Arrington, Barbara

Porter, Josephine B.

Seavey, John W.

English

UNH Scholars' Repository

University of New HampshireUniversity of New Hampshire Scholars' RepositoryThe University Dialogue Discovery Program2009Building the foundation for a healthy life:individuals, communities and the stateJohn W. SeaveyUniversity of New Hampshire, John.Seavey@unh.eduJosephine B. PorterUniversity of New Hampshire, jo.porter@unh.eduBarbara ArringtonUniversity of New HampshireFollow this and additional works at: https://scholars.unh.edu/discovery_udPart of the Health Policy Commons, and the Medicine and Health CommonsThis Article is brought to you for free and open access by the Discovery Program at University of New Hampshire Scholars' Repository. It has beenaccepted for inclusion in The University Dialogue by an authorized administrator of University of New Hampshire Scholars' Repository. For moreinformation, please contact nicole.hentz@unh.edu.Recommended CitationSeavey, John W.; Porter, Josephine B.; and Arrington, Barbara, "Building the foundation for a healthy life: individuals, communitiesand the state" (2009). The University Dialogue. 45.https://scholars.unh.edu/discovery_ud/45Population HealthSocieties create the conditions leading to a population’s health or lack thereof. While this is a simplistic statement, it has dramatic conse-quences as reflected in the variation in levels of health from community to community that have nothing to do with the natural conditions of life. Housing, educa-tion, crime, food supply, pollution, employment, access to medical care, unemployment, and other factors not associated with biological processes interdependently create the foundation on which healthy lives are built. What are these factors and how can those be changed to optimize health of individuals and populations? Multiple models have been developed to explain why certain communities are healthier than others. A popular model, developed by Robert Evans and Greg Stoddart in 1990 and re-designed in 2003 takes into account our current understanding of the determi-nants of health.i The Evans and Stoddart model comes out of the Canadian Institute for Advanced Research (CIAR) and has been widely used by communities (including the state of New Hampshire) to model the determinants of health.The model indicates that health begins with individ-ual values and beliefs, and then builds on knowledge gained through experience, our evaluation of what we do (evidence-based medicine/public health) and scientific research. As our knowledge expands so does our understanding of what makes us healthy and how we can restore health. The model has various determi-nants of health (income and social status, social sup-port systems, education, working conditions, physical environment, biology and genetics, personal health practices, healthy child development, and health ser-vices). The income and social status determinant sug-gests that not only does health differ between the rich and the poor, but also that there is a social gradient, i.e., as income increases one’s health also increases.ii Some of the other determinants (such as education and working conditions) may be correlated with income but also have their own impact on health. The contri-bution of genetics has become increasingly apparent with the genome-mapping project. However, genetics is not destiny; a genetic predisposition to a disease may or may not materialize given individual behavior or social and physical environmental characteristics. At the bottom of the list of determinants is health care services. While health care is a $2.7 trillion a year in-dustry in the United States, its contribution for health status is estimated to account for approximately 10per-cent of the variation in a country’s health status.iiiThe Evans and Stoddart model also assigns respon-sibilities for improving health. Those include the in-dividual, family, community, health care system, and society as a whole. It also delineates various strategies that individuals/societies can use, including reori-enting the health system, developing personal skills, creating supportive environments, building healthy public policy, and strengthening community action. Reorient health services is meant to build a health sys-tem that focuses more on health promotion and dis-ease prevention rather than fixing people after they are sick or disabled. Building a healthy public policy will be discussed later in this essay.The Role of the IndividualIndividual responsibility is an ever-present consider-ation in current conversations concerning health and health reform. The word responsibility has many defi-nitions. Responsibility can be legal or moral, an obli-gation; responsibility can be causal—accountability or fault can be assigned; role responsibilities are parent, Building the Foundation for a Healthy Life: Individuals,  Communities, and the StateJohn W. Seavey, PhD, MPHJosephine Porter, MPHBarbara Arrington, PhD, FACHETaking Care of Self and Communityteacher, learner, etc.; and scope of responsibility can range from great to little. Regardless of definition, the central questions are two: Who is responsible? For what? In terms of the “who”, the Evans and Stoddart model shows that responsibility for health is complex and shared, but for what are individuals most directly responsible?As we come to understand the multiple determi-nants of health, the list of agents whose actions have a role in its maintenance and restoration grows long—ranging from international orga-nizations to states, communities, employers, insurers, and the health professions…who is responsible for health? …it is increasingly clear that individual choices…are at least as signifi-cant in achieving good health outcomes as costly medical interventions… actions taken can have a marked and positive impact on one’s health while also radiating good effects on other dimensions of life and on other people.iv It is difficult to be precise as to where individual responsibility begins. For example, many people feel that if a person engages in risky behavior (smoking, drinking alcohol, eating high fatty foods, etc.) that society’s obligation to the individual is diminished. However, it is tricky to lay responsibility on the indi-vidual. One must assume that the individual is acting freely and with full knowledge of the consequences. However, that is not always easy to demonstrate. When do you assume that all individuals should know the danger of “X”? Societal/cultural norms as well as economic conditions shape an individual’s expecta-tion of what is acceptable, permissible, and affordable. Is smoking in the South to be treated differently than smoking in the Northeast? How much of a person’s limited income should we expect them to spend on expensive fresh fruits and vegetables? While we tend to fault people for risky behaviors, we do not do so for people that engage in sports that might be dangerous. It is easy to turn individual responsibility into “vic-tim blaming,” blaming people whose choices may be unwise in the larger picture but not truly voluntary or acted upon with clear knowledge of the risks. It is also not clear where individual responsibil-ity ends. One of the major principles of the German health care system is “obligation,” that the individual has a social obligation to pay for health insurance, to share the burden of caring for illness. This has been adopted by the state of Massachusetts in its require-ment for mandatory health insurance and is now being considered as a cornerstone of health reform at the federal level.It is easy to suggest that individuals are responsible for their own health; at one level they are. However, it is difficult to draw the line between individual re-sponsibility and the role of other actors such as family, communities, and society as a whole. Competencies and SkillsAt the individual level, much has been written about health literacy. According to the U.S. Department of Health and Human Services, health literacy is “the de-gree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”v An individual’s level of health literacy can impact their decisions and outcomes along the continuum of health. Whether or not people understand how infectious diseases spread can impact hygiene, recognizing the consequences of food choices can impact healthy eat-ing habits, and misunderstanding the instructions for medication use can cause adverse drug events.How an individual becomes health literate is not always clear. Some information is learned in school. Familial and cultural influences can impact health literacy (hand washing and healthy eating). The public health system conveys important health messages. In recent years, advertising about pharmaceuticals has become a major source of “health education.” Many people get health information from the Internet with-out a way to determine its accuracy. Some argue that improving health literacy is the responsibility of health care providers. The ability to comprehend health infor-mation can vary. How well can one understand medi-cal information when it is part of a devastating diag-nosis? Do we expect an 85 year old to navigate through the myriad of private pharmaceutical plans available under Medicare?What role does an individual have in his/her own health care decision-making? Is it the responsibility of the care provider to offer multiple options, or the responsibility of the person to ask? Extensive research on supplier-induced care indicates thatvi medical care services will be used to the extent they are available, at times irrespective of actual need. In the face of multi-ple treatment choices, individuals need to understand the pros and cons of different treatment choices and how those align with personal preferences and values. For this to happen, people need to be active partici-pants in decision-making.A University Dialogue on Health  2009–2010The Role of Public Policy and HealthAny political system has to determine the role of gov-ernment and individual freedoms/responsibilities. To what extent does society restrain individual actions for the purpose of society as a whole? Erich Fromm de-scribes this as the difference between “freedom from” government and “freedom to” or the use of govern-ment to provide the conditions for freedom.vii The re-cent legislative debate on mandatory use of seatbelts in New Hampshire came down on the side of individual “freedom from.” “Freedom to” can be exemplified by the use of mandatory public education (restricting in-dividual freedom) to provide individuals with the tools necessary to live a full life and participate in a demo-cratic society. For health and medical care, societies are on a continuum, with the United States placing more emphasis than others on individual freedom and responsibility and reliance on market mechanisms.Within health there are two areas where govern-ment policies play a major role, one is in the area of public health and the other is the correction of mar-ket forces. The many environmental factors affecting health that are outside an individual’s control (water, air, purity of food and medicines, infectious diseases) are best addressed through public health initiatives. The recent spread of H1N1 virus demonstrates the need for global coordination. All societies (to some degree) attempt to modify behavior of individuals (e.g., smoking) and corporations (e.g., pollution con-trols) in order to protect the public’s health. All coun-tries have policies to correct defects when the market system fails. In the United States, we have determined that because the market does not work well for the elderly (Medicare), the poor (Medicaid), children (SCHIP) and veterans (Veteran’s Administration) we have public medical care systems or insurance plans. Another example of correcting market failure is to provide assurance that services and products are safe and effective (e.g., the role of the Food and Drug  Administration).The determinants of health are multiple and com-plex with most of them involving to one degree or an-other public policy. For example, as seen in the Evans and Stoddart model, education is one of the variables that has a strong relationship with health. The more education one has the better the health for both the in-dividual and a community; education policy becomes health policy. Transportation policy (the creation of sidewalks and bike paths to encourage exercise; mass transit, and lower polluting vehicles to decrease energy consumption and create cleaner air) becomes health policy. Agricultural policy becomes health policy. Energy policy becomes health policy. During the cur-rent year, the Congress and the Presidency will be dis-cussing “health reform.” This is better understood as “Medical Insurance Reform”—changing the ways that people gain and retain medical insurance rather than actually reforming health care. While critically im-portant to individuals without access to medical care, this legislation is unlikely to result in much “health reform” since medical care is a small component of health. Our “health policy” remains focused on medi-cal care rather than on health.The importance of policy to health is frequently overlooked in this country; we do not consciously con-sider the health impacts of most enacted policies. In Europe Health Impact Assessmentviii is gaining accep-tance. This approach analyzes the direct and indirect health impacts of all proposed legislation. Similar to environmental impact statements, there would be an analysis of the health impacts of widening interstate highways as opposed to the construction of rail lines, the health impacts of mandating completion of high school or the health impacts of allowing vending ma-chines in schools. Despite potential methodological and data problems, even at the most basic level, such analyses would sensitize both voters and politicians to the intended and unintended health consequences of policy decisions.Concluding StatementThe health of individuals and communities depends on a complex web of interdependent interactions among individuals, families, communities, corpora-tions, non-profit organizations, states, nations, and international cooperation. Understanding these in-terdependencies along with associated individual and collective responsibilities and making informed and effective choices in light of this understanding builds the foundation for a healthy life.Taking Care of Self and CommunityEndnotesi. Evans R.G. and Stoddart G.L. Consuming research, pro-ducing policy? American Journal of Public Health. 2003; 93: 371-379.ii. Marmot M.G., Rose G.A., Shipley M.J., and Hamilton P.J.S. Employment grade and coronary heart disease in British civil servants. Journal of Epidemiology and Community Health. 1978; 32: 244-249.iii. Schroeder S.A. We can do better—Improving the health of the American people. New England Journal of Medicine. 2007; 357: 1221-1228. iv. Wikler D. Personal and social responsibility for health. Ethics and International Affairs. 2002; 16 (2): 47-55. Highbeam Research June 8, 2009 www.highbeam.com.v. U.S. Department of Health and Human Services. Healthy People 2010. Available at: http://www.healthypeople.gov/Document/pdf/uih/2010uih.pdf, accessed June 4, 2009.vi. Dartmouth Atlas Working Group. Dartmouth Atlas of Healthcare. Available at: http://www.dartmouthatlas.org/, accessed June 4, 2009.vii. Fromm E. Escape from Freedom. New York: Avon Books, 1941.viii. Dannenberg A.L., et al. Growing the field of health as-sessment in the United States: An agenda for research and practice, American Journal of Public Health. 2006; 96: 262-270.

Building the foundation for a healthy life: individuals, communities and the state

University of New Hampshire

University of New Hampshire
University of New Hampshire Scholars' Repository
The University Dialogue Discovery Program
2009
Building the foundation for a healthy life:
individuals, communities and the state
John W. Seavey
University of New Hampshire, John.Seavey@unh.edu
Josephine B. Porter
University of New Hampshire, jo.porter@unh.edu
Barbara Arrington
University of New Hampshire
Follow this and additional works at: https://scholars.unh.edu/discovery_ud
Part of the Health Policy Commons, and the Medicine and Health Commons
This Article is brought to you for free and open access by the Discovery Program at University of New Hampshire Scholars' Repository. It has been
accepted for inclusion in The University Dialogue by an authorized administrator of University of New Hampshire Scholars' Repository. For more
information, please contact nicole.hentz@unh.edu.
Recommended Citation
Seavey, John W.; Porter, Josephine B.; and Arrington, Barbara, "Building the foundation for a healthy life: individuals, communities
and the state" (2009). The University Dialogue. 45.
https://scholars.unh.edu/discovery_ud/45
Population Health
Societies create the conditions leading to a population’s health or lack thereof. While this is a simplistic statement, it has dramatic conse-
quences as reflected in the variation in levels of health 
from community to community that have nothing to 
do with the natural conditions of life. Housing, educa-
tion, crime, food supply, pollution, employment, access 
to medical care, unemployment, and other factors not 
associated with biological processes interdependently 
create the foundation on which healthy lives are built. 
What are these factors and how can those be changed 
to optimize health of individuals and populations? 
Multiple models have been developed to explain why 
certain communities are healthier than others. A 
popular model, developed by Robert Evans and Greg 
Stoddart in 1990 and re-designed in 2003 takes into 
account our current understanding of the determi-
nants of health.i The Evans and Stoddart model comes 
out of the Canadian Institute for Advanced Research 
(CIAR) and has been widely used by communities 
(including the state of New Hampshire) to model the 
determinants of health.
The model indicates that health begins with individ-
ual values and beliefs, and then builds on knowledge 
gained through experience, our evaluation of what 
we do (evidence-based medicine/public health) and 
scientific research. As our knowledge expands so does 
our understanding of what makes us healthy and how 
we can restore health. The model has various determi-
nants of health (income and social status, social sup-
port systems, education, working conditions, physical 
environment, biology and genetics, personal health 
practices, healthy child development, and health ser-
vices). The income and social status determinant sug-
gests that not only does health differ between the rich 
and the poor, but also that there is a social gradient, 
i.e., as income increases one’s health also increases.ii 
Some of the other determinants (such as education and 
working conditions) may be correlated with income 
but also have their own impact on health. The contri-
bution of genetics has become increasingly apparent 
with the genome-mapping project. However, genetics 
is not destiny; a genetic predisposition to a disease 
may or may not materialize given individual behavior 
or social and physical environmental characteristics. 
At the bottom of the list of determinants is health care 
services. While health care is a $2.7 trillion a year in-
dustry in the United States, its contribution for health 
status is estimated to account for approximately 10per-
cent of the variation in a country’s health status.iii
The Evans and Stoddart model also assigns respon-
sibilities for improving health. Those include the in-
dividual, family, community, health care system, and 
society as a whole. It also delineates various strategies 
that individuals/societies can use, including reori-
enting the health system, developing personal skills, 
creating supportive environments, building healthy 
public policy, and strengthening community action. 
Reorient health services is meant to build a health sys-
tem that focuses more on health promotion and dis-
ease prevention rather than fixing people after they are 
sick or disabled. Building a healthy public policy will 
be discussed later in this essay.
The Role of the Individual
Individual responsibility is an ever-present consider-
ation in current conversations concerning health and 
health reform. The word responsibility has many defi-
nitions. Responsibility can be legal or moral, an obli-
gation; responsibility can be causal—accountability or 
fault can be assigned; role responsibilities are parent, 
Building the Foundation for a Healthy Life: Individuals,  
Communities, and the State
John W. Seavey, PhD, MPH
Josephine Porter, MPH
Barbara Arrington, PhD, FACHE
Taking Care of Self and Community
teacher, learner, etc.; and scope of responsibility can 
range from great to little. Regardless of definition, the 
central questions are two: Who is responsible? For 
what? In terms of the “who”, the Evans and Stoddart 
model shows that responsibility for health is complex 
and shared, but for what are individuals most directly 
responsible?
As we come to understand the multiple determi-
nants of health, the list of agents whose actions 
have a role in its maintenance and restoration 
grows long—ranging from international orga-
nizations to states, communities, employers, 
insurers, and the health professions…who is 
responsible for health? …it is increasingly clear 
that individual choices…are at least as signifi-
cant in achieving good health outcomes as costly 
medical interventions… actions taken can have a 
marked and positive impact on one’s health while 
also radiating good effects on other dimensions 
of life and on other people.iv 
It is difficult to be precise as to where individual 
responsibility begins. For example, many people feel 
that if a person engages in risky behavior (smoking, 
drinking alcohol, eating high fatty foods, etc.) that 
society’s obligation to the individual is diminished. 
However, it is tricky to lay responsibility on the indi-
vidual. One must assume that the individual is acting 
freely and with full knowledge of the consequences. 
However, that is not always easy to demonstrate. 
When do you assume that all individuals should know 
the danger of “X”? Societal/cultural norms as well as 
economic conditions shape an individual’s expecta-
tion of what is acceptable, permissible, and affordable. 
Is smoking in the South to be treated differently than 
smoking in the Northeast? How much of a person’s 
limited income should we expect them to spend on 
expensive fresh fruits and vegetables? While we tend 
to fault people for risky behaviors, we do not do so for 
people that engage in sports that might be dangerous. 
It is easy to turn individual responsibility into “vic-
tim blaming,” blaming people whose choices may be 
unwise in the larger picture but not truly voluntary or 
acted upon with clear knowledge of the risks. 
It is also not clear where individual responsibil-
ity ends. One of the major principles of the German 
health care system is “obligation,” that the individual 
has a social obligation to pay for health insurance, to 
share the burden of caring for illness. This has been 
adopted by the state of Massachusetts in its require-
ment for mandatory health insurance and is now being 
considered as a cornerstone of health reform at the 
federal level.
It is easy to suggest that individuals are responsible 
for their own health; at one level they are. However, 
it is difficult to draw the line between individual re-
sponsibility and the role of other actors such as family, 
communities, and society as a whole. 
Competencies and Skills
At the individual level, much has been written about 
health literacy. According to the U.S. Department of 
Health and Human Services, health literacy is “the de-
gree to which individuals have the capacity to obtain, 
process, and understand basic health information and 
services needed to make appropriate health decisions.”v 
An individual’s level of health literacy can impact their 
decisions and outcomes along the continuum of health. 
Whether or not people understand how infectious 
diseases spread can impact hygiene, recognizing the 
consequences of food choices can impact healthy eat-
ing habits, and misunderstanding the instructions for 
medication use can cause adverse drug events.
How an individual becomes health literate is not 
always clear. Some information is learned in school. 
Familial and cultural influences can impact health 
literacy (hand washing and healthy eating). The public 
health system conveys important health messages. In 
recent years, advertising about pharmaceuticals has 
become a major source of “health education.” Many 
people get health information from the Internet with-
out a way to determine its accuracy. Some argue that 
improving health literacy is the responsibility of health 
care providers. The ability to comprehend health infor-
mation can vary. How well can one understand medi-
cal information when it is part of a devastating diag-
nosis? Do we expect an 85 year old to navigate through 
the myriad of private pharmaceutical plans available 
under Medicare?
What role does an individual have in his/her own 
health care decision-making? Is it the responsibility 
of the care provider to offer multiple options, or the 
responsibility of the person to ask? Extensive research 
on supplier-induced care indicates thatvi medical care 
services will be used to the extent they are available, at 
times irrespective of actual need. In the face of multi-
ple treatment choices, individuals need to understand 
the pros and cons of different treatment choices and 
how those align with personal preferences and values. 
For this to happen, people need to be active partici-
pants in decision-making.
A University Dialogue on Health  2009–2010
The Role of Public Policy and Health
Any political system has to determine the role of gov-
ernment and individual freedoms/responsibilities. To 
what extent does society restrain individual actions for 
the purpose of society as a whole? Erich Fromm de-
scribes this as the difference between “freedom from” 
government and “freedom to” or the use of govern-
ment to provide the conditions for freedom.vii The re-
cent legislative debate on mandatory use of seatbelts in 
New Hampshire came down on the side of individual 
“freedom from.” “Freedom to” can be exemplified by 
the use of mandatory public education (restricting in-
dividual freedom) to provide individuals with the tools 
necessary to live a full life and participate in a demo-
cratic society. For health and medical care, societies 
are on a continuum, with the United States placing 
more emphasis than others on individual freedom and 
responsibility and reliance on market mechanisms.
Within health there are two areas where govern-
ment policies play a major role, one is in the area of 
public health and the other is the correction of mar-
ket forces. The many environmental factors affecting 
health that are outside an individual’s control (water, 
air, purity of food and medicines, infectious diseases) 
are best addressed through public health initiatives. 
The recent spread of H1N1 virus demonstrates the 
need for global coordination. All societies (to some 
degree) attempt to modify behavior of individuals 
(e.g., smoking) and corporations (e.g., pollution con-
trols) in order to protect the public’s health. All coun-
tries have policies to correct defects when the market 
system fails. In the United States, we have determined 
that because the market does not work well for the 
elderly (Medicare), the poor (Medicaid), children 
(SCHIP) and veterans (Veteran’s Administration) we 
have public medical care systems or insurance plans. 
Another example of correcting market failure is to 
provide assurance that services and products are safe 
and effective (e.g., the role of the Food and Drug  
Administration).
The determinants of health are multiple and com-
plex with most of them involving to one degree or an-
other public policy. For example, as seen in the Evans 
and Stoddart model, education is one of the variables 
that has a strong relationship with health. The more 
education one has the better the health for both the in-
dividual and a community; education policy becomes 
health policy. Transportation policy (the creation of 
sidewalks and bike paths to encourage exercise; mass 
transit, and lower polluting vehicles to decrease energy 
consumption and create cleaner air) becomes health 
policy. Agricultural policy becomes health policy. 
Energy policy becomes health policy. During the cur-
rent year, the Congress and the Presidency will be dis-
cussing “health reform.” This is better understood as 
“Medical Insurance Reform”—changing the ways that 
people gain and retain medical insurance rather than 
actually reforming health care. While critically im-
portant to individuals without access to medical care, 
this legislation is unlikely to result in much “health 
reform” since medical care is a small component of 
health. Our “health policy” remains focused on medi-
cal care rather than on health.
The importance of policy to health is frequently 
overlooked in this country; we do not consciously con-
sider the health impacts of most enacted policies. In 
Europe Health Impact Assessmentviii is gaining accep-
tance. This approach analyzes the direct and indirect 
health impacts of all proposed legislation. Similar to 
environmental impact statements, there would be an 
analysis of the health impacts of widening interstate 
highways as opposed to the construction of rail lines, 
the health impacts of mandating completion of high 
school or the health impacts of allowing vending ma-
chines in schools. Despite potential methodological 
and data problems, even at the most basic level, such 
analyses would sensitize both voters and politicians to 
the intended and unintended health consequences of 
policy decisions.
Concluding Statement
The health of individuals and communities depends 
on a complex web of interdependent interactions 
among individuals, families, communities, corpora-
tions, non-profit organizations, states, nations, and 
international cooperation. Understanding these in-
terdependencies along with associated individual and 
collective responsibilities and making informed and 
effective choices in light of this understanding builds 
the foundation for a healthy life.
Taking Care of Self and Community
Endnotes
i. Evans R.G. and Stoddart G.L. Consuming research, pro-
ducing policy? American Journal of Public Health. 2003; 93: 
371-379.
ii. Marmot M.G., Rose G.A., Shipley M.J., and Hamilton 
P.J.S. Employment grade and coronary heart disease 
in British civil servants. Journal of Epidemiology and 
Community Health. 1978; 32: 244-249.
iii. Schroeder S.A. We can do better—Improving the health 
of the American people. New England Journal of Medicine. 
2007; 357: 1221-1228. 
iv. Wikler D. Personal and social responsibility for health. 
Ethics and International Affairs. 2002; 16 (2): 47-55. 
Highbeam Research June 8, 2009 www.highbeam.com.
v. U.S. Department of Health and Human Services. Healthy 
People 2010. Available at: http://www.healthypeople.gov/
Document/pdf/uih/2010uih.pdf, accessed June 4, 2009.
vi. Dartmouth Atlas Working Group. Dartmouth Atlas of 
Healthcare. Available at: http://www.dartmouthatlas.org/, 
accessed June 4, 2009.
vii. Fromm E. Escape from Freedom. New York: Avon Books, 
1941.
viii. Dannenberg A.L., et al. Growing the field of health as-
sessment in the United States: An agenda for research and 
practice, American Journal of Public Health. 2006; 96: 262-
270.


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Building the foundation for a healthy life: individuals, communities and the state

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