1) The document discusses American beliefs and values related to health, including viewing health care as an economic good subject to market forces rather than a publicly financed system. 2) Key determinants of health are discussed, including behaviors, environment, medical care, and social factors. Health is influenced by multiple levels from genetic to societal. 3) Public health aims to promote community health through disease prevention, health education, and policies addressing environmental and societal risks to health. It complements medicine's focus on treatment of individuals.

2. Chapter 2
Beliefs, Values and Health

3. Learning Objectives
• At the end of class, you should:
– understand the concept of health and disease
– know the determinants of health
– know the American beliefs and values in the
delivery of health care
– understand the promotion of health and the
prevention of disease
– develop a position on the equitable
distribution of health care
– know basic measures of health and its utilization

4. Beliefs, Values and Health
• Beliefs and values in US have remained mostly
private
– not a tax financed national health care program

5. For Managers and Policy Makers
1. Health of a population determines health care
utilization
a) planning a health service is determined by health
trends and demographics
2. The health appraisal should determine
a) education, prevention and therapies
3. Evaluating health care organizations on
contributions made to community

6. For Managers and Policy Makers
4) Use of justice and equity a concern
5) Measure of health status and utilization to
evaluate:
a) existing programs, plan new strategies, measure
progress, discontinue a service

7. What Is Health?
• Absence of illness and disease
• “A state of physical and mental well-being
that facilitates the achievements of individual
and societal goals”
– Society for Academic Medicine
• A return to an illness free or disease free state
after an ill spell.

8. What Is Health?
• “A complete state of physical, mental and social well
being, not just merely the absence of disease”
– WHO
• Biopsychosocial model of health
– “Social”
•positive relationships
•support network for life stresses, self-esteem
•responsible for community and population’s
well-being
– To promote, restore and maintain health

9. What Is Health?
• U.S. health care has followed a
medical/biomedical model
– the existence of illness or disease
– have a clinical diagnosis and medical
interventions

10. What Is Health?
• Biomedical Model
• Governs the U.S. concept of health and health care
1. The existence of an illness or disease
2. Seek and use care
3. Find relief of symptoms and discomfort
4. Diagnosis of illness and treatment of disease to
restoration
5. Once relief is obtained, the person is considered well,
whether or not the disease is cured
• Therefore, clinical intervention once disease is
diagnosed.

11. Illness vs. Disease
• Illness
– identified by a person’s perception and evaluation
of how he/she is feeling
– people are ill when they infer a diminished
capacity to perform tasks and roles that are
expected by society
• Disease
– based on a professional evaluation
– caused by more than one single factor (e.g.,
tuberculosis, poverty, overcrowding)

12. An Explanation of Disease Occurrence
• Tripartite or Epidemiology Model
1) Host
– the organism
– usually a human
– for host to be ill, an agent must be present
2) Agent
– (i.e. TB, tobacco smoke, bad diet...)
– presence of tuberculosis does not assure host will
be ill
3) Environment
– external to the host to enhance or reduce disease

13. Tripartite or Epidemiology Model
• Risk Factors
– attributes that increase the likelihood of
developing a disease or negative health
condition
•Agent: (i.e. tobacco smoke, poor diet)
•Host: (i.e. genetic make up, level of fitness)
•Environment: (i.e. poor sanitation, low
socioeconomics)
• Prevention
– to rid risk factors

14. Behavioral Risk Factors
• Smoking
– increases risk of heart disease, stroke, lung
cancer, lung disease (CDC)
• Substance abuse
• Lack of physical exercise
• High fat diet
• Improper use of motor vehicles
• Unsafe intimate relations
– See Table 2-1

15. Interventions to Counteract Key Risk
Factors
• Behavior modification
– education
– personal motivation
– financial incentives
– environmental inducements

16. Acute, Subacute, & Chronic Conditions
• Acute
– relatively severe, episodic (of short duration) and
often treatable (i.e. myocardial infarct, sudden
kidney interruption)
• Subacute
– some acute features
– post acute treatment after discharge (i.e. head
trauma, ventilator)
• Chronic
– less severe, but long and continuous
– can be controlled, but can be serious (i.e. asthma,
diabetes, hypertension)

17. Holistic Health
• The well-being of all aspects that make a person
whole and complete
• Growing interest
• Holistic medicine
– treat the whole person
– spiritual is added to medical, mental and social
• Literature shows that religious & spiritual belief has a
positive impact on overall well-being

18. Wellness Model
• Efforts and programs that prevent disease and
optimize well-being
• Built on three factors:
1) understand risk factors
•done through a health risk appraisal
•when known, interventions can take place
2) intervention
•behavior modifications
•therapeutic (primary, secondary, tertiary
prevention)
3) adequate public health and social services

19. Therapeutic Preventions
• Primary: activities to decrease or restrain the
problem or develop that a disease will occur
– Smoking cessation to prevent lung disease
– Handwashing to decrease spread of infection
• Secondary: early detection and treatment of disease
to block progression of disease or injury
– Pap smears, mammograms, prostate exams
• Tertiary: rehabilitation and monitoring to prevent
further injury or complications
– Turning bed-bound patients

20. Public Health
• To fulfill “society’s interest in assuring
conditions in which people can be healthy”
(IOM)
• Deals with broad societal concerns promoting
optimum health for the society as a whole
• A health-related service to minimize risk
factors to prevent, control and contain
disease

21. Public Health
• The science and art of preventing disease,
prolonging life, and promoting health and
efficiency through organized community
effort
• Seeks to apply current knowledge of health
and disease in ways that will have the
maximum impact on a population’s health
status

22. Public Health Roles
1. Prevention
2. Health Promotion
3. Health Protection (new- due to 20th century
industrialization)
– Environmental Protection Agency (EPA)
– Occupational Safety and Health Administration
(OSHA)
– Bioterrorism, Homeland Security Act 2002
•the use of chemical, biological & nuclear agents
to harm populations
•training, civil defense, countermeasures &
cooperation between interagency groups (i.e.
anthrax, small pox)

23. Medicine vs. Public Health
• Medicine
– focuses on the individual patient
– biological causes of disease with treatment
– treat disease and recover health
• Public Health
– focuses on the populations
– identify environment, social & behavior then develop
population-based interventions
– prevent disease and promote health through influence
– provides education to pass laws
– disseminate information

24. Medicine vs. Public Health
• Medicine
– Physicians, nurses, dentists, therapists, social
workers, psychologists, nutritionists, health
educators, pharmacists, laboratory,
administration
• Public Health
– same as above, but also includes sanitarians,
epidemiologists, statisticians, hygienists,
environmental health specialists, food/drug
inspectors, toxicologists, and economists

25. Environmental Health
• Aims to prevent the spread of disease through
water, air & food
• 1900s top three killers:
– pneumonia, tuberculosis, diarrhea
• 1999 top three killers:
– heart disease, cancer, lung disease
• New challenges in the 21st century
– hazards of chemicals, asbestos, industrial waste,
infectious waste, radiation

26. Quality of Life
• Overall satisfaction with life during and following a
person’s encounter with the health care delivery
system
• An indicator of how satisfied a person was with the
experiences while receiving health care
• Comfort, respect, privacy, security, autonomy
• A person’s overall satisfaction with life and self-
perceptions of health, especially after a medical
intervention
• Goal: have a positive effect on an individual ability to
function, meet obligations, feeling of self-worth

27. Determinants of Health
• Factors that influence an individual and a
population’s health:
– Genetic make up
•20% of premature deaths
– Individual Behaviors
•50% of premature deaths
– Medical Practice
•10% of premature deaths
– Social and Environmental
•20% of premature deaths

28. Blum’s Force Field & Well-being
Paradigms of Health
• Force Fields:
– Environment
• Physical, social, cultural, and economic factors
– Lifestyle
• Behaviors, attitudes toward health
– Heredity
• Current health and lifestyle practices are likely to
impact future generations
– Medical care
• Health care delivery system (access, availability of
service)

29. WHO Commission on Social
Determinants of Health
• Socioeconomic and political context
• Governance
• Policy
• Social/Cultural Norms
• See Figure 2-4

30. Americans’ Beliefs and Values
1) The advancement of science
•helped to create the medical model
2) A champion of capitalism
•an economic good
3) Entrepreneurial spirit and self determination
4) A concern for the underprivileged
•poor, elderly, disabled
5) Free enterprise and distrust of
government

31. The Equitable Distribution of Health
• We have scarce resources.
1. How much health care should be
produced?
2. How should health care be distributed?
– Distribution creates inequalities
– Need justice and fairness

32. Theories of Equitable Distribution
• Two Contrasting Principles:
– Market Justice
•The Economic Good
– Social Justice
•A Social Good

33. Market Justice: The Economic Good
• Fair distribution of health care to the market
forces in a free economy
– Medical services distributed on the basis of
people’s willingness and ability to pay.

34. Principles of Market Justice
• Health care is an economic good governed by free
market forces and supply and demand
• Individuals are responsible for their own
achievements
• People make rational choices in their decision to buy
health care products and services
• People consult with their physicians who know what
is best for them
• The market works best without interference from
government

35. Market Justice
• In association with Classical Ethical Theory
– A physician is duty-bound to do whatever is
necessary to restore a patient’s health
– An individual is responsible for paying the
physician for his/her service
– The poor can be served by charity
– Ignores the societal good and people’s
responsibility to the community at large

36. Market Justice
• In association with Libertarianism:
– Equity is achieved when resources are distributed
according to merits
– Health care distributed according to minimal
standards and financed through willingness to
pay
– Health care is not a central priority

37. Market Justice
• The production of health care is determined
by how much the consumers are willing and
able to buy at the prevailing price.
• Those not able to pay have barriers to health
care
– “rationing by ability to pay”
• Focus on individual rather than a collective
responsibility for health

38. Social Justice: The Good Society
• Theory is at odds with capitalism and market
justice
• The equitable distribution of health care is
society’ responsibility
– Best when a central agency is responsible for the
production and distribution of health care
• Health care is a social good
– Should be collectively financed and available to
every citizen.

39. Principles of Social Justice
• Health care should be based on need rather
than cost
• There is a shared responsibility for health
– Factors outside a person’s control might have
brought on the condition
• There is an obligation to the collective good
– The well being of the community is superior than
that of the individual

40. Principles of Social Justice
• Government rather than the market can
better decide
– Through planning how much health care to
provide and how to distribute among all citizens
– See Table 2-4

41. Community Health Assessment
• An assessment of the population at a local or
state level
• Collaboration with:
– public health agencies
– hospitals
– other providers
• A JCAHO requirement, especially for
community not-for-profit hospitals

42. Healthy People 2020
• 10 year plans
• Key national health objectives
• Founded on the integration of medical care
and prevention, health promotion and
education
• Action model to achieve overarching goals
– See Figure 2-6
– See Table 2-5

43. Evaluation of Health Status
• Health status is an indicator of health and
well-being interpreted through:
– Morbidity
•Disease or Disability
– Mortality
•Death rate

44. Evaluation of Health Status
• Longevity
– Life expectancy
•A prediction of how long a person will live
– Life expectancy at birth
•How long a newborn can expect to live
•See Table 2-5
– Life expectancy at age 65
•Expected remaining years of life for a 65 year
old

45. Evaluation of Health Status
• Morbidity
– At risk population: all people in the same
community or group who can acquire a disease or
a condition
– Incidence: number of new cases
occurring/population at risk
– Epidemic: large number of people who acquire a
specific disease from a common source
– Prevalence: measure the total number of cases at
specific point in time/specified population

46. Evaluation of Health Status
• Activities of Daily Living (ADL) Scale evaluates
seven activities of self care & mobility:
– feeding
– bathing
– dressing
– using the toilet
– transferring
– grooming
– walking eight feet

47. Evaluation of Health Status
• Instrumental activities of daily living (IADL) evaluates
activities necessary for independent living
– using phone
– driving a car, traveling alone on bus, taxi
– shopping
– preparing meals
– doing heavy housework
– taking medications
– handling money
– walk up/down stairs
– walk 1/2 mi without assistance

48. Evaluation of Health Status
• Crude Death Rate
– Total deaths/Total population
• Age Specific
– Number of deaths within a certain age
group/Total # of persons in that age group
• Cause Specific
– Number of deaths from a specific disease/Total
population
• Infant Mortality
– Number of deaths from birth to one year of
age/Number of live births that same year

49. Demographic Change
• Changes in the composition of a population over time
• Births
– Natality
•birth rate
•measured by crude birth rate (number of live
births / total population)
– Fertility
•capacity of a population to reproduce
•measured by fertility rate (number of live births /
number of females 15-44 years old)

50. Demographic Change
• Migration: the geographic movement of
populations between defined geographic
units and a permanent change of address
– immigration
•in migration
– emigration
•out migration

51. Measures of Health Service Utilization
• Utilization
– the consumption of health care services or the
extent to which health care services are used
•Crude Measure of Utilization
•Specific Measure of Utilization
•Institution-Specific Utilization

52. ACA Takeaway
• Insurance plans are required to cover
preventive services with no out-of-pocket
costs.
• Allocate funds to expand preventive national
efforts.
• Will move US health care toward social
justice, although unlikely to achieve universal
access.