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editorial2014
PED22210.1177/1757975914534108EditorialD. V. McQueen
Editorial
Health promotion applied to infectious diseases
David V. McQueen1
In its brief history, health promotion, despite its
efforts to focus on health rather than disease, as a
field of research and practice has generally been
associated with efforts at disease prevention. In
addition and despite the broadening of the theoretical
underpinning of the field up to the present, the
disease emphasis continues and is largely focused on
the non-communicable diseases (NCDs) (1).
Meanwhile the greater field of public health
continued with its major emphasis and resource
commitment on infectious diseases. Even in advanced
industrial countries where the causes of death and
disabilities are overwhelmingly related to chronic
diseases and injuries, the allocation of funding
resources in the public health sector goes to the
classical infectious diseases. The emergence of HIV/
AIDS further exacerbated the secondary position of
NCDs and injuries in terms of resource allocations in
major public health institutions and in government
ministries. As a result, the marginalization of health
promotion approaches is the outcome. Or is it?
A recent study undertaken under the auspices of
the IUHPE (2) sought to examine in some depth the
thesis that health promotion approaches used on
NCDs would also be relevant and useful to consider
for infectious diseases in developed economies. To
begin with there are notable conceptual limitations
in undertaking to demonstrate this thesis. First,
infectious disease approaches in public health are
very much found in silos that are based on the
disease itself. Thus there is an enormous literature
on malaria, syphilis, tuberculosis, polio, AIDS,
various infections, parasites, etc. The list is long, and
large departments in schools and institutions of
public health are based on high specialization and
literatures and journals that often are very distinct.
In contrast, the NCDs are often lumped together in
single institutes, centers or departments around
cancers, heart diseases, injuries, etc. Another critical
aspect of this is that the behavioral and social
1. Correspondence to: David V. McQueen, Global consultant, 2418 Midvale Court, Tucker, GA 30084 USA. Email:
dvmcqueengc@comcast.net
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sciences activities and departments are often highly
tied to the NCDs and stand alone as departments. In
contrast, where such approaches exist in infectious
disease prevention and control, the individual social
science researchers work within an infectious disease
setting. In our review of the literature to address our
thesis, these structural aspects became apparent in
terms of outcome and approaches. Second and also
salient, health promotions theoretical underpinnings
largely stem from the social and behavioral sciences,
notably education, sociology, psychology and
political science. However, the practice of health
promotion and in particular the component of
health education is seen most applied in medical
rather than social settings. As a result of these
limiting aspects, historically there have been only
limited health promotion approaches in the area of
population approaches to infectious diseases.
As a result of these limitations we chose to study
the importance of health promotion approaches to
infectious diseases by an argument from analogy.
Our emphasis was to examine the widely used
health promotion models adapted for use on NCDs
and determine if these approaches would be useful
and appropriate for infectious diseases. However,
this is not a simple analogy to make. To begin with,
we recognized a certain duplicity, a continuing
artificial distinction, namely that many chronic
diseases have infectious components, for example
certain cancers, heart diseases, etc.; and that many
so-called infectious diseases, mainly defined by
initial causality, have chronic outcomes, e.g. polio,
AIDS. The reality that emerged was that probably
all disease, regardless of etiology, had an essential
background of related causality. This was, and is,
particularly true in the so-called case of the causes
of the causes. That is, regardless of disease outcomes,
the underlying causes of inequity, poverty,
environment, etc., were apparent and relevant. Thus
health promotion models based on such distal
4 D. V. McQueen
factors are inherently important for interventions
addressing infectious diseases. The underlying
analogy thesis is a very strong one. The difficulty in
showing the strength of this thesis occurs when
seeking empirical studies showing this and in
providing the evidentiary basis for proving the
underlying causes to be valid in terms of infectious
disease.
A classical review and search of the literature,
both published and grey, was undertaken. Using
the typical search engine approach revealed the
limitations of simply relying on such devices. To
begin with, the widely used health promotion
models and community approaches are simply not
easily accessible by classification systems that rely
on key words and the normal disease outcomes
classification. Thus we also turned to the evidence
collecting institutional efforts such as the Cochrane
Collaboration, the CDC Community Guide, NICE
and others. The advantage of their approaches was
that they looked at type and content of the
intervention on a specific disease outcome from an
evidentiary point of view. The findings, however,
were at best scarce, namely because when content-
based research is undertaken the methodology and
design drive the success or failure of the intervention
being included and assessed by such institutional
efforts. At the end of the day the classical review
approach reveals a vast unexamined literature that
is impossible to categorize, and the institutional
approach yields a paltry sum of successful
interventions and in most cases insufficient findings.
The utility of our study has been to reveal this
shortcoming and at the same time offer
recommendations for what may be done to remedy
this situation and further the cause of health
promotion approaches as a way to address all health
and illness problems. First, the field of health
promotion shares much with the emerging field of
intervention research in public health and the need to
understand a) the process mechanisms involved in an
intervention, as opposed to a focus on outcomes, b)
the need to see causality as difficult to determine
when interventions are complicated and multivariate,
and c) that new ways of understanding the successes
and failures of interventions need to be developed.
Second, health promotion interventions are both
practical and dynamic: the variables being considered
in any intervention are themselves very dynamic and
subject to change during the time of the intervention,
IUHPE Global Health Promotion Vol. 22, No. 2 2015
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and importantly the participants are not seen as the
subject of the study, but rather as active participants
in the study. Interventions with highly fixed designs
are not applicable to health promotion interventions,
but unfortunately are commonplace in most public
health research. There is a major need to develop
better participatory methodologies and to have these
methodologies recognized in the scientific literature
and in research protocols. Finally, health promotion
would benefit from an in-depth study of an area of
great success of health promoting interventions in
chronic disease, e.g. tobacco and health. We know
the outcomes of the many health promotion efforts
regarding tobacco, from the policy area, as in the
Framework Convention on Tobacco Control (3), to
the individual efforts, and in health education to
reduce individual smoking behavior. But we need
greater understanding and systematic investigation
of the dynamics of these efforts and how they might
be modeled to guide us in understanding the contexts
and mechanisms of interventions that involve
multiple components.
Acknowledgements
Many thanks to my co-investigator Erma Manoncourt on
this challenging project. She brilliantly covered the
obscure and difficult-to-understand area of grey literature
related to this subject; to Yuri Cartier, IUHPE staffer of
diligence, pursuit and oversight who made the project
come together and added immeasurably to the ideas; and
to Marie-Claude Lamarre, the ever competent and
perceptive executive director of IUHPE whose ongoing
encouragement and advice was perfect. This also
acknowledges the funders of this project, the European
Centre for Disease Prevention and Control (ECDC) for
giving resources to this intriguing area of public health.
Of course, the opinions expressed in this editorial are
those of the author and do not necessarily represent those
of my colleagues, the funders or the IUHPE.
References
1. McQueen DV. The health promotion argument:
NCDs and public health. In McQueen DV, Ed. Global
Handbook on Noncommunicable Diseases and
Health Promotion. New York: Springer; 2013,
Chapter 22, pp. 337342.
2. McQueen DV, Manoncourt E, Cartier Y. The added
value of Health Promotion and Health Education
methods and concepts in the prevention of
communicable diseases. Stockholm: European Centre
for Disease Prevention and Control [In press].
3. World Health Organization. Framework Convention
on Tobacco Control. Geneva, Switzerland: WHO; 21
May 2003.