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Chapter 1
Concepts of Health
Helen Keleher and Colin MacDougall
Key concepts
–– Health
–– Health equity and inequity
–– Theories of health
Chapter objectives
Once you have read and worked through this chapter, you should be able to:
–– describe different concepts of individual and population health, explaining the key
differences between them
–– explain the concepts and theories of health that are most common in health and related
professions
–– identify key theories that underpin concepts of health
–– identify different theories of health used by different professions
–– distinguish between inequity and inequality
–– understand the social gradient in health.
health
INTRODUCTION A resource that
permits people to lead
Health is one of the most fundamental conditions of life. Feeling healthy is core to our individually, socially
everyday lives and is reflected in the common greeting, ‘How are you?’ Rarely does a day go and economically
by when we don’t consider our own health, and inquire about the health of others. productive lives. It
is a positive concept
Of course, people and cultures, groups and societies interpret the concept of the health
emphasising social
in different ways. Moreover, in Australia and around the world, we are seeing rising rates of and personal
poor health. Australia’s National Health Priorities reflect the conditions causing the highest resources as well as
burden—heart disease, cancer, type 2 diabetes, mental health conditions, injury, violence physical capabilities.
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biological approach against women and children, and dementia. In the developing countries of the world, where
to health four-fifths of the world’s people live, non-communicable diseases such as depression, heart
Explores the role
disease and road traffic deaths are fast replacing infectious diseases and malnutrition as the
of genes and risk
leading causes of disability and premature death. As a result, there is increasing interest
markers and their
interactions with in what can be done to stem the tide of poor health and to better understand the causal
other determinants of pathways to health and illness. A common question asked by health researchers is, ‘Why are
health. some people healthy and others not?’ Researchers and practitioners who are concerned with
biomedical approach poor health also want to make a difference to people’s lives and opportunities by improving
to health health.
Sees health and
This book is about the health of communities and populations including the health of
illness in terms of an
environments around us because we are only as healthy as the world in which we live.
individual’s medically
defined pathology. As a professional whose work affects health, your work is essential to that vision. This
primary health care book, Understanding Health, will lead you into journeys that will enable you to understand
Community-based health, how it is created, and what we can do as a society to improve people’s health.
services based on the In this chapter we explain some of the different ways that professions and cultures think
social model of health,
about health and compare those views to the many different ways in which citizens think
guided by principles
about health. In later chapters of the first part of this book you will read about the approaches
of equity, acceptability,
cultural competence, and practices of primary health care, public health, global health, health promotion and
affordability, and primary prevention, and the determinants of health—those factors that influence health. All
universalism, and these approaches are concerned with the health of the most vulnerable people in our society,
a commitment to and these are also a focus of this book. Once you understand the determinants of health, you
community and
will have a powerful foundation for understanding approaches to advance health and well-
health development.
being for populations.
Primary health care
incorporates essential
health care made
accessible at a cost CONCEPTS OF HEALTH
that a country and
Health is a dynamic concept with multiple meanings that are dependent on the context in
community can afford
with methods that are which the term is used and the people who use it. People see health as essential to well-being,
practical, scientifically but how people define their own health varies according to their own social experience,
sound and socially particularly in relation to their age, personal knowledge, and social and illness experiences.
acceptable as People put a high value on health because while money and power provide the means for
well as essential
people to attain material things that may benefit their lives, no one can actually buy health.
services for health
including water and In other words, health itself cannot be bought and sold in the marketplace, although health
sanitation, housing, services can be both bought and sold. Health is intrinsically tied to people’s sense of well-
shelter, freedom being and therefore occupies a higher order of meaning in people’s lives (Anand 2007).
from violence, and The Greek, Democritus, writing in the fifth century BC, said that ‘without health
adequate food.
nothing is of any use, not money nor anything else’; and the famous philosopher Descartes,
some 2000 years later, wrote: ‘The preservation of health is … without doubt the first good
and the foundation of all the other goods of this life’ (cited in Anand 2007, p. 17).
Koos (1954) captures the complex and mysterious nature of health in his statement that
‘health is an imponderable’. In other words, the state of health is one of the mysteries of life.
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It is complex and difficult to describe. In keeping with that we choose not to recommend behavioural approach
a particular definition of health but instead identify a number of different approaches to to health
understanding health and well-being. Underpins the types
of health promotion
The section below explains how different disciplines have different perspectives in how that focus on risk
they understand health. Each perspective affects how those disciplines or practitioners factors and lifestyle
approach their health practices so it is useful to grasp the differences between their behaviours.
approaches: determinants
–– The biological approach: biology is the study of life and living organisms in cells, approach
Sees health and
tissues and organs, so the biological approach to health explores the role of micro-
social problems in
organisms in disease, as well as the study of genetics and risk markers.
the context of broader
–– The biomedical approach studies health and illness in terms of people’s medically social, structural and
defined pathology. cultural conditions
–– The primary health care approach seeks to advance equity, access, empowerment, of our society and
informs public health
community self-determination and intersectoral collaboration.
and health promotion
–– The behavioural approach is focused on changing risk factors and lifestyle approaches.
behaviours. health promotion
–– The determinants approach situates health and social problems in the broader approach
social, structural and cultural conditions of our society and informs public health and The process of
health promotion approaches. enabling people to
take control over those
–– The health promotion approach is the process of enabling people to increase
factors that determine
control over, and to improve, their health. Health promotion work is strongly influenced their health.
by the knowledge derived from the determinants of health approach.
public health
–– The public health approach refers to all organised measures to protect health approach
among populations, and to prevent disease, promote health, and prolong life among Social and political
the population as a whole. Public health uses methods of epidemiology and biostatistics actions aimed at
to inform health protection and prevention efforts. Three more specialised approaches improving health,
prolonging life and
have developed from the broader public health approach:
improving the quality
1 New public health aims to learn from the political and practical experience of of life among whole
historical successes and failures in public health to achieve higher standards of populations through
health, particularly of those who have the least resources, to achieve a more just and health promotion,
socially responsible distribution of resources. disease prevention
and other forms of
2 Ecological public health emphasises relationships between the health of the
health intervention.
planet and the health of populations, demonstrating the essential interdependence of
people’s health with the health of the planet.
3 Population health studies a wide range of other data sources to understand the
health of whole populations, alongside profiling the health of people in local areas.
Further, population health emphasises the dual purpose of improving the health
of the entire population while targeting reduction of health inequities among
population groups. In order to reach these objectives, population health studies the
broad range of factors and conditions that have a strong influence on people’s health
to inform the work of health promotion and primary prevention practitioners.
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new public health –– Indigenous approaches see that one cannot separate health from life, social and spiritual
An explicitly social and relations and the environment.
political approach to
–– Sociological approaches study health and illness from social, political, economic and
health development
that emphasises structural dimensions.
the translation –– Spiritual approaches conceptualise health decisions as the actions of a God or other
of knowledge to ethereal force(s) beyond the control of the individual.
action on the social
–– Cultural approaches to health differ very widely. Most of the approaches listed here
determinants of
are based on Western systems but every culture has developed its own practices and
health, intersectoral
action to support beliefs about health, illness and disease. In our multicultural, diverse world, all health
health, healthy public practitioners need to become culturally competent and acquire knowledge about
policy, environments culturally safe health care practices.
for health, sustainable –– Popular or lay approaches see that people define health in different ways according to
development and
their culture, experience and life situation. Health is related to personal expectations.
equity in health.
Health and illness are not ‘either/or’ states because, in reality, people can feel quite
ecological public
healthy even though they may be living with an illness.
health
The outcome
Each of these approaches has its own value, but no single approach is universally valid—
of complex
indeed, there is overlap between many of the approaches. That said, no one approach is
interrelationships and
interdependencies able to comprehensively define health in a way that would hold good for all people, in all
between human communities, in all places.
beings, the Most of these approaches have a theoretical foundation. Nevertheless, you will also see
determinants of that many people and organisations hold ideas about health that are determined more by
health, and the
values and beliefs than by scientific evidence. As a professional who will contribute to health,
broader environment
in which they exist. you will benefit from gaining understanding of the theories underpinning these approaches
so you have a well-rounded understanding of how health is created, how people cope with
population health
approach
illness and how different professions work to maintain health and well-being. The next
An approach to health section provides a snapshot to get you started.
that aims to improve
the health of the entire
population, rather THEORIES OF HEALTH
than individuals,
and to reduce health There are many, many theories underpinning the various approaches to health. Of course, no
inequities among theory stands alone—there is interaction between the ideas and concepts within these theories
and between specific that inform how we think about health and well-being. A theory is a set of assumptions,
population groups. or propositions, or hypotheses or accepted facts that are assembled to provide a plausible
or rational explanation of the cause and effect of observed occurrences or experiences in
the world. To become an accepted theory, those assumptions, hypotheses or propositions
have been tested repeatedly to strengthen the internal and external validity of the theory.
Theories are generally a set of abstract ideas, tested for their validity and generalisability.
The function of a theory is to explain the complexity of the world and predict what
might happen if one or more important factors change—all in the simplest and most elegant
way possible. Theories are usually based on a set of principles that can be applied to the
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real world. Theory then can be established, or emerge, but all theories are subject to new
knowledge and learning and may be subject to challenge.
Paradigm shifts in theory
Thomas Kuhn (1970) was a leading thinker of the 1960s and 1970s; his arguments about
the ‘structure of scientific revolutions’ changed accepted wisdom about how new knowledge
becomes accepted into new paradigms. A paradigm is a distinct form of thought patterns
that gives shape to thinking with the sciences and social sciences. He argued that when new
questions are asked of established or accepted data and ways of thinking about something,
the paradigm shifts or changes. Figure 1.1 below is a simplified illustration of the cycle of
paradigm change that Kuhn put forward.
Figure 1.1 Kuhn’s cycle of paradigm shifts
5. Paradigm 1. Normal
Change Science
The Kuhn
Cycle
4. Model 2. Model
Revolution Drift
3. Model
Crisis
Source: Thomas Kuhn.
To understand Kuhn’s cycle, consider the bacteriology era of the nineteenth century that
fundamentally changed our understanding of the causation of disease. In earlier centuries,
miasmic theories of disease causation were considered normal science, but as bacteria and
viruses were discovered using new scientific technology, miasmic theories were rejected,
causing a theoretical revolution. Indeed, the model of treating disease was in crisis. So, the
era of bacteriology was a scientific revolution that caused a huge paradigm shift in how we
understand, diagnose and treat disease, and produced the curriculum that is taught to health
professionals today.
In more contemporary life, we are seeing a paradigm shift in relation to climate change
and the sustainability of the planet (see also Chapter 13). Paradigm shifts are often, but not For more information
always, characterised by conflict and debate as people defend positions or argue for the new on climate change,
scientific positions. Kuhn’s work inspired scholars from around the world to see shifting see Chapter 13
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landscapes in thinking and knowledge and analyse how the institutions of society have been
affected or influenced by those shifts. The concept of a ‘paradigm shift’ has entered our
lexicon and is used widely to describe changes in thinking that have occurred.
Building on the approaches to health earlier in this chapter, we now consider the theories
of health that come from different types of science. One group of theories looks to the natural
sciences because they share the same paradigm, or perspective, on science. These are:
–– body: biological and biomedical theories look inside the body and generally come about
through a hypothesis or group of hypotheses that have been supported with repeated
testing of biological phenomena
–– behaviour: behavioural approaches examine how lifestyle and risky behaviours impact
on health
–– mind: psychological theories attempt to explain social and cognitive phenomena,
including social psychology, personality, attribution and many others.
Using the language of Kuhn, another group of theories comes from a different paradigm
from those about body, behaviour and mind; those that look to the social and cultural
sciences. These are:
–– beliefs and spirituality: analysis of culture, religion and belief system reveal complex
and powerful explanations for health and illness that invoke the supernatural or
religious, or strong beliefs that bind people of a particular culture together. Cultural
theories are developed by anthropologists who study cultural belief systems and
practices to inform our understandings of cultures that differ from the mainstream in
any society.
–– sociological theories: are more likely to emerge from questioning about observations
of the social world and the societies in which people live, and attempt to explain social
phenomena.
–– politics: brings a more political analysis to the explanation of health and illness.
–– public health, population health and health promotion: draw on concepts and models
from a range of theories including epidemiological, causal and ethical theories.
Public health workers also develop theories of the determinants (including biological,
behavioural, community and structural levels) and the distribution of disease across
population groups. They then apply that knowledge, using implementation theories, to
the prevention of disease and to improve the health of populations. Theories of politics
including political culture, political ideologies, political philosophy, political science
theories, and political systems are central to understanding health.
To understand a person’s health status, professionals and community members always
need to take account of people’s own perspectives and their capacity to manage or control
the challenges and changes in the environments surrounding them. As well, professionals
need to understand the theoretical and conceptual understandings derived from the formal
literature, and to use all these sources of knowledge in their judgments about how best to
assist those consulting them for treatment.
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You will find that approaches to health are influenced by systems of beliefs and values
about health and that some beliefs and values are given precedence over others. It is also the
case that knowledge is not linear and can’t be understood in silos of information. In other
words, the chapters in this book illustrate that there is no single causal pathway to poor
health or disease in a population (Tesh 1988).
PROFESSIONS’ VIEWS OF HEALTH
The profession of medicine draws on natural science paradigms based on the science or
practice of the diagnosis, treatment, and prevention of illness and disease. Similarly, nursing
and the allied health professions are educated in modalities designed to treat disease or
prevent its recurrence. Midwifery is entirely about the care of women during pregnancy,
labour, and the postpartum period, as well as care of the newborn. The focus of these
professions is largely on individualised care, so their views of health are predominantly about
the health and well-being of an individual. Their work is mostly, but not entirely, based on
their observation of diagnosable symptoms, which is why they are called clinicians.
Public health and health promotion professions draw on more structural and political
paradigms to learn much more about the health of populations and ask why different
populations have different rates of health and disease. They are concerned with activities that
aim to provide conditions in which people can be healthy so their focus is on entire populations,
not on individual patients or diseases. Many clinicians take up postgraduate studies in public
health to broaden their understanding of health beyond the care of individuals.
As the study of health and illness added the expertise of social and political scientists to
its natural science paradigm, we began to understand that the pattern of health and illness in
populations cannot be explained, let alone influenced, by professionals from the health sector
alone. Contemporary public health and health promotion therefore emphasises and embraces
the role of many sectors beyond the health sector, because they are major contributors to the
environments and structures that support and create health. As a result, we hope that this
book will be used in university courses and in professional development not only in the health
sector, but also in those sectors whose activities contribute to how the day-to-day organisation
of our lives adds to, or takes away from, disease and disability years in the lives of individuals,
groups and populations. Below we provide some examples of fields of study and practice that
are vital for understanding and action on health. This is by no means an exhaustive list, but
serves to illustrate how critical it is that public health and health promotion moves beyond the
health sector to understand and work in new disciplines and frontiers.
Local government is increasingly involved in matters of health including the creation
of safe and healthy places for people to live and work, planning schemes to manage where
and how people live and work, a wide range of support services, mechanisms for residents
to participate in decisions affecting the community, and planning for infrastructure such
as transport and land use schemes. Increasingly, local government is responsible for public For more information
health and well-being plans and their implementation, and is increasingly involved in health on health promotion,
promotion (see Chapter 7). see Chapter 7
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You will see in this book how urban and regional planning shapes the way our houses
connect to our work, education and leisure, and what this means for people’s physical activity,
social relationships and engagement with nature.
The education sector is also critical for health. A person’s level of education directly
influences literacy, which includes health literacy, cultural literacy and scientific literacy as
well as reading ability. Levels of education develop interpersonal and life skills, and are a
major influence on pathways through life that contribute to good health such as being able to
gain steady employment and live in stable housing, being an active community member, and
being able to make healthy relationship and food choices, as well as choices about smoking
and substance use.
In Chapter 13 we explain why the future of the climate and ecology is inextricably
linked with new and potentially catastrophic patterns of health and illness in just a few
generations’ time. Therefore, ecologists, conservationists and those who develop new
approaches to industry, power and transport will play key roles in preserving the health
of the planet, which in turn is becoming the most powerful determinant of the health of
people and civilisations.
Information technology is revolutionising the way we learn, work and play. It also changes
the way medical records are kept and how, for example, the internet and smart phones and
smart watches are being used in health promotion.
This book, and the broad field of public health, seeks to bring together a variety of
professions, disciplines and communities to understand old health problems, and anticipate
new problems, so that we can help create a better world for our children and their children.
THE POLITICS OF HEALTH
Throughout this book it will become clear that health is a highly political terrain. We have
already seen in this chapter how paradigms in science promote and defend themselves,
therefore becoming resistant to change. For example, the paradigms explaining health
in terms of the body and mind are very different from those invoking more cultural and
political factors. These are not unemotional decisions decided by rational debates about
scientific evidence. On the contrary, we have seen that, according to Kuhn, paradigm
changes are difficult and contested because they involve power and values that challenge
accepted thinking. That is why many political struggles are played out over the health
system, particularly at levels of government where different political philosophies determine
the budgets for health programs and services.
In the nineteenth century, Rudolf Virchow, the German physician and politician, wrote:
Medicine is a social science, and politics is nothing else but medicine on a large scale.
Medicine, as a social science, as the science of human beings, has the obligation to
point out problems and to attempt their theoretical solution: the politician, the practical
anthropologist, must find the means for their actual solution (cited in Rosen 1979, p. 29).
His pronouncement still rings true today.
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Different governments, groups of health professionals and corporations have different
ideas about the types of programs and services they want to fund, and politics drives the
policies that sit behind those programs and services. Indeed, the dominance in Australia of
the primary medical care model is a political outcome of the strength of medicine over the
social model of health. More recently with conservative governments in Australia, we have
seen attempts to wind back the universal system of Medicare and its coverage of essential
health care for all Australians.
The political nature of health can be understood at three levels:
1 Health is political because, like any other resource or commodity, some social groups
have more of it than others.
2 Health is political because its social determinants are amenable to political
interventions. They are therefore dependent on political action (or, more usually,
inaction) on the social determinants of health.
3 Health is political because the right to a standard of living adequate for health and
well-being is, or should be, an aspect of citizenship and a human right (Bambra, Fox &
Scott-Samuel 2007, pp. 48–9).
Health is intensely political because there are opposing ideological positions about how
much responsibility governments should take with regard to health. The health system
becomes a battleground between those who support universal access to high-quality health
care and access to both hospitals and primary health care, and those who support greater
provision by private interests. Many in public health are very concerned about attempts
to wind back universal publicly provided health care through Medicare, Australia’s health
insurance scheme, because it provides a foundation of care for people throughout their lives,
at an affordable cost. Another way to think about universal health care is that it aims to
provide the right service, at the right cost, at the right time, by the right provider. These
principles are about access, which in turn increases equity. Medicare is intended to increase
both access and equity as Box 1.1 describes.
BOX 1.1 AUSTRALIA’S MEDICARE SYSTEM
Australia’s Medicare system is a government run, universal, tax-funded, health insurance
scheme where individuals’ contributions are independent of health status. Australian citizens
and most permanent Australian residents are eligible for Medicare, which guarantees all
citizens access to a wide range of health services at little or no cost.
Medicare is funded through a mix of general revenue and a Medicare levy that is currently
set at 1.5 per cent of taxable income with an additional surcharge of 1 per cent for high-income
earners who have not taken private health insurance cover. People can choose whether to have
Medicare cover only, or a combination of Medicare and private health insurance.
Medicare is built on the principal of universal access to health care because it is a key
platform to improving the health of everybody, and provides equitably for disadvantaged and
vulnerable groups. Universal health care is an essential responsibility of governments but it is
increasingly a battleground of health policy between different sides of government.
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HEALTH EQUITY AND INEQUITY
Health inequities arise from economic, cultural and social conditions and the way that a
health equity society’s resources are distributed. This includes, for example, people’s access to money, to
The rights of people to health and social services, and to quality educational opportunities. Another way to think
have equitable access
about health is to see in what ways health plays an essential role in human life and freedom
to services on the
for people to do the things they want to do with their lives (Sen 2004). These are issues of
basis of need, and the
resources, capacities social justice. But not everyone has the same level of freedom to pursue their aspirations
and power they because where someone lives, and the emotional and economic support a person is provided
need to act upon the with to pursue their ambitions, are not available to everyone in the same measure. When we
circumstances of their talk about health equity, we open a conversation about issues of fairness and justice in the
lives that determine
way a society arranges the social conditions of living and how those conditions create health
their health.
or illness.
health inequity Social justice approaches to health are a necessary underpinning for health systems in
Those inequalities in
order for priority to be put on the achievement of health as a resource for life and as a human
health deemed to be
unfair or stemming right. Understanding inequity in theoretical and ethical terms will give you a foundation for
from some form of thinking about how the health system tackles health inequities and injustices, while also
injustice. seeking to improve the health of populations overall.
BOX 1.2 THEORETICAL CONCEPTS OF HEALTH EQUITY AND HEALTH INEQUITY
The terms ‘equity’ and ‘equality’ are sometimes used interchangeably but there are important
distinctions between them.
Equity involves trying to understand and give people the resources they need to enjoy a
healthy life. Equity requires the more or less equal distribution of goods and services usually
on the basis of need.
Equality aims to ensure that everyone gets the same things in order to enjoy a healthy life.
People who advocate equality can still believe in fairness and justice, but the pursuit of equality
can only work if everyone starts from the same place and needs the same things.
health inequality Inequality and equality are dimensional concepts, meaning they are terms that simply
An observable, refer to quantities or distributions that are measurable. Health inequality is a term used to
often measurable designate the (measurable) differences, variations, and disparities in the health achievements
difference in health
of individuals and groups whatever the cause.
status between
individuals, groups
Inequity and equity are relational concepts, with political and social justice dimensions.
or populations, Inequity and equity involve relations of equal and unequal power (political, social and economic)
whatever the cause. as well as justice and injustice, and assert the need for public policy–driven solutions. Kawachi,
Subramanian & Almeida-Filho (2002) make the point that not only is it important to understand
the essential differences between the concepts of inequality and inequity, but it’s also critical to
appreciate that inequity is grounded in social injustice.
