BIO 201 Public Health and the Enviroment Paper

In Chapters 2-4 (attached), the authors’ goal is to help public health professionals understand how an array of disciplines in biological and social sciences contribute to public health policies, programs, and approaches to building health and well-being in communities and the population as a whole.

Along with this, the success of a community action plan hinges not only on strong leadership but also on an interdisciplinary approach to community involvement.

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Watch the video below, (Links to an external site.)

Description: The California Endowment’s film crew put together this short piece about the Building Healthy Communities Initiative. The City Heights Community Congress features prominently.

Identify at least four strategies that you might use to increase and maintain community involvement in solving a public health issue in your own community.

State the public health issue and the four strategies you would use.

Tips: In choosing your strategies, you’ll want to consider factors including the composition of your community, the amount of time that would need to be invested in order to implement strategies, and the resources and skills that might already be present in your community. Think about how you would go about recruiting people to support your action plan or how you would obtain needed resources to solve your issue.

Key Concepts in Public Health
Determinants of Health
Contributors: Soumen Sengupta
Edited by: Frances Wilson & Mzwandile Mabhala
Book Title: Key Concepts in Public Health
Chapter Title: “Determinants of Health”
Pub. Date: 2009
Access Date: December 31, 2019
Publishing Company: SAGE Publications Ltd
City: London
Print ISBN: 9781412948807
Online ISBN: 9781446216736
Print pages: 16-20
© 2009 SAGE Publications Ltd All Rights Reserved.
This PDF has been generated from SAGE Knowledge. Please note that the pagination of the online
version will vary from the pagination of the print book.
© Frances Wilson and Mzwandile Mabhala 2009 (editorial arrangement)
SAGE Books
Determinants of Health
Health is classically defined as ‘a state of complete physical, social and mental health, and not merely the
absence of disease or infirmity’ (WHO, 1948). As such, health is as much a social construct as a biological
characteristic. It is the product of a complex interaction of different factors: this is true at both individual and
population levels. These determinants include not just an individual’s particular characteristics and behaviours but also their economic, physical and social environments (Ashton and Seymour, 1992).
Key Points
• Health is created by a complicated interaction of different factors, only some of which can be directly
influenced by individuals.
• Social determinants tend to have a greater impact on population health status than healthcare services.
• Different determinants have a differential influence on different groups of people: this can contribute
to health inequalities.
• An appreciation of the differential influence of determinants should be used to develop and deploy a
wider array of public policy activities to promote good health.
How different disciplines consider determinants of health is born of their traditions and values. There are four
schools of thought (Beaglehole, 2004):
• The biomedical view – emphasis on specific causes and discrete treatments for ill health amongst
• The lifestyle view – emphasis on individual responsibility for lifestyle choices.
• The broad socio-economic approach – emphasis on factors outside the healthcare sector, especially
economic and social.
• The population health view – emphasis on the impact on population health of wealth generation and
Whilst the biomedical view has traditionally dominated health policy, recent years have seen increasing recognition of a more comprehensive suite of determinants (HM Treasury, 2004). Although healthcare services
have some impact, more influential on population health are the economic, physical and social conditions that
foster ill health – and that, if orientated correctly, should actively engender good health (Ashton and Seymour,
Developing a Comprehensive Perspective
Canada’s Lalonde Report was the first official statement to describe a broader view of health (Lalonde, 1974).
Its ‘health field’ concept described how health status was not just affected by biology and healthcare services, but was explicitly a product of lifestyle behaviours and the environment. This was then developed, most
prominently in the Ottawa Charter for Health Promotion (WHO, 1984) which set out nine prerequisites for
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good health:

A stable ecosystem
Sustainable resources
Social justice
Consequently, an ambitious proposition has been developed for prioritising resources ‘upstream’, from services targeted at the individual to policy action on the economic, physical and social determinants of population health. Unfortunately, most investment in health still reflects and reinforces the biomedical worldview
(Hunter, 2003).
Social Determinants of Health
Systems theory states that a system is composed of interdependent and interrelated parts, with change in
one part producing changes in others (von Bertalanffy, 1968). In order to explore the impacts of and the potential to influence different determinants it is thus necessary to appreciate their interrelationships. A number
of conceptual models assist this. The most frequently cited is the Dahlgren and Whitehead ‘rainbow’ – Figure
3.1 (Dahlgren and Whitehead, 1991).
The extent to which different determinants can be influenced varies; certainly no individual is likely to exert
direct control over most of them. Furthermore, these determinants can have a differential impact at different
stages of an individual’s life; between different social groups; and between different countries (Solar and Irwin, 2007). Clearly context is crucial.
Much of the discussion on determinants within the public health arena has focused on social factors. The rationale is that, however important individual genetic susceptibilities to disease may be, population health has
been influenced much more by the rapidly changing social conditions in which people live (WHO, 2003). By
focusing on social determinants, Graham and Kelly (2004) has suggested that different models implicitly follow a common structure that articulates a causal chain between the wider environmental elements and health
Figure 3.1 Dahlgren and Whitehead’s determinants of health model (1991)
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That said, it is important to recognise the value of healthcare interventions in reducing disease susceptibility
(e.g. immunisation programmes). It is also important to remember that wider environmental factors should not
be viewed as disconnected from the experiences of individuals. Simply put, these social systems are a product of individuals and their interactions. Moreover, the choices that individuals make should not be dismissed.
However, they are a product of the choices available and the confidence different groups have in exercising them (i.e. the degree of self-efficacy possessed). Circumstances and conditions that provide people with
greater control over different facets of their lives (and consequently nurture a greater sense of self-esteem)
are associated with better health outcomes (Marmot, 2003).
Health Inequalities
Consideration of the differential influences of health determinants is almost inextricably linked to the question
of why economically or socially disadvantaged groups consistently experience relatively poorer health status
(Graham and Kelly, 2004). Such disadvantage can manifest in different forms, e.g. limited aspirations, low
income and discrimination. Critically, such disadvantages tend to gravitate towards one another, creating vicious circles in which people get trapped.
In the UK, the Black Report (Townsend et al., 1992) identified the primary reasons for worsening social gradients in mortality and other indicators of ill health as material deprivation and poverty; and its recommendations highlighted economic and social policy solutions. These conclusions were reinforced by subsequent
publications, with the Acheson Report (Acheson, 1998) stating that: ‘the weight of scientific evidence supports
a socio-economic explanation of health inequalities. This traces the roots of ill health to such determinants
as income, education and employment as well as material environment and lifestyle.’ While there are clearly
overlaps, the determinants of health are not exactly the same as the determinants of health inequality: the
latter concerns the unequal (and by implication, unfair) distribution of health determinants (Graham and Kelly,
Case Study
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Understanding determinants should help identify different policy levers (local, regional, national and transnational) that can promote health amongst different communities. This could include action to develop resilience
amongst young people and vulnerable adults; strengthen social capital; improve infrastructure and access to
services; and tighten environmental legislation. It should enable identification and mitigation of policy action
that could have a detrimental impact – this is the essence of health impact assessment (Brown et al., 2005).
It should also help develop a realistic sense of the limitations of any given intervention to improve population
health. For example, although statins are a relatively effective pharmacological intervention for reducing the
risk of heart disease (NICE, 2006), against the backdrop of an escalating obesity epidemic they can only have
a limited impact in themselves (WHO, 2007). That does not mean they are not worth providing, but rather that
they need to be part of a multi-dimensional package of activities.
Understanding health determinants has relevance to all aspects of public health. In using this textbook, it
would be particularly useful to cross-reference with inequalities in health (Chapter 5); assessing public health
need (Chapter 21); planning public health initiatives (Chapter 22); health impact assessment (Chapter 24);
and collaborative and partnership working (Chapter 34).
Health at both individual and population levels is the product of a complicated interaction of different factors.
Health policy is still dominated by a biomedical paradigm, yet there is a substantial theoretical and evidence
base to support a more comprehensive perspective. It is now widely understood that the primary determinants of health are the economic, physical and social environments within which individuals live. Few determinants can be directly influenced by the individual; and most social determinants have a greater impact on
population health status than healthcare services. Critically, many determinants have a differential impact on
different groups of people: this can contribute to inequalities in health. Developing an understanding of the
complex nature of the health determinants is not a merely theoretical exercise; nor should the recognition of
that complexity act as an excuse for inaction on discrete issues. Rather this understanding should be used to
develop and deploy a wider array of public policy activities to promote good health.
Further Reading
Irwin, A. and Scali, E., (2005) Action on the Social Determinants of Health: Learning from Previous Experiences. Geneva: World Health Organization.
Kelly, M., Bonnefoy, J., Morgan, A. and Florenzano, F., (2006) The Development of the Evidence Base about
the Social Determinants of Health. Geneva: World Health Organization.

health inequalities
health care services
health care
health impact assessment
ill health
health status
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Key Concepts in Public Health
Modern Public Health
Contributors: Fiona Adshead & Allison Thorpe
Edited by: Frances Wilson & Mzwandile Mabhala
Book Title: Key Concepts in Public Health
Chapter Title: “Modern Public Health”
Pub. Date: 2009
Access Date: December 31, 2019
Publishing Company: SAGE Publications Ltd
City: London
Print ISBN: 9781412948807
Online ISBN: 9781446216736
Print pages: 11-15
© 2009 SAGE Publications Ltd All Rights Reserved.
This PDF has been generated from SAGE Knowledge. Please note that the pagination of the online
version will vary from the pagination of the print book.
© Frances Wilson and Mzwandile Mabhala 2009 (editorial arrangement)
SAGE Books
Modern Public Health
FionaAdshead, and AllisonThorpe
Public policy has been defined as ‘the broad framework of ideas and values within which decisions are taken
and action, or inaction, is pursued by governments in relation to some issue or problem’ (O’Neill and Pederson, 1992). As such, policy generically can be described as a guiding principle of, not a guarantee for, action.
Public health policy more specifically reflects an increasingly diverse agenda, developed against a context
of global forces and changing social and political environments. An active social justice agenda and growing
evidence of the impact of the social determinants of health on health inequalities and outcomes make more
complex an already crowded picture. In this chapter we will look at the implications of current policy drivers
in England for public health, with a particular focus on how at a national level policy directions are often influenced by, and influence, legislative frameworks and policies which are enacted at a European or global level.
Key Points
• Public health policy is not designed or delivered in isolation from the social and political context – it
is linked to a wide range of social resources and infrastructures, social capital, social interaction and
social support.
• Policy boundaries are often blurred – European directives can both limit autonomy of action at a national level and ensure local activity has a resonance over a larger population level by setting clear
parameters for action across nation states.
• Modern public health policy and practice has to be able to respond to economic, demographic and
epidemiological transitions, while still enabling everyday action on the ground.
• With lifestyle-related diseases rising, people’s expectation of active engagement in promoting and
protecting their own health means that the practice of public health is becoming increasingly personalised. This is reflected in the policy arena.
Policy-makers working in the field of public health today face a very different environment to that which faced
our forebears in the nineteenth century. Then, the primary focus of public health activity centred on sanitation, slum clearance and the prevention of infectious diseases (Gorsky, 2007). In our more modern complex
society, we face new challenges. Rising rates of diabetes linked to obesity, escalating chronic diseases, and
global tobacco control – to name but a small selection of our concerns – are juxtaposed with an increasingly
articulate, educated consumer society and an increasingly engaged media and business presence. Unsurprisingly, against such a backdrop, it has long been remarked that for public health ‘boundaries are fiction’
(Terry, 1964).
Determining how best to assure the health of our populations remains an enormous agenda – and one in
which the whole of society has a shared interest, with roles for government, the healthcare system, the wider
population, the community, and business itself. There has been a tangible policy move in recent years towards
health improvement initiatives which take a wider partnership approach to delivering on health (DH, 2007d).
Reports, such as the eponymous Wanless reports, have been successful in driving home the message that
a sustainable healthcare system requires ‘full engagement’ of the people in its delivery (HM Treasury, 2002,
2004). With recent economic analysis suggesting that the total cost of preventable illness is 19 per cent of
total GDP for England (NSMC, 2006), prevention is increasingly seen as the key factor in addressing growing
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concerns about the affordability of healthcare systems into the future (HM Treasury, 2002, 2004). Successive
policy documents, such as Choosing Health (DH, 2004a) and Our Health, Our Care, Our Say (DH, 2006e)
have reinforced this message, reflecting a recognition that no amount of legislation, regulation or structural
adjustment can compete with the ability of people to choose how they live their lives. But such a person-centred approach for public health policy is a challenge in itself.
Case Study
The recent smoke-free legislation, which came into effect on 1 July 2007 in England, provides a tangible
demonstration of the relationship between politics, policy development, the individual and the evidence. Despite evidence that second-hand smoke was a determinant of ill health, there was considerable resistance to
the idea of taking a comprehensive legislative approach to the issue, largely centred around the human rights
of smokers. The eventual policy decision to allow an open vote on how to progress the legislation was the
culmination of a long campaign, which drew upon:

policy-driven public consultations;
high levels of popular and professional support;
an extensive evidence base;
examples of local-level action which was considerably ahead of the proposed national policy direction;
• international and, in the case of Scotland and Ireland, more local examples of the success of enacting
national legislation in other countries, with Scotland, for example, demonstrating a drop in symptoms
in bar workers from 79 per cent to 53 per cent within one month of implementation (Menzies et al.,
The combination of these factors raised the level of debate, and ultimately influenced politicians to vote for
the more radical and visionary legislation which was eventually enacted. This reinforces the need to recognise that public health policy cannot be designed or delivered in isolation from the social and political context:
political decisions have to reflect a balance between the evidence and public opinion regarding what is right
– and both affordable and sustainable – for society at the given point in time. The journey there, and the full
engagement which characterised it, critically determines the success of the outcome.
However, the success of the policy direction does not lie solely in the enactment of the legislation, but will
be measured by its cumulative effect on the health of the population. In this case, enactment of the legislation is only one manifestation of the policy direction. Alongside this policy-makers are working to build on this
historic milestone, through effective enforcement, policing and publicity, to encourage people to take advantage of health improvement initiatives, such as smoking cessation services, which will spare thousands more
lives, and through consultations to raise the age of sale, to ensure that more people are spared the misery of
watching their families and friends suffer with preventable smoke-related illnesses (DH, 2007a).
This recognition of the need to take a more personalised approach to health underpinned the Choosing Health
White Paper, reflecting a policy commitment to a broader social contract between the state and individuals,
with choice and civic action being key elements of this contract. In effect, it recognised that public health policy needs both to provide a direction for and support action in relation to our key health priorities. In practice
this means that policies must facilitate partnership across society, with joined up action at governmental, national, regional and local levels, and enable those who have an ability to contribute to do so. In practice, this
means that policy direction must be supported by the appropriate levers to drive delivery:
• realistic shared, cross-government targets which commit governments to improving health outcomes
in their population;
• co-ordination across government, and where necessary across national boundaries;
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• a commitment to wider action to improve the health of the most disadvantaged and tackle health inequalities, e.g. through action on housing, fuel poverty and employment;
• use of social marketing and other techniques to change social norms.
Policy direction in England reflects our understanding that health cannot be imposed on people, nor can we
expect them to be co-producers of sustainable good health without support from government. The relationship between public health, the state and the population is complex. Today, more than ever, we need to face
up to a complex conundrum:
• Applying policy consistently across nation states sets clear parameters for action and enables local
action to have a stronger resonance across a wider population. Legislation provides one route to ensure this, but legislation alone will not deliver behavioural change.
• Working with the population, targeting our efforts appropriately, ensures that the effects of our policy
will be instrumental in informing a culture that is motivated, progressive, ambitious and constantly
striving to improve services: not for the sake of it or to satisfy ‘managers’, but for the benefit of service users.
But, as the case study demonstrated, it is not an ‘either/or’ scenario. Policy-makers today working in the field
of public health face a complex agenda – but they also have a unique range of opportunities. It is up to the
population as a whole to ensure that we maximise their potential.
Further Reading
FrenchJ. and BlairS. C., (2006) ‘From snake oil salesmen to trusted policy advisors. The development of
a strategic approach to the application of social marketing in England’, Social Marketing Quarterly, 12(3):
HM Treasury (2002) Securing our Future: Taking a Long Term View. London: HM Treasury.
O’Neill, M. and Pederson, A., (1992) ‘Building a methods bridge between policy analysis and healthy public
policy’, Canadian Journal of Public Health, 83(32): 25–30.
World Health Organisation. (2006) WHO Framework Convention on Tobacco Control. Retrieved January
21, 2007, from World Health Organisation (2007) Interim
Statement of the Commission on Social Determinants of Health 2007. Retrieved January 21, 2007, from

health and public policy
public health
health policy
health inequalities
public policy
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Key Concepts in Public Health
Public Health Theories
Contributors: Ann Bryan
Edited by: Frances Wilson & Mzwandile Mabhala
Book Title: Key Concepts in Public Health
Chapter Title: “Public Health Theories”
Pub. Date: 2009
Access Date: December 31, 2019
Publishing Company: SAGE Publications Ltd
City: London
Print ISBN: 9781412948807
Online ISBN: 9781446216736
Print pages: 21-25
© 2009 SAGE Publications Ltd All Rights Reserved.
This PDF has been generated from SAGE Knowledge. Please note that the pagination of the online
version will vary from the pagination of the print book.
© Frances Wilson and Mzwandile Mabhala 2009 (editorial arrangement)
SAGE Books
Public Health Theories
A theory is the articulation of the framework of beliefs and knowledge which enable us to explain a specific
phenomenon. One of the major problems for public health practitioners is that theories are not articulated in
everyday language but are made up of concepts and constructs which are often difficult to understand. Perhaps this is one reason why some commentators have argued that theories are unnecessary and need to
be eradicated and replaced by common sense or professional judgement (Pring, 2000). However, the practical understanding which underpins common sense and professional judgement is built on assumptions and
lacks the validity and truth of theoretical explanations. It is the theoretical perspective which informs research
methodology and provides a context for its logic and criteria.
Defining public health theory is a complex issue. As a term, it is used in a variety of contexts according to the
knowledge base of the occupational group promoting public health. For example, biomedicine, psychology,
social policy and education all bring different theoretical interpretations to the subject. It has even been suggested that public health is atheoretical in the sense that practice has been largely unaffected by the explicit
application of theory (Weed, 2002). Indeed, Wills and Earle (2007: 129) state it is possible to promote public
health ‘without any knowledge, or understanding, of the theory that underpins practice’, although they do not
believe this will lead to effective strategies.
This chapter aims to review the value and limitations of the traditional theory base of public health. It will also
highlight the potential importance of current emerging theories in public health research and their implications
for promoting effective practice. As public health practitioners have an obligation to act in the best interests of
the population they are serving, it is vital that all theories underpinning knowledge and practice are given due
Key Points
• Public health theory is a dynamic process.
• Public health theory has been influenced by chronological eras, distinguished by dominant theories.
• Public health theory has important implications for public health strategy and application to practice.
The development of public health theory is evolutionary in nature. It has always reflected different chronological eras which are defined by their prevailing paradigms, research methods and preventative practices (Nicolau et al., 2007). These eras have been categorised by Susser and Susser in the epidemiological literature
(1996a) as the sanitary movement era, the germ theory era and the chronic disease era. Current developments in public health theory suggest that a fourth era has now emerged (March and Susser 2006).
Sanitary Movement Era
Public health has its roots in the sanitary movement which gained strength during the first half of the nineteenth century and was based on the miasma theory of disease causation. Miasma theorists believed that
decomposing organic matter created harmful odours and particles within the atmosphere which contributed
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to the development of disease.
Hence, public health measures to a large extent were concerned with sanitation. The focus was on disease
prevention and the health needs of the total population. The sanitary reforms brought about major health improvements even though the underlying theory was inaccurate. At this time epidemiology, centring on the
causes of disease in populations, was truly a part of public health and public health practitioners were largely
involved in population-wide health improvements (Susser and Susser, 1996a).
Germ Theory Era
Germ theory was the foremost theory in public health science from the latter half of the nineteenth century
until at least the mid-twentieth century. Following the discovery of bacteria, laboratory-based diagnosis, immunisation and treatment gradually marginalised miasma theory. The dominant paradigm moved from being
population-based to being focused on disease pathology and the treatment of individuals. This analysis became even more ascendant with the growth of the medical-industrial complex which, as MacDonald (2004:
384) states, ‘cemented the biomedical emphasis on single-causative agents’ and led to the weakening of
population-based public health with the centralisation of power and resources in hospital-based services. Epidemiology became a derivative activity rather than a creative science in its own right as it had been earlier.
Chronic Disease Era
By the mid-twentieth century infectious-disease mortality had started to decline in the industrialised world and
much more consideration was given to other causes of disease. This led to a corresponding decline in germ
theory and the evolution of a new epidemiological paradigm which came to be known as the ‘risk factor’ or
‘black box’ paradigm (Susser and Susser, 1996b). The fundamental premise of this paradigm is that chronic
disease is multi-causal and cannot be explained by a specific factor. Some of the theory’s leading proponents
accepted the need for a multi-professional approach and specified populations as the sample of investigation.
However, in general, chronic disease epidemiology has centred on individual personal behaviour and has often failed to consider the wider public health agenda (Pearce, 1996).
Current Theoretical Trends
Contemporary public health theory appears to be polarising. One move is towards the micro level of molecular
and genetic epidemiology and the other is towards a broader, macro level social perspective described by
some commentators as social epidemiology (Saracci, 1999; Susser, 1999; Krieger, 2001).
Biological technology has altered the way in which disease is understood at the micro level. It is popular with
the public as it gives definite solutions to identifiable problems. However, the research methods and preventative practices involved in biological techniques are extremely expensive and may not necessarily have a
global impact.
According to Krieger (2001), there are three main social epidemiological theories: psychosocial, social production of disease/political economy of health, and ecosocial. These theories illuminate principles which attempt to give reasons for the social inequalities in health and disease distribution. They argue that health and
disease are the consequence of social, political, environmental, fiscal and demographic causes. Where they
diverge is in the weight they allocate to ‘different aspects of social and biological conditions in shaping popPage 3 of 5
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ulation health, how they integrate social and biological explanations, and thus their recommendations for action’ (Krieger, 2001: 669). Psychosocial and social production of disease/political economy of health theories,
place little emphasis on the biological process, whereas the ecosocial paradigm grants it due recognition.
Ecosocial theory accepts the holistic notion that individual human beings, societal structures, the environment
and biology are mutually significant in formulating patterns of health, wellbeing and disease in the total population (MacDonald, 2004). This multi-level paradigm offers inter-disciplinary public health practitioners a way
forward with its new methodologies and practices. Its defining characteristics are not only the environmental
standpoint but also the social concepts of collaboration and community participation. Hence, ecosocial theory
can provide a practitioner with the knowledge base to devise strategies which will impact on the delivery of
effective public health practice.
Case Study
Margaret is the health visitor for an isolated, council-owned, traveller site which has recently been vandalised
and is in an insanitary condition. She is the key contact for the traveller families and visits them regularly. One
of her clients is Carla, a 26-year-old mother, who lives on benefits in a caravan. She is overweight, suffers
from depression and smokes at least 40 cigarettes a day. Her father died at 45 from a heart attack and her
mother has a chronic chest condition. She has four children. Mary, aged 7, and Danny, aged 6, have not received a regular education, while Jade and Thomas, who are both under 3, are behind in their development.
Furthermore, all the family and many other site dwellers are suffering from impetigo.
Margaret, drawing on her knowledge of contemporary, ecosocial, public health theory, calls a multi-agency
meeting, including traveller representatives, to discuss the public health issues relating to the above circumstances. As a result of this consultation, the agencies and the site community are able to secure financial
support for the upgrading of sanitary facilities and organise transport to enable the children to attend school.
Furthermore, they succeed in improving access to medical and social amenities for all site members. By viewing health, disease and wellbeing from an ecosocial perspective, Margaret has formulated an effective public
health strategy at the individual, community and environmental levels.
Public health theory is constantly evolving and will continue to play an important part in promoting effective
practice. As outlined above, dominant paradigms have been superseded as health patterns and technologies
have changed (Susser and Susser, 1996a). In the last decade there has been a move in the level of analysis
from the individual back towards the population. This has resulted in new methodologies and practices which
are reflected in the more diverse and comprehensive nature of interdisciplinary public health which dominates
our modern era.
Further Reading
Naidoo, J. and Wills, J., (2005) Public Health and Health Promotion: Developing Practice,
2nd edn.
Edinburgh: Ballière, Tindall.
Earle, S., Lloyd, C. E., Sidell, M. and Spurr, S., (2007) Theory and Research in Promoting Public Health. London: Sage.
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public health
ecosocial theory
chronic illness
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