Introduction to Public Health Research
Introduction
Welcome to the first unit of Public Health Research, a Masters level unit which aims to help you to develop an understanding of the nature and scope of Public Health and how to conduct research on a Public Health problem.
At strategic points across the module we will ask you to consider questions related to your assignments. These will help you formulate ideas for the research protocol or proposal which forms the main outcome of this module. For any research undertaking, it is common practice to develop an outline, which is known as a proposal or a protocol according to a prescribed format. This is what you will submit to the Faculty Higher Degrees Committee, or to a funding committee if you are undertaking the research outside of the university. You will find the format for your protocol detailed in the diagram called Stages in the Development of a Research Protocol in the Module Introduction. By the end of this unit, you should have identified a research problem and developed a research question that is appropriate to address a Public Health problem, that is you will have completed Stage 1.
Study Sessions
There are three study sessions in this unit:
Study Session 1: What is Public Health?
Study Session 2: Approaches in Public Health Research.
Study Session 3: Analysing Problems in Public Health.
Unit 1 - Session 1
What is Public Health?
Introduction
This study session aims to distinguish the concept of Public Health from individual health, and begins to provide you with different views of Public Health. From this discussion, you should begin to formulate your own definition of Public Health. You will also consider the interaction of Public Health practices in various sectors such as education, environment, local government, etc., and describe the activities of Public Health practitioners in the health and other sectors.
The session includes a substantial reading and there are several tasks which you should complete while you read it. You will find the feedback to the tasks integrated across the session.
Session contents
1Learning outcomes of this session
2Readings
3What is Public Health?
4Current scope and concerns in Public Health
5Session summary
6References
Timing of this session
There is one reading in this session, and there are three tasks to help you read actively. The session should take you about five hours to complete, depending on your reading speed. You should try to take time to engage with the reading thoroughly however.
1LEARNING OUTCOMES OF THIS SESSION
By the end of this session, you should be able to:- Explore the concept of Public Health.
- Define Public Health.
2READINGS
There is one reading in this session.
Detels, R., Breslow, L., Walter, W., McEwen, J. & Omenn, G. S. (Eds). (1997). Current scope and concerns in Public Health. In TheOxford Textbook of Public Health. Oxford: Oxford University Press, pp3-17.
3WHAT IS PUBLIC HEALTH?
Although it may sound simple, defining Public Health is in fact quite complex and difficult. This is because there is no universally accepted definition of Public Health. In addition, definitions of Public Health have changed over time. This means that within one time period, most Public Health practitioners would have accepted (even if grudgingly) a particular definition, but ten years later, that definition may not be acceptable to the majority. The implication is either that Public Health practitioners are a very confused bunch, or that Public Health is dynamic, fluid and constantly changing to meet the challenges of a given time period.
3.1Definitions of Public Health
In the first reading, several definitions of Public Health through the ages are provided. Make a mind map in your notebook as you read, with the words Public Health in the centre. Jot down any key words you come across as you read which still seem relevant to your understanding of Public Health.
Some Definitions of Public Health through the ages
In 1923, Winslow of the American Public Health Movement defined Public Health as:
‘… the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organised community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organisation of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health’.
The third World Health Assembly in 1950 called Public Health:
‘… the science and art of preventing disease, prolonging life and promoting mental and physical health and efficiency through organised community efforts for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organisation of medical and nursing services for the early diagnosis and preventive treatment of disease and the development of social machinery to ensure to every individual a standard of living adequate for the maintenance of health, so-organising these benefits as to enable every citizen to realise his birthright of health and longevity’.
Stewart (1985) described it as:
‘… the reaction to the demands of the people of a region and must reflect the attitudes of the people; social action should complement preventive and curative action and should be tailored to the needs of that specific community. [It] is thus concernedwith the health and disease distribution in population groups, with the epidemiology of disease, [social and behavioural factors] and with statistics. It actively seeks to promote health and to control disease by the manipulation of cause and effect. The knowledge and will to apply it is the basis of Public Health’.
In 1987 in the United Kingdom, the Acheson Report defined Public Health as ‘the art and science of preventing disease, promoting health, and prolonging life through organised efforts of society’.
In 1988 in the USA, the Committee for the Study of the Future of Public Health proposed that Public Health be defined as ‘… the organised community efforts aimed at the prevention of disease and the promotion of health. It links many disciplines and rests upon the scientific core of epidemiology’.
In 1990, the US Institute of Medicine defined Public Health as ‘… what we, as a society, do collectively to assure the conditions in which people can be healthy’.
Last’s Dictionary of Epidemiology (1995) definition is:
‘… one of the efforts organised by society to protect, promote and restore the health of the population. It is the combination of sciences, skills and beliefs that are directed to the maintenance and improvement of the health of all of the people through collective or social action. The programmes, services and institutions involved emphasise the prevention of disease and the health needs of the population as a whole. Public Health activities change with changing technology and social values but the goals remain the same, to reduce the amount of disease, premature death and discomfort and disability in the population. Public Health is thus a social institution, a discipline and a practice’.
The Oxford Textbook of Public Health (1997) identified Public Health as:
‘… the process of mobilizing local, state, national, and international resources to ensure the conditions in which people can be healthy. The scope of Public Health in the last part of the 20th century has expanded greatly. The number of recognised health hazards to the public have increased and the strategies available to solve them have grown commensurately. Public Health has borrowed and adapted knowledge from the physiological, biological medical, physical, behavioural, and mathematical sciences, and been quick to recognize the potential of new fields such as computer sciences for improving, safeguarding, maintaining, promoting the health of the community. Although the biological sciences remain an important underpinning of Public Health, the contributions of the physical, mathematical, and behavioural sciences are recognized increasingly. The health of the public in future will be achieved by inducing public awareness and concern, which results in the introduction and passage of effective legislation and regulations, implemented by professionals with a commitment, to the principles of Public Health. The effectiveness of such efforts in the past and the realisation of the costeffectiveness of preventive strategies for promoting and maintaining health, have brought renewed attention to Public Health and have set the stage for a new Public Health revolution’.
In 1997, Beaglehole and Bonnita, commented that, ‘Public Health has been defined in many different ways. All definitions of Public Health have in common the idea that Public Health is defined in terms of its aims to reduce disease and maintain health of the whole population rather than by a theoretical framework or a specific body of knowledge …’
The essential elements of modern Public Health theory and practice are:
- emphasis on collective responsibility for health and a primary role for the state in protecting and promoting Public Health;
- a focus on whole populations;
- an emphasis on prevention, especially the population strategy for primary prevention;
- a concern for the underlying socio-economic determinants of health and disease, as well as more proximal risk factors;
- a multidisciplinary basis which incorporates quantitative and qualitative research methods as appropriate;
- and a partnership with the populations served.
The variety of definitions of Public Health and the change in definitions over time, eloquently demonstrate that there are different perspectives as to what Public Health really encompasses.
Work critically through the reading in the next section, adding to your mind map, and then formulate your own definition of Public Health.
TASK 1 – Clarify the concept of Public Health
Go to the reading for this session (Detels et al, 1997), which we have summarised for you on the next 16 pages, and while you read, take notes in order to develop your own definition of Public Health which would be appropriate for the 21st century. Include who it serves, how it does so, its aims, and which sectors participate in it.
4CURRENT SCOPE AND CONCERNS IN PUBLIC HEALTH
This edited chapter provides a very good and comprehensive introduction to Public Health. Unfortunately it describes Public Health mainly from the perspective of wealthy industrialised countries. It does however occasionally compare conditions and Public Health issues in these countries to those in poor, minimally industrialised, developing countries.
Detels and Breslow define Public Health in terms of its presumed function, which is to provide the conditions that are likely to enable the population to be healthy. They believe that, given a particular set of health problems which exist within a particular physical, social and economic situation, it is the role of Public Health to pragmatically strategise how best to serve the population within the limits of resources available and within the prevailing political climate. To achieve this, they encourage Public Health workers to utilise the various theoretical and practical Public Health tools and where necessary to borrow tools from other disciplines. They then provide a comprehensive description of the functions and typical organisation of Public Health Services.
To help you focus your reading, we have interspersed some prompting questions in italics at the start of each section. Remember that to read actively, it is helpful to preview the section, and to develop several questions for which you search for answers. Normally, you would have to develop those questions yourself, and to keep them in mind as you read. We have, in this instance, included questions (in a box) for each sub-section of the reading to help you to read in a more focused way. Try to make this strategy part of your normal reading habits.
Reading
Extract from Detels, R., Breslow, L., Walter, W., McEwen, J. & Omenn, G. S. (Eds). (1997). In TheOxford Textbook of Public Health; Oxford: Oxford University Press, pp3-17.
Introduction
What changes have we seen in health problems since the 19th century?
Public Health is the process of mobilizing local, state, national, and international resources to ensure the conditions in which people can be healthy. In the nineteenth and early twentieth centuries health problems reflected primarily faecal contamination of water supplies and the widespread under-nutrition, crowding, and exhaustion associated with early industrialization. These conditions resulted in a high prevalence of tuberculosis, enteric infections, infant mortality, and acute respiratory diseases. In response, communities, provinces, and nations developed successful ways of dealing with these important problems through public action to promote health. From the outset, Public Health embraced both social action and scientific knowledge. This partnership meant linking the antipoverty (reform) movement with the findings from epidemiological and bacteriological investigations, for example, to combat such diseases as tuberculosis and typhoid fever.
Now, at the end of the 20th century, another set of health problems, including new infectious diseases and major noncommunicable diseases, confront the United Kingdom, Japan, the United States, and other highly industrialized nations. These non-communicable diseases stem from an overly rich diet, cigarette use, excessive alcohol consumption, too little physical activity, and other lifestyle factors that typify the way that many people live in these countries. Communicable diseases are still a major cause of death in developing countries, and in fact are still the leading cause of death worldwide. However, increasing numbers of people in these countries are now encountering relative affluence for the first time and thus are beginning to suffer the same health consequences as people in developed countries. In this chapter we will present broadly the current scope and concerns of Public Health as well as issues that confront Public Health organizations in both industrialized and developing societies.
Which Public Health strategies are covered in this chapter?
This chapter outlines major health problems facing the world today, including infectious diseases, chronic diseases, trauma and mental health, key determinants of health such as nutritional problems, environmental hazards, and disorders resulting from lifestyle choices. It explores the scientific responses that Public Health uses to cope with the problems, including strategies basic to Public Health, such as epidemiology, and those that are borrowed and modified from other disciplines including the social, biological, and physical sciences. Five major Public Health strategies for influencing health, namely preventing disease, promoting health, improving medical care, promoting healthenhancing behaviour, and controlling the environment are presented along with the techniques for applying these scientific approaches to Public Health problems. The interaction between governmental and voluntary actions aimed at improving the health of communities is highlighted.
What is the influence of context?
Of course, Public Health is only one of the major influences on a community's health. The basic economic and social condition of existence have a direct impact on people's level and mode of living, and thus constitute the foundation of health. These conditions limit and, to a considerable extent, determine the resources that can be devoted specifically to health promotion and disease intervention. Prevailing economic and social conditions also affect health in ways beyond the level of living and the concomitant ability of people to obtain the necessities of healthy life. Strong economic forces expressed in agriculture, manufacturing commerce, advertisement and politics, for example, may sway people to usetobacco and thus injure their health.
The magnitude and success of Public Health efforts will vary both in time and place in different areas of the world.Nevertheless, the principles of Public Health remain the same. The actions that should be taken are determined by the nature and magnitude of the problems affecting the health of the community. What can bedone will be determined by the scientific knowledge and resources available. What is done will be determined by the social and political commitments existing at the particular time and place.
The reading focuses on health problems, before looking at some of the most important health determinants (or factors which influence health).
Health problems
Before 1981 it appeared that pandemics of infectious disease other than influenza had been eliminated as a major problem in developed countries. The decline in the incidence of the traditional infectious diseases in developed countries had been controlled largely, through provision of safe drinking water, better handling of sewage, effective vaccine campaigns, improved personal hygiene, and improved nutrition, especially among children. However, the recognition of the worldwide epidemic of acquired immune deficiency syndrome (AIDS) dramatically emphasized the fact that infectious diseases are likely to remain an important problem even in developed countries, for many years to come (Mann et al. 1992). In fact, AIDS is not the leading cause of death due to infectious diseases in the world. Table 1.1 presents the major infectious diseases occurring in 1990 in the order of the annual number of deaths worldwide. The leading causes of deaths from infectious disease are still acute respiratory infections, which claim 4.3 million deaths per year, diarrhoea diseases, which cause 3.2 million deaths per year, and tuberculosis, which causes 3.0 million deaths per year. The first two still cause deaths primarily in developing countries; however, the rate of tuberculosis in the United States and in some other developed countries, as well as worldwide, is actually increasing, In part because of the increased number of susceptible people resulting from the epidemic of another infectious agent, human immunodeficiency virus (HIV). (Cantwell et al, 1994)