This site is being preserved as it was on 17 September 2001 as a memorial to the life and work of Eberhard Wenzel.
Website by Eberhard Wenzel is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Assessment of the outcomes
of health intervention

Rosmarie Erben, Peter Franzkowiak & Eberhard Wenzel
Manila, Wiesbaden, Cologne

Paper presented to the Twelfth International Conference on the Social Sciences and Medicine,
Peebles, Scotland, 14-18 September, 1992


In this article we discuss basic assumptions of health interventions with regard to their underlying concepts and selected strategies. Particularly, the lifestyle model of health promotion is presented and its consequences for health promotion and health interventions are discussed. Reference is made to two fields of interventions: prevention of cardiovascular diseases and worksite health promotion. It is concluded that health interventions have to clarify their concepts and strategies in detail before an evaluation of their outcomes can be carried out reasonably.


Health promotion, lifestyles, prevention, worksite health promotion, health intervention


Why are we interested in behavioral interventions related to the health of individuals and collectives? Who gives us the legitimation to carry out these interventions? Which are the scientific reasons and results that seem to call for health interventions? Are there scientific solutions to health-related behaviors? Is it possible to organize everyday-life as an arena for scientific purposes? Do we control what we intend to control or do the scientific control mechanisms available control our intentions? Do health interventions intervene in health?

The past twenty years, at least, have brought numerous studies and projects aiming at health-related behaviors of individuals and collectives. Threats to human health have been identified and have subsequently become the objective of health interventions. Smoking, alcohol abuse, lack of physical exercise, unbalanced diet, unprotected sexual behavior, back pain, noise, etc. have been subject of local, regional, national, and international studies. Millions of data has been recorded and analyzed, hundreds of thousands of people have been studied - and there are still the same threats to human health alive. In some instances, the rate of smokers declined among a certain population group while it increased in another one, the quality of nutrition has become better among one group while becoming worse among another, the noise at the workplace may have been reduced while becoming louder in other places. Can we really tell a success story about health interventions or do we have to reconsider our basic assumptions, concepts and strategies in order to outline new goals and objectives, revised models and strategies helping to analyse and change the world we are living in? We feel that health-related issues are issues concerning the ways of living which have been evolved in line with the evolution of the societies in general. One concept providing us with a new perspective on possible areas of work of health intervention is the "body".

In many cultures, people tend to perceive themselves and others as social beings rather than as "embodied" persons. The body seems to be a rather difficult issue in social communication except in terms of illness, disease and sports. However, as Bryan S. Turner states in his book The body and society (1): "...human beings are embodied, just as they are enselved", and: "The body is the most proximate and immediate feature of my social self, a necessary feature of my social location and of my personal enselfment and at the same time an aspect of my personal alienation in the natural environment."

The body is the bearer of the human being and at the same time the expression of his/her existential, i.e., economic, political, social, cultural and environmental situation. Individual and social biography are represented in the body, as are the social and cultural circumstances in which it developed; moreover, economic and ecological living conditions also find their expression in the human body. Therefore, body awareness, bodily experiences and bodily expressions are not only subject to individual choices of lifestyle over another; they are primarily structured by social communication and interaction, both of which are dependent upon the symbolic structure of the social system, i.e., the value system, normative expectations and symbolic categories such as health, wealth, happiness, satisfaction, power, etc. Relationships between the individual and collective, between personal and social development, between economic and ecological processes are both directly sensed and expressed by the body.

In introducing the concept of the body with regard to health intervention, we are referring to the materialistic basis of both health and disease. All measures taken in this respect have an impact on body awareness, bodily experiences and bodily expressions. They interfere with bodily communication and the interaction of individuals and collectives.

There is one aspect of the body which has become more and more relevant for health promotion: the presentation of the "self" as a bearer of a specifically-styled body. Individual and collective strategies for the development of successful images of "oneself" are pursued in a variety of social and cultural settings. As Turner (3) states: "successful images require successful bodies, which have been trained, disciplined and orchestrated to enhance our personal value". The symbolic power of fashion and the associated trained, styled and altered body are obvious. Practices such as scarification, tattooing and circumcision are clear examples of this. Turner further adds (4): "We jog, slim and sleep not for their intrinsic enjoyment but to improve our chances at sex, work and longevity." The body is thus used as a tool to enhance individual and social attractiveness. It is not viewed primarily in terms of health but in terms of social relations. Health may be a prerequisite, but it is certainly not the objective of such body management.

Given the above, it can be seen that "health" may play a minor role in peoples' body-related thought and actions. The WHO definition of health focuses on physical, mental and social well-being as indicators. In many cultures, however, well-being seems to be related to fun, pleasure, relaxation, happiness, productivity, reproduction, etc., but not necessarily to "health" per se.

In this paper, we will focus on some of the basic ideas underlying health interventions and we will present two fields of interventions, i.e. health intervention research of the prevention of cardiovascular diseases and worksite health promotion. We feel, however, that similar conclusions will apply for fields like the prevention and control of HIV transmission and AIDS, environmental health or drug abuse programs.

Biomedical and psychological models

In discussing the biomedical and psychological approaches to health education, we will outline some of the major differences between them in order to make clear which strategies they imply and which of these are relevant to health education in general.

The biomedical model is characterized by Hannu Vuori as follows (5):

    "1. Diseases are specific entities constituting specific problems and needing specific solutions. When health education is being used as a solution, it is organized in the form of campaigns focussing on one medically defined problem at a time.

    2. Diseases are basically biological problems. Biological problems are dealt with by medical means. Thus, one of the main tasks of health education is to direct the consumers to use 'properly' the available health services, without questioning their relevance and effectiveness.

    3. Biological knowledge is neutral and value-free. As a consequence, health education should also be neutral, and the essence of health education is the dissemination of knowledge produced by medical research ...

    4. Biological problems are essentially those of an individual.

    5. Because medical problems are those of an individual, health education does not need to be concerned with societal means creating a favourable attitude for their use.

    6. Because health education focusses on medically defined problems it is essentially a medical activity."

This model assumes that health education is disease-oriented and that the physician transmits information concerning specific diseases and their prevention to individuals. It is the individuals responsibility to comply with the physician's advice. The basic concept underlying the biomedical model is one of hierarchy and the subordination of people to the medical system and its personnel.

The biomedical approach to health education was followed by a psychological one, well-known as the Health Belief Model. Its basic assumptions are:

    "...that in order for an individual to take action to avoid a disease he would need to believe [1] that he was personally susceptible to it, [2] that the occurrence of the disease would have at least moderate severity on some component of his life, and [3] that taking a particular action would in fact be beneficial by reducing his susceptibility to the condition or, if the disease occurred, by reducing its severity, and that it would not entail overcoming important psychological barriers such as cost, convenience, pain, embarrassment." (6)

This model assumes that the individual will:

  • evaluate his/her personal health status;
  • assess the results in terms of his/her value system;
  • compare his/her individual value system to the overall social and cultural one;
  • review the existing information on certain hazards to his/her health;
  • check the advantages/disadvantages of possible measures with regard to their psychological, social, cultural and financial costs; and
  • decide upon certain measures to be taken to protect him/herself against the hazards perceived.

The basic concept underlying the Health Belief Model is one of reason and rational choice. Human beings are thought to develop behaviors according to what they believe would be useful and supportive for their health. It is assumed that they constantly review their behaviors regarding their impact on health. Reality, of course, is quite different.

The socially-oriented lifestyle model

A social model of health education arose as a critique on the individually-oriented biomedical and psychological approaches. The key phrase in it is "lifestyles conducive to health".

The lifestyle concept draws heavily on sociological and anthropological knowledge concerning patterns of human action and interaction and their relation to health (7). A fundamental difference is made between collective and individual lifestyles, which can be defined as follows (8).

    "The lifestyle of a social group characterises the totality of patterns of meaning and forms of expression which are produced by a group in the course of collective efforts to cope with the demands and contradictions of the social structures and situations common to all members of that group. The lifestyle brings together efforts related to the demands made, i.e. the external [social, political, economic and cultural] conditions and efforts related to the subjective situation and condition. In the lifestyle is expressed under what conditions a social group acts or reacts in a particular way, i.e. the lifestyle tells us in which directions a group tends to develop its behavior in the ongoing process of coping with the conditions in which they live. These tendencies, in the forms of common social values, norms, language forms, interaction rituals etc., provide a reservoir for individuals or sub-groups which they can draw on for their personal and social identity; it makes it possible for them to give some sense and meaning to their specific situation. The lifestyle of an individual characterises the totality of normative behavioral structures which is developed in the course of his or her life in the ongoing interaction with his or her social and natural environment. Subjective motivation and also potential action are expressed through the lifestyles and are used by the individual according to social situations. The individual's lifestyle contains variations, additions to and omissions from the collective lifestyle which are specific to that individual's personality; nevertheless the individual remains linked to his particular social group - i.e. any change in his or her lifestyle is bound by the collectively developed framework - unless, with this change, there is also a change of the social group, or it is the group which wishes to undergo such a change. This concept of lifestyles creates a close link between the living conditions of an individual, his activities and socially formed strategies for coping with life. Characteristic for this is the linking of individual and collective lifestyles in relation to the particular socio-structural conditions in which the individual lives. Individual behavior is understood as being largely socially determined - with the implication, among others, that to change it, social changes are necessary. Thus the message for health promotion and health education is that integrative strategies for prevention and intervention must be developed - strategies whose chief characteristic is that they link up the various social sectors and are also effective within them."

The basic concept underlying the lifestyle approach is one of socialization of individuals and social groups and social interaction. The health-related behaviors of individuals and collectives are viewed as reflections of certain living conditions and attempts to cope with and/or alter these conditions. Individual behavior in a social situation is considered an outcome at a certain point in time of the life-long socialization process; since social situations change, individual behavior is also always subject to constant change.

Using this approach, it is possible to study various aspects of health care, including epidemiological patterns, methods used in providing clinical care, patient-caregiver interactions, prevention efforts, etc.

The lifestyle concept provides a frame of reference for:

  • studying human behavior and its implications for health in the ecological context of the community [for example, social epidemiology];
  • identifying linkages between social, cultural, economic, environmental and political living conditions and the development of certain individual and collective lifestyles;
  • identifying the implications of individual and collective lifestyles for all kinds of health-related behaviors;
  • identifying individual, collective, social, cultural, political, economic, and ecological resources helping to develop lifestyles conducive to health;
  • identifying the value systems, normative orientations and motivational patterns of individual and collective lifestyles and their impact on all kinds of health-related behaviors; and
  • studying social support systems in the community and their impact on the development of individual and collective lifestyles conducive to health.

Health promotion within the lifestyle approach

The lifestyle concept has affected the concept of health education. Health education in its broadest sense is defined as strategies related to information, education and communication, all of which are primarily oriented towards transmitting knowledge, attitudes and beliefs to individuals and social groups. The new and broader social-scientific perspective replaces the individually- and group-oriented approaches to health education with a comprehensive social and ecological concept called health promotion. Health education plays a role in this approach but it is integrated with other strategies. This conceptual development reflects an increasing understanding of health issues as being embedded in peoples' social, cultural and ecological living and working conditions. Health in its fullest sense is seen as an important element and outcome of social, economic, cultural and ecological policies. It is not solely a concern of the medical system but of all sectors of society.

    "But to turn our attention beyond the individual - to recognize the social and economic determinants of disease, health and 'wellness' - is complex and threatening. Doing something about poverty, racism, unemployment, inequitable access to education and other resources, and quality of environment - involves notions of planned social and economic change, alterations not likely to be achieved by lowering the public's cholesterol levels" (9).

Health promotion refers to the basic principles of ecological systems theory (10) by linking various social sectors in the development, implementation and evaluation of communication and interaction strategies. In this way certain problems are tackled from different perspectives using different strategies and methods, but following common objectives.

    "Public health is the science and art of promoting health. It does so based on the understanding that health is a process engaging social, mental, spiritual and physical well-being. Public health acts on the knowledge that health is a fundamental resource to the individual, to the community and to society as a whole and must be supported by soundly investing in living conditions that create, maintain and protect health." (11)

Cardiovascular community intervention studies

Cardiovascular prevention in the community has become the focus of large-scale longitudinal health intervention studies in the developed countries. The basic idea underlying these studies is the application of controlled clinical methodologies in real-life settings. The best known and well-documented intervention studies in the United States of America and Western Europe (e.g. Stanford-Five-City-Project, Minnesota Heart Health Program, Pawtucket Heart Health Program, German Multi-Center Community Cardiovascular Prevention Study) have shown great distinction when it comes to elaborating controlled or quasi-experimental intervention designs and to improving measures of risk factors.

The German Cardiovascular Prevention Study Group summarizes its "intervention philosophy" as follows:

    "There is sufficient evidence from various longitudinal epidemiological studies linking the risk of cardiovascular diseases to certain individual characteristics ... For the prevention of cardiovascular diseases, the logical progression from controlled clinical trials is the implementation of community intervention studies" (12).

Since it is difficult to achieve a hardcore experimental design in community-oriented health interventions, only a quasi-experimental study design with reference concept could be applied in these studies. That is, the level of aspiration created by the concept of these interventions has never been achieved by its practice.

Furthermore, most of the large-scale intervention studies mentioned here have suffered from social selectivity regarding the access to participants and the rate of participation in health intervention activities. In a review of community participation related to the German Cardiovascular Prevention Study, a group of social scientists stated that "the probability of participation was highest for people with an interest in health-related issues and for members of higher social classes" (13).

A German medical sociologist has pointed at the "excess risk" that members of lower social classes have due to their higher exposition to coronary and other risk factors. The author concludes:

    "The existing cardiovascular intervention programs in Germany and abroad have not directed the necessary attention to this specific problem. In future, prevention and intervention should be carried out focussing upon the decrease of class specific excess morbidity and mortality" (14).

The contemporary concept of community cardiovascular risk factor intervention studies with their extensive and obtrusive mass screenings and medical examination surveys neglects the complexity of physical, psychological, social, and ecological determinants of health in the context of everyday-life. They focus on individual risk behaviors and their modification. Determinants of social and ecological changes are not taken into account:

    "The conventional risk factors explain a great deal about the occurence of coronary heart disease, but they leave a great deal unexplained ... A man's employment status was a stronger predictor of his risk of dying from coronary heart disease than any of the more familiar risk factors" (15).

The existing cardiovascular community intervention studies seem to:

  • favor restrictive designs and methodologies aiming at the obtainment of "hard" measures for health and health risks;
  • favor selective concepts of individual health risks and their prevention;
  • lack a comprehensive and positive vision of health and health indicators;
  • not recognize the importance of the lifestyle-concept including the determining role of psycho-socio-ecological resources;
  • neglect the explicit relationship of health to both, quality of life and the individual and collective control over its determinants;
  • suffer from social selectivity and conceptual blindness with regard to the synergetic interaction of socio-emotional distress due to unfavorable working and living conditions, inadequate illness behavior, and the specific lifestyles of lower social classes and groups.

One of the leading experts in the field summarizes his comments on this kind of intervention research as follows:

    "... much of this research is generally uninformed by any systematic theory or logic concerning why the object of scrutinity should cause ill health" (16).

Worksite health promotion

Worksite health promotion aims at the enhancement of the health status of the employees and the health quality of every single workplace as well as of the work organization in general. It is basically oriented towards three different levels of action:

  1. the individual and collective health-related behavior; health-hazardous behavior is often easy to identify: smoking, alcohol and drug abuse, unbalanced diet, lack of physical exercise, etc. Most of available worksite health promotion programs are established on this level (17);
  2. the health and safety conditions of every single workplace; occupational health and safety measures related to every single workplace are carried out due to national legislation and state and community regulations. Health and safety take care of the quality of the workplaces and the work process with regard to health issues of the individual and the collective (18);
  3. the corporate level of health promotion; the corporate level of health promotion covers the health policy of the corporation, the cooperation between trade unions, employer's organization, and national, regional and local government, the relations between the corporation and the community as well as other environmental relations of the corporation.

When reviewing the literature on worksite health promotion, it becomes clear that the majority of programs is oriented to the intervention of single health habits of the individual. As Richard P. Sloan puts it:

    "... in virtually all of these health promotion programs, the organizational changes are in the service of helping individuals to modify their health-related behavior. Reports of attempts to influence health by modifying the illness-conducive aspects of work itself or of the organization's climate are extremely uncommon" (19).

Programs which focus on health and safety aspects are very common in Europe, North America, Australia, and Japan, i.e. in highly industrialized countries with a strong legislation and infrastructure in this field; but very little is happening in this respect in the developing world. Particularly, these programs focus on health education activities directed to the workers; they cover a wide range of subjects, their major issues, however, deal with personal health and safety behavior and with the use of personal protective devices in the workplace (20).

In order to enhance the quality and effects of worksite health promotion, it seems to be appropriate to consider complementary approaches of behavior- and organization-related programs, i.e. programs reflecting upon the complexity of human conditions in the worksite and taking care of the manifold relations between the company, its employees, the trade unions, governmental agencies, and its greater social, physical, and political environment. Worksite health promotion, then, is viewed both as health action and organizational action (21). Within such a frame of reference, programs related to individual behaviors are complemented by programs which take care of organizational and ecological aspects.


Three aspects may be highlighted at this stage:

  • definition and measurement of outcome must be expanded to include positive measures; i.e., comprehensive "health" indicators which emphasize physical capacities in connection with psycho-social and socio-ecological resources;
  • the role of subjective health appraisal should be acknowledged as well as the importance of functional capacity and psycho-social resources in health and in health interventions;
  • outcome indices and measures must be developed with sensitivity to the variety of physical, social, cultural, and ecological dimensions involved.

Raeburn & Rootman have recently pointed at the methodological short-comings of current health policy and research:

    "In both a policy and research framework, the usual goal is to obtain hard measures or variables; objectivity is the accepted standard and subjectivity, suspect. In moving away from the old models, however, people must face the importance of subjective aspects of health. Most studies examining the relationships between input (such as living conditions or social support) and health finally arrive at the conclusion that how people appraise or perceive input is more important than the objective nature of the input. With a variable such as coping ability, perceived rather than actual ability is related to health ... On the output side, the whole area of health policy and research has been strongly led by the desire to show impact in terms of hard indicators: typically disease, death or other biomedical measures ... The role of subjective measures will be of increasing importance if justice is to be done to the broad new multidimensional approach to health heralded by the Ottawa Charter" (22).

An integration of quantitative and qualitative methodology for research output with regard to an expanded health field concept is needed. Raeburn & Rootman (23) propose to integrate four hitherto isolated health intervention outcome categories:

  • traditional medical-model measures of morbidity and mortality;
  • positive health indicators;
  • subjective perceptions and appraisals of people's physical, mental, social and overall conditions;
  • people's functional capacity and coping with the demands of everyday life, the state of economy and ecology, etc.

    "There are many indications of appropriate measures ... and, in theory, there is no reason why even quite objective measures of positive physical and mental health cannot be developed and standardized. If credibility (and hence resources) is to be given to a concept of health that goes beyond morbidity and mortality measures, then clearly this is an area for urgent research development ... It would be desirable to move towards some universally acceptable indices, with due consideration to the variety of cultural, social and physical dimensions involved" (24).

The authors provide a model of representation of the expanded health field concept for health promotion intervention research:


Determinants of health Measurable health outputs
Public policy Morbidity / mortality
Society, culture & environment Positive health indicators
Community / social support Subjective perceptions
Personal behaviour / skills Functional capacity / coping
Health services  

Fig. 1: An expanded health field concept (Raeburn & Rootman 1989: 390)

We do not, however, share the distinction between determinants of health and health outputs with regard to their measurability. Thus, we propose to include health-determining, non-individual variables into health intervention research such as:

  • health-related behavior settings of everyday-life (e.g., worksite, school, public transport, public places, public buildings, etc.) and their continuous change;
  • structural determinants of health (e.g., ecology, social status, employment status, education, housing, public health care system) and their continuous change.

These variables gain their importance with regard to the explanation why certain population groups may be rather reluctant concerning their involvement in health intervention activities - and they will probably contribute to the examination of success and failures of intervention studies.


[1] Turner, B.S. [1984]: The Body and Society. Explorations in Social Theory. London [Cambridge University Press], p.1

[2] op.cit., p.8

[3] op.cit., p.111

[4] op.cit., p.112

[5] Vuori, H. [1980]: The medical model and the objectives in health education. In: International Journal of Health Education, 23, 1, p. 17

[6] Rosenstock, I.M. [1974]: The Health Belief Model and preventive health behavior. In: Health Education Monographs, 2, 4, p.330

[7] Armstrong, D. [1983]: Political Anatomy of the Body. London [Cambridge University Press]; Bateson, G. [1979]: Mind and Nature. A Necessary Unity. New York [Dutton]; Berger, P.L. & Luckmann, T. [1967]: The Social Construction of Reality. A Treatise in the Sociology of Knowledge. Harmondsworth [Penguin]; Crawford, R. [1984]: A cultural account of "health": control, release, and the social body. In: McKinlay, J.B. [ed.]: Issues in the Political Economy of Health Care. New York/London [Tavistock], 60-103; Freund, P. [1982]: The Civilized Body. Social Domination, Control, and Health. Philadelphia [Temple University Press]; Goffman, E. [1971]: Relations in Public. Microstudies of the Public Order. New York [Basic Books]; Polhemus, T. [ed.] [1978]: Social Aspects of the Human Body. Harmondsworth [Penguin]; Sobel, M.E. [1981]: Lifestyles and Social Structure. Concepts, Definitions, Analyses. New York [Academic Press]; Strunk, D. [1983]: Political Dimensions of the Body. London [Cambridge University Press]

[8] Wenzel, E. [1983]: Lifestyles and living conditions and their impact on health. A report of the meeting. In: Scottish Health Education Group, European Monographs in Health Education Research, Vol. 5, p.7-8

[9] Becker, M.H. [1986]: The tyranny of health promotion. In: Public Health Reviews 1986, p.19

[10] Bateson, G. [1979]: Mind and Nature. A Necessary Unity. New York [Dutton]

[11] Kickbusch, I. [1989]: Good planets are hard to find. Copenhagen [WHO-EURO, Healthy Cities Papers, No 5]

[12] GCP Study Group [1988]: The German Cardiovascular Prevention Study [GCP]: design and methods. In: European Heart Journal, 9, p.1058

[13] Tempel, G. et al. [1991]: Sozial selektive Erreichungsgrade in der gemeindeorientierten Intervention - Eine Analyse der Beteiligung an Gesundheitsaktionen der Deutschen Herz-Kreislauf-Praeventionsstudie [Social selectivity in community-based intervention - An analysis of participation in campaigns of the German Cardiovascular Prevention Study]. In: Sozial- und Praeventivmedizin, 36, 2, p.78

[14] Siegrist, J. [1989]: Soziale Lage und koronares Risiko - Eine Herausforderung fuer die Praevention [Socio-economic status and coronary risk - A challenge]. In: Sozial- und Praeventivmedizin, Supplement 1, p.15 [translation by us]

[15] Rose, G. & Marmot, M.G. [1981]: Social class and coronary heart disease. In: British Heart Journal, 45, p.17-18

[16] Becker, M.H., op.cit., p.18

[17] Fielding, J.E. & Piserchia, P.V. [1989]: Frequency of worksite health promotion activities. In: American Journal of Public Health, 79, 1, 16-20

[18] Levy, B.S. & Wegman, D.H. [1983]: Occupational Health. Boston [Little, Brown & Co.]

[19] Sloan, R.P. [1987]: Workplace health promotion: a commentary on the evolution of a paradigm. In: Health Education Quarterly, 14, 2, p.186

[20] Vojtecky, M.A. [1988]: Education for job safety and health. In: Health Education Quarterly, 15, 3, 289-298

[21] Sloan, R.P. & Gruman, J.C. [1988]: Participation in workplace health promotion programs: the contribution of health and organizational factors. In: Health Education Quarterly, 15, 3, 269-288

[22] Raeburn, J.M. & Rootman, I. [1989]: Towards an expanded health field concept: conceptual and research issues in a new era of health promotion. In: Health Promotion, 4, 3, p.386-387

[23] op.cit.

Copyright © by Eberhard Wenzel, 1997-2001