Psm long question 10 marks Health and disease concept, dimensions, determinant
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Let me now read the Dimensions section and the Determinants/Concept of Disease sections.
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Concept of Health and Disease, Dimensions of Health, and Determinants of Health
(Park's Textbook of Preventive and Social Medicine, Chapter 2)
CONCEPT OF HEALTH
Evolution of the Concept
Health is a universal theme across all cultures. The evolution of its concept has passed through several stages:
1. Biomedical Concept
The oldest and most traditional view defines health as the "absence of disease." This arose from the "germ theory of disease" which dominated medical thought at the turn of the 20th century. The human body was viewed as a machine, disease as its breakdown, and the doctor's role as repair. Criticism: it minimized the role of environmental, social, psychological, and cultural determinants.
2. Ecological Concept
Deficiencies of the biomedical model gave rise to the ecological concept. Health is viewed as a "dynamic equilibrium between man and his environment," and disease as a maladjustment of the human organism to the environment. Dubos defined health as "the relative absence of pain and discomfort and a continuous adaptation to ensure optimal function."
3. Psychosocial Concept
Advances in social sciences revealed that health is not only a biomedical phenomenon but is also influenced by social, psychological, cultural, economic, and political factors. Health is both a biological and social phenomenon.
4. Holistic Concept
The holistic model is a synthesis of all the above. It recognizes the strength of social, economic, political, and environmental influences on health. It views health as a "unified or multidimensional process involving the well-being of the whole person in the context of his environment." It corresponds to the ancient Indian and Greek view: a sound mind, in a sound body, in a sound family, in a sound environment.
WHO Definition of Health (1948)
"Health is a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity."
Later amplified to include: "the ability to lead a socially and economically productive life."
Criticism: It is idealistic, not operational (cannot be directly measured), and defines health as a "state" rather than a dynamic process. Despite this, it sets the standard of "positive health" and represents a worldwide social goal.
Operational Definition (WHO Study Group):
In a narrow sense, health means: (a) no obvious evidence of disease, with the person functioning normally within accepted norms for age/sex/community; and (b) organs functioning adequately in harmonious equilibrium (homeostasis).
Positive Health
"Positive health" means more than the absence of disease - it implies a perfect state of well-being. Biologically: every cell and organ functioning at optimum capacity; psychologically: a sense of well-being and mastery over environment; socially: optimal capacity for participation in the social system.
Dubos cautioned: "The concept of perfect positive health cannot become a reality because man will never be so perfectly adapted to his environment that his life will not involve struggles, failures and sufferings."
Health - A Relative Concept
Health is a relative concept. Health standards vary among cultures, social classes, and age groups. For example, a newborn in India averages 2.8 kg vs. 3.5 kg in developed countries, yet both may be healthy. Each country must define health norms based on its own prevailing ecological conditions.
CONCEPT OF DISEASE
Disease is defined variously:
- Webster: "A condition in which body health is impaired, a departure from a state of health, an alteration of the human body interrupting the performance of vital functions."
- Ecological view: "A maladjustment of the human organism to the environment."
- Simple definition: Any deviation from normal functioning or a state of complete physical or mental well-being.
WHO has not defined disease because disease has many shades - the "spectrum of disease" ranges from inapparent (subclinical) cases to severe manifest illness.
Disease vs. Illness vs. Sickness (Susser)
| Term | Definition |
|---|---|
| Disease | A physiological/psychological dysfunction |
| Illness | A subjective state - the person feels unwell; also includes individual's perceptions and behaviour in response to disease |
| Sickness | A state of social dysfunction - a role the individual assumes when ill ("sick role") |
DIMENSIONS OF HEALTH
Health is multidimensional. The WHO definition envisages three dimensions - physical, mental, and social. Additional dimensions include spiritual, emotional, vocational, and political.
1. Physical Dimension
The easiest to understand. It conceptualizes health biologically as a state in which every cell and organ is functioning at optimum capacity and in perfect harmony with the rest of the body. Signs of physical health: good complexion, clean skin, bright eyes, lustrous hair, good appetite, sound sleep, regular bowel/bladder activity, smooth coordinated movements. Assessed by clinical examination, biochemical investigations, nutritional assessment.
2. Mental Dimension
Good mental health is the ability to respond to life's experiences with flexibility and a sense of purpose. Defined as "a state of balance between the individual and the surrounding world, a state of harmony between oneself and others." Attributes of a mentally healthy person:
- Free from internal conflicts
- Well-adjusted and able to get along with others
- Has a strong sense of self-esteem
- Knows his needs, problems, and goals (self-actualization)
- Good self-control; balances rationality and emotionality
- Copes with stress and anxiety
3. Social Dimension
Social well-being implies "harmony and integration within the individual, between each individual and other members of society, and between individuals and the world in which they live." It has been defined as the "quantity and quality of an individual's interpersonal ties and the extent of involvement with the community." Social health accounts for every individual as part of a family and of a wider community.
4. Spiritual Dimension
Refers to that part of the individual which reaches out and strives for meaning and purpose in life - the intangible "something" that transcends physiology and psychology. Includes integrity, principles and ethics, purpose in life, commitment to a higher being, and beliefs not subject to scientific explanation.
5. Emotional Dimension
Distinct from mental health - mental health relates to "knowing" (cognition) while emotional health relates to "feeling." Research in psychobiology has isolated these as two separate dimensions.
6. Vocational Dimension
Work is part of human existence. When work is adapted to human goals and capacities, it promotes both physical and mental health. Physical work improves physical capacity; goal achievement in work is a source of satisfaction and enhanced self-esteem. This dimension is exposed when individuals lose jobs or face mandatory retirement.
7. Other Dimensions
- Philosophical dimension
- Cultural dimension
- Socio-economic dimension
- Environmental dimension
DETERMINANTS OF HEALTH
The major determinants of health (as illustrated in the "Wheel of Health" or Mandala of Health) are:
1. Biological Determinants
The physical and mental traits of every human being are determined partly by genes at conception. The genetic make-up cannot be altered after conception. Diseases of genetic origin include chromosomal anomalies, errors of metabolism, mental retardation, and some types of diabetes. Medical genetics offers tools for genetic screening and gene therapy. Health from a genetic standpoint is the absence of deleterious genes and aberrations in the karyotype.
2. Behavioural and Socio-cultural Conditions (Lifestyle)
"Lifestyle" denotes "the way people live" - reflecting social values, attitudes, and activities. It includes cultural and behavioural patterns and lifelong personal habits (smoking, alcoholism) developed through socialization. Learned through interaction with parents, peer groups, friends, siblings, school, and mass media. Positive lifestyles (adequate nutrition, sleep, physical activity) promote health. Health is both a consequence of an individual's lifestyle and a factor in determining it.
3. Environment
Hippocrates first related disease to environment (climate, water, air). Environment is classified as:
- Internal environment: Every tissue, organ, and organ-system and their harmonious functioning
- External (macro) environment: All that is external to the human host - physical, biological, and psychosocial components
Environment has a direct impact on physical, mental, and social well-being. Environmental factors range from housing, water supply, and psychosocial stress to social and economic support systems.
4. Socio-economic Conditions
For the majority of the world's people, health status is determined primarily by level of socio-economic development. Major factors include:
- Economic status (per capita GNP): Determines purchasing power, standard of living, quality of life, family size, and pattern of disease
- Education: Literacy and education are strongly associated with improved health outcomes, especially maternal education and child health
- Occupation: Work-related hazards and occupational diseases; unemployment itself is a health hazard
- Political system: The political will to ensure equitable distribution of health resources
5. Health and Family Services
Health services include preventive, curative, and rehabilitative care, family welfare, nutrition, and school health services. However, the paradox noted is that "health care does not produce good health" - there is strong correlation between GNP and life expectancy, but no significant correlation between medical density and life expectancy. The most that effective health services can offer is good care.
6. Ageing of the Population
By 2020, 1.4 billion people are estimated to be aged 60 and over, with two-thirds in developing countries. Rapid population ageing increases the prevalence of chronic diseases and disabilities, requiring special attention.
7. Gender
Women's health issues include nutrition, reproductive health, health consequences of violence, ageing, lifestyle-related conditions, and occupational environment. The Global Commission on Women's Health (1993) brought increased awareness among policy-makers.
8. Other Factors
- Information and communication technology facilitating access to medical information
- Health-related systems: food and agriculture, education, industry, social welfare, rural development
- Intersectoral contributions to health are increasingly recognized - medicine is not the sole contributor to health and well-being.
ECOLOGY OF HEALTH (Spectrum of Health and Disease)
Ecology comes from the Greek Oikos (house). It is the science of mutual relationships between living organisms and their environments. According to ecological concepts, health is "a state of dynamic equilibrium between man and his environment." Disease is embedded in the ecosystem of man. The spectrum ranges from:
Positive health → Better health → Freedom from sickness → Unrecognized sickness → Mild sickness → Severe sickness → Death
This spectrum concept (the "iceberg phenomenon") is important in epidemiology - only the tip of the disease iceberg is visible clinically; the submerged portion represents undiagnosed and subclinical cases.
Source: Park's Textbook of Preventive and Social Medicine, Chapter 2 - "Concept of Health and Disease."
Exam format answer
Here is the exam-format answer for a 10-mark PSM long question:
Concept of Health and Disease, Dimensions and Determinants of Health
CONCEPT OF HEALTH
Health is a universal concept that has evolved over time through four main models:
1. Biomedical Concept
Traditional view - health is "absence of disease." Based on germ theory. Viewed the body as a machine and disease as its breakdown. Limitation: Ignores environmental, social, and psychological factors.
2. Ecological Concept
Health is a "dynamic equilibrium between man and his environment." Disease is a maladjustment of the human organism to the environment (Dubos).
3. Psychosocial Concept
Health is influenced by social, psychological, cultural, economic, and political factors. Health is both a biological and social phenomenon.
4. Holistic Concept
Synthesis of all above concepts. Health = well-being of the whole person in the context of his environment. Sound mind, in a sound body, in a sound family, in a sound environment.
WHO Definition (1948)
"Health is a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity."
Later amplified: to include ability to lead a "socially and economically productive life."
Criticism: Idealistic, not operational, defines health as a static "state" rather than a dynamic process.
Positive Health
More than absence of disease - implies perfect well-being. Dubos cautioned: "Perfect positive health cannot become a reality because man will never be so perfectly adapted to his environment."
Health as a Relative Concept
Health standards vary among cultures, social classes, and age groups. Each country defines norms based on its own ecological conditions.
CONCEPT OF DISEASE
| Term | Definition |
|---|---|
| Disease | Physiological/psychological dysfunction |
| Illness | Subjective feeling of not being well; individual's perception and response to disease |
| Sickness | State of social dysfunction - the "sick role" |
- Webster: "A condition in which body health is impaired, interrupting the performance of vital functions."
- Ecological view: "A maladjustment of the human organism to the environment."
WHO has not defined disease because disease has a "spectrum" - ranging from inapparent (subclinical) cases to severe manifest illness, carrier states, and variable end-points (recovery, disability, death).
DIMENSIONS OF HEALTH
Health is multidimensional. WHO envisages 3 core dimensions; additional ones are also recognized.
| # | Dimension | Key Points |
|---|---|---|
| 1 | Physical | Every cell and organ functioning at optimum capacity. Signs: good complexion, bright eyes, sound sleep, normal vitals, coordinated movements. |
| 2 | Mental | Ability to respond to life experiences with flexibility and purpose. Attributes: free from internal conflict, well-adjusted, good self-esteem, self-actualization, coping with stress. |
| 3 | Social | Harmony and integration within the individual and with society. Quantity and quality of interpersonal ties and community involvement. |
| 4 | Spiritual | Striving for meaning and purpose in life. Includes integrity, ethics, commitment to a higher being. |
| 5 | Emotional | Distinct from mental - relates to "feeling" vs. "knowing." Isolated by psychobiology research. |
| 6 | Vocational | Work adapted to human goals promotes health. Source of satisfaction and self-esteem. Loss of job is itself a health hazard. |
| 7 | Others | Philosophical, cultural, socio-economic, environmental dimensions. |
DETERMINANTS OF HEALTH
The determinants of health are the range of personal, social, economic, and environmental factors that determine the health status of individuals or populations.
1. Biological Determinants
- Genetic make-up determined at conception; cannot be altered afterward.
- Genetic diseases: chromosomal anomalies, errors of metabolism, mental retardation, some forms of diabetes.
- Medical genetics: genetic screening and gene therapy offer prospects for disease prevention.
2. Behavioural and Socio-cultural Conditions (Lifestyle)
- "The way people live" - values, attitudes, habits (smoking, alcoholism, diet, exercise).
- Learned through socialization - parents, peers, school, mass media.
- "Health is both a consequence of an individual's lifestyle and a factor in determining it."
3. Environment
- Hippocrates first related disease to environment.
- Internal environment: Every organ and its harmonious functioning.
- External (macro) environment: Physical, biological, and psychosocial components.
- Includes housing, water supply, psychosocial stress, social support systems.
4. Socio-economic Conditions
- Per capita GNP, education, occupation, nutrition, employment, housing, political system.
- Economic status: Determines purchasing power, standard of living, quality of life, disease pattern.
- Education: Maternal literacy strongly linked to child health and survival.
- Political system: Determines equitable distribution of health resources.
5. Health and Family Services
- Preventive, curative, and rehabilitative services.
- Paradox: Strong correlation between GNP and life expectancy; but NO significant correlation between medical density and life expectancy.
- "Health care does not produce good health" - the most we can expect is good care.
6. Ageing of Population
- Projected 1.4 billion aged 60+ by 2020; 2/3 in developing countries.
- Increased burden of chronic diseases and disabilities.
7. Gender
- Women's health issues: nutrition, reproductive health, violence, occupational hazards.
- Global Commission on Women's Health established in 1993.
8. Other Factors
- Information and communication technology.
- Intersectoral contributions: agriculture, education, industry, social welfare, rural development.
- "Medicine is not the sole contributor to health and well-being."
SPECTRUM OF HEALTH AND DISEASE
Health and disease are not absolute states but a continuum:
Positive health → Good health → Freedom from sickness → Unrecognized sickness → Mild sickness → Severe sickness → Death
This is the basis of the "Iceberg Phenomenon" - only the tip (clinical cases) is visible; the large submerged portion represents subclinical and undiagnosed disease.
Source: Park's Textbook of Preventive and Social Medicine, Chapter 2
What if I will add concept of disease in end of the question
Great question. If the exam question ends with "...determinants, concept of disease", here is how you restructure and write it:
Concept of Health, Dimensions, Determinants, and Concept of Disease
CONCEPT OF HEALTH
Health has evolved through four models:
1. Biomedical Concept
Health = "absence of disease." Based on germ theory. Body viewed as a machine. Limitation: Ignores social, psychological, and environmental factors.
2. Ecological Concept
Health = "dynamic equilibrium between man and his environment." Disease = maladjustment to environment (Dubos).
3. Psychosocial Concept
Health influenced by social, psychological, cultural, economic, and political factors. Health is both a biological and social phenomenon.
4. Holistic Concept
Synthesis of all above. Well-being of the whole person in context of his environment. Sound mind, sound body, sound family, sound environment.
WHO Definition (1948)
"Health is a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity."
Criticism: Idealistic, not operational, defines health as a static state.
Positive Health
More than absence of disease - implies perfect well-being. Health is a relative concept - standards vary across cultures, age groups, and socioeconomic classes.
DIMENSIONS OF HEALTH
Health is multidimensional. WHO envisages 3 core dimensions; additional ones are also recognized.
| # | Dimension | Key Points |
|---|---|---|
| 1 | Physical | Every cell and organ functioning optimally. Signs: good complexion, sound sleep, normal vitals, coordinated movements. |
| 2 | Mental | Ability to respond to life with flexibility and purpose. Free from internal conflict, good self-esteem, coping with stress. |
| 3 | Social | Harmony with oneself and society. Quantity and quality of interpersonal ties and community involvement. |
| 4 | Spiritual | Striving for meaning and purpose in life. Integrity, ethics, commitment to a higher being. |
| 5 | Emotional | Relates to "feeling" (distinct from mental which is "knowing"). |
| 6 | Vocational | Work adapted to human goals promotes health. Loss of job is itself a health hazard. |
| 7 | Others | Philosophical, cultural, socio-economic, environmental. |
DETERMINANTS OF HEALTH
Factors that determine the health status of individuals or populations:
1. Biological Determinants
Genetic make-up determined at conception; cannot be altered. Genetic diseases: chromosomal anomalies, errors of metabolism, mental retardation, some types of diabetes. Tools: genetic screening, gene therapy.
2. Behavioural and Socio-cultural Conditions (Lifestyle)
The way people live - habits, values, attitudes (smoking, alcoholism, diet, exercise). Learned through socialization.
"Health is both a consequence of an individual's lifestyle and a factor in determining it."
3. Environment
- Internal: every organ and its harmonious functioning.
- External (macro): physical, biological, psychosocial components.
- Includes housing, water supply, psychosocial stress, social support.
4. Socio-economic Conditions
Per capita GNP, education, occupation, employment, housing, political system.
- Economic status determines standard of living, quality of life, and disease pattern.
- Maternal education strongly linked to child health.
5. Health and Family Services
"Health care does not produce good health" - strong correlation between GNP and life expectancy, but NO significant correlation between medical density and life expectancy.
6. Ageing of Population
1.4 billion aged 60+ projected by 2020. Increased burden of chronic diseases and disabilities.
7. Gender
Women's health: nutrition, reproductive health, violence, occupational hazards. Global Commission on Women's Health, 1993.
8. Other Factors
Information technology, intersectoral contributions (agriculture, education, industry, social welfare).
"Medicine is not the sole contributor to health and well-being."
CONCEPT OF DISEASE
Definitions
- Webster: "A condition in which body health is impaired, interrupting the performance of vital functions."
- Oxford: "A condition of the body in which its functions are disrupted or deranged."
- Ecological: "A maladjustment of the human organism to the environment."
- Simple: Any deviation from normal functioning or state of complete well-being.
WHO has not defined disease because disease has a "spectrum" ranging from inapparent (subclinical) cases to severe manifest illness, with variable end-points (recovery, disability, or death).
Disease vs. Illness vs. Sickness (Susser's Classification)
| Term | Definition |
|---|---|
| Disease | Physiological / psychological dysfunction |
| Illness | Subjective feeling of not being well; individual's perception of and response to disease |
| Sickness | State of social dysfunction - the "sick role" assumed when ill |
It is possible to be a victim of disease without feeling ill (e.g., subclinical infection), and to feel ill without signs of physical impairment.
Spectrum of Disease
Health and disease are not absolute states but exist on a continuum:
Positive Health → Good Health → Freedom from Sickness → Unrecognized Sickness → Mild Sickness → Severe Sickness → Death
This forms the basis of the Iceberg Phenomenon - only the clinical (manifest) cases form the visible tip; the large submerged portion represents subclinical and undiagnosed disease in the community.
Source: Park's Textbook of Preventive and Social Medicine, Chapter 2
Exam Writing Tip
When the question asks "health and disease concept, dimensions, determinants" - follow this exact sequence in your answer. Adding concept of disease at the end simply means you write the Disease section last, after Determinants, as shown above. Each section should take roughly equal space for balanced marks.
Summary of this answer
Summary
1. CONCEPT OF HEALTH
4 Models:
- Biomedical - absence of disease (germ theory)
- Ecological - dynamic equilibrium with environment
- Psychosocial - influenced by social, psychological, cultural factors
- Holistic - synthesis of all; whole person in context of environment
WHO Definition (1948):
"Complete physical, mental and social well-being, not merely absence of disease."
Key points: Positive health = more than absence of disease. Health is a relative concept - varies by culture, age, socioeconomic class.
2. DIMENSIONS OF HEALTH (6+)
| Dimension | One-liner |
|---|---|
| Physical | Optimum functioning of every cell and organ |
| Mental | Flexibility, self-esteem, coping with stress |
| Social | Harmony with self, others, and community |
| Spiritual | Meaning and purpose in life |
| Emotional | "Feeling" (distinct from mental = "knowing") |
| Vocational | Work promotes health; job loss = health hazard |
3. DETERMINANTS OF HEALTH (8)
| # | Determinant | Key Point |
|---|---|---|
| 1 | Biological | Genetic makeup; cannot be altered after conception |
| 2 | Lifestyle | Habits, smoking, diet; learnt through socialization |
| 3 | Environment | Internal + external (physical, biological, psychosocial) |
| 4 | Socio-economic | GNP, education, occupation, housing, political system |
| 5 | Health services | "Health care does not produce good health" |
| 6 | Ageing | Chronic disease burden in elderly |
| 7 | Gender | Women's nutrition, reproductive health, violence |
| 8 | Other factors | IT, intersectoral contributions |
4. CONCEPT OF DISEASE
Susser's Classification:
- Disease = physiological/psychological dysfunction
- Illness = subjective feeling of being unwell
- Sickness = social dysfunction (sick role)
WHO has NOT defined disease - because disease has a spectrum from subclinical to severe.
Spectrum:
Positive health → Good health → Unrecognized sickness → Mild sickness → Severe sickness → Death
Iceberg Phenomenon - only manifest (clinical) cases are visible; large submerged portion = subclinical and undiagnosed cases.
Source: Park's PSM, Chapter 2
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