3 Health and Disease, Influence of Family and Community

Your Own Views on Health

Note down your responses to the following questions:

• What does health mean to you?
• How important is health to you?
• What do you do (if anything) to stay healthy?

Illness and Disease

Although clearly related, the concepts of illness and disease are distinct. People have illness and physicians diagnose and treat disease.

• Disease is an objective term which implies a malfunctioning of the body or part of the body. Disease is pathological and is diagnosed on the basis of recognizable signs and symptoms.
• Illness is the subjective experience of pain, discomfort or disorder.

Although it is mostly safe to say that illness is the subjective experience of disease, it is possible to experience illness without having a disease and it is possible to have a disease and not feel ill.

Health Education: Basic Principles

In this session you will learn about the nature of health, health education, health promotion and some related concepts. This will help you to understand the social, psychological and physical components of health.

Definition and Concepts of Health

In the Oxford English Dictionary health is defined as: ‘the state of being free from sickness, injury, disease, bodily conditions; something indicating good bodily condition.”

• Now stop for a moment and think about someone you think is healthy and someone else who you would consider to be not healthy.
  • Look at the definition of health again.
  • Is it similar to the things you thought about when you thought of a healthy and an unhealthy person?

This definition of health is a widely publicized one. But you may have thought of someone who has a disability or wondered about someone who looks OK but who you know does no exercise. Clearly health is not quite as simple as the definition implies.
The concept of health is wide and the way we define health also depends on individual perception, religious beliefs, cultural values, norms, and social class. Generally, there are two different perspectives concerning people’s own definitions of health: a narrow perspective and a broader perspective.

Narrow Perspectives of Health

People with a narrow perspective consider health as the absence of disease or disability or biological dysfunction. According to this view (or model), to call someone unhealthy or sick means there should be evidence of a particular illness. Social, emotional and psychological factors are not believed to cause unhealthy conditions. This model is narrow and limits the definition of health to the physical and physiological capabilities that are necessary to perform routine tasks.

According to this definition, the individual is healthy if all the body parts, cells, tissues and organ systems are functioning well and there is no apparent dysfunction of the body.

Using this model people view the human body in the same terms as a computer, or mechanical device when something is wrong you take it to experts who maintain it. Physicians, unlike behavioral experts, often focus on treatment and clinical interventions with medication rather than educational interventions to bring about behavior change.

In the next section we will discuss the broader perspective of health which includes other factors in addition to physical ones.

Broader Perspectives of Health

In the previous section you read about a narrow definition of health. This section will help you understand the concept of health in a broader and more holistic way.

Defining Health

The most widely used of the broader definitions of health is that within the constitution of the World Health Organization (1948), which defines health as: A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. This classic definition is important, as it identifies the vital components of health. To more fully understand the meaning of health, it is important to understand each of its individual components.

Physical Health

To understand physical health you need to know what is considered to be physically unhealthy so that you can contrast the two. Physical health, which is one of the components of the definition of health, could be defined as the absence of diseases or disability of the body parts. Physical health could be defined as the ability to perform routine tasks without any physical restriction.
The following examples can help you to understand someone who is physically unhealthy:

• A person who has been harmed due to a car accident
• A farmer infected by malaria and unable to do their farming duties
• A person infected by tuberculosis and unable to perform his or her tasks.

Think about someone with physical damage, perhaps due to a car accident.

Health is not limited to the biological integrity and the physiological functioning of the human body. Psychological health is also an important aspect of a health definition.

Psychological Health

• Think about people in the community who are showing behavior that may indicate they are going through a period of mental distress in their lives.
• Or think about Serena again.
• Do you think that everyone in distress shows the same sorts of symptoms?

Sometimes it can be really hard from the outside to tell if the person is struggling with mental health issues, but at other times they show symptoms that suggest a lack of self-awareness or personal identity, or an inability of rational and logical decision-making.

At other times it might be apparent that they are not looking after themselves and are without a proper purpose in their life. They may be drinking alcohol and have a non-logical response to any request. You may also notice that they have an inability to maintain their personal autonomy and are unable to maintain good relationships with people around them.

Social component

The social component of health is considered to be the ability to make and maintain ‘acceptable’ and ‘proper’ interactions and communicate with other people within the social environment. This component also includes being able to maintain satisfying interpersonal relationships and being able to fulfill a social role. Having a social role is the ability that people have to maintain their own identity while sharing, cooperating, communicating and enjoying the company of others. This is really important when participating in friendships and taking a full part in family and community life.

Which of the following examples could be considered to contribute to social health? Explain your answers.

1. Mourning when a close family member dies
2. Going to a football game or involvement in a community meeting
3. Celebrating traditional cultural events within your community
4. Shopping in the market
5. Creating and maintaining friendship.

In reality all these events could have a social component and help towards building people’s social view of health. They all involve interacting with others and gaining support, friendship and in many instances joy from being with other people.

The World Health Organization in its Ottawa Charter said that health promotion is defined as the process of enabling people to increase control over, and to improve, their health. The aim of health promotion is to reduce the underlying causes of ill-health so that there is a long-term reduction in many diseases.

Definitions of Health

If there are complexities in defining disease, there are even more in defining health. Definitions have evolved over time. In keeping with the biomedical perspective, early definitions of health focused on the theme of the body’s ability to function; health was seen as a state of normal function that could be disrupted from time to time by disease. An example of such a definition of health is: “a state characterized by anatomic, physiologic, and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biologic, psychological, and social stress.”

Just as there was a shift from viewing disease as a state to thinking of it as a process, the same shift happened in definitions of health. Again, the WHO played a leading role when it fostered the development of the health promotion movement in the 1980s. This brought in a new conception of health, not as a state, but in dynamic terms of resiliency, in other words, as “a resource for living.” The 1984 WHO revised definition of health defined it as “the extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities. Thus, health referred to the ability to maintain homeostasis and recover from insults. Mental, intellectual, emotional, and social health referred to a person’s ability to handle stress, to acquire skills, to maintain relationships, all of which form resources for resiliency and independent living.

Wellness

Many practitioners have expanded their focus to include wellness at the positive end of the health continuum. Some distinguish two interacting dimensions: disease versus non-disease and well-being versus ill-being; others expand the number of dimensions to include spiritual, emotional, social, and mental. Last commented that wellness is “a word used by behavioral scientists to describe a state of dynamic physical, mental, social, and spiritual well-being that enables a person to achieve full potential and an enjoyable life.”

But with so much disease to treat, should physicians concern themselves with wellness? Is it appropriate for medicine to seek ways to promote positive health states? Some academics distinguish between a medical care system and a health care system, arguing that, to constrain costs, public funding should be limited to treating illness and restoring the patient’s functional capacity. Others note that activities such as counseling and educating healthy individuals on diet and exercise promote wellness and resiliency, and so fall within the scope of normal practice as a part of preventive medicine. Some go further and argue that physicians should advocate for improved work and environmental conditions, such as promoting walking and cycling rather than driving, and should advocate for policies that redistribute income, limit access to unhealthy foods, and support children’s programs.

As concepts of health and disease continue to broaden, there will no doubt be pressure for physicians to expand their role to include the promotion of positive health states in their patients. Reflecting this trend, clinical trials evaluating new pharmaceuticals must now include improved quality of life as an outcome, which obviously extends beyond simply improving biomedical indicators of pathology.

Discussions of wellness eroded the hold of the biomedical model. In its place, ecological models of health appeared; these recognize the complex interactions among people, their personal characteristics and the environment, and how these influence health.

Disease or Syndrome?

As we learn more about the biological basis for a patient’s illness, it may be reclassified as a disease. For example, constant feelings of tiredness became accepted as the medical condition of chronic fatigue syndrome. Sometimes when a doctor formally labels (diagnoses) a patient’s complaint, the complaint is legitimized and this may reassure the patient. Often, however, a set of signs and symptoms eludes biomedical understanding. If the set is frequent enough to be a recognized pattern, it is termed a syndrome instead of a disease.

A syndrome refers to a complex of symptoms that occur together more often than would be expected by chance alone. Whereas diseases often receive explanatory labels (such as hemorrhagic stroke), syndromes are often given purely descriptive labels (e.g., Restless Leg Syndrome). Confusingly, the label ‘syndrome’ often persists long after the cause is discovered, as with Down syndrome, AIDS (Acquired Immunodeficiency Syndrome) or SARS (Severe Acute Respiratory Syndrome). Meanwhile, Chronic Fatigue Syndrome, Fibromyalgia, Irritable Bowel Syndrome, and Restless Leg Syndrome remain syndromic conditions which, so far, are not well explained by conventional biomedical models.

Well-being Concepts

Well-being is a positive outcome that is meaningful for people and for many sectors of society, because it tells us that people perceive that their lives are going well. Good living conditions (e.g., housing, employment) are fundamental to well-being. Tracking these conditions is important for public policy. However, many indicators that measure living conditions fail to measure what people think and feel about their lives, such as the quality of their relationships, their positive emotions and resilience, the realization of their potential, or their overall satisfaction with life—i.e., their “well-being.” Well-being generally includes global judgments of life satisfaction and feelings ranging from depression to joy.

Why is well-being useful for public health?

• Well-being integrates mental health (mind) and physical health (body) resulting in more holistic approaches to disease prevention and health promotion.
• Well-being is a valid population outcome measure beyond morbidity, mortality, and economic status that tells us how people perceive their life is going from their own perspective.
• Well-being is an outcome that is meaningful to the public.
• Advances in psychology, neuroscience, and measurement theory suggest that well-being can be measured with some degree of accuracy.
• Results from cross-sectional, longitudinal and experimental studies find that well-being is associated with:
  • Self-perceived health
  • Longevity
  • Healthy behaviors
  • Mental and physical illness
  • Social connectedness
  • Productivity
  • Factors in the physical and social environment

Well-being can provide a common metric that can help policy makers shape and compare the effects of different policies (e.g., loss of greenspace might impact well-being more so than commercial development of an area).

Measuring, tracking and promoting well-being can be useful for multiple stakeholders involved in disease prevention and health promotion.

Well-being is associated with numerous health-, job-, family-, and economically-related benefits. For example, higher levels of well-being are associated with decreased risk of disease, illness, and injury; better immune functioning; speedier recovery; and increased longevity. Individuals with high levels of well-being are more productive at work and are more likely to contribute to their communities.

Previous research lends support to the view that the negative affect component of well-being is strongly associated with neuroticism and that positive affect component has a similar association with extraversion. This research also supports the view that positive emotions—central components of well-being—are not merely the opposite of negative emotions, but are independent dimensions of mental health that can, and should be fostered. Although a substantial proportion of the variance in well-being can be attributed to heritable factors, environmental factors play an equally if not more important role.

How does well-being relate to health promotion?

Health is more than the absence of disease; it is a resource that allows people to realize their aspirations, satisfy their needs and to cope with the environment in order to live a long, productive, and fruitful life. In this sense, health enables social, economic and personal development fundamental to well-being. Health promotion is the process of enabling people to increase control over, and to improve their health. Environmental and social resources for health can include: peace, economic security, a stable ecosystem, and safe housing. Individual resources for health can include: physical activity, healthful diet, social ties, resiliency, positive emotions, and autonomy. Health promotion activities aimed at strengthening such individual, environmental and social resources may ultimately improve well-being.

How is well-being defined?

There is no consensus around a single definition of well-being, but there is general agreement that at minimum, well-being includes the presence of positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety), satisfaction with life, fulfillment and positive functioning. In simple terms, well-being can be described as judging life positively and feeling good. For public health purposes, physical well-being (e.g., feeling very healthy and full of energy) is also viewed as critical to overall well-being. Researchers from different disciplines have examined different aspects of well-being that include the following:

• Physical well-being
• Economic well-being
• Social well-being
• Development and activity
• Emotional well-being
• Psychological well-being
• Life satisfaction
• Domain specific satisfaction
• Engaging activities and work

How is well-being measured?

Because well-being is subjective, it is typically measured with self-reports. The use of self-reported measures is fundamentally different from using objective measures (e.g., household income, unemployment levels, neighborhood crime) often used to assess well-being. The use of both objective and subjective measures, when available, are desirable for public policy purposes.

There are many well-being instruments available that measure self-reported well-being in different ways, depending on whether one measures well-being as a clinical outcome, a population health outcome, for cost-effectiveness studies, or for other purposes. For example, well-being measures can be psychometrically-based or utility-based. Psychometrically-based measures are based on the relationship between, and strength among, multiple items that are intended to measure one or more domains of well-being. Utility-based measures are based on an individual or group’s preference for a particular state, and are typically anchored between 0 (death) to 1 (optimum health). Some studies support use of single items (e.g., global life satisfaction) to measure well-being parsimoniously. Peer reports, observational methods, physiological methods, experience sampling methods, ecological momentary assessment, and other methods are used by psychologists to measure different aspects of well-being.

What are some correlates and determinants of individual-level well-being?

There is no sole determinant of individual well-being, but in general, well-being is dependent upon good health, positive social relationships, and availability and access to basic resources (e.g., shelter, income).
Numerous studies have examined the associations between determinants of individual and national levels of well-being. Many of these studies have used different measures of well-being (e.g., life satisfaction, positive affect, psychological well-being), and different methodologies resulting in occasional inconsistent findings related to well-being and its predictors. In general, life satisfaction is dependent more closely on the availability of basic needs being met (food, shelter, income) as well as access to modern conveniences (e.g., electricity). Pleasant emotions are more closely associated with having supportive relationships.

Some general findings on associations between well-being and its associations with other factors are as follows:

Genes and Personality

At the individual level, genetic factors, personality, and demographic factors are related to well-being. For example, positive emotions are heritable to some degree, suggesting that there may be a genetically determined set-point for emotions such as happiness and sadness. However, the expression of genetic effects are often influenced by factors in the environment implying that circumstances and social conditions do matter and are actionable from a public policy perspective. Longitudinal studies have found that well-being is sensitive to life events (e.g., unemployment, marriage). Additionally, genetic factors alone cannot explain differences in well-being between nations or trends within nations.
Some personality factors that are strongly associated with well-being include optimism, extroversion, and self-esteem. Genetic factors and personality factors are closely related and can interact in influencing individual well-being.
While genetic factors and personality factors are important determinants of well-being, they are beyond the realm of public policy goals.

Age and Gender

Depending on which types of measures are used (e.g., life satisfaction vs. positive affect), age and gender also have been shown to be related to well-being. In general, men and women have similar levels of well-being, but this pattern changes with age, and has changed over time. There is a U-shaped distribution of well-being by age younger and older adults tend to have more well-being compared to middle-aged adults.

Income and Work

The relationship between income and well-being is complex. Depending on which types of measures are used and which comparisons are made, income correlates only modestly with well-being. In general, associations between income and well-being (usually measured in terms of life satisfaction) are stronger for those at lower economic levels, but studies also have found effects for those at higher income levels. Paid employment is critical to the well-being of individuals by conferring direct access to resources, as well as fostering satisfaction, meaning and purpose for some. Unemployment negatively affects well-being, both in the short- and long-term.

Relationships

Having supportive relationships is one of the strongest predictors of well-being, having a notably positive effect.

What are some correlates of well-being at the national level?

Countries differ substantially in their levels of well-being. Societies with higher well-being are those that are more economically developed, have effective governments with low levels of corruption, have high levels of trust, and can meet citizens’ basic needs for food and health. Cultural factors (e.g., individualism vs. collectivism, social norms) also play a role in national estimates of well-being.

What is the difference between health-related quality of life, well-being, flourishing, positive mental health, optimal health, happiness, subjective well-being, psychological well-being, life satisfaction, hedonic well-being, and other terms that exist in the literature?

Subjective well-being typically refers to self-reports contrasted with objective indicators of well-being. The term, “positive mental health” calls attention to the psychological components that comprise well-being from the perspective of individuals interested primarily in the mental health domain. From this perspective, positive mental health is a resource, broadly inclusive of psychological assets and skills essential for well-being. But, the latter generally excludes the physical component of well-being. “Hedonic” well-being focuses on the “feeling” component of well-being (e.g., happiness) in contrast to “eudaimonic” well-being which focuses on the “thinking” component of well-being (e.g., fulfillment). People with high levels of positive emotions, and those who are functioning well psychologically and socially are described by some as having complete mental health, or as “flourishing.”

In summary, positive mental health, well-being and flourishing refer to the presence of high levels of positive functioning—primarily in the mental health domain (inclusive of social health). However, in its broadest sense, well-being encompasses physical, mental, and social domains.

Public and Population Health

While public health is a familiar term, it can be difficult to give it a single precise definition. Its general focus is on preventing disease and protecting health: “Public health is defined as the organized efforts of society to keep people healthy and prevent injury, illness, and premature death.” But this definition does not give us a clear picture of what is, and what is not, included. In part the difficulty arises because public health does not concern a specific organ system, type of disease or therapeutic approach, but employs a variety of approaches to address whatever health issues are most pressing in each place and time. The discipline has seen a succession of names as it wrestled with whether environmental factors, or individual behavior, or societal policies should form the main focus of interventions.
This debate gave rise to the population health perspective, which holds that, while fostering individual responsibility for health, we must also address underlying social determinants, such as poverty or lack of access to care, that constrain people’s ability to achieve real gains in health.

Blaming the Victim

As population health is a relatively new concept, uncertainties remain over details of how, precisely, it differs from public health. Both are concerned with patterns of health and illness in groups of people rather than in individuals; both monitor health trends, examine their determinants, propose interventions at the population level to protect and promote health, and discuss options for delivering these interventions. The distinction is subtle, but population health is seen as broader, as offering a unifying paradigm that links disciplines from the biological to the sociological. It provides a rational basis for allocating health resources that balances health protection and promotion against illness prevention and treatment, while also making a significant contribution to basic science.
When public health tackles a health issue, its interventions are focused on maintaining health or preventing disease.

• For example, the public health approach to childhood obesity might advocate education for parents and children, subsidized healthy school lunch programs, banning soft drinks in school vending machines, tougher regulations on marketing of junk food to children, promoting physical activity, etc.
• A population health approach would tackle childhood obesity in a broader context. A population health approach might be to consider the food system itself: How do agricultural subsidies affect the price of food? Can city planning policies prevent the problem of urban food deserts where significant areas of the population lack access to a grocery store?

Public health focuses on prevention and health protection services, whereas the population health approach is somewhat broader. It still values “health” as a key outcome, but views issues from a broader perspective and tends to include additional considerations, such as economics, environmental sustainability, social justice, etc.