Blum's model of health determinants

Chapter 2

Beliefs, Values, and Health

Learning Objectives

• To study the concepts of health and disease, risk factors, and the role of health promotion and disease prevention

• To summarize the disease prevention requisites under the Affordable Care Act

• To get an overview of public health and appreciate its expanding role in health protection both in the United States and globally

• To explore the determinants of health, and measures related to health

• To understand the American anthro-cultural values and their implications for health care delivery

• To evaluate justice and equity in health care according to contrasting theories

• To explore the integration of individual and population health

“This is the market justice system. Social justice is over there.”

Introduction

From an economic perspective, curative medicine appears to produce decreasing returns in health improvement while increasing health care expenditures (Saward and Sorensen 1980). There has also been a growing recognition of the benefits to society from the promotion of health and prevention of disease, disability, and premature death. However, progress in this direction has been slow because of the prevailing social values and beliefs that still focus on curing diseases rather than promoting health. The common definitions of health, as well as measures for evaluating health status, reflect similar inclinations. This chapter proposes a balanced approach to health, although fully achieving such an ideal is not without difficult challenges. The 10-year Healthy People initiatives, undertaken by the US Department of Health and Human Services (DHHS) since 1980, illustrate steps taken in this direction, even though these initiatives have been typically strong in rhetoric but weak in actionable strategies and sustainable funding.

Anthro-cultural factors reflected in the beliefs and values ingrained in the American culture have been influential in laying the foundations of a system that has remained predominantly private, as opposed to a tax-financed national health care program. Discussion on this theme begins in this chapter and continues in Chapter 3, where failures of past proposals to create a nationalized health care system are discussed in the context of cultural beliefs and values.

This chapter further explores the issue of equity in the distribution of health services, using the contrasting theories of market justice and social justice. US health care delivery incorporates both principles, which are complementary in some ways and create conflicts in other areas. The Affordable Care Act (ACA) tilts the system more toward a social justice orientation, places a greater emphasis on preventive services, but does not quite promise to achieve equitable access to health care for all Americans.

Significance for Managers and Policymakers

Materials covered in this chapter have several implications for health services managers and policymakers: (1) The health status of a population has tremendous bearing on the utilization of health services, assuming the services are readily available. Planning of health services must be governed by demographic and health trends and initiatives toward reducing disease and disability. (2) The basic meanings of health, determinants of health, and health risk appraisal should be used to design appropriate educational, preventive, and therapeutic initiatives. (3) There is a growing emphasis on evaluating the effectiveness of health care organizations based on the contributions they make to community and population health. The concepts discussed in this chapter can guide administrators in implementing programs of most value to their communities. (4) Quantified measures of health status and utilization can be used by managers and policymakers to evaluate the adequacy and effectiveness of existing programs, plan new strategies, measure progress, and discontinue ineffective services.

Basic Concepts of Health

Health

In the United States, the concepts of health and health care have largely been governed by the medical model, more specifically referred to as the biomedical model. The medical model defines health as the absence of illness or disease. This definition implies that optimum health exists when a person is free of symptoms and does not require medical treatment. However, it is not a definition of health in the true sense. This prevailing view of health emphasizes clinical diagnosis and medical interventions to treat disease or symptoms of disease, while prevention of disease and health promotion are not included. Therefore, when the term “health care delivery” is used, in reality it refers to medical care delivery.

Medical sociologists have gone a step further in defining health as the state of optimum capacity of an individual to perform his or her expected social roles and tasks, such as work, school, and doing household chores (Parsons 1972). A person who is unable (as opposed to unwilling) to perform his or her social roles in society is considered sick. However, this concept also seems inadequate because many people continue to engage in their social obligations despite suffering from pain, cough, colds, and other types of temporary disabilities, including mental distress. Then, there are those who shirk from their social responsibilities even when they may be in good health. In other words, optimal health is not necessarily reflected in a person’s engagement in social roles and responsibilities.

An emphasis on both physical and mental dimensions of health is found in the definition of health proposed by the Society for Academic Emergency Medicine, according to which health is “a state of physical and mental well-being that facilitates the achievement of individual and societal goals” (Ethics Committee, Society for Academic Emergency Medicine 1992). This view of health recognizes the importance of achieving harmony between the physiological and emotional dimensions.

The World Health Organization’s (WHO) definition of health is most often cited as the ideal for health care delivery systems; it recognizes that optimal health is more than a mere absence of disease or infirmity. WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO 1948). As a biopsychosocial model, WHO’s definition specifically identifies social well-being as a third dimension of health. For example, having a social support network is positively associated with life stresses, self-esteem, and social relations. Conversely, many studies show that social isolation is associated with a higher risk for poor health and mortality (Pantell et al. 2013).

WHO has also defined a health care system as all the activities whose primary purpose is to promote, restore, or maintain health (McKee 2001). As this chapter points out, health care should include much more than medical care. Thus, health care can be defined as a variety of services believed to improve a person’s health and well-being.

There has been a growing interest in holistic health , which emphasizes the well-being of every aspect of what makes a person whole and complete. Thus, holistic medicine seeks to treat the individual as a whole person (Ward 1995). For example, diagnosis and treatment should take into account the mental, emotional, spiritual, nutritional, environmental, and other factors surrounding the origin of disease (Cohen 2003).

Holistic health incorporates the spiritual dimension as a fourth element—in addition to the physical, mental, and social aspects—necessary for optimal health (Figure 2–1). A growing volume of medical literature, both in the United States and abroad, points to the healing effects of a person’s religion and spirituality on morbidity and mortality. The importance of spirituality as an aspect of health care is also reflected in a number of policy documents produced by the WHO (2003) and other bodies.

From an extensive review of literature, Chida et al. (2009) concluded that religious practice/spirituality was associated with reductions in death from all causes and death from cardiovascular diseases. Heart patients who attended regular religious services were found to have a significant survival advantage (Oman et al. 2002). Religious and spiritual beliefs and practices have shown a positive impact on a person’s physical, mental, and social well-being. Many studies have shown positive relations between religious practice and protective health behaviors (Chida et al. 2009). Several religious communities promote healthy lifestyles associated with tobacco use, alcohol consumption, and diet. An examination of literature found a reduced risk for cancer in these communities (Hoff et al. 2008). Spiritual well-being has also been recognized as an important internal resource for helping people cope with illness. For instance, a study conducted at the University of Michigan found that 93% of the women undergoing cancer treatment indicated that their religious lives helped them sustain their hope (Roberts et al. 1997). Studies have found that a large percentage of patients want their physicians to consider their spiritual needs, and almost half expressed a desire for the physicians to pray with them if they could (see Post et al. 2000).

Figure 2–1 The Four Dimensions of Holistic Health.

The spiritual dimension is frequently tied to one’s religious beliefs, values, morals, and practices. Broadly, it is described as meaning, purpose, and fulfillment in life; hope and will to live; faith; and a person’s relationship with God (Marwick 1995; Ross 1995; Swanson 1995). A clinically tested scale to measure spiritual wellbeing included categories such as belief in a power greater than oneself, purpose in life, faith, trust in providence, prayer, meditation, group worship, ability to forgive, and gratitude for life (Hatch et al. 1998).

The Committee on Religion and Psychiatry of the American Psychiatric Association has issued a position statement to emphasize the importance of maintaining respect for a patient’s religious/spiritual beliefs. For the first time, “religious or spiritual problem” was included as a diagnostic category in DSM-5.1 The holistic approach to health also alludes to the need for incorporating alternative therapies (discussed in Chapter 7) into the predominant medical model.

Quality of Life

The term quality of life is used to capture the essence of overall satisfaction with life during and following a person’s encounter with the health care delivery system. Thus, the term is employed in two ways. First, it is an indicator of how satisfied a person is with the experiences while receiving health care. Specific life domains, such as comfort factors, respect, privacy, security, degree of independence, decision-making autonomy, and attention to personal preferences are significant to most people. These factors are now regarded as rights that patients can demand during any type of health care encounter. Second, quality of life can refer to a person’s overall satisfaction with life and with self-perceptions of health, particularly after some medical intervention. The implication is that desirable processes during medical treatment and successful outcomes would, subsequently, have a positive effect on an individual’s ability to function, carry out social roles and obligations, and have a sense of fulfillment and self-worth.

Risk Factors and Disease

The occurrence of disease involves more than just a single factor. For example, the mere presence of tubercle bacillus does not mean the infected person will develop tuberculosis. Other factors, such as poverty, overcrowding, and malnutrition, may be essential for development of the disease (Friedman 1980). Hence, tracing risk factors —attributes that increase the likelihood of developing a particular disease or negative health condition in the future—requires a broad approach. One useful explanation of disease occurrence (for communicable diseases, in particular) is provided by the tripartite model, sometimes referred to as the Epidemiology2 Triangle (Figure 2–2). Of the three entities in this model, the host is the organism—generally, a human—that becomes sick. Factors associated with the host include genetic makeup, level of immunity, fitness, and personal habits and behaviors. However, for the host to become sick, an agent must be present, although presence of an agent does not ensure that disease will occur. In the previous example, tubercle bacillus is the agent for tuberculosis. Other examples are chemical agents, radiation, tobacco smoke, dietary indiscretions, and nutritional deficiencies. The third entity, environment , is external to the host and includes the physical, social, cultural, and economic aspects of the environment. Examples include sanitation, air pollution, anthro-cultural beliefs, social equity, social norms, and economic status. The environmental factors play a moderating role that can either enhance or reduce susceptibility to disease. Because the three entities often interact to produce disease, disease prevention efforts should focus on a broad approach to mitigate or eliminate risk factors associated with all three entities.

Figure 2–2 The Epidemiology Triangle.

Behavioral Risk Factors

Certain individual behaviors and personal lifestyle choices represent important risk factors for illness and disease. For example, smoking has been identified as the leading cause of preventable disease and death in the United States, because it significantly increases the risk of heart disease, stroke, lung cancer, and chronic lung disease (DHHS 2004). Substance abuse, inadequate physical exercise, a high-fat diet, irresponsible use of motor vehicles, and unsafe sex are additional examples of behavioral risk factors. (Table 2–1 presents the percentage of the US population with selected behavioral risks.)

Acute, Subacute, and Chronic Conditions

Disease can be classified as acute, subacute, or chronic. An acute condition is relatively severe, episodic (of short duration), and often treatable and subject to recovery. Treatments are generally provided in a hospital. Examples of acute conditions are a sudden interruption of kidney function or a myocardial infarction (heart attack). A subacute condition is a less severe phase of an acute illness. It can be a postacute condition, requiring continuity of treatment after discharge from a hospital. Examples include ventilator and head trauma care. A chronic condition is one that persists over time, is not severe, but is generally irreversible. A chronic condition may be kept under control through appropriate medical treatment, but if left untreated, the condition may lead to severe and life-threatening health problems. Examples of chronic conditions are hypertension, asthma, arthritis, heart disease, and diabetes. Contributors to chronic disease include ethnic, cultural, and behavioral factors and the social and physical environment, discussed later in this chapter.

Table 2–1 Percentage of US Population with Behavioral Risks

Behavioral Risks

Percentage of Population

Year

Alcohol (12 years and over)

51.8

2010

Marijuana (12 years and over)

6.9

2010

Cocaine use (12th graders)

1.1

2011

Cocaine use (10th graders)

0.7

2011

Cocaine use (8th graders)

0.8

2011

Cigarette smoking (18 years and over)

19.0

2011

Hypertension (20 years and over)

31.9

2009–10

Overweight (20–74 years)

68.5

2007–10

Serum cholesterol (20 years and over)

13.6

2009–10

Note: Data are based on household interviews of a sample of the civilian noninstitutionalized population 12 years of age and over in the coterminous United States.

Source: Data from National Center for Health Statistics. Health, United States, 2009. Hyattsville, MD: US Department of Health and Human Services, 2012, pp. 276, 281, 283, 292, 293, 301.

In the United States, chronic diseases have become the leading cause of death and disability. Almost 50% of Americans have at least one chronic illness (Robert Wood Johnson Foundation 2010), and 8.7 out of every 10 deaths are attributable to chronic disease (WHO 2011). Among both the younger and older age groups (ages 18 and up), hypertension was ranked the most common chronic condition, followed by cholesterol disorders. Among children up to age 17, respiratory diseases and asthma were the most common chronic conditions (Agency for Healthcare Research and Quality 2006). The incidence of childhood chronic diseases has almost quadrupled over the past four decades, mostly due to a threefold increase in childhood obesity (PFCD 2009). Moreover, 26% of adults aged 18 or older had multiple chronic conditions in 2010. The combination of arthritis and hypertension was the most common dyad, and the combination of arthritis, hypertension, and diabetes was the most common triad (Ward and Schiller 2010).

It is estimated that 75% of total health expenditures in the United States are attributable to the treatment of chronic conditions (PFCD 2009). In 2011, total health care costs associated with the treatment of chronic diseases were approximately $1.7 trillion (PFCD 2009). In addition, health disparities continue to be a serious threat to the health and well-being of some population groups. For example, African American, Hispanic, American Indian, and Alaskan Native adults are twice as likely as white adults to have diabetes (CDC 2010a).

There are three main reasons behind the rise of chronic conditions in the US population: (1) New diagnostic methods, medical procedures, and pharmaceuticals have significantly improved the treatment of acute illnesses, survival rates, and longevity, but these achievements have come at the consequence of a larger number of people living with chronic conditions. The prevalence of chronic disease is expected to continue to rise with an aging population and longer life expectancy. (2) Screening and diagnosis have expanded in scope, frequency, and accuracy (Robert Wood Johnson Foundation 2010). (3) Lifestyle choices, such as high-salt and high-fat diets and sedentary lifestyles, are risk factors that contribute to the development of chronic conditions. To address these issues, the DHHS launched a comprehensive initiative with the aid of $650 million allocated under the American Recovery and Reinvestment Act of 2009. The goal of this initiative—Communities Putting Prevention to Work—is to “reduce risk factors, prevent/delay chronic disease, promote wellness in children and adults, and provide positive, sustainable health change in communities” (DHHS 2010a).

Health Promotion and Disease Prevention

A program of health promotion and disease prevention is built on three main principles: (1) An understanding of risk factors associated with host, agent, and/or environment. Risk factors and their health consequences are evaluated through a process called health risk appraisal . Only when the risk factors and their health consequences are known can interventions be developed to help individuals adopt healthier lifestyles. (2) Interventions for counteracting the key risk factors include two main approaches: (a) behavior modification geared toward the goal of adopting healthier lifestyles and (b) therapeutic interventions. Both are discussed in the next paragraph. (3) Adequate public health and social services, as discussed later in this chapter, include all health-related services designed to minimize risk factors and their negative effects in order to prevent disease, control disease outbreaks, and contain the spread of infectious agents.

Various avenues can be used for motivating individuals to alter behaviors that may contribute to disease, disability, or death. Behavior can be modified through educational programs and incentives directed at specific high-risk populations. In the case of cigarette smoking, for example, health promotion aims at building people’s knowledge, attitudes, and skills to avoid or quit smoking. It also involves reducing advertisements and other environmental enticements that promote nicotine addiction. Financial incentives/disincentives, such as a higher cigarette tax, have been used to discourage purchase of cigarettes.

Therapeutic interventions fall into three areas of preventive effort: primary prevention, secondary prevention, and tertiary prevention. Primary prevention refers to activities undertaken to reduce the probability that a disease will develop in the future (Kane 1988). Its objective is to restrain the development of a disease or negative health condition before it occurs. Therapeutic intervention would include community health efforts to assist patients in smoking cessation and exercise programs to prevent conditions such as lung cancer and heart disease. Safety training and practices at the workplace can reduce serious work-related injuries. Prenatal care is known to lower infant mortality rates. Immunization has had a greater impact on prevention against childhood diseases and mortality reduction than any other public health intervention besides clean water (Plotkin and Plotkin 1999). Hand washing, refrigeration of foods, garbage collection, sewage treatment, and protection of the water supply are also examples of primary prevention (Timmreck 1994). There have been numerous incidents where emphasis on food safety and proper cooking could have prevented outbreaks of potentially deadly episodes, such as those caused by E. coli.

Secondary prevention refers to early detection and treatment of disease. Health screenings and periodic health examinations are just two examples. Screening for hypertension, cancers, and diabetes, for example, have been instrumental in prescribing early treatment. The main objective of secondary prevention is to block the progression of a disease or an injury from developing into an impairment or disability (Timmreck 1994).

Tertiary prevention refers to interventions that could prevent complications from chronic conditions and prevent further illness, injury, or disability. For example, regular turning of bed-bound patients prevents pressure sores; rehabilitation therapies can prevent permanent disability; and infection control practices in hospitals and nursing homes are designed to prevent iatrogenic illnesses , that is, illnesses or injuries caused by the process of health care.

As shown in Table 2–2, prevention, early detection, and treatment efforts helped reduce cancer mortality quite significantly between 1991 and 2010. This decrease was the first sustained decline since record keeping was instituted in the 1930s.

Disease Prevention Under Health Care Reform

Prevention and wellness have received a great deal of emphasis in the health reform law. The ACA requires Medicare and private health insurance plans to provide a range of preventive services with no out-of-pocket costs (see Chapter 6). As a result, in 2011 and 2012, an estimated 71 million Americans with private insurance gained access to preventive services (DHHS 2013).

The ACA established the Prevention and Public Health Fund (PPHF) which has distributed almost $3.2 billion toward national preventive efforts and toward improving health outcomes and enhancing quality of health care (American Public Health Association 2013). Grants have been issued to reduce chronic diseases. The Office of the Surgeon General has developed a National Prevention Strategy that encourages partnerships among federal, state, tribal, local, and territorial governments; business, industry, and other private sector partners; philanthropic organizations; community and faith-based organizations; and everyday Americans to improve health through prevention (National Prevention Council 2011). The Centers for Disease Control and Prevention (CDC) established a National Diabetes Prevention Program. In 2012, six organizations received $6.75 million to develop partnerships that reach a large numbers of individuals with pre-diabetes (CDC 2013a, 2013b).

Table 2–2 Annual Percent Decline in US Cancer Mortality 1991–2010

Source: Data from National Center for Health Statistics of the Centers for Disease Control and Prevention, National Cancer Institute, SEER Cancer Statistics Review, 1975–2010.

In 2011, $10 million was made available to establish and evaluate comprehensive workplace wellness programs (DHHS 2011b). Beginning in 2014, $200 million in wellness grant funding will be available to small businesses to encourage the formation of wellness programs and employee incentivizing (Anderko et al. 2012).

Public Health

Public health remains poorly understood by its prime beneficiaries, the public. For some people, public health evokes images of a massive social enterprise or welfare system. To others, the term means health care services for everyone. Still another image of public health is that of a body of knowledge and techniques that can be applied to health-related problems (Turnock 1997). However, none of these ideas adequately reflects what public health is.

The Institute of Medicine (IOM) proposed that the mission of public health is to fulfill “society’s interest in assuring conditions in which people can be healthy” (IOM 1988). Public health deals with broad societal concerns about ensuring conditions that promote optimum health for the society as a whole. It involves the application of scientific knowledge to counteract any threats that may jeopardize health and safety of the general population. Because of its extensive scope, the vast majority of public health efforts are carried out by government agencies, such as the CDC in the United States.

Three main distinctions can be seen between the practices of medicine and public health: (1) Medicine focuses on the individual patient—diagnosing symptoms, treating and preventing disease, relieving pain and suffering, and maintaining or restoring normal function. Public health, conversely, focuses on populations (Shi and Johnson 2014). (2) The emphases in modern medicine are on the biological causes of disease and developing treatments and therapies. Public health focuses on (a) identifying the environmental, social, and behavioral risk factors as well as emerging or potential risks that may threaten people’s health and safety, and (b) implementing population-wide interventions to minimize those risk factors (Peters et al. 2001). (3) Medicine focuses on the treatment of disease and recovery of health. Public health deals with various efforts to prevent disease and counteract threats that may negatively affect people’s health.