534108
editorial2014
PED22210.1177/1757975914534108EditorialD. V. McQueen
Editorial Health promotion applied to infectious diseases David V. McQueen1 In its brief history, health promotion, despite its efforts to focus on health rather than disease, as a field of research and practice has generally been associated with efforts at disease prevention. In addition and despite the broadening of the theoretical underpinning of the field up to the present, the disease emphasis continues and is largely focused on the non-communicable diseases (NCDs) (1). Meanwhile the greater field of public health continued with its major emphasis and resource commitment on infectious diseases. Even in advanced industrial countries where the causes of death and disabilities are overwhelmingly related to chronic diseases and injuries, the allocation of funding resources in the public health sector goes to the classical infectious diseases. The emergence of HIV/ AIDS further exacerbated the secondary position of NCDs and injuries in terms of resource allocations in major public health institutions and in government ministries. As a result, the marginalization of health promotion approaches is the outcome. Or is it? A recent study undertaken under the auspices of the IUHPE (2) sought to examine in some depth the thesis that health promotion approaches used on NCDs would also be relevant and useful to consider for infectious diseases in developed economies. To begin with there are notable conceptual limitations in undertaking to demonstrate this thesis. First, infectious disease approaches in public health are very much found in silos that are based on the disease itself. Thus there is an enormous literature on malaria, syphilis, tuberculosis, polio, AIDS, various infections, parasites, etc. The list is long, and large departments in schools and institutions of public health are based on high specialization and literatures and journals that often are very distinct. In contrast, the NCDs are often lumped together in single institutes, centers or departments around cancers, heart diseases, injuries, etc. Another critical aspect of this is that the behavioral and social
sciences activities and departments are often highly tied to the NCDs and stand alone as departments. In contrast, where such approaches exist in infectious disease prevention and control, the individual social science researchers work within an infectious disease setting. In our review of the literature to address our thesis, these structural aspects became apparent in terms of outcome and approaches. Second and also salient, health promotion’s theoretical underpinnings largely stem from the social and behavioral sciences, notably education, sociology, psychology and political science. However, the practice of health promotion and in particular the component of health education is seen most applied in medical rather than social settings. As a result of these limiting aspects, historically there have been only limited health promotion approaches in the area of population approaches to infectious diseases. As a result of these limitations we chose to study the importance of health promotion approaches to infectious diseases by an argument from analogy. Our emphasis was to examine the widely used health promotion models adapted for use on NCDs and determine if these approaches would be useful and appropriate for infectious diseases. However, this is not a simple analogy to make. To begin with, we recognized a certain duplicity, a continuing artificial distinction, namely that many chronic diseases have infectious components, for example certain cancers, heart diseases, etc.; and that many so-called infectious diseases, mainly defined by initial causality, have chronic outcomes, e.g. polio, AIDS. The reality that emerged was that probably all disease, regardless of etiology, had an essential background of related causality. This was, and is, particularly true in the so-called case of the ‘causes of the causes’. That is, regardless of disease outcomes, the underlying causes of inequity, poverty, environment, etc., were apparent and relevant. Thus health promotion models based on such distal
1. Correspondence to: David V. McQueen, Global consultant, 2418 Midvale Court, Tucker, GA 30084 USA. Email: [email protected] Global Health Promotion 1757-9759; Vol 22(2): 3 –4; 534108 Copyright © The Author(s) 2014, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914534108 http://ghp.sagepub.com Downloaded from ped.sagepub.com by guest on November 14, 2015
4
D. V. McQueen
factors are inherently important for interventions addressing infectious diseases. The underlying analogy thesis is a very strong one. The difficulty in showing the strength of this thesis occurs when seeking empirical studies showing this and in providing the evidentiary basis for proving the underlying causes to be valid in terms of infectious disease. A classical review and search of the literature, both published and ‘grey’, was undertaken. Using the typical search engine approach revealed the limitations of simply relying on such devices. To begin with, the widely used health promotion models and community approaches are simply not easily accessible by classification systems that rely on key words and the normal disease outcomes classification. Thus we also turned to the evidence collecting institutional efforts such as the Cochrane Collaboration, the CDC Community Guide, NICE and others. The advantage of their approaches was that they looked at type and content of the intervention on a specific disease outcome from an evidentiary point of view. The findings, however, were at best scarce, namely because when contentbased research is undertaken the methodology and design drive the success or failure of the intervention being included and assessed by such institutional efforts. At the end of the day the classical review approach reveals a vast unexamined literature that is impossible to categorize, and the institutional approach yields a paltry sum of successful interventions and in most cases insufficient findings. The utility of our study has been to reveal this shortcoming and at the same time offer recommendations for what may be done to remedy this situation and further the cause of health promotion approaches as a way to address all health and illness problems. First, the field of health promotion shares much with the emerging field of intervention research in public health and the need to understand a) the process mechanisms involved in an intervention, as opposed to a focus on outcomes, b) the need to see causality as difficult to determine when interventions are complicated and multivariate, and c) that new ways of understanding the successes and failures of interventions need to be developed. Second, health promotion interventions are both practical and dynamic: the variables being considered in any intervention are themselves very dynamic and subject to change during the time of the intervention,
and importantly the participants are not seen as the subject of the study, but rather as active participants in the study. Interventions with highly fixed designs are not applicable to health promotion interventions, but unfortunately are commonplace in most public health research. There is a major need to develop better participatory methodologies and to have these methodologies recognized in the scientific literature and in research protocols. Finally, health promotion would benefit from an in-depth study of an area of great success of health promoting interventions in chronic disease, e.g. tobacco and health. We know the outcomes of the many health promotion efforts regarding tobacco, from the policy area, as in the Framework Convention on Tobacco Control (3), to the individual efforts, and in health education to reduce individual smoking behavior. But we need greater understanding and systematic investigation of the dynamics of these efforts and how they might be modeled to guide us in understanding the contexts and mechanisms of interventions that involve multiple components. Acknowledgements Many thanks to my co-investigator Erma Manoncourt on this challenging project. She brilliantly covered the obscure and difficult-to-understand area of grey literature related to this subject; to Yuri Cartier, IUHPE staffer of diligence, pursuit and oversight who made the project come together and added immeasurably to the ideas; and to Marie-Claude Lamarre, the ever competent and perceptive executive director of IUHPE whose ongoing encouragement and advice was perfect. This also acknowledges the funders of this project, the European Centre for Disease Prevention and Control (ECDC) for giving resources to this intriguing area of public health. Of course, the opinions expressed in this editorial are those of the author and do not necessarily represent those of my colleagues, the funders or the IUHPE.
References 1. McQueen DV. The health promotion argument: NCDs and public health. In McQueen DV, Ed. Global Handbook on Noncommunicable Diseases and Health Promotion. New York: Springer; 2013, Chapter 22, pp. 337–342. 2. McQueen DV, Manoncourt E, Cartier Y. The added value of Health Promotion and Health Education methods and concepts in the prevention of communicable diseases. Stockholm: European Centre for Disease Prevention and Control [In press]. 3. World Health Organization. Framework Convention on Tobacco Control. Geneva, Switzerland: WHO; 21 May 2003.
IUHPE – Global Health Promotion Vol. 22, No. 2 2015
Downloaded from ped.sagepub.com by guest on November 14, 2015
editorial2014
PED22210.1177/1757975914534108EditorialD. V. McQueen
Editorial Health promotion applied to infectious diseases David V. McQueen1 In its brief history, health promotion, despite its efforts to focus on health rather than disease, as a field of research and practice has generally been associated with efforts at disease prevention. In addition and despite the broadening of the theoretical underpinning of the field up to the present, the disease emphasis continues and is largely focused on the non-communicable diseases (NCDs) (1). Meanwhile the greater field of public health continued with its major emphasis and resource commitment on infectious diseases. Even in advanced industrial countries where the causes of death and disabilities are overwhelmingly related to chronic diseases and injuries, the allocation of funding resources in the public health sector goes to the classical infectious diseases. The emergence of HIV/ AIDS further exacerbated the secondary position of NCDs and injuries in terms of resource allocations in major public health institutions and in government ministries. As a result, the marginalization of health promotion approaches is the outcome. Or is it? A recent study undertaken under the auspices of the IUHPE (2) sought to examine in some depth the thesis that health promotion approaches used on NCDs would also be relevant and useful to consider for infectious diseases in developed economies. To begin with there are notable conceptual limitations in undertaking to demonstrate this thesis. First, infectious disease approaches in public health are very much found in silos that are based on the disease itself. Thus there is an enormous literature on malaria, syphilis, tuberculosis, polio, AIDS, various infections, parasites, etc. The list is long, and large departments in schools and institutions of public health are based on high specialization and literatures and journals that often are very distinct. In contrast, the NCDs are often lumped together in single institutes, centers or departments around cancers, heart diseases, injuries, etc. Another critical aspect of this is that the behavioral and social
sciences activities and departments are often highly tied to the NCDs and stand alone as departments. In contrast, where such approaches exist in infectious disease prevention and control, the individual social science researchers work within an infectious disease setting. In our review of the literature to address our thesis, these structural aspects became apparent in terms of outcome and approaches. Second and also salient, health promotion’s theoretical underpinnings largely stem from the social and behavioral sciences, notably education, sociology, psychology and political science. However, the practice of health promotion and in particular the component of health education is seen most applied in medical rather than social settings. As a result of these limiting aspects, historically there have been only limited health promotion approaches in the area of population approaches to infectious diseases. As a result of these limitations we chose to study the importance of health promotion approaches to infectious diseases by an argument from analogy. Our emphasis was to examine the widely used health promotion models adapted for use on NCDs and determine if these approaches would be useful and appropriate for infectious diseases. However, this is not a simple analogy to make. To begin with, we recognized a certain duplicity, a continuing artificial distinction, namely that many chronic diseases have infectious components, for example certain cancers, heart diseases, etc.; and that many so-called infectious diseases, mainly defined by initial causality, have chronic outcomes, e.g. polio, AIDS. The reality that emerged was that probably all disease, regardless of etiology, had an essential background of related causality. This was, and is, particularly true in the so-called case of the ‘causes of the causes’. That is, regardless of disease outcomes, the underlying causes of inequity, poverty, environment, etc., were apparent and relevant. Thus health promotion models based on such distal
1. Correspondence to: David V. McQueen, Global consultant, 2418 Midvale Court, Tucker, GA 30084 USA. Email: [email protected] Global Health Promotion 1757-9759; Vol 22(2): 3 –4; 534108 Copyright © The Author(s) 2014, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914534108 http://ghp.sagepub.com Downloaded from ped.sagepub.com by guest on November 14, 2015
4
D. V. McQueen
factors are inherently important for interventions addressing infectious diseases. The underlying analogy thesis is a very strong one. The difficulty in showing the strength of this thesis occurs when seeking empirical studies showing this and in providing the evidentiary basis for proving the underlying causes to be valid in terms of infectious disease. A classical review and search of the literature, both published and ‘grey’, was undertaken. Using the typical search engine approach revealed the limitations of simply relying on such devices. To begin with, the widely used health promotion models and community approaches are simply not easily accessible by classification systems that rely on key words and the normal disease outcomes classification. Thus we also turned to the evidence collecting institutional efforts such as the Cochrane Collaboration, the CDC Community Guide, NICE and others. The advantage of their approaches was that they looked at type and content of the intervention on a specific disease outcome from an evidentiary point of view. The findings, however, were at best scarce, namely because when contentbased research is undertaken the methodology and design drive the success or failure of the intervention being included and assessed by such institutional efforts. At the end of the day the classical review approach reveals a vast unexamined literature that is impossible to categorize, and the institutional approach yields a paltry sum of successful interventions and in most cases insufficient findings. The utility of our study has been to reveal this shortcoming and at the same time offer recommendations for what may be done to remedy this situation and further the cause of health promotion approaches as a way to address all health and illness problems. First, the field of health promotion shares much with the emerging field of intervention research in public health and the need to understand a) the process mechanisms involved in an intervention, as opposed to a focus on outcomes, b) the need to see causality as difficult to determine when interventions are complicated and multivariate, and c) that new ways of understanding the successes and failures of interventions need to be developed. Second, health promotion interventions are both practical and dynamic: the variables being considered in any intervention are themselves very dynamic and subject to change during the time of the intervention,
and importantly the participants are not seen as the subject of the study, but rather as active participants in the study. Interventions with highly fixed designs are not applicable to health promotion interventions, but unfortunately are commonplace in most public health research. There is a major need to develop better participatory methodologies and to have these methodologies recognized in the scientific literature and in research protocols. Finally, health promotion would benefit from an in-depth study of an area of great success of health promoting interventions in chronic disease, e.g. tobacco and health. We know the outcomes of the many health promotion efforts regarding tobacco, from the policy area, as in the Framework Convention on Tobacco Control (3), to the individual efforts, and in health education to reduce individual smoking behavior. But we need greater understanding and systematic investigation of the dynamics of these efforts and how they might be modeled to guide us in understanding the contexts and mechanisms of interventions that involve multiple components. Acknowledgements Many thanks to my co-investigator Erma Manoncourt on this challenging project. She brilliantly covered the obscure and difficult-to-understand area of grey literature related to this subject; to Yuri Cartier, IUHPE staffer of diligence, pursuit and oversight who made the project come together and added immeasurably to the ideas; and to Marie-Claude Lamarre, the ever competent and perceptive executive director of IUHPE whose ongoing encouragement and advice was perfect. This also acknowledges the funders of this project, the European Centre for Disease Prevention and Control (ECDC) for giving resources to this intriguing area of public health. Of course, the opinions expressed in this editorial are those of the author and do not necessarily represent those of my colleagues, the funders or the IUHPE.
References 1. McQueen DV. The health promotion argument: NCDs and public health. In McQueen DV, Ed. Global Handbook on Noncommunicable Diseases and Health Promotion. New York: Springer; 2013, Chapter 22, pp. 337–342. 2. McQueen DV, Manoncourt E, Cartier Y. The added value of Health Promotion and Health Education methods and concepts in the prevention of communicable diseases. Stockholm: European Centre for Disease Prevention and Control [In press]. 3. World Health Organization. Framework Convention on Tobacco Control. Geneva, Switzerland: WHO; 21 May 2003.
IUHPE – Global Health Promotion Vol. 22, No. 2 2015
Downloaded from ped.sagepub.com by guest on November 14, 2015
![[Health promotion: Mental health promotion].](/assets/img/hold.png)
