Improving Health in the Community A Role for Performance Monitoring (1997) / Chapter Skim
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2 Understanding Health and Its Determinants
2 Understanding Health and Its Determinants
Pages 40-58
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From page 40... ...
The latter definition views health more broadly but risks assigning to the "health" system full responsibility for the economic and social welfare of members of society. Neither definition explicitly takes account of how individuals experience disease.
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From page 41... ...
The committee has adopted a broad definition of health, echoing a WHO (1986) health promotion perspective, that acknowledges multiple possible goals for the health system and underscores the important contributions to health that occur outside the formal medical care and public health systems.
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Communities embarking on health improvement initiatives should consider carefully their definition of health and ground their work in an evidence-based conceptual model of the determinants of health. Three arguments supporting such action are discussed below.
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These programs markedly reduced financial barriers for the poor and elderly, and they also ensured a supply of well-trained physicians by providing funds for medical school and residency training programs. The biomedical model of health has fostered the development of a personal health care system centered around technologically advanced hospitals and highly trained medical specialists.
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recommended a focus on three core functions -- assessment, policy development, and assurance. In this framework, the direct provision of clinical and personal preventive services is only a small portion of the assurance function of public health departments.
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. This alliance is using financial and market share incentives to influence health plans to provide access to high-quality health promotion and disease prevention services.
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. The project coordinates a cross section of community services, in cluding law enforcement, hospital emergency rooms, and community agen cies.
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. A MODEL OF THE DETERMINANTS OF HEALTH A resurgence of interest in broader definitions of health and its determinants is, in part, a response to the growing realization that investments in clinical care and personal preventive health services were not leading to commensurate gains in the health of populations (Evans and Stoddart, 1994)
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From page 48... ...
Unlike a biomedical model that views health as the absence of disease, this dynamic framework includes functional capacity and well-being as health outcomes of interest. It also presents the behavioral and biologic responses of individuals as factors that influence health but are themselves influenced by social, physical, and genetic factors that are beyond the control of the individual.
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The model • emphasizes the importance of considering the origins of health and the underlying causes of disease in individuals and populations; • encourages explicit hypothesizing about the production of health in the community; • underscores the interdisciplinary and multisectorial efforts often required to achieve health improvement in communities; • makes explicit the possible trade-offs and benefits that occur across sectors; and • encourages communities to identify possible performance and outcome measures from all of the categories. In selecting indicators for performance monitoring, the determinants of health approach is useful in expanding the potential universe of indicators that should be considered.
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From page 50... ...
Children's relationships with their parents, social support, nurturance, and sense of self-efficacy have been shown to be related to their mental and physical health and even to their future economic productivity (Schor and Menaghan, 1995)
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Examples include exposures to toxic substances, which can produce disorders such as lung disease or cancers; safety at home and work, which influences injury rates; the design of vehicles and roadways, which can alter crash survival rates; poor housing conditions and overcrowding, which can increase the likelihood of violence, transmission of infectious diseases, and mental health problems; and urban–rural differences in cancer rates. Genetic Endowment The contribution of genetic makeup to the health of an individual is a new and emerging area of scientific inquiry.
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Genetic factors also interact with social and environmental factors to influence health and disease. It will be important to understand these interactions to learn why certain individuals with similar environmental exposures develop diseases whereas others do not (e.g., why most smokers do not develop lung cancer)
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In turn, they influence elements such as community response, activation, and social support, and ultimately community outcomes including social behaviors, community health, and quality of life. For example, establishing a smoke-free workplace policy exerts an influence on exposure to tobacco smoke separate from the smoking practices of individuals.
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, and church-based programs. Whether focused on individuals or the community as a whole, health improvement efforts should be targeted at specific causal pathways or should employ interventions that have been proven effective.
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For example, information on social support, perceived barriers to service utilization, and attitudes toward the community and its resources are all relevant to performance monitoring and can be obtained from community surveys. Performance monitoring provides an opportunity for a community to define and articulate expectations for organizations' contributions to the population's health.
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From page 56... ...
A performance monitoring program can promote the articulation of roles and responsibilities among these participants. The committee has concluded that entities engaged in performance monitoring for community health improvement should • adopt a broad definition of health; • adopt a comprehensive and conceptual model of the way in which health is produced within the community; the field model, as elaborated by Evans and Stoddart, is a good starting point; and • develop a concrete and specific hypothesis of how the multiple sectors of the community and individual stakeholders in each sector can contribute to the solution of a health problem.
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1994. Producing Health, Consuming Health Care.
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From page 58... ...
1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives.
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