The second public health revolution: a critical appraisal

Best Practices in Integrating Theory and Practice in Graduate Education in Public Health Promotion

Over the last several decades, consistent concerns have been raised about the quality of education and training provided to students in public health. In this article, we consider the implications of epidemiological transition-the decline of infectious diseases and rise of chronic diseases-for the types of education and training that would be most well suited for preparing students in health promotion to address the social and behavioral factors now associated with the leading causes of morbidity and mortality. As a result of this historic shift in disease etiology, the recommendation is to expand opportunities for applied experiential learning. Students need to become more adept at diagnosing the complex social, moral, and political dynamics that shape community priorities, perceptions of causes, and framing of health issues. The specific constellation of players, their history, relationships, and interpersonal dynamics are unique to each particular community setting, and hence, students need to become more sensitive to and proficient at picking up on the most significant influences and characteristics at work in the situation at hand. This type of "practical reasoning" stands in contrast to the perceived value of generalizable knowledge characteristic of models developed in the natural sciences. The ability to recognize and respond appropriately to the unique characteristics of a specific situation is best strengthened through extended practical experience.

Tensions between the conduct of randomised controlled trials in health promotion research and the role of autonomy in human health and well being

The goal of developing increasingly effective interventions to change health-related behaviours, which is an inevitable result of the use of the scientific method, conflicts with respect for the autonomy and dignity of the individual. This paper recommends a new direction for the field of health promotion based on building people's capacity to exercise autonomy, in the ethically relevant meaning of the term, and thereby promote a more comprehensive understanding of the goals of the field, a state of health that includes the irreducible ethical dimension signified by human dignity.

Considerations for Incorporating "Well-Being" in Public Policy for Workers and Workplaces

Action to address workforce functioning and productivity requires a broader approach than the traditional scope of occupational safety and health. Focus on "well-being" may be one way to develop a more encompassing objective. Well-being is widely cited in public policy pronouncements, but often as ". . . and well-being" (e.g., health and well-being). It is generally not defined in policy and rarely operationalized for functional use. Many definitions of well-being exist in the occupational realm. Generally, it is a synonym for health and a summative term to describe a flourishing worker who benefits from a safe, supportive workplace, engages in satisfying work, and enjoys a fulfilling work life. We identified issues for considering well-being in public policy related to workers and the workplace.

Exploring health promotion practitioners' experiences of moral distress in Canada and Australia

This article introduces moral distress - the experience of painful feelings due to institutional constraints on personal moral action - as a significant issue for the international health promotion workforce. Our exploratory study of practitioners' experiences of health promotion in Australia and Canada during 2009-2010 indicated that practitioners who work in upstream policy- and systems-level health promotion are affected by experiences of moral distress. Health promotion practitioners at all levels of the health promotion continuum also described themselves as being engaged in a minority practice within a larger dominant system that does not always value health promotion. We argue that health promotion practitioners are vulnerable to moral distress due to the values-driven and political nature of the practice, the emphasis on systems change and the inherent complexity and diversity of the practice. This vulnerability to moral distress poses significant challenges to both workers and organisations and the communities they seek to benefit. We propose that further research should be undertaken to fully identify the causes and symptoms of moral distress in health promotion. Extensive existing research on moral distress in nursing provides ample resources to conduct such research.

Globalization and emerging governance modalities

This paper explores the possibilities for global governance effectively dealing with the international transmission of disease. First, zoonotic regulation and control pose a special case for public health agencies, and this paper proposes a propositional model for an effective public health stance. Second, globalization dynamics are briefly reviewed in terms of an emerging consensus on the need for global governance in public health. Third, a brief examination of global governance modalities suggests that a strong global governance case has distinct limitations (despite its possible justification); an exploration of contemporary directions in global governance follows. Finally, the paper examines the phenomenon of contemporary zoonotic control within the conditions of an effective regulatory regime.

Personal responsibility for health? A review of the arguments and the evidence at century's end

This article examines the continuing controversies regarding personal versus social responsibility for health as they are being played out at the turn of the century. Following a brief examination of the contested meaning of "personal responsibility for health" in recent historical context, attention is focused on the arguments for and against holding the individual to be primarily accountable for his or her health behavior. The paper then makes the case for more balanced, ecological approaches that stress individual responsibility for health within the context of broader social responsibility. The article concludes by briefly summarizing the Canadian approach to health promotion as a useful example of what such a balanced, ecological approach might look like.

Changing patterns of pharmaceutical practice in the United States

In the United States, contradictions related to medicine use abound in a social environment in which the pursuit of health has become a cultural project. In a marketplace where over half a million health products are available, choices at once seem to foster agency and encourage dependency on medical fixes. The aggressive marketing of medicines as indispensable commodities co-exits with rising concerns among the lay population about what is safe in the short- and long-term. In this paper we broadly consider medication-related practice in the United States as it is affected by social, cultural, and political-economic factors. We direct attention to changes in medicine use related to product proliferation, lowered thresholds of discomfort, the economics of health care, and a revival of the self-help ethic. We also consider the manner in which the demand for and use of medications reflect deeply embedded cultural ideals and emergent perceptions of need. We juxtapose two trends in American thinking about medicines: (1) the perception that "more is better," associated with cultural impatience with illness; and (2) a growing doubt about medicine necessity, safety, and efficacy.

The effects of workplace health promotion on absenteeism and employment costs in a large industrial population

We evaluated the impact of a comprehensive workplace health promotion program on absences among full-time employees in a large, multi-location, diversified industrial company. A pretest-posttest control group design was used to study 41 intervention sites and 19 control sites with 29,315 and 14,573 hourly employees, respectively. Blue-collar employees at intervention sites experienced an 14.0 percent decline in disability days over two years versus a 5.8 percent decline at control sites. This resulted in a net difference of 11,726 fewer disability days over two years at program sites compared with non-program sites. Savings due to lower disability costs at intervention sites offset program costs in the first year, and provided a return of $2.05 for every dollar invested in the program by the end of the second year. These results suggest that comprehensive workplace health promotion programs can reduce disability days among blue collar employees and provide a good return on investment.

Community health advocacy for racial and ethnic minorities in the United States: issues and challenges for health education

The 1985 Heckler report on Black and minority health clearly demonstrated that minority groups suffer excess morbidity and mortality directly related to social inequalities. Subsequently, improving the health status of minorities must go beyond personal health care delivery and address the broad issues of health policy. There is increasing evidence that wide public support is mounting to address many of the major health problems facing minority groups. In order to modify health behavior of minorities, health educators must recognize that traditional health promotion activities, focused on voluntary personal behavior change, may not be effective in reducing morbidity and mortality rates. Efforts to improve the health status of minorities must include an aggressive health policy dimension. Personal behavior change effort without an equal or greater emphasis on policy change is tantamount to blaming the victim. A health educators become increasingly aware of the political nature of health issues, it will be necessary to examine the health status of ethnic and racial minority populations from the perspective of community health advocacy.

The business of health promotion: ethical issues and professional responsibilities

In the nine years since an entire issue of Health Education Quarterly (then Health Education Monographs) was devoted to considering ethical issues in health education, several important social changes have occurred which have substantially influenced the practice of that discipline. New practice contexts and ethical issues have resulted, which require a fresh look at both these new issues as well as those addressed in the earlier monograph. The importance of understanding the principles underlying the ethical dilemmas raised by the authors is emphasized as a concern for both the individual practitioner as well as the profession of health education itself. Recommendations for personal and professional action are made by the authors.