SEE ALSO communicable disease; definition; Health in All Policies; health policy; health promotion; lifestyle; non-communicable disease; overweight and obesity
Health can be defined as a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity (World Health Organization, 1998).
This definition of health has been criticized for not taking other dimensions into account, namely the emotional, spiritual and societal aspects of health. The definition has also been criticized for viewing health as a state or product rather than as a dynamic relationship, a capacity, a potential or a process and for specifying an idealistic state that is impossible to attain (Ewles and Simnett, 2003). Despite the multiplicity of meanings assigned to our understandings of health, the above WHO definition remains popular in practice.
Health is a fundamental human right and all people should have access to basic resources for health. Health is linked inextricably to social, political and economic conditions, the physical environment and individual lifestyles. A comprehensive understanding of public health implies that all systems and structures which govern social and economic conditions and the physical environment should take account of the implications of their activities in relation to their impact on health (Ewles and Simnett, 2003). Salutogenesis, for example, describes an approach focusing on factors that support human health and well-being, rather than on factors that cause disease. More specifically, the salutogenic approach is concerned with the relationship between health, stress and coping (Antonovsky, 1979).
The public health interpretation of health goes beyond health care and lifestyle to encompass feelings of well-being. Well-being covers a social, physical and mental state and describes a satisfactory condition of existence, characterized by health, happiness and prosperity. Social well-being includes interpersonal relationships as well as wider social issues such as marital satisfaction and community involvement. The role of relations, the family and status at work are important to a person’s social well-being as these help to increase a sense of inclusion, connectedness and self-esteem. Physical well-being is concerned with concepts such as the proper functioning of the body, biological normality and the capacity to perform tasks such that an individual is physically fit and unimpaired. Mental well-being involves concepts such as self-efficacy and social inclusion and is the ability of people to adapt to their environment and the society in which they function (Walker and Marie, 2011).
The way in which people interpret the meaning of their own health is a personal experience and is relative to the environment and culture in which they find themselves. Health can mean different things to different people and can be defined by them in functional terms by their ability to carry out certain roles and responsibilities rather than the absence of disease. People may be willing to bear the discomfort and pain of an illness because it does not outweigh the inconvenience, loss of control or financial cost of having the condition treated (Laverack, 2009).
Some commentators have concluded that it is futile to try and define health and well-being because they are too subjective and complex and are better framed within the context of the services offered and that society can afford (Jadad and O’Grady, 2008). In practice, health is considered to be a means to an end that can be expressed in functional terms as a resource which permits people to lead an individually, socially and economically productive life. Public health has, for the time being, decided to take the pragmatic view that whatever interpretation of health is used it must be measurable and accountable, otherwise programmes will be in jeopardy of being unable to justify their economic and quantifiable effectiveness. This being the case, the measurement of health has focused on the bio-medical approach that is concerned with demonstrating a relationship between a health status measure and a health-related behaviour such as smoking or a condition such as the incidence of lung cancer. The boundaries for practice and discourse have consequently been defined by the interpretations of illness and disease rather than by the way in which most people generally view or feel that they need to maintain their own health.
•Baxter, M. (2010) Health (Key Concepts). 2nd edn (Oxford: Polity Press)
•Jadad, A. and O’Grady, L. (2008) ‘How Should Health Be Defined?’ British Medical Journal. Editorial, 337: a2900
•Walker, P. and Marie, J. (2011) From Public Health to Wellbeing: The New Driver for Policy and Action (Basingstoke: Palgrave Macmillan)
SEE ALSO evidence-based; Health in All Policies; health information systems; health policy
Health economics is a branch of economics concerned with issues related to efficiency, effectiveness, value and behaviour in the production and consumption of health and health care (Glied and Smith, 2013).
A key aim of health economics is to obtain maximum value for money by ensuring not just the clinical-effectiveness but also the cost-effectiveness of health care delivery. Achieving maximum value for money implies a desire to achieve a predetermined objective, at the least cost, and this requires services to be evaluated for their efficiency. This uses a structure which involves the explicit measurement of inputs or costs and outcomes or benefits. Health economics also focuses on the markets for health and health care: the way in which health and health care are produced (supply) and the determinants of how much individuals consume (demand) (Haycox, 2009).
The scope of health economics can be divided into eight distinct topics:
1.What influences health? (other than health care);
2.What is health and what is its value?
3.The demand for health care;
4.The supply of health care;
5.Micro-economic evaluation at the treatment level;
6.The market equilibrium;
7.Evaluation at whole-system level;
8.Planning, budgeting and monitoring mechanisms (Williams, 1987).
Economic evaluation is often used in public health programmes in terms of cost-effectiveness, cost-benefit and cost-utility analyses, for example, for different injury prevention programmes. The main difference is in the way benefits are measured. Cost-effectiveness uses a single (simple) benefit, cost-utility uses a composite benefit typically incorporating mortality and morbidity and cost-benefit values benefits in monetary terms. Cost-effectiveness analysis is a popular means of evaluation and ‘compares the costs and health effects of an intervention to assess the extent to which it can be regarded as providing value for money and to better inform where to allocate healthcare resources’ (Phillips, 2009, p.1). The consequences of different interventions are measured using a single outcome – for example, life years gained, deaths avoided, heart attacks avoided or cases detected. Alternative interventions are then compared in terms of cost per unit of effectiveness. Cost-effectiveness analysis can therefore indicate which one of a number of alternative interventions represents the best value for money, but it is not as useful when comparisons need to be made across different areas of health care, since the outcome measures used may be very different. The quality of cost-effectiveness analyses is also dependent on the quality of the data used and should therefore include a sensitivity analysis to test the extent to which changes in the parameters used in the analysis may affect the results obtained. Cost-effectiveness is one of a number of criteria that are used in determining whether interventions are made available as other issues such as equity, needs and priorities should also form part of the decision-making process (Phillips, 2009).
As an applied sub-discipline of economics, health economics has become dominated by a medical model of health and by the influence of the needs of the pharmaceutical industry, in which the main function is health care rather than a broader socio-environmental approach. Health economics is also beset by uncertainty concerning the exactness of costs and benefits in health care with a growing need to balance the science on clinical and cost-effectiveness through the application of a broader evidence-based approach (Haycox, 2009). This would include not only the scientific evidence but also the judgement (knowledge and experience) of the practitioner and of their professional partners including health care professionals and patients.
•Glied, S. and Smith, P. (eds) (2013) The Oxford Handbook of Health Economics. Reprint edn (Oxford: Oxford University Press)
•Guinness, L. and Wiseman, V. (2011) Introduction to Health Economics (Understanding Public Health). 2nd edn (London: Open University Press)
•McPake, B., Normand, C. and Smith, S. (2013) Health Economics: An International Perspective. 3rd edn (London: Routledge)
SEE ALSO epidemiology; health information systems; health policy; needs assessment; policy change
Health Impact Assessment (HIA) is the assessment of the health effects, positive or negative, of a project, programme or policy. It is concerned with the future consequences of plans, proposals and policies on the health of communities and populations (Birley, 2011).
Health Impact Assessment uses a combination of procedures, methods and tools, quantitative, qualitative and participatory techniques and is usually described as following five steps:
1.Screening to determine if an HIA is warranted/required;
2.Scoping to determine which impacts will be considered and the plan for the HIA;
3.Identification and assessment of impacts to determine the magnitude, nature, extent and likelihood of potential health impacts, using a variety of different methods and types of information;
4.Decision-making and recommendations to make explicit the compromises that may have to be made in decision-making;
5.Evaluation, monitoring and follow-up of process and impact evaluation of the HIA and the monitoring and management of any health impacts (International Finance Corporation, 2009).
Two key descriptive terms, comprehensive and rapid appraisal, indicate the different depths of analysis and consultation required for the performance of the HIA. In many situations, a rapid appraisal HIA will be sufficient although it can uncover significant data gaps and indicate the need for a more comprehensive HIA. Typically, rapid appraisal HIAs are subdivided into desktop HIAs and limited in-country HIAs. A desktop HIA is a qualitative review of potential health impacts and is used to internally inform and comment on the proposed design of a project. Limited in-country HIAs use information that is already available or easily accessible and thus no new data collection is required. Data sources may include peer-reviewed scientific literature and grey literature and interviews with key stakeholders. A comprehensive HIA is more likely to be considered for large, complex projects, particularly if resettlement or relocation is involved and requires some type of new data collection in potentially affected areas and for helping to predict changes in health (International Finance Corporation, 2009).
Health Need Assessments (HNAs) generally describe the health needs and health assets of different groups in the local population. The primary function of a HNA is to inform decisions about strategies, service priorities, commissioning and local delivery plans. In contrast with the HIA, which focuses on the proposed development or project in relation to the community, the starting point of the HNA is the existing health problems, deficiencies and assets in a community, unrelated to a proposed project (Cavanagh and Chadwick, 2005).
The International Association for Impact Assessment (IAIA) is the leading global network on best practice in the use of impact assessment for informed decision-making regarding policies, plans and projects. Safeguard policies and standards of the International Finance Corporation (IFC) were established in 2006 and provide the internationally agreed requirements and guidelines to direct theory and best practice for HIA, especially for large-scale, complex projects (International Finance Corporation, 2009).
HIA is primarily concerned with the future consequences of plans, proposals and policies on the health of communities and their engagement in the process of assessment. For example, transport is a major factor in traffic injuries, air pollution and noise and the impact assessment of healthy transport policy can help reduce these risks. The engagement of communities in the process can also help to promote physical activity such as the use of walking and cycling tracks (Taylor, Gowman and Quigley, 2003). HIA can help civil society organizations to make choices about improvements to policy, for example, when having to deal with conflicting evidence on the benefits of screening for breast cancer using mammography (Smith, 2002). However, as is the case with other approaches that engage with communities for the purpose of data collection, HIA can present problems in regard to who represents the majority and can allow those in authority to claim that all sides were considered whilst only a few benefit from engaging in the process.
KEY TEXTS
•Birley, M. (2011) Health Impact Assessment: Principles and Practice (London: Routledge)
•Cavanagh, S. and Chadwick, K. (2005) Health Needs Assessment: A Practical Guide (London: National Institute for Health and Clinical Excellence (NICE))
•Kimm, J. Parry, J. and Palmer, S. (2004) Health Impact Assessment: Concepts, Theory, Techniques and Applications (Oxford: Oxford University Press)
SEE ALSO definition; health policy; health promotion; injury; policy change
Health in All Policies (HiAP) is an approach that cuts across sectors and systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve population health and health equity (WHO, 2014).
HiAP reflects the principles of legitimacy, accountability, transparency and access to information, participation, sustainability and collaboration across sectors and at different levels of government. It is an approach which emphasizes that health and well-being are influenced by government sectors other than health and highlights the connections and interactions between different policies. A HiAP approach improves accountability of policymakers for health impacts at all levels of policymaking and includes an emphasis on the consequences of policies on health systems, determinants of health and contributes to sustainable development. By considering health impacts across all policies such as agriculture, education, the environment, housing and transport, health outcomes can be better achieved (WHO, 2008). Health in All Policies is designed to complement a whole of government (WoG) approach which focuses on public coherence, coordination and efficiency. When a health issue is not a WoG priority, then the HiAP approach can be used to engage and support other sectors to deliver the desired health and equity outcomes. Therefore if policies that serve economic goals want to improve human conditions they must include health as an explicit policy objective.
The six key components that need to be addressed in order to put the HiAP approach into action are (1) establish the need and priorities for HiAP; (2) frame planned action; (3) identify supportive structures and processes; (4) facilitate assessment and engagement; (5) ensure monitoring, evaluation and reporting; (6) build capacity. Although governments have the responsibility for the health of their citizens, health authorities at all levels (national, regional, local) are key actors in promoting HiAP. However, there is no single model for health authorities to follow to put the HiAP approach into action and the six components detailed above must therefore be used in ways that best suit their own political and cultural situations (WHO, 2014).
Road traffic injury accounted for 2.4 million unintentional deaths globally in 2004 and the level of mortality is predicted to increase by 65% before 2020 (WHO, 2004a). The Swedish Road and Traffic Safety Agency contributed significantly to improved population health by pushing for the enactment of the Road Traffic Safety Bill in 1997 aiming to reduce road traffic fatalities to zero by 2020. This policy used a systems approach that brought together the transport, justice, environment, health and education sectors, and established partnerships with the private sector and civil society. The Swedish health authorities also worked alongside the country’s emergency services to reduce fatalities and to improve health outcomes. Through the police, road safety measures such as speed limits, seat-belt use and random breath testing were enforced, while civil society organizations and the private sector promoted safe driving. The HiAP policy approach had led to a fall in the numbers of fatal road crashes from 9.1 deaths per 100,000 in 1990 to 2.8 deaths per 100,000 in 2010, despite a significant increase in traffic volumes (International Road Traffic and Accident Database, 2012).
HiAP is considered to be a work in progress to which actors in many countries and at many levels are continuing to contribute guided by the World Health Organization Health in All Policies Framework For Country Action (WHO, 2014).
KEY TEXTS
•International Road Traffic and Accident Database (IRTAD) (2012) Road Safety Annual Report 2011. Paris: OECD/International Transport Forum. Available at http://www.stop100.ca/roadsafetyreport.pdf. Accessed 20 December 2013
•Leppo, K. (2013) ‘Health in All Policies: Seizing Opportunities, Implementing Policies’. Ministry of Social Affairs and Health, Finland. Available at http://www.euro.who.int/__data/assets/pdf_file/0007/188809/Health-in-All-Policies-final.pdf. Accessed 20 January 2014
•World Health Organization (2014) Health in All Policies (HiAP) Framework For Country Action. January 2014 (Geneva: World Health Organization)
SEE ALSO epidemiology; evidence based; Health in All Policies; Health Impact Assessment
Health information systems are an integrated effort to collect, process, report and use health information and other knowledge to influence policymaking, programme action and research (Lippeveld, 2001).
Health information systems include a wide range of population-based and health facility-based data sources. The main population-based sources of health information are census, household surveys and registration systems. Examples of the use of health information systems for data collection at the population level include the 30 cluster-sample surveys of the Expanded Programme on Immunization (EPI), health-oriented demographic and health surveys, household surveys designed to measure the use of health care services, service-generated data derived from facilities and patient–provider interactions covering aspects such as quality of care (AbouZahr and Boerma, 2005).
The main health facility-related data sources are public health surveillance, health services data and health system monitoring data. The health information system is part of both the health system and the wider statistical data collection system and accountability is often distributed across different agencies. At the level of individuals and communities, information is needed for effective clinical management and for assessing the extent to which services are meeting the needs and demands of communities. At the level of the district, health information enables health planners and managers to take decisions regarding the effective functioning of health facilities and of the health system (WHO, 2000a).
Quality of care is a systematic process that allows the effective design and implementation of interventions to promote quality in health systems. It has a particular relevance to professionals who have a strategic responsibility for quality so that they can create a more enabling environment for all the quality improvement initiatives being undertaken at the medical care level (WHO, 2006). This can include changes in how the health system is financed, the ownership of health care delivery organizations, systems of accountability and models of care. It is sometimes called whole-system reform and focuses on three key dimensions within a health system: efficiency, effectiveness and accessibility. A health system, also called a health care system, is the organization of people, institutions and resources to deliver health care services to meet the needs of target populations. There is a wide variety of health systems managed by governments, charities, faith organizations, the private sector and other coordinated bodies to deliver planned health care services (WHO, 2000a).
Screening is designed to identify disease early, thus enabling prevention management and treatment to reduce mortality (Raffle and Muir Gray, 2007) and to provide valuable data for health information systems. The systematic, ongoing collection, collation and analysis of health-related information through screening are important with communicable disease prevention because of its infectious nature and the rapid spread that can result in the population. Information therefore has to come from reliable sources, including reported cases of communicable diseases, hospital admissions, laboratory reports, population surveys, reports of absence from school or work and reported causes of death (PHAC, 2013).
The challenges of implementing health information systems can be illustrated by the Millennium Development Goals which have a strong health component but for which few countries have sufficiently developed systems to permit regular monitoring. Health information systems have been criticized for being too heavily biased towards quantitative data, health status and mortality data and for the quantification of associations between health outcomes and risk or protective factors (AbouZahr and Boerma, 2005). Health information systems have also been criticized for the discrepancies that can arise when using different data collection methods for the same indicators, for example, the proportion of the population with access to an improved water source can be generated using household surveys and administrative data. However, these two sources of data would use different tools to measure the same indicator and tend to contain systematic biases in one or the other that if not clearly understood can create confusion and contradiction (Carraro et al., 2003).
Increasing the emphasis on the need for an evidence-based approach to public health is creating the demand for data generated through reliable and transparent health information systems. The resources, capacity and responsibility that are needed address the data supply side of the health information system but equally as important is the demand side. For example, who needs the data and what do they need it for? In practice, decision-making in health is often based on political opportunism and expediency without the systems being in place that are necessary to provide reliable information (AbouZahr and Boerma, 2005).
KEY TEXTS
•AbouZahr, C. and Boerma, T. (2005) ‘Health Information Systems: The Foundations of Public Health’, World Health Organisation Bulletin, 83 (8): pp. 578–583
•Wager, K., Lee, F. and Glaser, J. (2013) Health Care Information Systems: A Practical Approach for Health Care Management. 3rd edn (New York/Toronto: John Wiley & sons)
•World Health Organization (2000a) ‘Health Systems: Improving Performance’. The World Health Report 2000 (Geneva: World Health Organization)
SEE ALSO empowerment; participation; social movements
A health network is a structure of relationships, both personal and professional, through which individuals maintain and receive emotional support, resources, services and information for the improvement of their health and well-being (Walker, MacBride and Vachon, 1977).
Networks set a context within groups, formal organizations and institutions for those who work in or are served by them, which, in turn, affects what people do, how they feel and what happens to them (Wright, 1997). A network is therefore a structure of relationships linking social actors (Wasserman and Faust, 1994) that in turn are the building blocks of human experience, mapping the connections that individuals have to one another (Pescosolido, 1991). Social structures are not based therefore on categorizations such as age, gender or race but on the actual nature of the social contacts that individuals have and the impact on people’s lives (White, 1992).
Networks can be an indication of related health behaviour, for example, the biological and behavioural traits associated with obesity appear to be spread through social ties. People who experience the weight gain of others in their social networks may then more readily accept weight gain in themselves. Moreover, social distance was more important than geographic distance within networks and there was an important role for a process involving the induction and person-to-person spread of obesity. Peer support interventions that allow for a modification of people’s social networks are more successful than those that do not. Social networks can be used to also spread positive health behaviours because people’s perceptions of their own risk of illness depend on the people around them (Christakis and Fowler, 2007).
In a fundamental way, our health is a reflection of the quality of our relationships with one another and social networks offer many people the opportunity to strengthen the level of social capital in their lives. Social capital in the form of trust, social norms of reciprocity and cooperation resides in relationships, not individuals, and therefore in the social networks in which they participate. Active participation within social networks builds the trust and cohesiveness between individuals that are important to mobilize and create the resources necessary to support collective action. Social capital is a feature of social organization in which people invest in and use the resources embedded in networks because they expect returns of some sort although resources are not equally available to everyone and are differentially distributed across groups in society (Lin, 2000).
The Patients Association (UK) is a health network about common patient issues, for better information and for better support. The most frequent complaints received were poor communication, toileting, pain relief, nutrition and hydration. The Association addresses the shared concerns of its members including the duty to refer, for patients to be able to trust that their doctors are making sure they are getting access to the best treatment. Access to information is the best way to ensure this is happening and patient support groups are ideally placed to provide this service. Doctors cannot be experts in all fields and so it is important for them to be able to direct patients to other organizations which have the expertise. Doctors can then actively support patients in finding support groups and other networks that could help them with managing their condition (Patients Association, 2011).
Health networks require significant investment for both their establishment and maintenance and may absorb rather than unlock resources, at least in the short term. Networks also require a non-hierarchical management style which allows an interaction between its members but that is in contrast to the bureaucratic and hierarchical style of the public health sector, making collaboration sometimes difficult.
KEY TEXTS
•Christakis, N. A. and Fowler, J. H. (2007) ‘The Spread of Obesity in a Large Social Network Over 32 Years’, New England Journal of Medicine, 357 (4): pp. 370–379
•Pescosolido, B. A. (1991) ‘Illness Careers and Network Ties: A Conceptual Approach of Utilization and Compliance’ in G. Albrecht and J. Levy. (eds), Advances in Medical Sociology (Greenwich, CT: JAI Press), pp. 161–184
•Wasserman, S. and Faust. K. B. (1994) Social Network Analysis: Methods and Applications (New York: Cambridge University Press)
SEE ALSO activism; child protection; counter tactics; Health in All Policies; inequalities agenda; policy change; social movements; tobacco control
Health policy is concerned with the financing and operation of health care services through taking decisions, setting goals and stating ways to address these goals through, for example, projects, legislation, guidelines and codes of practice (Brown, 1992).
Health policy includes decisions, plans and actions that are undertaken to achieve health care goals for the short and medium term often as part of a government vision. Health policy differs from healthy public policy that embraces a holistic approach to health, to the impact of existing health policies and to health problems at an individual, community and population level. Health policy provides priorities, roles and responsibilities of the different stakeholders, builds consensus and aims to inform people. Health policy can focus on particular areas including personal health care, pharmaceuticals, vaccination, tobacco control and breast feeding. Health policy also covers health financing and the delivery of health care, access to care, quality of care and health equity. Health policy reform typically attempts to broaden the population that receives health care coverage, to expand the range of health care providers, to improve the access to health care specialists and the quality of health care and to decrease the cost of health care.
Healthy public policy covers a range of activities and decisions that cut across a number of different sectors – for example, housing, transport and employment – and that influence quality of life, well-being and health (Baum, 2008). Healthy public policy engages with a wide range of interest groups including consumers, government services, non-government organizations, pressure groups and the commercial sector. Because of the range of issues that healthy public policy addresses including tobacco and alcohol, its formulation and development can be the target for pressure and advocacy groups. The competing interests involved in many healthy public policy decisions means that its implementation can result in challenging the power of some groups who have a great deal of influence and wish to protect the interests of their shareholders, employees and members.
Healthy public policy can overlap with social policy as this also focuses on aspects of the economy, society and politics (Dixey et al., 2013). Social policy primarily refers to guidelines, principles, legislation and activities that affect the living conditions conducive to welfare. Social policy can therefore be described as actions that affect the well-being of members of a society through shaping the distribution of and access to goods and resources in that society. Social policy aims to improve well-being and welfare and to address population needs including employment, social security, social housing, education, health insurance, child protection, social exclusion and pensions (Cheyne et al., 2009).
Health stewardship refers to the wide range of functions carried out by governments as they seek to achieve national health policy objectives often framed in terms of equity, coverage, access, quality and patients’ rights and the role of the third sector in the provision and financing of health care. Stewardship is a political process that is concerned with managing resources to build capacity for leadership and to strengthen national health management systems. This requires a better understanding of what constitutes as being evidence-based and of what is best practice in delivering health policy (Robinson, 2012).
A particular problem in developing health policy can be defining a link between a specific policy intervention and an improvement in a specific health outcome. This is because the causes of poor health are complex involving the social, economic and political determinants of people’s lives. There can also be large differences in these determinants between population groups, often within the same locality (Labonte and Laverack, 2008). Developing policy solutions therefore involves the use of a range of inter-sectoral strategies (Gauld 2006) and a sensitivity to its intrinsic political nature that should involve the communities they are designed to benefit (Yeatman 1998). Health in All Policies, for example, is an approach which recognizes that health and well-being are influenced by government sectors other than health. It highlights the connections and interactions between different policies in agriculture, education, the environment, housing and transport and the impact that these can have on health outcomes (World Health Organization, 2014b).
KEY TEXTS
•Clavier, C. and de Leeuw, E. (eds) (2013) Health Promotion and the Policy Process (Oxford: Oxford University Press)
•Hunter, D. (2003) Public Health Policy (Cambridge: Polity Press)
•Robinson, J. (2012) Toward Healthcare Resource Stewardship: Health Care Issues, Costs, and Access (New York: Nova Science Publishers Inc)
SEE ALSO behaviour change; capacity building; community; definition; empowerment; hygiene; volunteerism
Health promotion remains a contested concept and whilst there is no singularly accepted definition, it can be broadly interpreted as aiming to enable people to take more control over the determinants of their lives and health. Health promotion is both a set of principles involving equity and empowerment and a practice encompassing a range of communication, capacity building, training and politically orientated activities. Health promoters try to increase the assets and attributes of individuals, groups, organizations and communities to gain more control over decisions and resources regarding their health and well-being (Laverack, 2014).
‘Health promotion represents a comprehensive social and political process, embracing actions directed at strengthening the skills and capabilities of individuals, and actions directed at changing social, environmental and economic conditions so as to alleviate their impact on health’ (WHO, 1998). In practice it is often this broad WHO interpretation of health promotion, stated in the Ottawa and the Bangkok Charters, that is commonly used and can be summarized as: health promotion is the process of enabling people to increase control over, and to improve, their health and its determinants (WHO, 1986, 2005a).
The concept of empowerment has been formalized in two key health promotion charters: the Ottawa Charter for Health Promotion (WHO, 1986) and the Bangkok Charter for Health Promotion in a Globalized World (WHO, 2005a). In the 20 years, in-between the publication of these two charters the core theme of empowerment has remained unchanged in which practitioners act as facilitators to assist their clients to gain more power. Individual and collective empowerment is central to both health promotion theory and practice.
Health promotion practice is set within the design of an intervention, a project or a programme, most often controlled by government departments, agencies or (government-funded) non-governmental organizations. It is usually managed and monitored by a practitioner and addresses prioritized concerns, stated as aims and objectives, identifying in advance suitable indicators of progress and the assessment of risks. Practitioners are employed to deliver information, resources and services and are often seen as an outside agent to the people who benefit from the programme. Although many countries have a dedicated health promotion workforce, the greater human resource is to be found among the wider health workforce such as nursing and in sectors other than health, for example, in education and social welfare, and from the actions of lay persons within civil society. The clients cover the range of people with whom health promoters work including women, adolescents, the homeless, men and other professional groups (Laverack, 2005).
The term ‘supportive environments’ is used in some definitions of health promotion to mean the protection of people from threats to health and to enable people to expand their capabilities and to develop self-reliance in health. Supportive environments encompass where people live, their local community, their home, where they work and play, including people’s access to resources for health and opportunities for empowerment. Action to create supportive environments for health includes policies and regulations to foster sustainable economic development and social action (WHO, 1998).
Infrastructure for health promotion refers to those ‘human and material resources, organizational and administrative structures, policies, regulations and incentives which facilitate an organized response to health issues and challenges’ (WHO, 1998, p. 14). Infrastructures for health promotion may be found through a diverse range of organizational structures, including primary health care, government, private sector and non-governmental organizations, self-help organizations and foundations. They can also be found through the extent of public and political awareness of health issues, and participation in action to address those issues.
Health education is traditionally regarded to represent planned opportunities for people to learn about health and to make changes to their behaviour. Health education provides the latest technical information, motivating people to change unhealthy behaviours and giving people the necessary skills and confidence to make those changes (Naidoo and Wills, 2009). There is sometimes confusion about the differences between health promotion and health education. The most practical way forward is to view health promotion as encompassing health education as a range of educational and awareness-raising activities.
KEY TEXTS
•Ewles, L. and Simnett, I. (2003) Promoting Health: A Practical Guide (London: Bailliere Tindall)
•Keleher, H., Mac Dougall, C. and Murphy, B. (2007) Understanding Health Promotion (Melbourne: Oxford University Press)
•Tones, K. and Green, J. (2004) Health Promotion: Planning and Strategies (London: Sage)
SEE ALSO globalization; health information systems; risk communication; volunteerism
Human resources for health also known as health human resources or the health workforce are all people engaged in actions whose primary intent is to enhance health. Human resources for health deals with the planning, development, performance, management, staff retention, research and development for the health care sector (WHO, 2006a).
Statistical information on human resources for health are collated in the Global Atlas of the Health Workforce (WHO, 2014a), which estimates that in 2006 there were over 59 million full-time paid health workers worldwide. Health workers include doctors, nurses, midwives, dentists, allied health professionals, social workers, management and support staff and health supply chain managers. There is also an estimated shortage of almost 4.3 million doctors, midwives, skilled birth attendants, nurses and support workers worldwide; this is most severe in Sub-Saharan Africa (WHO, 2006a). Shortages of skilled workers are pronounced in specific areas of care, for example, in 2005 a shortage in mental health was estimated at 1.18 million workers, including 55,000 psychiatrists, 628,000 nurses in mental health settings and 493,000 psychosocial care providers (WHO, 2011a).
There is a mal-distribution of professional and skilled health workers which can lead to localized shortages of staff in remote and rural areas within countries; for example, in Vietnam about 53% of physicians are concentrated in urban areas where only 28% of the population lives. Policies for the recruitment and retention in rural and remote areas need to combine different packages of interventions according to the factors influencing the health worker’s decision and match their preferences and expectations influencing their employment decisions (Araujo and Maeda, 2013).
The geographical distribution of health workers is skewed towards urban and wealthier areas. The reasons for health worker shortages is complex; in Sub-Saharan Africa, for example, this has been attributed to past investment shortfalls in pre-service training, international migration, career changes among health workers and premature retirement. In 2005 it was estimated that 25% of all doctors and 5% of all nurses trained in Sub-Saharan Africa had emigrated to work in OECD member countries (WHO, 2006a). Demographic and epidemiological transitions drive changes in health worker needs, social, welfare and financial policies. Technological advances and consumer expectations can also dramatically shift demands on the health workforce who may seek opportunities and job security in other labour markets that are part of the global political economy. Shifting labour markets have intensified professional concentrations in urban areas and accelerated international migration from the poor to wealthier countries where there are resources to pay for health workers. The consequent workforce crisis is characterized by severe staff shortages, inappropriate skill mixes and gaps in service delivery (WHO, 2006a).
An essential component of planned human resources for health is therefore a supply and demand modelling of all stages from entry to health training, to job recruitment through to retirement. This can help to provide an evidence base for policy development to guide workforce sustainability. However, in resource-poor countries the human resources for health can be driven by the needs of targeted health programmes or projects, for example, those responding to the recruitment needs of meeting the Millennium Development Goals (Dreesch et al., 2005).
The Global Code of Practice on the International Recruitment of Health Personnel, adopted by the 63rd World Health Assembly in 2010, provides an international policy framework for addressing shortages and mal-distribution of health professionals. Although non-binding on member states and recruitment agencies, the Code promotes principles and practices for the ethical international recruitment of health personnel. Member states should discourage active recruitment of health personnel from developing countries facing critical shortages of health workers. The code also advocates the strengthening of health worker information systems to support effective workforce policies and planning at the national and international levels. This is important because the international evidence base for human resources for health remains incomplete and requires a comprehensive information system within all countries to be able to provide more accurate information (WHO, 2010a).
Pre-service education, training and mentorship are important short-term strategies to strengthen human health resources, institutional capacity and to foster sustainability of training curricula. Health worker retention and performance at local and national facilities can also be enhanced by improving the remuneration and working conditions of health workers, addressing unemployment, using telemedicine and encouraging short-term in-migration from surplus to deficit countries, making investments in infrastructure improvement, ensuring adequate equipment, and supplies, improving workplace safety and by improving supervision.
The future challenges for human resources for health include staff mobilization to address specific health issues such as chronic diseases and new paradigms of care that are driving a shift from acute tertiary hospital care to patient-centred, home-based and team-driven care. This will require new skills and competencies for health workers. Health crises and emergencies such as epidemics, natural disasters and conflict require special skills by health workers including coordinated planning, risk communication, rapid mobilization and control responses. Specialized workforce capacities are also needed for the surveillance of epidemics and workforce preparedness based on local capacity. The tasks and functions required will be very demanding but must be integrated into coherent national health systems (WHO, 2006a).
KEY TEXTS
•Araujo, E. and Maeda, A. (2013) ‘How to Recruit and Retain Health Workers in Rural and Remote Areas in Developing Countries’. Health, Nutrition and Population (HNP) Discussion Paper (Washington DC: World Bank)
•World Health Organization (2006) ‘Working Together for Health’. The World Health Report (Geneva: World Health Organization)
•World Health Organization (2014) Global Atlas of the Health Workforce. Online Database. Available at http://www.who.int/globalatlas/autologin/hrh_login.asp. Accessed 28 April 2014
SEE ALSO behaviour change; communicable disease; health promotion; Maternal, Newborn and Child Health; peer education
Hygiene refers to conditions and practices that help to maintain health and prevent the spread of diseases. Good hygiene is theoretically capable of reducing most instances of infection with pathogens transmitted, for example, by the faecal-oral route (Curtis and Cairncross, 2003).
Hygiene practices such as hand-washing with soap after contact with faeces is a simple intervention with potentially large health benefits and if widely practiced can reduce diarrhoea by up to 50% (Curtis and Cairncross, 2003). Hand-washing with soap can also help to reduce respiratory infections, skin diseases, eye infections and intestinal worms. Other hygiene practices, such as the safe disposal of waste and care of domestic animals, are also important to break the chain of infection transmission. Medical hygiene includes a specific set of practices associated with the preservation of health including environmental cleaning, sterilization of equipment, hand hygiene, water and sanitation and safe disposal of medical waste.
Hygiene promotion is a planned approach to preventing communicable diseases, especially diarrhoeal diseases, through the widespread adoption of safe hygiene practices. It begins with systematic data collection to find out and understand what different groups of people know about hygiene, what they do, what they want and why this is so. The results are then used to set objectives and to identify and implement interventions that enable the different groups to considerably reduce risky conditions, to promote hygiene practices and to strengthen positive health behaviours (Appleton and Sijbesma, 2005).
Hygiene promotion can be delivered as a five-step process, as follows:
1.Action with the target communities and the team is initiated;
2.A detailed work plan for the formative research is made;
3.The formative research is carried out;
4.An analysis and report on the results;
5.The results are fed back and discussed with key stakeholders and used to make the hygiene promotion plan (UNICEF, 1999).
PHAST is an approach based on a set of participatory techniques that has demonstrated its ability to promote hygienic behaviour, sanitation improvements, and community management of water and sanitation facilities. PHAST is an acronym for the Participatory Hygiene and Sanitation Transformation approach and was developed in Africa. SARAR is another education and training methodology for working with stakeholders at different levels to engage them for hygiene promotion in planning, problem solving and evaluation. The acronym SARAR stands for: Self-esteem: a sense of self-worth as a person as well as a valuable resource for development; Associative strength: the capacity to define and work towards a common vision through mutual respect, trust and collaborative effort; Resourcefulness: the capacity to visualize new solutions to problems even against the odds, and the willingness to be challenged and take risks; Action planning: combining critical thinking and creativity to come up with new, effective, and reality-based plans in which each participant has a useful and fulfilling role; Responsibility: for follow-through until the commitments made are fully discharged and the hoped-for benefits achieved. SARAR is based on the principle of fostering and strengthening these five attributes among the stakeholders involved in the hygiene promotion programme. SARAR enables the development of people’s capacities for self-direction and management and enhances the quality of participation among all stakeholders (International Water and Sanitation Centre, 2013).
An example of a hygiene promotion project is the ‘Saniya’ intervention in Burkina Faso, Africa. This project targeted the mothers and carers of young children and children of primary school age. The key messages were simply to (1) wash hands after contact with stools and (2) that stools in potties should be disposed of safely in the latrine. The project used youth street theatre, local radio, monthly house-to-house visits, discussion groups, neighbourhood inspection teams and the development of a hygiene curriculum to channel messages to the target audience. The project was evaluated after a three-year period and it was found that half of the mothers and carers could remember the two key messages. Hand-washing after handling children’s stools had increased from 13% to 31% and the number of mothers who washed their hands after using the latrine had increased by 16%. The hygiene promotion intervention had been effective in changing behaviour because it used locally appropriate channels of communication repeated over an extended period of time (Curtis et al., 2001).
The popularity of hygiene promotion needs to be supported by a more evidence-based approach in regard to the costs and long-term sustained effectiveness of interventions so as to be better able to inform decision-makers.
KEY TEXTS
•Appleton, B. and Sijbesma, C. (2005) Hygiene Promotion: Thematic Overview Paper 1. International Water and Sanitation Centre (The Netherlands: Delft)
•International Water and Sanitation Centre (IRC) (2013). Available at http://www.irc.nl/ Accessed 27 February 2013
•UNICEF (1999) A Manual on Health Promotion. Water, Environment and Sanitation Technical Guidelines. Series 6 (New York: UNICEF)