313394 Lecture Notes - Lecture 9: Primary Healthcare, Population Health, Health Promotion
WEEK 9: Supporting Healthy Behaviours
Approaches to health disease
• The downstream approach – individual level intervention deals with the presenting medical
problem or disease. Links to the biomedical model.
• The midstream approach – population interventions that target defined populations in order to
change and /or prevent behavioural risk factors. It could be labelled as the ‘behavioural’. Links
to behavioural, health promotion and prevention lifestyle and prevention programs.
• The upstream approach – concerned with identifying the ‘causes of the causes’ of illness and
disease that stem from social, political, economic or cultural perspectives and then implementing
national and regional public policies or environmental interventions at a macro level to eradicate
the sources of the problems.
No approach is mutually exclusive all three approaches are often combined but recent years has seen a
change in emphasis, from a downstream to an upstream, population and comprehensive primary health
care strategies as we have moved from a time when acute disease was the major cause of death to
chronic disease being the major health issue. The social and environmental originals of disease (the
social determinants of health) are now under the spotlight as are the lifestyle choices that people face.
Population and public health:
Population health is the study of health and disease in defined populations. Epidemiological data
identifies at risk populations. This can be a patient population, geographic populations e.g. a community.
Population health is interested in why some people are healthy and others are not and aims to improve
the health of entire populations.
The population health approach aims to achieve:
‘A reduction in the incidence of preventable mortality and morbidity, including through
national public health initiatives, promotion of healthy lifestyles, and approaches covering
disease prevention, health screening and immunisation’ (Department of Health, 2014, p.
49).
Public health occurs in the community and focuses on:
‘Prevention, promotion and protection rather than on treatment: on populations rather than individuals,
and on factors and behaviours that affect health and cause illness and injury’
Population health is evidence based, focusing on upstream health promotion and disease preventions
strategies aimed at populations or population groups as opposed to the individuals who are members of
populations. The lens focuses on underlying social determinants of health that impact the health of the
whole population and aims to tackle the ‘upstream’ social, political, economic and cultural aspects of
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society. High quality ‘downstream’ services for the sick or injured are a vital part of service provision
and health strategies but population health initiatives aim to prevent illness and reduce the need for
downstream services.
Primary health care:
It is often the first level of contact with that individuals, families and communities have with the
healthcare system (Keleher, 2001). It supports the notion that everyone has the right to affordable,
accessible and appropriate health services and adopts a social justice perspective to health care based
on the principle that access to quality health care is a fundamental human right. It adopts a holistic
approach and acknowledges and responds to the social determinants of health.
Most Australians will receive primary health care through their General Practitioner (GP - doctor).
Primary health care providers also include nurses (including general practice nurses, community nurses
and nurse practitioners), allied health professionals, midwives, pharmacists, dentists, and Aboriginal
health workers. Traditionally, GP services have treated the ‘illness’ rather than supporting ‘wellness’,
working primarily from the ‘medical model’. The aim of the WHO (1978) to achieve ‘health for all’ by the
year 2000 has long gone and the evidence suggests that a more ‘comprehensive’ primary health care
approach will result in improved, more equitable health outcomes.
In Australia, there have been health policy changes in recent years, health now being placed on a
continuum from health prevention to illness care. With regards too Aboriginal and Torres Strait Islander
people, health policy changes have resulted in access to social and emotional wellbeing services
(Australian Institutes of Health and Welfare, 20011b). These include the ‘Bringing them home’ and ‘Link
Up’ programs and counselling services that aim to support the social and emotional wellbeing of
individuals and communities with regards to the ‘Stolen Generations’. These support services aim to
facilitate engagement in the healing process, reconnection with family and community and restoration
of social and emotional ‘wellbeing’ (Crisp & Taylor, 2014).
The types of services delivered under a ‘comprehensive’ implementation of primary health care include:
health promotion, prevention and screening, early intervention, treatment and management that places
a necessary emphasis on keeping people healthy. This is reflected in the National Primary Health Care
Strategic Framework (2013) which aims to:
• improve health care for all Australians, particularly those who currently experience inequitable
health outcomes
• keep people healthy
• prevent illness
• reduce the need for unnecessary hospital presentations
• improve the management of complex and chronic conditions.
Based on the Alma Ata Declaration (WHO 1978), the Primary Health Care Research and Information
Service (PHCRIS) has additional elements suggesting that comprehensive primary health care:
‘is socially appropriate, universally accessible, scientifically sound first level care provided
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by health services and systems with a suitably trained workforce comprised of multi-
disciplinary teams supported by integrated referral systems in a way that: gives priority to
those most in need and addresses health inequalities; maximises community and individual
self-reliance, participation and control; and involves collaboration and partnership with other
sectors to promote public health. Comprehensive primary health care includes health
promotion, illness prevention, treatment and care of the sick, community development, and
advocacy and rehabilitation’ (PHCRIS, 2015).
Primary care and public /population health approaches need to be integrated so that strategies and
services to promote the health and wellbeing of populations can be further developed. This merger would
also increase the power base of those advocating for health policy and environmental change.
Aboriginal community controlled health services (ACCHSs)
An Aboriginal Community Controlled Health Service is a comprehensive primary health care service
initiated and operated by the local Aboriginal community to deliver holistic, comprehensive, and
culturally appropriate health care to the community which controls it, through a locally elected Board of
Management.
The ACCHS model is based on the Aboriginal concept of health.
‘Aboriginal health means not just the physical wellbeing of an individual but refers to the
social, emotional and cultural wellbeing of the whole community in which each individual is
able to achieve their full potential as a human being’ (National Aboriginal Health Strategy,
1989).
The National Aboriginal Community Controlled Health Organisation (NACCHO) 2013 describes the
ACCHS model of comprehensive primary health care as including:
• Clinical services for the prevention and management of acute and chronic disease.
• Illness prevention services including immunisation, antenatal screening and
environmental3health programs.
• Specific programs for health gain such as antenatal care, nutrition, physical activity, social and
emotional wellbeing, oral health and substance misuse.
• Access to secondary and tertiary health services and community services including aged and
disability care.
• Community assistance and advocacy services (NACCHO, 2013 p, 3).
This comprehensive primary health care service is offered through a multidisciplinary team
incorporating Aboriginal Health Workers who are central to the ACCHS model of care. ACCHSs are
significant employers and trainers of Aboriginal people. In addition, ACCHSs provide training to non-
Aboriginal health professionals.
The primary role of Aboriginal Health Workers is delivering health care. Aboriginal Health Workers
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Document Summary
Approaches to health disease: the downstream approach individual level intervention deals with the presenting medical problem or disease. Links to the biomedical model: the midstream approach population interventions that target defined populations in order to change and /or prevent behavioural risk factors. The social and environmental originals of disease (the social determinants of health) are now under the spotlight as are the lifestyle choices that people face. Population health is the study of health and disease in defined populations. This can be a patient population, geographic populations e. g. a community. Population health is interested in why some people are healthy and others are not and aims to improve the health of entire populations. A reduction in the incidence of preventable mortality and morbidity, including through national public health initiatives, promotion of healthy lifestyles, and approaches covering disease prevention, health screening and immunisation" (department of health, 2014, p. Public health occurs in the community and focuses on:
