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In addition, research has found that survival of car- diovascular disease events and stroke is higher among people with close ties to others, particularly emotional ties. Social relations have been found to predict compliance with medical care recommendations, adaptation to adverse life events such as death of a loved one or natural disaster, and coping with long- term difficulties such as caring for a dependent parent or a disabled child.

A great deal of research in the area of social support was conducted during the s and s. A seminal review article published in by Kaplan, Cassel, and Gore identified methodological issues that needed to be addressed. Since then, there has been further specification of the relationship between social support and health to explain the relationship. For example, Cohen discusses three factors that indicate differ- ent aspects of social relationships: social integration, negative interaction, and social support, each influencing health through different mechanisms.

Thoits reanalyzed data to test the hypothesis that disadvantaged sociodemographic groups such as low-income women are more vulnerable to the effects of life events because they experience more negative events and have fewer psychological resources to copy with them. Although the relationship between social support and health is still not well understood, it is found over and over again in health studies. Genetic Inheritance Our knowledge about the effects of genetic inheritance on health is growing rapidly.

These usually interact, and individuals with a particular set of genes may be either more or less likely, if exposed, to be at risk of developing a particular disease.

Chapter 1 Introduction and Overview 17 Health Behavior The term health behavior can refer to behaviors that are beneficial to health. However, the term is generally used in the negative to refer to behaviors that harm health, including smoking, abusing alcohol or other substances, failing to use seat belts or practicing other unsafe behaviors, making un- healthy food choices, and not engaging in adequate physical activity.

The effect of health behaviors on health status has been widely studied and found to be an important determinant of health. In one way or another, personal health behavior has an impact on the occurrence in any given individual of most of the diseases and conditions on this list. Further, looking at the cause of death in a different way, that is, by major contributing cause of the disease to which the death was attributed rather than by the disease itself, in the first study of its kind, McGinnis and Foege showed that, as of , the leading factors were tobacco use, dietary patterns, sedentary lifestyle, alcohol consumption, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles, and use of illicit drugs.

Often by the time the individual interacts with the health care system, the determinants of health have had their impact on their health status, for better or for worse. Thus, the need for health care may be seen as a failure to prevent the determinants of health from adversely affecting the individual patient.

Genetic predisposition to breast cancer may limit the long- term success rates of cancer treatment. Continued exposure to toxins in the environment or at work may decrease the likelihood that the physician can stabilize an individual with allergies. Health behaviors, such as smoking or substance abuse, may stymie the best health care system when treating an individual with lung disease.

The lack of support at home for changes in be- haviors or adherence to medical regimens may undermine the ability of the health care system to treat an individual with diabetes successfully. We recognize that health, as well as health care, exist within a biological, physical, and social context, and all of these factors influence the level of probability of success of a health care system.

Health care is only one determinant of health. Relationship Between the Determinants of Health The determinants of health do not act independently of each other. They are interconnected, and the concepts of ecology provide the framework for understanding how to model their interconnectedness.

In the most general sense, the ecological approach means that the person is viewed as embed- ded in the environment—both social and physical—and is both influenced by and influences that environment. Stokols outlines the history of ecology, and social ecology, which are fundamental to the public health perspective and its practice: The term ecology refers to the study of the relationships between organisms and their environments. Early ecological analyses of the relations between plant and animal populations and their natural habitats were later extended and applied to the study of human communities and environments within the fields of sociology, psychology, and public health.

The field of social ecol- ogy, which emerged during the mid s and early s, gives greater attention to the social, institutional, and cultural contexts of people-environ- ment relations than did earlier versions of human ecology, which focused primarily on biologic processes and the geographic environment. Second, ecological models include characteristics of individuals, and for example, can incorporate their genetic heritage, psychological attributes, and behavioral practices.

Third, concepts from systems theory are used to understand the interplay between environmental and individual characteristics and their mutual influence on health. Thus, efforts to promote human health must take into account the inter- dependencies that exist among immediate and more distant environments e.

Stokols, , p. With the multitude of factors that affect human health, many disciplines are required to understand the interplay between them and their effect on health and to bring about health improvement.

The classic book, Mirage of Health, by Rene Dubos provides an example of how the ecological approach is applied to human health. Dubos describes the causes of the tuberculosis epidemic in the tenements of New York City and other U. He recounts The story of the roundabout way in which a microscopic fungus prob- ably native to Central America destroyed the potato crop in Ireland and exerted thereby a dramatic influence on the destiny of the Irish people, illustrating the complexity of the interplay between the external environ- ment and the affairs of man.

The profound upheaval in their way of life made them ready victims to all sorts of infection. The sudden and dramatic increase of tuberculosis mor- tality in the Philadelphia, New York and Boston Areas around can be traced in large part to the Irish immigrants who settled in these cities at that time.

Dubos, , p. In- terestingly, he does not mention health care, or its absence, as a factor leading to the tuberculosis epidemic, but then there was little that medicine offered at that time for the treatment of tuberculosis. These included the impetus among Europeans to explore and trade that caused the transport of the wild potato from Central America to Europe; the application of scientific principles to farming that caused the improvement of the potato; the political and economic relationships between Ireland and England that caused the dependence of the Irish on the potato for food; and so forth.

We understand the disease, not only in terms of immediate individual actions, for example, sanitary habits of the individuals with tuberculosis, but in terms of societal attributes that reach back into history and relate to political and eco- nomic events and policies of the times.

Ecological Models and Public Health Practice The environment, or context, influences the way people live and their health outcomes, for better or for worse. That is, context can have positive or nega- tive impacts on the health of individuals. As a field, public health attempts to maintain or create healthy contexts in which people live and prevent or dismantle unhealthy contexts—to promote health and reduce morbidity, disability, and premature mortality.

The way in which public health attempts to affect contexts is the story of public health practice, and public health practice reflects public health ecological models. However, the ecological models in use change over time to respond to the health problems predominant in their day and incorporate the knowledge, beliefs, values, and resources of that time and place. For example, in times and places where infectious diseases are pre- dominant, models reflect the issues required to understand their spread and control.

A classic public health model that uses the ecological approach for understanding and preventing disease is the epidemiological triangle with its agent-host-environment triad. The epidemiological triangle see Figure 1. The three points of the triangle are the agent, host, and environment. The agent is the microbial organism that causes the infectious disease—virus, bacteria, protozoa, or fungus; the host is the organism that harbors the agent; and the environmental aspects included in an epidemiological triangle are those factors that facilitate transmission of the agent to the host.

These could be aspects of the natural environment, the built environment, or the social environment, including policies. Prevention measures are those that disrupt the relationship between at least two of the factors in the triangle— agent, host, and environment. Although there are no explicitly specified environmental factors in- cluded in the epidemiological triangle, the environment is central to con- ceptualizing disease transmission among individuals at risk the hosts.

The environment is the total of factors that enable the agent to infect the host. The environmental factors specified in the model can include, depending upon the disease itself, an array of social and physical attributes that permit the agent to infect the host.

For example, Friis and Sellers write: The external environment is the sum total of influences that are not part of the host and comprises physical, climatologic, biologic, social, and eco- nomic components. The physical environment includes weather, tem- perature, humidity, geologic formations, and similar physical dimensions. Contrasted with the physical environment is the social environment, which is the totality of the behavioral, personality, attitudinal, and cultural characteristics of a group of people.

Both these facets of the external envi- ronment have an impact on agents of disease and potential hosts because the environment may either enhance or diminish the survival of disease agents and may serve to bring agent and host into contact. In the case of other kinds of diseases or health problems, it is not as helpful because of its emphasis on a single agent, its isolation of the agent from the environment, and its conceptually unspecified environment.

Chapter 1 Introduction and Overview 23 The wheel of causation is another model exemplifying the ecological approach See Figure 1. It has also been used, but not as extensively as the epidemiological triangle for explaining infectious disease transmis- sion. However, it has some advantages over the epidemiological triangle, as Peterson notes, Although it is not used as often as the epidemiological triangle model, it has several appealing attributes Fig.

For instance, the wheel contains a hub with the host at its center. For our use, humans represent the host. Also, surrounding the host is the total environment divided into the biological, physical, and social environments. These divisions, of course, are not true divisions—there are considerable interactions among the environment types.

Although it is a general model, the wheel of causation does illustrate the multiple etiological factors of human infectious diseases.

One of the major issues in developing public health models is where to place the emphasis and, thus, where to intervene to improve health? Is it at the individual level or at the environmental level?

This issue is at the heart of public health practice. Therefore, in the simplest conceptualization of prevention strategies, we have two choices: We can focus our efforts on changing individual behavior directly or on changing the environment in which individual be- havior occurs. These habits might have included hand washing, housekeeping, food preparation practices, and so forth.

Changing behavior might have taken the form of encouraging compliance through education or coercing compliance through surveillance and laws. On the other hand, we might decide that the tuberculosis epidemics should have been prevented by changing the social, political, or physical environments. For instance, if the cities to which the Irish emigrated had provided more healthful housing and working conditions, the Irish immi- grants would not have been as susceptible to illness, including tuberculosis.

We might have targeted the crowding and other relevant conditions in the neighborhoods where the immigrants came to live. Thus, instead of moti- vating individuals to change their behavior—through education—we might argue that we could have changed the physical environment to reduce the spread of tuberculosis. Alternatively, stepping further back in the causal chain, we might decide that the political environment in Ireland should have been the focus of in- tervention.

If England had provided aid to the Irish during the potato blight, the Irish would not have perished in such numbers and survivors, poor and already weakened by famine, would not have been motivated to emigrate to the United States where they were highly susceptible to tuberculosis.

On the other hand, going back even further, we might decide that the un- diversified diet of the Irish should have been the subject of intervention. If the Irish food supply had been diversified, the potato blight would not have become a crisis for the people of that country. Again, this was a political decision on the part of the English.

Thus, political strategies might be pro- posed that would have changed the environment, and, thus, prevented the tuberculosis epidemics of the s in the United States. The general ecological model is extremely flexible and can assume many different forms.

The model becomes differentiated when a specific health problem is identified for intervention in a particular time and place. The ecological models developed beginning in the s in response to the increased importance of chronic diseases made a significant departure from the classic models such as the epidemiological triangle and the wheel of cau- sation see Figure 1.

Let us explain. Chapter 1 Introduction and Overview 25 Health Promotion and the Ecological Models in Public Health Since Beginning in the s, the models explaining health status became increas- ingly limited to the behavioral determinants of health such as smoking, sed- entary lifestyle, poor dietary habits, unprotected sexual activity, and failure to use seat belts, which placed the focus of public health interventions on chang- ing individuals rather than their context.

The watchwords of this trend were health promotion and disease prevention. As Green states, was a turning point when health promotion was accepted as a significant component of health policy. In the public sector this interest has led to national campaigns to control hypertension and cholesterol, the establish- ment of the Office of Disease Prevention and Health Promotion within the Public Health Service and the Center for Health Promotion and Education within the Centers for Disease Control, the development and implementa- tion of community-wide health promotion programs by both governmental agencies and private foundations, and the establishment and monitoring of the Objectives for the Nation in health promotion.

More recently, jour- nals have appeared which are devoted exclusively to articles on health pro- motion programs and activities; existing journals both within and outside of traditional public health disciplines have devoted theme issues to health promotion topics; international conferences on health promotion have been held; and health education training programs have begun to focus more extensively on health promotion topics and issues.

These initiatives were in contrast to historic interventions such as sewage disposal or food inspection that emphasized changing the environment, as we will explore in the next chapter. Enabling factors are those skills, resources, or barriers that can help or hinder the desired behavioral changes as well as environmental changes. Reinforcing factors, the rewards received, and the feedback the learner receives from others following adoption of the behavior, may encourage or discourage continuation of the behavior.

Thus, edu- cation about the risks of certain behaviors and the benefits of others is a primary component of health promotion initiatives.

These include initia- tives to modify unfavorable dietary habits, sedentary lifestyle, substance abuse, smoking, and unsafe practices such as failure to use seat belts or fol- low safety precautions at work. That is, once the knowledge about health behaviors is conveyed, the challenge is to motivate individuals to change their behavior from risky to healthy.

Knowledge alone is not sufficient to bring about change in health behaviors. Thus, a major tool of health promotion is the applica- tion of psychological theories to understand why people engage in unhealthy behaviors and how to stimulate them to modify these behaviors. These theories underlie the methods used in health promotion initia- tives to motivate health behavior change. The model visualizes the assumed causal chain, which shows that behavioral problems produce health problems, which then in turn, produce social problems, such as illegitimacy, unemployment, absenteeism, hostility, alienation, discrimination, riots, and crime.

The effect of the environment on individual behavior is assumed under enabling factors such as availability of resources, accessibility, and referrals and reinforcing factors as attitudes of program personnel. However, note that this is a very restricted environment, which is limited to the immediate setting of the health education program.

There is also a nonbehavioral factors box, which contributes to health problems and could contain larger environmental factors, but is not the main focus of the model and is not seen as contributing to behavior problems.

Predisposing factors are the characteristics of the individual beliefs, attitudes, values, etc. Predisposing factors are con- ceptualized as providing the motivation for behavior.

The threat-related beliefs and efficacy expectancies that are prominent features of the val- ue-expectancy models psychological theories for health behavior would be included here. Most barriers or costs would be classified as enabling factors. Importantly, the environment—in this case, the physical workplace and the people who manage it—is seen as reinforcing and enabling the worker to engage in safety habits, but not as the target of the intervention.

Rather, improving workplace safety is focused on motivating the individual worker to practice safety habits, not motivating the employer or the larger society to modify the workplace.

Also, note that the environment is quite proscribed. Its bounds are the specific workplace itself. The environment, in this example, does not include larger political and economic factors that may affect what occurs within the workplace. For instance, the political and economic factors that impact the availability of protective equipment and other resources re- quired for safety are not considered. Regulations governing safety in the workplace are not considered, nor are the enforcement of regulations.

This example is typical of health promotion programs, particularly through the s. The larger environment could certainly be incorporated into the model, but it usually was not.

Why Health Promotion? Educating individuals about health was seen as a way to make people more self-sufficient in health, engage in self-care, and become better informed consumers of health services. Because of concern about spiraling health care costs in the s and onward, health promotion was presented as a means to control costs through the demand side Green, Practitioners and the agencies funding health services and public health research eagerly embraced this search for magic-bullet solutions to the behavioral change problems pre- sented by medical care and public health.

A generation of highly con- trolled randomized trials and fine-grained behavioral research ensued. These tested, by trial and error, specific ways to improve patient com- pliance.

They included ways to reduce broken appointments, educate mothers to restrain their tendency to bring a child to health maintenance organization or pediatric services for each earache or sore throat, improve smoking cessation, and modify a range of specific consumer and self-care behaviors.

The targets of the magic bullet interventions were as much those behaviors thought to account for some of the unnecessary and inap- propriate uses of health services as those accounting for leading causes of death or disability. If risky health behaviors could be changed, it was argued, the inci- dence of chronic diseases would be reduced. Of course, this is true.

The question, however, is whether trying to motivate individuals to change their behavior—through education, incentives, and disincentives—is the most effective and just means of accomplishing this goal.

Is placing accountability for behavior change onto the individual, without changing the environment in which that behavior occurs, realistic and fair? Chapter 1 Introduction and Overview 31 Criticisms of Health Promotion Placing the locus of accountability for poor health on the individual is one of the major criticisms of the health promotion movement. For example, poor people and those of minority groups often live in neighborhoods with supermarkets that carry limited amounts of healthy foods, especially fruits and vegetables.

Does the fairer and more effective public health intervention, aimed at improving the diet of people in such neighborhoods, target the residents themselves or the supermarkets? Not surprisingly, beginning in the s, the pendulum began to swing back to a focus on environmentally targeted interventions and an interest in understanding the interaction between individuals and their environment. Further: In , the First International Conference on Health Promotion pro- duced the Ottawa Charter, which helped reorient policy, programs, and practices away from these proximal risk factors.

The shift that followed was to the more distal risk factors in time, space, or scope, which we shall call risk conditions.

These also influence health, either through the risk factors or by operating directly on human biology over time, but they are less likely than risk factors to be under the control of the individual at risk. In addition, the model now includes a policy regulation organization factor, which impacts the enabling factors and, through these, the environment. These include adequate housing; secure income; healthful and safe com- munity and work environment; enforcement of policies and regulations controlling the manufacture, marketing, labeling, and sale of potentially harmful products; and the use of these products such as alcohol and tobacco where they can harm others.

The context was identi- fied in the model as necessary to achieve individual behavioral changes. However, in practice, changes to the context within health promotion pro- grams were usually still limited and proscribed to the immediate setting.

They did not aim to change underlying social structures or other larger environmental factors. Population Health and Reemphasis of the Social Environment in Public Health Models At the same time that health promotion was coming under attack, the population health approach was introduced and began to gain followers in the field of public health.

Stirred by antipathy toward the emphasis on interventions that used education and psychologically based strategies to motivate individuals to change their behavior rather than changing the context or structure in which behavior occurs, this approach to pub- lic health focused on the distal social environment—power, wealth, and status—as the root cause of health problems.

The evidence supporting this approach is the large body of research on disparities or inequalities in health status between the rich and the poor, the powerful and power- less, and those of high social status and those of low status. The Whitehall study was one of the first to demonstrate what has become a consistent finding— people who are structurally disadvantaged are far more likely than the advantaged to have poor health.

As Marmot states, The gross inequalities in health that we see within and between coun- tries present a challenge to the world. That there should be a spread of life expectancy of 48 years among countries and 20 years or more within countries is not inevitable. A burgeoning volume of research identifies social factors i. Social determinants are relevant to communicable and non-communicable disease alike. That is, the social context is viewed as having a causal impact on health behaviors.

Social determinants of health are widely described but few research- ers have more than cursory contact with those whose lives fall into the most impoverished, epidemiological categories. Framing the prob- lems as inappropriate emergency room visits and non-compliance with treatment regimens sheds little light on the choices driving such behaviors.

Drawing on 11 years of working continually among resi- dents of a highly diverse and grindingly poor urban neighborhood, this paper examines the meanings people assign to their health behaviors. Each type is illustrated with authentic stories rarely surfaced by traditional scientific methods and validated through re- views by community participants. While several resulting composites mirror frequently cited stereotypes of downtrodden lives, others chal- lenge prevailing beliefs about why and how the poor make health care decisions.

Not surprisingly, money plays a central role in care seeking among the population studied. However, the connection is frequently misunderstood by health providers and policymakers, with frustrat- ingly predictable results. Opportunities for more successful therapeu- tic engagement emerge from this new mapping of social perceptions.

For example, a recent study of the original Whitehall participants who have been followed for 24 years Stringhini et al. The behaviors studied included smoking, alcohol consumption, diet, and physical activity. Braveman, , p. Summary Over the last 50 years, the emphasis of public health initiatives on behav- ior, rather than on environment, became widespread. Even though the ecological approach of public health views the individual as embedded in a physical and social environment and affected by it, the health promo- tion orientation led to an emphasis on behavior and a de-emphasis on the environment—both physical and social.

Of the more than 80, chemical used in the United States today, only a few hundred have been tested for health effects. Environmental contaminants come from industrial and manufac- turing processes, agriculture, household products, medical technologies, military practices, and the natural environment. The report argues that the problem has not been addressed adequately by the National Cancer Program, which has focused on individual behaviors, screening, diagno- sis, and treatment.

Suggesting that the risk is much higher, when there is no proof, may divert attention from things that are much bigger causes of cancer, like smoking. This discussion exemplifies some of the complexities of taking a pri- mary prevention approach to health, that is, to prevent health problems from beginning.

There are many choices made when determining how to improve or maintain health, and one is the choice of an individual- or environmental-level intervention.

Given the premise of the ecological model—that individuals are embedded in an environment, which they both influence and are influenced by—both components of the model are rele- vant.

Within the ecological model, both the individual and the context are potential sites of public health interventions, and both have been employed throughout the history of public health. For example, in the early part of the 20th century, there were interventions that focused on the individual level—teaching and encouraging individuals in immigrant communities to engage in certain health behaviors such as hand washing that prevent infectious diseases—and those that focused on the environmental level, notably the environmental engineering interventions that brought clean water, safe food supply, and sanitary disposal of waste to these communi- ties and also prevented the spread of infectious diseases.

The emphasis on environmental over individual-level interventions changes over time, as we have seen in the discussion of public health models since Neither approach is ever entirely abandoned, but in different eras, one may be em- phasized over the other. Public health, as a field, plans and initiates prevention activities— primary, secondary, and ter- tiary. However, many important choices about these activities translate the public health mission into public health practice.

To clarify these choices and how they impact practice, we can examine the provision of clean water in the United States. Although water treatment has been practiced throughout human history as far back as BC in ancient Greece and India, before the mids, the motivation to treat water, usually with some form of filtering, was to improve taste and reduce turbidity. In the mids, the need to treat water to prevent infectious disease outbreaks was beginning to be understood, even before we knew that water could contain microorganisms that caused these diseases.

Whenever cholera broke out—which it did four times between and —nothing whatsoever was done to contain it, and it rampaged through the industrial cities, leaving tens of thousands dead in its wake. In the London epidemic the worst-hit areas at first were Southwark and Lambeth.

Soho suffered only a few, seemingly iso- lated, cases in late August. It was as violent as it was sudden.

During the next three days, people living in or around Broad Street died. Few families, rich or poor, were spared the loss of at least one member. Within a week, three-quarters of the residents had fled from their homes, leaving their shops shuttered, their houses locked and the streets deserted. Only those who could not afford to leave remained there. It was like the Great Plague all over again.

That it did not rise even higher was thanks only to Dr John Snow. Snow lived in Frith Street, so his local contacts made him ideally placed to monitor the epidemic which had broken out on his doorstep. Now he saw his chance to prove his theories once and for all, by linking the Soho outbreak to a single source of polluted water. From day one he patrolled the district, interviewing the families of the victims.

His research led him to a pump on the corner of Broad Street and Cambridge Street, at the epicenter of the epidemic. When they did so, the spread of chol- era dramatically stopped. Cholera, typhoid, hepatitis, and other infectious diseases were understood to be waterborne and controllable through water treatment.

Because of the tremendous death toll from such diseases, by the advent of the 20th century, water purification was consid- ered an important public health issue, and methods to provide clean water were underway.

The filtration systems of the past had been somewhat, but not entirely, effective against waterborne diseases. The first widely used method to eliminate waterborne disease organisms was chlorination. In , public health concerns shifted from waterborne illnesses caused by microorganisms, to water pollution from pesticide residues, industrial waste, and organic chemicals.

Regulations and water treatment plants were developed to respond to this source of water contamination as well Jesperson, In the United States as in many other countries, providing clean water was viewed as a public good or utility.

As a result, government at every level invested in water purification systems, and water treatment became a staple public health service. Government regulations set standards for water used for human consumption, and clean water was provided throughout the country by public or publicly regulated organizations. The exceptions were for people who lived in remote areas and obtained their water from private wells. With respect to public health choices about how to improve health, this approach to preventing waterborne infectious diseases may be viewed as an archetypical primary prevention; purifying water supplies is intended to prevent infectious diseases such as cholera, typhoid, and hepatitis from occurring at all.

As for the strategy chosen to prevent waterborne infectious diseases, water treatment systems such as those in the United States are environmental-level interventions.

Our systems of preventing exposure to unclean water do not depend on individual behaviors such as boiling water or adding chlorine to water for individual use. In addition, the water treatment organization in the United States is generally a public utility, not a private enterprise. At the base of this pyramid, indicating interventions with the greatest potential impact, are efforts to address socio-economic de- terminants of health.

From Frieden, T. A frame- work for public health action: The health impact pyramid. American Journal of Public Health, , Also note that the second level—changing the con- text—is a primary prevention strategy, which includes provision of clean water and safe food, as well as passage of laws that prevent injuries and exposure to disease-producing agents.

In the following chapters, we will discuss the practice of public health. We will examine what public health practitioners actually do and how their practice relates to the mission of public health and to primary, secondary, and tertiary prevention. So far, we have discussed public health in the ideal. However, the actual practice of public health does not always attain the ideal. In the next set of chapters, we will discuss the public health system as it is currently practiced in the United States and its historical origins.

This will involve discussing the components of the public health system, includ- ing organization, financing, management, and performance, as well as the health problems that are addressed by public health. The promise of public health rests on social justice—everyone is en- titled to the conditions that can maintain health.

In practice, public health is a loose confederation of organizations and public agencies that are often not in a position to maintain or create the conditions that lead to health. Therefore, what are the prospects for public health? What conditions can public health affect? As Marmot writes: Health status, therefore, should be of concern to policy makers in every sector, not solely those involved in health policy.

A major thrust of the commission is turning public health knowledge into political action. It will be easier to maintain a focus on motivating individuals to change their own behavior, rather than taking on the difficult task of providing, in the broadest sense, the conditions in which people can be healthy.

These issues will be considered in the final chapter. Another issue will be who will provide public health services. For example, we, in the United States, where access to clean water is guaranteed by public utilities through environmental-level structures that deliver potable water to individuals in their homes, worksites, and public places, may assume that our system was the only way the goal of provid- ing water free from disease-producing agents could have been achieved.

However, this is not the case. Other models have been developed and are being tried throughout the world, mostly in poor countries and poor communities. They include water systems developed by the private sector such as in Bolivia, where the government licensed water distribution in the s to private companies, headed by Bechtel Salzman, They include the Acumen Fund water ini- tiatives that provide potable water in poor countries using market-based concepts and private investment without government help Acumen Fund, These alternative strategies to providing potable water that is free from water-borne disease agents illustrate the variety of ways that public health problems can be addressed.

However, the questions that must be raised about the selection of strategies to achieve public health goals are related to their effective- ness, efficiency, and equity. The purpose of this book is to open the field of public health to those new to it. Many complexities are not discussed in this attempt to make the overall values, goals, and practices of the field accessible to those unfamiliar with public health.

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Grady, D. May 6, The New York Times. Green, L. Toward cost-benefit evaluations of health education: Some concepts, methods, and examples. Health Education Monographs, 2 Supp. Annual Review of Public Health, 20, 67— Health promotion planning 2nd ed. Health promotion planning: An educational and ecological approach 3rd ed. Institute of Medicine IOM. The future of public health. Jesperson, K. Search for clean water continues. Social support and health. Medi- cal Care, 15 5 Suppl.

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Journal of Occupational Health Psychology, 3 4 , — Kasl, S. The impact of job loss and retirement on health. The impact of unemployment on health and well-being. Dohrenwend Ed. New York: Oxford University Press. Krieger, N. Discrimination and health. In: L. Social epidemiology 36— A vision of social justice as the foundation of public health: Commemorating years of the spirit of American Journal of Public Health, 88 11 , — Lasagna, L.

Lynch, J. Income in- equality and mortality: Importance to health of individual income, psycho- social environment, or material conditions. British Medical Journal, , — Mays, V. Race, race-based dis- crimination, and health outcomes among african americans, Annual Review of Psychology, 58, — Marmot, M.

Social determinants of health inequalities. Lancet, , — Explanations for social in- equalities in health. Amick III, S. Levine, A. Walsh Eds. Actual causes of death in the United States.

Journal of the American Medical Association, , — McGinnis, J. The case for more active policy attention to health promotion. Health Affairs, 21, 78— McLeroy, K. An ecological per- spective on health promotion programs.

Health Education Quarterly, 15 4 , — Moore, L. Associations of neighborhood character- istics with the location and type of food stores.

American Journal of Public Health, 96 2 , — National Academy of Engineering. Water supply and distribution timeline. Oxford handbook of public health practice. Peterson, R. Insects, disease, and military history: The Napoleonic campaigns and historical perception. American Entomologist, 41, — Pickard, R.

April, Reduc- ing environmental cancer risk: What we can do now. Washington, DC: U. Prochaska, J. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, research, and practice, 20, — Purslow L. Socioeconomic position and risk of short-term weight gain: Prospective study of 14, middle-aged men and women.

BMC Public Health, 8, Rogers, R. Cognitive and psychological processes in fear appeals and attitude change: A revised theory of protection motivation. Petty Eds. New York: Guilford Press. Rosenstock, I. M, Strecher, V. H Social learning theory and the health belief model. Health Education Quarterly, 15 2 , — Salzman, J. Thirst: A short history of drinking water.

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The determinants of health. Population health: Concepts and methods. To examine this issue, we will first discuss the origins of public health in the Industrial Revo- lution of the 18th and 19th centuries. The Romans built the great aqueducts, for instance, to bring clean water to the city. The Venetians during the 17th and 18th centuries controlled plague through public measures including surveillance and control of travel: During the 17th and 18th centuries, measures were taken by the Venetian administration to combat plague on the Ionian Islands.

At that time, although the scientific basis of plague was unknown, the Venetians recognized its infectious nature and successfully decreased its spread by implementing an information network.

Additionally, by activating a system of inspection that involved establishing garrisons along the coasts, the Venetians were able to control all local move- ments in plague-infested areas, which were immediately isolated. In contrast, the neighboring coast of mainland Greece, which was under Ottoman rule, was a plague-endemic area during the same period.

Classification of Health Problems Before considering the origins of modern public health, we need a classifica- tion scheme for health problems. We can consider health problems to be of two broad types: diseases and injuries. Diseases can be classified as infectious or noninfectious, with infectious diseases caused by pathogenic microorganisms— bacteria, viruses, fungi, multicellular parasites, and prions—that can be trans- mitted from person to person or from other species to persons.

The term communicable disease is used interchangeably with infectious disease, as a result. Examples of infectious diseases are tuberculosis, plague, cholera, influ- enza, and human immunodeficiency virus HIV. Noninfectious diseases are those that are not caused by a pathogenic microbe, but by factors that are not communicable or contagious such as environmental exposures to toxins, nu- tritional deficiencies, health behaviors, and genetic inheritance.

They include dietary and autoimmune conditions; hereditary diseases such as hemophilia; diabetes; cardiovascular disease; and cancer. Mental health conditions such as depression, anxiety, and others are noninfectious. Noninfectious diseases are sometimes referred to as chronic diseases. However, the concept of chronic and acute may be applied to either infectious or noninfectious diseases. For example, HIV infection has become a chronic condition, at least in developed countries such as the United States, and nutritional deficiency diseases, once di- agnosed, can be acute; that is, curable without lingering or permanent effects.

Injuries are the other broad category of health problems. A useful clas- sification of injuries for public health practice is intentional and uninten- tional. Intentional injuries are self-inflicted such as suicide or inflicted by a person or persons on others such as homicide. Intentional injuries may re- sult in death or morbidity. Domestic violence, child abuse, and elder abuse are intentional injuries. Unintentional or accidental injuries, again, can be self-inflicted or inflicted by others and result in mortality or morbidity.

The most common unintentional injuries result from motor vehicle crashes, but injuries in the home and workplace are sites of a great many unintentional injuries including burns, falls, drownings, poisonings, and lacerations. Distinguishing between diseases and injuries, infectious and non-infectious diseases, and intentional and unintentional injuries facilitates an understanding of the causes of health problems, and therefore, strategies to prevent them.

The exemplar is Britain. During industri- alization, cities grew rapidly as factories replaced the domestic system of pro- duction, beginning with textiles. The poor living and working conditions in the burgeoning industrial cities, where infectious diseases were prevalent and fre- quently epidemic, are well documented. Housing was crowded, sanitation was grossly inadequate, clean water was scarce, and a healthful diet was beyond the means of most people.

Work consisted of long days in unsafe and poorly venti- lated factories, often exposed to toxic substances. The smells of raw sewage, horse and cattle manure, slaughter houses, unwashed bodies, and coal fires filled the air. Fog from the smoke of these fires made breathing difficult. Housing was cramped, often airless, and without a clean water supply or sanitary disposal of garbage and sewage. Diet was poor.

On housing in London, Dr. Vinen, a medical officer of health, reported in on the living conditions typical of the day: In one small miserably dirty dilapidated room, occupied by a man, his wife and four children, in which they live day and night, was a child in its coffin that had died of measles eleven days before and, although decomposition was going on, it had not even been fastened down.

The excuse made for its not having been buried before was that burials by the parish did not take place unless there were more than one to convey away at a time. In another miserable apartment scarce seven feet wide lived five persons and in which there was not one atom of furniture of any kind; the room contained nothing but a heap of filthy rags on the floor.

The front door is never closed day or night and in consequence the staircase and landing form a nightly resort for thieves and prostitutes, where every kind of nuisance is committed. There are two yards at the back of this house, in each of which is an open privy; one of them is so abominably filthy and emitted a smell so foul that I was almost overpowered.

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