Summary of The New Public Health by Baum - 4th edition

Chapter 1: How can we understand health?

What is the definition of health?

The clockwork definition of medicine studies the body through its component parts. Health is then defined as the body operating efficiently like machine. Any breakdowns in the body system mean that it is not healthy. The isolation, labeling and systematic classification of specific diseases by Linnaeus in the eighteenth century was an important part of the development of the clockwork model, later consolidated by an increasingly sophisticated understanding of the specific causes of diseases. 

How can we view health as the absence of illness?

Biomedicine distinguishes between disease and illness. 

• Disease involves a set of signs and symptoms and medically diagnosed pathological abnormalities. It is viewed more objectively, involving professional rather than lay diagnosis.
• Illness is primarily about how an individual experiences the disease. It can be culturally specific and may have social, moral or psychological aspects. 

Other perspectives on health have existed alongside the biomedical view. Behavioral psychology adds another dimension, for example, namely the need to protect and maintain the body by appropriate lifestyle behaviors that minimise the risk of disease. Behavioral change and the promotion of healthy lifestyles have become major factors in the professional perspective eon health over the past three decades. Then, the biomedical model also assumes a mind/body dichotomy and does not place much emphasis on how an individual's mental health might affect physical health status. Curtis and Take have pointed out that the biomedical moddel of health has less legitimacy than it had in the past. The model has been critiqued for extending the definition of disease, as risk factors such as obesity are often also defined as disease. Comprehending the various ways in which health is understood is an important background to appreciating the change in thinking about health that is called for by the new public health movement with its emphasis on the social, environmental and economic determinants of health. 

How does health relate to well-being?

The limitations of health being defined as 'the absence of disease' led to the World Health Organisation (WHO) defining it as the 'complete state of physical, entail and social well-being, and not merely the absence of disease or infirmity'. A recent famous on mental health has led to definitions that go beyond the concentration of physical factors. Indigenous definitions of health focus on the whole person within their context of land, community and culture. Health can be viewed as a complex outcome that results from a range of genetic, social, political and economic factors. 

How can we measure health?

Measuring well-being is not easy. Many instruments have been developed, but none adequately captures a positive health state measure. Measures are often static and so do not express the dynamic picture of health that appears to more accurately represent the ways in which health can be interpreted. Overall, health has defied any straightforward quantitative measurement, reflecting both the limitations of questionnaire surveys and the actual complexity of health. It is easier to measure disease or tis absence than to measure a more positive state of health or well-being. Even in health promotion, there is a tendency for a disease and risk factor orientation to continue.

What are the conclusions from the research of Baxter towards the definition of health?

Health literature recognises that ordinary people may not see health in the same way as health professionals. Research findings indicate that health is a complex concept that combines a number of different dimensions. People find it harder to define health than illness, probably because illness presents as a problem to which societies have to respond, and being healthy requires no action and may be taken for granted. One of the most thorough delineations of the lay understanding of health has come from Blaxter in 2010. Combining a survey with detailed follow-up of a sample of the survey group, she set out to define what people mean when they talk of health. She defined eight main perspectives on the definition of health.

• Health can be viewed as being not ill or diseased: typical comments were "Health is when you don't have a cold" or "Health is when you don't feel tired and short of breath."Some responses indicated a view that people could be healthy even if they did have a disease: "I am very healthy apart from this arthritis".
• Health is also viewed as a reserve: some people saw health as a reserve-if someone becomes sick, they are able to recover quickly. Health as behaviour, health as 'the healthy life': primarily used when describing the health of other people as opposed to the respondent's. "I call her healthy because she goes jogging and doesn't eat fried food". "She walks a lot and doesn't drink alcohol." 
• Health was also observed as physical fitness: particularly popular with young men and less favoured by older people. Men tended to express health in terms of physical strength and fitness. Typical quotes were: "There's tone to my body, I feel fit"; "I can do something strenuous and not feel that tired after I've done it." Women were more likely to define health in terms of outwards appearance, such as being slim, a good complexion, bright eyes and shining hair.
• Health can be seen as the presence of energy or vitality: seen in terms of both physical and psycho-social energy to do things, signified by being able to get up easily, not feeling tired and getting on with activities, having energy and enthusiasm for work and generally feeling good.
• Health can also be measured alongside the criterium of social relationships: defining health in terms of relationships with other people, and more likely to be expressed by women. Younger people saw this as being able to have good relationships with their families: having more patience with them, and enjoying the family. Older people saw it as being able to help others and enjoying doing so: "You feel as though everyone is your friend".
• Health can also be seen as a function: health is the ability to do things, which overlaps with the association between health and energy and vitality. More older people mentioned this, possibly because they no longer took doing things for granted: "She's 81 and she gets her work done quicker than me, and she does the garden."
• Lastly, health is also seen as psycho-social well-being: some people defined health solely in terms of their mental state, typified by the statement: "I think health is when you feel happy. When I'm happy I feel quite well."

Blaxter also asked her respondents to differentiate between health in themselves and in others. She found that being healthy for oneself was to be unstressed and able to cope with life. For other people, health was fitness, the ability to work and perform normal roles and simply 'not being ill'. It is interesting that people assess their own health subjectively and in terms of a reasonable expectation for their age and disability.  

What are the conclusions from the research of Cornwell towards the definition of health?

Another useful perspective has come form the work of Cornwell, who interviewed working-class women and men in the East End of London. She found that stye offered public and private accounts fo what they understood by health, and that she only heard the private accounts when she knew them reasonably well. This implies that studies based on one-off interviews may not get to people's private accounts of health. In their public accounts, respondents presented a view of health that conformed to a biomedical model, tending to have a moral component and talking about the division of causes of illness into those that were or were not the individual's fault. The private theories, by contrast, were based on their own experiences or those of people they knew. 

What are the conclusions from the research of Crawford towards the definition of health?

Crawford's work involved interviews with 60 adults in the Chicago metropolitan area. He found that interpretations of health reflect the cultural and economic context of people's lives. For most people health represents a status, socially recognised and admired. He discovered two main discourses of health: health as a means of exerting self control, and health as a release mechanism. This suggests that health fulfils different functions for different people. 

• Health was seen by some as self-control and a set of related concepts that include self-discipline, self-denial and willpower. This was primarily the view of middle-class professional people. health was something to be achieved through healthy behavior.
• Health was seen by some respondents as a release mechanism, who equated it with feeling good as distinct from following rules of medical authority. Life is seen as a series of pressures, anxiety, frustration dn worry, and as leaving no time for health-promoting activity. Health is not rejected as a value but is often repudiated as a goal to be achieved thorough instrumental action. 

How does the definition of health also have spiritual aspects?

Lay definitions of health may also include a spiritual dimension. Staintain-Rogers reported that some people saw their health as dominated by external religious or supernatural powers. healing could results form intervention by God or some other supernatural power, as could falling ill in the first place. Indigenous people are particularly likely to have a belief system that is related to health and illness, which emphasised spiritual dimensions. The position of traditional healers may often rest of their perceived ability to call on external forces. The growing literature on lay definitions of health presents a picture of complexity and cultural and social embeddedness. 

What critical perspectives on health exist?

Critical perspective son health are those that seek to explain the purposes that are achieved through particular means of defining health. They are critical in the sense that they look beneath the surface appearance of a concept or phenomenon and offer an explanation as to why it is this way. One such perspective on health that has been particularly influential is that which maintains that health is defined in such a way by the dominant forces in a capitalist society that it becomes a defining and controlling mechanism. Central to this view it the idea that capitalist societies are structures in such a way that they produce illness. The system is geared up to maximising profit rather than protecting the health of workers and their families. health is affected by practices such as shiftwork, overtime, monotonous work and dangerous chemicals in the workplace. 

The political economy perspective on health criticises the individualistic definition of health that is sees as prevalent under capitalism. The issue of individualism and health is of central importance in understanding public health. It underpins a notion of health that stresses personal responsibility for maintaining health. The political economy view sees health in terms of its distribution in society and in terms of the structural factors that create or detract from health, such as environmental, housing and occupational conditions. From this perspective, studying the health of individuals is less valuable that studying the collective health of societies and the social and economic forces that affect collective health. Increasingly the political economy view stresses the connections between the health of peoples in rich countries and those in poor countries as the processes of economic globalisation continue apace. 

How can health be perceived as a factor of outcome?

Around the world health departments and ministries are seeking evidence that their efforts result in health outcomes. Almost always this search reflects a clockwork view on health in which short-term improvements brought about by clinical interventions are able to produce an outcome that can be measured by a randomised control trial. In order to e able to attribute a change in health status to any particular intervention it is necessary to exclude the contribution of all other factors, which is generally very difficult to achieve as it requires a research design that controls for all other possible factors. 

In practice, most of the outcomes measured relate to individuals and not populations. For many, health promotion and public health outcomes are crucial, but it is often more feasible to measure outcome in terms of capacities rather than health status. The value of health promotion and public health interventions over clinical care should be in their capacity to improve health in the longer term. 

How can we define collective health?

Most literature that defines health does so in terms of what it means to individuals, but in recent times health promotion has given more attention to what constitutes health in terms of a place or a population as whole. Lay and health professional definitions of health rarely encompass the wide-ranging social, physical and economic factors, perhaps because people take them for granted. A critical perspective, based on an analysis of structural factors, leads to a broader view of health as does a perspective that takes as its starting point a consideration of collective entities. Defining health in such terms is useful for the new public health because it appears more likely to keep a focus on positive definitions and on structurally rather than individually driven factors that affect people's health. In recent years the concept of ecosystem health has been used by ecologists, which is characterised by diversity, vigour and effective internal organisation and resilience. This approach to health integrates an overall consideration of the environment and the interdependence of systems with the overall ecosystem. 

What is at the heart of public health: population or individual health?

The distinguishing feature of public health is its focus on populations rather than individuals. Public health studies the distribution of ideas and positive attributes of health in whole populations. Clinical work is based on work with individuals who are either at high risk for a disease or who have a disease. Both an individual as well as a population-related perspective on health are important. Treating high-risk or diseased individuals does not have much impact on population health levels overall, but changing a risk factor across a whole population by just a small amount can have a great impact on the incidence of a disease or problem in the community. Analysis on an individual level may be appropriate for understanding how individuals may be affected by a disease or some other problem, but may miss the influence of broad structural factors on health. So, viewing health and disease from a public health perspective means taking a view of the health of populations, not just of individuals within them.

Chapter 2: What does the history of public health look like?

Why should we look at the history of public health?

Contemporary public health approaches in western countries reflect practices that came from nineteenth-century Europe and were spread around the globe through the processes of colonisation. An appreciation of their history, and of the cubical philosophies and practices that have been representative of public health at different times, are important to understanding why the new public health was labelled as such and how it is both a continuation of the past and a departure from it. 

There have been seven distinct periods in the development of public health thinking and practice in all countries. 

• The era of Indigenous control estimated to be in excess of 40 000 years. In policies and ideologies, there were strong links with land, traditional handed on through oral tradition.  
• In the colonial era (from white invasion until 1890s), policies and ideologies were strongly influenced by infectious disease and British Acts practices. There was a great emphasis on sanitary clean water and sanitation measures.
• In the Nation-building era, from the 1890s to 1940s, state action was exerted to improve the health of the nation. People wanted to improve the race. Health was linked to ideas of vitality, efficiency, purity and virtue
• In the time of affluence, medicine and infrastructure [1950s-early 1970s), economic affluence and interventionist governments committed to improving quality of life. Considerable state intervention occurred in areas that have an impact on health, such as housing and education. Health services associated with more and more sophisticated medical technology such as organ transplantations. There was a growth of hospitals and expanding health service budgets, but little focus on public health.
• In the lifestyle era (late 1960s-mid-1980s), there was a great focus on effects of affluence in terms of chronic disease. It evolved around the rediscovery of philosophy of prevention reflecting a desire to control costs of health services. There was a great focus on individual behaviour. Epidemiological methods were developed. Population surveys of risk factors were collected.  
• In the new public health era (mid-1980s- mid-1990s), there was a great influence of the World Health Development of healthy public policy, such as legislation to control sale and use of tobacco, drink- drive legislative controls. There was great policy support for community involvement in health promotion. There was focus on collective measures, especially policy, and emphasis on poverty and social justice in public health policies.
• In the global new public health (mid-1990s to twenty-first century), there is increased focus on measures against terrorism including bioterrorism. There is increased fear and preparation for pandemic disease including bird flu, SARS and Ebola. There are calls for interventions to ensure trade treaties support health. Health impact assessments of a wide range of issues are exerted including infrastructure developments, welfare policies and transnational corporations. There is continued development of the settings approach but increasing recognition that the progress these might make is limited by the powerful forces of economic globalisation. This era is characterised by increased recognition of the impact of the policies and practices of international financial institutions. on health, by the shrinking of the state and subsequent privatisation in so many parts of the world. The revolution in communications has led to a vibrant civil society that is opposing many aspects of economic globalisation. There are calls for public health to be seen as a global public good and to be protected by international treaties and laws.

What did the era of indigenous control look like?

While there is little firm historical evidence relating to the public health practices of Australia's Indigenous peoples, there is enough to know that health was a concern, but that concepts of health and illness differed significantly from those of Europeans. Traditional healers were an integral part of society, using a range of natural products such as plants and animals for healing. The notion of public health, in the Western sense, would make little sense to indigenous people. Health appears to have been a concept that was literally part of life. The societies were based on intense cooperation and intricately linked relationships, possibly reflecting the needs of survival in a hostile physical environment. 

What is the colonial legacy when we talk about public health?

Histories of public health show that some form of collective public health measures has always been implemented by societies. British responses to major nineteenth-century public health problems influenced the development of responses in its colonies. European societies were the first to focus considerable public effort on controlling disease and attempting to create healthier living environments. The nineteenth-century public health reforms were a response to the dislocation and disease brought about by rapid industrialisation, especially when two classic waterborne sanitation diseases, cholera and typhoid, unknown in Britain before the nineteenth century, became major causes of death.

What theories on disease causation arose?

In the nineteenth century there were a number of rival theories as to how infectious disease was spread.

• The miasma theory held that disease resulted form inhaling bad smells from filth.
• The germ or contagion theory held that pathogens, air or waterborne, were responsible for disease.
• Supernatural theories were also common, such as the one that saw disease as a reflection of God's wrath.
• Other theories involved the unsanitary habits of individuals.

Public health consequences were that the contagion theory supported quarantining of people and goods, while the miasma theory advocated cleaning up cities.

How did public health legislation lead to sanitary reforms?

The prime tool of the nineteenth-century public health movement in Britain and Australia was legislation. A defining moment in public health history was when the London physician John Snow removed the handle from the water pump in Broad Street in 1854 because he was convinced, on the basis of limited epidemiological evidence, that the water was the source of the current cholera epidemic. Snow's attempt to persuade the water companies to mov either intake upstream away from the pollution were only successful because people were concerned about the aesthetic qualities of the water. Nonetheless, experiences such as Snow's, together with public health legislation, led to the appointment of medical officers of health by local authorities to enforce public health legislation and advise on appropriate measures. The history of public health in nineteenth-century Britain suggests that the 1848 Public Health Act, which gave local authorities the powers to remedy unsanitary conditions and to require adequate drainage and sanitation in towns, led to public health measures being enthusiastically taken up around the country. It was however only after 1866 that an effective public health movement could be said to have evolved. 

What was the Australian response to the developments in public health in Britain?

In Australia, as in Britain, public health measures were partly in response to a series of epidemics. In the last two decades of the nineteenth century all Australian colonies passed comprehensive Public Health Acts that were closely modelled on the British Acts, except for one important respect: the responsibility for administering public health lay with central Boards of Health rather than local government. 

How did Chadwick's ideas influence public health?

There are at least two broad traditions of public health activism in the history of nineteenth-century British and Australian public health. One is typified by a desire to control disease and the poor who were seen to be the cause of it, rather than by a more altruistic desire to make society a fairer place. In Britain, Chadwick was greatly influenced by thinkers such as Malthus and Bentham, and was one of the authors of the notorious Poor Law Amendment Act, which was based on the notion of the 'undeserving poor'. Benefits were no longer available to poor people except in workhouses where the conditions were so miserable that only the completely destitute would go to them. Epidemic disease repressed a threat to social order and productivity and so warranted attention from society. Engels and Virchow recognised that disease generally affected the poor more than the rich. They were convicted that the ability to resist disease was a reflection of an individual's class and social position, which meant that changes to working and living conditions were likely to be influential in preventing disease. Recommendations called for improved nutrition, more employment, better housing and free public education. Environmental and sanitary reforms followed these recommendations. Important lessons were drawn form this nineteenth-century public health movement.

How do McKeown and Szreter view public health?

The successes of the nineteenth-century public health movement have been celebrated by the new public health movement since the 1980s, but the lessons had been forgotten in the decades following World War II. McKeown has been one of the most significant modern voices to remind us of the importance of non-medical factors in improving the health of populations in industrialised countries. He concludes that, with the exception of vaccination against smallpox, immunisation or medical therapies are unlikely to have had a significant impact on mortality in the nineteenth and early twentieth century. He argues that mortality was declining before effective medical interventions were available. 

McKeown's analysis has been used by Australian public health activists keen to convince policy makers of the value of interventions. He believed that improved living standards, especially nutrition, were responsible for the decline in mortality. Szreter challenged McKeown's interpretations. He argues that rising living standards contributed to longer life expectancy, pointing to economic growth. He argues that economic growth itself does not guarantee improved health but rather it all depends on how the fruits of that growth are deployed. Both McKeown's thesis and Szreter's revision are crucial for the new public health. Collectively, they establish the importance of general standards of living and of state intervention in improving the health of populations. 

What did the nation-building era look like in terms of public health development?

The third period in public health history, lasting form the first decade of the twentieth century until the 1930s, saw public health promoted and used for nation building. Public health was typical of the growing state intervention in what had been civil society activities including education, social services, regulation of industry and labour relations. Each of these areas played a role in improving health through action on the social determinants. Across industrialised countries this period was characterised by a concern with strengthening the nation by improving the health and fitness of white citizens in particular and the quality and quantity of the population. Maintaining health was seen as a part of a citizen's duty. Eugenics formed a major part of this nation-building phase; the pursuit of a 'pure race' being very much part of the agenda. Public health services for infants, mothers and schoolchildren developed in this period. Economic progress was seen as leading to improvements in health. The attitude towards public health demonstrates that the social and economic understanding of factors that create health were well and truly alive. There was awareness of the importance of social and economic determinants of health. 

Powles reports that this period of nation building was characterised by two main strands of thought.

• One was the ideology of progressivism, which reflected both European modernism and the ideas of the American president Theodore Roosevelt. In health this ideology was linked to notions of vitality, efficiency, purity and virtue.
• The other strand was that of national efficiency, which stemmed form the belief that strong actions were essential for national protection and advancement. Strong nations were seem to result from reformed education systems, linking science and government, and more business-like government. This period consolidate the health of citizens as a legitimate concern of governments.

What does the period of affluence, medicine and social infrastructure look like?

The postwar period was one of considerable affluence for industrial countries. Unemployment was low, immigration high, per capita income had never been higher, and successive governments were prepared to invest in social infrastructure. Education services were expanded in this period, state housing trusts and commissions provided social rather than welfare housing, and the provision of health services expanded considerably. Public health services were, however, in an in-between period. The period from World War II until the 1970s was one in which available medical therapies mushroomed. After the 1950s, new drugs were developed, diagnostic techniques became more and more sophisticated and surgery opened up many new areas for medical intervention. The period was a golden age for medicine because, in Western countries, these medical developments came at a time when economies were expanding, so there was finance for medical research and services to utilise and expand the new discoveries. Additionally, the growth of medicine coincided with a period of affluence, and rising living standards and life expectancy. 

Chapter 3: How has the new public health evolved?

Why is the new public health innovative?

The second revolution in public health is called the new public health. International developments in the new public health have been innovative, for several reasons:

• The new public health puts the pursuit of equity at the centre of public health endeavours.
• It is based on the assumption that social and environmental factors are responsible for much ill health.
• It argues for helath-promoting health services that are based on a strong system of primary health care.
• It stresses the role of all sectors in impacting on health and the importance of health in all policies.
• Lastly, it stresses the importance of participation and involvement in all new public health endeavours.

What international developments in the new public health have passed since the 1970s?

By the 1970s the idea that medical advances had been responsible for extending average life expectancy in britain was being challenged. In all rich countries the costs of medicine were increasing and the turns per dollar appeared to be decreasing. All this contributed to changing ideas about the production and protection of health and set the scene for the development of the new public health. The general social climate of the 1960s and 1970s was also important in these developing ideas: radicalism and social discontent was in the air in western societies. The social revolution created a greater generation gap, among other factors.

Internationally, the 1970s saw the discovery of lifestyle and its impact on health. This era brought about many different approaches to creating change in individual lifestyles. These almost exclusively drew on psychological theory and had little regard for individuals' social and economic circumstances. The Lalonde report described medicine and health care services as one of four 'health fields' that influenced health and illness, the others being human biology, the environment and lifestyle. This report was significant in broadening the international health debate beyond medicine and treatment. In industrialised countries the behavior modification approaches to health were developing alongside growing concern about inequities in health and the failure of health services to do much about then. The 1970s saw highly individual, behavioral approaches to health being developed, while social structural causes of illness and health were coming to be understood in more detail.

What did the Health for All by the Year 2000 rapport entail?

The World Health Organisation set the goal to achieve Health for All by the Year 2000, preferably by the promotion of primary health care. The key elements of this strategy were:

• an emphasis on global cooperation and peace as important aspects of primary health care. 
• recognition that primary health care should be adapted to the particular circumstances of a country and communities within it.
• recognition that health status reflects broader social and economic development.
• primary health care as the backbone of a nation's health strategy with an emphasis on health promotion and disease prevention strategies.
• achievement of equity in health status.
• participation in the planning, organisation, operation and control of primary health care, supported by appropriate education.
• involvement of all sectors in the promotion of health.
• the call for a 'new economic order.

The initial application of the Health for All package was to developing countries where it was, at first, interpreted as a comprehensive package that tied health improvement to overall social and economic development. Selective primary health care encourages the view that medical interventions are the most crucial, usually to the detriment of other measures such as housing, education and nutrition. A WHO document suggests that a selective approach to primary health care often means that while a particular disease problem may be resolved, this will simply be replaced by another problem as the underlying causes of ill health have not been dealt with. Some believe both a comprehensive approach as well as a selective primary health care approach can be used to advance health. 

What international developments evolved in the 1980s in international public health?

Health care budgets continued to expand in the 1980s and the prospect of cutting these by improving the health of populations became increasingly attractive. Green and Raeburn characterise two approaches to health promotion as the 'individual versus the system', observing that these two views lead to divided ideological and theoretical perspectives on health promotion. The Ottawa Charter integrated many of the different perspective son health promotion. It considers five key strategies that have become something of a mantra for health promotion:

• The development of healthy public policy, which recognises that most of the private and public sector policies that affect health lie outside the conventional concerns of health agencies. Rather they are in policies such as free and universal education, environmental protection legislation, progressive taxation, welfare, occupational health and safety legislation and enforcement, land rights legislation and control of the sale and distribution of substances such as alcohol and tobacco. Health becomes, therefore, a concern and responsibility of each sector of government.
• The creation of supportive environments in which people can realise their full potential as healthy individuals. The Charter recognises the importance of social, economic and physical environmental factors in shaping people's experiences of health.
• Strengthening community action refers to those activities that increase the ability of communities to achieve change in their physical and social environments through collective organisation and taking of action.
• The development of personal skills acknowledges the role that behaviour and lifestyles plays in promoting health. The skills called for are those that enable people to make healthy choices. It also extends the skills base for health to those associated with community organisation, lobbying and advocacy, and the ability to analyse individual problems within a structural framework.
• Reorientation of health services is a call for health systems to shift their emphasis from (in most industrialised countries) an almost total concentration on hospital- based care and extensive technological diagnostic and intervention to a system that is community based, more user-friendly and controlled, which focuses on health.  

The Ottawa Charter stresses the importance of, and recommends: advocacy for health, enabling people to achieve their full health potential, and mediation between different interests in society for the pursuit of health.

What international developments evolved in the 1990s in international public health?

By the late 1980s a new style of public health theory and practice was emerging, with both continuities with the past and distinct differences. From the mid-1980s the term the new public health was taken up enthusiastically. A central strategic direction for the new public health was WHO's Healthy Cities program, which in essence took cities as the units for public health program planning, rather than individuals. Despite some questioning about aspects of its implementation, it has signified new directions in public health. Through the 1980s and subsequently, research methods in public health were progressively broadened so that the portion of epidemiology as the only valid method of public health research was challenged. Qualitative methods have developed and become more widely used in public health research, indicating the need for methods that were able to reflect the complexity of social perspectives on health. 

What international developments evolved in the 1990s up until the 00s in international public health?

Some of the key developments relevant to the new public health was a focus on policy as a powerful tool of public health. The main aim of healthy public policy as being to create the preconditions for healthy living through, according to the WHO, were the following:

• Closing the health gap between social groups and between nations.
• Broadening the choices of people to make the healthy choices the easier and most possible.
• Ensuring supportive social environments. 

Mahler, chief of the WHO, stresses that community participation and collaboration between all sectors of government were crucial aspects of healthy public policy. The new public health agenda does not offer much promise for corporate shareholders. Corporations invest in health  services because they want to return a profit to their shareholders. In order to do this, they may be keen to advance individualised health promotion practices among their members. But they are very unlikely to engage in the community-building work that challenges the underlying inequities in health status or act on the social and economic determinants of health. There have been several WHO conferences devoted to the implementation of the new public health. Environmental issues, the role of transnational corporations and the globalisation of economic life and communications are now all vital issues for the new public health.

What international developments evolved in the 21st century in international public health?

The Commission on social Determinants of Health worked form 2005 to 2008 amassing the evidence on the social determinants of health and what policies, initiatives and programs can best address then. The Millennium Development Goals (MDG) are one of the ways in which the United Nations systems support action of the social determinants of health. These have been revised and will be agreed in 2015 as Sustainable Development Goals. They promise to e broader and more inclusive of a social determinants perspectives than the original MDGs. They include the following general recommendations:

• Improve daily living conditions.
• Tackle the inequitable distribution of power, money and resources.
• And measure and understand the problem and assess the impact of action. 

WHO's aspirational goal of Health for All by the Year 200 was not met, and in sub-Saharan Africa, life expectancy even went backwards in response to the HVI epidemic. Health inequities between and within countries have been tending to increase rather than decrease in the past two decades. Since the 1990s increasing doubts have been raised about the power of the WHO as an effective voice in international health. The People's Health Movement was formed in 2000 in response to a perception that WHO was out of touch with the health concerns of people at the grassroots. Health systems in rich countries also have a tendency to focus on specific diseases and direct their strategies to lifestyle responses rather than those that tackle the underlying causes of ill health. This is despite the lack of evidence for lifestyle interventions in the absence of more systematic policy change. In all settings, health systems are associated with the provision of curative health services to individuals. This is a crucial function to support population health.

What should be the fundamental features of health systems?

The fundamental features of health systems should be the following:

• A high proportion of public expenditure.
• Adoption of comprehensive primary health care as the backbone of the health system.
• Resistance to growing medicalisation.
• And finally, commitment to a stewardship function for total population health, which involves influencing policies and actions in all the sectors that may affect health.

Does spending more on care determine health outcomes?

Evidence suggests that the amount of overall expenditure on health is not the key determinant of population outcomes but that the proportion of public expenditure is more important. Anderson noted in 2006 that member states of the OECD with high public expenditure on health perform better in minimising infant mortality than those that rely on mixed public-private systems. A high proportion of public expenditure encourages equity in provision and outcome. There is a lack of relationship between gross national income and health care expenditure and life expectancy and infant mortality. 

There is strong evidence in favour of universal access and public funding of health care. For example, Canada, Australia and Britain spend less on their predominantly publicly funded systems, but all of these countries have longer average life expectancy than the USA, where access to health care is largely determined by insurance status. Public health has contributed to much soul-searching in industrialised countries about the extent of health care expenditure. Health systems based on the principle of universal coverage achieved through public financing are generally cheaper, more efficient and more equitable. The finding runs counter to the general belief that production and distribution of services is more efficient in the private sector, based on market principles. The reasons for this are complex, but arise from the fact that health is essentially a public good, where market principles do not work. Despite the evidence, public-private partnerships are being pursued in rich and poor countries alike. There is an urgent need to reverse this trend and ensure that health services are accessible and affordable for all people through the provision of a comprehensive service. A commitment to social justice and willingness to use state mechanisms to provide universal access and supportive social environments is vital to equitable improvement in health. 

How does comprehensive primary health care form the basis of health systems?

A massive global investment in a comprehensive primary health care strategy will go a long way towards making health care accessible. The WHO reinforced the importance of primary health care in the 2008 World Health Report, which identifies three disturbing trends that have a negative influence on population health outcomes and equity and undermine primary health care:

• There is a disproportionate focus on specialised curative care.
• There is a command-and-control approach to disease control, focused on short-term results.
• And in some health systems, there is an unregulated commercialisation of health, which has been allowed to flourish. 

Recommended reforms refer to access and equity, a more people-centred focus, securing healthier communities, and implementing inclusive leadership. 

How can we resits growing medicalisation?

The health and pharmaceutical industry is one of the fastest growing industries in the world. This means that there are strong global incentives to provide more drugs and health services.  Means need to be found of having a citizen debate based on a community-wide view of priorities. Health systems have to learn to prioritise service provision and consider the balance between investment in heroic medicine, which benefits a few individuals, and in comprehensive services, which make more efficient use of scarce resources in delivering overall population health gains.

How can the health sector adopt a steward function?

health systems equipped to promote health in the twenty-first century must be prepared to take on a stewardship role for ht health of the population they are responsible for. This means monitoring the state of population health and the extent of equity, and being a facilitator and advocate for all sectors to see health as an outcome of their actions. The importance of this approach was recognised by the WHO. The challenge for the twenty-first century is for states to invest in a health system and governance system that sees health as a measure of the outcome of all activities of government and the private sector.

Chapter 4: How do ethics, politics and ideologies form the invisible hands of public health?

How did Tesh view politics in relation to public health?

Public health exists to make people and their communities healthier through change. Tesh argued in 1988 that political beliefs and values have a defining influence on people's often implicit notions of disease prevention policy, and that this influence is exerted through hidden arguments. She sees these implicit assumptions as fundamental. The idea about different pathways leading to differing understandings affects all public health activity. The values and politics within a society help people to interpret and make sense of seemingly objective facts. Recognition of these values is important and their role in public health policy should be openly debated. 

Why is public health a political activity?

Public health is a political activity because it is about change, and its history shows that public health actions are expressions of prevailing political ideologies, the beliefs of those in government and the extent to which formal power holders are influenced by interest groups. Decisions to control harmful substances, to restrict individuals' behavior, or take away their freedom of movement are invariably political and reflect the underpinning ideologies of those making the decisions.

How do political systems and ideologies impact public health?

Political ideologies and forms of government have varied considerably in the last few hundred years. Political science should be a key public health discipline as it provides a framework for understanding these forces. Blondel distinguished three basic criteria for the classification of political systems as reflecting points on the following dichotomies: democratic or undemocratic, liberal or authoritarian, and egalitarian or inegalitarian. The potential for implementing the new public health differs over time and between societies. The political and economic context of countries plays a major role in shaping opportunities for health. The social democratic model is the most in tune with the aspirations of the new public health with its emphasis on universal rights and state intervention to reduce inequities. More right-wing systems are more committed to a market model and less committed to intervention. 

How do the political left and right differ in their views on public health?

Social democratic and liberal societies have distinct ideological differences between political parties. Broadly speaking, the political ideologies on the right of the spectrum believe in the power of the market to meet the needs of people, and stress individual responsibility. Those more to the left are more likely to believe that the state should intervene to ensure that the capitalist system does not ignore the needs and rights of those who are not powerful in the market. They are also more likely to believe in the value of an institutional welfare state to redistribute income and protect the interests of the poor and vulnerable. After World War II all social democratic and some liberal states agreed that state provision of services and intervention to curb the excesses of capitalism were desirable or pragmatic. As a result, welfare states of various sorts were developed in a wide variety of Western countries.

Several studies have compared the impact of different political regimes on health. The social democratic political tradition was found to be more committed to redistributive economic and social policies and full employment was generally more successful in improving the health of populations, such as by reducing infant mortality. Neo-liberal globalisation was found to be associated with increasing inequalities within rich nations. 

What do egalitarianism, socialism and capitalism entail in relation to public health?

Socialist and communist governments promote centralised control over the economy and many other aspects of society, and ban private, capitalist enterprises. They aim to create egalitarian societies in which the differences between rich and poor are minimised. Questioning of capitalism as a dominant economic form has increased since the global financial crisis of 2008. Climate change is also increasingly seen as the greatest moral challenge of our age and the most important public health issue we face. The urgency for the potential for climate disaster makes this the central political question for governments of all political persuasions and for all public policies, public health included.

What are some ethical issues in public health?

The drift of liberal-democratic states towards the right and the widespread adoption of neo-liberal policies since 1980 made individualistic ideologies more influential in the shaping of public policy. Individualism holds individuals totally responsible for their actions and the consequences, including health. In philosophical and ethical terms, its key principle is autonomy. Autonomy refers to an individual's capacity to make free choices and ability to control the direction of his or her own life. A central concern of public health and health promotion has been the process of describing and quantifying risks to health. Paternalism, on the other hand, refers to practices that restrict the liberty of individuals, without their consent, where the justification for such actions is either the prevention of some harm they will do to themselves or the production of some benefit for them that they would not otherwise secure. Empowerment and autonomy, in the view of the new  public health, are increased when individuals have information about the risks to their health from their environment and their behavior.

What forms the dialectic between individualism and collectivism?

The roots of individualism are found in the writings of Thomas Hobbes. He portrayed people as acting in accordance with certain psychological principles. In his view of the world, life was about individual self-interest. The dialectic between individualism and collectivism as a basis for understanding social and community organisation is one of the most fundamental to grasp and explore in the development of public health. Debate about vaccinations and drug control have struggled with the issue of the maleficent consequences of public policy. The dialectic between individualism and collectivism has strong political implications. Those promoting individualism tend to be on the political right and argue that state intervention is promoting a 'nanny state' that excessively restricts the rights of individuals. Those on the left are more likely to argue for measures to protect the collective good even when they impinge on individual rights. However, neo-liberalism has been accompanied by a growing paternalism in the provision of social services. This indicates that a more right wing perspective can also lead to nanny state-style interventions.

What does consequentialism entail in relation to ethics?

Discussions about autonomy and paternalism should be considered within a broader ethical context. There are tow broad groups of ethical theories: consequentialist and non-consequentialist. 

• Consequentialism holds that most ethical decisions are based on a calculation of the good that derives as a consequence of a given decision. Traditionally, this is known as teleology, and is summarised as 'the end justifies the means'. 
• Conversely, a non-consequentialist or deontological position is based on the view that decisions should be guided by a set of inherent moral principles that one ahas a duty to follow, regardless of context or consequence. Thus, the process rather than the outcome determines the rightness of an action.

Utilitarianism is a consequentialist theory that is summed up as 'the greatest good for the greatest number'. It has been used to support public health measures, including immunisation. However, while utilitarianism is seen as a driving force behind liberal and reformist social policies, it is also critiqued as being insensitive to the needs of the disadvantaged individual. Natural or human rights arguments are essentially deontological, and are based on the concept of a set of natural rights being the birthright of every human being. it is argued that any action that violates and established human right is immoral.

How does individualism lead to victim blaming?

One of the direct consequences of individualism for public health is a tendency to blame victims for their ill health, seeing people as totally responsible for things that happen to them. Thus, the success of well-off people in the employment market is attributed to their particular efforts, rather than to the advantage of having affluent parents who were able to buy them the best education, et cetera. Crawford pointed to an increasing individualism in health services through the 1970s, explaining it by the contradictions arising form the threat of high medical costs, political pressures for the extension of health services entitlement and the politicisation of environmental and occupational health issues. He argues that victim blaming means 'the emphasis on individual responsibility for health mystifies the social production of ideas and undermines demands for rights and entitlements to medical care'. Health has then become an issue of individual responsibility. 

Victim blaming inherent in much health education and health promotion creates a political smokescreen that masks a host of factors that are fundamental to the creation of illness: poverty, gender inequality, racism, occupational hazards and environmental pollution. Not surprisingly, victim blaming and individualism is particularly popular with governments whose philosophical roots are based on free markets unfettered by government control. Victim blaming in regard to health also assumes that health has a centrality to people's lives that may not be accurate. Another feature of cities blaming is that those defined as victims may themselves identify with the label.

How do public health policies and individualism relate to one another?

Tesh has argued that individualism is the principal ideology affecting disease prevention policy in the USA. A strong tenet of neo-liberalism is that what is in the interests of private individuals ends up being for the good of society. There is, however, an alternative view that may help to reconcile the apparent conflict between individual autonomy and state paternalism. Contractarian theorists argue that rights or responsibilities held by an individual stem from an implicit contract with society. Within this context, justice arguments are made. The philosophy of individualism, however, has a powerful effect on people interpretations as to why disease and illness occur. The tendency to focus on individual analysis means the social, structural and epidemiological perspectives on health are, at best, a confusing background to explaining why individuals have particular health problems.

Biomedical and psychosocial perspectives focus almost exclusively on individuals, their risk factors and their response to these. Issues of exposure to physical, economic, social or cultural factors tend to be left to epidemiologists, who zoom in on factors that individuals have been exposed to. The risk factor approach appears to follow the utilitarian path of calculating the risk and benefit to enable a redistribution of risk to benefit the population as a whole, there are major assumptions inherent in the identification and analysis of those risks. So, while they may study the effect of diet on individuals' health status, their risk factors and their exposure to particular foods, epidemiologists do not typically look at more structural questions concerning the advertising of food substances and the availability of healthy foods. The fundamental question as to who gains and who loses is usually left unasked.

What do social-structural and communitarian perspectives on public health entail?

By contrast, a social-structural perspective on health brings to the fore the underlying social, economic, cultural and power issues, which tend to be hazy in the other perspectives. It is concerned with how society is organised and its impact on health and illness. Key issues for public health from this perspective involve the construction of social risk, the exercise of power on participation in society and the effects of income and wealth distribution on the pattern of health. Contractarian and social justice theories see these issues as central. In particular, communitarian theory has become prominent in recent decades in response to the dominance of rights-based arguments and the limits of neo-classical economic theory and practice. The central principles evolved around the idea that individuals rights need to be balanced with social responsibilities and that autonomous selves do not exist in isolation, but are shaped by the values and cultures of communities.

Communitarianism is based on the belief that humans are social animals: 'Their being is composed in part by the community in which they exist; being in and of a community matters, and they take their identity partly from that. Key principles are that:

• the community is more than the sum of its individual parts;
• sharing and reciprocity are core values;
• community participation is out of both self-interest and community interest, and there is a merging between the two;
• people are citizens before being consumers;
• justice and social values are embedded in a society (compared to universalism of liberalism);
• and finally, it is only a good thing if the community it draws on is good.

Why is the social-structural and communitarian perspective less evident in public health literature?

However, such perspectives on health are less evident in public health literature than are the epidemiological, biomedical and psychosocial. Three reasons have been advanced to explain this.

1. Social structures are abstract and elusive while biological and psychological evidence is more tangible and obvious.
2. Western societies have a bias towards explaining social events in terms of personal characteristics. Walsh and colleagues point out that in the West people 'have an analytic bias in favour of reductionism at the expense of integrative, intuitive, and convergent styles of knowing'. This supports Tesh's arguments that claim public health policy in the USA is based on philosophies of individualism.
3. Recognition of the importance of social-structural factors in the creation of health and illness can lead to a sense of powerlessness. Explanations located in individual behaviour can lead to far more manageable policies and plans. When explanations are broadened to consider the range of social processes, the extent of change implied can be overwhelming to the point of paralysis. This is even more so given the power of entrenched interests that may oppose change because it will threaten their position.

What is the role of individualism in the welfare state?

The tendency towards individualism and victim blaming is not just a reflection of individual beliefs about why people from particular groups are sicker or suffer more social misfortune. These ideologies express themselves in the forms of health and welfare provision available. The liberal approach views social welfare as a stopgap measure when economic market forces do not support people. It should support people until the market again provides for people's needs. In terms of ethical theory, a liberal model is based on consequentialist assumptions, while the social democratic model is based on a brief in the inherent value of its humanitarian ideals and it can therefore be seen as deontologically based. 

Chapter 5: How do neo-liberalism and globalisation influence contemporary public health?

What is globalisation?

There is extensive debate about the meaning and implications of globalisation. For public health, globalisation has far-reaching implications, potentially both positive and negative. The process of globalisation has been continuing for some centuries. Giddens describes globalisation as economic, political, technological and cultural. We distinguish several different types of globalisation:

• Economic globalisation refers to the process of trade liberalisation, tariff reduction, standards harmonisation and deregulation.
• Political globalisation refers to the creation of global institutions that are establishing global forms of governance, such as the World Trade Organisation. 
• Technological globalisation concerns the rapid breakthrough in communication technologies, such as satellites and the internet, which have made worldwide communication so much more rapid.
• Cultural globalisation makes cultural exchange easier; the processes result in breaking established social orders, but also may establish new social movements. It involves the fast transmission of ideas, images, fashion and information through new communication media.
• Lastly, ideological globalisation concerns the way in which political and corporate leaders sell a view that there is no alternative to the neo-liberal package of reforms. The argument is that citizens, companies and whole societies have no option but to accommodate these reforms, despite the negative consequences.

Economic globalisation is the aspect of the phenomenon over which there has been most debate and discussion in relation to health. 

What is neo-liberalism?

Neoliberalism is a term used to describe trends since the 1970s that have seen a progressive reliance on economic factors as the basis for organising society and making government decisions. It describes a school of economic thinking which is known as laissez-faire or neo-classical economic thought. Neo-liberalism's basic tenet is that the free market should determine all economic transactions. Open competition in a free market will provide the greatest efficiency, intervention being seen as a distortion that results in efficient industry unfairly supporting inefficient industry. Neo-liberalism promotes deregulation. There is thought to be a force behind the scenes that guides the free market to ensure that outcomes are efficient and just. Neo-liberalism has come to dominate the policies of international agencies and national governments around the world in the last forty years. 

The emergence of neo-liberalism consisted of three stages:

1. Neo-liberalims's dominance in political and economic decision making began to emerge in the early 1970s. This was a decade marked by an increasing pace of economic recessions.
2. Neo-liberalism's second phase was during Reagan and the global financial crisis (GFC) of 2008.
3. Post-GFC, neo-liberalism's third phase entailed growth in income and wealth inequities.

What key institutions shaped neo-liberalism in the modern world?

Key institutions shaping neo-liberalism are the World Bank, the International Monetary Fund (IMF), the World Trade Organisation (WTO), the Group of Eight (G8) and the Group of Twenty (G20).

• The World Bank and the IMF were created in the wake of World War II. The two institutions were given two distinct functions when they were formed. The World Bank was designed to assist the rebuilding of Europe following devastation of the war. The IMF was assigned the more difficult task of ensuring global economic stability and to save the world from future economic depression like that of the 1930s. The creation of these institutions was heavily influenced by the economist John Maynard Keynes, who believed that government intervention to direct and control markets was both desirable and necessary to economic prosperity and stability. The World Bank has been heavily criticised in recent years on the grounds that it has funded many environmentally damaging projects and that it runs undemocratically for the benefit of high-income countries rather than for the befit of low-income countries. The World Bank's role has changed from its original mission of European reconstruction to focusing on poverty reduction in the de-colonising developing world. It is financed by the richest countries lending money to the poorest. Voting power depends on the amount of money each country contributes. While the World Bank and IMF supported greater public investment in the immediate aftermath of the Global Financial Crisis, this prescription very quickly reverted to the more normal neo-liberal focus under the guise of austerity policies. 
• The World Trade Organisation is a more behind closed doors organisation.
• The G8 was formed from the world's leading industrialised nations. The G8 uses neo-liberal economic assumptions and sees these as the solution to both global poverty and maintaining economic stability. 
• The G20 members represent around 85 per cent of global gross domestic product. The influence of G8 has reduced somewhat as the G20 gains greater ascendancy. 

How does the world trade system influence public health?

In the globalised world, trade is one of the most powerful forces linking our lives. It is also a source of unprecedented wealth. Yet billions of the world's poorest people are being left behind. Increased prosperity has gone hand in hand with mass poverty and the widening of already obscene inequalities between rich and poor. Understanding how such economic inequities come about requires and understanding of the ways in which the world's trade regime works to support the growth of capital and its concentration in a few hands. Two factors are keys to considering the impact of globalisation on health: international treaties and agreements, and the increased power and size of transnational corporations (TNCs).

• The adoption of neo-liberal policies by the World Bank and IMF led to a series of international agreements that liberalised trade and investment intensively from the 1990s. These agreements establish a transnational regulatory framework that overrides national, regional and municipal jurisdictions and was.
  • An example of the way in which these international treaties can have an impact ton health is provided by the TRIPS agreement. This agreement requires that protections are extended, specifically extending corporate monopolies over drugs, foods, and other 'intellectual poverty'. TRIPS is an exception to other WTO agreements that liberalise trade. The TRIPS agreement means that small farmers in poor countries cannot pay the genetic resources, sustainable agriculture, food security and their own well-being, due to the patenting of seeds. The TRIPS agreement has also been used to ensure that low-income countries offer patent protection for pharmaceuticals. Implications are that access to medicine in poor countries is difficult and the costs are likely to impose a strain on poor households. 
  • Another internal agreement that has an impact on health is the Trade in Services Agreement (TISA). Negotiations about this agreement started in secret in 2012 and seek to convert all forms of services across the world into traceable commodities. This agreement wil reduce the policy space in which member states can operate to manage and regulate health.
• A main factor underpinning the rapid growth of globalisation is TNCs. Aided by innovations in transportation and communication, and as a result of competition between developing countries for foreign investment, TNCs have been able to extend operations and take advantage of favourable regulatory and financial environments that seek to attract the investment of such corporations, particularly in low-income countries. Trade agreements are widely seen to favour the position of TNCs, and these corporations have massive lobbying power through which they can influence these agreements to create a favourable operating environment for them, often at the expense of human rights or public health concerns. TNCs receive and increasing amount of criticism. 

What is the impact of neo-liberalism on health? 

Neo-liberalism is the quintessential upstream variable and, as such, evidence of patterns of causality will be hard to prove in ways accepted by epidemiology, at it comprises 'multiple, interaction policy dynamics or processes, the effects of which may be difficult if not impossible to separate'. Thus, trade liberalisation may reduce the incomes of some workers or shift them into the informal economy, while reducing tariff revenues before the benefits of any revenue gains from income and consumption taxes are felt. 

The principal effect on health of neo-liberal globalisation are the following:

• Neo-liberalism encourages economic growth, which will ultimately benefit everyone through a trickle-down effect. On the other hand, structured unfairness of the world trade system ensures an unfair distribution of wealth and is strongly biased in favour of the highest income strata of rich countries and transnational corporations. Evidence suggests that the key issue is how governments invest the fruits of economic growth that determine health outcomes.
• Neo-liberalism encourages economic growth and so is good for the incomes of the poor and therefore for their health. On the other hand, foreign direct investment and deregulation of financial markets has introduced economic vulnerabilities and insecurities globally.
• Privatisation and deregulation will improve the efficiency of the provision of a wide range of services that are vital to health, including housing, water, transport and health services. However, neo-liberalism for poor countries has meant the imposition of structural adjustment packages and poverty reduction strategy papers, and private provision of services, which has affected the level of services and protection for local industries and resulted in rundown of public infrastructure and less services for the poor. Privatisation is also concerned more with opening up markets for transnational corporations than health and well-being. Furthermore, privatised services are concerned with profits more than public health.
• Public services are ideology to operate as more efficient markets do. However, reformed bureaucracies do not stress nation building and transformed by neo-liberal public health is not a commodity that can be bought and sold. Long-term outcomes are neglected.
• Opening up markets and deregulating trade will benefit all populations, increase wealth and reduce poverty. However, neo-liberalism increases inequities both within countries and between them and, while there has been a reduction in poverty by some measures, levels of poverty continue to be high and unjust when wealth gaps are widening.
• Globalisation opens up communication around the world and creates a global village. This will result in more understanding and less conflict. However, globalisation threatens tow amp the variety of cultures around the world and impose a common Americanised McCulture aided by the spread of TNCs.
• Neo-liberalism provides a variety of consumer goods that enrich people's lives. However, growth of advertising and marketing form TNCs imposes unhealthy diets, consumerism creates pressures for individuals and is a threat to mental health, and there is a digital gradient between and within countries which means the benefits of communications revolution are not shared equally.
• The current system of global governance provides sufficient safeguards for health. However, the current system of global governance is dysfunctional and needs strengthening so that it is able to regulate the market in favour of health.

How are neo-liberal policies justified?

The justification for neo-liberal policies lies in the belief that, ultimately, policies that encourage economic growth will be beneficial for human health and well-being. Proponents of this viewpoint refer to the experience of Western industrial societies, where economic growth appears to have been associated with better standards of living and longevity. Those arguing that neo-liberalism is good for health base their case on the economic benefits of globalisation and the benefits that, it is argued, this brings to the poor. Economic growth is good for the incomes of the poor, and what is good for the incomes of the poor is good for the health of the poor, is the idea. The net result is, however that the processes of economic globalisation are not a positive force for poorer people in rich countries and for the vast majority of the population in developing countries. 

What do the processes of privatisation and deregulation entail?

Neo-liberalism has led to a pandemic of privatisation; the contracting out of public services. This is justified by the rhetoric that the role of the government is to steer, not row. Governments arounds the world that followed neo-liberal policy prescriptions have pursued policies of privatisation of many core services, among which public health services. The effect of privatisation will take time to filter though to health outcomes, but the evaluation that has occurred suggests that it will have a negative impact on health. There is no evidence that privatisation of health services will increase access for poor people. Paddon assessed that privatisation of utilities in the Asia-Pacific region made two decades ago led to higher costs, potentially significant environmental costs, overstated benefits of revenue and debt reduction, social costs of privatisation and growing inequality. 

How does consumerism influence public health?

The last three decades have seen an increasingly rampant consumerism, much of which has promoted a North American culture. Globalisation is not a process that encourages cross-cultural interaction, but rather the imposition of a particular culture on all of the others. Neo-liberalism has been presented as spreading the benefits and choices of consumer society to an increasing number of people. Others, however, see that the choice is illusory and does not necessarily contribute to increased happiness or well-being. Consumerism is encouraged by clever marketing and the often artificial creation of demand. The Western ideals of diet, body shape and looks are becoming widespread in non-Western countries and create markets. Consumerism may form a threat to health and well-being, in the form of for example increased depression in these societies. 

What civil society movements have challenged neo-liberalism?

The past decade has seen the growth of civil society movements directly challenging the tenets and goals of neo-liberalism. The People's health Movement has led the way among health civil society. This movement protests against wealth inequity, TNCs and the impact of neo-liberalism on working people and their communities. The power of civil society to change the behavior of capitalism was shown during the industrial revolution in the UK. Various groups in society began to advocate and lobby for legislative control over working conditions and living conditions that life improved for the new urban populations. Protests against neo-liberal globalisation have been growing over the past decades. Since its formation, the People's Health Movement has become increasingly influential as a global voice of conscience. The World Social Forum also provides an opportunity for discussion of issues associated with economic globalisation but with a focus on human rights. 

Why are there protests against international financial and trade institutions?

In the past decade just about every meeting of the key international financial and trade institutions have attracted censorable protests from vivil society concerned about the impact of the actions of these largely unaccountable international bodies. This protests reflect the serious concerns that groups ahi about the impact of economic globalisation on health and especially the suite of international trade and investment treaties negotiated through the WTO agreements.  Another role of global civil society is that of a watchdog. 

Chapter 6: What does the research field into the new public health entail?

What does the history of research into public health look like?

Two decades ago, research into public health only looked at epidemiology. Now public health is becoming increasingly methodologically eclectic and uses a range of methods from a variety of social science disciplines and epidemiology. Despite this eclecticism, the debate about public health methodologies has become polarised. Epidemiologists often maintain that their set of methods is superior and more 'scientific', while those pointing out its limitations have tended to overlook its value in the quest to promote alternative research methods. Collaborative and multidisciplinary approaches to research should be encouraged as the hallmark of the new public health. Good public health research involves interdisciplinary cooperation from colleagues to encourage dialogue across methodological divides.

What are the limits to epidemiology as a research method?

Epidemiology offers much to public health. It is particularly well suited to tracking down the causes of disease and to describing the patterns of disease in populations. It is not, however, a sufficient methodology to answer all public health questions. Indeed, any research, like all knowledge, will be conditional and bounded by time and circumstance. For a number of decades, epidemiology was the lamp of public health. Other methods were 'unscientific' because they did not allow the rigorous control that was possible with many epidemiological methods. Yet many of the problems sought by public health to research are out in the dark, beyond the light that can be shed by epidemiology. Realisation of this has led to an increasing recognition and use of meany methods in public health research.

Public health, in contrast to for example chemistry or anatomy, has seen more and more questioning of methodologies. The discipline evolved from medical science, and, until recently, most practitioners were doctors and nurses. Epidemiology is basically modelled on laboratory research and operates by establishing and testing hypotheses through carefully designed research methods. The growing realisation that health and illness reflect the structure, culture, power relationships, economy and politics of a society has resulted in public health seeking to understand more about health and disease that the immediate causes of any particular disease. Criticism of epidemiology from social scientists centre on its almost total focus on controlled measurement to the exclusion of other forms of knowledge and analysis. Public health also involves biological, social, economic and political factors that account for disease patterns over time and across cultures. The limitations of epidemiology become very evident when such broad views are adopted. Shy therefore accuses academic epidemiology of serving clinical medicine more than public health. He urges epidemiology to attempt to understand disease as a 'consequence of how society is organised and behaves, what impact social and economic forces have eon incidence rates, and what community actions will be effective in altering incidence rates'. 

In defence of epidemiology, it should be noted that it has made important contributions to understanding disease patterns and factors that cause disease, as it is good at establishing causal links. There is, however, need to encourage a broader range of methods in public health. 

What other forms of knowledge generation methods can be used in public health research?

Since around 1970 there has been a growing body of criticism against conventional science. Social science postmodernist thinking over the past two decades has argued that knowledge is relative, its understanding depending on a range of social and cultural factors. Thus, people's positions in society play a crucial role in their interpretation of events and factors. Postmodernist theory suggest that discourses determine how people view the world and are a mechanism for maintaining power within society. A postmodern perspective argues that all bodies of knowledge and the network they support should be treated critically.  

The debate about knowledge generation in public health can also be seen as medical sciences versus social sciences. Medical practice is not solely based on evidence derived from clinical trials, but also relies on clinical judgment and qualitative assessments of previous experience. there has been debate about whether differences between quantitative and qualitative research methods are a matter of fundamental epistemological issues or, more simply, those of a technical nature. By an epistemological issue is meant a matter which has to do with the question of what is to pass as warrantable, and hence acceptable knowledge. Bryman demonstrates that there have been strong views that the differences between the two approaches to research are based on epistemology, and equally story ones that they are simply differences in technique. He is an advocate for methodological pluralism. This debate has also been evident in public health.

What four research paradigms do we distinguish?

The debate about the desirability of different research methods is underpinned by beliefs about the nature of knowledge and understanding. Guba and Lincoln defined four research paradigms of which they believe two represent the received view and two challenge it:

• Positivism aims for definition of objective truth and reduces all relationships to a statistical level.
• Postpositivism retains the basic beliefs of positivism but accepts some of the criticisms of the search for absolute truth and seeks hypothesis falsification rather than verification. It incorporates qualitative techniques to add a subjective perspective to the otherwise objective one.
• Critical theory focuses on critiquing and understanding inequities in society, seeking to change them as a result of research.
• Constructivism is the joint creation of knowledge between the researcher and the researched. In this view there is no static truth, but instead multiple and shifting realities.

What is the difference between conventional and constructivist approaches?

In the discussion of research paradigms, it is common for textbooks to discuss two of these approaches: the conventional and the constructivist.

• The former is based on a positivist and reductionist approach to science-on the belief of a single truth that holds, regardless of time and place. The researcher studies a phenomenon objectively, removing values and contaminating factors. Gold standard research methods are experimentation and, in epidemiology, randomised control trials. Deviations from these methods are viewed as second-best options. The aim of science in this paradigm is to test hypotheses to discover the objective truth about the world and so make predictions. The notion of falsification or refutation is central. Conventional science has undoubtedly enjoyed hegemony in medical science and public health.
• By contrast, the constructivist paradigm believes that truths are socially constructed and that reality is specific to time, place and culture. The researcher is seen as part of the reality being researched. The existence of objective knowledge is denied. The research process is one of enquiry, relying on a continuous process of iteration, analysis, critique, reiteration, reanalysis, synthesis.

The methodological and epistemological debates between aficionados of these two paradigms are often fierce, with little room for dialogue. Public health may be one of the few arenas where a more constructive and respectful dialogue is developing, based on the recognition that both approaches need to understand the complexities of public health problems, and the essential necessity of knowing the extent and pattern of disease and health. 

What are the strengths of qualitative and qualitative methods?

Quantitative and qualitative methods heave very different strengths.

• Qualitative research is essential for describing the extent and pattern of disease and the factors that are related to it within a community.
• Qualitative research can describe the meaning of disease, poverty or caring and can help us understand how public health strategies can assist in solving the problems.

In what way is there a need to change focus in public health research?

The Global Forum for Health Research has raised a series of problems with the focus of global research on health. In essence, the critique of global health research is that it focuses on diseases in the rich world.

• First, worldwide only 10 percent of health research funds are allocated to the problems responsible for 90 percent of the world's burden of disease.
• Second, greater emphasis should be placed on research on the social, economic and political determinants of ill health, relative to clinical and biological research.
• Third, there are significant barriers in terms of translating research into knowledge. 

Very little research focuses on efficacy research or implementation research. The reasons for the basis in research funding reflect a myriad of social, political and economic forces including the influence of pharmaceutical companies, and the entrenched power of the biomedical research establishment in rich country health and medical research bodies. Changing the balance of the research conducted is an important aspect of the new public health agenda. There needs to be more research on the ways in which social and economic factors affect health and what social, educational, housing and health interventions most improve health and health equity. It is vital that governments invest in this research to a greater degree than they do currently. The past few years have also seen a much greater call for effective transfer of research findings into practice so that there is a bridging of the gap between what is known and what is actually done. One of the major blocks to this happening is the gap between the intentions, motivations and rewards that are the work experience of university researchers and policy makers. 

What does a reflective research practice entail?

Most published research presents a sanitised view of the research process. Public health research, like most other, is subject to the setting in which it is conducted and the researchers who conduct it. Social scientists have some tradition of reflection in their research practice and opening up their processes to take an honest look at them. Feminist researchers have argued for the value of reflexivity in research, particularly in regard to how the researcher influences research. A modernist movement is on the go around the idea that all knowledge should be questionable. Reflection is an important skill for a researcher and, while the tradition is most common among those using broadly qualitative measures, all researchers are likely to benefit form it. Epidemiology does not have a tradition of reflective research practice, and could benefit from one.

How do postmodern and poststructuralist frameworks encourage reflection on research practice?

Fook argues that postmodern and poststructuralist theory provide frameworks that encourage reflection on practice.

• Postmodernism stresses the importance of 'narratives' or 'discourses' in understanding how sense is made of the world. 
• Poststructuralism is based on the notion that meaning is open to numerous interpretations, is not fixed and changes in different contexts.

While most public health researchers do not see themselves as postmodernists or poststructuralist, they increasingly accept the importance of relativities, shifting meaning and individual interpretations, and use these to inform their practice while having a clear vision of what needs to change to create a more just and healthy world. 

How can previous research findings be used in systematic reviews?

Increasingly emphasis has been placed on evidence-based practice in both medicine and public health. Obtaining evidence is easier to do for most medical procedures that is often the case for health promotion and public health because the criteria and parameters of the review are typically more limited in scope. Systematic review of research evidence is important for researchers to ensure they build on existing knowledge and research, and for practitioners so that they can find out what evidence there is for what works.

Peersman distinguishes the steps to these systematic reviews. Each of these stages is crucial and must be done with great rigour if the review is to be useful and accurate.

1. First, the review question should be formulated.
2. The relevant primary research is then identified.
3. Identified studies are assessed for inclusion in the review.
4. The studies meeting the inclusion criteria are critically appraised.
5. Then, the study quality is assessed and incorporated in the review.
6. The relevant data is extracted.
7. The results are analysed and presented.
8. Lastly, the results are interpreted.

Evidence from systematic reviews is important for informing policy but will only ever be one of the factors taken into account in policy making. In public health, culture, human behavior and social difference in populations play a much more significant role than in clinical medicine. This means that external validity form research is a problem when conducting systematic reviews and that extrapolation form evidence to policy inevitably involves matters of judgment. 

What are some ethical issues in research and how are they dealt with?

Researchers are required to have ethical approval for their research from an ethics committee. The task of these committees has been growing more complicated as the nature of health research has diversified to include that based on social science methodologies. Their work is based on certain guidelines. While there have been some voices critical of the role of ethics committees, they are now accepted as part of the research scene and as arbiters on the ethical standards of research.

Medical practice has been based on the principle that no harm should be done to a patient. This principle has not always been adhered to and some medical experiments have caused considerable harm. Most public health research is not physically invasive, with the potential for harm being more likely to be psychological, such as a respondent to an interview survey being asked too sensitive questions.

How is methodological soundness assessed?

Conducting badly designed research is also considered to be unethical. Difficulties arise in determining what constitutes a sound design. Qualitative research methods are the most difficult to describe and are commonly misunderstood by both funding bodies and ethics committees. The misunderstanding relates to both the scientific credibility of the methods used and the issues of ethics raised by invasion of people's social lives to collect data. A common methodological difficulty is understanding the different assumptions about reliability and validity. Daly has pointed out that social research using less structured research procedures is dependent on the integrity of the researcher to collect data in an ethical and responsible manner. Daly suggests that ethical research should be base don appropriate research methods, defined as those that are most likely to address the research problem fully, given the constraints in the field. She warns that methodological prejudice is unethical.

What does informed consent entail?

The informed consent of participants in all forms of research is a basic ethical right intended to protect the autonomy of participants. In most public health research the process of gaining informed consent involves the provision of an information sheet to participants and asking them to sign a consent form. This information sheet should explain how the individual's privacy and confidentiality are to be maintained and assure people that they have the right to withdraw from the study at any point, without any consequences for them. The situation is complicated when people have reduced capacity to provide informed consent, such as children or people with a psychiatric of intellectual disability.

Considerable epidemiological research is based on existing databases. It is very often impracticable for informed consent to be given for access to routine medical records, yet data from routine records and the reporting of them provide important information about disease patterns.There have been instances of social research based on covert methods. Some sociologists have expressed concern that most social research is conducted among the less advantaged members of society and that studies of the rich and powerful are extremely rare. One reason may be because poor people are less likely to object to the research process because of their relatively low social power. This raises the question of whether public health research has an inherent paternalism. A major argument in favour of participative research is that it is less exploitative and therefore more ethical.

What do privacy, confidentiality and anonymity in health research entail?

Participants in research are entitled to protection of their privacy, which means they should not be identifiable in research reports and that any identifying information should be removed form data as soon as possible. This concerns the principle of 'not to do harm', in other words, the principle of non-maleficence. Researchers using questionnaires and interviews have to ensure that their data is stored in such a way that particular individuals cannot be identified. Social, epidemiological and medical research can be intrusive, but should be planned so that it intrudes as little as possible. Epidemiologists use existing data sets to study the causes of disease. Use of these statistics is considered ethical as individual privacy is not at stake. Epidemiology also benefits by linking information from different data sets, but this raises particular issues relating to privacy, confidentiality and anonymity. 

How can researchers make sure they behave ethical?

Punch, Mils and Huberman provided thoughtful and full accounts of the ethical implications of qualitative research. 

• A researcher should consider the worthiness of the project: Is the study worth doing? Will it make a significant contribution to public health?
• A researcher should also consider competence boundaries: Does the research team have the expertise to carry out a study of good quality? If not, is the necessary expertise available elsewhere?
• Then, he or she should also consider informed consent: Do the people involved have full information about the study? Can their consent be given freely and without coercion?
• Researchers should consider benefits, costs and reciprocity.
• Harm and risk should also be considered.
• Honesty and trust are also important factors.
• Privacy, confidentiality and anonymity are also important factors a researcher should consider.
• Intervention and advocacy are also important: What will we do if we see harmful behavior on the part of others during the study?
• Research integrity and quality are crucial as well.
• A researcher should also consider the ownership of data and conclusions.
• Lastly, the use and misuse of results should be considered and ensured. 

Chapter 7: How is epidemiology used in public health research?

What is epidemiology?

According to Last, epidemiology is the study of the distribution and determinants of health-related states or events in specified populations, and the aplllicaiton of this study to control of health problems. Despite Last's definition, epidemiological approaches often focus on disease. Brown pointed out that the discipline paid far less attention to health and its creation, probably reflecting the origins of epidemiology as a medical speciality primarily concerned with curing disease. Certainly its strength appears to be in understanding and explaining disease. We distinguish several uses of epidemiology:

• It is used to describe the distribution and extent of disease in populations including measuring disease frequency.
• It is also used for identifying the causes of diseases.
• It is used to assess the effectiveness and efficacy of interventions to prevent, control and treat disease. 

What does population epidemiology entail?

Population epidemiology focuses on studies describing and explaining diseases in whole populations, such as the workers in a company, students in a school, or populations defined by geographical boundaries. This can be concerned with studying acute and chronic illness, communicable and non-communicable disease, and focussing on environmental or behavioral factors. Population epidemiology has been sued to document the links between ill health and many substances, including asbestos, lead and tobacco smoke. Behavioral epidemiology concentrates on describing the extent of particular health-related behaviors in a given population and how these behaviors might relate to disease. This research has been criticised as detracting attention away form the social and structural determinants of health. 

What does clinical epidemiology entail?

Clinical epidemiology applies epidemiological principles and methods to the practice of clinical medicine. Bonita define its central concerns as: definitions of normality and abnormality, accuracy of diagnostic tests, natural history and prognosis of disease, and effectiveness of treatment and prevention in clinical practice. Clinical epidemiology has made important contributions by developing techniques to make accurate estimates of important clinical issues. Public health has recently become more interested in assessing the effectiveness of treatments and preventive strategies in clinical practice. The rising costs of medical care and increase in possible medical procedures and treatments has led to a growing interest in 'evidence-based' medicine. 

What do social and eco-social epidemiology entail?

Social epidemiology has emerged as a new paradigm for epidemiology. It promises to overcome some of the shortcomings of epidemiology that have been noted above. Fundamentally social epidemiology studies 'the social distribution and social determinants of states of health'. It draws on social psychology and sociology and engages more effectively with social science theory than forms of epidemiology.

Krieger proposes the use of an eco-sociological approach which she describes as ecologically oriented integrative, multilevel and dynamic epidemiological frameworks, explicitly linking societal and biophysical determinants of disease distribution and health inequities. This framework includes socioeconomic status, social networks, social capital, discrimination, work demand and sense of control. Social epidemiologists use multi-level analysis to try and disentangle the effects of compositional from the contextual effects. It is particularly useful with complex concepts that are composed of a number of variables such as trust, socioeconomic status or early life experience. They will often adopt a developmental or life-course perspective as well. Social and eco-social epidemiology are a good fit with the new public health agenda.

What does popular epidemiology entail?

Popular epidemiology has evolved from the environmental justice movement and involves epidemiologists working with community people in social movements who want to research environmental threat to their health. Popular epidemiology is responding to the criticism of epidemiology as having become divorced from public health practice and policy and to the charges that epidemiology is only concerned with individual risk factors. 

What are the key concepts and methods in epidemiology?

Information on health status is crucial to epidemiology. Such data typically come from national institutes of health. We distinguish the types of data:

• Administrative data are collected during the delivery of health services.
• Population health surveys involve the collection of data related to health and disease within a sample of a defined population.
• Health registers are collections of records containing data about individuals who are typically patients or clients of a health service or health program. They aim for complete coverage of the relevant population and timely data supply, although this can vary between registers. They can be used to measure incidence and prevalence, follow up individuals for further treatment, plan services, monitor survival rates and recall following adverse events.
• Health surveillance is the ongoing systematic collection, assembly, analysis and interpretation of health data, and the communication of information derived from these data. It can be used the measure the incidence of selected diseases and identify emerging threats.

The quality of these data can be judged on the basis of the following criteria:

• Institutional environment relates to the factors that may provide insight on the effectiveness and credibility of the agency producing the statistics.
• Relevance refers to how well the statistics or product meets the needs of users.
• Timeliness refers to the delay between the reference period and the date at which the data become available.
• Accuracy is the degree to which the data correctly describe what they are designed to measure.
• Coherence relates to the internal consistency of a product, its comparability with other sources of information and over time.
• Interpretability refers to the availability of information to help provide insight into the data.
• Accessibility is the ease by which the data can be obtained by users.

What is the difference between incidence and prevalence?

To understand epidemiology, it is essential to appreciate the meanings of and difference between incidence and prevalence. 

• Incidence refers to the number of new cases of disease occurring in a defined population over a specified time period. The incidence rate is determined by taking the number of cases over a specified time period and expressing these as a proportion of the total population.
• Prevalence refers to the number of cases of daises that exists in a defined population at a particular point in time. The prevalence rate is determined by taking the cross-sectional count of dais and expressing this as a proportion of the total population at that time. Prevalence rates will depend on the duration and incidence of a dais. 

Epidemiology relies heavily on demographic data that describe the composition of populations, such as the overall size of it, breakdown according to age and sex, and a host of other variables. 

What different types of epidemiological studies do we distinguish?

Epidemiological studies are either descriptive, analytical or experimental. Based on the type of study, there are specific methods that can be applied.

What are descriptive studies?

Descriptive studies often rely on routine data collection, ecological studies or descriptive cross-sectional studies. Descriptive studies are based on routinely collected data relating to mortality and morbidity. They involve correlational data or case studies. Descriptive studies provide useful data, but they do not allow the cause of a dais to be ascertained. Routinely collected data should be treated critically like any other data. In ecological studies, the units of analysis are populations or groups of people rather than individuals, which means the link between exposure and effect cannot be made. Associations observed at the group level do not necessarily represent the associations at the individual level. Descriptive studies are often the starting point for more sophisticated epidemiological and other public health research.

What are analytical studies?

Analytical studies make use of cohort studies, case-control studies or comparative cross-sectional surveys.

• Cross-sectional studies may be aimed at simple fact finding or occasionally to test a hypothesis. They are useful to establish the prevalence of a disease or health-related behavior. The main weakness of cross-sectional surveys is that they do not include a time dimension, which is crucial in assessing whether an association is causal. Cohort studies follow a population over time until a specified end point.
• Case-control studies look retrospectively at people with a particular disease, comparing them with a control group who are unaffected by the disease.
• Comparative cross-sectional studies investigate the relationship between a disease and other variables of interest in a defined population at one particular time.

What are experimental studies?

Experimental studies use randomised controlled trials or community trials. Randomised controlled trials (RCT) are experiments designed to test new preventive or therapeutic interventions. People in a population are randomly assigned to groups. The treatment group receives the treatment, and then the outcomes for the two groups are compared. The strength of randomised controlled trials depends on the ability of researchers to achieve internal validity by establishing statistical control over systematic and random error. An issue in randomised controlled trials is that generalisation from them cannot automatically be made to a wider population than that represented by the people in the trial. Randomised controlled trials have conventionally been seen as the gold standard for epidemiological research. The RCT methodology, however, relies on the assumption that the experimental and control groups are identical. Given that RCTs are not particularly well suited to monitoring subtle effects in comparing treatments, the methodology is usually difficult to use in the evaluation of community-based initiatives. In a community-based trial, three conditions must be met:

• The control community has to be largely the same as the one experiencing the intervention.
• The control community has to have no health promotion intervention of its own.
• The external forces on the control and experimental communities have to be very similar.

The impact of social and economic factors on health status and the importance of participation in health decision-making at a collective end individual level have been stressed as key aspects of the new public health. The track records of RCTs on either of these aspects has not been good: They do not usually consider the effects of social factors. Randomisation is not easily compatible with the new public health philosophy of encouraging people to participate in decisions about public health and health care. the methodology sits more easily with more paternalistic concepts of decision-making, in which the expert is assumed to know best and decision-making is left to those experts. 

How are quality and error assessed in epidemiological studies?

Epidemiological studies are best suited to documenting the links between a particular biomedical, individual, behavioral or social structural risk factor. In isolation, any particular epidemiological study will not be convincing about these relationships, but a number of studies, taken together, will be more revealing about causality. Causal inference in epidemiology depends on accusing sufficient consistent evidence so that there is a high probability that the observed association between exposure and disease reflects an underlying causal relationship.

The studies have to ensure that the inference was not due to chance, in other words, random error, some kind of bias (systematic error), or uncontrolled confounding.

• Random error can never be completely eliminated, but can be reduced by careful measurement.
• Systematic error results primarily form bias in the selection of participants and from measurement or classification bias. It can be reduced by careful selection and ensuring that measurement is as accurate as possible.
• Confounding can be a real problem in epidemiology unless it is controlled. The term describes the situation in which the effects of two processes are not separated. This is when an exposure to a risk occurs in a study population, and is associated with obit the disease and the exposure. 

What is the aim of epidemiological research?

Epidemiology, like other natural sciences, does not produce absolute proof, but the best available understanding of the causes of disease, given the aggregate of research available to date. The aim of epidemiological research is to eliminate as many of the sources of error and bias as possible. This is challenging, but possible.

Chapter 8: What survey research methods are implemented in public health research?

What are survey research methods?

Surveys are the most widely used method of data collection in public health research, being used as part of evaluations, epidemiological designs, needs assessments and planning exercises. These surveys may be government initiated or conducted within universities or health departments for specific purposes. They can be used to collect data on occupational histories, obtain a snapshot view of a community's health status to use as part of a needs assessment, assess the level of participation in community activity or collect opinion data to inform decision making. Interview surveys collect data orally. Questionnaire surveys collect data in a written form and are self-administered. 

What are some strengths to the survey research method?

Surveys collect data in which the same variables are measured across units. Units can be individuals, households or health care settings. They produce a standard set of data for each unit that can be analysed using statistics to produce patterns within the data and to examine the relationships between the variables measured. Surveys are particularly suited to descriptive data that describes the extent of a phenomenon. Surveys are a relatively cheap means of collecting data, not requiring the detailed, time-consuming data collection and analysis of most of the qualitative methods. They can also, as a consequence, produce relatively quick results as the data are collected in preselected categories. They may also be more acceptable to the participants as they do not take up too much time. 

Interviews can deal with more complex issues and can be longer than questionnaires. They permit the possibility of recording spontaneous answers. They usually obtain higher response rates, partly because of the personal contact, but also because they are more acceptable to people with low levels of literacy. The easy administration of surveys means that they can be used with large numbers of respondents, which is especially useful when the aim of the research is to generalise to a particular population. For instance, the findings of a needs assessment may be more convincing if data relating to health service use are collected from a representative sample of the population. 

What are some weaknesses to the survey research method?

There are several weaknesses to the survey research method as well.

• Surveys evolved within a social science that was modelled on the natural sciences, and were seen as a precise means of measuring social phenomena. Yet, surveys are very different from experiments, which offer researchers total control over the experiment's environment. This control is not possible with surveys. Surveys do not have the same power to establish causality, but they can suggest correlations between variables. The types of data produced by surveys have been criticised by researchers from within social science. 
• Aggregation assumes that meanings are unproblematic and that words have uniform and agreed meanings that are not contingent on their context. Aggregation means that a particular variable is rarely considered in the context of the respondent's wider set of ideas and values. This means the pattern and structure of variables are not considered, and also assumes a uniformity in significance of variables that consideration of them in context will demonstrate does not exist. The limitations of surveys mean that they are most suited to questions with a narrow range of meanings and to the collection of factual data.
• The generalisation of findings form surveys is often cited as one of their benefits. However, the full benefits of generalisation can only be realised if the sample is indeed representative, and then only to the relevant population. Public health research based on surveys of randomly selected samples of particular populations is often reported as if it can be extrapolated to a more general population. In practice, error can affect random sampling. Most surveys suffer from non-response and refusals. These factors undermine the generalisability of research based on surveys and need to be borne in mind when interpreting and using their results. 
• Most public health surveys are cross-sectional, based on some form of random sampling and analysed using cross-tabulation. This form of survey is static and does not capture the dynamic aspects of behavior and attitude, especially in relation to time.

Results from surveys can be powerful but should not be used unquestioningly. The inaccuracies in the research process should be both reported and taken into account when interpreting the meaning of the survey results. Surveys are most powerful when used to collect factual data. They do still form an essential part of good public health practice. 

How are surveys planned?

Planning surveys involves a series of decisions about whether the survey methodology is appropriate, and what form is most suitable, given the available resources. The first decision to be made is a crucial one that is font not given sufficient attention in public health. This essential question is: Is the research question amenable to questionnaire or interview survey? Consideration should be given to whether a survey is the best methodology to answer the research question. A survey may be suitable for collecting factual information and straightforward behavioural data. Surveys are appealing because they yield a set of statistics that suggests the legitimacy of traditional science. But surveys are usually fairly crude instruments that rarely give more than partial insight to the complexity of public health issues and the interconnected influences on them.

What types of surveys do we distinguish?

There are three types of surveys. Each type has specific strengths. 

• Internet and mail surveys are cheaper to conduct but generally cannot be used to collect more complex information. They are usually not acceptable to people with low literacy levels. 
• Telephone interview surveys are increasingly popular as they are cheaper than face-to-face interviews and may be perceived as less intrusive. Bias can be introduced by not everyone having a telephone and the absence of complete listing for mobile phones.
• Face-to-face interview surveys generally result in a higher response rate, probably because they require less motivation for completion and people are more likely to agree to be interviewed when personally approach.

How are respondents selected?

It is rare that a survey will include a total population, except in a survey of all people involved in a health promotion initiative. Surveys in public health typically involve some form of sampling. When populations are large, surveying the whole population is impractical, expensive and unnecessary. 

We distinguish two types of sampling; random or probability sampling and non-probability sampling. Simple random sampling relies on identifying a sampling frame, which is a list of people in the group the research is focused on. This may be community based on geography, or with a particular characteristic. The accuracy of the sampling frame determines how well the final sample represents the group of interest. A variety of methods is available to select the sample from the sampling frame: lottery, which involves putting number representing each person in the sampling frame in a hat and picking out the required sample size, using a random numbers table, or selecting people at random according to their randomly selected birth date. Random samples can be stratified when you want to ensure that your final sample contains sufficient numbers of particular groups of the population. Another popular method is cluster sampling, whereby you randomly select a setting from which you randomly select individuals. 

How many people should be included in a survey?

The main purpose of a random survey is to provide data that will be representative of the sampled population so that generalisations can be made to the total population. Most public health researchers will refer to a statistician to calculate the required sample size, taking into account the confidence level, population size, expected results and type of analysis to be done. The crucial issue to understand in talking with statisticians is that their assurances are estimates based on probability, not absolute truth, and that by adjusting the size of a sample the error range can alter. Analysis of survey data according to different subgroups in a total sample requires ensuring that the subgroups are of sufficient size to allow generalisations. 

How is a survey instrument designed?

Survey instruments have to be carefully designed to be useful. There are many pitfalls and few shortcuts that can be taken, no matter how experienced the researcher. The design process involves the ordering and content of questions, and, for mailed surveys, the design of the questionnaire. The order of questions is important. Sensitive questions should be left until later in the survey so people are not discouraged from continuing. 

The following guidelines have been distinguished for the design of self-administered questionnaires:

• Use a plain easy-to-read typeface.
• Leave lots of space between questions so the questionnaire does not look crumpled, but has an open look.
• Consider including cartoons that may help keep the respondent interested in the form.
• Do not precode the questions as these may make the questionnaire appear intimidating.

Interviewers need to have as many aids as possible to make the process smooth. Questions asked in public health surveys may be factual, behavioral or attitudinal. Public health has become increasingly concerned with inequities in health status and the conditions that produce health. It is therefore often important for public health researchers to use surveys to gain a picture of the pattern of inequities within the population with which they are concerned. The complexities of designing behavioral and attitudinal questions are much greater than is the case with factual questions. Attitudes deal with abstract concepts and are difficult to measure. A central concern of public health is obtaining measures of people's health status so that the distribution of health in a population can be studied in detail.

What kind of questions can be asked on a survey?

Questions asked on a survey can either be open-ended or closed-ended.

• Closed-ended questions contain a list of answers from which the respondents are instructed to pick one or more.
• Open-ended questions are ones that ask the respondents to reply in their own words.

The aim of question construction should be to make the questions as clear and unambiguous as possible. Common problems are leading questions that bias the respondent in a particular direction, double-barrelled questions that treat two or more separate pieces of information together, jargon that may not be familiar to people in the survey, or double negatives that confuse the respondent. It is essential that a new questionnaire or interview schedule is piloted. Designing effective and meaningful survey instruments takes time and practice, but it is a skill that will be useful to most public health practitioners and researchers. Knowing how to design a survey means being able to assess the value of others' questionnaires and interview schedules.

What different methods can be applied?

Survey fieldwork, self-completion questionnaires, telephone surveys and face-to-face surveys are the different types of survey methods that we distinguish.

• In the case of survey fieldwork, the larger the survey to be conducted, the more complicated the fieldwork. If the survey is intended fro a random sample of a large population, more thought should be given to its organisation. 
• Self-completion questionnaires used to be mailed but are now often internet based using software. If the survey is to be conducted over the internet then a covering email substitutes for the letter. This should stress the importance of the survey and the respondent's cooperation, detail how the respondent may benefit from the research, estimate how long it will take to complete, explain how the respondents were selected, give reassurances about confidentiality, detail the ethical clearance for the research, explain how the research will be reported back, express your appreciation and give a contact person to answer queries. 
• Telephone surveys have increased in popularity because they are cheaper and less intrusive than face-to-face surveys although the increase in telemarketing has seen people become less tolerant of interruptions by phone. 
• Face-to-face surveys require interviewers who are sufficiently trained to ensure they ask questions in a consistent way. Survey textbooks used to advocate a neutral and objective stance but it is now accepted that people are more likely to give honest answers and open up to someone with whom they can empathise. 

What is a common response rate to a survey?

The response rate to a survey is an important aspect of assessing the quality of the information from the survey. This is calculated by determining how many people of those eligible to respond to the survey did so. A higher response rate means the survey is more representative of the population it is conducted in. When non-random methods are used to select the survey sample it is obviously not possible to ascertain such an accurate response rate because the characteristics of the whole population are not known. There is increasing evidence that response rates to surveys are dropping and this has led to questioning of whether response rate is necessarily the only way to judge study quality and validity. It has been suggested that participation rates may be more appropriate. The participation rate includes several factors:

• A description of the eligible study population and how they were contacted.
• The cooperation rate, which is the number of completed interviews form those who were able to be contacted.
• And lastly, the refusal rate, which is the number of people who refused at some point to complete the interview process after some contact was made. 

How are survey results analysed?

The analysis of quantitative data involves setting up a coding guide, coding the collected ifnroamtion, putting it into a computer file and then analysing it. There are numerous statistical packages to assist the analysis of survey information. Much of the factual data collected can be analysed by using descriptive statistics such as frequencies and percentages, and means. More complex statistical tests require a statistician, but there are many tests to determine whether differences between subgroups in any population are statistically significant and which determine which variables are entering most influence.

When interpreting quantitative analysis, bear in mind the limitations of statistical inference: Survey data analysis provides correlation data, not causative data. Critics also point out that statistical tests assume random selection of survey respondents. In most public health surveys, non-response reduces the power of statistical tests, and precludes this being true. In the wider debate about the relative value and contribution of quantitative and qualitative research, the power of quantitative research rests on assumptions that are not usually realise din practice. There is little doubt about the benefits of survey research, especially in relation to factual data, but there are many sources of error. Statistical modelling techniques for analysing survey dat can now examine multiple variables at one time, and so offer better mechanisms for studying interrelationships. Multivariate data analysis enables researchers to assess more than one study factor and allow adjustments for the influence of other study factors.

Chapter 9: What qualitative research methods are used to study public health?

What are qualitative research methods?

It is only in the past two decades that the potential of qualitative research methods to public health has been appreciated. The so-called 'qualitative revolution' has overtaken the social sciences and related professional fields. The acceptance of qualitative methods has been slower in public health, possibly because public health has long drawn on the same traditions of modernity and science as the biomedical paradigm, which maintains that only the classic experimental design can produce valid results. This method is based on hypothesis testing and is effective in cases that can be easily randomised and control din a laboratory setting. Unfortunately, public health research rarely has such opportunities for control, and humans are typically complex and continually changing. Qualitative methods offer considerable strengths in understanding and interpreting this complexity both as a complement to epidemiology and in their own right. 

Most professional disciplines have increasingly adopted qualitative research methods. There has been extensive methodological and epistemological debate about the nature of qualitative research, positions taken including postpositivism, various degrees of relativism, critical theory and interactionism. 

For what purposes are qualitative research methods applied?

Four main applications of qualitative research methods to public have been defined:

• The first application is to study and explain the economic, political, social and cultural factors that influence health and disease in more depth than is possible through a survey or other quantitative methods. For instance, a survey can tell you how many people participate in community activities in a given community, but interviews are needed to explain why they take part in such activities.
• Another application is to understand how people interpret health and disease and make sense of their health experiences.
• Another application is to elaborate causal hypotheses emerging from epidemiological and clinical research. For instance, experimental and quasi-experimental research explains the link between tobacco smoke and lung cancer, but not why people continue to smoke despite evidence about the health effects.
• Lastly, another purpose is to provide contextual data to improve the validity and cultural specificity of quantitative survey instruments.

What types of qualitative data do we distinguish?

There are three kinds of qualitative data:

• The first type is in-depth, open-ended data collected from individuals or groups.
• The second type is direct observation and description of people's activities, behaviours, actions and interactions, including analysis of audio- and video-taped material. Kellehear extends the definition to include the study of 'material culture' (graffiti, garbage, cemeteries).
• The last type is written data, usually excerpts, quotations or entire passages from organisational, clinical or program records, personal diaries, official records or publications and open-ended written responses to questionnaires.

The main methods used to collect these data are case studies, participant observation, in-depth interviews and focus groups.

What are case studies?

Case studies are empirical enquiries, using multiple sources of evidence, that investigate contemporary phenomena within their real-life context. The boundaries between the phenomena and their contexts are not obvious. Case studies are useful when researchers cannot control contexts and want to offer an accurate and detailed view of a particular phenomenon. Their main advantages are that they allow study in a natural setting, as well as the complexity of the subject. Case studies have become accepted as evaluation tools, their value now recognised by such development agencies as the World Bank, which previously had preferred large-scale quantitative studies. Evaluators ar enow likely to use case studies for their inherent strengths, not just because they are more manageable. Case studies have been sued to study the extent to which primary health care services are comprehensive, and the contrast between the services highlighted the value of comparative case studies. 

Yin suggests that a case study should be planned according to a protocol that contains several elements:

• It should contain a description, justification for the choice and particular characteristics of the case(s) to be investigated, aim of the study and expected outcomes.
• It should also contain documentation of the field procedures and main respondents and how access has been negotiated with relevant people and institutions. 
• Then, it should also contain a plan for data analysis: how it will be coded, prepared for analysis, and the process for analysing patterns and drawing more general insights.

Case studies usually collect information from a variety of sources, including in-depth individual or group interviews, interview or self-completion surveys and the collection and analysis of relevant documents. A case study proposal can be judged on the basis of the quality of communication, the context, the method and practicality. Factors making for an exemplary case study include significance, completeness, consideration of alternative perspectives, sufficient evidence, and an engaging manner. Case studies probably have more potential application in public health than has been realised, being useful for providing a complete view of a particular community or people. 

What does participant observation entail?

Participant observation focuses on the meanings of human existence as seen from the standpoint of insiders. It seeks to uncover, make accessible and reveal the meanings people use to make sense out of their daily lives. This methodology has its roots in anthropology. Participant observation has not been extensively used in public health research, although its use has increased in the past decade. The basic process of doing participant observation involves defining the research question, selecting and entering a setting, participating in the life of the setting, observing, gathering and documenting information, and analysis. Participant observation is also suited to studying deviant behaviors about which people may be reluctant to be interviewed. Researchers have a choice of position to adopt when undertaking participant observation: being a complete observer, an observer as a participant, a participant as an observer or a complete participant. 

It is important go gain the trust of people so they become reliable informants. Therefore it is important to be unobtrusive, honest, unassuming, a reflective listener and self-revealing. Trust is crucial if people are to reveal insights and details of their lives that they would not through interviews or other methods. Building trust can be a complicated process, however, and there is no reason to assume that people will be sympathetic to the aims of the researcher. There is a delicate balance between building trust and understanding the issues of relevance  to it while still being able to act as a critical observer. Data are usually collected in the form of field notes, which are written up as soon as possible after the observation. As a public health researcher, you need to consider the various positions towards participant observation. 

What does in-depth interviewing entail?

Interviews can vary from a quick interview through to a number of sessions over many hours with the same person. They can involve only fixed choice questions or be entirely open-ended with only broad topic areas to guide the conversation. Structured surveys have already been described; now we consider interviews that are based on semi- or unstructured interviews that produce mainly textual data. In essence these are discussions to collect information for subsequent analysis. Their advantage is that they usually provide richer, more complex data than tick-in-a-box questionnaires.

Factors influencing the decision of the style of interview to use are the following:

• The resources available to the researcher. Long, in-depth interviews are costly to conduct and transcribe, and limited by the volume of data they generate. It is necessary to decide on a smaller number of detailed interviews or a larger number of less detailed ones.
• Tolerance of the interview group. Some groups may be more willing to take part in detailed interviews than others. Medical practitioners are generally unwilling, but older people are often more willing to spend time being interviewed.
• Topic of the research. Some research topics demand longer, more detailed interviews than others. Research into people's fertility behaviour, for instance, requires an in-depth detailed interview to build up a rapport with the people being interviewed.

There are numerous uses for in-depth interviews in public health. In-depth interviewing is a skilled process that can only really be carried out by people who are familiar with the research purposes and aims, usually the researchers who are also responsible for most of the analysis and writing. The key stages of the in-depth interviewing process are contacting and explaining the research to potential respondents, establishing rapport and empathy, and ensuring that appropriate information is collected.

When is an in-depth interview successful?

Some attributes that contribute to successful interviews are the following elements:

• Anticipation; which means being prepared to explain the purpose of the research, reflecting on each interview in order to improve the next.
• Establishing rapport by showing a genuine interest in what the interviewee is saying and encouraging discussion of the central issues. This will be helped by being warm and caring taking a naive position, meaning that you keep an open mind and search for meaning from your respondent, rather than assume you know what they mean.
• Being analytic; meaning that interviewing is not just data gathering but also an analytical act that begins the process of understanding and meaning. Being analytical assists in appropriate prompts for more information and new avenues to explore.  Researchers are dependent on the willingness of their respondents to participate, and so detailed interviewing involves a delicate balancing act.
• Patiently probing: In-depth interviewing requires considerable patience and probing if you are to understand the topic being researched.

In-depth interviews require people to be open and honest about their lives, habits and behaviors, and so interviews can be quite intrusive. Data from the interview can be hand-written or recorded. In-depth interviews are a powerful way of getting detailed pictures of how people experience and explain their world, which can be cubical in public health for understanding why people behave as they do and how structural factors come to impact their health.

What do focus groups entail?

Focus groups involve open-ended interviews with between five and ten people on a particular focused issue for up to two hours. The methodology originated as a way of gaining accurate information about consumer product preference. Participants are asked to reflect on the interviewer's questions. The focus group method was pioneered in market research. The reliance on focus groups by commercial companies suggests they yield useful and accurate information. They can be sued to both supplement and validate quantitative and other qualitative techniques or as a self-contained means of data collection. Focus groups ar enow commonly used in health promotion needs assessment and in both exploratory and theory-building research within public health. 

What are the advantages and weaknesses of focus groups?

There are several advantages to focus groups:

• The advantages of focus groups are that they are an economical and efficient method of collecting qualitative data, as they save on interviewer time and travel. Information can be gathered from up to 10 people in one hour, instead of from one person.
• They yield lively interaction between participants, leading to discussion and debate that may not occur in a one-to-one interview.
• They can be exploratory and open-ended, allowing participants to formulate their opinions within the group in a way that would not be possible in individual interviews.
• Then, they also allow more control over the agenda of the discussion than in individual interviews.
• They are particularly useful when researchers do not know much about the issue they are beginning to research, as they allow an open-ended format in which topics of interest can be explored.

There are also possible weaknesses of focus groups:

• A form of group think' operates, discouraging participants from expressing opinions that are at odds with the majority of the group. 'Devil's advocates' may overcome this tendency 
• Focus groups may not tap into emotions. For some people, an individual interview is better, although others may find that a supportive group encourages emotional sharing.
• Dominant individuals can influence results so skilful moderation to minimise this risk is vital.
• The researcher's control over the data collected is less than that possible in one-to-one interviews. 
• High-quality recording equipment and transcription are required if direct quotations are to be taken.

How are focus groups conducted?

The number and size of focus groups will often be dictated by research goals as well as available resources. There is no easy formula for determining the number of focus groups that should be run, but the extent of heterogeneity in the group being researched is relevant. The more heterogeneous, the more groups will be needed. You will also need to consider how you might want to divide you population. Each group is likely to have valid but differing perspectives, and be more likely to express their attitude and opinions frankly in a group of peers. The topic of your research will usually determine how easy it is to recruit people to your groups. Generally, the more sensitive the topic is, the more trouble you will experience with recruitment. Market research companies typically pay participants in their groups, and this is beginning to happen in some social research. It raises the ethical question of the point at which the payment becomes an unfair incumbent to take part in the research. 

How you run your focus group is crucial to obtaining higher quality information. A suitable venue must be found for the event where participants will feel comfortable and relaxed. The data from a focus group are more easily recorded don audio tapes or digital media. focus groups work best when participant feel comfortable, respected and free to give their opinions without being judged. Focus group information, like other textual data, may be analysed according to its content and themes drawn out. 

What does document analysis entail?

Document analysis is a valuable method in qualitative research that provides a particularly rich source of information about many organisations and programs and is often used in combination with other methods. It has been used to assess uptake of research evidence in health policies and the extent to which health policies address equity issues and is emerging as a method to assess uptake of evidence on social determinants of health and health inequities. 

What are some common issues of concern?

We distinguish several common issues of concern in qualitative research.

• The first concern relates to scaling. Although qualitative research does not aim for statistical representativeness, researchers want their theories to be meaningful to a wider population. Consequently, it is usually important to explore many aspect of the topic of interest. There are no closely defined rules for sample size. Qualitative researchers may be asked to specify their sample size in advance because of funding. A proposal should be able to describe the sampling strategy clearly, state the selection criteria and provide an approximation of the sample size.
• Validity, reliability and generalisability are concepts that enable the value of positivist research to be judged. Face validity is concerned with whether the methods assess what they set out to do, internal validity refers to the rigour of the methods, and external validity refers to the extent to which the results can be generalised beyond the selected sample. Reliability refers to research consistency, and generalisability refers to the extent to which the research findings can be applied to other settings and still have meaning. There is uncertainty in the literature about the extent to which these concepts can be applied to qualitative research.
• Preference is used to assess qualitative research. It focuses on the rigour of the techniques, the credibility of the researcher, and the assumptions that underpinned the study.
• Transferability refers to the ability of qualitative researchers to extend their finding to other settings.
• The features dependability and reliability refer to whether the research is likely to be consistent over time and across researchers and methods.
• Confirmability refers to the need to conform research results with a source outside the research team, such as the research participants. It shifts the focus from the objectivity of the researcher to the data.

How is qualitative data analysed?

Analysis imposes meaning and interpretation on mainly textual data, which are usually instructed and unwieldy. There exist different traditions to this process. qualitative data are priamrily textual and typically comprise a mix of field or observational notes and transcripts from interviews. A framework that involves five stages describes the process of shifting, charting and sorting material according to key issues and themes.

1. First, the researcher becomes familiar with the range and diversity of data collected.
2. From the researcher's initial notes, themes are identified to form the basis of a thematic framework.
3. When indexing, the thematic framework is applied to the data.
4. Charting refers to the process of taking the data from its original context and rearranging it according to the appropriate thematic reference. 
5. In the final stage of mapping and interpretation, the researcher pulls together key characteristics of the data and so makes sense of the study as a whole. The process involves reviewing the themes, comparing accounts and experiences, searching for patterns and connections and seeking explanations for them within the data. 

What does participatory action research entail?

Participatory action research (PAR) seeks to understand and improve the world by changing it. At its heart is collective, self-reflective enquiry that researchers and participants undertake, so they can understand and improve upon the practices in which they participate and the situations in which they find themselves. The method is based on the belief that objective truth is a problematic concept and that there are multiple ideas of truth. The literature on participatory research tends to eulogise the potential contribution of research participants. The practice of action research in public health presents dilemmas. Key issues are those to do with whose knowledge is valued, who owns the research, why the research is being done and the importance of recognising the complementary skills of community members, researchers and practitioners. 

Chapter 10: How are community-based health promotion projects planned and evaluated?

What are community-based public health projects?

Increasingly public health involves community-based initiatives that tofus on social, policy, organisational and individual change. These initiatives often focus on particular settings and pose particular challenges for planning and evaluation. They are very rarely amenable to evaluation using conventional medical techniques such as randomised controlled trials. They are typically long-term activities that seek to change the ways in which organisation work, and to put health and the environment on the top of their agendas. The broadness of the new public health agenda means that decisions about which health issues to tackle are crucial. Practitioners have to choose between many competing priorities, and there are a variety of techniques to determine needs. 

Community-based public health projects, including healthy settings, are based on a social and environmental understanding of health, and any planning work should also use this framework. The process of amassing and interpreting the data may be a useful means of initiating and consolidating the work of an intersectional committee. A shift in mindset from disease to health is crucial in developing proactive new public health projects. Encouraging a sense of vision in planning for new public health initiatives is important. Vision is important to establish the overriding goal of the initiative and to keep people focused and committed to it. Another important factor in planning and needs assessment is to ensure that their is not a sole focus on problems. Health professionals have a tendency to define need in terms of their own solutions. The usefulness and effectiveness of planning will be greatly increased if it involves a broad section of the community and encourages learning among the organisations and individuals involved. 

What tools are required for needs assessment?

There is no set formula for carrying out a needs assessment. The particular mix of methods will reflect the resources available, the scope of the planned project, this ize of the community and the skills of the project staff. In many ways, assessing needs is like doing a jigsaw, as it involves fitting together different bits of information to produce a complete picture of the issues. 

• One of the first steps in deciding which methods to use is to audit what information is routinely available.
• Health and environment indicators can be used to provide information about a setting, monitor changes in a setting, determine issues of most concern and inform decision making. 
• Indicators can be based on quantitative or qualitative information. 
• The search for a perfect set of indicators is complex. 
• Surveys can also produce useful information, but are relatively expensive to do properly and may not always produce the expected information.
• The various methods for collecting qualitative data can be applied to needs assessment. Increasingly, the importance of community stories is being recognised. Stories have great potential as a way of engaging people in a needs assessment process. 
• Rapid appraisal is a means of doing needs assessment quickly and economically. Two of the main benefits are cheapness and its ability to provide information rapidly so that it is of maximum use when the assessment is needed by decision-makers. 

How are priorities set?

Most new public health projects base din communities or organisations will never be able to tackle all the issues they identify, hence the need to establish priorities. It is rare that the process of establishing these will be based purely on the information collected. Other considerations are the particular interest of the researchers, political interest or lack of interest, issues considered important by the community and local policies rallying to health and previous work in the area. Priorities that gain the commitment and passion of local people and people who work in their communities are most likely to win the support and commitment necessary for success. 

The broader planning framework aims to equip communities and health promoters with the ability to respond to locally defined illness problems and health issues and to establish priorities for action. It is base don the belief that it is more important to establish structures that encourage local people to work in partnership with professionals from a number of different sectors than it is to spend time establishing specific goals and targets. Details project planning ensures goals and aims are achieved by designing feasible means, managing workloads, making the best use of everyone's talents and establishing the basis for good decisions making. 

By what type of groups is the new public health characterised?

The new public health is characterised by complex interest groups who are unlikely to have single voice. Communities are never entirely homogeneous. Planning to meet the public health needs of these people will inevitably be complex. Hancock recommends the use of a regular process of environmental scanning to discern the current major issues, threats and opportunities. He suggests that this process be kept relatively simple so that people are not swamped by detail.

What does the evaluation process of complex public health initiatives look like?

Evaluation assists sense-making about policies and programs thought he conduct of systematic enquiry that describes and explains the policies' and program's operations, effects, justifications and social implications. The ultimate goal of evaluation is social betterment, to which evaluation can contribute by assisting democratic institutions to better elect, oversee, improve and make sense of social programs and policies. There has ben increasing attention to the need for evaluation to cope better with the complexity of social and community settings and how these affect public health programs. Evaluation designs are being constructed that are better able to do this.

How do objectives and outcomes play a role in the process of evaluation?

The objectives of community development and healthy settings initiatives can only partly be specified in advance, as they depend on definition by the community and may take some time to evolve. They are also likely to change as the context, setting and people involved change. These shifting objective make it more difficult for evaluators, but have to e considered if they are to do their job of describing and assessing the progress of the initiative. Rather than viewing the shifting objectives as a difficulty, the evaluator should incorporate regular reassessment of objectives into the evaluation design. 

Defining and measuring outcomes in community development and healthy settings projects means recognising that the choice of outcome measure will depend on the perspective adopted. In evaluating community development and healthy settings projects, different groups may not even agree on what the outcome of a project should be. Each groups' values become crucial in the evaluation process. The nature of community development and healthy settings initiatives means that evaluation cannot happen realistically in less than five years. A sustained effort tis required to develop a group of people, and for them to define their objectives, take action, learn from their mistakes and successes, and establish sufficient confidence in their ability to effect change. Evaluation of community development and healthy settings projects is as much about partnerships and community participation as the projects themselves. The aims and objectives of the evaluation process need to be negotiated with those who are participating in the project. 

How can change be measured at the community level?

The extent of participation can be measured by assessing the extent of participation in needs assessment, leadership, organisational focus and operation, style of resource mobilisation and management and decision-making processes.As core is allocated to each of these indicators to note the extent of participation. The debate that may ensure between players about their differing participation could itself become part of the participatory process. 

How can causality be attributed?

Determining the impact of a community development or healthy settings project on health status and the quality of the social and physical environment is difficult. It is relatively straightforward to produce a set of indicators, but making inferences about the causes of any changes in the indicators monitored is far more hazardous. The 'gold standard' for epidemiology in dealing with the issue of attribution is the randomised controlled trial. But community projects can rarely, if ever, sue a control as no two communities are identify. Causality is not established through statistical tests of correlations but by a burden of evidence that supports logically coherent chains of relations that emerge through he contrasting and comparing of findings from many forms of evidence. The quality of argument and plausibility of the claims and attributions becomes vital. 

How can a reflective approach be ensured?

The dynamic nature of community-based health promotion initiatives means that frequent reflection on the methods used is vital. This reflection enables evaluators to be responsive to changing policy and community circumstances and adjust methods to adapt to the changes. This also enables project actors to be involve din the evaluative process. This process calls for the evaluators and the project actors to engage in a reflective spiral. The spiral analogy is particularly suited to community development as it begins to capture its dynamic nature and incorporates the shifting and changing nature of this work. 

What methods for community-based evaluation are there at hand?

Randomised controlled trials offer very little for community development and healthy settings evaluation, as the naturalistic setting and evolutionary nature of these approaches mean that a control community is impractical. Even in health promotion programs that are largely based on beahviro change goals, control communities are not as attractive a methodological solution as they might appear. While communities may often be similar, they are never going to be identical, so their power to determine patterns of causality is reduced. The activity in a community development and healthy settings initiative is essentially human centred and about the interaction and relationships between people, and between people and organisations. 

How can the validity of the evaluation be determined?

The use of a number of evaluation methods enables triangulation of the different data sources, thus increasing their validity.  A further important means of validation is checking the data with key participants in the particular initiative. This process is typically used to reflect on, and make changes to, the way of working. It enables people to play a role in the evaluation and will increase ownership of the evaluation findings. Validity is increased through the process of critical thinking. To be critical does not mean attacking the initiative, but reflecting on the meaning of the data in a way that questions taken-for-granted assumptions.

Chapter 11: What are the profiles, patterns and explanations of health inequities?

In what way are health inequities central in the new public health movement?

Central to the new public health is a concern to reduce health inequities that result form unfair social and economic arrangements and processes. 

What data sources are there about public health?

The WHO produces an annual World Health Report that contains data on each country. The World Bank also has an extensive database on health and other statistics. Although data quality for rich countries is much better than that for poorer countries, even in rich countries there is no generally accepted measure of well-being, and self-perceived measures of health are becoming more accepted as valid. Generally, however the health status of a population is commonly assessed by mortality rates. Morbidity data are also used but are generally harder to obtain.

How does life expectancy form an indicator of public health?

The difference in health status between the poorest and richest countries is vast. In industrialised countries, life expectancy has increased dramatically during the twentieth century. This was the general trend globally. In the 1990s and the early twenty-first century his trend has been reversed in Africa, where the HIV epidemic has resulted in a reduction in life expectancy in a number of countries. There has been recovery in the last decade but Africa still has less health improvement than the rest of the world. 

Globally, infant mortality rates range from 53 per 1000 live births in low-income countries to 5 per 1000 births in high-income countries. There are considerable differences in infant mortality rates between high-, middle- and low-income countries, and also especially within the low-income grouping. While progress has been made, it is unequally distributed.  

What are the social determinants of health?

A key argument in this book is that health is determined by social and economic factors. The pattern of some of these determinants follow that of the mortality patterns. People in poor countries have lower incomes, are less likely to enrol in secondary schools or use the internet, and have limited access to drinkable water and sanitation. These factors are: gross national income, malnutrition prevalence, percentage of secondary school enrolment, percentage of population with access to improved water source, percentage of urban population with access to improved sanitation facilities, internet users, and access to electricity. 

What are common causes of death?

There are distinct differences in the patterns of mortality between countries according to their wealth. Coronary heart disease and stroke feature in the top ten killers in all three income groups. Infectious and perinatal conditions are much more evident as causes of death in low-income countries whereas cancers and other chronic ideates are more prevalent in high-income countries. The most striking differences are that deaths resulting from communicable diseases are much more common in low-income countries and chronic diseases are more common in middle- and high-income countries. 

Communicable diseases are responsible for more than 40 per cent of deaths in low-income countries, but for 1 per cent in richer countries. although in wealthy countries people ar most likely to die of non-communicable diseases, in low-income countries they are most likely to die from infectious biases. More chronic disease occurs in low- and middle-income countries. Three trends in diseases are of particular note internationally: deaths from injuries and violence, the emergence of new infectious disease from the late twentieth century to the present, and the growth in the prevalence of chronic disease in both rich and poor countries. 

How do deaths from injuries and violence form an international trend as a cause of death?

Rates of violent death vary according to country income levels. People in low-income countries are more than three times more likely to die as a result of interpersonal violence, while those in high-income countries are more likely than other income groups to kill themselves. Since World War II, armed conflicts have taken a much heavier toll on the populations of low-income countries than on industrialised countries. War is continuing to be a feature of life in the twenty-first century, with civil war and attack from a US-led alliance taking a significant toll in Iraq and Afghanistan and the continuing struggle between Israel and Palestine causing the loss of significant numbers of people. 

Children and young people comprise a significant proportion of the population in many of the countries that suffer most from armed conflict or political emergencies. Some die as a result of conflict, others are forced into military services, and others have to take on new family responsibilities when members of their families are killed or injured. 

How does the resurgence of infectious diseases form an international trend as a cause of death?

The resurgence of infectious diseases around the world has been attributed in part to the increased volume of international travel. Global infectious disease trends include increasing mortality in developed countries, including the USA, whose death rate from infectious disease increased by more than 50 per cent between 1980 and 1992. Conditions such as tuberculosis and pneumonia, especially antibiotic-resistant strains, which were predicted to decline developed countries, are actually increasing in the twenty-first century. New human pathogens such as HIV and Ebola virus have focused lay and professional attention on the issue of infectious disease. These fave been categorised into four groups:

• Infectious agents that are new as human pathogens.
• 'Old' human pathogens that are spreading beyond their traditional geographic areas.
• New strains of 'old' pathogens, including drug-resistant strains.
• Pathogens re-emerging as public health problems after decades of declining incidence. 

The developed world accounts fro only a very small proportion of HIV infections. In many parts of the developing world, the majority of new infections occurred in young adults, with young women especially vulnerable. About a third of those currently living with HIV are aged 15-24.

How does chronic disease form an international trend as a cause of death?

Estimates suggest that by 2030, 51.7 million people will die of chronic disease worldwide and the majority will live in low- and middle-income countries. Chronic diseases such as cardiovascular disease, cancer, diabetes, asthma, arthritis and musculoskeletal conditions are all areas of national health priority in Western countries. Chronic disease incurs many costs for society. Chronic illness frequently has an impact on a person's quality of life and may mean they are unable to work, so lose income and fall into poverty. In many low- and middle-income countries the cost of treatment for chronic disease means patients bearing out-of-pocket payments and so contributing to family poverty. 

In rich countries, social and economic changes have seen more women in the workforce and seen adult children move long distances from their parents to find employment, making family care less accessible. Professional and institutionally driven illness care services to be fragmented, but chronic care often requires close coordination from a wide range of services. Improving the care of older people and people with chronic disease is a top policy priority in all countries. Prevention of chronic disease is also vital. 

How does disability form an international trend as a cause of death?

More than a billion people in the world experience disability. The prevalence of disability is growing due to population ageing and the global increase in chronic health conditions. People with disabilities generally have poorer health, lower education achievements, fewer economic opportunities and higher rates of poverty than people without disabilities. This is largely due to the lack of services available to them and the many obstacles they face in their everyday lives.

Disabilities include intellectual or physical and include a wide range of conditions that result in different impacts on daily living. typical effects are difficulties with transport, meal preparation, housework, health care, communication and self care. In rich countries the last 20 years have seen some major changes in policy approaches to disability. Advocacy groups have asserted that disability is not an illness and should not be treated as such. Medical dominance of the disability sphere has diminished accordingly, and there has been a movement away from institutional care to home- and community-based living. As populations age, there will be a greater need for home-based care to support people with disabilities and to support their carers.

Chapter 12: What are the patterns of health inequities in Australia?

What will this chapter be about?

Health is a product of people's everyday experience, and is therefore unequal. In this chapter, the health inequities within Australia are used as a means to explore the patterns. There are many ways of looking at patterns and trends in health and illness in Australia. Doing well in terms of employment, income, education and the associated material resources appears to be good for health. 

What are the key factors in health inequalities in Australia?

While Australia has a very high overall life expectancy, this is not shared equally across the population. 

• The first factor is gender: Male shave a mortality rate that is 1.5 items higher than the rate for females.
• Another factor is location: People living in remote and very remote areas have mortality rates that are 1.4 times higher than the rates for people living in major cities, and also higher rates of death due to diabetes and land transport accidents.
• A third factor is socioeconomic status: People living in the lowest socioeconomic status areas have a mortality rate that is 1.3 times higher than the rate among people living in the highest socioeconomic status areas, and higher rates of death due to diabetes and chronic obstructive pulmonary disease.
• The final factor is country of birth: Overseas-born Australian residents on average had lower mortality rates than Australian-born residents. Asian-born Australian residents had a mortality rate that is 36 per cent lower than the rate for Australian-born residents. 

What is the strength of the evidence relating socioeconomic status to health?

Data collections in Australia do not usually collect measures of socioeconomic status for individuals that can be linked to health and illness data. In Australia, the evidence relating to socioeconomic status and health has to be sought out and fitted together, but is does not form a cohesive pattern as the data have been collected for different purposes using varying assumptions. While acknowledging that occupation, education, income and geographic area all have methodological and theoretical problems, the size and consistency of the direction of the relationship does indicate a real relationship.

There is increasing literature that attempts to understand the complex relationships between variables relating to class, race, ethnicity, gender and education, while recognising the difficulties of health measurement and phenomena associated with class, such as poverty. These difficulties of measuring and understanding social class should not lead to the conclusions that such measures are futile. The social patterning of health and illness is fundamental to the new public health and the challenge is to explain the patterns while refining and improving existing measures. 

What does poverty entail?

Poverty has a strong influence on health. Rowntree's work sought to establish a measure of absolute poverty. The notion of the undeserving poor was widespread at the time, and the concept of a technical poverty line below which even the most efficient household managers could not be adequately fed and housed was appealing. Rising living standards in the twentieth century meant that absolute poverty proved to be a less useful concept in developed countries, and the notion of relative poverty was introduced.

Poverty is defined as the lack of access to an adequate material standard of living resulting primarily, but not only, from inadequate income. It is the lack of opportunity to participate fully in society. 

What does socioeconomic status entail?

A large body of Australian and international literature shows that there is a consistent trend for people in more disadvantaged circumstances to suffer worse health and die earlier than those in better circumstances. In Australia, people who are poorer or socioeconomically disadvantaged in other ways generally live shorter lives and suffer more illness and reduced quality of life than those who are well-off. Mortality rates are 1.3 times higher for the lowest socioeconomic status areas than the highest socioeconomic status areas for males, 1.2 times higher for females and 1.3 times higher for males and females combined. 

As age increases, relative inequalities by socioeconomic status (SES) are less pronounced, and for people aged 85 and older, there is no difference in the overall mortality rates between the lowest and highest SES areas, showing that death is a great equaliser. Also, Indigenous Australians are far more likely than non-Indigenous Australians to be living in a position of socioeconomic disadvantage. The impact is reflected in the poorer health status of Indigenous people. 

In what way are inequities increasing?

Economic inequalities are increasing around the world and these appear to be translating to increased health inequities. There has been a sharp fall in the real value of wage and salary income for households in the bottom half of the income distribution, and senior executive pay is now 150 times greater than average weekly earnings. There has been growing acceptance that inequities are increasing despite some earlier debate. Wealth concentration is increasing with the richest 1 per cent gaining a greater proportion than in the 1970s. The current levels of inequity are unsustainable in terms of creating a cohesive and well-functioning society. 

How is unemployment related to health?

In Australia, few differences exist between people who are employed and people who are unemployed in terms of long-term conditions, except for mental and behavioral problems. Unemployed people also report more asthma, are more likely to be current smokers, but less likely to report a risky or high alcohol intake or be overweight. There are no good national data on death rates and unemployment.

What do public health patterns of occupational illness and injury look like in Australia?

According to the most recent figures available, mortality rates from all causes of death combined among males working in both manual and non-manual occupations declined markedly during the period 1966 to 2001. Safe Work Australia has the responsibility of providing data on the distribution of occupational illness and injury over occupational and industrial groupings. Occupational illness and injury is obviously a crucial public health issue because of the pain and suffering it causes. it also has a significant economic cost for employers, workers and the community as a whole. There is a national plan to reduce occupational disease and injury; the Australian Work Health and Safety Strategy.

Occupational health is a neglected area of public health enquiry. There is considerable scope to extend documentation and understanding about the impact of work on health. This is particularly important at a time when the nature of work is changing in ways that are likely to be detrimental to health. There has been a fall in the number of permanent full-time jobs, and a rise in casual, contract and part-time jobs. People are much more likely than they were in the past to change workplaces, and so gain less social support form work. Australian households have become increasingly divided between the 'work rich', where two people are in paid employment, and the 'work poor', where there are no people in paid employment, or they have insufficient employment. Concentrated disadvantage is common, where the inherent disadvantage of having a low income is compounded by living in poor areas, which tends to produce a self-perpetuating cycle of unemployment, social marginalisation and stigmatisation. The pressure to work longer hours appears to be increasing in most countries. 

What are the health consequences of Indigenous peoples in Australia?

Analysing Aboriginal mortality data is difficult as the definition of an Aboriginal person changes and records of deaths are subject to error because of under-reporting. However, it is clear that Aboriginal and Torres Strait Islander peoples have a lower life expectancy compared to non-Indigenous Australians. The excess mortality and failure to reduce the difference between Aboriginal and Torres Strait Islander peoples and the rest of the Australian population to nay significant degree is widely seen as an Australian failure, but there is cause for hope. While the gap in life expectancy is considerably larger than in other countries where indigenous peoples share a similar history of recent European colonisation it is beginning to close. 

What are the health consequences for refugees and migrants?

The number of regress and asylum seekers is growing and raises new public health concerns. The number of people worldwide recognised by the United Nations as being of concern has risen from just under 15 million in 1990 to almost 42.9 million in 2013. Most refugees and asylum seekers take significant risks with their lives and health when they flee their country or origin. Some may have been victims of political terrorism in their own country and have suffered torture before escaping. Many are also separated from their families and friends. Once they are accepted in a host country, the consequences of torture and years of living as a refugee take their toll. Refugee camps pose massive public health problems in terms of the need for clean water, sanitation and constant vigilance for outbreak of infectious diseases. 

Australia, along with some other develop status, has taken a tough stance on asylum seekers. There are hard-line policies. A majority of Australian people support these hard-line policies but there is a substantial minority who have continued active protests. This disquiet in the Australian public lead to the government reducing the number of child refugees held in detention, although all are held there during assessment. For public health, an important question is what impact does an increase in intolerance have on a population. Overall, the net effect of the discussion about asylum seekers may be to make Australia a less welcoming and inclusive society. This is likely to have a negative impact on our collective health. 

In what way does gender relate to health outcomes?

Gender has a powerful impact on mortality. The mortality rate for males is 1.5 times higher than the rate for females. There are distinct differences in causes of mortality between men and women. One of the factors that accounted for the increasing difference between male and female death rates is the dramatic decrease in maternal mortality since the early twentieth century. The reasons for the decline in difference in more recent years reflects in part increased smoking rates and labour-force participation rates for women and decreased smoking rates for men. 

Ischaemic heart disease and cerebrovascular disease accounts for a little under a quarter of deaths of Australian men and women. However, heart diseased declined from the main cause in the early 1970s and cancer deaths increased for women to become the main cause. The pattern of cancer deaths differs for men and women too, with men being more likely to die of cancer than women. Deaths from accidents, poisoning and violence are the most frequent cause of death for men and women between the ages of 15 and 34 years of age, although men are more likely to die of these causes than women. Deaths from road traffic accidents have declined over the past 30 years.

What does the pattern of suicide look like in Australia?

Suicide is a significant cause of death in Australia. Suicide deaths make up more than 20 per cent of deaths form all causes in each 5-year age group fro males between 20 to 34 years. The human costs of suicide are huge, and campaigns in recent years have been successful in bringing about a decline in rate.s It has a very distinct gender pattern: The male suicide rate is higher than the fame rate across all age groups. 

In the past 30 years young male suicide rates have been a chief cause for concern. The high and rising rate of suicide among men aged 34 years and under made suicide a top focus for public health action since the mid-1990s. Over the course of the past century the number of suicide deaths in men increased steadily for men younger than 34 years old. Rates for females hospitalised as a result of intentional self-harm were at least 40 per cent higher than male rates over the period form 1999-2000 to 2011-2012, with female cases outnumbering male cases most markedly in the teenage years.

How are gender and morbidity related?

Despite women having longer life expectancy than men, they are more likely to report illness, both for recent and long-term conditions. In 2011, women were less likely to consume alcohol at a risky level, be a current smoker, or be overweight or obese, and more likely to eat fruit, while men were more likely to undertake a high level of exercise and less likely to be sedentary. 

What is the relationship between location and health?

Location has a profound effect on health, as can be seen even within a city or region, where different locations may reflect different levels of socioeconomic status and related health status, or in the differences between metropolitan and rural lives. Health disadvantage correlates with socioeconomic disadvantage. The lower socioeconomic areas have higher proportions of one-parent families, low income, low-skilled workers, unemployment, homes without cars, and lower rates of internet use. Australian cities are increasingly divided by socioeconomic status, with the outer suburban areas containing a high proportion of disadvantaged people compared with affluent areas nearer the city centre. 

In the past two decades there has been a strong policy focus in Australia on the 30 per cent of Australians who live in rural or remote areas. The mortality rate for all people living in remote and very remote areas is 1.4 times higher than the rate among people living in major cities. The rate of potentially avoidable deaths also increased as remoteness increased. The increasing mortality rates hols for both males and females. The mortality rate among females living in remote areas is 1.3 times higher than the rate among females in major cities, and in very remote areas it was even 1.6 times as high. For males, the rate ratios are 1.2 and 1.4 respectively. Coronary heat disease rates are between 1.2 and 1.5 times higher in regional and remote areas as in major cities. In remote and very remote areas, the rate of dying due to a land transport accident was more than 4 times higher than in major cities. 

What factors contribute to poorer health in rural areas?

Compared with people who live in major cities, people who live outside major cities are more likely to be smokers, drink alcohol in hazardous quantities, be overweight, be physically inactive, have lower levels of education, have poorer access to work, have less access to specialist medical services, work in physically risky occupations and have a lower SES. 

These broad groupings, of course, conceal more specific locational factors such as those between inner and outer metropolitan areas or between country towns and more remote rural locations. The picture is also complicated by the presence of a much higher proportion of Indigenous peoples in non-metropolitan areas, making it hard to estimate what proportion of the higher disease burden reflects Indigenous health issues rather than rural or remoteness. Nonetheless, they provide a guide to locational differences. From a position of being relatively affluent as a result of its strong agricultural base, rural Australia has undergone dramatic change in the past 30 years. Increasing world competition, falling commodity prices, a decrease in the profitability of traditional primary industries and widespread drought has resulted in rural recession, causing significant social and economic dislocation. For much of rural and remote Australia the decade to the early twenty-first century has seen the withdrawal of services and a declining population with a consequent threat to the viability of rural communities. For some areas the mining boom and the sea change' phenomenon has seen a reversal of this decline.

Chapter 13: What are the social determinants of health inequity?

What do we mean with health inequities?

Striving to achieve equity in health status is a crucial part of the new public health. In the past 200 years there has been a doubling of the human lifespan and the increase in life expectancy is continuing in most countries. However, major health inequities exist within populations. There is growing policy attention on health inequities and what to do about them. The growing interest reflects the fact that economic inequalities are increasing both between and within countries and wealth concentration is increasingly considerably and may also reflect disenchantment with the neo-liberal public policies. 

What is the difference between equality and equity?

Much of the literature on health differentials uses the terms equity and equality interchangeably, but their different meanings have implications for policy action: equality is concerned with sameness; equity with fairness. Policies are unlikely to be able to make people the same, but they can ensure fair treatment. 

How can we explain socioeconomic status inequities in health status?

Inequities in health status appear to be universal across cultures and persistent. They relate to socio-economic status, gender and ethnicity. Reviews of the research in the area concluded that the international evidence based on socioeconomic status and health is consistent:

• The relationship has been observed in numerous countries and has peristed over long periods of time.
• The relationship exists for virtually all measures of health and health habits.
• It is evident irrespective of how socioeconomic status is measured. It is also evident for almost all health outcomes, irrespective of the measure of health that is used.
• The relationship is also evident for all age groups and for both men and women.
• Also, the relationship occurs in a gradient whereby those at the top have better health than those in the middle, who in turn have better health than those at the bottom. 

What explanatory framework for health inequities do we use?

The Commission on Social Determinants of Health has produced an explanatory framework for health inequities that sees health and its distribution resulting from social context, socioeconomic position that leads to distinct patterns of stratification, and a range of intermediary determinants of health that create differential exposure and vulnerabilities. This model is designed to be relevant globally and so is broad and conceptual. 

What are the four possible explanations for variations in health?

The UK Black Report and the subsequent Acheson Report are the most comprehensive considerations of health inequities from one country. The framework used to explain inequities in these reports is a useful one for our discussion. Four possible explanations were put forward for the variations in health: artefact explanations, theories of natural or social selection, cultural/behavioral explanations, and materialist or structuralist explanations. 

How do artefact explanations explain variations in health?

The ways in which social class has been measured may be unreliable and artificially inflating the size and importance of observed health differences. The argument hangs on the claim that the classification and nature of occupations have changed so much in recent decades that any comparison with earlier decades is meaningless. Results from major longitudinal studies using alternative measures to occupational class have provided additional evidence of a social gradient in mortality. On the basis of recent evidence, the studies reported in the Black Report may be underestimating the extent of health inequities rather than overestimating them. Statistical inaccuracies are insufficient to account for the consistency and scale of the association between SES and health.

How do theories of natural or social selection explain variations in health?

These theories suggest that inequities arise as a result of social mobility; healthier people rise to higher social classes. Those in poor health are less likely to be socially mobile. A similar argument is also made in relation to employment; unhealthy people are more likely to become unemployed and good health makes it easier for people to enter, remain and gain promotion in the labour market, and thus to live and work in low-risk environments.

The social selection theory received support from the work of Illsley, which demonstrated that taller women tended to marry into a social class higher than their father's more often than shorter women. the infant mortality rates and the birthweight of their babies were better than their shorter peers, who remained in their fathers' social class. However, socioeconomic conditions are critical in determining life expectancy and health status in adults, suggesting that selection is not an adequate explanation. A similar debate is evident regarding intelligence and life expectancy. While some studies suggest intelligence predicts mortality, the relationship needs unpicking. Cognitive function in childhood is influenced by biological and social conditions in early life. 

Migrants to Australia tend to have lower mortality rates than Australian-born people. It was suggested this may be the result of the selective effects of migration. Migrating brothers differed only modestly from non-migrating brothers, but migrating sisters appeared to be relatively advantaged. This study finding implies that selection is a contributor to the mortality advantage of female immigrants. 

How do cultural and behavioral explanations and materialist or structuralist explanations explain variations in health?

Cultural/behavioral explanations focus on differences in how the various social groups make lifestyle choices. They maintain that people in less well-off groups typically adopt lifestyles that are likely to be damaging to their health. The materialist/structural explanation focuses on the material conditions under which people live, maintaining that health inequalities stem form the less affluent social groups being the victims of unhealthy environments. They have less income for healthy food, engage in more dangerous occupations, have worse housing, more risk of unemployment and fewer resources with which to cushion themselves from illness. These two sets of explanation are often seen as opposing. Each explanation reflects the different philosophical positions of individualism and collectivism. The behavioral explanations see the cause of greater burdens of illness lying within the individual, whereas the structural stresses the impact of the collective on individuals.

Behavior reflects social context and the social consequences of people's different material circumstances. This explanation is evident in the model from the Commission on Social Determinants of Health, which puts little emphasis on behaviors other than as a reflection of patterns of social stratification and differential exposure to health risks. Most reviews of the evidence now focus on a range of structural factors including income, housing, employment, extent of social support and characteristics of the localities in which people live. Good health appears to rely on a contribution from material and social factors.  

Is behavior an individual choice or a social constraint?

We ha?e already seen that behaviors linked to health differ between social groups. The social grouping of beavhiros supports the arguments in favour of structural influences on health. Status and class position appear to have powerful, if subtle, effect on people's ability to control and change their behavior. Higher senses of personal efficacy typically associated with higher social position encourage beliefs about one's ability to break addictions and make positive changes to lifestyle. Lifestyle differences can account for some of the health differentials between various groups. Behavior factors are not major factors related to the increased risk of death, but rather the general living conditions and environment of the poor. 

Only people in more favourable circumstances are likely to either damage or improve their health by changing their behavior in relation to activities such as smoking and exercise. This finding certainly makes sense if you consider health in extreme circumstances such as someone who is very poor. Material, behavioural and psychosocial risk factors cluster together. People in lower socioeconomic groups are likely to suffer from all three and this fact has led researchers to call for a greater focus on a life course perspective, which maintains that health inequalities are the outcome of cumulative differential exposure to each of these types of risks. 

What do materialist or structuralist explanations entail?

This set of explanations draws on both social epidemiology and social sincere evidence and considers both the impact of economic and social structures on individuals and also on comparisons between countries with differing levels of inequality. An increasing body of evidence has linked material resources to health status. Reviews of the evidence on a broader range of material deprivation and health can be found globally. People with lower incomes report more illness and die earlier. Low income often means people do not have access to those factors that have a direct effect on health, including housing, safe employment, nutritious food, and educational opportunity. An increasing body of evidence also indicates that the relationship of health to socioeconomic status is linear rather than threshold. In other words, it is not only the absolute poor whose health is worse than that of more prosperous people, but people who are relatively less well-off than others also suffer worse health. 

There is little doubt from this literature that relative and absolute poverty are health hazards. The stark contrasts between industrialised and developing countries are powerful evidence of the impact of absolute poverty on health. Social science literature on class inequalities that underpin health inequalities has been summarised by Graham. She notes that there are a variety of ways in which class disadvantage is transmitted in high-income countries, including through unfavourable childhood environments. 

How does income inequality play a role in health?

Societies in which income is more equally divided also have longer life expectancy and better outcomes on a range of measures. There is growing literature on the relationship between inequality and health, and studies have related income inequality to infant mortality, adult mortality from several broad causes, life expectancy, height and morbidity. The countries now experiencing the largest increases income inequality are precisely those that have systematically underinvested in human resources for many years.

Explanations for the link between income distribution and population health outcomes have been made by exploring what it is about more egalitarian societies that may make them healthier. These societies appear to be more socially cohesive, more supportive and less conflictual than societies where income differences are larger. Inequities in health status are most likely to be reduce din societies that implement redistributive social policies that make an investment in social infrastructures, such as education, affordable housing, welfare support and employment option. The evidence also underlines the necessity for intersectional health action, as it is only through action in all government portfolio areas that inequities will be adressed. 

How does wealth form a public health equity problem?

Inequities in health are underpinned by gross inequities in wealth. Wealth is defined as things people own and use to produce goods and services and enjoy directly without consuming them in the process. Examples are land, natural resources and shares. While the epidemiology of wealth is not as well documented as that for income, all indications are that wealth is extremely unequally distributed between countries and within counter,s and that this underpins the distribution of health. If the conventional public health problem of poverty is recast as one of wealth, the options for achieving equity are broadened. Through this new lens, the increasing worldwide concentration of wealth is a threat to health equity. understanding the growing concentration of wealth requires a global perspective, as wealth is increasingly held by a global elite operating through transnational corporations, primarily outside the influence of national governments. Wealth distribution has been persistently unequal.

Does the use of health services explain variations in health outcomes?

The notion that social inequalities in health might be due to uneven access to medical care has largely been discounted as a major contributing factor, even though access to health care is an important social determinant of health. It was concluded that medical care has a limited role in improving life expectancy. Access to care might be more significant in determining how well people cope with disability and chronic conditions. Good health is however much more than absolute health services spending. it also concerns the nature of health services and the extent to which they emphasise disease prevention and health promotion rather than acute, expensive hospital care.

Can housing explain variations in health?

Adequate housing has been recognised for centuries as a fundamental requirement for health. Adequate housing includes reasonable quality materials, facilities and infrastructure, habitability, affordability, accessibility, legal security, viable location and cultural suitability. Poor housing was one of the key issues driving the public health revolution in nineteenth-century Europe. The sight of slums in rapidly growing cities is a familiar image of that period and is now reproduced in many fast-growing cities in low- and middle-income countries. The restructuring of cities through the processes of globalisation has led to benefits for some, but this has occurred through the rapid, often unplanned, urbanisation that has outstripped the ability of governments to build essential infrastructure and services and provide basic needs for living. This has contributed to a growing gap between rich and poor in terms of adequate urban housing, employment opportunities, transportation, levels of pollution and sanitary conditions. In low-income countries, slums are once again a major health risk. One billion people liv sin urban slums and face major health risks as a result of their inadequate housing, through dampness, overcrowding, indoor pollution form fires for heating and cooking or a range of other injury risks. 

Homelessness appears to have a particularly strong impact on health. Those who experience long-term homelessness often suffer from disabilities, substance abuse, and medical and psychiatric comorbidity. Homelessness has also been shown to be an independent risk factor for mortality in individuals who are already in poor health and socioeconomically disadvantaged. It is the result as well as the cause of illness. 

How do health inequities relate to employment?

Employment has a significant impact on health status, either because it is insecure and/or unsafe or not available. employment plays a significantly different role in people's lives as they juggle work and family responsibilities. Self-reported health status was found to be related to employment status for both men and women. The nature of employment variously affects health. Some work is physically dangerous. In many poor countries the regulations for this physically dangerous work are few or non-existent. Work is a significant and often undocumented cause of illness and death. 

The psychological demand of various jobs can also have a differential effect. Precarious work has been associated with poor mental health. Karaoke classified jobs on a two-dimensional grid according to whether they are high or low on demands and autonomy; or in other words, the ability to make decisions. Self-reported depression, exhaustion, job dissatisfaction, life dissatisfaction and days off work all peak at the high demand-low autonomy corner of the job distribution. Workplace gender inequality mean women are more likely to be employed in casual work, sometimes out of limited choices to enable their caring responsibilities and so experience different health and well-being consequences from exposure to more work-related stressors such as low decision-making latitude, low wages and unsociable hours. Unemployment appears to affect health through the poverty it brings, and the fact that it is a stressful life event in which people lose status and social context and a reason to exist; it may also lead to health-damaging behaviors such as smoking and drug use. People who experience unemployment, impoverishment and family disruptions have a significantly greater risk of mental health problems such as depression, alcohol use disorders and suicide, than their unaffected counterparts. 

How do nutrition and food choices relate to health inequities?

Poverty and low income have a significant effect on nutrition and food choices, affecting health in many and varied ways, including effects on growth, links with specific disease and through general resistance to infection. Hunger is a major health issue in all low-income countries. Malnutrition is a major cause of death for children in these countries.

A systematic review of studies concluded that a healthy diet is more expensive than an unhealthy one. Food considered 'bad' for health is cheaper to provide than healthier foods like fresh vegetables and fish. The increase in high-fat and high-sugar foods has created an obesogenic environment that is fuelling the growth in obesity worldwide. Changes to the ways food is marketed and sold have brought about three key changes to the food systems: Domestic markets has been opened to international food trade, which has led to the local expansion of transnational food corporation, which heavily market unhealthy food. Rising levels of overweight and obesity and the resultant chronic disease burden in the past decade around the world have heightened concerns about the need for policies to encourage healthy eating. 

How does educational opportunity from early childhood to adulthood relate to health?

Education is important for health for three reasons:

• Early childhood development has a powerful impact on later health and well-being. There is a significant body of evidence that poverty has an impact on the physical, social-emotional and language and cognitive development of children. 
• Educational qualifications play a considerable role in determining employment opportunities.
• Education increases knowledge, which may in turn improve health. 

How do social capital, support and cohesion relate to health inequities?

The evidence that social support, social capital and social cohesion is beneficial to the health of both individuals and communities and that social isolation leads to high incidence of disease is now considerable. These factors are structured according to the social and economic resources available to communities and individuals. Bourdieu's theory on social capital describes that networks act as a resource to provide people with access to other benefits such as jobs, educational opportunities or helpful legal or financial advice. In this way, social capital reinforces an individual's position of privilege. Cultural capital also reinforces social capital. 

In public health social capital has been used as shorthand for a measure of the level of trust, positive social networks and extent of cooperative relationships that exist in a society and the resources that flow from these. While social capital is theoretically and methodologically complex, the research does enable some conclusions to be drawn about the ways in which the social aspects of life affect health and health equity. Epidemiological research on the psychosocial risk factors for poor health has identified some factors that appear to be mediated through an individual's social circumstances: namely isolation, lack of social support, poor social networks, levels of civic engagement, low self-esteem, high self-blame and low perceived power. There is robust prospective evidence that having strong social support is protective of health. Studies of disease levels support the hypothesis that strong social networks provide a buffer against disease, especially coronary heart disease. Lower levels of social support are more frequent among poorer and less educated people.

Social cohesion also appears to be related to health. Social capital, as measured by levels of trust, networks and reciprocity, is associated with petter population health outcomes. Responses to building social capital and cohesion and reducing social isolation have concerned social exclusion and inclusion. 

What are some negative effects of social support and social capital?

Kunitz reviewed the literature on social support and health and noted that social relations are now always supportive. Much depends on the structure, functioning and effectiveness of networks. Networks are more likely to be unsupportive when poverty, unemployment, insecurity and inadequate infrastructure of formal organisations are prevalent.

Some evidence suggests that stressful and negative interactions can have a negative impact on health. Sudden increases in the number of an individual's social relationships may produce demands for reciprocal support that exceed their ability to meet them and so result in anxiety. Generally, people with less power, control and resources will have less ability to cope with stressful social relationships and so stand a greater chance of being damaged by them. It is also clear that when groups are highly bonded and trusting they may also be exclusionary and suspicious of other groups who are different.

How does social hierarchy relate to stress and illness?

Differences in health according to socio-economic status may have something to do with the experience of hierarchy per se. Recent findings from animal immunology suites suggest that stress can act to suppress immune systems and so make people more vulnerable to disease. Subtle biological effects of the social and cultural environment affect groups of people and that the relationships between social and physical factors are subtle and complex. There is a chain that runs from the behavior of cells and molecules, to the health of populations, and back again, a chain in which the past and present social environments of individuals, and their perceptions of those environments, constitutes a set of links. No one would pretend that the chain is fully understood, or is likely to be for a considerable time to come. But the research evidence currently available no longer permits anyone to deny its existence. 

What does the theory of learned helplessness entail?

There is an increasing amount of research that links low self-esteem, unhappiness, low perceived power and high levels of self-blame to people in the most disadvantaged socioeconomic circumstances. Lerner adapted the theory of learned helplessness to persons with little objective power. He hypothesised that people living in poor socioeconomic conditions tend to internalise their powerlessness, create a psychological barrier and begin to accept aspects of their world that are self-destructive to their own health and well-being, thinking that these are unalterable features of what they take to be reality.  This internalising process leads to isolation and further removal form active group participation.

Lerner also maintain that self-blame and internalised anger are associated with increased health risks and poorer health. The literature on health inequalities indicates that their existence has to be accounted for by more than the operation of absolute poverty and its effects. Lower ranking civil servants may experience learned helplessness. High psychological demands and low control at work are linked to cardiovascular and other diseases.

In what way does location influence health?

Location has a powerful impact on health. Debate continues on the relative contribution on the relative contribution of compositional factors and contextual factors. Developments in multilevel statistical techniques have enabled researchers to untangle these complex factors. 

The features of areas that contribute to poorer health are material hazards like environmental pollution, traffic volume and road accidents, and the nature of resources such as shops, recreational facilities, public transport and primary health care services. 

How do all these factors interact with one another in shaping health?

All the factors relating to socioeconomic status reviewed above do not operate independently but rather interact with one another and combine to result in inequitable health outcomes. This interaction is often mediated by long-term chronic stress and chronic disease, depression and anxiety. 

How does gender influence health?

Research on socioeconomic inequalities shows that people living in poorer circumstances are likely to die learner than their richer counterparts. Women in industrialised countries are more likely to be living in poverty than men. Despite their greater longevity, women are more likely to report and be treated for illness than are men. They also make more use of health services. In developing countries, on the other hand, men have a longer life expectancy than women. 

The reasons for this differences are complex and we are far from understanding them. The geopolitical environment, social roles, cultural norms and sanctions, health-related mediating factors and actual health outcomes affect women's health.

What different explanations have been put forward to explain the general gender differences?

Three main explanations have been but forward that aim to explain why women report more sickness than men but the mortality differentials are considerable: biological explanations, bender-based variations in the reporting of illness, and social explanations. 

• Biological arguments suggests that there are innate physiological differences in the constitutional resistance to disease. Women's excess morbidity may partly be explained by biological reasons associated with childbirth, menstruation and the menopause. 
• Some commentators have argued that men have lower rates of illness because they are less likely than women to perceive symptoms, articulate them and then seek professional help, possibly because of societal expectations for male behavior. They are expected to be in control of their emotions, not show pain, be self-sufficient and not appear weak. 
• Socially determined behavior and the fact that men typically work in high-risk industries could account for higher male mortality rates. Some commentators argue that women's higher morbidity reflects the consequences of a largely patriarchal society on women. Women are also increasingly carrying a double burden of workforce participation and being the main child and home carer. The evidence from longitudinal research linking social ties to longevity combined with evidence that women generally have more and stronger social ties than men may account for their mortality advantage.

Chapter 14: What are some global physical threats to the environment and public health?

Why should we look at physical threats to the environment and their impact on human health?

It is argued that the impact of human activity on the global environment is now so great it rivals that of major natural forces. Population growth, the energy intrusiveness of lifestyles in many countries and the misuse of non-renewable resources are greatly affecting our planet and its capacity to sustain human life. While the details of the changes and the precise nature of the strain on the planet are disputed, there is increasing consensus that business as usual will result in ecological disasters. There are many ways in which the strain on our ecosystem will affect human health.

The evidence in each area is far from certain. The exact nature of causality is difficult to determine and most outcomes are produced by a number of different influences. The challenges for public health are numerous. Perhaps the most crucial initially is understanding the magnitude and complexity of the threats.

What does climate and atmospheric change look like?

The scientific evidence on climate change is complex and difficult for a non-expert to understand, but there is now a strong acceptance that the earth's climate is changing more rapidly than might be expected and that this change is likely to have resulted from human activity. The underlying cause of global warming appears to be fossil fuel burning. Global warming results from the emission of several greenhouse gasses, most notably carbon dioxide (CO2). The IPCC has reported that more frequent and severe extreme weather events are likely in the future warmer world. 

What are the effects of climate change on human health?

These changes to the global climate have the potential to affect many aspects of human life in ways that are complex and involve interactions between systems. The effects will depend on several factors, including the rate of change in the environment, the sensitivity of the biosphere and the degrees to which humans can respond to the changes. The cumulative effect of these possible consequences on human health could significantly stretch public health resources, especially at a time when, around the world, public health infrastructures are being reduced rather than strengthened. The IPCC concluded that the effects of climate change are expected to be greatest in low- and middle-income countries in terms of loss of life and relative effects on investment and the economy, and saw multiple direct and indirect connections between climate and health. 

What are the direct effects of climate change on human health?

Climate change has several direct effects on human health:

• Climate may affect the respiratory tract, in three ways: seasonal effects, direct effect of specific weather conditions and the combined effects of weather conditions and other environmental or topographical factors.
• Thermal extremes can make life difficult for people, especially very old and very young people. 
• Greenhouse emissions have caused a thinning of the ozone layer, permitting more ultraviolet-B (UVB) tradition to enter the earth's atmosphere. This increases the incidence of eye damage, skin cancers, and depressions in the body's immune system.
• There is clear evidence that insurance companies, reeling under the ever-increasing costs of natural disasters, have accepted, without doubt, that human-induced global warming is the cause of the increase in the number of severe natural disasters. Natural disasters not only bring considerable physical damage to people and their homes and livelihood, but also result in long-lasting psychological damage. 

What are the indirect effects of climate change on human health?

Climate change has several indirect effects on human health as well:

• Both vector- and waterborne diseases may increase in the face of climate change. Increases in malaria have been connected with climate change. Vector-borne diseases, including viruses, may be more prevalent in the face of global warming. Global warming also leads to an increase in water-borne diarrhoeal diseases, such as cholera and dysentery. 
• The sea level is also rising due to global warming. The links between food security and climate change have to be seen in terms of other factors that are reducing food security, including desertification, deforestation, water logging and salinisation of land. 

What is the conclusion about the effect of climate change on human health?

There is an overwhelming research consensus that the world's climate is changing as a result of human activity. scientists note that climates do not change in a linear manner and the system of feedbacks within the earth's atmosphere mean that some seemingly small change could lead to catastrophic consequences. Positive feedback loops such as the release of methane from the tundra permafrost could dramatically increase the greenhouse effect and lead to very dramatic warming. 

Damage to population health may also be mediated via the social inequity resulting from the direct effects of climate change. Thus poorer people with fewer resources or access to what will be demising overall amounts of water, food, housing and health care will be further disadvantaged with more risk from armed conflicts and less access to options such as migration. Inequity will increase and population health will decline. 

In what way is the air and water quality declining?

Cities are polluted to varying degrees, according to local circumstances such as housing, forms of transportation, level of industrialisation, water supply, sanitation and removal of refuse. Environmentally related communicable diseases are the most pressing problem in developing countries. Every corner of the planet is affected by chemical and others forms of pollution that affect the soils, air, groundwater and animals, including people. 

Determining the health effects of air pollution is methodologically difficult because it is made up of a cocktail of pollutants that varies in concentration and does not have a standard effect. There appears to be a linear relationships between particle concentrations in the air and increased mortality rates. Indoor air pollution is a significant cause of ill-health in developing countries. Polycyclic aromatic hydrocarbons (PAHs) are a group of chemicals that are formed during the incomplete burning of coal, oil, gas, wood, garbage or other organic substances. They enter the environment mostly as releases to air from volcanoes, forest fires, residential wood burning, and exhaust from automobiles and trucks. Coastal ecosystems are deteriorating because of contamination from inadequately controlled industrial, agricultural and domestic waste disposal. Ensuring an adequate supply of clean drinking water is a central public health issue. 

How does water availability form a key issue in public health?

Water availability is becoming a key issue for the future. this has obvious implications for public health as a supply of clean, drinkable water is one of the fundamental requirements for health. Water stress has become a commonplace expression as well as a widespread phenomenon, of which lack of clean water is a substantial part. Three factors have eicnreased the stress on water:

• Population growth.
• The fact that one-third of the world's population lives in areas suffering water stress.
• Climate change has brought increased drought to many arid or semi-arid regions.

Unsustainable extraction from major aquifers and rivers ahas lead to a 'peak water scenario, such that expansion of irrigation farming has stopped while fresh water reserves diminish at an unparalleled rate. desalination is offered as a solution but has significant environmental threats. 

How does nuclear power form a key issue in public health?

In the past decade the possibility of the expansion of the nuclear power industry re-entered the policy agenda in many countries around the world as a response to the threat of global warming. One of the most potent threats to environmental health comes from the possibility of an accident at a nuclear power plant. Because of the different ways in which people can be exposed to radiation and the different parts of the body affected by each radionuclide, there is a wide range of possible health effects. There is controversy over the effects of living near a nuclear installation..

How does the loss of biodiversity form a key issue in public health?

There is increasing recognition of the importance of biodiversity to human health. In all natural environment, the destruction of habitat is causing loss of biodiversity at an alarming rate. Biodiversity refers to the variety of all types of life and the ecosystems of which they are a part. For several reasons, biodiversity is of crucial importance to human health:

• Biodiversity is essential to healthy functioning ecosystems, controlling pest plants, animals and disease, for pollinating crops and for providing food, clothing an many kinds of raw material.
• Ensuring the survival of species and preserving biodiversity for future generations is an ethical value of importance.
• Ecosystem disturbance to biodiversity can increase the spread of infectious disease among humans.
• Biodiversity will help preserve places of beauty, tranquillity and isolation. 
• Biodiversity is important to the human spirit.
• Biodiversity has economic value by preserving areas for ecotourism and providing food stocks.
• Preserving biodiversity means preserving plants that may have pharmaceutical properties. 
• Biodiversity is important to ensuring sufficient world food production, and monocultures threaten global food security.

The world's forests are a particularly important reservoir of biological wealth. Agricultural practices also encourage the depletion of native biodiversity. Bio-invasions can directly threaten human health and well-being. Overall, the importance of biodiversity reminds us that people are an integral part of nature and must learn to live in balance with its other species and within its ecosystems. If we fail to do this then the prospects for human health and even survival are bleak.

How do consumerism and neo-liberal globalisation relate to the environment?

It is necessary to see global warming as one of a suite of problems arising form the system of capitalist policy economy, a system that is now globalised. The world is experiencing a period of unprecedented social and economic change as well as the environmental crisis. Globalisation of economies and social and environmental issues have been key features of the last two decades. Consumerism, driven by an aggressive advertising industry worldwide, is causing people to consume more and more. The environmental health problems we face are largely a result of social and economic arrangements. This means that they are open to change and adaptation. 

What are the reasons we do not take action?

Concern about the environment is receiving an increasing amount of attention, yet action to protect and promote the health of the environment is slow. Public health's reluctance to recognise and incorporate the implications of environmental crisis has mirrored the broader myopia on this topic. The evidence on the impacts of climate change and other environmental threats to our health continue to amass. Yet despite serious effort of the United Nations, no binding global treaty has been reached an many still deny the evidence that climate change is real. 

Many expert have discussed the possible reasons underlying this reluctance:

• Vested interests in the corporate sector are likely to obstruct changes that reduce consumption and pollution. The dominant culture globally has lost sight of the fact that people are living organisms that are totally dependent on life and nature. There is no appreciation for this ecological dependence. 
• There is also a lack of value attached to the environment. Our global system of economics has no way of valuing the environment unless it is developed and exploited. 
• Also, industry lobbyists have great power. The desire to control markets leads to strong political lobbying from the fossil fuel and forestry industries to protect their commercial interests, which are likely to be most affected by any move to reduce greenhouse gas emissions or to curtail logging. 
• Lastly, most of the environmental threats are happening over long time scales. The public health challenge is to respond to long-term and gradual danger. It seems the threat will have to be perceived as extreme if concern or the environment is to take priority over the need for economic growth. 

What does environmental justice entail?

It is also universally true that poor people live in the worst deteriorating and health-damaging environments. The impacts of climate change will be felt most by those in low- and middle-income countries. They will disproportionately affect vulnerable groups within each country including the poor, children, older people and those with pre-existing medical conditions. Poor people also have less resources with which to challenge and prevent the sources of pollution of their local environment. 

How does feminism relate to environmental justice?

A further perspective on environmental justice has been offered by the feminist and scientist Shiva. She examines the position of women in relation to development. She maintains that women in ecological societies of forest 'dwellers and peasants' have played a key role in maintaining the sustainability and ecological diversity of these societies. The feminine principle is central to them. A return to environmental justice for women in developing countries will, according to Shiva, only be achieved when indigenous knowledge is valued and their societal values more widely adopted. Central among these is the importance that women in these societies accord nature as the very basis and matrix of economic life through its function in life support and livelihood. 

What does the precautionary principle entail?

Around the world, whenever there is conflict over an environmental threat, the onus is on the community to prove that an environmental hazard is dangerous rather than on the industry or developer to prove that is is safe. The precautionary principle holds that once there is reasonable evidence, but still some level of uncertainty, that a particular practice might be harmful, it is advisable to take preventive or ameliorative action. In practice, implementation of this principle depends on operational 'reasonableness'. The basis of the precautionary principle is 'better safe than sorry'. 

A counter-argument to the precautionary principle is that all activity involves some risk and that the fundamental question is in deciding what is a socially acceptable level of risk. The question for public health is whether community concerns about potential environmental effects can be taken as warnings and so accorded more credence than at present.

Chapter 15: How do urbanisation, population, communities and environments form global trends?

Why is it important to look at urbanisation and population growth when talking about public health?

This chapter considers two key trends that are putting strain on our ecological systems: urbanisation and population growth. The shift of populations form rural to urban areas has been one of the defining features of the world since the 1950s. This chapter considers the impact of urbanisation in rich and poor countries in terms of both physical and social aspects of the urban environment. A consideration of the impact of cars as the dominant form of urban transport continues the theme of factors contributing to climate change. This chapter also considers the debate about the extent to which population growth threatens health and argues that overconsumption poses more of a threat.

What does urbanisation entail? 

Cities create both problems and opportunities. Throughout recorded history people aha been drawn to cities to experience the excitement, the variety of people and the wide range of social and employment opportunities they can offer. yet cities also create problems and challenge our ingenuity to the limit. In terms of health, cities can promote and create health. Urban density and economies of scale can provide services and resources that would not be possible in more dispersed populations. Urbanisation represents one of the great mass migrations of history.

How does urbanisation affect public health?

While cities may provide their residents with access to services and employment, rapid urbanisation can also produce damaging combinations of health determinants. There is a triple threat from infectious disease, non-communicable disses and injuries.

Although the relative severity and exact nature of these problems differ form city to city and between developing and developed countries, there are global problems of urbanisation and industrialisation being faced by nearly all cities and countries in the world. In all large cities there are marginal groups or underclasses, who live in extreme poverty. 

What is the role of violence and crime in the relationship between urbanisation and health?

The WHO reports that problems of crime and violence have become increasingly serious in all cities, particularly in Africa and the Americas. People in low-income countries are over three times more likely to die as a result of interpersonal violence. The underlying causes of violence are deeply rooted in social and economic structures. 

Crime rates, especially violent crime, are contributing to a change in the spatial form of cities. richer people in all countries increasingly live, work, shop and take their leisure in fortified enclaves with sophisticated security systems. Some city centres are now only inhabited by the poor, who have few choices. These trends are less evident in Australia but community concern about violent crime is high, although is has been suggested that the perception of risk is greater than the actual risk. 

What is the role of living conditions in the relationship between urbanisation and health?

People in developed countries take the supplements of safe drinking water and the efficient and safe disposal of waste water and sewerage for granted. Living conditions in industrialised countries are far superior to those in the developing world, where the problems faced are similar to those tackled in the industrialised cities in the nineteenth century. The fact that the living standards achieved in industrialised countries rested, in part at least, on the fruits of the colonial era adds to the moral argument for ensuring improved living conditions in all countries. Industrialised countries consume far more resources than non-industrialised countries, and the challenge for public health is to contribute to a world in which resources are shared more equally and living standards for the world's poorest citizens are significantly improved.

In developed countries in both rural and urban areas there are pockets of housing where conditions are inadequate to support healthy living. Environmental conditions helping to spread communicable diseases include insufficient and unsafe water supplies, poor sanitation, inadequate disposal of solid wastes, inadequate drainage of surface water, inadequate housing and overcrowding. The most vulnerable populations are the informal communities living on the edge of cities in developing countries. 

What are the key aspects of poverty?

We distinguish several key aspects of poverty.

• Inadequate and often unstable income.
• Inadequate, unstable or risky asset base for individuals, households or communities.
• Poor quality and often insecure, hazardous and overcrowded housing.
• Inadequate provision of 'public' infrastructure, which increases the health burden and often the work burden.
• Inadequate provision of basic services such as day care, schools, vocational training, healthcare, emergency services, public transport, communications and law enforcement.
• Limited or no safety net to ensure that basic consumption can be maintained when income falls or to ensure access to housing, healthcare and other necessities when these no longer can be paid for.
• Inadequate protection of poorer groups' rights through the operation of the law, including laws, regulations and procedures regarding civil and political rights; occupational health and safety: pollution control; environmental health; protection from violence and other crimes; and protection from discrimination and exploitation.
• Poorer groups' voicelessness and powerlessness within political systems and bureaucratic structures, leading to little or no possibility of receiving entitlements to goods and services; of organising, making demands and getting a fair response; and of receiving support for developing their own initiatives. In addition, there is no means of ensuring accountability from aid agencies, non-government organisations (NGOs), public agencies and private utilities and of being able to participate in defining and implementing their urban poverty programs.
• Low-income groups may also be particularly seriously affected by high or rising prices for necessities.

How does crowding relate to health?

Crowding is a relative concept. Despite numerous psychological studies, it has not been possible to determine at what density abnormal behavior occurs. The relationship between residential density and health is a complex one. Perceptions of overcrowding appear to be a culturally determined concept, rather than determined by density. 

Epidemiological perspectives on density were most prominent in the nineteenth-century public health revolution, when overcrowding and high-density living were seen as enemies. The desire of reformers to eradicate poor housing and infectious disease led directly to ideas like garden cities and suburbs. The epidemiological evidence at the time of the Industrial Revolution led to the assumption that high-density living is a health hazard. A more likely explanation is that the lack of the most basic public health measures, such as sewerage, solid waste collection, water treatment and control of air pollution, was the real culprit. One of the issues associated with high density is the extent to which a city environment provides green space. The density of populations within cities makes them particularly vulnerable to man-made or natural disasters. 

How is high density related to social disorder?

Sociologists Simmel has claimed an association between high urban density and social disorder, but his claims are based on casual observation rather than systematic studies. Research has established a relation between stress and social strain and mental and physical health. Recent research is suggesting an association between urban neighbourhood contexts and adverse health behaviours.

How is high density related to environmental sustainability?

Well-managed high-density urban environments have the potential to minimise their ecological footprint. There is much debate about how the urban structures we live in affect our health. 

What are the health impacts of living in slums?

The health impacts of living in informal settlements have been well documented and are summarised as the following:

• lack of basic services, especially water and sanitation.
• substandard housing or illegal and inadequate building structures.
• overcrowding and high-density living.
• unhealthy living conditions and hazardous locations.
• insecure tenure or informal settlements.
• poverty and social exclusion.
• minimum settlement size.

Is social capital declining?

An important concern about life in urban areas is that the stocks of social capital appear to be declining. Social capital is the term used for the processes between people which establish networks, norms, social trust and facilitate coordination and cooperation for mutual benefit. Generally, communities high in these characteristics are seen to be more functional because people are able to get along better and achieve more for the collective good. 

The two theorists on social capital whose work has been used in public health are Bourdieu and Putnam.

• Bourdieu presents social capital as a resource that assist people in getting on in life. Its distribution is uneven, so that people who are economically more advantaged also have access to more social capital.
• Putnam stresses a more consensus view of society and doe snot link social capital to individual economic advancement as Bourdieu does. Putnam's work has been criticised for assuming an overly homogeneous view of societies in terms of levels of social capital. 

Increasing social capital cannot be expected to solve problems that are essentially those of poverty and deprivation. 

What role does transport in urban areas play in health?

Heavy traffic and pollution from carbon-fuelled vehicles are major problems for cities around the world. The health problems caused by transport include respiratory diseases from vehicle emissions, road accidents, stresses associated with extreme traffic and the social dislocation caused by car-dominated cities. The needs of individual car users have shaped the form of most cities in industrialised countries, especially in the USA, Canada and Australia.

• The environmental problems caused by cars include traffic noise, air pollution, visual intrusion and disruption of neighbourhoods by roads. 
• Cars also make a significant contribution to air pollution, leading to adverse health effects such as asthma and bronchitis.
• The traffic associated with cars has been associated with increased. Noise from traffic is a source of stress.
• Furthermore, road accidents are one of the great public health hazards of the car.
• Transport arrangements and options contribute significantly to health inequities as well. People with disabilities are greatly disadvantaged by transport systems and special effort have to be made to increase accessibility for them.
• Cities that encourage almost total dependence on cars for travel disadvantage those without access to them.
• Cities that encourage car use above other forms of transport also encourage sedentary lifestyles and overweight. Physical activity levels have declined as cars are increasingly used. 

Chapter 16: How can we create healthy and equitable economic policies?

In what domains does the current economic system need to change to ensure public health development?

The strategies to achieve health and equity would be much easier to achieve if the global economic system put as much emphasis on promoting the health and well-being of people and the environment as it does on economic growth. The present global economic system has been highlighted as a threat to public and environmental health. Economists have promoted alternative economic systems with the potential to be more benign to human health and the physical environment. Introducing these alternative economic systems may prove to be the most important development of human health and sustainability. In the past decades, neo-classical economics has assumed an unparalleled centrality in government and public service policy making. 

Five main areas have been identified in which the current system needs to change:

• The need to challenge the assumptions of economic growth.
• The need for new indicators of economic and social development.
• The need to restrict the domination of the international economic system by multinational corporations and for the development fo smaller scale locally controlled economic systems.
• The need for a fair taxation and income system within countries.
• The need to create fair terms of global trade and especially fair trading conditions for poor countries.

In what way should economic growth be challenged?

The need for economic growth has become paramount throughout the world. Neo-liberal economics was founded on growth as the means by which wealth is produced, and wreath production is assumed to be good for well-being. From a health perspective it seems to be beneficial, as wealthier countries are mostly also healthier. The links between wealth, well-being and health are being increasingly questioned on both environmental and social grounds. Economic growth and the resultant wealth production are only possible because of the exploitation of non-renewable resources, especially fossil fuels. Neo-liberal economics does not account for the impact of resource extraction and use on the environment. For many people the possibility of our society shifting away from the consumption-oriented system seems extraordinarily unlikely. The transition will be difficult.

Does GNP form a good indicator of well-being?

The environment is an essential foundation of economic activity and can be considered to be part of the capital from which income is derived. Yet the state of this environmental 'capital' does not feature in national accounts. There have been many criticisms of the gross national product (GNP) as a measure of the health of an economy. It measures the annual national revenue of firms and industries, production being valued at the price people pay for it. If GNP goes up, it is seen as economic growth.

However, the GNP measure does not allow for any calculation of the distribution of wealth and income. Economic growth has not alleviated poverty. In most developed countries, inequities have remained steady or even increased. Not only does the GNP measure view positively many things that detract from health, but it also undervalues activities that are not part of the formal system of production, such as housework, childcare done in the home, and emotional caring. The critics of conventional economics often argue for an alternative form of national accounting. There is a discussion about the limitations of the GNP and suggested alternative measures and approaches that protect health and the environment. For example, the happy planet index (HPI) is a league table ranking the nations of the world according to their performance on three criteria that are designed to summarise national performance in delivering long and happy human lives without overstitching natural resources; life expectancy, life satisfaction and ecological footprint. 

What does the polluter-pays principle entail?

A further key concern of those promoting an alternative or new economics is to develop systems that prevent manufacturers and others from externalising their environmental costs. These costs impose on people without compensating them. Policies that encourage the polluter to pay the costs associated with the pollution it creates would discourage the activities that create it. The externalisation of environmental costs is most likely to happen in a system in a system of centralised technologies and industries. The move to systematically internalising costs is most likely to happen with small-scale, decentralised, conserving technologies and industries, owned and controlled by the people who use them and have to live with their impact. This argument is supported by comparing nuclear power with renewable energy.

Freudenberg argued that it is vital to develop new strategies to reduce negative externalities. He lists possible strategies as litigation by governments to recover the costs of corporate-induced harm, taxes on unhealthy and high-carbon products, and eliminating subsidies and tax breaks fro unhealthy and high-carbon products. As the perceivable aspects of climate change have become more evident it is being suggested that personal carbon allowances could become a carbon control mechanisms. 

How can we retreat from consumerism?

The neo-liberal economics system that has dominated public policy since the 1980s is primarily geared to a market that supplies goods and services and encourages demand for these through advertising. Things not mediated through the market are neither literally nor figuratively counted in this system. Social wellbeing is inevitably influenced by more than the flow of goods and services through the marketplace, and that people's physical and social environments, experiences and the quality and richness of the cultural experience and personal relationships all have a crucial impact on well-being. 

Since the 1970s there have been challenges to the increasingly consumption-focused society. Economic growth is uniformly seen as a good thing by mainstream society; and consumption fuels economic growth. Consequently, curbing patterns of consumption will require a dramatic change in societal views. Increasingly public health academics and activists are seeing the practices of corporations in advertising as unhealthy and unsustainable, and are arguing for legislative control of the marketing of unhealthy products and for generally greater control fo the practices of transnational corporations in the interests of health and sustainability. Much of the consumerist push is linked to competing for status with friends and neighbours. This competition inevitably make people dissatisfied. Turning this consumerism around will require a considerable change in the way goods are marketed and a change in the ways in which people gain satisfaction from life. 

How can we make healthier economic choices?

Keynesian economics has been the main challenge to neo-classical economics. According to Keynes, the great depression was neither a temporary thing nor just a self-correcting manifestation of the business cycle, but might itself become the equilibrium. Classical economic theory could lead to a downward spiral in which wages were reduced and worker income and spending lowered, resulting in less sales and more unemployment. Keynes pointed to the importance of aggregate demand, which was the effect of any economic development or public action on the larger flow of purchasing power. There is also a need to supplemented aggregate demand by breaking the unemployment equilibrium to increase output and employment. 

Neo-liberal economics argues that economic development leads to a trickle-down effect but the evidence suggests it is how the profits of economic growth are sued by societies that is important to well-being. The rapid growth in economic inequalities in the past two decades indicate that the latter is the case and suggest tat increased revenue raising is vital in order to fund public health and other health-producing infrastructure. Add to this the reality of the ecological sustainability the key aim of economic policy. 

How can we create a more ecological economy?

A new economic system that would result in all countries scoring higher on the Happy Planet Index needs to be developed. Brown has listed some of the assures that would make practical contributions towards an ecological economy:

• Moving to efficient energy sources;
• Building energy-efficient buildings;
• Designing cities for people, not cars, with emphasis on public and active transport;
• developing high-speed intercity rail links;
• Changing the throwaway economy to one based on recycling;
• Restoring the economy's natural support systems;
• Supporting local sustainable food supplies that are low on carbon;
• Eradicating poverty, stabilising populations and rescuing failing states.

Why should we control transnational corporations?

The growth and power of multinational companies are seen by an increasing number of commentators as threatening the sustainability of the environment and human health and well-being. These companies are seen to be lacking in social and environmental awareness. A healthy economy would rest on companies that operate very differently. There are some companies that do try to operate in a more responsible manner and their corporate social responsibility is to be encouraged. An increasing number of international non-government organisations are lobbying transnational corporations (TNCs) about the detrimental effects of their activities and advocating protests and actions against them. The power and wealth of TNCs is immense. 

What are the items on Korten's agenda for restoring health to our economic system?

Korten's agenda is wide-ranging and radical but appears to offer the sort of changes necessary to restore health to our economic system:

• Restore political democracy by reforming the system of political campaign finance. The aim of this is to remove TNCs from the political process and so restore the trust in democratic systems.
• End the legal fiction of corporate personhood. Korten claims that the legal fiction that the corporation is a natural person under the law is the means by which corporations have acquired rights to act in the way that they do. He says this measure would place strict limits on corporate privileges and facilitate the conduct of business in the public interest.
• Establish an international agreement regulating international corporations and finance. Currently international agreements under the World Trade Organization such as GATS and GATT maintain an international trading regime that permits TNCs to operate with very few controls on their activities and to appeal to the WTO if there are restrictions that impede their profit-taking. This item would use international agreements to control the TNCs and hold them accountable to the public good.
• Eliminate corporate welfare. TNCs receive considerable direct public subsidies and tax breaks. They also externalise a range of costs like pollution, worker health and safety, and dangerous and defective products. 
• Restore money's role as a medium of exchange. The aim is to prevent unproductive financial speculation, which only serves to make short-term profits for the speculators.
• Advance economic democracy. Public policy should be proactive in promoting human-scale, stakeholder-owned enterprises to displace the subsidised TNCs.  

Korten argues that while his proposals are radical and would require a massive shift in power, they are possible. It is certainly easier to imagine the new public health agenda being achieved in a world governed by Korten's agenda than in the current world of domination by a handful of unaccountable corporations that put profit above health at every turn.

Why should we make a shift from global to local?

As dissatisfaction with the power and control exercised by transnational corporations grows, there are an increasing number of alternative visions of economic systems published. Once again the solution to the ever-increasing global concentration of economic power and wealth is seen to be an increase in community ownership and control of productive enterprises. Korten has argued for locally owned, community-oriented enterprises in which success is measured by the impact on people. These sentiments are compatible with those of the new public health's emphasis on community empowerment and control. 

What local action can be exerted to resist globalisation?

If the global trend towards increased corporate concentration and rampant consumerism is to be halted and reversed then an important part of the change is likely to stem from popular action and protest. Globally there are numerous examples of local action to resist economic globalisation. These local sites of resistance to the negative effects of globalisation may well prove to be one of the most effective means of providing an alternative vision of what society can be like if they are based on the needs of people in their local communities rather than on the needs for large TNCs to make a profit. 

In what way is there a need for a fair taxation and income system?

Taxation cuts to the heart of creating a society based on the principles of solidarity and fairness. It is also vital to creating a society has the ability to control and regulate the private sector and its profit-seeking motives, which so often win ahead of questions of public health and environment. Reynolds describes that taxation can be seen as a useful form of public health regulation. A healthy taxation system would be progressive is when it taxes people on high incomes more than those on low incomes, or those with more capital more than those with less.  

What does trade justice entail?

A healthy economic system will depend on the evolution of a global system of fair trade. Small moves are being made towards greater trade justice through the fair trade movement but there eave been criticisms of this movement as being marginal to the more structural changes required. 

How can an economy encourage healthy work?

Work patterns and conditions are changing rapidly in Australia and overseas. An important aspect of changing the social logic of our current materialistic society is to reduce working time so that opportunities for work are spread more evenly, and that less work would reduce outputs, which would be good for the environment. An increasing concern among people in developed countries is the trend towards longer working hours and both adults in a family working, which leaves less time for other aspects of life. While rich country workers are facing worsening working conditions, the situation is much worse in the world's poor countries.

Crucial goals for healthy public policy in the twenty-first century are to protect working conditions and redistribute and create more work opportunities. The role and distribution of work and family will be crucial to reducing health inequities and promoting population health. 

Chapter 17: How can we create sustainable infrastructures for health, well-being and equity?

What does ecological sustainability entail?

Ecological sustainability is at the heart of the aspirations of a public health for the twenty-first century. The environmental stresses and burdens we are collectively placing on the earth offer compelling evidence that the physical support systems for human life are already threatened and will continue to be so in the coming decades. Climate change has moved to the top of public concerns and is on political agendas around the world. Crafting an ecological public health is an absolute priority for public health practitioners. To ensure sustainability, changes will have to be made to the ways our cities and communities operate. Changes are required to make cities less polluted, more energy efficient, less carbon-burning dependent, more human-scale with social space and tress, and less wasteful with more emphasis on recycling and reducing refuse and more self-sufficiency in food production. If these changes were to happen they would promote health and make cities healthier places to live. 

What does the global framework entail on this matter?

The United Nations has led a series of initiatives to improve environmental sustainability. Although these summits and declarations have been criticised for being too consensual and accommodating the needs of transnational corporations they do provide a vision and a framework for establishing what should happen. For future sustainable development, it is important to strengthen the United Nations so that it is able to provide a counterpoint to the lobbying power of the industry. A key goal for achieving a world in which environmental sustainability is a reality should be strong international organisations that can negotiate international consensus and mediate conflicts. 

The international frameworks are essential to ensuring global cooperation and agreement on environmental  protection and restoration. The actual work of creating sustainable environments will happen in countries, cities and local environments. 

What does sustainability entail?

The word sustainability has been popular and so widely used that its meaning can become unclear. Retailers use it to persuade consumers to buy their green products; politicians find it useful to persuade voters, and academics form many different disciplines and theoretical perspectives use the term 'sustainability' in varying ways. In general, sustainability is "a relationship between dynamic human economic systems and larger dynamic, but normally slower changing, ecological systems, in which human life can continue indefinitely, human individuals can flourish and human cultures can develop, but in which effects of human activities remain within bounds, so as not to destroy the diversity, complexity and function of the ecological life support systems". 

How can we create ecologically sustainable and healthy communities?

Ecological sustainability is at the heart of the aspirations of a public health for the twenty-first century. The environmental stresses and burdens we are collectively placing on the earth offer compelling evidence that the physical support systems for human life are already threatened and will continue to be so in the coming decades. Communities that place priority on sustainability and that are designed to provide a healthy and satisfying life seem much more feasible in rich countries where some communities are well-advanced towards these goals. 

What are the characteristics of healthy and sustainable cities and communities?

Urban planners have been particularly influential in designing cities since the nineteenth-century, some working on idealistic views of towns and cities in which people could live most healthily and happily. One of the major challenges for the twenty-first century will be to create liveable cities for all. Slums first became a political issue in the nineteenth century and were a focus for public health action and have been since then. However, as we move further into the twenty-first century, slums are becoming the norm in most cities in developing countries. 

The characteristics of resilient cities that are able to respond to peak oil and climate change are: renewable energy, carbon-neutral, distributed, photosynthetic, eco-efficient, place-based and sustainable transport. 

What are the tensions in creating healthy cities and communities?

Three tensions can be distinguished that burden the creation of healthy cities and communities:

• The complexity of sustainability. The environmental issues previously discussed interrelate in ways that defy simple or straightforward causal links. Sustainable cities and communities will only evolve with multidisciplinary, lateral thinking and cooperation across sectors.
• The constant tension between the desire for economic growth and development and the need to protect and maintain the viability of the physical ecosystem and the social welfare and health needs of people. In all cities and communities the battle between these forces is being waged. Sustainability requires a shift to development that is not dominated by short-term economic decision making and which stresses hope rather than fear.
• Effective management and leadership capacity within communities. The scale of the task facing city government is often frightening and will require considerable skills and capacity building as cities in many poor countries grow rapidly and throw up massive problems. Rural areas face equally challenging situations, often shaped by de-population as people leave for the bright lights and opportunities offered by cities. Leaders will have to juggle the different values and politics in determining acceptable strategies and principles for tackling problems in both urban and rural contexts.

In communities around the world discussions on the influence of values in public health are taking place. They all have a local flavour and reflect particular local political traditions and culture. However, there are also some fundamental questions about the dominance of economics, the importance of local participation and the priority placed on environmental protection that lead to disagreement and sometimes conflict in cities, especially those that are developing rapidly. Cities and other communities need to learn to deal with areas of major disagreement at an operational level. There must be a scope for negotiation, mediation and consensus building, and this calls for a new kind of political and professional leadership that takes a facilitating rather than a controlling role.

Why is shifting energy systems important in creating more sustainable infrastructures?

Sustainability and prevention of global warming depends on shifting energy systems towards non-polluting and renewable options. Energy policies at federal, state and local levels need to move towards sustainability. Policies relating to energy are not conventionally related to public health, but the consequences for human health of continuing with current high energy consumption suggest that public health should at least advocate and lobby for the adoption of healthy energy options.

Renewable energy sources are wind power, solar energy, geothermal energy and hydropower. The potential for a less-polluting energy system is considerable. Manufacturing, transportation and buildings all contribute to the burden of energy use, and suggestions for reducing energy use, especially fossil fuels, have been well documented. The challenge is a political and economic one that involves ensuring that research and development investment are direct towards those options that do not affect environmental and human health. The signs for a change to renewable and less-polluting energy use are a little more encouraging now. We should reduce fossil fuel use, ensuring that cities are less car dependent, encouraging cycling and walking and creating efficient public transport.

How can we ensure the equitable provision of healthy infrastructure?

Resilient cities will also be equitable. Health is dependent of access to affordable infrastructure: housing, transport, clean environment, clean water, sanitation, education, nutritious food and supportive social relations. Ensuring supportive environments for all groups, especially for children, is an important way of reducing inequities. The most efficient way to reduce the disease burden associated with poor health behaviors and psychosocial characteristics is to improve the socioeconomic conditions that generate them. 

In poor countries, providing clean water and sanitation and reducing pollution will require significant change in the way that most cities are managed. The growth of sum areas is proceeding rapidly and there needs to be dramatic action to arrest this development and ensure that all people have access to the basic requirements for healthy living in their environment. The improvement of slum areas is only likely to come about when the underlying problem of land price speculation and the need for fair and just city planning are accepted. Equity should be a central goal of urban development policies, because of their impact on the health of cities and suburbs. They should aim at achieving cities that are as unsegregated in terms socioeconomic characteristics as possible. Essential to achieving a voice for poor people in city affairs is a reform of governance so that is more inclusive and democratic. 

Why is housing important in creating sustainable infrastructures?

Secure, appropriate housing is an essential element of a healthy lifestyles, and policies that ensure cheap, safe, reasonable-quality housing are important in reducing health inequities. In poor countries, the challenge of providing housing is massive because many people do not have secure housing, and the quality of the housing is extremely poor. The lack of government controls means poor people are subjected to evictions, exploitation, and suffer poor housing and insecurity of tenure. State control is needed to ensure that poor people are protected, and that city land allocations are made fairly and are not unduly generous to those with power and influence. 

Homeless people are particularly vulnerable to illness and premature death, and so policies to prevent people sliding into homelessness are particularly important. Evidence from rich countries suggests that intervention in the first three weeks is particularly effective in ensuring that temporary homelessness does not become entrenched. Emergency shelters, support to encourage people back to secure housing and the provision of appropriate health care for homeless people are all policies that should reduce the impact of homelessness on health. The best solution to homelessness is the provision of affordable and appropriate shelter. Housing for all is a crucial part of ensuring health for all and should be considered in any national public health strategies. 

Why is the preservation of agricultural land and natural spaces important?

Around the world, communities are juggling the tensions between development and preservation of natural environments. Three key component have been defined as crucial to sustainable development of the environment:

• Biodiversity refers to the variety of species, populations, habitats and ecosystems.
• Ecological integrity refers to the general health and resilience of natural life-support systems, including their ability to assimilate wastes and withstand stresses such as climate change and ozone depletion.
• Natural capital refers to the stock of productive soils, fresh water, forests, clean air, ocean and other renewable resources that underpin the survival, health and prosperity of human communities. 

Sustainable agriculture that provides sufficient food and the availability of areas of natural beauty are obviously crucial to healthy and sustainable environments. There is a continual struggle between traditional exploitative practices, usually for immediate profit, and the protection of the environment. Apart from the environmental arguments for the preservation of nature in terms of protection of biodiversity, there is a strong public health rationale for maintaining these places for recreation. Keeping a balance between tourism and environmental preservation is however often tricky. 

How can the sustainability of rural areas be ensured?

An important factor driving the rapid global trend of urbanisation is the lack of opportunities in rural areas for people to advance the well-being of themselves and their families. Policy responses to this need to consider how rural living can be made more attractive, including in terms of environmentally sound practice. Many rural areas require a regenerated economy to improve the prospects of health and well-being. The policy challenge is to find how to do this in a way that also ensures that the social and physical environments are sustainable and promote health. Public services and private companies have not be persuaded to support rural infrastructures so that people can, and want to, continue living in the communities. 

Chapter 18: What medical and health service interventions can help achieving healthy and equitable societies?

Why is there a need for health promotion strategies?

Several approaches can be used by health promotion and public health to achieve healthy and more equitable societies. The past 30 years have seen a continuous tension between approaches to health promotion and public health that emphasise the agency of individuals and try to change their behavior directly, and those stemming from the Ottawa Charter for Health Promotion, which pay more attention to the need to create supportive environments and make healthy choices the easy choices. Health promotion strategies have varied widely in different countries, at different times and among different professional groups, but all approaches to health promotion reflect the values and beliefs of the promoters. Although medical and health services and behavioral interventions are limited in their contribution to achieving health communities and societies, they are still important for a few reasons:

• They have been the dominant form of formal health promotion activity.
• Their limitations need to be acknowledged so that, wherever possible, they can be overcome. This is particularly important as behavioral health promotion is still widely, and often inappropriately, practiced in isolation, even though evidence suggests its power derives from being one aspect of a broader strategy that seeks to make healthy choices the say choices.
• Medical and behavioral approaches to health promotion do have place in the portfolio of health promotion approaches, particularly if they can be modified to be part of a broader socio-environmental approach and to empower people to act on their own agency in favour of their health. 

What different approaches to health promotion do we distinguish?

Labonté provides a framework to consider three different approaches to health promotion. 

• The medical approach tries to return sick people to a disease-free state;
• The behavioral approach promotes healthy lifestyles;
• The socio-environmental approach is concerned with the totality of health experiences and the factors that help to maintain health, including those connected directly with people.

The dynamic links between these different factors mean that health promotion is only likely to be successful when based on an understanding of these complexities. 

Why are health service interventions hard to adopt for general practitioners?

Health care stems are dominated by medicine. Health care approaches to health promotion concentrate on the prevention of disease mainly through primary medical services. However, numerous barriers have been identified to general practitioners (GPs) being more involved in prevention. There are moves in most settings to encourage GPs to place more emphasis on health promotion. Comprehensive primary health care, in which medicine is one of a range of approaches, offers the best care setting in which to practice health promotion. GPs have a longer term relationship with their patients than other medical practitioners and this provides a basis for health promotion and disease prevention. The effectivenss of lifestyle advice provided by GPs was conducting in a meta-analysis. While many interventions shows promise in bringing about small changes in behavior, none appeared to produce substantial change. The main barriers to GP's involvement in health promotion aside from the limited basis for its effectiveness are the following:

• Structural factors, namely a lack of initial and continuing education and training in health promotion, non-standardised guidelines and low financial incentives.
• Factors relating to office organisation, such as a lack of time in consultations, lack of support staff and sheer forgetfulness.
• Factors relating to patient reluctance and competing priorities for the time available in consultation.
• Low confidence or frustration of the doctor because they'd o not receive rapid feedback.

GPs may be able to influence patients to change their lifestyle, undergo screening for the early detection of a range of conditions, present for health-protecting vaccinations, and manage chronic conditions to improve quality of life. General practice has put more emphasis on these aspects of its work. The two areas where medical interventions have made most impact on public health are screening and immunisation.

In what way has the implementation of screening made impact on public health?

Screening involves the investigation of individuals to find out whether they are at risk of a particular disease through tests that either seek the existence of a risk factor for the disease or early physiological indications. Risk factors may be physical or behavioral attributes. For disease and risk factor screening to be effective the following conditions need to be met:

• The disease or risk factor should have a long preclinical phase so that a screening test will not miss its signs. 
• Earlier treatment should improve disease outcomes. 
• The test must also be sensitive so that it will detect everyone with the disease. People who are told they are clear of a disease or risk factor when they in fact have it are referred to as false negatives.
• Furthermore, the test should be specific and detect only those with the disease. People who are told they have a disease when they do not are referred to as false positives. 
• Then, the test should be acceptable, easy to perform and safe.
• Finally, it should be cost-effective.

Screening for diseases has become increasingly common in recent decades. 

What has been the effect of specific screening on public health?

Heart disease screening involves blood cholesterol levels and hypertension testing. Screening for high cholesterol levels is controversial, as the strength of the relationship between high cholesterol and heart disease may not be that strong. Screening for behavioral risk factors for cardiovascular disease in terms of dietary assessment, stress assessment and lifestyle appraisal has been more prevalent in recent years. Such screening aims to bring about individual behavior change, but its success has been very limited. 

Mechanisms for cancer screening have become more sophisticated. For example, the mammography test has led to a substantial increase in the number of diagnosed cases of breast cancer and some decline in mortality. Systematic screening for cancer of the cervix through the establishment of state-based Pap smear registers, recall systems and various promotion strategies to encourage women to participate in screening is widespread. Screening for prostate cancer is also contentious. An extensive review of the literature shows that there is insufficient evidence to assess the value of screening asymptomatic men. The effectiveness of screening has remained uncertain. Recent research on the benefits and harms of screening fo cancer has suggested that the two are finely balanced and that evidence should be available to individuals so they can make an informed decision. There have been calls for assessment of the psycho-social impact of screening on people. Crucial to the success of screening is increasing uptake, as evidence shows that lower socioeconomic groups are likely to have lower rates of uptake. Factors such as translation of key materials, culturally appropriate materials, group health education and lay workers may help uptake. 

What is the effectiveness of screening for behavioural risk factors and follow-up on population health?

The available evidence indicates that screening followed by educational intervention has little impact on risk factors. There seems to be little evidence for the value of advice in relation to alcohol and smoking. The limited interventions possible in a primary medical care session are unlikely to affect individual risk factors to any great degree. The potential for GPs to contribute to population health outcomes is even less supported by the evidence. Although the medical model of health promotion regards people with a particular disease or risk factors as differing in some categorical way from the rest of the population, they actually represent one end of a continuum. We cannot reduce the proportion of the population at high risk without reducing the whole society's exposure to the risk. Strategies aimed at individuals are not expected to achieve much change. 

Wilkinson observes that strategies focused on individuals leave the underlying societal causes of disease untouched. Inevitably, this means there will continue to be a demand for new services to cope with people identified as being at high risk. The implications of this are that it would not be sensible to pursue a strategy that solely puts emphasis on individual change. 

In what way is immunisation an important public health tool?

Ever since jenner's 1796 discovery of the effects of vaccination with calf-lymph against smallpox infection, immunisation has been an important public health tool. As a public health strategy, immunisation depends on creating a sufficient pool of immunised people to prevent outbreaks from spreading more widely among the population. This is the concept of herd immunity. If immunisation levels in the population are not sufficiently high, it will not be possible control acute, vaccine-preventable diseases. Worldwide, it has been estimated that immunisation programs prevent approximately 2.5 million deaths each years. Many countries provide free vaccines.

On a global level, the eradication of smallpox is the best example of the success of immunisation, and one of the major achievements of public health. Smallpox has been eradicated from the planet after an immunisation campaign. The process was difficult and possible only because the characteristics of smallpox make it responsive to vaccination. There has also been established a Global Polio Eradication Initiative for the eradication of poliomyelinatis. There has been a large decline in the measles notification rate. Actions undertaken to increase coverage include greater use of opportunistic vaccination and legislation requiring parents to present evidence of vaccination status to schools and childcare centres, so that unvaccinated children can be kept away from school during outbreaks.

What are the individual risks and social benefits of immunisation?

Vaccination offers health, social and economic benefits and can contribute to health equity. All immunisation involves some risk: the nature, severity and rate of incidence varying with the process in question. It is possible to calculate a reasonably accurate equation of the risks and benefits in a given vaccination program.

Research suggests that lack of access accounts for about half of people who are unvaccinated, and the other half from lack of acceptance. Of these, only 2 per cent of parents are vaccine refusers. Anti-vaccination groups exist and an increasingly individualist trend in social values may aid their cause. however, there is also the risk of public health protagonists being seen as unconcerned with the suffering of individuals, or as censoring alternative views. Those who conduct public immunisation programs must ensure that all who consent to have their children immunised are aware of the risks. However, there is also an ethical responsibility to advise the community of the benefits of an adequate level of immunity, and the potential risks of letting that level drop. This implies a role in fostering public education and informed debate, as well as a clinical responsibility.

What is the contribution of the health sector in promoting population health and reducing inequity?

A review of studies of the impact of medical services on health showed that even the small proportion of deaths that are wholly amenable to medical treatment seems less influenced by differences in medical provision than by socioeconomic factors. However, other evidence does suggest that medicine may have had a greater role in extending life expectancy in that later twentieth century, when most of the gain in life expectancy in industrialised countries occurred in older age groups. Medical interventions have made an important contribution of about 20 per cent of increased life expectancy this century. Medical intervention in regard to cardiovascular disease has made a significant contribution to reducing death rates among older people. As access to medical technology is determined in part by socioeconomic status, then inequities may increase as medical technology comes to have some impact ton life expectancy. This means of course that equal access to medical care is an important part of an equitable social policy. 

The main determinants of health and health inequities are chiefly outside the health care sector. However, there is still room for action within the health sector. Policy statements endorsing action against inequities can be powerful supports for services, which can use them to claim legitimacy for their social justice work. There may be some frustration among health bureaucrats and service providers that they can do little to reduce inequities, given that the crucial factors are outside of the health sector. This is reinforced by the tendency for social factors to be regarded as epidemiologically fixed and unchangeable. Health policy makers need to be reminded that the factors are not inflexible and can be changed. Primary health care should be a key feature of a health system designed to promote equity in population health outcomes. 

What does comprehensive primary health care entail?

The WHO endorses comprehensive primary health care as the basis of good health systems. Primary health care services are particularly effective at working with disempowered, poor communities by using community development strategies in addition to clinical work. They try to change the conditions that create inequities by working with local environmental action groups or with public housing tenants, providing nutrition education and advice that is sensitive to the constraints imposed by poverty. While GPs have an important role in disease prevention, they are just one part of the primary health care landscape. 

A comprehensive approach to primary health care includes medical care but also pays significant attention to disease prevention and health promotion. It is also based on multidisciplinary teamwork and uses a range of strategies, from clinical work with individuals, to the provision of health promotion and support groups, and community development work with the broader community. 

Chapter 19: What are the limits of behaviourism, and what are alternatives to this approach?

In what way does behaviorism play a role in public health?

Ultimately, improving the health of populations may require changes in behaviour. However, one of the crucial premises of the new public health is that behaviours are socially structured and so it follows that changing these behaviours requires changing the structures within which behaviours occur. Despite the acceptance of this within the new public health, behaviourism is still often promoted as a solution to 'lifestyle' diseases while paying little attention to structures. This reflects the dominance of neo-liberal ideology, which stresses individualism and which has seen lifestyle change programs receive considerable acceptance despite the lack of evidence for their effectiveness. There is a strong inherent logic to behaviour change strategies. If the problem of smoking is seen as one of people choosing to smoke and obesity as one of people over-eating, then telling them not to do so seems to make sense. Powerful tobacco and food corporations also influence the agenda of the World Health Organization and national governments to persuade them to focus on individual factors rather than systematic issues with the sale and marketing of unhealthy foods.

Consequently it is important for new public health advocates to understand the evidence on the limitations of behaviour change in order to argue effectively for more structural change and to design means of changing behaviour that focus on creating supportive environments and which do not focus on individual blame.  

What theories underpin behavior change approaches?

A number of overlapping theories, most of which stem from social psychology, form the basis of behavioural approaches to health promotion. They attempt to explain the influence of different variables on an individual's health behaviour and are concerned with attitudes, beliefs, motivations, values and instincts. Early models of behaviour change were based on the assumption of a relatively stable link between knowledge, attitude and behaviour-if people were given relevant information from a credible source they would change their attitudes towards their diet and, in turn, their behaviour. Experience showed that this was not correct, and so psychologists developed more sophisticated models of behaviour determinants and change. Some of these are described in this chapter. Most of these theories have not been rigorously tested when compared with theories in the physical sciences and suggests that they might be more accurately termed 'models'. The other major limitation is that these models pay scant attention to the social, economic and cultural environments in which people's behaviours occur.  

Behaviorist teories that underpin behaviour change approaches are social learning theory, the health belief model, the stages of change model and the health action model. 

What does the social learning theory entail?

Bandura was the main proponent of the social learning theory, which argues that most learning occurs by modelling rather than trial and error and that the more positive the consequences of a behaviour change, the more likely people are to engage in it. The theory differentiates between people's beliefs in the outcome and their ability to perform the behavior. Their behavior is likely to be strongly influenced by their confidence in their ability to change, and personal behavior can be learned and unlearned through influences in the family, community, work and the media. 

Lefebvre and Flora describe the model as being put into practice in the following way:

• Promotion and motivation to interest people in changing a particular behavior.
• Skills training to provide people with specific behavior-changing skills.
• The development of support networks so new behavior can be maintained.
• Maintenance of behavior through reinforcement.

What does the concept of locus of control entail?

The concept of locus of control has also been associated with social learning theory, and in the context of health can be understood in terms of two things:

• Internal locus of control is where people believe they are responsible for their own health.
• External locus of control is where people see their health as being influenced primarily by outside forces such as other people and chase, fate or luck.

Self-efficacy, which refers to individuals' beliefs about their capacity to perform specific behaviors in particular situations, is crucial to bheaivor change, according to Bandura. 

What does the health belief model entail?

The health belief model was developed specifically to explain health-related behavior. It is based on the belief that when people consider changing behavior they do a cost-benefit analysis, which includes the likelihood of the illness or injury happening to them, the severity of it, the likely effect of the behavior change, and whether it will have some personal benefit. The revised model added to this an assessment fo sufficient motivation to make health issues salient or relevant, and the belief that change following a health recommendation will be beneficial to the individual. With the latter, the costs involved is taken into account. 

Thus, individuals may be more likely to stop smoking if they are aware of the health consequences and think they are vulnerable to, for example, lung cancer. Connected with their risk assessment is their belief in the cessation of smoking benefit their health and whether it will have nay other benefits. The health belief model has been most useful when applied to relatively straightforward actions such as encouraging screening and immunisation. It has been less effective in long-term, complex and socially determined behavior changes. 

What does the theory of reasoned action entail?

Ajzen and Fishbein's theory of reasoned action maintains that behavior is governed by intention and that personal attitudinal and social normative factors determine behavioral intentions. Each personal attitude is made up of a belief and people may have ea number of conflicting attitudes towards a certain behavior. The social normative influence on behavior refers to the individual's perception of what important others will think of their behaving in certain ways. These two major influences combine to form an intention to behave in a particular way and this intention is predictive of the behavior. So, the link between attitude and behavior is mediated by beliefs and perceptions of normative expectations. These mediating factors explain why people do not always behave in accordance with their expressed attitudes. So this theory emphasis individual's motivation to conform with significant others. 

What does the stages of change model entail?

People do not usually change their behaviour suddenly, completely and permanently. The stages of change model is important as it shows that the changes people make are only part of an ongoing process. This model suggests that people cycle and relapse through five distinct stages:

1. The first stage is that of precontemplation, with no intention to change behavior.
2. Then follows the stage of contemplation and making a disunion about whether or not to change.
3. Hereafter, preparation for changing behavior in the near future occurs.
4. Then follows the stage of action, whereby the individual successfully changes behaviour over a relatively short time.
5. Lastly is the stage of maintenance, in which the individual successfully changes behavior over a lengthy time.

Few people go through these stages sequentially, typically going backwards and forwards. Identifying the precontemplative stage is important for health workers, as they can focus their attention on other issues such as minimising the risk associated with a behavior. This model has been important in encouraging health promoters not to assume that an intervention will be equally applicable to all people. It is important to tailor programs to the range of needs in a population, recognising that these may change.

What does the health action model entail?

The Health Action Model (HAM) posits that the belief, motivation and normative systems all influence the intention to act. Certain facilitating factors also need to be present before the action intention is translated into health action. Environmental circumstances must also b favourable if the healthy choice is to be taken. It is this aspect of the HAM that really distinguishes it form others that draw exclusively on social psychology models.

Intrinsic to the HAM is the two-way interaction between motivation and belief systems. Beliefs about a particular health action will be assessed in the context of an individual's values. Intention to act will depend on the relative strength of these motivators. An environmental inhibitor could be the cost of condoms or the embarrassment of buying them. The HAM model also considers emotional states, whether instinctive, acquired or derived. Self-esteem is a central factor in the HAM. Beliefs about competence and control are central to self-esteem. High self-esteem is considered to be healthy, as it represents a significant feature of mental health, it encourages to take care of your health, is makes you less likely to succumb to pressures to conform, and it is related to better coping skills.

How are these behavioral theories applied in heart health campaigns?

Community-wide campaigns to encourage people to adopt healthier lifestyles came into vogue int he 1970s and remained popular through the 1980s. The programs started from the recognition that cardiovascular disease was the main cause of death in industrialised countries in the second half of the twentieth century. The community health heart programs focused on improving the health status of entire communities by controlling modifiable risk factors. These programs put much emphasis on evaluation. These evaluations were complex and failed to produce particularly conclusive findings. However, it became clear that the assumption of generalisability cannot be made. 

The striking feature of the community-based large-scale programs is that they use mass media to mobilise and coordinate community resources to promote and support behavior change. Population-based health promotion programs have the potential to bring about population-wide changes that are far more significant than clinics. The evaluations of the community heart health programs paid little attention to issues of equity. The first generation of these programs was not easily translated to other settings. By the 1990s, the importance of interventions with multiple strategies supported by community organisation and participation was recognised as crucial if any success was to be likely. The lessons from the first generation of heart health campaigns have certainly been taken on board by health promotors. In the early twenty-first century health programs incorporate many of these lessons.

In what way does social marketing apply behaviourist theories?

Social marketing applies marketing techniques to social psychology theories in order to bring about population-wide behavior change. The most commonly used technique is mass media campaigns. A social marketingg campaign follows a specified sequence of steps:

1. Defining the target audience.
2. Developing a concept for intervention.
3. Developing a message based on the concept.
4. Testing the message.
5. Running the message.
6. Evaluating the message.
7. Evaluating the outcome.

Recent developments in social marketing have involved the use of marketing data and stage-of-behavior change models to define specific, relatively homogenous audiences, and behavioral theories to fit health messages to specific needs. Social marketing is now also able to use social media extensively, with organisation establishing websites and Facebook pages to spread health promotion messages. 

What do mass media campaigns aimed at lifestyle behavior entail?

The past four decades has witnessed a burgeoning of mass media campaigns aimed at persuading people to change their lifestyle and behavior to be more health promoting. Mass communication has become a major strategy used by health promoters. Yet the value of mass media campaigns in contributing to behavior change is much disputed and only moderate impact tis found in most cases. The advantages of mass media campaigns are that they can reach large numbers of people. Mass media campaigns have contributed to people quitting smoking and fewer people taking up the habit, so the prevalence is in decline. Mass media campaigns are most effective when used as part of comprehensive approaches to improving health behaviors, such as the approach to smoking. 

How can health education be implemented through entertainment?

Public health messages have also been embedded within entertainment. This is predicated on the assumption that entertainment will attract more people than education messages, that people will understand and be receptive to educational messages within entertainment and that the heightened audience size, attention and receptivity can influence cognitive, affective and behavioral outcomes that underlie many public health problems. Typically, these techniques will use behavioral modelling. 

How are social media channels used for health promotion purposes?

Social media are now used widely to deliver health promotion messages. The online world has become an important part of people's lives. Although social media have an increasingly wide reach, some groups are digitally excluded for reasons of cost, lack of skills and opportunities to acquire the skills. Social marketing can be a useful tool if employed within an overall health promotion strategy that is community driven and, therefore, culturally sensitive. The community control of media campaigns can ensure that messages are culturally appropriate and likely to be effective. 

What are some criticisms of social marketing?

Behaviour-based health promotion starts form the premise that modification of the lifestyles linked to chronic disease or injury will be beneficial to people's health. Most of the large-scale community projects primarily theories behavioral problems with some minor recognition of the role of societal factors. Their theory is drawn form social psychology, which is reflected in the primarily individualist focus of the programs. Mass media is used most effectively in public health when they are accompanied by concomitant structural change that provides the opportunity structure for the target audience to ac ton the recommended message. Campaigns that help to build community coalitions or influence policy may have more positive long-term effects on health. One of the most powerful arguments against programs focusing on individual behavior change has been the lack of evidence on the effectiveness of programs. 

Why may the assumption that, with sufficient information, people will change their behavior, be shortcoming? 

The individualist focus of most behavioural health promotion creates an undercurrent of victim-blaming, which maintains that individuals are responsible for their own health status, whatever their social and eoconomic circumstances. The various models of individual behavior change conceptualise health behavior as based on reason and rational choice. The assumption is that once people are provided with sufficient information, provided with support for their decision, then they will change their behavior. The models assume that people will actively choose their behaviors according to what they believe is good for their health. This assumes that health is a central consideration in people's decision-making, which is likely only true for people in favourable social and economic circumstances.

The assumption that people will change their behavior if given sufficient information has also been questioned on the grounds the this implies that knowledge acquisition is a one-way process. New understandings of the gap that may exist between professional and lay understandings of health and associated issues give some clues as to why this one-way process is ineffective. Behavioral approaches to health promotion are based on a linear understanding of knowledge and has not tangled with more complex understanding and interpretations of people's health.

What other approaches to health promotion for individuals do we distinguish?

Perhaps the most promising approaches to changing behaviours in individuals are those that focus on improving mental health but also have flow-on impacts on people's physical health and related behaviors. Advances in the understanding of neurobiology suggest that people's physical health and well-being depend on their mental state. Siegel has noted that humans are really rational and that human thinking processes are relational, embodied and embed din a social context. He says that society shapes synoptic connection. The behavioral health promotion movement assumed that people were relational and that when they received information about healthy behaviours, this would automatically lead to change behaviours. In fact, well-being appears to depend on healthy relationships and a sense of awareness and mindfulness about one's own life as well.

How do healthy relationship influence health?

Increasing evidence suggests that stressful social relationships are bad for our health. Stressful social relations were found to be associated with increased mortality risk. Given this emerging evidence, it seems important that public health pays attention to ways of reducing interpersonal conflicts by determining the means by which people can avoid these conflict in the first place and cope with them better when they do occur. Conflicts can occur in any social setting. There are a wide range of psychological techniques and training that enable people to communicate better and so avoid conflict or cope better when it does occur. 

Improving relationships has been one of the aims of the positive psychology movement. This has been informed by the work of Seligman, whose model is based on the principles of PERMA, outlining the five building blocks of well-being and happiness: Positive emotions, engagement, relationships, meaning and achievement. 

How do self-awareness and mindfulness influence health?

There has been a burgeoning interest in methods of increasing sled-awareness and mindfulness. These have primarily been promoted as a means of improving mental health, but have also been shown to have benefits for physical health. These techniques do not assume a rational link between information and behaviour, but rely on changing how people view themselves and on changing their stress levels.

What are social determinants of healthy relationships and mindfulness?

The support for healthy relationships and mindfulness-based training is much more available to richer people who can afford to pay for it. This means that the people who already have access to health-promoting social determinants also have the best opportunity to further improve their health. Investing in systematic approaches to developing the skills for healthy relationships and self-awareness through mindfulness and other techniques would reap rewards through reduced conflict and so less stress and illness in the longer term. Given the increasing evidence on the links between mental states and physical health, this would also benefit overall population health.

Chapter 20: How does participation play a role in health promotion strategies?

Why is democratic participation important when talking about public health?

This chapter examines the importance of democratic participation and the mechanisms that can encourage it in public health. These mechanisms include community development, which has been a crucial way in which people have been involved in public health. The role of participation in society in general should also be considered, as well as in health services and public health specifically. 

What does participation practice entail?

One of the most important threads in the past 200 years has been the demand for increased participation in decision-making processes. The suffrage and national liberation movements  and European revolutions in the nineteenth century, the industrial democracy, women's rights, civil rights and indigenous people's rights movements in the twentieth century, and the Occupy movement in the twenty-first century all demanded a wider involvement of people in decision making. The demand for increased participation has often been a protest against concentration of power. Since white settlement, protest has been an important feature of Australian political life. 

What values underlie public participation?

The International Association for Public Participation (IAP2) developed the following values for public participation based on a two-year international consultation:

• Public participation is based on the belief that those who are affected by a decision have a right to be involved in the decision-making process.
• Public participation includes the promise that the public's contribution will influence the decision.
• Public participation promotes sustainable decisions by recognising and communicating the needs and interests of all participants, including decision makers.
• Public participation seeks out and facilitates the involvement of those potentially affected by or interested in a decision.
• Public participation seeks input from participants in designing how they participate.
• Public participation provides participants with the information they need to participate in a meaningful way.
• Public participation communicates to participants how their input affected the decision. 

What principles were formulated that underlie public participation? 

These values are useful when supplemented by the following eight key principles that organisations need to bear in mind in order to make participation genuine and effective:

• Participation means partnerships, which means accepting uncertainty.
• Bringing about effective participation means organisational change.
• Community involvement plans need to be aligned with organisational capacity and the capacity of staff has to be developed.
• Community participation must be supported by the management of an organisation.
• While the top-down support of management is crucial, the participation must be built from the bottom up.
• Effective participation is built by using well-developed people skills.
• The partnerships developed with communities require dialogue and trust, so developing these is crucial.
• Using a range of strategies and not relying on one is most effective.

What experiments have been conducted on participation in public health?

The focus on participation in public policy was a hallmark of the Whitlam government in the 1970s in Australia. It was also seen in other initiatives, such as the Australian Assistance Plan. The Community Health Program that was created did not achieve its aim of community participation to any significant extent, however it did establish the importance of participation as an element of effective community and public health practice, and set thinking and practice patterns for the 1980s and 1990s. 

There have been many experiments with participation in health in the 25 years since the launch of the Community Health Program.

• One of the types of participation in health is participation in health searches, which can take the form of client feedback and evaluation, membership on boards of management of health services, volunteer work, and self-help care.
• Another type is participating in bureaucratic processes, including responding to the agendas of services and government.
• People can also participate in needs assessment and planning on public and environmental health issues.
• Furthermore, people can participate in pressure groups campaigning on public health issues, including environmental concerns.

In what way does social media influence participation?

Communication patterns have changed dramatically in the past decades. New forms of communication via innovations such as social media sites have revolutionised communication and opened up new possibilities for citizen participation. These changes have significant implications for the ways in which participatory processes are conducted. However, while new forms of communication mean there is more potential for citizen participation, the dilemmas concerning power and effective, non-token means of participation is also relevant. Although new forms of participation are increasing, not everyone has equal access to them, meaning that these mechanisms may also exclude groups whose power and representation is already low. 

What questions should we ask ourselves when thinking about health participation?

Key issues have merged through the practice of participation in health. These questions should be considered by governments as well as citizens:

• To what extent does participation actually occur? Is it pseudo or real?
• What are the types of participation?
• What is the relationship between participation and power?
• Who participates?
• What is the role of professionals in participation?

How can we distinguish between pseudo and real participation?

To what extent do participatory exercises really involve participation? The idea of a hierarchy of participation has often been used in health to distinguish genuine from pseudo participation. Commentators often judge participations to be unhelpful unless it involves the exercise of full citizen control. But giving information and consultation can be useful if it does not masquerade as full participation. It is crucial that the form of participation and its potential for power sharing are recognised by those seeking partners in a collaborative exercise. So if a bureaucracy intends to consult on a policy, it should be clear what the parameters are. In this way people do not develop unrealistic expectations and are aware of the rules of the exercise. A major factor that can make participation pseudo is when there is a high turnover of organisational form or people within an organisation. We have seen trust is vital to good participation and this is difficult to establish in the absence of long-term relationships.

There have been examples of attempts by health departments to encourage participation in health planning and issue identification. Victoria established District Health Councils in the 1980s and for a short period these councils were successful in providing a community voice in health decision making. Some of these councils also produced some useful resources. 

What types of participation do we distinguish?

Oakley discusses the role of participation in health development in developing countries. He distinguishes between participation as a means and participation as an end:

• Participation can be the means of achieving a set objective or goal. There is less concern with the act of participation and more with the results. The emphasis is on rapid mobilisation and direct involvement in the task at hand. The participation is abandoned once the task has been completed.
• Participation may also be an end in itself. This process is dynamic, unquantifiable and essentially unpredictable. Participation is not limited to the life of a particular project but is a permanent and intrinsic feature of an organisation or community. The critical elements in the process are to increase people's awareness and develop organisational capacities. Full engaged participation does not happen immediately. Structural participation is integral and forms the basis for all activity. Community members play an active and direct role in the initiative and have the power to ensure their opinions are heeded. The concept of participation as an end is somewhat problematic in that it can be taken to imply that participation itself is sufficient. However, a situation in which people participate but do not achieve the desired changes is unlikely to be empowering.

It is important that health promoters recognise what form of participation they are seeking. Structural participation may be a fine ideal but it is not always achievable. There are four main forms of participation used within public health and health promotion in Australia. Participation can be categorised on a continuum, from consultation and participation as a means to substantive participation and to structural participation. 

How does participation relate to power?

Demands for more participation inevitably mean some people feel aggrieved that they do not have access to sufficient power to influence events that have a significant impact on their lives. Participation is a complex, dynamic, relational and political process of negotiation in which groups with differing interests and agendas vie with one another for power. Two beliefs appear evident in the literature on participation and health:

• The first is that involving people in health initiatives improves the quality, relevance and effectiveness of the initiatives.
• The second is that participation helps overcome community and individual powerlessness and so leads to people being healthier. This issue of power relates to the importance of self-esteem and feelings of control over health outcomes. People gain power by coming together with others, building up networks and relationships and taking collective action.

Empowerment aims to reduce the number of people who are powerless. Powerlessness refers to the inability to get what one wants or needs and the inability to influence others effectively in ways furthering our own interests. Concern with empowerment is reflected in literature form a number of relevant disciplines, including radical social and community work, health promotion and education, and community psychology. Empowerment, in the most general sense, refers to the ability of people to gain understanding and control over personal, social, economic and political forces in order to take action to improve their life situations. Empowerment can operate at an individual, organisational or community level. 

What are the elements of personal empowerment?

Labonté detailed the elements of personal empowerment:

• improved status, self-esteem and cultural identity;
• the ability to reflect critically and solve problems;
• the ability to make choices;
• increased access to resources;
• increased bargaining power;
• the legitimation of people's demands by officials;
• and self-discipline and the ability to work with others.

This recognises that participation empowers when it results in material change in people's situations and when they have increased access to resources. It also recognises the importance of collective action to increasing people's power. Public health initiatives that wish to engage communities will have to be grounded in an understanding of the ways in which power operates if they are to avoid the traps. 

What do structuralist theories of power entail?

Structuralists or Marxists see political and economic power as intimately related. Power represents a struggle between the forces of capital and workers, and empowerment of the poor is very limited under capitalism. While they make some limited gains in terms of bargaining power or ability to influence the fine-tuning of pans and policies, empowerment is ultimately limited and circumscribed by the wider requirements of the capitalist system to maximise profits. If empowerment moves towards challenging the structural aspects of the political and economic system so that, for instance, a more equitable distribution or resources is achieved, then resistance is likely to increase.

Marx and Weber both viewed power in zero-sum terms, saying that there was a limited amount to go around and that struggle for control is inevitable. Weber saw that power involves the ability of individuals or groups to realise their will. Power can be asserted through the exercise of force or influence. He recognised how some groups have greater status in particular cultures and, therefore, have greater power. The exercise of power also extends to control of the power of ideas.

What does the elite theory entail?

The elite theory of power recognises that all groups and individuals in society do not have equal power and influence over decisions. Elites are able to reproduce their privilege through institutions such as private schools, clubs and societies with exclusive memberships and professional associations. They are seen to hold more wealth, resources and influential connections than other members of society. Society is seen as hierarchical with a small number at the top controlling the rest of society through the key institutions of society, such as the media, education, policy-making, the senior parts of the state bureaucracy, political parties and the professionals. 

How do pluralist theories view power?

Pluralist theories see power being distributed through a variety of institutions and groups in society. In contrast to the more elitist view of the Marxist political theorists, they do not see a concentration of power in the hands of a few. Various groups and individuals within society are continuously competing for power, according to this theory. Such groups would include trade unions, churches, pressure groups, resident action groups, professions, media and consumer lobby groups. This view of power basically accepts the status quo and encourages people to be able to engage with the system in a more effective way. From a pluralist perspective, empowerment is concerned with helping people develop skills to engage with the system and win power more effectively.

What do postmodern and poststructuralist views of power entail?

More recent views of power have seen it as inextricably linked with knowledge and woven throughout the fabric of society. Foucault sees power operating as a network of relationships throughout society. Rather than seeing a binary system with the powerful on the one hand and the repressed on the other, Foucault sees power operating both horizontally and vertically in society and being deeply enmeshed in social institutions. Such is this enmeshment that power is often invisible. He defined three main expressions of power:

• Exploitative power is the power to control people's economic lives.
• Dominance is the direct power to control people's choice.
• Hegemony refers to the power to control people's perceptions so that their actions are controlled by dominance.

Foucault believes power can be challenged via the complex 'discourses' that support its maintenance. These discourses are based on claims of superior expertise and knowledge. Because power is diffuse, there are many opportunities for resisting its expression. 

Building on all these theories, how can we understand power?

The common theme to all theories of power is that resistance or change to the patterns of power relations must be preceded by analysis, with people understanding their own relationship to power and its expression in their particular context. Without this, the potential for structural participation is almost certainly going to be limited. While many public health practitioners may be frustrated by an abstract discussion on the nature of power in society, these theories are crucial in determine and understanding people's actions.

• A structuralist approach to public health inevitably means challenging the powerful in society, and seeing public health struggles as conflict with powerful forces that act to maximise their economic power.
• An elite perspective may imply joining forces with elite groups in society to persuade them that public health is a cause they should support.
• A pluralist view will lead to approaches based on compromise, and learning to compete within the established rules. 

Poststructuralism implies a less clear path ago action in which cultural means and discourses are deconstructed in an attempt to understand the multiplicity of perspectives held by different gorse within society.

What does medical power entail?

Power has particular relevance in the new public health in terms of medical power. Health debates are dominated by a biomedical view of health. Within health systems medical systems medical doctors have a powerful position, documented over many years that depends of their control over diagnosis and treatment of illness, subsequent authority over other health professions and overrepresentation's on health boards and policy broads.

In what way is there an issue of representation when we talk about health participation?

Questions to do with representativeness have been raised by commentators who are sympathetic to the ideal of democratic participation. Those who participate may not include women, ethnic and cultural minority gourds or inarticulate people. Not all members of a community may participate in an activity. The inclusion of some will often ensure a view that is different to that of the usually white, often male, professionals involved. Health services participation community members can offer a counterpoint to the medical perspective that often dominates. There is a tendency in the literature to overstate the problems of representation in community participation and development. The reality is that most communities are made up of an amalgam of competing interests and factions that often have competing purposes. Successful community development recognises this and overcome the problem by focusing on small groups that come together around a common interest.

Possibly the cubical issue is identifying who the participants are, rather than asking if they are representative of the total community. Community representatives need to consider how they can represent everyone in their community, and if it is their role to do so. This problem is at the heart of democratic society. 

When talking about health, should we talk about citizens or consumers?

There is a shift in public policy rhetoric towards using the term 'customer' instead of 'citizen'. Many recent policy statements in relation to health services have use the term 'consumer' and health consumer councils exist. There is plenty of anecdotal evidence that this term is more acceptable to governments than 'citizen'.  Participation in health and community development implies an active citizenship with links to notions of democratic participation. 'Citizens' does not restrict participation in health services to those who are users of the service, but also extends to citizens in general who have a legitimate interest in shaping health services and the decisions that they make about resource allocation and types of services and in lobbying to improve environmental and other conditions that may affect their health. 

What is the role of professionals in participation?

Many social movements involve the citizens having grievances with the state and setting about, unaided, to establish movements to bring about changes to the status quo. In the new public health movement, the primary push for community participation appears to have come from professionals employed by the state.

• Health professionals working within a risk factor and disease prevention model tend to see community participation in instrumental terms. For them, it is a means of encouraging behavior change or generating community support for a program they have designed. 
• This instrumental approach is contrasted with a more developmental one that starts with the concerns of people and encourages professionals to work alongside people in a way that gives them a significant degree of control, but does not manipulate them to achieve their ends to the exclusion of the community priorities.

What does the health promotion winners' and losers' triangle illustrate?

The health promotion winners' and losers' triangles illustrate the shift in patterns of working that might be required.

• In the losers' triangle, health promoters fall into either the persecutor or rescuer role. The persecutors tend to blame tivicitms and work form a positions that people could be healthy if only they would change their habits. Rescuers tend to see people as victims and believe their role is to be their rescuer. The rescuing health promoter will believe they have the solutions and know best. The chances are that this approach will leave communities and their members feeling like victims. Certainly, nothing will be done to challenge their position of relative powerlessness or increase their self-esteem or belief in their ability to initiate and bring about change.
• By contrast the health promotion winners' triangle puts the community in a controlling position. The health promoters are assertive and caring, offering to use their skills to work with people. The issues selected result from a dialogue between the professionals and community members.

In the losers' triangle, problems will tend to be patched rather than solved. The winners' triangle should provide the community with solutions, power, respect, information and control. While it offers a potentially more rewarding way of working, it is, however, at odds with much professional training, which tends to see professionals as rescuers and does little to examine victim-blaming philosophies that are often prevalent.

Chapter 21: Why is community development important for public health?

What does community development entail?

The use of community development strategies to promote health or development was popularised by the South American educator Paulo Freire through his popular education approaches, and the work of Saul Alinsky. The popularity of community development has waxed and waned in recent decades. In Australia and in the UK they are most commonly adopted by Labour parties and are often associated with strategies designed to reduce inequities. In the late 1990s, community development began to be advocated for under a new policy discourse of social capital, community capacity building or reducing social exclusion. Central to these concepts is the notion of community. 

What is a community?

The word 'community' is both symbolically and descriptively used. In government statements it often conveys a comfortable and secure image. This use draws on images of close, caring communities, often invoking the past where problems seemed less pressing and life easier. This notion has had much appeal over the past century and community is often use din a romantic way. Critiques of the normative use of the word 'community' have noted that its can obscure conflicting interests in social and political life and assume consensus that may not exist. 

The word 'community' can also be used to descriptively refer to the people who live in a defined geographic locality and who share a sense of identity or have common concerns. This use of the term is common in public health. Community health refers to services designed to meet the health needs of a defined, usually geographic community. Communities are rarely homogeneous. They have spatial dimensions, non-spatial dimensions (such as identities or interests), social interactions that are dynamic, and shared needs and concerns. 

How does community development boost social capital?

One of the important aims of community development is to strengthen communities so that they are better able to support the health and well-being of residents, and enable them to promote and protect health in their community. Two decades of research on social capital suggests that it is important to health, especially mental health. Community development or organising can be one strategy through which social capital can be strengthened. Social capital refers to a network between peel of trust that leads to cooperation and beneficial outcomes. Social capital is important to community development as the relationships built through its processes develop networks and trust. Trust is also seen as central to the successful operation of these networks. Bourdieu stresses the power and status dimensions of social capital. His view fo social capital is particularly relevant to the new public health because he considers social capital as one of the ways in which economic capital is reproduced and consolidated. Reciprocity and trust characterise societies in which people are able to cooperate effectively to achieve common goals. 

What three types of social capital do we distinguish?

Increasingly, commentators distinguish between three types of social capital: bonding, bridging and linking.

• Bonding social capital is that between relatively closely knit groups, who are likely to share many characteristics in common. It may be exclusionary and may not act to produce society-wide benefits of cooperation and trust.
• Bridging ties looser than bonding ties and operate across differences in culture of ethnicity, but not in terms of institutional power and influence.
• Linking social capital refers to relationships between people and groups that operate across explicit, formal or institutionalised power or authority gradients in society. 

It is the latter two forms of social capital that community development is likely to contribute to in order to promote health and to reduce health inequity.

Why is social capital important in the new public health movement?

It has been noted that as well as consisting of trust and respect, social cattail also reflects the creation of alliances across difference. Where social capital exists or can be created, mutual aid societies spring into existence. Social capital makes possible participatory development and good governance. This makes the concept particularly important to the new public health and to community development strategies. Evidence of links between social capital and health has major implications for health promotion and public health policy and practice. clearly community development is one of the goals.

How can community development be used to increase health?

Community development can be used to build social capital as a pathway to creating health and well-being. Community development in a number of areas, including public health, has brown in both popularity and credibility. There are several advantages of community development:

• The first advantage relates to efficiency: Participation can increase efficiency as people are more likely to be convinced of the benefits of initiatives they have helped develop. If local people are involved in projects, this reduces the amount of time needed by paid professional staff, and so becomes a cost-effective option.  
• Then, effectivenesss: Community development can make initiative more effective by allowing people to have a voice in determining objectives supporting project administration and making their local knowledge, skills and resources available.
• Self-reliance refers to the positive effect on people of participating in community development in health projects. The participation can help to break dependency and so promote self-awareness and confidence, helping people examine their problems and be positive about solutions. Community development also involves individual development and increases people's sense of control over issues that affect their lives, helping them to learn how to plan and implement, and equipping them for participation at regional and national levels. This helps create social capital, a hallmark of a healthy community.
• Another advantage is coverage: Health promotion has tended to be more successful in reaching those who are already relatively healthy. Community development offers a way of working with people who are the least healthy.
• Finally, another advantage relates to sustainability: Experience from numerous development projects indicates that those who are externally motivated frequently fail to be sustained once the initial level of support is reduced or withdrawn. The chances of sustainability are increased in situations where local people are the main dynamic. Community development can contribute to a momentum of change in an area.

How does community development shape health services?

Comprehensive approaches to public health and primary health care emphasise community development, empowerment and capacity building as the basis of effective strategies. More selective approaches tend to be of limited effectiveness because, while one particular disease may be cured, another comes along to take its place because the underlying structural problems have not been cured. A more developmental approach enable a health service to adapt to people's needs and be responsive to different sections of the community they serve. Community development strategies enable people to become familiar and comfortable with a health service and so are more likely to use the services when needed.

Existing community groups can be the basis of community development activities by health services. These groups can be an efficient and effective way for health service personnel to use the knowledge and skills of their local community in planning, service development, fundraising and advocacy work. Underlying this approach is the increasing recognition that a healthy society is one with high levels of civic engagement providing cohesiveness and trust.

What are the different possible ways of working in community development?

Community development practice draws heavily on the work of Freire, who advocated education for liberation using these stages:

• First, reflection on people's lived reality;
• Then, analysis and collective identification of the root cause of that reality;
• Hereafter, examination of their implication;
• And lastly, development of a plan of action to bring about change.

In this process professionals and community members should ideally meet as equal and develop a dialogue on trust. The aim of the process is critical consciousness. The challenge for the new public health activist is to find a means by which passion and rage against injustice can be channelled into a useful practice that results in action that makes a difference. Community development workers have to understand how the processes of power affect their work.

What are some dilemmas in the process of community development?

We distinguish several dilemmas in the process of community development.

• One crucial issue concerning community development is whether its aim is to bring about real change in people's lives and the structures that constrain them or if it acts to make the conditions poor people are living in a little more bearable. Reflective community development should address issues of class, gender, race, age, disability and sexuality. This is often difficult and the extent to which it can be done will vary between communities and depend on the broader political climate.
• Another dilemma is the extent to which action at the local level can be effective in bringing about significant, as opposed to superficial, change. There is a risk that local action can ultimately be disempowering. Shifts in power are unlikely to result from local action but rather from a shift in policy nationally and increasingly internationally. 
• The ultimate aim of community development in health is to empower people and their communities in such a way that individual and collective health status is improved. The values base of community development and the relinquishing of at least some control to the community mean that public health organisations  have to ensure they develop management and evaluation frameworks that support community development activity. 
• The experiences of health promoters suggest that community development is often not understood or valued by health funding authorities. Activity initiated by community members and without formal links to any health promotion agency is part of public health activity. There is sometimes no alternative to government support, but such sponsorship weakens rather than strengthens the community basis of initiatives.
• A further dilemma of community development, from the perspective of funding bodies, is the developmental and long-term nature of the work. Much community development work has to be seen as an investment that should take place over a long time scale to yield maximum rewards.
• Community development is also difficult to evaluate using traditional research methods. Action research and qualitative methods are more fruitful, but not always acceptable to funders. 

Chapter 22: What do advocacy and activism for public health involve?

What does advocacy entail?

Public health advocacy and activism involves individuals and organisations who operate locally, regionally, nationally and globally and work to combat unhealthy policies, products and practices. Issues may relate directly to health, concern a particular risk factor or express overarching concerns about structural threats to health. Advocacy for public health has played a crucial role in translating research into policy and practice, yet its study and teaching is neglected. There is incompatibility between achieving scientific credibility and the overtly political nature of advocacy and activism. Yet if researcher wants their research to influence public policy, advocacy is one of the main ways by which this can happen. The strategies used by advocates and activists are many and varied. 

What is public health advocacy and activism?

One of the most important ways of influencing policy related to health is through advocacy and activism. Chapman notes that public health advocacy is used most often to refer to the process of overcoming major structural barriers to public health goals. Advocacy is a powerful tool of the new public health. It is necessary to step public attention away from disease as a personal problem to health as a social issue, and the mass media are an invaluable tool in this process. advocacy is a strategy for blending science and politics with a social justice value orientation to make the system work better particularly for those with least resources. Activism can be defined as an action on behalf of a cause, action that goes beyond what is convention or routine.

Public health objectives that are addressed with advocacy and activism include new law and regulations, more funding for programs, enforcement of existing laws and regulations, tax rises or eduction on products, changing clinical or institutional practices, and having others sectors direct energy at a health issue.

Who are public health advocates and activists?

There is a high degree of overlap between advocates and activists, and the dividing line between them is blurry. Public health advocacy and activism can be undertaken by individuals in their role as concerned citizens, organisations, and coalitions of organisations. Advocacy and activism can happen locally, regionally, nationally and internationally.

Increasing activism occurs online. New information technologies have given public health and environmental movements unprecedented ability to make quick responses to events, share information and put pressure on governments and corporations. The potential of the internet as a global advocacy mechanism was first demonstrated on a major global health policy issue in 1998 by a concerted campaign by non-government organisations around the world against the multilateral Agreement on Investment. These groups sued websites to publicise the details of the porpoises MAI and analysis of its likely impact. The internet was used to maintain communication between NGOs around the world and to spread the latest details of the negotiations.

Civil society is the heart of advocacy and activism and is defined as the associational life that brings people together and allows civic values and skills to develop. A healthy civil society is one where voluntary associations of people, groups and organisations focused on an identified common good can thrive. Worldwide there are millions of civil society organisations with concerns that relate to health services, the determinants of health and health equity. 

What are key advocacy and activism strategies?

Successful strategies should set an agenda, frame the issue for public consumption and advocate specific solutions. Wallack suggests that public health advocates can catalyse public opinion, bolster the public's willingness to support the proposed solution and gain access to key opinion leaders and community decision-makers. Strategies are as varied as the imagination of activists, and include lobbying politicians and public awareness campaigning. 

• Lobbying governments and politicians is a key advocacy activity. Emailing and meeting with local politicians or with ministers is a crucial means of public health advocates and activists putting their points across. 
• Boycotts involve not using, buying or dealing with a person, organisation, country or product as a deliberate protest. 
• Public protests take many forms and can include marches of thousands of people, street theatre with an activist message or other staged events. 
• Non-violent direct action is another form of activism. 
• Picketing originated as actions by trade unions against employers when a picket line was formed to protest against employer practices, but it has also been used more generally to draw public attention to a cause. 
• Civil disobedience is the active, professed refusal to obey certain laws, demands or commands of a government.
• Public art is often used as a form of protest as well.
• Petitions are increasingly used to target single issues and are much easier to organise than in the past because of the internet.
• Media advocacy, including that on social media, has become an increasingly important public health activity because of its society-wide influence. Mass media serve a number of functions in contemporary society, as sources of information, as propaganda mechanisms, as agents of legitimacy for the dominant political and economic institutions, and as agents of socialisation by transmitting society's culture, values and norms. Media advocacy addresses power gaps between powerful and less powerful groups in society. 
• Lastly, research can also be used fo activist purposes and is increasingly common in civil society. A willingness and capacity to engage with the mass media is seen as an essential attribute of influential public health researchers. It is however rare for researchers to receive any training that enables them to engage the media effectively. 

What are some advocacy and activism dilemmas?

Both advocacy and activism pose dilemmas that have to be faced and resolved as part of activism and advocacy work.

• Single-issue advocacy campaigns are generally easier to pursue than those that focus on broad scale system reform. Thus the campaign against the adverse health effect of tobacco was able to be very target and specific. Aiming for a broad system change is more difficult because the goals and strategies are likely to be less clear and more open to debate. 
• Activism can be more grounded in either consensus or conflict approaches. Most campaigns will have a mix of both, and judgments have to be made by activists about which approach suits which circumstance. strategies involving public protest, for example, are more conflictual than those involving direct lobbying of politicians. 
• Civil society and non-government organisations are an important part of the policy-making machine because they provide an independent voice and, as such, are vital to democratic society. Yet their role has been progressively undermined in recent years. There is a dilemma for non-government organisations whether to accept government funding but then find that their ability to speak out is limited, as no government wants to finance an organisation that bites the hand that feeds it. This is a real dilemma for civil society and professional associations that receive funding form government or whose members rely on government for their employment. On an individual level advocates and activists may be perceived as troublemakers and so suffer personally as a result of their activities. 
• Public health advocates and activists face extremely powerful advocates who are concerned primarily with corporate profits rather than health. One tactic form corporations that may undermine the work of public health activists is that corporations provide sponsorship to existing consumer groups and this is highly likely to influence the agenda of the group. An example is a drug company funding a consumer group who then argues for that drug to be made available through public health systems.
• Then, it can also be hard for advocates to get their activities reported in the mainstream media. Great political and social power is exercised by a few media proprietors.
• Being an advocate or an activist also involves being reflective about the different types of relationships involved. 
• Being an advocate is not easy on the personal level, as it requires emotional energy and commitment. Effective advocates know that they will be subject to criticism form the powerful interests they are opposing. A real risk for health activists is burning out.. 

Chapter 23: What strategies for boosting public health are used in the twenty-first century?

What are the core elements of good health promotion strategies?

Initiatives around the world are focusing on health promotion strategies that aim to change the social and/or physical environment to promote the health of people and environments. This builds on the finding of Rose, who says that effective and sustainable public health strategies must lower the risk of the whole population and not just those at the high-risk end of the distribution. These initiatives work across sectors and use strategies to engage communities. Leadership comes form local government, health departments, environment departments, workplaces, schools and community groups. Together, they represent a powerful force for change through which to create healthier and more equitable.

What do 'setting' approaches to health promotion entail?

The ideal shape of health promotion in the twenty-first century is that it should be embedded within the operation of organisations such as school and workplaces and evident in the way local communities and cities plan for the future. This approach involves a shift away from the behaviourally focused health promotion of previous decades. Kickbusch stressed that the healthy settings approach is about asking the question: What creates health in our setting? She stresses that many of the first step solutions are organisational rather than linked directly to health behavior. For an organisation or other setting to ask this key question, requires a concerted strategy of change in the way the organisation works, relates to the world outside its boundaries and its understanding of the factors that create health and well-being. The settings projects usually reflect the health promotion philosophy expressed in the Ottawa Charter, with an emphasis on the achievement of health through an integrated holistic approach. 

The World Health Organisation defines settings for health promotion as the place or social context in which people engage in daily activities, in which environmental, organisational and personal factors interact to affect health and well-being. 

What are the hallmarks of a settings approach to creating health?

The settings approach to creating health has several core hallmarks:

• The focus of the settings approach is on the setting and enhancing its ability to create health rather than on changing the behaviour of individuals directly-social, economic and environmental change strategies rather than those based on the psychology of individuals.
• The focus is not only on reducing social, economic and environmental risk conditions but also about creating a healthy setting in a positive and holistic sense.
• Genuine participation by all key stakeholders is encouraged.
• Change in the culture of the setting and organisation is one of the goals, and change management will be a central point of the activity. Health creation is the centre point of a planning process that generally includes devising a vision of improved health in the setting and a series of goals and strategies to achieve this vision.
• Health is conceived as being about more than physical safety risks and has a broad socio-environmental conception of health.
• The setting is conceived of as being networked to a variety of other settings and organisations rather than as existing in isolation.
• The creation of more equitable access to goods and services that promote health is a central focus so that more equitable health outcomes can be achieved.

The health settings approach can be implemented in healthy schools projects, healthy food market projects, health promoting prisons, and the health promoting health services key approach. The latter approach aims to move form an exclusive focus on disease to a mandate to improve and promote health. It involves the health service as a whole and its relationship with the broader community. 

How can we bring about change in healthy settings initiatives?

Most settings are either based in an organisation or comprise a series of organisations such as in a Healthy Cities project. Thus, healthy settings projects have to be very cognisant of the need to change and adapt the culture of organisations so that they can take on the proactive and positive perspectives health promotion requires. A health-promoting organisation needs to adopt a broader perspective eon health, recognising that it has an impact on the health of all its members. healthy settings require change in the orientation and focus of organisations.

Managing change has become an industry in its own right and there are numerous manuals, books and courses focused on the issue. Literature relating to change management is principally aimed at private sector businesses and corporations, whose main aim is making a profit, rather than pursuing social or health objectives. Nevertheless, there are lessons to be learnt form these insights. The shift from an organisation with a limited behavioural view on health promotion to one with a broader perspective will involve significant organisational change. A typology of change strategies suggests that the magnitude of the required change needs to be determined beforehand. Leadership styles will vary but more radical change may often require more directive and coercive management. Most recent management literature stresses the value and effectiveness of collaborative and consultative management styles. Action learning, action research and participatory action research have all been used in processes of organisational change in the public and private sectors. these methods seek to involve the key players and work in collaborative ways to bring about transformation of various types. 

What strategies are effective at bringing about change?

Effective reorientation requires managers with a strong vision and commitment to the ideals of the new public health.  The beliefs and values of senior management are likely to be crucial in determining the effects of change. Auer and colleagues have suggested some strategies that can successfully bring about change in an organisation:

• Accept that change will also involve conflict, especially resistance and anger-blocking and even sabotage can be expected. People may be threatened, feeling they have neither the skills nor knowledge to change to the new approach. The new public health is discomforting because its focus on equity and questioning of structures and practices that have long been taken for granted will be resisted by many who are content with the status quo.
• Discomfort can help the process of change: managers often gloss over discomfort, hoping it will somehow resolve itself, but recognition of discomfort may release energy for change. For example, speech pathologists at a community health centre may not want to change their way of working as they feel oppressed by the long waiting list. Recognising this may encourage enthusiasm for change. Or a CEO of a hospital may not want to reorientate his or her service to health promotion because they fear the opposition of powerful medical specialists, some of whom may ridicule what they would see as a 'waste' of valuable resources.
• The need for vision and a plan: the vision is seen as crucial to determining the future direction of an organisation.

What others elements are important when trying to bring about change in an organisation?

Several others elements are also important when trying to bring about change in an organisation:

• Clear information is important: People feel hostile to change if they believe information is being withheld. As far as possible, clear information about decisions that have been made, what is and is not negotiable and how people will be involved should be provided.
• Then, the element of participation and consensus building is important as well: The involvement of staff in decision-making is compatible with the philosophy of the new public health, and will ensure wider understanding of the goals and commitment to the process of change. Involvement can mean a broader group of people actively support the change process. The focus on equity in the new public health means it is crucial to build consensus about the importance of the social and economic determinants of health. People easily see that behaviour influences risk factors but less easily see the impact of upstream causal factors such as income, housing, education opportunity, racism. Behaviours seem easy to change directly while action on the social determinants is more complex and generally seen as more politically risky. The strategies for achieving such change in perspective include the importance of focusing on people and encouraging their participation in the running of the organisation; encouraging lateral and innovative thinking; celebrating and recognising achievements; and taking a holistic view of the organisation. Much emphasis is placed on teamwork and creating small, self-managing teams that have a degree of autonomy, especially compared to the situation in the past when hierarchical organisations were prevalent. There are techniques that can be used to develop effective teams, including the use of 'quality circles'. These are groups that meet regularly to review and improve work performance and provide support to each other. They often use a facilitator (who is not a line manager of anyone in the group), but are staff- rather than management-led. Staff explore an issue in detail and work out how they could improve their practice.  
• Reorganising or redirecting resources is crucial as well: However, it may require tough decisions and be met with resistance. In public health organisations this process will generally involve shifting resources from curative care to prevention and health promotion. In other organisations, it may require a commitment of new funds to a health promotion process that mainly offers long-term outcomes and few short-term wins. This situation will never be popular with politicians who, with a few visionary exceptions, are focused on short electoral periods and with demonstrating outcomes within that period.
• Evaluating the process is also important: It entails encouraging a climate of critical reflection is important so that processes can be realistically measured. Techniques such as the quality circles can be useful here.
• Lastly, the process of changing an organisation will often be a time of personal change. Managers may have to develop new forms of leadership and drop those that are unsuccessful. For workers the switch to focusing on prevention and health promotion in their work may require a considerable amount of retraining and support.

The aim of the change is to create a learning organisation that gives scope to question and looks for opportunities to improve existing practice.

What questions should organisations ask themselves when trying to adopt a new public health and health promotion perspective?

When organisations are aiming to adopt a public health and health promotion perspective, it is helpful when they pose the following questions:

• What health promotion and public health goals are we trying to achieve?
• How do we understand health promotion and public health?
• What is our vision for the best possible health promotion work we could do?
• How would we know if we were successful? How would outsiders know if we were successful?
• How will the different groups we relate to view quality health promotion?
• What improvements can we make so that we can meet the needs of these groups work while moving closer to our vision of health promotion?
• How can we demonstrate that our improvements are working in practice?

In what way are political and policy leadership and commitment essential to change?

From the start of the European WHO Healthy Cities Project, the crucial role of political and leadership commitment to the success of the projects has been stressed. The need for awareness of the political issues is common to all healthy settings projects. Political support is generally essential when introducing a healthy settings project that results in real change. Projects that stick to trying to change behaviour rather than more structural factors are generally less contentious. Gaining political support from mayors and ministers is vital, and so is having policy actors who are able to take advantage of windows of opportunity when they occur.

Inspirational leadership is crucial to the success of healthy settings initiatives. This type of leadership comprises several characteristics:

• Skills in political insight and an ability to chart a path in confusing territory;
• The ability to take insights from different places and bring coherence to them in the context of a program in action;
• The ability to listen to people and reflect back, with added value;
• Clarity of vision and an ability to depict possibilities as achievable confidence and readiness to act (even when full certainty is still not possible);
• The ability to inspire others to act even where (and especially where) there is uncertainty about the outcomes;
• And readiness to examine what happens critically, to take feedback and to learn how to do it differently and better next time.

How can action be encouraged across sectors?

A very common theme in thinking about promoting health and creating sustainability for the environment is the need for action across sectors. This is true for all healthy settings projects. This approach requires organisations to become more outward focused. The need for intersectional action is based on recognition of the complexity of the problems faced by modern society. No one sector can tackle these fundamental issues and come up with sufficiently innovative and radical solutions on its own. Cooperation and collaboration across sectors becomes more crucial as health and environment issues grow in complexity. 

What types of partnerships do we distinguish?

VicHealth suggests that there are four types of partnerships in health promotion:

• The first type of partnership is networking: It is concerned with the exchange of information for mutual benefit. This requires little time or trust.
• Then, coordinating involves exchanging information and altering activities for a common purpose.
• Then, cooperating involves exchanging information, altering activities and sharing resources. This will require a significant amount of time, a high level of trust and some sharing of trust.
• Collaborating involves the activities of cooperation and in addition enhancing the capacity of the other partner for mutual benefit and a common purpose. It will often involve sharing resources and giving up some turf.

A really effective healthy settings initiative would fall into the collaborating type. The key elements for successful partnerships entail determining the need for the partnership, choosing partners, making sure these partnerships work, planning collaborative action, implementing collaborative action, minimising the barriers to partnerships and reflecting on and continuing the partnership. A further factor that seems to be essential for collaboration is the development of trust. Collaboration between organisations with very different structures will be difficult. 

What healthy settings projects have been implemented in the workplace?

Unions have been critical of the victim-blaming nature of behaviour-based health promotion, preferring to put heir efforts into occupational health and safety. More recent developments in workplace health promotion have seen more comprehensive strategies that acknowledge the impact of environmental factors, including the impact of shift work on worker's health, the provision of nutritious food in canteens, secure space of bicycles, et cetera.  Equity is a key consideration, as behavioural interventions are most likely to be effective for people who have the other aspects of their life going well. The best workplace health promotion strategy for many workers is likely to be improved basic conditions of work. Organisations should consider equity when devising strategies for a health promoting approach. 

What do healthy cities and communities entail?

There are a burgeoning number of initiatives around the world that use very similar values, principles and processes to the healthy settings approach and are based at city, municipal or local government level. In a nutshell, these projects are concerned with integrating economic, social, community and environmental issues, with using participatory processes, encouraging sectors to work together and integrate their activities, building local capacity to act to improve health and well-being in an equitable manner. 

What does the WHO's Healthy Cities Program entail?

WHO's Healthy Cities Program was originally an initiative of the WHO Regional Office for Europe and was designed to implement the Ottawa Charter at a city level. since then, it has captured the imagination of cities and other communities around the world as a means of tackling complex public health issues at a city, community or regional level. A healthy city is defined by a process, not an outcome. It has several key elements:

• A healthy city is not one that has achieved a particular health status.
• It is conscious of health and striving to improve it. Thus any city can be a healthy city, regardless of its current health status.
• The requirements are: a commitment to health and a process and structure to achieve it.
• A healthy city is one that continually creates and improves its physical and social environments and expands the community resources that enable people to mutually support each other in performing all the functions of life and developing to their maximum potential.
• The Healthy Cities approach recognizes the determinants of health and the need to work in collaboration across public, private, voluntary and community sector organizations. This way of working and thinking includes involving local people in decision-making, requires political commitment and organizational and community development, and recognizes the process to be as important as the outcomes.

The types of initiatives labelled as Healthy Cities vary between and within countries. The same key ideas are at the heart of each project, so that while the problems and priorities may differ form city to city, the processes to be followed is similar. This means that Healthy Cities is both a concept and a project. 

What are the twenty steps for developing a Healthy Cities Project?

The development of a Healthy Cities Project entails twenty steps. Steps 1-7 are about getting started, steps 8-14 about getting organised, and steps 15-20 about taking action.

1. Build a support group that includes people with an understanding of the new public health and who have leadership and determination.
2. Understand and explore the concepts behind healthy cities, especially the links between health and the environment. Ensure all the support groups are involved.
3. Know the city by conducting some kind of community needs assessment.
4. Identify potential project partners and if possible obtain some seed monies.
5. Decide on where the project will be located options include local government, community organisations, or independently).
6. Prepare a sound proposal, which is concise, clear, convincing and pragmatic.
7. Get approval from the relevant authorities, which normally involves seeking the support of powerful political and community groups.
8. Appoint a steering committee with clear responsibilities to plan, lead and coordinate the project. Subcommittees for fundraising, personnel and specific projects can be established if necessary.
9. Review, rework and research the project environment to ensure it is feasible and is being implemented in an appropriate way. Check that communication between the relevant organisations is happening effectively.
10. Define project work with a detailed plan, which includes innovative but workable strategies.
11. Set up a project office.
12. Plan strategy and develop a city health plan that provides for the short- and long-term vision of the project. 
13. Build capacity in terms of resources and personnel.
14. Establish accountability by putting monitoring and evaluation systems in place. Regular reports should be made available to key people in the city or community.
15. Increase health awareness among politicians, community members and bureaucrats.
16. Advocate strategic planning to ensure that all opportunities are used and plans put into practice.
17. Mobilise intersectoral action so that it is collaborative, not competitive.
18. Encourage community participation from all sections of society. Support local action programs and initiatives for health development.
19. Promote innovation, flexibility and health promotion.
20. Healthy policies make healthy cities and create an urban environment that can promote health.

What do action for health look like in Healthy Cities projects?

A description of the Healthy Cities initiatives does not capture their variety and colour. Most projects have many things happening at once. Healthy Cities involves an overall commitment by a municipality to ensuring health considerations are involved in all aspects of the city's or community's decision-making and practices. This is a long-term process necessitating a range of local initiatives. Many Healthy Cities Projects have initiatives that are tackling specific diseases or risk factors. Other Healthy Cities Projects focus on people or organisations. Within the overall framework, the projects often contain initiatives focusing on organisational change in particular settings such as schools, workplaces, markets or hospitals. Environmental initiatives are an important part of many Healthy Cities Projects. Also typical of Healthy Cities initiatives is the engagement in systematic city-wide planning. 

What do critical perspectives on healthy settings approaches entail?

By their nature, healthy settings initiatives focus on local issues. This means, of course, that there is a limit to what they can achieve. It is often difficult for evaluators of healthy settings projects to report negative results, as there is usually strong pressure to present the work in a positive light. Healthy settings projects are ignited in the main by bureaucracies and this means that they are unlikely to be supportive of progressive change and may rather be protective of the status quo. Questions raised about the potential for genuine participation in healthy settings, as they are normally introduced by the management of organisations. This means that as students, prisoners, patients or workers are unlikely to initiate the project and their participation may be limited. Also, not all healthy settings approaches show evidence of a focus on equity.

Chapter 24: What does a healthy public policy look like?

What is the aim of a healthy public policy?

The first strategy in the Ottawa Charter is Building Healthy Public Policy, which recognises the limitations of behavioural approaches to health promotion and puts emphasis on policies in all sectors to ensure protection from disease and injury and promotion of health. The main aim of healthy public policy is to create environments in which people can live healthy lives and make healthy choices. Public health policies can be implemented by local, state or federal governments, and organisations in the private, public and non-government sectors, and there have been some spectacular successes. Much government policy takes the form of legislation. 

What is policy?

Political scientists have extensive debates about the definition of policy. Definitions stress that policy is about taking decisions, setting goals and ways of achieving them and taking action or not to achieve these goals. Most commentators see policy as a course of action or a web of decisions rather than just one decision and that the values underlying policy are important. Hill notes that several crucial factors stem from this:

• First, action may result from a decision network of considerable complexity that extends over a long period of time far beyond the initial decision-making process.
• Second, there will be a series of decisions. 
• Third, policies invariably change over time because the policy-making process is dynamic rather than static and changes in response to external events. 
• Fourth, the policy process does not exist ion a desert island. 

Policy results from an interaction between structures, actors and ideas. Structures refer to the entities and rules within organisations or systems that influence policy making. Actors refer to the stakeholders involved in policy making and ideas refer to the content of policy making.

What does healthy public policy entail?

According to the WHO, healthy public policy is characterised by an explicit concern for health and equity in all areas of policy and by accountability for health impact. The main aim of healthy public policy is to create a supportive environment to enable people to lead healthy lives. Healthy public policy covers a broad range of activities in most sectors of society, and aims to alter the socioeconomic and physical environments in which we live, and ultimately to affect individual behaviors so that quality of life, well-being and health are enhanced. It is distinct from health policy, which is concerned with those policies that determine the financing and operation of sickness care services. 

It is difficult to imagine policy areas that do not have implications for health. Draper has defined six features of healthy public policy:

• Public health issues are, invariably multi-sectoral and involve a range of interest groups. For instance, attempts to control drink-driving involve the police, hospital emergency departments, alcohol producers and retailers, schools and workplaces.
• Healthy public policy should involve commerce and industry, voluntary organisations, the community and all three tiers of government.
• Increasingly, risks to public health are international and not confined within regional or national boundaries. This is particularly true of environmental problems.
• The aim should be 'educational and persuasive rather than dictatorial or puritanical' and should aim to make the healthy choices the easy choices. However, health legislation may be necessary in some circumstances.
• Action for healthy public policy takes many forms, through formally organised lobby groups or the actions of local community health initiatives.
• Healthy public policy is an intrinsically political activity.

What does the process of formulating a policy look like?

Policy is a nebulous term, used in many different contexts form general references to the foreign policy of a country to the particular policies of an organisation. Policy sets priorities and guides resource allocation. Inevitably, creating policy complex, and take years or decades. Policy should be viewed as a narrative that provides guidelines for coordinated action across sectors and institutions. A government's decision not to do something may represent policy, so policy must include what governments say they will do, what they actually do, and what they decide not to do. Policy commentators note that the present developments in the nature of bureaucracies and how they relate to other parts of society have complicated the policy-making process. 

A final and crucial point about policy making is that the formulation of a policy issue is crucial to how the policy is determined. Individualism is often prevalent, so policies will find solutions in terms of changing individuals' behaviors rather than in changing the structures that set the context for those behaviours. These hidden arguments underline the importance of values behind policy formulation. 

What are the phases in the process of policy making?

Policy making usually involves a series of phases, such as this framework offered by Walt:

• Problem identification and issue recognition refers to analysis asking which issues do and do not get on the policy agenda, and why.
• Policy formulation refers to determining who formulates policy and how, and where the initiatives come from.
• Policy implementation refers to asking how policies are implemented, what resources are available, and how implementation is enforced.
• Policy evaluation refers to asking how the policy is monitored, whether it achieves its objectives, and whether it has unintended outcomes.

It would be very rare for policy stages to follow such a rational or ordered linear process in reality. Policy making and implementation are usually more iterative, subjective, and are affected by the social environment. Kingdon argues that policy agendas are shaped and change in response to a range of influences - ideas, interests and institutions. The policy process is better understood as a series of ongoing interactions between actors, ideas and structures, all of which affect each other and re-shape positions and connections in an interdependent network. 

What are some different approaches to policy formulation?

Most literature on policy formulation identifies three main approaches:

• The rational-deductive approach starts with a problem and work through to its solution in a rational and linear way. The main features of this approach are its rationality, following a logical sequence to arrive at decisions and making use of as much information as possible. Policy making tries as far as possible to follow a deductive approach to decision making, which is akin to the traditional scientific method. 
• The incremental approach is an opportunistic approach that recognises that all implications are never known at the outset and so there is a constant need to reflect and amend. 
• The mixed-scanning approach aims to combine the best features of the previous two. It is based on the understanding that the rational-deductive approach does not pay sufficient attention to the politics and values of any policy environment and that the incremental approach tends to be overly reactive.

The process of policy formulation is complex and context specific, especially in relation to politics. Assuming a political determination to take policy action, it is vital that there are mechanisms through which to formulate and enact policy. 

How do policies relate to power?

Milio defined the public policy environment in which policies for health come about. Key players are politicians, bureaucrats, media representatives and interest groups, and the process involves struggles between groups to ensure their desired policy ends are achieved preference to those put forward by other groups. Inevitably, policy formulation is entangled with issues of power and influence. Different groups have different mounts of power and influence with which they can guide policy decisions.

Analysis of power is complex. Political science has presented an increasingly sophisticated understanding of how it operates in pluralist societies. Power doe snot just involve one person or group persuading another to act in a particular way, but also influencing the actual wants and desires of another person or group. In analysing policy it is crucial to ask whose interests will be served or threatened by a policy change and their power to affect the policy formulation process. An equally important question is to consider involved groups that have no power or influence to affect policy. 

In what way is policy influenced by policy networks and communities?

Policy commentators point out that in the postmodern state, policy is influenced by policy networks and policy communities. These networks and communities introduce a range of voices into the policy process and make it possible for public health advocates to play a role in the policy process. For the purposes of healthy public policy a consideration of the possible influence of these communities and networks is that it offers a way to study the actors that are likely to be arguing for or against a healthy public policy. They also underline the fact that the political system and the operation of the state are far from being unified and homogeneous systems but are in fact fluid systems that are open to influence at each stage of policy making.

What does a healthy public policy in the globalised world look like?

Kickbusch and Seck state that we are presently in a situation that all progress achieved so far towards health and well-being could be wasted unless effective global health policies are formulated. They suggest four factors that indicate the current global governance crisis:

• The lack of sustainable bealth systems as shown by the increasing costs of health care in rich countries and the weakening health infrastructure in many poor countries. They stress this is especially dangerous at a time in which new disease challenges such as HIV/AIDS, SARS and Avian influenza threaten.
• Then, the consequences of global restructuring of economies, which has led to a very different socioeconomic-political context of health. Inequities between rich and poor countries are increasing and public health is weakly protected under the new global trade agreements.
• Furthermore, global health has no defined centre of action and is characterised by a growing and complex set of actors including business; international agencies like the World Bank, G8 and World Economic Forum; diverse new organisations, networks and alliances, UNAIDS, Global Alliance in Vaccines and Immunization (GAVI) and the Gates Foundation making the scene more fragmented, harder to navigate and coordinate.
• Lastly, there are no obvious mechanisms for global accountability for health as there is no systematic effort to build health globally.

Thus advancing healthy public policy globally will require clear international commitment to health as a global public health good and to establishing mechanisms for the governance of health internationally. 

What are some examples of a healthy public policy?

Examples of healthy public policy range form those that provide for the universal provision of services and those that address a single issue. Both types are important to healthy and equitable societies. Examples are gun control, universal policies like publicly funded health care, policy and legislation relating to alcohol, drugs and tobacco, food and nutrition policies, and road safety policies. 

What makes for healthy public policy?

The processes needed for the successful adoption of healthy public policies are the following:

• There should be an issue over which there is clear evidence about adverse effects on health.
• There should be effective lobby groups in favour of policy and legislation to control the source of the adverse effects on health.
• Then, there should be winning of support for policy and legislation change from key opinion leaders, including the media and politicians, in spite of opposition from groups who favour the status quo. Healthy public policy will often mean challenging the power of groups who are influential and wish to protect their profits with unhealthy policies.
• Furthermore, there should be supportive bureaucratic players in key positions who are keen to advocate the public good over private interests.
• Also, there should be a policy environment that supports government intervention to change social and economic structures in order to promote health.
• Finally, it should be ensured that there are wins both for health and the other sectors involved.

Chapter 25: In conclusion, what does public health in the twenty-first century look like?

What are the characteristics of public health policies in the twenty-first century?

Public health in the twenty-first century faces a world characterised by growing social unrest: Economic austerity has seen economic inequities soar, and evidence is increasing that the scientific predictions of climate change are proving to be accurate. Responses to climate change are weak and not meeting the scale of the threats. There is also growing sectarian conflict in the Middle East, introducing new instabilities. Refugee numbers are also increasing, while new xenophobias flourish in the wake of the uncertainties and insecurities this brings. Although many of these developments do not bode well for our collective health, there is also a growing realisation that only a radical change in our priorities and values will save the world form the dire predictions many commentators are making.

Public health's central raison d'être is about shaping this future and working to ensure it as healthy, sustainable and equitable as possible. Public health offers arenas of assessing how well we are doing in creating a better global community. Shaping creative alternatives will be a central task for our future and the new public health has a central role in this journey.

What did this book demonstrate about the influence of socioeconomic factors on health?

Health results from people's experiences in their everyday lives. These lives are influenced by powerful social and economic forces nationally and globally, many of which are not health promoting. This book has demonstrated that, while medicine has been based on an understanding of health as an absence of illness, broader understandings have existed alongside it. Public health has come to embrace a broad view of health and increasingly its practitioners operate from the assumption that longer term and meaningful change will result only if the powerful structural factors that affect people are the focus of public health initiatives. This book has also stressed that our collective health and equity depends on effective stewardship of the natural environment.

Public health policy and practice reflect the economic, political and social climate in which they occur. Dominant political and social ideas have a crucial impact on health. Current ideas that are partially crucial in shaping public health are the balance between individualism and collectivism, the dominance of economic considerations and market philosophy in public policy-making and the importance accorded to social solidarity and social participation. Each of these has a strong impact on health.

What did this book demonstrate about the inequity of outcomes of health policies?

Evidence suggests that attempt to change behavior without a parallel effort tot change structures will only benefit those people who already have favourable living conditions such as employment, reasonable income, good housing and a safe environment. The very limited gains of the behavioral public health experiments have resulted in public health revisiting and extending the strategies used by earlier generations of public health reformers. As a result, public health concentrates more and more on reforming the operation and practices of organisations, institutions and communities. 

What did this book demonstrate about the influence of social factors on public health initiatives?

Social issues are assuming more prominence in public health. Social support, high self-esteem and a sense of personal control are important determinants of health, best achieved in societies and communities that are relatively equal and that have reasonable levels of social solidarity. The development of supportive societies and communities should be at the heart of public health strategies for the future. The necessary strategies will include public policies, legislation, public sector interventions and local actions. Social capital and the trust it relies on are likely to be central to public health endeavours in the future.

If the focus of public health is to reflect the importance of social factors and achieving ecological sustainability, then policy will be the fundamental and essential tool.

What is the mission of the new public health movement?

The overall mission of the new public health is to create a healthy and equitable society in which the natural environment is sustainable, political will for equity is articulated, policies are sued to create health and equity in a proactive manner, and there are numerous opportunities for lifelong personal, intellectual, social and emotional development. Stacking these factors up together in a coherent way will result in healthy populations with equitably distributed health. 

What are the global issues of ecology?

Humanity is facing the enormity of the ecology crisis. Climate change and the resultant global warming are putting the environment at the centre of political and commercial debates. While some details of this crisis are disputed among experts, the overwhelming majority of scientists accept the evidence that the world's natural systems are out of balance, that the effects of this are unpredictable and that the cause is human activity. That public health is showing more concern with the environment has been evident in international and national public health policies and in community-based action to tackle local environmental problems. However, in the broader political community, action to reduce the use of carbon is timid. Achieving an international treaty is proving extremely difficult and even if achieved, its likely goals appear unambitious,

In what way have these ecological challenges become more complex over time?

The first public health movement was concerned with providing clean water and effective sanitation to fast-growing industrial cities. Now public health cannot simply ensure that waste is removed but must also be concerned about the impact of waste on the environment and the sustainability of solutions. The complexity of the problems faced today is far greater than those faced by earlier generations of public health reformers.

Re-emergent and emergent infections are continuing to challenge public health. The increase in international travel appears to have assisted the spread of infectious diseases and makes global pandemics more likely. Most recently, Ebola in West Africa has claimed thousands of lives and required a concerted international response. Public health will have to be global to be effective. Global inequities and inequities within countries show every sign of increasing and will be evident in the pattern of new diseases and burden of environmental problems. Social and economic justice will become more difficult to achieve, and public health will have to take on a stronger advocacy role. Redressing the disparity in wealth between rich and poor countries will become more pressing as the differences widen and fuel social, political and environmental problems.  

What should be the goal of public health practitioners?

Public health practitioners should be at the forefront of advocacy for equity. Public health arguments need to be marshalled to support the importance of reducing the gaps between rich and poor, both within and between countries. Public health will have the task of encouraging governments to make long-term investments in health and environmental enterprises. The environment continues to deteriorate because many governments will not slow development or invest in environmental protection.

The new public health practitioners will need to take a critical and sceptical view of genetic technology, questioning its potential for impact on population health status and the impact its availability would have on equity. If genetics have an impact on health, almost certainly the rich and powerful will benefit more than others.  

Do global public health differences reflect a just world?

While poor countries suffer from a very uneven playing field, capitalism is producing larger and larger profits. The new 'barons' of the system, the chief executive officers of corporations, are paid huge salaries that, as a percentage of average salaries, have zoomed out of all proportion. The extent of these salaries commonly receives negative coverage in the media. Shareholders are receiving large dividends. The gap between the wealth of rich and poor continues to grow. Increasing attention is paid to the 0.1 per cent who have come to own an increasing share of the world's wealth in the past decade.

Despite this somewhat gloomy picture there are many people and social movements, including public health and health promotion activists, who believe the world should be more just. They recognise that the struggle for health equity is a struggle for social and economic justice.

What kind of leadership is needed for a healthy future?

Economic considerations have come to dominate public decision-making to the extent that this in itself has become a public health risk for society. The goal of public policy is being progressively narrowed to a preoccupation with reducing public sector costs and privatising public services, and a rejection of social ends as a goal of public policy. Political parties in most countries are adopting such views or having them thrust upon them by international monetary agencies. Public health is quintessentially a public service activity that has always challenged the logic of neo-liberalism. While part of the reason for public health activity may be to support a healthy workforce and protect the interests of trade and commerce, it also rests on a strong ethical argument that promoting health in communities and individuals is a social good in its own right.

For the future, public health has an investment in joining the voices that are arguing for a return to public policies that seek to promote civil society, encourage an investment in the social fabric of communities and protect the environment. Without a strong state that sees its role as leading societal efforts to balance social, environmental and economic concerns it is hard to imagine public health's goals of equity, sustainability and health being achieved.

What kind of attitude is needed from public health practitioners?

Effective public health practitioners should be reflective in their practice and use theories from a variety of disciplines in an eclectic way. Evidence is essential to good public health practice, but there will never be enough to provide complete certainty. There is need for creativity and willingness to experiment.

The methodologies available to public health are numerous and most areas of human enquiry can offer some insights to public health issues. None of their own will offer sufficient insight, however. Consequently, public health work is best done by multidisciplinary approaches bringing a variety of complementary perspectives to work. Most crucially, there must be a focus on populations and societies rather than the currently dominant thinking in health, which is on individuals and cure.

What does the vision for public health in 2050 look like?

Among public health advocates, there is a vision of a much healthier world in 2050. This vision requires changes that are not that huge, is easily achievable within existing resources but needs political will to realise it. Another powerful means of overcoming feelings of hopelessness is to join others in collective action. This vision is characterized by several elements:

• We should accept our limits to growth. Global citizens no longer look to economic growth as a measure of their progress. Rather, they consider human well-being, health, happiness and extent of equity. The rampant consumerism of the late twentieth and early twenty-first centuries is seen as a period of madness. In 2050 satisfaction is gained from such things as conviviality, visiting places of natural beauty, live art performances and slow food. Natural resources are used with care and recycling is 'cool' among young people and part of accepted norms. The excessive consumption of the early twenty-first century is viewed with disdain.
• The physical environment should be protected and restored. Ecological thinking has imbued governments' policies and practices around the world and so decisions are made to restore, protect and enhance the physical environment. The importance of physical ecology to human health and all life on planet Earth is well respected and this has resulted in areas such as the Amazon rainforest being protected for future generations.  
• Corporations will be tamed. In 2050, the empires established by the transnational corporations (TNCs) have been dismantled. In the previous years there was increasing disquiet at the size of the TNCs' chief executive pay packets, the way in which the TNCs externalised the environmental and other costs of their activities, and their tax avoidance behaviour. By 2050 business and industry is on a much smaller scale, more locally controlled and seen as a part of local communities to whom they give back through community projects, fair tax and skills.
• National and global governance and regulation for health and well-being will hopefully be the norm. Internationally there are many global treaties in 2050 to control the activities of the market when its activities impinge on health and well-being-for example, regulation of food and water to ensure equitable supply, good quality and local production. The World Bank is unrecognisable from the body it was at the turn of the century and now works to assist development and promote health equity. The privatisation of the late twentieth century and early twenty-first century is regarded as a mistake. In most countries, services judged as central to health and well-being are controlled or owned by the public. This includes water, power utilities, communications infrastructure, prisons and schools. Taxation is now seen as a public good that people are willing to contribute to because of the benefits they see they gain. By 2050 the inequities between countries have been dramatically reduced and this has flowed through to reduced health inequities.
• Health should be for all people. In 2050 the stark health inequities of the first decade of the twentieth century have been largely reduced.  
• Health services have been shaped into a better form. Primary health care services form the basis of health systems around the world in 2050. Most systems are publicly funded and run and they provide pretty much seamless integration. Local health centres are the heart of the system and provide a full range of services including nursing, medical, physiotherapy, psychology and social work, delivered through one-to-one encounters, groups and community development. These centres advocate for the health and environment of their local community. Hospitals are less prominent and powerful in the system but provide good care and make judgments about the value of treatment at the end of life. Around the world strong public health departments conduct health equity impact assessments on major developments and on the operations of TNCs and work to protect the health of their community and promote it in a positive way.

Source and more study assistance:

• Type: Book summary
• Book title: The New Public Health
• Author: Baum
• Edition: 4th edition
• Study assistance: For all available summaries, practice questions, bulletpoints and examtips with the book, go to Study Guide for summaries with The New Public Health by Baum