Chapter 1. What is health?
Chapter Contents
What does being healthy mean to you?3
Concepts of health4
What affects health?7
Improving health – historical overview10
International initiatives for improving health11
National initiatives12
Where are we now?13
Summary
This chapter starts with an exercise which enables you to examine what being healthy means to you, and reviews the wide variation in people’s concepts of health. Dimensions of health are considered (physical, mental, emotional, social, spiritual and societal) and health is explored as a holistic concept. Factors that affect health are identified, with a particular focus on medicine and inequalities in health. Case studies illustrate the factors that shape the health of people in differing circumstances. In the final section there is a historical overview of the contribution of international and national movements towards better health.
What Does Being Healthy Mean to You?
Being healthy means different things to different people, and much has been researched and written about people’s varying concepts of health (see, for example, Hughner & Kleine 2004 and Earle 2007). It is fundamental that you, as a health promoter, explore and define for yourself what being healthy means to you and what it may mean to your clients. This is the aim of Exercise 1.1.
EXERCISE 1.1
What does being healthy mean to you?
In Column 1, tick any of the statements that seem to you to be important aspects of your health. Tick as many as you like.
| For me, being healthy involves: | Column 1 | Column 2 | Column 3 |
|---|---|---|---|
| 1.Enjoying being with my family and friends | □ | □ | □ |
| 2.Living to a ripe old age | □ | □ | □ |
| 3.Feeling happy most of the time | □ | □ | □ |
| 4.Having a job | □ | □ | □ |
| 5.Hardly ever taking tablets or medicines | □ | □ | □ |
| 6.Being the ideal weight for my height | □ | □ | □ |
| 7.Taking regular exercise | □ | □ | □ |
| 8.Feeling at peace with myself | □ | □ | □ |
| 9.Never smoking | □ | □ | □ |
| 10.Never suffering from anything more serious than a mild cold, flu or stomach upset | □ | □ | □ |
| 11.Not getting things confused or out of proportion – assessing situations realistically | □ | □ | □ |
| 12.Being able to adapt easily to big changes in my life such as moving house or a new job | □ | □ | □ |
| 13.Drinking only moderate amounts of alcohol or none at all | □ | □ | □ |
| 14.Enjoying my work without too much stress | □ | □ | □ |
| 15.Having all the parts of my body in good working condition | □ | □ | □ |
| 16.Getting on well with other people most of the time | □ | □ | □ |
| 17.Eating the ‘right’ foods | □ | □ | □ |
| 18.Enjoying some form of relaxation or recreation | □ | □ | □ |
In Column 2, tick the six statements which are the most important aspects of ‘being healthy’ to you.
Then in Column 3, rank these six in the order of importance – put 1 by the most important, 2 by the next most important and so on down to 6.
If you are working in a group, compare your list with other people’s. Look at the similarities and differences, and discuss the reasons for your choices.
(Adapted with kind permission from Open University 1980.)
Exercise 1.1 generally shows that different people identify different aspects of being healthy as important. What you choose is often a reflection of your particular circumstances at the time, your experiences and/or your professional background. For example, if you are feeling stressed at work you may consider enjoying work without too much stress as important, or if you work in a smoking cessation service you may prioritise not smoking as a crucial aspect of being healthy. As your circumstances change, your idea of what being healthy means to you is also likely to change.
Concepts of Health
As Exercise 1.1 will have indicated, health is a difficult concept to define in absolute terms. The meaning can be culturally and professionally determined and has changed over time (Thomas 2003). A variety of definitions and explanations of what it means to be healthy exists (Duncan 2007) and none can be deemed to be right or wrong.
Lay Perceptions
It is important to understand the way lay people think about health and wellness, as this influences their health and wellness-related behaviours (Hughner & Kleine 2004). Researchers have found a wealth of complex lay notions about health. Some lay perceptions are based on pragmatism, where health is regarded as a relative phenomenon, experienced and evaluated according to what an individual finds reasonable to expect, given their age, medical condition and social situation. For them being healthy may just mean not having a health problem which interferes with their everyday lives (Bury 2005). Thomas (2003) has classified some personal constructs of health into models. The functional model, for example, is based on social role performance and social normality, rather than physical normality; the psychological model emphasises the ability to deal with stress and having resilience. Whatever the lay understandings of health are based on, however, they illustrate that lay accounts are unique, and health and strategies for health must be individualised. For example:
• Homeless, single young people in Scotland viewed their health in terms of functional concepts such as taking regular exercise and getting a good night’s sleep. In this respect, health was seen as a tool for everyday living (Watts et al 2006).
• Lay men’s understanding of health and wellbeing has been shown in a study to relate to notions of control, and the associated issues of risk and responsibility. Specifically, men saw health in more psychological terms (Robertson 2006).
• Exploration of children’s concepts of health has shown that their ideas of being healthy and what makes them healthy are strongly tied up with notions of infection; health for them is the lack of symptoms like a cough or running nose. Children in the study also linked environmental pollution with health, with smoking seen as an environmental pollutant, but did not mention violence, being homeless or similar social factors among health determinants (Piko & Bak 2006).
Concepts of health, illness and disease have generally been linked with people’s social and cultural situations. Knowledge of illness, prevention and treatment can also be powerful in shaping people’s concept of health. Such knowledge may be part of a cultural heritage, passed on through generations (Kue Young 2005).
Standards of what may be considered healthy also vary. An elderly woman may say she is in good health on a day when her chronic arthritis has eased up enough to enable her to get to the shops. A man who smokes may not regard his early morning cough as a symptom of ill health, because to him it is normal. People assess their own health subjectively, according to their own norms and expectations.
People may also trade-off different aspects of health. A common example is that people may accept the physical health damage from smoking as the price they pay for the emotional benefit.
Because of this variety and complexity of the ways in which people conceptualise health, it is difficult to measure health.
For more about measuring health, see Chapter 6, section on finding and using information.
Professional Concepts of Health
Professional concepts of health have changed over time. In the late 19th and 20th century, as medical discoveries were made and medical practice developed, there was a preoccupation with a mechanistic view of the body and consequently with physical health. Earlier still, there have been centuries of many philosophies of health in different civilisations, such as Greek and Chinese, where a more holistic view of health has been held. See Lloyd & Sivin (2002) for a comparison of these two cultures and their view on health, science and medicine.
One way of understanding the various meanings that the different professional groups hold is to put health into broad categories or models. Three models are identified below and include the medical model, the holistic model, and the wellness model.
The medical model
• The medical model dominated thinking about health for most of the 20th century.
• Health is defined and measured as the absence of disease and the presence of high levels of function.
• In its most extreme form, the medical model views the body as a machine, to be fixed when broken.
• It emphasises treating specific physical diseases, does not accommodate mental or social problems well and de-emphasises prevention.
The holistic model
• The holistic model was exemplified by the World Health Organization (WHO) constitution which referred to health as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity (WHO 1948).
• This broadened the medical model perspective, and highlighted the idea of positive health, although the WHO did not originally use that term, and linked health to wellbeing.
• The WHO definition is in many ways difficult to measure. This is less because of the complexity of measuring wellbeing, as psychologists have done (for example White 2007), but more because doing so required subjective assessments that contrast sharply with the objective indicators favoured by the medical model.
The wellness model
• In 1984, a WHO discussion document proposed moving away from viewing health as a state, toward a dynamic model that presented it as a process or a force (WHO 1984). This was amplified in the Ottawa Charter for Health Promotion which proposed that health is the extent to which an individual or group is able to realise aspirations and satisfy needs, and to change or cope with the environment. Health is seen as a resource for everyday life, not the objective of living; it is a positive concept, emphasising social and personal resources, as well as physical capacities (WHO 1986).
• Related to this is the notion of resiliency, such as the success with which individuals and communities adapt to changing circumstances (see Antonovsky 1979 and 1987 and his Sense of Coherence theory).
There are advantages and disadvantages to each of these models. The advantage of the medical model is that disease represents a major public health issue facing society, and disease states need to be treated and can be readily diagnosed and counted. But this approach is narrow, negative and reductionist, and in an extreme form implies that people with disabilities are unhealthy, and that health is only about the absence of morbidity. A further potential limitation to the medical model is its omission of a time dimension. Should we consider as equally healthy two people in equal functional status, one of whom is carrying a fatal gene that may lead to early death?
The holistic and wellness models have the advantage of allowing for mental as well as physical health, and on broader issues of active participation in life. They also allow for more subtle discrimination of people who succeed in living productive lives despite a physical impairment. The visually impaired or amputees, for example, may still be able to satisfy aspirations, be productive, happy and so be viewed as healthy. The disadvantage is that these conceptions run the risk of excessive breadth, of incorporating all of life. Thus, they do not distinguish clearly between the state of being healthy and the consequences of being healthy; nor do they distinguish between health and the determinants of health (some of the above is adjusted from http://courseweb.edteched.uottawa.ca).
It is important to note that the WHO (1948) constitution definition of health mentioned above has been heavily criticised, mainly on two grounds: it is unrealistic and idealistic and it implies a static position. A study by Jadad & O’Grady (2008) found that some criticisms of the WHO definition focused on its lack of operational value and the problem created by use of the word ‘complete’. An extreme critique, such as Smith (2008), call it a ludicrous definition that would leave most of us unhealthy most of the time. In support of the definition, Jadad & O’Grady (2008) argue that the WHO invited nations to expand the conceptual framework of their health systems beyond the traditional boundaries set by the physical condition of individuals and their diseases, and it challenged political, community and professional organisations devoted to improving or preserving health to pay more attention to the social determinants of health.
Even just using these three broad categories of health, it follows that there will be differences between health practitioners’ concepts of health. To take one example, practitioners of complementary medicine hold to a range of beliefs about what health is and how health can be restored or improved which is based on holism and empowerment (Barrett et al 2004).
In exploring the concept of health further it is useful to consider the identification of different dimensions of health which began with the WHO definition but have been subsequently expanded. The dimensions now include:
Physical health
This is perhaps the most obvious dimension of health, and is concerned with the mechanistic functioning of the body.
Mental health
Mental health refers to the ability to think clearly and coherently. It can be distinguished from emotional and social health, although there is a close association between the three.
Emotional health
This means the ability to recognise emotions such as fear, joy, grief and anger and to express such emotions appropriately. Emotional (or affective) health also means coping with stress, tension, depression and anxiety.
Social health
Social health means the ability to make and maintain relationships with other people.
Spiritual health
For some people, spiritual health might be connected with religious beliefs and practices; for other people it might be associated with personal creeds, principles of behaviour and ways of achieving peace of mind and being at peace with oneself.
Societal health
So far, health has been considered at the level of the individual, but a person’s health is inextricably related to everything surrounding that person. It is impossible to be healthy in a sick society that does not provide the resources for basic physical and emotional needs. For example, people obviously cannot be healthy if they cannot afford necessities like food, clothing and shelter, but neither can they be healthy in countries of extreme political oppression where basic human rights are denied. Women cannot be healthy when their contribution to society is undervalued, and neither black nor white can be healthy in a racist society where racism undermines human worth, self-esteem and social relationships. Unemployed people cannot be healthy in a society that values only people in paid employment, and it is very unlikely that anyone can be healthy if they live in an area that lacks basic services and facilities such as health care, transport and recreation.
The identification of these different aspects of health is a useful exercise in raising awareness of the complexity and the holistic nature of health. But in practice it is obvious that dividing people’s health into categories such as physical and mental can impose artificial divisions and unhelpful distortions. Sexual health, for example, can cross all these boundaries proving that the dimensions of health are interrelated.
Some writers have provided useful analyses of what health means from different disciplinary perspectives. Seedhouse (2001), for example, proposes the idea of health as the foundation for achieving a person’s realistic potential.
Similarly, when the WHO broadened their definition, as noted in the wellness model outlined earlier in the chapter, they also identified key aspects of health. The conception of health is the extent to which an individual or group is able to realise aspirations and satisfy needs, to change or cope with the environment, where health is seen as a resource for everyday life, not the objective of living; it is a positive concept emphasising social and personal resources, as well as physical capacities, not simply the absence of disease (WHO 1984).
This is a rich view of health. It encompasses ideas of:
• Personal growth and development (‘realise aspirations’).
• Meeting personal basic needs (‘satisfy needs’).
• The ability to adapt to environmental changes (resilience to change and cope with the environment’).
• A means to an end, not an end in itself (a resource for everyday life, not the objective of living).
• Not just absence of disease (a positive concept).
• A holistic concept (social and personal resources … physical capacities).
This notion of health has much to offer the health promoter. It recognises that health is a dynamic state, that a person’s potential is different, and that each person’s health needs vary. Working for health is both an individual and a societal responsibility, and involves empowering people to improve their quality of life.
This discussion of health as a concept is an important prerequisite to thinking about what determines people’s health. Before moving on to a consideration of what affects health, it might be useful to undertake Exercise 1.2 and to read Case studies 1.1 and 1.2 and answer the associated questions.
EXERCISE 1.2
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Dimensions of health
1. Go back to your answers in Exercise 1.1‘What does being healthy mean to you?’ Tick if any of the following dimensions of health are reflected in the statements you ticked in Column 1:
| Physical | □ | Emotional | □ |
| Mental | □ | Spiritual | □ |
| Social | □ | Societal | □ |
Is any one of these dimensions more important to you than the others? How do they relate to each other?
2. Has your idea of health changed since childhood? If so, how and why? How do you think your idea of health may change as you grow older?
3. If you have had professional training in health or a related area of work, what difference has this made to your idea of health?
4. What do you think being healthy may mean to someone who:
▪ has learning difficulties?
▪ has a permanent physical disability such as deafness or paralysis?
▪ has an illness or infection for which there is currently no known cure such as diabetes, arthritis, HIV, schizophrenia?
▪ lives in poverty?
5. Identify three or four key points you have learnt from this exercise about your own ideas of being healthy.
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