# Principles of Public Health Practice/Strategies and contexts for public health interventions

In this topic we are looking at some innovative strategies for public health interventions and some of the key concerns and criticisms. Social media and the web are now important contexts for communicating messages. Social stigma around issues such as mental health and obesity is also an issue to be aware of in terms of the context in which we work.

## Learning activity instructions

Each week we hold a lectorial and a tutorial. A lectorial is a short lecture followed by a group activity, and the tutorials are for discussion and practising group activities.
Lectorial
* Review the learning outcomes for this week and evaluate how you have been doing with engaging these outcomes during the semester.
* View the playlist here.
* Read the introductory materials here.
* Attend the lectorial.
Tutorial
* Progress your assignment with your tutorial groups both outside of and in your tutorial sessions. You will soon be presenting your recorded presentation and discussing in your tutorials.
* Attend the tutorial to work with your group.

## What are the various strategies used for public health interventions and how are they influenced by the context of their implementation?

There is an old saying, "A three-fold cord is not easily broken." Where one string might tear apart under the strain, three wound together are less likely to separate. Each strand mutually supports the other and distributes the weight more evenly across the material. Of course, heat or cold might influence the strength of the cords as well; so might dryness or damp. Salt tends to corrode. The nature and relationship of the material and the context in which it is used influence the effectiveness of the cord. Also, using cord when a chain is called for is not wise. Then again, there are many times when a chain will cause more damage than good.
So, how might this help us to think about the principles involved in considering strategies?
First of all, multiple strategies are typically better than single strategies. This is particularly true of strategies that work to enhance each other. For instance, if you need to lose weight, it is probably better to cut down on some foods, increase others and lift your physical activity. If you do this with the support of friends and family, you are more likely to both stay motivated. You are also likely to fewer inhibiting factors in your environment.
What do I mean? Well, imagine that you are sitting in your lounge room watching a film after having walked briskly for forty minutes. Your flat mate makes a large bowl of buttered popcorn to eat while watching the film with you. It would be hard not to join in the feast. If that person were to cut up healthy finger food to nibble on, that would be both refreshing and helpful in terms of weight loss.
A second principle is to ensure that the strategies are as close to normal operating conditions as possible. It helps if they are also built into the normal routine. For instance, it might be easier to walk further down the tram line in the morning and to get off earlier in the evening, than to promise yourself that you will take a brisk walk after you have had something to eat at the end of the day. It is possible to break up physical activity into smaller units. If you cannot walk for thirty or forty minutes at a time, you might be able to walk five minutes in one direction and, then, return. If you do this three or four times a day, you will increase both your physical activity and your relaxation from the tensions of sitting at a desk or working at a counter.
A third principle is to consider the short-term, medium-term and long-term benefits of any process. There should be early pay-offs that get people excited about doing something different. There should be a modest increase in difficulty and a greater reward to keep people interested in the mid-term. Finally, there should be a long-term goal that is of great significance. For instance, in a recent campaign to reduce smoking rates among Aboriginal and Torres Strait Islander people, the ability to SEE your grandchildren growing up was deemed to be a culturally appropriate long-term goal. Smoking can not only kill you; it can keep you from seeing well due to its influence on small blood vessels, especially in the retina.
Finally, there should be some transition to a sustainable process for maintaining a new practice. This requires an understanding that people often stop doing a good thing many times before they continue to do that activity through time. You have probably seen the advertisements where the young person talks about all of the times they started smoking again. Then, after repeated attempts, they finally say that they are no longer smoking. In other words, people will relapse several times before the behaviour change sticks. So, there are personal, social, cultural and environmental strategies that can change depending on the context.

## Background

Issues relating to public health have been around as long as humans have thought about cause and effect relationships. People have known about the importance of food, water, shelter, peace, education and so forth throughout the course of recorded human history. What is changing is the awareness of how the statistical imagination helps us to look at change across large numbers of people. As a result, epidemiology helps to inform our interventions. However, there is a need to translate this evidence for a number of audiences in order for it to have its most powerful effect (Krishnan, Yadav, Kaur and Kumar 2010). What has also changed is a greater awareness of and commitment to systematic approaches which are well evidenced scientifically and well considered in terms of human values (HCU-CHPUT 2001).
Sanitation and infectious disease control was a key hallmark of the nineteenth century. Dealing with the devastation of high explosives, genocide and mass dislocation of peoples was a concern early in the twentieth century. There was a marked rise in handling refugees and in dealing with rehabilitation related concerns. Additionally, communicable and chronic diseases were of concern. Vaccinations helped to reduce the scourge of the first. However, life-style approaches were the focus of the later. In the twenty-first century, we are aware of and concerned about ecological and habitat issues (Lin, Smith & Fawkes 2007).
We have a much clearing understanding of the social gradient and its relationship to health. We are also cognizant of issues relating to gender, ethnicity, age, developmental stage, class, colonization and so forth. We recognize that it is important to have well planned and evidenced interventions that cover multiple domains and engage a wide variety of stakeholders equitably. So, one of the key contexts in our rapidly expanding knowledge of cause and effect (Wilkinson & Pickett 2010).
Yet, there are whole domains where we still need to learn about and understand more. One context is that of the semantic web and the influence of social media (Feigenbaum, Herman, Hongsermeier, Neumann, & Stephens 2007). As we move from "mass communication" to increased "market segmentation" we are entering a situation where whole groups of people may be influenced by thoughts, attitudes and behaviours that are quite alien to previous generations and our current cultural neighbours. Stigma around various issues is an area that we are much more sensitive about. Yet, we have a long ways to go in terms of diffusing its negative effects (Puhland & Heuer 2010). There will always be an art to public health.
References and resources
Feigenbaum, L., Herman, I., Hongsermeier, T., Neumann, E. and Stephens, S.(2007) The Semantic Web in Action. Scientific American 297(6):90-97.
Krishnan A1, Yadav K, Kaur M, and Kumar R. (2010) Epidemiology to public health intervention for preventing cardiovascular diseases: the role of translational research.Indian Journal of Medidcal Research 132:643-50.
Lin, V., Smith, J. and Fawkes, S. (2007) Public Health Practice in Australia: The organised effort. Crows Nest, NSW: Allen and Unwin.
HCU-CHPUT (2001) Introduction to Health Promotion Program Planning. Toronto, ONT: Health Communication Unit, Centre for Health Promotion, University of Toronto.
Puhland, R.M. and Heuer, C.A. (2010) "Obesity Stigma: Important considerations for public health." American Journal of Public Health 100(6):1019-1028.
WHO (2011) "Mixed uptake of social media among public health specialists." Bulletin of the World Health Organization 89(11):784-785.
Wilkinson, R. and Pickett, K. (2010) The Spirit Level: Why equality is better for everyone. Camberwell, VIC: Penguin.

## Learning Outcomes

What are the various strategies used for public health interventions and how are they influenced by the context of their implementation?
Upon completion of this topic, through your own investigations, group preparation, tutorial participation and lectorial explorations, you should be able to:
   * Recount the development of public health strategies from the mid-Nineteenth Century to the present and appraise their suitableness for various circumstances.
   * Distinguish the influence that the social, cultural and environmental context plays on the various strategies.
   * Outline the sorts of evidence that should be used in determining which strategies might be successful for the various contexts.
   * Explain the importance of using multiple strategies and engaging multiple partners and sectors to implement strategies.