimes complex relationship. For example, overweight and obesity can be determined by genetic factors, but also by the balance between energy intake via food and energy consumption by motion behavior. Movement behavior may also be affected by environmental factors, such as sitting work, support from the social environment, and the financial situation (being able to afford to use sports facilities). The determinants of personal characteristics, lifestyle, and environmental factors, are closely linked. The interrelationship between health determinants needs attention, and this may have important implications for health promotion and disease prevention.
In health problems, we often see a combination of endogenous health factors, lifestyle factors and environmental factors; and social environmental factors are better known. For example, depression has a relationship with the endogenous health determinant personality traits. The exogenous health determinant social environment, such as family problems, social relations, social vulnerability, (early) life events, workload and stress, SES, and household composition, also plays a role. Furthermore, the exogenous health determinant physical environment is involved, including environmental factors such as micro-organisms. Finally, the health determinant health care organization shows that GPs are able to notice the early warning signs of depression.
Another example is that breast cancer has a relationship with the health determinants lifestyle and behavior. Nutritional behavior plays a role, in addition to protection given by breast feeding. Not only alcohol consumption has an influence on breast cancer, but also the degree of alcohol dependence. Physical activity and higher fitness levels have a positive influence. The use of the contraceptive pill is also involved. In addition, breast cancer has a relationship with the endogenous health determinant body weight.
2.2 Endogenous, Personal Health Determinant
Endogenous, personal health determinant, both physiological and psychological factors that affect health or health problems
The endogenous determinant concerns both physiological and psychological factors that affect human health or health problems. We call this the personal health determinant (Fig. 2.2). When a health problem is under consideration, all factors that have a relationship with the health problem should be identified. The endogenous health determinant is subdivided into first genetic and hereditary factors, and second, acquired properties. Both the genetic and hereditary factors and the acquired properties (each individual) have specific health effects.
2.2.1 Endogenous Health Determinant: Genetic, Hereditary Factors
Endogenous, personal health determinant
Hereditary factors: abnormalities in the genes, abnormalities in chromosomes, multifactorial health problems, and facilities for health problems
There is no doubt that genetic, hereditary factors have a major influence on our health. This endogenous health determinant determines the differences between people and plays a role in physiological characteristics, intelligence, and personal characteristics. Hereditary factors influence health if there are any abnormalities in the genes, abnormalities in chromosomes or multifactorial health problems, and if there is a predisposition to a disease. This endogenous health determinant usually leads to permanent health damage.
Which abnormalities in the genes do we know? We speak of monogenic diseases if the onset of the disease is based on one gene. Although this is a rare disease picture, the numbers increase. An example is xeroderma pigmentosum (XP), caused by the influence of sunlight, that confers a greatly increased risk of certain types of skin cancer. Abnormalities in the genes can be passed from parents to children, a child may inherit a recessive disorder because the healthy parents pass the abnormal gene to the child. For example, cystic fibrosis and phenylketonuria. In dominant inheritance (such as Huntington’s disease and familial hypercholesterolemia), if one of the parents is sick, there is a 50% chance of the child getting the disease too. Abnormalities in the genes occur in 1–2% of the population.
What do we know about abnormalities in chromosomes? In addition to abnormalities in the genes, we can distinguish chromosomal abnormalities. For example, Down syndrome. Birth prevalence of children with Down syndrome increases with the age at which women have children. Furthermore, improved treatment, surgery and intensive care capabilities has led to a decrease in mortality among children with Down syndrome, and on the other hand, possibilities for screening and prenatal diagnosis have increased.
What are multifactorial health problems? When hereditary factors play a role, but others are involved too, this is known as multifactorial health problems. For example, congenital heart defects, and spina bifida. It is expected that the number of children with birth defects will decrease, as more women take folic acid tablets, which reduces the risk of a birth defect. In addition, the use of prenatal diagnosis has increased, and treatment and care for children with birth defects have improved (Cornel 2004). Birth defects of the cardiovascular system may be the result of health problems of the mother during pregnancy, such as type 2 diabetes, untreated phenylketonuria, use of alcohol and lithium, and infectious diseases (such as rubella and mumps).
Is there a predisposition to health problems? For the endogenous determinant, the predisposition to diseases is also of interest, for example, in the case of schizophrenia, manic depression, asthma, and allergies, adult-onset diabetes, epilepsy, and rheumatism. These health problems are caused by an interaction between a genetic predisposition and exogenous factors. For schizophrenia, a chronic psychiatric health problem, genetic predisposition plays a role, in combination with (far more important) exogenous factors. Prevention of schizophrenia is aimed at preventing the first or recurrent psychosis. However, it may also take the form of stress management for vulnerable people, or promoting the social development of children at an increased risk of psychosis (Hoek and Kahn 1995; Maas and Jansen 2000). For depression, too, a predisposition is possible. Depression is a genetically determined response pattern that occurs at an increased vulnerability in combination with triggering factors (Bijl 2001). Depression can be explained from an integrated bio-psycho-social explanation model. Heredity, age, low self-esteem, social vulnerability, gender, and marital status are factors that play a role in the explanation model. The depressive disorder may be shortly lived or of a chronic nature; it is seen in all age groups, but more often in women than in men. A dysthymic depression is a mild form of depression with a minimum duration of 2 years, and is more common in older people. The number of people with a depressive and/or dysthymic disorder is increasing, because the condition is detected earlier today by family doctors and because people seek professional help sooner. The occurrence of depressive and dysthymic disorders in young people needs attention.
The health-for-all strategy legacy.library.ucsf.edu/documentStore/g/w/o/gwo93a99/Sgwo93a99.pdf of the WHO had 38 goals. Themes are primary health care, health promotion, participation, justice, and multi-sectoral cooperation. The goals of the strategy include maintenance of health; increase healthy behavior (healthy nutrition, moving behavior), decrease unhealthy behavior (alcohol use, drug use, unsafe behavior in traffic, and violent social behavior); and controlling adverse environmental factors (water and air pollution, food unsafety, work-related health risk).
2.2.2 Endogenous, Personal Health Determinant: Acquired Properties
Endogenous, personal health determinant:
Acquired properties: high blood pressure, high cholesterol, abnormality in the immune system, abnormality in glucose levels, overweight and obesity, mental health, and aging
In addition to hereditary factors, acquired properties are also endogenous health determinants.
Is high blood pressure an acquired trait? An important acquired trait is hypertension or high blood pressure. This is the case if the systolic blood pressure and/or diastolic blood pressure is too high or when people use blood pressure-lowering medications. An isolated elevated blood pressure exists, when either only the systolic blood pressure or only the diastolic blood pressure is increased. Both in men and in women, blood pressure increases with increasing age, especially after the age of 35. Isolated elevated blood pressure is most common in people aged over 85 years. High blood pressure is less common in people with higher education levels. Health effects associated with high blood pressure are chronic conditions, such as coronary heart disease and stroke, heart failure, and dementia. Factors that affect high blood pressure in a negative sense are overweight, physical inactivity, low consumption of fruits and vegetables, but also (excessive) alcohol use, smoking, and the consumption of salt and fat. Lifestyle factors greatly affect blood pressure. In the prevention of high blood pressure, optimizing lifestyle factors is most important. If optimizing lifestyle is insufficient, drug treatment creates a considerable reduction in the number of people with high blood pressure and cardiovascular diseases.
Is an abnormality in the immune system an acquired trait? The immune system plays an important role in maintaining the health, and abnormalities caused by bacteria, viruses, fungi, and parasites may lead to various forms of cancer. Health problems are allergies, chronic auto-immune diseases (such as rheumatoid arthritis), liver cancer, and infectious diseases (such as HIV, pneumonia, and flu). In a normal state, the human immune system protects against external influences, the so-called exogenous factors. There is an increase in the number of adults and children with allergies and autoimmune diseases, possibly due to a disturbed balance caused by fewer infection sources in the area. A disturbed balance may lead to increased production of the antibody IgE, which may ultimately evoke an allergic reaction. Chronic diseases, such as HIV, Hodgkin’s disease, and hepatitis B and C have a clear relationship with impaired immunological defense against certain viruses.
Is a high cholesterol level an acquired trait? If the LDL cholesterol level in the blood is too high, there is an increased risk of premature death from coronary heart diseases. In addition to a high cholesterol level, a lower level of protective HDL cholesterol is a risk factor for the development of coronary heart disease. Also, genetic and lifestyle factors play a role. Lifestyle factors such as saturated fats in the diet, overweight, and smoking play a negative role. Physical activity has a positive impact on cholesterol levels. Physical activity increases the beneficial HDL cholesterol levels in the blood. The prevalence of high total cholesterol in the blood decreases in both men and women, in all age groups, but the largest reduction is seen among older people. The decrease in cholesterol levels is due to the decline in the use of saturated fat in the diet. The decrease continues as the preferred nutritional habit persists.
Is a varying blood glucose level an acquired trait? The glucose tolerance indicates the degree to which the body properly deals with the varying concentrations of glucose in the blood. There may be a normal glucose tolerance, impaired glucose tolerance (untreated diabetes mellitus) or glucose intolerance (treated diabetes mellitus). People with impaired glucose tolerance have a greater chance of getting diabetes mellitus. Diabetes mellitus is a chronic metabolic disease and the risk increases with age. Factors that have a negative impact on the glucose tolerance, are overweight, specifically an unfavorable abdominal fat distribution. Physical (in)activity and a diet that is high in saturated fats and has too little dietary fiber also have a negative influence. Among young people, we see an increase in type 2 diabetes, (serious) overweight, combined with an unhealthy diet and a lack of physical activity. The impact on people’s lives is great. Diabetes patients experience their health as relatively poor. Younger diabetes patients often state that they are depressed and anxious. Diabetes patients rate their quality of life as less favorable, as the health problem is more serious. Diabetes mellitus confers a higher risk of coronary heart disease and stroke. Next to asthma, it is the most common chronic disease among children.
Is overweight and obesity an acquired trait? The acquired property overweight/obesity can cause or contribute to the development of health problems. Overweight people experience a lower quality of life. It leads more frequently to diseases and physical limitations rather than to early mortality. Being overweight has a link with chronic health problems such as cardiovascular diseases and diabetes mellitus type 2. But it is also linked to cancer (especially colon cancer), disorders of the musculoskeletal system (osteoarthritis), and disorders of the respiratory organs. In women with severe obesity, menstrual disorders and infertility are more often seen. Obesity also has a great influence on the development of chronic health problems, even more than smoking or excessive alcohol consumption. Obese people have a shorter life expectancy and a longer unhealthy life expectancy. Seriously overweight and obesity is more common in people with a lower level of education. Overweight and obesity increases in children from the age of 4 years and in this group, the prevalence increases most severely. Children with overweight and obesity have problems such as stigma and social issues. The main cause of being overweight is the imbalance of the energy intake from food and energy expenditure through physical activity. The increase in the number of overweight people and obesity is explained by a shift in eating patterns, but also by the reduction in physical activity. Fruit consumption has decreased and the intake of snacks, soft drinks, and fruit juices has increased. The treatment of obesity is usually complex, often with disappointing results in the long term.
The perception of body weight affects the quality of life. Men who thought that they were too heavy (rightly or wrongly), rated the health they experienced less favorably than men who thought they had a normal body weight. For women, it was shown that both the actual body weight and the perception of body weight influenced the assessment of the quality of life.
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