Promoting Human Wellness: New Frontiers for Research, Practice, and Policy / Edition 1 available in Paperback
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- University of California Press
This book is a state-of-the-art educational resource on the latest research and public-policy developments in the fields of wellness promotion and disease prevention. Based on award-winning lectures by University of California faculty on nine campuses as part of the Wellness Lectures Program jointly funded by The California Wellness Foundation, Health Net, and the University of California, the volume aims to widen the scope of health care research and policy to promote wellness rather than focus on illness and disease, and to incorporate proactive, interdisciplinary approaches to health care. The volume also contains chapters by distinguished scholars inthe fields of wellness promotion and disease prevention. Many of these articles fall outside the scope of what we conventionally call health promotion, bringing new perspectives to research and policy possibilities. Promoting Human Wellness is organized around core themes such as the importance of disease prevention programs that address multiple health risks, the link between poverty and minority status and disease susceptibility, and the challenge of evaluating health benefits and cost-effectiveness. The articles discuss such timely issues as genetic determinism as a paradigm in wellness promotion, adolescent health promotion and teen pregnancy prevention strategies, racial differences in cancer epidemiology, the California smokers' helpline, strategies for reducing youth violence, HIV/AIDS prevention, domestic violence education and prevention srategies, and the future of women's health research.Presented within the framework of social ecology, several of the chapters in this volume address new ideas and approaches in the wellness field that are only now beginning to be understood such as the social construction of variables including race, class, and gender. Promoting Human Wellness will be essential reading for health practitioners, policymakers, and others seeking to expand the ways we define and achieve health.Keywords: Public health, community health, medicine, nursing, social welfare, health education, health psychology, social ecology, public policy, aging, health promotion.
|Publisher:||University of California Press|
|Edition description:||First Edition|
|Product dimensions:||6.00(w) x 9.00(h) x 1.60(d)|
About the Author
Margaret Schneider Jamner is a Research Associate at the School of Social Ecology at the University of California, Irvine. Daniel Stokols is Professor and Dean Emeritus of the School of Social Ecology at the University of California, Irvine.
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PROMOTING HUMAN WELLNESSNew Frontiers for Research, Practice, and Policy
University of CaliforniaCopyright © 2000 Regents of the University of California
All right reserved.
IntroductionNew Frontiers for Research, Practice, and Policy
Wellness promotion, as this volume demonstrates, is at a critical juncture as we enter the new millennium. We have gained an appreciation for the complexity of the task and are beginning to develop methods for identifying the most effective strategies for improving the health-related quality of life among Americans. Moreover, we have expanded our sphere of influence to encompass not only the immediate causes of morbidity and mortality but also the more fundamental determinants that reside in the political, social, and physical environments. This volume illustrates the potential for promoting human wellness that has been generated by these developments. Future success in realizing this potential relies on recognizing that elements that are often encountered as barriers to health promotion (e.g., political agendas, idiosyncratic populations) can and must be embraced and incorporated into the methods that guide wellness research and practice. Only by employing these elements to serve the ends of wellness promotion will we sustain the current momentum toward creating a nation that supports and facilitates optimal health.
The chapters in this volume offer compelling evidence for the complex web of interrelated influences that operate dynamically to determine health and wellness. Regardless of the specific disease or disability being examined, it is clear that one must consider the likelihood that health status may be affected by variables at many levels, including (but certainly not limited to) the human genome, individual health behavior and psychological attributes, medical care, and the physical and social environments. Moreover, each level has the potential to interact with factors from other dimensions. As described by Leonard Duhl (1996), "It is as if there were a ball of interconnected strands that could be picked up at any point, and a relationship to all other issues, institutions, people, and places would exist" (p. 259).
The multidimensional model that could be constructed to depict any specific health problem threatens to be overwhelming in its complexity. Nevertheless, conceptualizing wellness promotion from a systems perspective may turn out to be a requirement for effective intervention (Wandersman et al., 1996). It is important, therefore, to note that work presented in these pages also provides testimony that adopting a systems approach to wellness does not preclude elegant solutions to health problems and, in fact, may simplify matters by identifying optimally effective leverage points for intervention. In order to realize the potential within the systems approach for identifying parsimonious pathways to promoting health, it is crucial that health researchers, health practitioners, and policy makers maintain an exceptionally broad vision of the range of activities and targets that may fall within the health promotion mandate. It is equally important that wellness professionals address explicitly the nonscientific forces bearing on the translation of wellness knowledge into effective action.
Public health, the parent discipline to wellness promotion, has been said to permeate "through all the social, environmental, and other activities of populations" (Holland, 1997, p. 1645). Likewise, although the promotion of human wellness is often identified with orchestrating a change in lifestyle, such individual modifications "usually require some combination of educational, organizational, economic, and environmental interventions in support of change in both behavior and conditions of living" (Green et al., 1997, p. 125). Appropriate targets for change in the pursuit of enhanced health and wellness for a population therefore include elements within the individual, the social milieu, the physical environment, the medical care system, the economy, and the political arena. This point is vividly illustrated by the chapters in this volume, several of which present impressive evidence of the powerful force for change that results from directly addressing contextual factors.
WELLNESS PROMOTION AND THE POLITICAL CONTEXT
A number of the authors featured in this volume argue that the influence of the political context on human wellness deserves greater attention. In particular, the politicization of health-related issues often results in a markedly skewed allocation of resources with respect to research. Strohman (chapter 5), for example, opines that the share of research funds devoted to mapping the human genome is grossly out of proportion to the health benefits that this project is likely to deliver. His work suggests that far greater salutary outcomes might be expected to accrue to the population if sufficient funds were directed to mapping out the ways in which genes interact with their immediate (i.e., organismic) and distal (i.e., extraorganismic) environments to determine phenotypic expression. It is in the interest of the goals of health promotion that scientists make a concerted effort toward educating political decision makers regarding the connection that proposed health research initiatives have to the objective of improving the health of the population.
This advice should not be interpreted as a condemnation of basic research, whose relationship to the human condition may at times be obscure or difficult to discern. Basic research is and will continue to be of great importance since expanding our understanding of the mechanics of our world can serve us in many unforeseen and significant ways. Nevertheless, in a society characterized by limited resources for research, the way in which these resources are distributed should be continually reassessed in order to determine whether adjustments in the allocation are likely to result in greater health returns.
Another instance of value-driven political agendas leading to inequitable resource allocation is the greater emphasis placed on men, as compared to women, in health research. As discussed by Stanton et al. (chapter 22), the historical view of the female as the lesser "deviation" from the male norm has contributed to the disproportionate attention paid to men in health research. The nominal representation of women in the sciences and politics in the past also has helped maintain the illusion that important research questions could be adequately addressed through research on men only. Villablanca (chapter 23) reaffirms this pattern in the case of heart disease. Although coronary heart disease is the leading cause of death for both men and women, the latter have been largely excluded until recently from most heart disease prevention trials. In the last decade, a shift toward greater recognition of the health needs of women has occurred and has led to attempts at establishing greater gender equity in research. This new movement has fueled the Women's Health Initiative, which will yield a wealth of data concerning the factors that influence the health and wellness of women. Wellness professionals would do well to note this apparently successful culmination to years of campaigning for gender equity in research. Results of the current wave of health research directed at women's issues will provide valuable scientific information useful in promoting women's health. In order to continue the momentum toward a more equitable health research agenda at the national level, wellness professionals must find effective ways to supply their expertise to the political decision-making process.
Values-laden political priorities also play a large role in determining the allocation of resources among interventions designed to improve or enhance health. Hofmann (chapter 20) eloquently lays out the argument for providing teens with complete information concerning contraception, yet recent federal legislation provides funds for school-based sex education that teaches abstinence-only pregnancy prevention. Given the strength of the evidence against the utility of the abstinence-only approach, it appears that this legislation is based not on scientific knowledge but rather on the values of individuals, lobbyists, and organized voter groups expressed as political will. Similarly, Waldo and Coates (chapter 24) describe the failure of HIV prevention programs and attribute this lack of success to a political climate that, for example, blocks widespread use of needle exchange despite ample evidence that allowing drug users to receive sterile syringes in exchange for used needles reduces HIV transmission without increasing drug use. A resolution issued in 1998 by the Presidential Advisory Council on HIV/AIDS (American Public Health Association, 1998) rebuked the president and the secretary of health and human services for failing to remove the ban on using federal funds for needle exchange programs and stated that "tragically, we must conclude that it is a lack of political will, not scientific evidence, that is creating this failure to act."
The persistence of the "agrarian myth" (a pervasive belief in the salutary conditions of agricultural occupations) in the face of data concerning the health problems of agricultural workers represents another case of an area in which policy and legislation have lagged behind available scientific information. As explained by Schenker (chapter 21), current health and safety legislation designed to protect farmers and farm laborers in the United States is notably insufficient. For example, Schenker notes that rollover protectors for tractors have been legislated in Europe but not in the United States, even though they essentially eliminate rollover fatalities. These examples demonstrate that successful wellness promotion requires engaging the political process in a data-based evaluation of funding and legislative priorities and pushing for policies that have the greatest likelihood for improving national health status by addressing the actual needs of the nation's constituent populations.
The theorem that the political context plays a large role as a force affecting how public health knowledge is translated into preventive action is generally acknowledged in the field of public health. In the first chapter of the 1997 edition of the Oxford Textbook of Public Health, Detels and Breslow state, "What can be done 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" (p. 3). One model of this process, proposed by Richmond and Kotelchuck (1983), posits three factors that contribute to the shaping of health policy: knowledge base, political will, and a social strategy. According to Richmond and Kotelchuck, the knowledge base refers to "the scientific and administrative data base upon which to make decisions." Thus, epidemiologic research, needs assessments, clinical trials, and other forms of intervention evaluations all contribute to this knowledge base that may be used to inform health policy decisions. How or even whether this information is used, however, depends greatly on the political climate.
In discussing the Richmond and Kotelchuck model, Atwood et al. (1997) address the example of preventive priorities in the United States with respect to tobacco control. They point out that, because of a lack of political will, the proportion of resources currently allocated to preventing tobacco use does not correspond to the magnitude of the toll that tobacco takes on human health. These authors suggest that public health researchers should pay greater attention to how their work may be used to shape health policy and should consider this issue as integral to the research planning process. Planning a research agenda with findings that will be useful in shaping health policy is certainly one way to increase the social validity of public health research (Geller, 1991), yet it would be unnecessarily restrictive to confine the spectrum of public health research to one that speaks directly to policy issues.
More to the point, the authors in this volume demonstrate that wellness professionals need not remain detached from the political arena; rather, they may be able to dramatically impact community health by mobilizing political will. In fact, it has been suggested that "one of health education's major supportive functions is to enhance self-confidence and provide the variety of skills needed by individuals and their communities to influence the policy-making process" (Tones, 1997, p. 785). The enormous potential for enhancing the impact of wellness promotion activities through shaping political will is illustrated in the interventions described by Minkler and Wallack in this volume. At the neighborhood level, Minkler (chapter 13) demonstrates that residents of a high-crime neighborhood can be successfully mobilized to lobby for increased police protection and consequently create an environment that facilitates improved health behavior. Although the connection between community crime levels and individual health habits has not been clearly established, there is an intuitive link between, for example, a fear of walking in one's neighborhood and the likelihood of walking for exercise. Moreover, as the chapter by Sanders-Phillips (chapter II) shows, there is evidence suggesting that being exposed to violence in one's community may induce negative psychological states (e.g., depression, hopelessness, ennui) that act as barriers to the establishment of a healthful lifestyle. The Violence Prevention Initiative (VPI) detailed by Wallack (chapter 19) offers a model of what can be accomplished via advocacy of public policy solutions to public health problems. The tools employed by the VPI toward the goal of reducing the widespread and easy availability of handguns to youth have included savvy use of a scientific and applied database, mobilization of a broad range of constituencies, and strategic use of the mass media. Coordination of these elements has resulted in a number of tangible results, including the passage of numerous local gun-control ordinances and statewide legislation (approved by the California State Legislature but later defeated by governor's veto) banning the sale and distribution of Saturday Night Specials.
The programs described by Minkler and Wallack are unique not only because they appear to succeed but also because they squarely address community-level issues that interfere with the "response-ability" of individuals to remain healthy. It is interesting to note that both of these programs are focused on violence. Whereas the VPI (Wallack) targets primarily potential perpetrators and victims of gun violence, the Tenderloin project (Minkler) addresses the indirect effects of living within a climate characterized by the threat of violence. Both programs, however, address the problem of violence through political influence exerted by members of the community.
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Table of Contents
Foreword, by Cornelius L. Hopper and Irene BronstonAcknowledgmentsIntroduction: New Frontiers for Research, Practice, and Policy, by Margaret Schneider JamnerPART ONE. NEW DIRECTIONS IN HUMAN WELLNESS PROMOTION1. The Social Ecological Paradigm of Wellness Promotion, by Daniel Stokols2. The Societal Context of Disease Prevention and Wellness Promotion, by Lester Breslow3. Promoting Wellness: Biomedical versus Outcomes Models, by Robert M. Kaplan4. Community Participation, Empowerment, and Health: Development of a Wellness Guide for California, by S. Leonard Syme5. Genetic Determinism as a Failing Paradigm in Biology and Medicine: Implications for Health and Wellness, by Richard C. StrohmanPART TWO. WELLNESS PROMOTION RESEARCH: INNOVATIVE STRATEGIES AND PERSPECTIVES6. Creating Health Promotive Environments: Implications for Theory and Research, by Daniel Stokols7. Theory-Based Evaluation: Investigating the How and Why of Wellness Promotion Programs, by Johanna Birckmayer and Carol Hirschon Weiss8. Pregnancy Prevention Opportunities Focusing on the Younger Sisters of Childbearing Teens, by Patricia L. East9. Immigrants May Hold Clues to Protecting Health during Pregnancy: Exploring a Paradox, by Sylvia Guendelman10. Race and Health: Implications for Health Care Delivery and Wellness Promotion, by Mack Roach III11. Health Promotion in Ethnic Minority Families: The Impact of Exposure to Violence, by Kathy Sanders-Phillips12. Valuing Future Health in Social Policy and Human Health Behavior, by Theodore G. Ganiats and William J. SieberPART THREE. WELLNESS PROMOTION PRACTICE: TOWARD MORE COMPREHENSIVE APPROACHES13. Health Promotion at the Dawn of the Twenty-first Century: Challenges and Dilemmas, by Meredith Minkler14. Bridging the Clinical and Public Health Approaches to Smoking Cessation: California Smokers’ Helpline, by Shu-Hong Zhu and Christopher M. Anderson15. Disease Prevention versus Health Promotion: Pitfalls of Preventive Care in the Geriatric Population, by Andrew Duxbury16. Preventing Disability in Older Americans: The Challenge of the 21st Century, by John C. Beck17. An Educational Approach to Engage Health Care Professionals in Wellness Promotion, by Stuart J. Slavin and Michael S. Wilkes18. University-Community Partnerships to Promote Wellness in Children, Youth, and Families, by Philip R. NaderPART FOUR. WELLNESS PROMOTION POLICY: TOWARD A MORE EXPLICIT CONSIDERATION OF THE POLITICAL CONTEXT19. Strategies for Reducing Youth Violence: Media, Community, and Policy, by Lawrence Wallack20. Adolescent Sexuality and Health Care Reform, by Adele Dellenbaugh Hofmann21. Improving Health and Safety in the Agricultural Workplace, by Marc B. Schenker22. Enhancing Women’s Health: Current Status and Directions in Research and Practice, by Annette L. Stanton, Sharon Danoff-Burg, and Sheryle J. Gallant23. Cardiovascular Disease in Women: Exploring Myths and Controversies, by Amparo C. Villablanca24. HIV/AIDS Prevention: Successes and Challenges, Craig R. Waldo and Thomas J. CoatesAfterwordSheldon Margen and Joyce C. LashofNotes on ContributorsIndex