While health is an individual attribute, it is influenced by many factors which lie beyond a person’s body or beliefs. It is affected by what others do in society. If we do not understand these connections, we place the responsibility of a person’s ill health solely on personal choices and conduct, rather than understanding the social conditions which enable or impede that person from gaining and retaining good health across life. While individuals must act to promote, preserve and protect health through personal actions, external factors that impact on their health must also be supportive.
Preventing disease and promoting good health, at the population level, is an important function of public health in a well-functioning society. Disease prevention acts at different levels. Primordial prevention is the prevention of the acquisition of risk factors in the first place. No child is born with an addiction to tobacco, alcohol or unhealthy foods. We can protect an entire generation from harm through the right social policies. Ensuring clean air, water and traffic safety is also primordial prevention at the population level.
Primary prevention is when a person has acquired risk factors of disease and the aim is to prevent disease from developing, by effectively reducing the risk. Treating high blood pressure to prevent heart attacks, strokes and kidney failure is achievable in a well-functioning health system. Vaccinating people against prevalent pathogenic microbes is primary prevention against infectious diseases at the population level.
Secondary prevention is when disease has manifested and we aim to slow down its progression and prevent complications or recurrent events. Treating a person who has had a heart attack, with medicines of proven efficacy, can slow down progression of the disease and reduce the risk of a second heart attack or early death. Getting a person to give up smoking or change to a healthy diet, after a heart attack, is also effective secondary prevention. Tertiary prevention involves rehabilitation to reduce disability caused by severe disease. These categories can overlap. A smoker can give up smoking (primary prevention) and decide to adopt healthy diet and exercise practices to prevent weight gain that follows smoking cessation (primordial prevention of obesity).
Health promotion embraces disease prevention but also espouses health and well-being as positive goals. While initial health promotion campaigns exhorted people to adopt healthy living habits, from practicing personal hygiene to avoiding harmful addictions, it was soon recognised that individual behaviours are greatly influenced by the social environments in which they live. In the Ottawa Charter of 1986, the World Health Organisation defined health promotion as the “process of enabling people to increase control over their health, and thereby improve their health.” Later on, ‘health in all policies’ was advocated to align the varied determinants of health, which lie in the domain of other sectors, to public health objectives.
Enhancing health and nutrition literacy of people, through programmes conducted at schools, worksites or community settings, is necessary. However, they are often insufficient to achieve impact, if there are formidable barriers that prevent adoption of healthy behaviours. Initially, health promotion efforts relied on a ‘knowledge-attitude-practice’ pathway of behaviour change focusing on individuals. It was later recognised that it is essential to alter the social, economic, cultural, environmental and commercial determinants of health that enable or impede behaviour change at the individual level.
Public policy, involving governmental actions, is a potent instrument for creating a health promoting social environment. Fiscal and regulatory measures have been shown to be highly effective in reducing population exposure to health risks. Raised taxes on tobacco products reduce tobacco consumption, as do bans on tobacco product advertising and smoking in public places. Taxes can raise prices of unhealthy foods while subsidies can make healthier foods more affordable. Laws requiring helmets for motorcyclists, protected pedestrian paths and designated cycle lanes have reduced road accident trauma. Mandating of masks during the Covid pandemic was an impactful measure of health protection.
Freedom of individual choice is a bogey loudly raised by industries which wish to escape regulation of their hazardous products, such as tobacco, ultra-processed food products or sugar sweetened beverages. However, individuals do not exercise unfettered choice in a social vacuum. Choice is conscious, conditioned or constrained. It is conscious, based on correct or incorrect information available to the person. So, society must endeavour to promote health and nutrition literacy to all.
Choice is conditioned by aggressive advertising and promotion of unhealthy products, manipulated peer pressure or unscientific cultural practices. Countering the promotion of unhealthy products and addressing cultural barriers is needed to help people make the right choices.
Even with the right knowledge, choice can be constrained by economic factors, such as the high price of fruit, vegetables and healthy edible oils. Air pollution, unsafe traffic and urban crime can be barriers to outdoor physical activity. Policy measures must remove barriers that constrain choices of healthy living. Health promotion needs to address the cascade of health determinants that extend from cell to society and person to policy.
Views expressed are personal