Psm long question 10 marks Health and disease concept, dimensions, determinant
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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."
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