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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: February 17, 2020

Publishing Company: SAGE Publications Ltd

City: London

Print ISBN: 9781412948807

Online ISBN: 9781446216736

DOI: http://dx.doi.org/10.4135/9781446216736.n5

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

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Public Health Theories AnnBryan

Definition

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. Per- haps 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 practi- cal 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 sug- gested 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 consideration.

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.

Discussion

The development of public health theory is evolutionary in nature. It has always reflected different chronologi- cal eras which are defined by their prevailing paradigms, research methods and preventative practices (Nico- lau 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 develop- ments 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 nine- teenth 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 im- provements 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, im- munisation 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 be- came 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. Epi- demiology 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 of- ten 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 preven- tative 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 pro- duction of disease/political economy of health, and ecosocial. These theories illuminate principles which at- tempt 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 pop-

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ulation health, how they integrate social and biological explanations, and thus their recommendations for ac- tion’ (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 popu- lation (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 re- ceived 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 circum- stances. 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 view- ing health, disease and wellbeing from an ecosocial perspective, Margaret has formulated an effective public health strategy at the individual, community and environmental levels.

Conclusion

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. Lon- don: Sage.

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• public health • ecosocial theory • disease • epidemiology • chronic illness • health • travelers

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