Assessment of the outcomes
Rosmarie Erben, Peter Franzkowiak & Eberhard Wenzel
Peebles, Scotland, 14-18 September, 1992
Abstract
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.
Keywords
Health promotion, lifestyles, prevention, worksite health promotion, health intervention
Introduction
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):
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:
This model assumes that the individual will:
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 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:
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.
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.
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:
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 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 existing cardiovascular community intervention studies seem to:
One of the leading experts in the field summarizes his comments on this kind of intervention research as follows:
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:
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:
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.
Conclusion
Three aspects may be highlighted at this stage:
Raeburn & Rootman have recently pointed at the methodological short-comings of current health policy and research:
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:
The authors provide a model of representation of the expanded health field concept for health promotion intervention research:
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:
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.
References
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[23] op.cit.
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Copyright © by Eberhard Wenzel, 1997-2001