Over approximately the past one hundred and fifty years there has seen a series of shifts in our definitions of health and disease and, as a result, also in the approaches taken by governments and health professionals towards it. After an initial focus on sanitation and public health in the late nineteenth century, health policy moved towards formal health care after the 1930s. With escalating costs of welfare, the 1970s and especially the 1980s, saw a greater emphasis on individual responsibility for health and behaviour change? and since then the concept of health promotion has come increasingly to the fore. In this essay we will examine the reasons for this change and its implications in theory and practice, as well as considering some of the criticisms that have been voiced against the health promotion approach.
[...] Tertiary prevention, lastly, intends to minimise the disability from a disease state that cannot be cured or leaves the individual with some loss of function. The workings and limitations of disease prevention are best illustrated using two examples, namely mass screening and targeted individual intervention. Screening is the active early diagnosis of a disease or risk factors with the aim to intervene to prevent the onset or progression of disease (Locker 1997) and thus, as mentioned, forms part of secondary prevention. [...]
[...] For example, someone told to use individual responsibility in order to lose weight could (as a consequence of the approach) suffer from worsened self-esteem. Unrealistic health promotion campaigns focusing on healthy eating and exercise may not seem achievable by people on low income and this too can lead to stress and anxiety. Becker (1986, cited in Locker 1997) warns of the ‘tyranny of health promotion', excessive proscription in the name of health, McCormick calls for ‘modified hedonism' instead and Reinharz (2001) complains that the never-ending health warnings take the joy out of life. [...]
[...] The objective of increasing awareness both about health risks and about what can be done to counter them is to empower communities and individuals by transferring the responsibility for, and control over health from professionals to the general public. This has its basis in studies showing that powerlessness is a major risk factor for disease and ill- health (Wallerstein 1992, cited in Locker 1997). Breslow (1999) offers more specific ways in which health professionals can be involved in ‘building health reserves'. [...]
[...] He highlights studies such as Pill and Stott (1990) which indicate that unwarranted advice is not well-received by patients and that it diverts time and resources from the other activities of primary care, and proposes that lifestyle changes should only be suggested to high- risk individuals. Further, he maintains that a great deal of attention must be paid to how advice is presented. Considering the factors influencing the motivation and ability of individuals to change their behaviour, he points to perceptions about susceptibility and severity of disease (health beliefs), beliefs about personal ability to change behaviour (self efficacy) and the crucial notion of ‘empowerment'. [...]
[...] Initial exploration should focus not only on the health problem but also on the patient's beliefs and expectations, while explanations, rather than being generalised statements, should reinforce positive attitudes and counter negative ideas. When negotiating future actions, opportunities and potential barriers should be taken into account and achievable goals should be selected by the patient rather than suggested by the health professional. Once these goals are chosen, support is crucial, including both feedback on progress and positive reinforcement. Conclusion Both health promotion and disease prevention form important and complementary parts of contemporary health care. [...]
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