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Health and determinants of health - a review of
literature, p.I
(Zdrowie i czynniki determinujące zdrowie - przegląd piśmiennictwa,
cz. I)
B Stawarz 1,A, D, F, M Sulima 2, B, M Lewicka 2, C, I Brukwicka 1, E, H Wiktor 2, B
Abstract – The concept of health involves a lot of sciences.
Over the years, health has been defined in different ways.
Modern holistic concept of health defines it as a state of dynamic equilibrium in the correlations of subsystems constituting a human being that are decisive for his or her physiological, social, and psychological functioning. Health is one of the
most important humanistic values; it is a prerequisite for the
realization of all other values, i.e.: a happy professional, social
and family life. Moreover, health is a determinant of the ability
to satisfactorily perform social tasks and roles as well as
achievements of socio-economic nature.
Individual responsibility for health is to a large extent based on
the belief that health is not only a human right and its highest
value, but also an investment, the consequence of which is the
ability of the choice of specific services and health behaviors.
Key words - health, concepts, determinants.
Streszczenie – Pojęciem zdrowia zajmuje się wiele dyscyplin
naukowych. Na przestrzeni lat zdrowie było definiowane w
różny sposób. Nowoczesna holistyczna koncepcja zdrowia
definiuje zdrowie jako stan dynamicznej równowagi w relacjach podsystemów konstytuujących człowieka, decydujących
o jego funkcjonowaniu w sferze fizjologicznej, społecznej oraz
psychologicznej. Zdrowie jest jedną z najwyższych wartości
humanistycznych, warunkuje realizację wszystkich innych
wartości tj.: szczęśliwe życie rodzinne, zawodowe oraz społeczne. Ponadto zdrowie jest wyznacznikiem zdolności wywiązywania się w zadawalającym stopniu z zadań i ról społecznych oraz uzyskiwania osiągnięć natury społecznoekonomicznej.
Indywidualna odpowiedzialność za zdrowie w znacznej mierze
polega na przekonaniu, że zdrowie jest nie tylko prawem człowieka i jego najwyższą wartością, ale również inwestycją, której konsekwencją jest umiejętność dokonywania wyboru określonych usług i zachowań zdrowotnych.
Słowa kluczowe - zdrowie, koncepcje, czynniki determinujące.
Author Affiliations:
1. Institute of Health Protection, The Bronisław Markiewicz
State Higher School of Technology and Economics in
Jarosław
2. Department of Obstetrics, Gynaecology and Obstetrical Gynaecological Nursing, Faculty of Nursing and Health
Sciences, Medical University of Lublin.
Authors’ contributions to the article:
A. The idea and the planning of the study
B. Gathering and listing data
C. The data analysis and interpretation
D. Writing the article
E. Critical review of the article
F. Final approval of the article
Correspondence to:
Barbara Stawarz, MD, PhD, Ostrów 109, PL-37-550 Radymno,
Poland; e-mail [email protected]
I. INTRODUCTION
ealth is a fundamental human value. Health as a
concept is considered by many fields including:
aetiology, epidemiology, diagnosis, treatment, rehabilitation, pedagogy and psychology. The concept of
health may be applied to an individual as well as the entire population – one can refer to a healthy or sick man or
a healthy or sick society [1,2]. Explanation and understanding of the essence and value of health and placing it
in the right place in the hierarchy of values plays an important role in human life [3,4].
H
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The development of medicine in the last two decades
has contributed to the development of new diagnostic
and therapeutic opportunities and allowed to devote more
attention to new scientific fields such as health education,
health promotion or public health. More and more authors advocate the concept of health which would include
complete and complementary definition of health in the
form of a paradigm [5].
II.
CHARACTERISTICS OF DIFFERENT
MODELS AND CONCEPTS OF HEALTH
In medicine and the social sciences, there are two paradigms that define the concept of health. The first is the
pathogenic paradigm, which focuses on identifying the
causes of a disease (considered a condition opposite to
health). This approach classifies people as healthy or sick
(health understood as dependent only on the individual
resistance of biological and genetic endowment remains
beyond the control of the body, and so does disease) [6].
Pathogenetic approach is evident in the biomedical
model of health, expressing the specificity of the era of
restorative medicine [6,7,8]. Defining health and its interpretation is based on the Newtonian-Cartesian paradigm, thanks to which precise understanding of health as
separate and independent components in the field of somatic, mental and social health is possible [9,10].
According to the biomedical model, the concepts of health and illness are considered primarily in the
field of biology. An important role in this model is
played by aetiology, pathogenesis of diseases, focusing
on the diagnosis of diseases and the improvement of
methods of treatment. Health is understood as the absence of disease - a condition in which it does not occur
among human empirical symptoms, while all morphological, biochemical, and physiological parameters are within normal limits. While a person’s condition is determined by a doctor, subjective health criteria are of only
marginal significance [10,11,12,13,14,15].
A complementation to the above paradigm of traditional medicine is salute-genetic health paradigm introduced by A. Antonovsky, which defines the concept of
health, aims to detect the factors contributing to its conservation and improvement and protection in case of a
health risk. This concept postulates that people cannot be
classified as healthy or sick because each person takes a
specific position on the continuum "extending from
health to disease, approaching to a lesser or greater extent in the direction of one of its poles” [11,16]. This is
dependent on the individual somatic and psychological
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features of people that are related to their response to
strains, as well as on external factors such as: the characteristics of the environment and socio - cultural conditions [6].
With time, it was noted that, alongside biological factors, also social ones impact health, which emphasises
the merits of taking into account somatic symptoms in
the diagnosis [5].
Established socio-medical health concept, according to
which a human being is primarily a set of elements associated with relatively simple relationships, knowledge of
every element and every relationship, provides the
knowledge of man as a whole [5,17]. Socio-medical approach to health does not mean that the search for factors
affecting positively the human well-being and the disease
of interest is defined as a disturbance in the normal structure or functioning of the human body [6].
Socio-ecological model of health shows the existence
of links between various factors, among which is a human being and his or her health. In the search for the
causes of diseases in addition to biological and social
factors, ecological factors are also taken into consideration. The essence of this model is the concept of a holistic view of humans, according to which the person is
treated as a whole (that is, that human health is dependent on physical, mental, social and spiritual factors) or
part of the whole (health is seen in the context of factors
that influence it; they are primarily behaviours related to
health, defining the style and standard of living)
[10,18,19].
Socio-ecological model of health care involves the
concept of equilibrium and health potential, which is a
condition of its maintenance. The balance of care is understood as an individual sense of well-being measured
by performance status, absence of pain and the feeling of
satisfaction; it is defined as a dynamic state of relations
between the structures that allow human functioning in
the physical, mental and social aspects, assuming that the
disturbances in the functioning of any of them are not
without affecting the others. The concept includes individual health potential biological resistance, intellectual
resources, incentive structures, patterns of behaviour,
material assets and cultural heritage [6, 7, 20,21].
The sociological paradigm has been used, among others, in the Health for All in 2000 "Created under the auspices of the World Health Organization in member countries. The axiological assumptions of health strategy has
been defined by the three slogans:
1. adding life to years (the desire to provide comprehensive human development opportunities and to make his
life meaningful and creative);
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2. adding health to life (making life worthy, giving a man
a sense of abundance);
3. adding years to life (the desire to prolong life expectancy as a precondition for the previously mentioned
dimensions of health) [22].
The definition of the WHO (World Health Organization) implies that health is a state of complete physical,
mental and social well-being and not merely the absence
of disease or infirmity. In this perspective, health is the
full integration of the system, lack of pain and lack of
reduced efficiency [23,24,25].
In recent years the concept of health has been developed by Popielski, who broadened the definition of
health on an existential dimension. The proposed multidimensionality of the importance of health provides opportunities to look at a human being from multiple angles, considering one’s work and life [5,17].
According to Dubois, health is not merely the absence
of disease but a syndrome of positive ability of a man to
use all the creative possibilities and achieve strength and
happiness "[26].
Brockington claimed that health is a state of physical,
mental and emotional well-being, including a sense of
reserve forces, based on the proper functioning of tissues, a practical understanding of healthy living, harmonious adaptation to the environment [22].
Health as described by Demel is not a gift from heaven a
man is bestowed upon once and for all. Health needs to
be improved, protected and disease should be actively
prevented [27].
Pawłeczyńska defines health as “the fundamental individual value which determines the existence and functioning of human beings according to their objectives and
a basic social value, which determines the chance of the
tasks embarked upon by society. It is a permanent disposition to a relatively systematic psychophysical energy
expenditure and the constant regeneration of forces to
regain mental well-being and satisfaction related to
achieving the purposes for which man strives and satisfaction resulting from the acceptance of a social group
(or unit, representing the reference system). It is also the
ability to live together in harmony and cooperation” [28].
The functional approach to health has been popularised by Parsons, who claimed that health is associated
with optimal ability to perform tasks and social roles,
while the disease limits that ability. Parsons’ concept
meant that health is no longer exclusively
a problem unit; that it has also become a social category
(come to be regarded as a necessary condition for the
effective participation of the individual in society) [22].
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Health is a state of relative balance of spiritual, psychic and somatic aspects of human life. This balance may
be disrupted if within at least one of the relevant structures is affected by clinical disturbances in the form of a
specific syndrome defined as a disease [29].
Today's health is increasingly frequently recognized in
terms of value. Among the meanings of health, we can
distinguish: the value of a healthy body, the patient's
body and the value of the body at risk of disorders.
Health as a value indicates the possibility of acquiring
health [30]. In the empirical study of values, including
the analysis of health culture phenomena, a division of
values into recognized and implemented ones is used (the
recognized values function in the realm of belief that
they should be valued, while the realized values are expressed in the actual activity of people) [30,31].
According to the ,,Health for All” strategy of WHO,
health is a value thanks to which a person or society can
fulfil their aims and the need for satisfaction, to change
the environment and function in it. Health is also wealth
for the society, which guarantees its social and economic
development; the means to achieving a better quality of
life [32,33].
Health is paramount, situated on a high position in the
hierarchy of the individuals and society. It is an important element in decision making, based on which
choice behaviour is performed as a part of human lifestyle [33,34,35].
Health is not merely the absence of disease and infirmity, but a state of good physical, mental and social wellbeing. This means that health includes resistance to diseases and ailments, physical, intellectual, ability to cope
with problems, a sense of strength and will to live as well
as mental balance and harmony [36].
In Christian ethics the respect for the value of health is
defined as a sacred. Life and physical health are precious
gifts for humans and everyone should care for them taking into account the common good of the needs of others
[28].
Health is not a static state, therefore it should be protected, refined and improved; its potential should be increased. Health should be sought in the event of outbreaks of disease [37].
Health is not just physical, mental or intellectual fitness, but also the desire for fullness of life, ability to
cope with various problems and the ability to fulfil professional and everyday-life roles. It is also the mental
strength and ability to cope with the individual ailments
and diseases [15].
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A person not only may, but is obliged to maintain and
multiply their health [29,30].
According to the WHO definition, there are three planes
of health:
 physical (somatic) - applies directly to an organism
that may be subject to various disorders and diseases. It affects the health of genetic factors, lifestyle factors and external training;
 mental health – it is linked with the process of integration of personality, as well as with the possibility of ontogenetic development, proper reception
of stimuli, using resources of higher emotionality,
toning emotions, having the intellectual capacity
(all of these factors are to ensure, mental balance
in the most natural way);
 public health - based on the proper relationship between the individual and society [28].
The consequence of the modern definition of health is
the expansion of the understanding of the human realm
of psychosocial functioning, including the following dimensions of its activity:
 physical dimension - identifying physical activity,
diet, avoidance of stimulants;
 social dimension - satisfying relationships with family, friends, activity in public life, the ability to interact and others;
 emotional dimension - the ability to express feelings
and acceptance, overcoming stressful situations,
emotional control;
 dimension pro - job satisfaction, attitudes towards
work, interaction with colleagues [38].
One should make an effort to make one’s health as biologically, psychologically and socially adapted as it is
possible in the most favourable circumstances. The internal balance ensures the proper functioning of the human
body in all aspects of life [39].
III. DETERMINANTS OF HEALTH
The health status of the population is expressed predominantly by the data describing the incidence of diseases, injuries or ailments. An important element of the
description of the health situation of the population is to
enable it to assess the information describing the health
conditions in which a population lives (so-called determinants of health). Factors determining a health problem
7
are complex due to the nature of multi-factor correlation
[40].
Genetic factors aside, determinants of health may be a
direct or indirect cause of disease, injury, pain or death.
Various groups of social, economic and environmental
conditions that have a significant impact on the health of
individual units as well as entire populations are referred
to as indirect determinants (affecting health in the long
term). In contrast, factors such as diet and type of food,
the quality of drinking water, smoking, alcohol abuse or
exposure to infection are referred to as direct determinants [15].
Potential positive or negative effects on human health
that direct determinants may have are closely related to
the impact of indirect determinants on health [15].
The first classification of health determinants was provided in 1973 by Lalonde (Canadian Minister of Health),
together with Bumem, a sociologist. They presented a
holistic model of health. They pointed to four areas corresponding to the main determinants of health, which
influenced the state of health of both individuals as well
as society as a whole.
Field of holistic health model:
 lifestyle and health behavior;
 the physical environment, social and economic life,
work and study;
 biological and genetic factors;
 health care interventions aimed at preventing disease, promoting health behaviours leading to
strengthening and rehabilitation [15,41].
Studies have shown that the state of human health for
the most part depends on your lifestyle. Behaviours beneficial to health allow one to maintain one’s good condition and even improve it. Thus, health promotion has
adopted development of individual health-related skills
as one of the areas of its activity.
This requires, among others, appropriate health education. As a part of this education, it should provide individuals the knowledge, motivation and skills to encourage a healthy lifestyle.
The concept of health has been modified as a result of
the proceedings of the international conference on health
promotion in Adelaide in 1988. A distribution of health
determinants into four groups depending on the type of
health risk factors proposed there is the following:
 social risk factors - environments including low income, the general poverty of people, lack of employment, poor housing and working conditions,
low education, lack of social authority;
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 psychosocial risk factors include social marginalization, lack of support and social ties, poor psychophysical condition, low sense of security, low
self-esteem, lack of proper recuperation;
 observed risks arising from one’s behaviour. These
include smoking, improper diet, lack of physical
activity, abuse drugs and alcohol, drug use;
 patho-physiological risk factors depend on the
pathological changes that occur. These include
hypertension, high cholesterol, diabetes, hormone
release increased stressors, elevated blood coagulation [42].
The authors of the National Health Program for 19962005 estimated that human health depends in 50-60% on
one’s lifestyle, in about 20% - on the environmental factors and in approximately 20% on the genetic factors.
The remaining part depends on health care (10-15%)
[43].
According to the World Health Organization, there are
12 major factors that determine health. These include:
physical and mental condition with reference to age and
sex, the use of civil rights, education, employment, working conditions, housing, food and nutrition, sense of security, the possibility of saving money, communication
and contact with other people, rejuvenation, relaxation
and entertainment, and appropriate clothing [2,44,45].
The factors negatively affecting health include: lack of
work (including periodic), adverse relations at work,
excessive exercise, exposure to harmful substances during work, exhausting and monotonous work system,
compaction and poor housing facilities, vandalism in
residence, the share of in road accidents, lack of physical
activity in their leisure time, addictions and bad nutrition
[2].
Factors affecting each other having a positive or negative impact on human health are:
 the physical environment - air, water, food, waste
and other factors affecting the functioning of the
human body;
 social environment - includes norms, values, customs, fashions, prejudices, habits;
 sectoral policy environment - it is the actions and
strategies represented by different areas of socio economic development (agriculture, transport, environment, health, education, culture, the market
economy, industry);
 environmental resources - the source of financial,
infrastructure, resources representing skills and
the ability of individuals or groups-individual;
8
 the political environment - the conditions in which
society lives [2].
The diagram showing variety of determinants of health
and the abundance of their interrelationships illustrates
the relationship between man and the environment. Mandala Health presents a model called the human ecosystem
developed by the Department of Public Health in Toronto. Holistically understood, the man is the centre point of
the Mandala and two Skare circles (biosphere and culture) as the basic reference systems in the definition of
health, which is shaped by direct human environment, its
biology and life style [6].
Analyzing the determinants of health status of people,
the adverse impact imposed upon a human being from
outside as well as the patterns of social behaviour and
health should be taken into account. Patterns and cultural
norms associated with the style of human life may condition positive or negative health behaviours. Culture regulates, among others, perceptions of health and disease,
how to feel, perceive and describe the symptoms of the
disease, the state of knowledge concerning the causes of
diseases, attitudes and behaviours towards their own illness and lifestyle considered decisive in shaping the
health of the community [3,38].
Social factors that are related to health include family
situation, especially the family structure, the nature of the
family ties, the functions of individual family members
and the living conditions of the family [46].
Human health affects the physical environment. To
adversely affect the health of environmental factors include: environmental pollution (air, water, soil), dust,
toxic gas fumes, heat and noise [6].
Genetic endowment of the human body determines the
direction and dynamics of the somatic and psychological
development, which are formed at a certain level related
to an accepted medical standard (deviations from this
standard manifest in the form of various types of somatic
or metabolic disorders and hereditary diseases) [6].
Epidemiological studies show a correlation between
health and sex. Women rate their health at all ages on
average lower than men. Women are ill more often than
men, whereas men die earlier than women. Women also
assess their psychological well-being more negatively as
compared to men.They are more likely to seek medical
care, use sick leaves, take more drugs and engage in para-medicine. In a situation of chronic diseases and health
emergencies of life-threatening incidents, significant differences between men and women are not observed.
Women have greater health awareness and knowledge of
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symptoms and more often seek social support as compared to men [38,47].
Studies have shown that married people are much less
likely to die compared to unmarried, divorced or widowed. Family enforces healthy lifestyle and has a positive effect on human health [47].
The health status of people depends also on where you
live. In the countryside, it is observed to be lower as
compared to the city, which is related to the level of education of the population, less wealth communities, poorer
housing conditions and sanitary-hygiene as well as limited access to medical facilities [47].
Education is a variable that shapes attitudes towards
health and disease, hierarchies of values and lifestyles.
Research shows that individuals with better education
lead a more healthy lifestyle. People with higher education have a more rational diet, eat more fruit and salads,
avoid fatty foods and meat, lead an active lifestyle, have
medical consultations and use drugs to a lesser extent;
also their working conditions are less likely to threaten
their health [47].
Literature also discussed the relationship between the
level and quality of health behaviours and the financial
situation of the individual. Considering the poor whose
financial situation is bad, one can refer to “lifestyle in the
conditions of limited choice” – they choose whatever
they need most at the moment (they are often limited to
the decision what to give up first). People on low incomes use stimulants to a greater extent, have worse diets
and use health care services less frequently as compared
to people whose financial situation is good [48].
IV. CONCLUSION
The health status of an individual and society depends
on how the individual perceives the value of his health,
which is taking action to strengthen, preserve and protect
health. Individualized health behaviours, acquired during
the socialization of every human being from the earliest
years, with the passing of time become conscious choices, which are habits difficult to eliminate. Choosing antihealthy behaviour explains a range of mechanisms which
justify a person’s actions. It is therefore important to
create patterns of action and generally accepted standards
to ensure the best conditions for the human health restoration, maintenance and reinforcement [49].
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