As lifelong public health professionals who have taught public health to undergraduate and gradu- ate students for many years, this was our aim in writing an Introduction to Public Health. These problems are amplified in the United States by the current break- down in civic discourse and the polarization of people and politicians along cultural, political, educational, racial, and economic lines. The conditions that helped us to become a great nation—tolerance of diversity and access to opportunity regardless of race, religion, social status, or family heritage—are threatened. Social justice is under attack.

Economic injustice is on the rise. Yet, public health offers an antidote. We have a proud history of fight- ing for social justice and the conditions needed for health: Clean water; a safe and nutritious food supply; adequate sewage and garbage disposal; safe housing and workplaces; and infectious disease control. These are just a few of the areas of health improvement that public health has pioneered. We have established premier organizations such as the Centers for Disease Control and Prevention and the World Health Organization, which advocate, monitor, and intervene to improve health and well-being for all people. This volume makes no attempt to be a comprehensive description of public health. It was written to provide a framework for understanding this complex field. Further enrichment in the classroom and through assign- ments and exercises will be needed to fill-in the picture.

Our hope is that it will be used to inform those seeking their professional identity and purpose about the values, goals, achievements, practice, and especially promise of public health in the hope that they will join us in working to fulfill that promise as future practitioners of public health. We wish to acknowledge the help of our wonderful students Skye Ostreicher, Chris Gladwin, Dennis Dorf, and Luxi Ji. The meet- ing expresses the public health priorities for that year and gives forum to the full range of current public health issues and activities. Current scientific and educational programs represent all sections, special interest groups, and caucuses. In the APHA annual meeting in Philadelphia, a typical recent year, the 27 sections, 6 special primary interest groups SPIGs , and 17 caucuses were represented.

Among the sections were the following: n฀ Alcohol, Tobacco, and Other Drugs; n฀ Chiropractic Health Care; n฀ Community Health Planning and Policy Development; n฀ International Health; n฀ Maternal and Child Health; n฀ Medical Care; n฀ Mental Health; n฀ Occupational Health and Safety; n฀ Oral Health; n฀ Podiatric Health; n฀ Population, Reproductive and Sexual Health; n฀ Statistics; and n฀ Vision Care. The six SPIGs were the following: n฀ Alternative and Complementary Health Practices; n฀ Community Health Workers; n฀ Ethics; n฀ Health Informatics Information Technology; n฀ Health Law; and n฀ Veterinary Public Health. The theme of the APHA Annual Meeting was Water and Public Health, and sessions directly related to this issue included: n฀ Water, development, and human rights; n฀ Water, women, and maternal mortality; and n฀ Drinking water: source-to-tap public health aspects.

This small sample of topics at one meeting indicates the diversity and abundance of subjects that concern public health professionals. We may have little in common on a day-to-day basis with our fellow public health professionals, and our knowledge base and skills may vary widely from others in our field. However, our mission is the same, and each of us contributes to that mission in some important way, which we will begin to explicate in the coming pages. Before proceeding, though, we need to examine this statement more closely to understand its assumptions and implications. By examining these, we understand our commonalities with other professionals focused on health—particularly the clinical professions such as medicine, nursing, dentistry, physical therapy, and others—as well as our unique role among health professionals.

First, the idea of assuring health for all people—the entire population— is embedded in the mission statement. Although public health will focus on different populations within the larger population when planning services, we are obligated to ensure health-producing conditions for all people—not just the poor, not just the rich, but people of all incomes; not only the young or the old, but people of all ages; not exclusively Whites or Blacks, but people of all races and ethnicities. Public health takes the view held by many professions and societies throughout human history that healthy people are more productive and creative, and these attributes create a strong society.

Healthy people lead to better societies. For the welfare of the society, as a whole, it is better for people to be healthy than sick. Thus, as public health professionals, we believe that society has an interest in the health of the population; it benefits the society, as a whole, when people are healthy. Third, the public health mission acknowledges that health is not guaranteed. However, not everyone will be healthy even if each one exists in health-producing conditions. Public health efforts will not result in every person being healthy—although we certainly would not object to that kind of success. Rather, public health creates conditions in which people can be healthy. Whether any single individual is healthy, we acknowledge, will vary. Chapter 1 Introduction and Overview 5 The fourth and fifth assumptions differentiate public health from the healing, or clinical, professions—medicine, nursing, dentistry, physical therapy, physician assistant, and others—that we will refer to for simplic- ity throughout the remainder of this book as the clinical professions.

All clinical professions believe in the obligation of their practitioners to care for all people in need of their services. Finally, all health care professions believe that improving health is a benefit, not only to the individuals treated, but also to the society, as a whole. Decla- ration of Geneva []. Adopted by the General Assembly of World Medical Association at Geneva Switzerland, September Thus, public health shares with the clinical professions a fundamental caring for humanity through concern for health. For these reasons, public health is sometimes viewed as a type of clinical profession. The critical differences between public health and the clinical professions relate to their strategies for creating a healthy populace. Here, an understanding of the different types of prevention—primary, secondary, and tertiary—is necessary to distinguish between public health and the clinical professions.

Primary, Secondary, and Tertiary Prevention There are three types of prevention: primary, secondary, and tertiary. Fos and Fine define primary, secondary, and tertiary prevention as follows: Primary prevention is concerned with eliminating risk factors for a disease. Secondary prevention focuses on early detection and treatment of disease subclinical and clinical. Tertiary prevention attempts to eliminate or moderate disability associated with advanced disease. Examples of primary prevention include the use of automobile seat belts, condom use, skin protection from ultraviolet light, and tobacco-use cessation programs.

Secondary prevention is concerned with treating disease after it has developed so that there are no permanent adverse consequences; early detection is emphasized. Secondary prevention activities are intended to identify the existence of disease early so that treatments that might not be as effective when applied later can be of benefit. Tertiary prevention often involves limiting disability that occurs if disease and injury are not effectively treated. The central focus of clinical professions is to restore health or pre- vent exacerbation of health problems. Thus, health care is primarily concerned with secondary and tertiary prevention: a early detection, diagnosis, and treatment of conditions that can be cured or reversed secondary prevention ; and b treatment of chronic diseases and other conditions to prevent exacerbation and minimize future complications tertiary prevention.

The health care system undoubtedly has its small- est impact on primary prevention, once again that group of interven- tions that focus on preventing disease, illness, and injury from occurring. These in turn are subsumed under a more general and rapidly growing set of interventions attempting to modify risk factors through transactions between clinicians and individual patients. The boundary becomes blurred between, e. The behaviors of large and powerful organi- zations, or the effects of economic and social policies, public and private, [are] not brought under scrutiny. n฀ I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. n฀ I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks.

But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. My responsibility includes these related problems, if I am to care adequately for the sick. n฀ I will prevent disease whenever I can, for prevention is preferable to cure. n฀ I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. n฀ If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Secondary and Tertiary Prevention and Public Health The public health emphasis on primary prevention does not mean that pub- lic health has no role or interest in secondary and tertiary prevention. On the contrary, public health professionals are vitally interested and involved in secondary and tertiary prevention. However, their focus is on ensuring access to effective clinical care, rather than on providing the care itself. Pre- venting long-term consequences of health problems and limiting the pro- gression of illness, disability, and disease is dependent on access to excellent medical care. Thus, ensuring that all people have health insurance has been an important issue for public health in the United States, as has health care reform that improves the quality and efficiency of health care. Access to pri- mary care and the specialties has historically been a target of public health initiatives.

These include such con- cerns as transportation to health providers, cultural competence of health care providers, health literacy of patients, and efficiency and effectiveness of health care delivery. Health Professional Shortage Areas HPSAs are designated by HRSA as having shortages of primary medical care, dental or mental health providers and may be geo- graphic a county or service area , demographic low income population , or institutional comprehensive health center, federally qualified health center or other public facility. Department of Health and Human Services [DHHS], Through designation of areas and populations as medically underserved, programs responding to their medical needs have been developed.

Public health is vitally interested and involved in the identification of MUPs and MUAs, as well as in the development of pro- grams to meet these needs. However, the language of epidemiology and ecology are preferred to describe the work of public health professionals, as we will explore later in this chapter. In summary, public health is proactive, rather than curative: Do not wait until people get sick and then treat them. Rather, go out and create conditions that promote health and prevent disease, injury, and disability. coli OH7 isolates with a particular DNA fingerprint or pulsed-field gel electrophoresis PFGE pattern reported from 13 states.

Health officials in several states who were investigating reports of E. coli OH7 illnesses in this cluster found that most ill persons had consumed beef, many in restaurants. CDC is continuing to collaborate with state and local health departments in an attempt to gather additional epidemiologic information and share this information with FSIS. At this time, at least some of the illnesses appear to be associated with prod- ucts subject to a recent FSIS recall. Centers for Disease Control and Prevention [CDC], a Thus, public health officials collaborated with physicians, who had diag- nosed and treated patients with the disease, as well as with officials from the U. Public health officials addressed the circumstances in which the infection developed so that others would be spared the illness resulting from exposure to the pathogen. Public health, as a field and as a collection of practicing professionals, will ensure that the environment in which people lead their lives promotes health.

Underlying this mission is a commitment to social justice because it as- sumes that all people are deserving of healthy conditions in which to live— not just the rich, but people of all incomes; not only the young or the old, but people of all ages; not exclusively the majority race or ethnicity, but peo- ple of all races and ethnicities. Public health is a leader and plays an integral role in carrying out this societal obligation. For this reason, public health is often associated with advocating and providing services for the structurally disadvantaged—those with the least power in their social circumstances. As Krieger and Birn argue powerfully: Social justice is the foundation of public health. This powerful proposi- tion—still contested-first emerged around years ago during the forma- tive years of public health as both a modern movement and a profession. It is an assertion that reminds us that public health is indeed a public matter, that societal patterns of disease and death, of health and well-being, of bodily integrity and disintegration, intimately reflect the workings of the body politic for good and for ill.

It is a statement that asks us, pointedly, to remember that worldwide dramatic declines—and continued inequalities- in mortality and morbidity signal as much the victories and defeats of social movements to create a just, fair, caring, and inclusive world as they do the achievements and unresolved challenges of scientific research and tech- nology. To declare that social justice is the foundation of public health is to call upon and nurture that invincible human spirit that led so many of us to enter the field of public health in the first place: a spirit that has a compel- ling desire to make the world a better place, free of misery, inequity, and preventable suffering, a world in which we all can live, love, work, play, ail and die with our dignity intact and our humanity cherished.

How public health has attempted to ensure conditions that promote health is the story of the practice of public health, which we will introduce next. In the answer to this question lies the source of the varied interests, knowledge, and skills that differentiate public health professionals from each other. The causes of poor health are many and complex, and therefore, solutions are complex and diverse, as well. Public health conceptualizes and organizes this complexity by applying the concepts and principles of ecology, which views individuals as embedded within their environment, or context. The ecological approach to understanding how health is either fostered or un- dermined is fundamental to public health practice. However, before we can discuss the practice of public health, that is, the ways that public health professionals attempt to influence context and promote health, we will discuss how we define health and conceptualize the complex set of factors that affect health, called the determinants of health.

How Do We Define Health? Many subsequent definitions have taken an equally broad view of health, including that of the International Epidemio- logical Association: A state characterized by anatomical, physiological and psychological integrity, ability to perform personally valued family, work, and community roles; ability to deal with physical, biological, psychological, and social stress; a feeling of well-being; and freedom from the risk of dis- ease and untimely death. Chapter 1 Introduction and Overview 13 Both definitions exemplify the tendency over the second half of the 20th century to enlarge the definition of health beyond morbidity, disability, and premature mortality to include sense of well-being, ability to adapt to change, and social functioning.

However, in practice, the more limited view of health as diagnosable morbidity, mortality, and disability usually guides public health efforts to improve health status. In this book, as in general public health practice, the term health will refer to the more restricted definition—diagnosable morbidity, disability, and premature mortality. The Determinants of Health There are many influences on individual and population health. As the WHO puts it: Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact.

A brief overview of the determi- nants of health follows. Physical Environment Physical environment includes both the natural and built environments. Health threats arise from both the physical and built environ- ments. Common health threats related to the natural environment include weather-related disasters such as tornados, hurricanes, and earthquakes, as well as exposure to infectious disease agents that are endemic in a region such as Plasmodium falciparum, the microbe that causes malaria and is endemic in Africa. Health threats related to the built environment include exposure to toxins and unsafe conditions, particularly in occupational and residential settings where people spend most of their time. Many occupations expose workers to disease-causing substances, high risk of injury, and other physical risks. For example, the greatest health threats to U. farm workers are in- juries from farm machinery and falls that result in sprains, strains, fractures, and abrasions Myers, Environmental Protection Agency, In residential settings, exposure to pollutants from nearby industrial facilities, power plants, toxic waste sites, or a high volume of traffic presents hazards for many.

In the United States, these threats are increasingly known to have a disproportionately heavy impact on low-income and minority com- munities CDC, ; Institute of Medicine, Social Environment The social environment is defined by the major organizing concepts of hu- man life: society, community, religion, social network, family, and occupation. These formal and informal rules, and the values, beliefs and norms they reflect, have historical roots, and they affect how individuals live and behave; their relationships with others; and what resources and opportunities individuals have to influence their lives. They shape the relationship between individuals and the natural environ- ment and how the built environment is conceived and developed. An important aspect of the social environment is the status, resources, and power that individuals have within their social environment or context.

Socioeconomic status is associated with significant variations in health status and risk for health problems. The famous Whitehall Study of English civil servants in the s was one of the first and most influential to demonstrate this relationship: The Whitehall Study consists of a group of people of relatively uniform ethnic background, all employed in stable office-based jobs and not sub- ject to industrial hazards, unemployment, or extremes of poverty or afflu- ence; all live and work in Greater London and adjoining areas. Yet in this relative homogeneous population, we observed a gradient in mortality— each group experiencing a higher mortality than the one above it in the hierarchy. The difference in mortality between the highest and lowest grades was threefold.

Nonphysical occupational factors also affect health. For example, a great deal of research demonstrates the relationship between poor health outcomes and the psychosocial work environment. In addi- tion, job loss and threat of job loss also have a negative impact on health. For example, numerous studies over the past 20 years have found that people who are isolated or disengaged from others have a higher risk of premature death. In addition, research has found that survival of car- diovascular disease events and stroke is higher among people with close ties to others, particularly emotional ties. Social relations have been found to predict compliance with medical care recommendations, adaptation to adverse life events such as death of a loved one or natural disaster, and coping with long- term difficulties such as caring for a dependent parent or a disabled child.

A great deal of research in the area of social support was conducted during the s and s. A seminal review article published in by Kaplan, Cassel, and Gore identified methodological issues that needed to be addressed. Since then, there has been further specification of the relationship between social support and health to explain the relationship. For example, Cohen discusses three factors that indicate differ- ent aspects of social relationships: social integration, negative interaction, and social support, each influencing health through different mechanisms. Thoits reanalyzed data to test the hypothesis that disadvantaged sociodemographic groups such as low-income women are more vulnerable to the effects of life events because they experience more negative events and have fewer psychological resources to copy with them.

Although the relationship between social support and health is still not well understood, it is found over and over again in health studies. Genetic Inheritance Our knowledge about the effects of genetic inheritance on health is growing rapidly. These usually interact, and individuals with a particular set of genes may be either more or less likely, if exposed, to be at risk of developing a particular disease. Chapter 1 Introduction and Overview 17 Health Behavior The term health behavior can refer to behaviors that are beneficial to health. However, the term is generally used in the negative to refer to behaviors that harm health, including smoking, abusing alcohol or other substances, failing to use seat belts or practicing other unsafe behaviors, making un- healthy food choices, and not engaging in adequate physical activity.

The effect of health behaviors on health status has been widely studied and found to be an important determinant of health. In one way or another, personal health behavior has an impact on the occurrence in any given individual of most of the diseases and conditions on this list. Further, looking at the cause of death in a different way, that is, by major contributing cause of the disease to which the death was attributed rather than by the disease itself, in the first study of its kind, McGinnis and Foege showed that, as of , the leading factors were tobacco use, dietary patterns, sedentary lifestyle, alcohol consumption, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles, and use of illicit drugs.

Often by the time the individual interacts with the health care system, the determinants of health have had their impact on their health status, for better or for worse. Thus, the need for health care may be seen as a failure to prevent the determinants of health from adversely affecting the individual patient. Genetic predisposition to breast cancer may limit the long- term success rates of cancer treatment. Continued exposure to toxins in the environment or at work may decrease the likelihood that the physician can stabilize an individual with allergies. Health behaviors, such as smoking or substance abuse, may stymie the best health care system when treating an individual with lung disease. The lack of support at home for changes in be- haviors or adherence to medical regimens may undermine the ability of the health care system to treat an individual with diabetes successfully.

We recognize that health, as well as health care, exist within a biological, physical, and social context, and all of these factors influence the level of probability of success of a health care system. Health care is only one determinant of health. Relationship Between the Determinants of Health The determinants of health do not act independently of each other. They are interconnected, and the concepts of ecology provide the framework for understanding how to model their interconnectedness. In the most general sense, the ecological approach means that the person is viewed as embed- ded in the environment—both social and physical—and is both influenced by and influences that environment. Stokols outlines the history of ecology, and social ecology, which are fundamental to the public health perspective and its practice: The term ecology refers to the study of the relationships between organisms and their environments.

Early ecological analyses of the relations between plant and animal populations and their natural habitats were later extended and applied to the study of human communities and environments within the fields of sociology, psychology, and public health. The field of social ecol- ogy, which emerged during the mid s and early s, gives greater attention to the social, institutional, and cultural contexts of people-environ- ment relations than did earlier versions of human ecology, which focused primarily on biologic processes and the geographic environment. Second, ecological models include characteristics of individuals, and for example, can incorporate their genetic heritage, psychological attributes, and behavioral practices. Third, concepts from systems theory are used to understand the interplay between environmental and individual characteristics and their mutual influence on health. Thus, efforts to promote human health must take into account the inter- dependencies that exist among immediate and more distant environments e.

Stokols, , p. With the multitude of factors that affect human health, many disciplines are required to understand the interplay between them and their effect on health and to bring about health improvement. The classic book, Mirage of Health, by Rene Dubos provides an example of how the ecological approach is applied to human health. Dubos describes the causes of the tuberculosis epidemic in the tenements of New York City and other U. He recounts The story of the roundabout way in which a microscopic fungus prob- ably native to Central America destroyed the potato crop in Ireland and exerted thereby a dramatic influence on the destiny of the Irish people, illustrating the complexity of the interplay between the external environ- ment and the affairs of man. The profound upheaval in their way of life made them ready victims to all sorts of infection. The sudden and dramatic increase of tuberculosis mor- tality in the Philadelphia, New York and Boston Areas around can be traced in large part to the Irish immigrants who settled in these cities at that time.

Dubos, , p. In- terestingly, he does not mention health care, or its absence, as a factor leading to the tuberculosis epidemic, but then there was little that medicine offered at that time for the treatment of tuberculosis. These included the impetus among Europeans to explore and trade that caused the transport of the wild potato from Central America to Europe; the application of scientific principles to farming that caused the improvement of the potato; the political and economic relationships between Ireland and England that caused the dependence of the Irish on the potato for food; and so forth.

We understand the disease, not only in terms of immediate individual actions, for example, sanitary habits of the individuals with tuberculosis, but in terms of societal attributes that reach back into history and relate to political and eco- nomic events and policies of the times. Ecological Models and Public Health Practice The environment, or context, influences the way people live and their health outcomes, for better or for worse. That is, context can have positive or nega- tive impacts on the health of individuals. As a field, public health attempts to maintain or create healthy contexts in which people live and prevent or dismantle unhealthy contexts—to promote health and reduce morbidity, disability, and premature mortality.

The way in which public health attempts to affect contexts is the story of public health practice, and public health practice reflects public health ecological models. However, the ecological models in use change over time to respond to the health problems predominant in their day and incorporate the knowledge, beliefs, values, and resources of that time and place. For example, in times and places where infectious diseases are pre- dominant, models reflect the issues required to understand their spread and control. A classic public health model that uses the ecological approach for understanding and preventing disease is the epidemiological triangle with its agent-host-environment triad. The epidemiological triangle see Figure 1. The three points of the triangle are the agent, host, and environment. The agent is the microbial organism that causes the infectious disease—virus, bacteria, protozoa, or fungus; the host is the organism that harbors the agent; and the environmental aspects included in an epidemiological triangle are those factors that facilitate transmission of the agent to the host.

These could be aspects of the natural environment, the built environment, or the social environment, including policies. Prevention measures are those that disrupt the relationship between at least two of the factors in the triangle— agent, host, and environment. Although there are no explicitly specified environmental factors in- cluded in the epidemiological triangle, the environment is central to con- ceptualizing disease transmission among individuals at risk the hosts. The environment is the total of factors that enable the agent to infect the host. The environmental factors specified in the model can include, depending upon the disease itself, an array of social and physical attributes that permit the agent to infect the host.

For example, Friis and Sellers write: The external environment is the sum total of influences that are not part of the host and comprises physical, climatologic, biologic, social, and eco- nomic components. The physical environment includes weather, tem- perature, humidity, geologic formations, and similar physical dimensions. Contrasted with the physical environment is the social environment, which is the totality of the behavioral, personality, attitudinal, and cultural characteristics of a group of people. Both these facets of the external envi- ronment have an impact on agents of disease and potential hosts because the environment may either enhance or diminish the survival of disease agents and may serve to bring agent and host into contact.

In the case of other kinds of diseases or health problems, it is not as helpful because of its emphasis on a single agent, its isolation of the agent from the environment, and its conceptually unspecified environment. Chapter 1 Introduction and Overview 23 The wheel of causation is another model exemplifying the ecological approach See Figure 1. It has also been used, but not as extensively as the epidemiological triangle for explaining infectious disease transmis- sion. However, it has some advantages over the epidemiological triangle, as Peterson notes, Although it is not used as often as the epidemiological triangle model, it has several appealing attributes Fig. For instance, the wheel contains a hub with the host at its center. For our use, humans represent the host. Also, surrounding the host is the total environment divided into the biological, physical, and social environments.

These divisions, of course, are not true divisions—there are considerable interactions among the environment types. Although it is a general model, the wheel of causation does illustrate the multiple etiological factors of human infectious diseases. One of the major issues in developing public health models is where to place the emphasis and, thus, where to intervene to improve health? Is it at the individual level or at the environmental level? This issue is at the heart of public health practice. Therefore, in the simplest conceptualization of prevention strategies, we have two choices: We can focus our efforts on changing individual behavior directly or on changing the environment in which individual be- havior occurs.

These habits might have included hand washing, housekeeping, food preparation practices, and so forth. Changing behavior might have taken the form of encouraging compliance through education or coercing compliance through surveillance and laws. On the other hand, we might decide that the tuberculosis epidemics should have been prevented by changing the social, political, or physical environments. For instance, if the cities to which the Irish emigrated had provided more healthful housing and working conditions, the Irish immi- grants would not have been as susceptible to illness, including tuberculosis. We might have targeted the crowding and other relevant conditions in the neighborhoods where the immigrants came to live.

Thus, instead of moti- vating individuals to change their behavior—through education—we might argue that we could have changed the physical environment to reduce the spread of tuberculosis. Alternatively, stepping further back in the causal chain, we might decide that the political environment in Ireland should have been the focus of in- tervention. If England had provided aid to the Irish during the potato blight, the Irish would not have perished in such numbers and survivors, poor and already weakened by famine, would not have been motivated to emigrate to the United States where they were highly susceptible to tuberculosis. On the other hand, going back even further, we might decide that the un- diversified diet of the Irish should have been the subject of intervention. If the Irish food supply had been diversified, the potato blight would not have become a crisis for the people of that country.

Again, this was a political decision on the part of the English. Thus, political strategies might be pro- posed that would have changed the environment, and, thus, prevented the tuberculosis epidemics of the s in the United States. The general ecological model is extremely flexible and can assume many different forms. The model becomes differentiated when a specific health problem is identified for intervention in a particular time and place. The ecological models developed beginning in the s in response to the increased importance of chronic diseases made a significant departure from the classic models such as the epidemiological triangle and the wheel of cau- sation see Figure 1. Let us explain. Chapter 1 Introduction and Overview 25 Health Promotion and the Ecological Models in Public Health Since Beginning in the s, the models explaining health status became increas- ingly limited to the behavioral determinants of health such as smoking, sed- entary lifestyle, poor dietary habits, unprotected sexual activity, and failure to use seat belts, which placed the focus of public health interventions on chang- ing individuals rather than their context.

The watchwords of this trend were health promotion and disease prevention. As Green states, was a turning point when health promotion was accepted as a significant component of health policy. In the public sector this interest has led to national campaigns to control hypertension and cholesterol, the establish- ment of the Office of Disease Prevention and Health Promotion within the Public Health Service and the Center for Health Promotion and Education within the Centers for Disease Control, the development and implementa- tion of community-wide health promotion programs by both governmental agencies and private foundations, and the establishment and monitoring of the Objectives for the Nation in health promotion. More recently, jour- nals have appeared which are devoted exclusively to articles on health pro- motion programs and activities; existing journals both within and outside of traditional public health disciplines have devoted theme issues to health promotion topics; international conferences on health promotion have been held; and health education training programs have begun to focus more extensively on health promotion topics and issues.

These initiatives were in contrast to historic interventions such as sewage disposal or food inspection that emphasized changing the environment, as we will explore in the next chapter. The PRECEDE— PROCEED model was developed in the s and has been applied, since then with a few modifications in the s, which we will discuss shortly. PRECEDE stands for Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation. Enabling factors are those skills, resources, or barriers that can help or hinder the desired behavioral changes as well as environmental changes. Reinforcing factors, the rewards received, and the feedback the learner receives from others following adoption of the behavior, may encourage or discourage continuation of the behavior.

Thus, edu- cation about the risks of certain behaviors and the benefits of others is a primary component of health promotion initiatives. These include initia- tives to modify unfavorable dietary habits, sedentary lifestyle, substance abuse, smoking, and unsafe practices such as failure to use seat belts or fol- low safety precautions at work. Chapter 1 Introduction and Overview 27 The second part of the answer structured by the PRECEDE—PROCEED model is related to attributes of the individual that hinder behavior change including motivation to change, appraisal of threat, self-efficacy, response efficacy, and so forth. That is, once the knowledge about health behaviors is conveyed, the challenge is to motivate individuals to change their behavior from risky to healthy.

Knowledge alone is not sufficient to bring about change in health behaviors. Thus, a major tool of health promotion is the applica- tion of psychological theories to understand why people engage in unhealthy behaviors and how to stimulate them to modify these behaviors. These theories underlie the methods used in health promotion initia- tives to motivate health behavior change. The original PRECEDE—PROCEED model see Figure 1. The model visualizes the assumed causal chain, which shows that behavioral problems produce health problems, which then in turn, produce social problems, such as illegitimacy, unemployment, absenteeism, hostility, alienation, discrimination, riots, and crime. The effect of the environment on individual behavior is assumed under enabling factors such as availability of resources, accessibility, and referrals and reinforcing factors as attitudes of program personnel. However, note that this is a very restricted environment, which is limited to the immediate setting of the health education program.

There is also a nonbehavioral factors box, which contributes to health problems and could contain larger environmental factors, but is not the main focus of the model and is not seen as contributing to behavior problems. As an example of the use of the PRECEDE—PROCEED model, DeJoy describes how the model would be applied to workplace safety: In the PRECEDE model, three sets of diagnostic or behavioral factors drive the development of prevention strategies. Predisposing factors are the characteristics of the individual beliefs, attitudes, values, etc. that facilitate or hinder self-protective behavior. Predisposing factors are con- ceptualized as providing the motivation for behavior. The threat-related beliefs and efficacy expectancies that are prominent features of the val- ue-expectancy models psychological theories for health behavior would be included here. environment or system that block or promote self-protective action. Most barriers or costs would be classified as enabling factors.

Importantly, the environment—in this case, the physical workplace and the people who manage it—is seen as reinforcing and enabling the worker to engage in safety habits, but not as the target of the intervention. Rather, improving workplace safety is focused on motivating the individual worker to practice safety habits, not motivating the employer or the larger society to modify the workplace. Also, note that the environment is quite proscribed. Its bounds are the specific workplace itself. The environment, in this example, does not include larger political and economic factors that may affect what occurs within the workplace. For instance, the political and economic factors that impact the availability of protective equipment and other resources re- quired for safety are not considered.

Regulations governing safety in the workplace are not considered, nor are the enforcement of regulations. This example is typical of health promotion programs, particularly through the s. The larger environment could certainly be incorporated into the model, but it usually was not. Why Health Promotion? Educating individuals about health was seen as a way to make people more self-sufficient in health, engage in self-care, and become better informed consumers of health services. Because of concern about spiraling health care costs in the s and onward, health promotion was presented as a means to control costs through the demand side Green, Practitioners and the agencies funding health services and public health research eagerly embraced this search for magic-bullet solutions to the behavioral change problems pre- sented by medical care and public health.

A generation of highly con- trolled randomized trials and fine-grained behavioral research ensued. These tested, by trial and error, specific ways to improve patient com- pliance. They included ways to reduce broken appointments, educate mothers to restrain their tendency to bring a child to health maintenance organization or pediatric services for each earache or sore throat, improve smoking cessation, and modify a range of specific consumer and self-care behaviors. The targets of the magic bullet interventions were as much those behaviors thought to account for some of the unnecessary and inap- propriate uses of health services as those accounting for leading causes of death or disability.

If risky health behaviors could be changed, it was argued, the inci- dence of chronic diseases would be reduced. Of course, this is true. The question, however, is whether trying to motivate individuals to change their behavior—through education, incentives, and disincentives—is the most effective and just means of accomplishing this goal. Is placing accountability for behavior change onto the individual, without changing the environment in which that behavior occurs, realistic and fair? Chapter 1 Introduction and Overview 31 Criticisms of Health Promotion Placing the locus of accountability for poor health on the individual is one of the major criticisms of the health promotion movement.

For example, poor people and those of minority groups often live in neighborhoods with supermarkets that carry limited amounts of healthy foods, especially fruits and vegetables. Does the fairer and more effective public health intervention, aimed at improving the diet of people in such neighborhoods, target the residents themselves or the supermarkets? These are the kinds of questions that arise from the debate over the PRECEDE— PROCEED model. Not surprisingly, beginning in the s, the pendulum began to swing back to a focus on environmentally targeted interventions and an interest in understanding the interaction between individuals and their environment.

Further: In , the First International Conference on Health Promotion pro- duced the Ottawa Charter, which helped reorient policy, programs, and practices away from these proximal risk factors. The shift that followed was to the more distal risk factors in time, space, or scope, which we shall call risk conditions. These also influence health, either through the risk factors or by operating directly on human biology over time, but they are less likely than risk factors to be under the control of the individual at risk. environmental influences, the model now contains a box labeled environ- ment, which notably both influences and is influenced by behavior and life- style. This change in the PRECEDE—PROCEED model now makes it in keeping with the general ecological model, which assumes that individuals are affected by their environment.

Part V: Environmental Issues in Public Health Role of Government in Environmental Health Identification of Hazards Pesticides and Industrial Chemicals Occupational Exposures—Workers as. New Source of Pollution—Factory Farms Setting Standards—How Safe Is Safe? Risk—Benefit Analysis Criteria Air Pollutants Strategies for Meeting Standards Indoor Air Quality Global Effects of Air Pollution Clean Water Act Safe Drinking Water Dilemmas in Compliance Is the Water Supply Running Out? Sanitary Landfills Alternatives to Landfills Hazardous Wastes Causes of Foodborne Illness Government Action to Prevent Foodborne Disease Additives and Contaminants Drugs and Cosmetics Food and Drug Labeling and Advertising Politics of the FDA Public Health and Population Growth Global Impact of Population Growth—Depletion of Resources Global Impact of Population Growth—Climate Change Dire Predictions and Fragile Hope Part VI: Medical Care and Public Health When Medical Care Is a Public Health Responsibility The Conflict Between Public Health and the.

Medical Profession Licensing and Regulation Ethical and Legal Issues in Medical Care Ethical Issues in Medical Resource Allocation Medical System Needs Reform Problems with Access Why Do Costs Keep Rising? Approaches to Controlling Medical Costs Managed Care and Beyond The Patient Protection and Affordable Care Act Reasons for Practice Variations The Field of Dreams Effect Outcomes Research Medical Care Report Cards Inequities in Medical Care The Relative Importance of Medical Care for. The Aging of the Population—Trends Health Status of the Older Population General Approaches to Maximizing Health.

Preventing Disease and Disability in Old Age Medical Costs of the Elderly Proposals for Rationing Part VII: The Future of Public Health Types of Disasters and Public Health Responses Response to Hurricane Katrina Principles of Emergency Planning and Preparedness Bioterrorism Preparedness Challenges for the 21st Century cookielawinfo-checkbox-functional 11 months The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional". cookielawinfo-checkbox-necessary 11 months This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".

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edu no longer supports Internet Explorer. To browse Academia. edu and the wider internet faster and more securely, please take a few seconds to upgrade your browser. How do we interest them in becoming public health professionals themselves, who will then offer their skills and enthusiasm in service of public health goals? As lifelong public health professionals who have taught public health to undergraduate and graduate students for many years, this was our aim in writing an Introduction to Public Health.

There is an urgent need to develop the public health perspective in more people to deal with the wide ranging problems that threaten health today. Despite many improvements in health and the conditions that pro- mote health in recent years, there are areas of deep concern. These include the deterioration of global water supplies; stress on world food supplies and the resulting hunger suffered by millions daily; warming of the earth and its adverse impact on the natural environment; manmade catastrophes related to industrialization that expose people needlessly to toxins and injury; wars that leave millions homeless and without adequate food, water, and shelter and a stable social environment in which to live and raise children; and disparities in access to resources needed to promote health and well-being.

For the many in the United States, these troubles may seem far away— difficulties that happen only in other countries and parts of the world—but they either exist here or have an impact on us indirectly. Log in with Facebook Log in with Google. Remember me on this computer. Enter the email address you signed up with and we'll email you a reset link. Need an account? Click here to sign up. Download Free PDF. Introduction to Public Health. Banune F Kens. Continue Reading Download Free PDF. Goldsteen, DrPH, is the Founding Director of the Graduate Program in Public Health and Professor of Preventive Medicine in the School of Medicine at SUNY, Stony Brook.

He received his doctoral degree from the Columbia University School of Public Health. He has an extensive background in health care and was formerly a director of health policy research centers at the University of Illinois in Urbana-Champaign, University of Oklahoma College of Public Health, and the West Virginia University School of Medicine. Karen Goldsteen, PhD, is Research Associate Professor in the Graduate Program in Public Health at SUNY, Stony Brook. She received an MPH from the Columbia University School of Public Health and a PhD in community health from the University of Illinois at Urbana-Champaign. She was a Pew Health Policy Fellow at the University of California, San Francisco. David G. Graham, MD, MPH, is the former Chief Deputy Commissioner and Director of Public Health of the Suffolk County Department of Health Services.

As the Director of Public Health, he managed epidemiology and disease control, public health protection, bioterrorism preparedness, preventive services, and the arthropodborne disease laboratory. As Chief Deputy Commissioner, he managed several major divisions, including public health, patient care, community mental hygiene, services for children with special needs, environmental quality, emergency medical services, and forensic sciences. His career in public health spans nearly 30 years. Introduction to Public Health Raymond L. Goldsteen, DrPH Karen Goldsteen, PhD David G. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc.

com or on the Web at www. Springer Publishing Company, LLC 11 West 42nd Street New York, NY www. com Acquisitions Editor: Jennifer Perillo Senior Production Editor: Diane Davis Cover Design: Joseph De Pinho Composition: Absolute Service, Inc. Because medical science is continually advancing, our knowledge base continues to expand. Therefore, as new information becomes available, changes in procedures become necessary. We recom- mend that the reader always consult current research and specific institutional policies before performing any clinical procedure. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet Web sites referred to in this publication and does not guarantee that any content on such Web sites is, or will remain, accurate or appropriate.

Goldsteen, Karen Goldsteen, David G. Includes bibliographical references and index. ISBN alk. paper — ISBN e-book 1. Public health. Goldsteen, Karen. Graham, David David G. Public Health Practice. WA ] RA G58 If you are interested in a custom book, including chapters from more than one of our titles, we can provide that service as well. For details, please contact: Special Sales Department, Springer Publishing Company, LLC 11 West 42nd Street, 15th Floor, New York, NY Phone: or ; Fax: Email: sales springerpub. com Printed in the United States of America by Bang Printing. This book is dedicated to public health professionals everywhere, who care deeply about the people they serve and strive daily to make the conditions in which they live healthful.

Contents Preface xiii 1. Introduction and Overview 1 The Promise of Public Health 1 Prevention: The Cornerstone of Public Health 6 Primary, Secondary, and Tertiary Prevention 6 Secondary and Tertiary Prevention and Public Health 9 Summary 11 The Practice of Public Health 12 How Do We Define Health? Organization and Financing of Public Health 73 Introduction 73 Organization of Public Health System 75 10 Essential Services 79 Federal Public Health 80 Department of Health and Human Services: Public Health Service 81 Centers for Disease Control and Prevention 84 Infectious Diseases 84 Noninfectious Diseases and Injuries 86 National Center for Health Statistics 87 Other Centers for Disease Control and Prevention Offices and Centers 89 Agency for Healthcare Research and Quality 90 Health Resources and Services Administration 90 Food and Drug Administration 92 National Institutes of Health 92 Indian Health Service 92 Substance Abuse and Mental Health Services Administration 93 Other Department of Health and Human Services Divisions 93 Other Federal Agencies 94 U.

Department of Agriculture 94 Environmental Protection Agency 95 U. Injuries and Noninfectious Diseases Introduction Motor Vehicle Injuries Surveillance and Research Child Passenger Safety Teen Drivers Interventions Child Passenger Safety Teen Drivers Childhood Obesity Surveillance and Research Interventions Improving Access to Medical Care References 6. Public Health: Promise and Prospects Has Public Health Lived Up to Its Ideal? How do we interest them in becom- ing public health professionals themselves, who will then offer their skills and enthusiasm in service of public health goals? As lifelong public health professionals who have taught public health to undergraduate and gradu- ate students for many years, this was our aim in writing an Introduction to Public Health.

These problems are amplified in the United States by the current break- down in civic discourse and the polarization of people and politicians along cultural, political, educational, racial, and economic lines. The conditions that helped us to become a great nation—tolerance of diversity and access to opportunity regardless of race, religion, social status, or family heritage—are threatened. Social justice is under attack. Economic injustice is on the rise. Yet, public health offers an antidote. We have a proud history of fight- ing for social justice and the conditions needed for health: Clean water; a safe and nutritious food supply; adequate sewage and garbage disposal; safe housing and workplaces; and infectious disease control. These are just a few of the areas of health improvement that public health has pioneered.

We have established premier organizations such as the Centers for Disease Control and Prevention and the World Health Organization, which advocate, monitor, and intervene to improve health and well-being for all people. This volume makes no attempt to be a comprehensive description of public health. It was written to provide a framework for understanding this complex field. Further enrichment in the classroom and through assign- ments and exercises will be needed to fill-in the picture. Our hope is that it will be used to inform those seeking their professional identity and purpose about the values, goals, achievements, practice, and especially promise of public health in the hope that they will join us in working to fulfill that promise as future practitioners of public health.

We wish to acknowledge the help of our wonderful students Skye Ostreicher, Chris Gladwin, Dennis Dorf, and Luxi Ji. The meet- ing expresses the public health priorities for that year and gives forum to the full range of current public health issues and activities. Current scientific and educational programs represent all sections, special interest groups, and caucuses. In the APHA annual meeting in Philadelphia, a typical recent year, the 27 sections, 6 special primary interest groups SPIGs , and 17 caucuses were represented. Among the sections were the following: n฀ Alcohol, Tobacco, and Other Drugs; n฀ Chiropractic Health Care; n฀ Community Health Planning and Policy Development; n฀ International Health; n฀ Maternal and Child Health; n฀ Medical Care; n฀ Mental Health; n฀ Occupational Health and Safety; n฀ Oral Health; n฀ Podiatric Health; n฀ Population, Reproductive and Sexual Health; n฀ Statistics; and n฀ Vision Care.

The six SPIGs were the following: n฀ Alternative and Complementary Health Practices; n฀ Community Health Workers; n฀ Ethics; n฀ Health Informatics Information Technology; n฀ Health Law; and n฀ Veterinary Public Health. The theme of the APHA Annual Meeting was Water and Public Health, and sessions directly related to this issue included: n฀ Water, development, and human rights; n฀ Water, women, and maternal mortality; and n฀ Drinking water: source-to-tap public health aspects. This small sample of topics at one meeting indicates the diversity and abundance of subjects that concern public health professionals. We may have little in common on a day-to-day basis with our fellow public health professionals, and our knowledge base and skills may vary widely from others in our field.

However, our mission is the same, and each of us contributes to that mission in some important way, which we will begin to explicate in the coming pages. Before proceeding, though, we need to examine this statement more closely to understand its assumptions and implications. By examining these, we understand our commonalities with other professionals focused on health—particularly the clinical professions such as medicine, nursing, dentistry, physical therapy, and others—as well as our unique role among health professionals. First, the idea of assuring health for all people—the entire population— is embedded in the mission statement.

Although public health will focus on different populations within the larger population when planning services, we are obligated to ensure health-producing conditions for all people—not just the poor, not just the rich, but people of all incomes; not only the young or the old, but people of all ages; not exclusively Whites or Blacks, but people of all races and ethnicities. Public health takes the view held by many professions and societies throughout human history that healthy people are more productive and creative, and these attributes create a strong society. Healthy people lead to better societies. For the welfare of the society, as a whole, it is better for people to be healthy than sick.

Thus, as public health professionals, we believe that society has an interest in the health of the population; it benefits the society, as a whole, when people are healthy. Third, the public health mission acknowledges that health is not guaranteed. However, not everyone will be healthy even if each one exists in health-producing conditions. Public health efforts will not result in every person being healthy—although we certainly would not object to that kind of success. Rather, public health creates conditions in which people can be healthy. Whether any single individual is healthy, we acknowledge, will vary.

Chapter 1 Introduction and Overview 5 The fourth and fifth assumptions differentiate public health from the healing, or clinical, professions—medicine, nursing, dentistry, physical therapy, physician assistant, and others—that we will refer to for simplic- ity throughout the remainder of this book as the clinical professions. All clinical professions believe in the obligation of their practitioners to care for all people in need of their services. Finally, all health care professions believe that improving health is a benefit, not only to the individuals treated, but also to the society, as a whole.

Social foundations of thought and action: A social cognitive theory. Key Features: — Up-to-date coverage of the newest developments in infectious disease, injury control, environmental health controversies, the reform of the American healthcare system, and more — Vivid presentation of Public Health principles through current stories in the news, such as Ebola in the United States, e-cigarettes, eating disorders, the California Measles outbreak, and traumatic brain injury in the NFL — Extensive discussion of current topics including population growth and climate change as contributors to drought, wars, and migrations in the Middle East; and the implementation of the Affordable Care Act in the United States. Question: As an overlooker did you stimulate them to labour by severity? TRY ADFREE Self publishing Discover products News Publishing. The cookie is used to store the user consent for the cookies in the category "Analytics".

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