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Foundations for Health Promotion
FOURTH EDITION
Jennie Naidoo
Principal Lecturer, Health Promotion and Public Health, University of the
West of England, Bristol, UK
Jane Wills
Professor of Health Promotion, London South Bank University, London, UK
Table of Contents
Cover image
Title page
Copyright
Preface
Acknowledgements
Part One. The theory of health promotion
Introduction
Chapter One. Concepts of health

Importance of the Topic
Defining health, well-being, disease, illness and ill health
Well-being
The Western scientific medical model of health
A critique of the medical model
Lay concepts of health

Cultural views of health
A unified view of health
Conclusion
Summary
Chapter Two. Influences on health

Determinants of health
Social class and health
Income and health
Housing and health
Employment and health
Gender and health
Health of ethnic minorities
Place and health
Explaining health inequalities
Tackling inequalities in health
Conclusion
Summary
Chapter Three. Measuring health

Why measure health?

Ways of measuring health
Measuring health as a negative variable (e.g. health is not being diseased

or ill)
Mortality statistics
Morbidity statistics
Measuring health and disease in populations
Measures of health as an objective attribute
Measuring deprivation
Subjective health measures
Physical well-being, functional ability and health status
Psychological well-being
Social capital and social cohesion
Quality of life
Conclusion
Summary
Chapter Four. Defining health promotion

Foundations of health promotion
Origins of health promotion in the UK
Public health
The World Health Organization and health promotion
Defining health promotion

Critiques of health promotion
The argument for health promotion
Advocacy
Enablement
Mediation
Conclusion
Summary
Chapter Five. Models and approaches to health promotion

The medical approach
Behaviour change
The educational approach
Empowerment
Social change
Models of health promotion
Theories in health promotion
Conclusion
Summary
Chapter Six. Ethical issues in health promotion

The need for a philosophy of health promotion

Duty and codes of practice
Consequentialism and utilitarianism: The individual and the common good
Ethical principles
Conclusion
Summary
Chapter Seven. The politics of health promotion

What is politics?
Political ideologies
Globalization
Health as political
The politics of health promotion structures and organization
The politics of health promotion methods
Being political
Conclusion
Summary
Part Two. Strategies and methods
Introduction
Chapter Eight. Reorienting health services

Introduction
Promoting health in and through the health sector
Primary healthcare and health promotion
Primary healthcare principles
Primary healthcare: strategies
Primary healthcare: service provision
Participation
Equity
Collaboration
Who promotes health?
Public health and health promotion workforce
Specialist community public health nurses
Mental health nurses
School nurses
Midwives
General practitioners
Practice nurses
Dentists
Pharmacists
Environmental health workers
Allied health workers
Care workers
Specialists
Conclusion
Summary
Chapter Nine. Developing personal skills

Definitions
The health belief model
Theory of reasoned action and theory of planned behaviour
The stages of change model
The prerequisites of change
Conclusion
Summary
Chapter Ten. Strengthening community action

Defining community
Why work with communities?
Approaches to strengthening community action
Defining community development
Community development and health promotion
Working with a community-centred approach
Types of activities involved in strengthening community action

Dilemmas and challenges in community-centred practice
Conclusion
Summary
Chapter Eleven. Developing healthy public policy

Defining HPP
Health in all policies (HiAP)
Health impact assessment (HIA)
The history of HPP
Key characteristics of HPP: advantages and barriers
The practitioner’s role in HPP
Evaluating an HPP approach
Conclusion
Summary
Chapter Twelve. Using media in health promotion

Introduction
The nature of media effects
The role of mass media
Planned campaigns
Unpaid media coverage

Media advocacy
Social marketing
What the mass media can and cannot do
Communication tools
Conclusion
Summary
Part Three. Settings for health promotion
Introduction
Chapter Thirteen. Health promoting schools

Why the school is a key setting for health promotion
Health promotion in schools
The health promoting school
Policies and practices
Links with the community
Effective interventions
Conclusion
Summary
Chapter Fourteen. Health promoting workplaces

Why is the workplace a key setting for health promotion?
The relationship between work and health
Responsibility for workplace health
Health promotion in the workplace
Conclusion
Summary
Chapter Fifteen. Health promoting neighbourhoods

Defining neighbourhoods
Why neighbourhoods are a key setting for health promotion
Conclusion
Summary
Chapter Sixteen. Health promoting health services

Defining a health promoting hospital
Why hospitals are a key setting for health promotion
Promoting the health of patients
Promoting the health of staff
The hospital and the community
Organizational health promotion
The HPH movement

Health promoting pharmacies
Conclusion
Summary
Chapter Seventeen. Health promoting prisons

Why prisons have been identified as a setting for health promotion
Barriers to prisons as health promoting settings
Health promoting prisons
Examples of effective interventions
Conclusion
Summary
Part Four. Implementing health promotion
Introduction
Chapter Eighteen. Assessing health needs

Defining health needs
The purpose of assessing health needs
Health needs assessment
Setting priorities
Conclusion
Summary
Chapter Nineteen. Planning health promotion interventions

Reasons for planning
Health promotion planning cycle
Strategic planning
Project planning
Planning models
Stage 1: What is the nature of the problem?
Stage 2: What needs to be done? Set aims and objectives
Stage 3: Identify appropriate methods for achieving the objectives
Stage 4: Identify resources and inputs
Stage 5: Plan evaluation methods
Stage 6: Set an action plan
Stage 7: Action, or implementation of the plan
Planning models
PRECEDE-PROCEED model
Quality and audit
Conclusion
Summary
Chapter Twenty. Evaluating health promotion interventions

Defining evaluation
Why evaluate?
What to evaluate
Process, impact and outcome evaluation
Evaluation research methodologies
How to evaluate: The process of evaluation
How to evaluate: Gathering and analysing data
Building an evidence base for health promotion
What to do with the evaluation: Putting the findings into practice
Conclusion
Summary
Glossary
Index
Copyright
© 2016, Elsevier Ltd. All rights reserved.
No part of this publication may be reproduced or transmitted in any

form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details on
how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as
the Copyright Clearance Center and the Copyright Licensing Agency,
can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are

protected under copyright by the Publisher (other than as may be
noted herein).
First edition 1994
Second edition 2000
Third edition 2009
ISBN 978-0-7020-5442-6
British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of
Congress
Notices
Knowledge and best practice in this field are constantly changing.
As new research and experience broaden our understanding,
changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own

experience and knowledge in evaluating and using any information,
methods, compounds, or experiments described herein. In using
such information or methods they should be mindful of their own
safety and the safety of others, including parties for whom they have
a professional responsibility.
With respect to any drug or pharmaceutical products identified,
readers are advised to check the most current information provided
(i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or
formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on
their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the
authors, contributors, or editors, assume any liability for any injury
and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the
material herein.
Printed in China
Preface
Health promotion is a core aspect of the work of a wide range of

healthcare workers and those engaged in education and social
welfare. It is an emerging area of practice and study, still defining its
boundaries and building its own theoretical base and principles. This
book aims to provide a theoretical framework for health promotion, as
this is vital to clarify practitioners’ intentions and desired outcomes. It
offers a foundation for practice which encourages practitioners to see
the potential for health promotion in their work, to be aware of the
implications of choosing from a range of strategies and to be able to
evaluate their health promotion interventions in an appropriate and
useful manner.
This fourth edition of Health Promotion: Foundations for Practice has
been comprehensively updated and expanded to reflect recent
research findings and major organizational and policy changes over
the last decade. Our companion volume, Public Health and Health
Promotion: Developing Practice (Naidoo and Wills, 2010), discusses in
more detail some of the challenges and dilemmas raised in this book,
e.g. partnership working, tackling inequalities and engaging the
public.
The book is divided into four main parts. The first part provides a
theoretical background, exploring the concepts of health, health
education and health promotion. Part One concludes that health
promotion is working towards positive health and well-being of
individuals, groups and communities. Health promotion includes
health education but also acknowledges the social, economic and
environmental factors which determine health status. Ethical and
political values inform practice, and it is important for practitioners to
reflect upon these values and their implications. Part One embraces
the shift towards well-being rather than a narrow interpretation of
health, and the move away from a simple focus on lifestyle changes as
the goal of health promotion. Its aim is to enable readers to
understand and reflect upon these theoretical drivers of health
promotion practice within the context of their own work.
Part Two explores strategies to promote health, and some of the
dilemmas they pose. Using the Ottawa Charter (World Health
Organization, 1986) framework to identify the range of strategies, the
potential, benefits and challenges of adopting each strategy are
discussed. Examples of interventions using the different strategies are
presented. What is reflected here is how health services have not
moved towards prioritizing prevention, although there is much
greater acceptance and support for empowerment approaches in work
with individuals and communities. While policies that impact on
health still get developed in isolation from each other, there is a
recognition of the need for health in all policies, and for deliberative
democracy and working methods that engage with communities as
the ways forward.
Part Three focuses on the provision of supportive environments for
health, identified as a key strategy in the Ottawa Charter. Part Three
explores how a range of different settings in which health promotion
interventions take place can be oriented towards positive health and
well-being. The settings discussed in this part – schools, workplaces,
neighbourhoods, health services and prisons – have all been targeted
by national and international policies as key for health promotion.
Reaching specific target groups, such as young people, adults or older
people, within these settings is also covered in Part Three. There is
much debate about the need for systems thinking and seeing such
settings more broadly as environments where physical, social and
economic drivers come together, and not just as places in which to
carry out health education and lifestyle behaviour interventions.
Part Four focuses on the implementation of health promotion
interventions. Each chapter in this part discusses a different stage in
the implementation process, from needs assessment through planning
to the final stage of evaluation. This part is designed to help
practitioners to reflect on their practice through examining what
drives their choice of practical implementation strategies. A range of
real-life examples helps to illustrate the options available and the
criteria that inform the practitioner’s choice of approach.
This book is suitable for a wide range of professional groups, and
this is reflected in the choice of examples and illustrative case studies,
which have been completely updated for this edition. In response to
reader feedback about the ways to engage with a textbook, we have
changed the format for this edition. Each chapter has between 6 and
15 learning activities which encourage readers to engage with the text
and extend their learning. Indicative feedback about the points that a
reader or student might wish to consider is provided at the end of the
chapter. Each chapter also includes at least one case study and
research example to provide the reader with examples of application
and encourage a focus on topics. Further questions at the end of each
chapter encourage readers to reflect on their practice, values and
experience, and to debate the issues. To reflect the huge changes in
information management since this book was first published in 1994,
website addresses are given for resources and further reading where
possible.
The book is targeted at a range of students, including those in basic
and post-basic training and qualified professionals. By combining an
academic critique with a readable and accessible style, this book will
inform, stimulate and encourage readers to engage in ongoing
enquiry and reflection regarding their health promotion practice. The
intention, as always, is to encourage readers to develop their practice
through considering its foundation in theory, policy and clear
principles.
Jennie Naidoo
Jane Wills, Bristol and London
References
Naidoo J, Wills J. Public Health and Health Promotion: Developing Practice. third
ed. London: Baillière Tindall; 2010.
World Health Organization. Ottawa Charter for Health
Promotion. Geneva: WHO; 1986.
Acknowledgements
It is 21 years since the publication of the first edition of this book,

which was initially prompted by our teaching on the first
postgraduate specialist courses in health promotion. Students and
colleagues at the University of the West of England and London South
Bank University have, as always, contributed to this edition through
their ideas, debates and practice examples. We continue to be
committed to the development of health promotion as a discipline.
We dedicate this fourth edition to our children, Declan, Jessica, Kate
and Alice.
PA R T O N E
The theory of health promotion
OUTLINE
Introduction
Chapter One. Concepts of health
Chapter Two. Influences on health
Chapter Three. Measuring health
Chapter Four. Defining health promotion
Chapter Five. Models and approaches to health promotion
Chapter Six. Ethical issues in health promotion
Chapter Seven. The politics of health promotion
Introduction
Part One explores the concepts of health, health education and health
promotion. Health promotion draws upon many different disciplines,
ranging from the scientific (e.g. epidemiology) and the social sciences
(e.g. sociology and psychology) to the humanities (e.g. ethics). This
provides a wealth of theoretical underpinnings for health promotion,
ranging from the scientific to the moralistic. This in turn means that
health promotion in practice may range from a scientific medical
exercise (e.g. vaccination) or an educational exercise (e.g. sex and
relationships education in schools) to a moral query (e.g. end-of-life
options). An important first step for health promoters is to clarify for
themselves where they stand in relation to these various different
strategies and goals. Are they educators, politicians or scientists? In
part this will be determined by their background and initial
education, but health promotion is an umbrella which encompasses
all these activities and more. Working together, practitioners can bring
their varied bodies of knowledge and skills to focus on promoting the
health of the population, and achieve more significant and sustainable
results than if they were operating on their own.
This first part of the book explores different understandings of the
concept of health and well-being, and the ways in which health can be
enhanced or promoted. The effect on health of structural factors such
as income, gender, sexuality and ethnicity and the way in which social
factors are important predictors of health status are explored in
Chapter 2. The different ways in which health is measured reflect
different views on health, from the absence of disease to holistic
concepts of well-being, and these are discussed in Chapter 3. Chapters
4 and 5 debate what health promotion is, adopting an ecological
model in which change in health is said to be influenced by the
interaction of individual, social and physical environmental variables.
Chapters 6 and 7 will help those who promote health to be clear about
their intentions and how they perceive the purpose of health
promotion. Is it to encourage healthy lifestyles? Or is it to redress
health inequalities and empower people to take control over their
lives?
CHAPTER ONE
Concepts of health
LEARNING OUTCOMES
By the end of this chapter you will be able to:

• define the concepts of health, well-being, disease, illness and ill
health, and understand the differences between them
• discuss the nature of health and well-being, and how culture and
populism influence our definitions
• understand the elements of the medical model of health and how it
influences healthcare practice.
KEY CONCEPTS AND DEFINITIONS

Biomedicine Focuses on the causes of ill health and disease within
the physical body. It is associated with the practice of medicine,
and contrasts with a social model of health.
Disease Is the medical term for a disorder, illness or condition that
prevents an individual from achieving the full functioning of all
his or her bodily parts.
Health Is the state of complete mental and physical well-being of an
individual, not merely the absence of disease or illness.
Ill health Is a state of poor health when there is some disease or
impairment, but not usually serious enough to curtail all
activities.
Illness Is a disease or period of sickness that affects an individual’s
body or mind and prevents the individual achieving his or her
optimal outputs.
Well-being Is the positive feeling that accompanies a lack of ill
health and illness, and is associated with the achievement of
personal goals and a sense of being well and feeling good.
Everyone engaged in the task of promoting health starts with a view
of what health is. However, these views, or concepts, of health vary
widely. It is important at the outset to be clear about the concepts of
health to which you personally adhere, and recognize where these
differ from those of your colleagues and clients. Otherwise, you may
find yourself drawn into conflicts about appropriate strategies and
advice that are actually due to different ideas concerning the end goal
of health. This chapter introduces different concepts of health and
traces the origin of these views. The Western scientific medical model
of health is dominant, but is challenged by social and holistic models.
Working your way through this chapter will enable you to clarify
your own views on the definition of health and locate these views
within a conceptual framework.
Defining health, well-being, disease, illness and
ill health
Health
Health is a broad concept which can embody a huge range of
meanings, from the narrowly technical to the all-embracing moral or
philosophical. The word ‘health’ is derived from the Old English word
for heal (hael) which means ‘whole’, signalling that health concerns the
whole person and his or her integrity, soundness or well-being. There
are ‘common-sense’ views of health which are passed through
generations as part of a common cultural heritage. These are termed
‘lay’ concepts of health, and everyone acquires a knowledge of them
through socialization into society. Different societies and different
groups within one society have different views on what constitutes
their ‘common-sense’ notions about health.
Lear ning Activity 1.1 What does health mean

to you?
What are your answers to the following?
• I feel healthy when…
• I am healthy because…
• To stay healthy I need…
• I become unhealthy when…
• My health improves when…
• (An event) affected my health by…
• (A situation) affected my health by…
• …is responsible for my health.
Health has two common meanings in everyday use, one negative

and one positive. The negative definition is the absence of disease or
illness. This is the meaning of health within the Western scientific
medical model, which is explored in greater detail later in this
chapter. The positive definition of health is a state of well-being,
interpreted by the World Health Organization in its constitution as ‘a
state of complete physical, mental and social well-being, not merely
the absence of disease or infirmity’ (World Health Organization,
1946).
Health is holistic and includes different dimensions, each of which
needs to be considered. Holistic health means taking account of the
separate influences and interaction of these dimensions.
Figure 1.1 shows a diagrammatic representation of the dimensions
of health.
The inner circle represents individual dimensions of health.
• Physical health concerns the body, e.g. fitness, not being ill.
• Mental health refers to a positive sense of purpose and an
underlying belief in one’s own worth, e.g. feeling good, feeling able
to cope.
• Emotional health concerns the ability to feel, recognize and give a
voice to feelings, and to develop and sustain relationships, e.g.
feeling loved.
• Social health concerns the sense of having support available from
family and friends, e.g. having friends to talk to, being involved in
activities with other people.
• Spiritual health is the recognition and ability to put into practice
moral or religious principles or beliefs, and the feeling of having a
‘higher’ purpose in life.
• Sexual health is the acceptance and ability to achieve a satisfactory
expression of one’s sexuality.
FIG. 1.1 Dimensions of health.
The three outer circles are broader dimensions of health which

affect the individual. Societal health refers to the link between health
and the way a society is structured. This includes the basic
infrastructure necessary for health (such as shelter, peace, food,
income), and the degree of integration or division within society. We
shall see in Chapter 2 how the existence of patterned inequalities
between groups of people harms the health of everyone.
Environmental health refers to the physical environment in which
people live, and the importance of good-quality housing, transport,
sanitation and pure-water facilities. Global health involves caring for
the planet and ensuring its sustainability for the future.
Lear ning Activity 1.2 Holistic model of health
What are the implications of a holistic model of health for the
professional practice of health workers?
Well-being
‘Well-being’ is a term widely used to describe ‘what makes a good
life’. It is also used in healthcare discourse to broaden views on what
health means beyond the absence of illness. Feeling good and
functioning well are seen as important components of mental well-
being. This, in turn, leads to better physical health, improved
productivity, less crime and more participation in community life
(DH, 2010). The New Economics Foundation has developed the
Happy Planet Index (New Economics Foundation, 2012) as a headline
indicator of how nations compare in enabling long and happy lives for
their citizens. In 2012:
• eight of the nine countries that are achieving high and sustainable
well-being are in Latin America and the Caribbean
• the highest-ranking Western European nation is Norway in 29th
place, just behind New Zealand in 28th place.
• the USA is in 105th position out of 151 countries.
Similarly, the UNICEF index of child well-being (UNICEF, 2013)
shows that well-being is greater in more egalitarian countries, such as
Norway and other Scandinavian countries.
Evidence (Government Office for Science, 2008) suggests that there
are five methods or steps that individuals can take to enable
themselves to achieve well-being:
• connect
• be active
• take notice
• give
• keep learning.
More recently, ‘Care (about the planet)’ has been added to this list.
Lear ning Activity 1.3 Five steps to well-being

What evidence is there for each of the steps to well-being?
Disease, illness and ill health
Disease, illness and ill health are often used interchangeably, although
they have very different meanings. Disease derives from desaise,
meaning uneasiness or discomfort. Nowadays, disease implies an
objective state of ill health, which may be verified by accepted canons
of proof. In our modern society these accepted canons are couched in
the language of scientific medicine. For example, microscopic analysis
may yield evidence of changes in cell structure, which may in turn
lead to a diagnosis of cancer. Disease is the existence of some
pathology or abnormality of the body which is capable of detection.
Disease can be due to exogenous (outside the body, e.g. viral
infection) or endogenous (inside the body, e.g. inadequate thyroid
function) factors.
Illness is the subjective experience of loss of health. This is couched
in terms of symptoms, for example the reporting of aches or pains, or
loss of function. One way that illness is given meaning is through the
narratives we construct about how we fall sick. The process of making
sense of illness is a task most sick people engage in to answer the
question ‘why me?’ Illness and disease are not the same, although
there is a large degree of coexistence. For example, a person may be
diagnosed as having cancer through screening, even when there have
been no reported symptoms; thus a disease may be diagnosed in
someone who has not reported any illness. When someone reports
symptoms, and further investigations such as blood tests prove a
disease process, the two concepts of disease and illness coincide. In
these instances, the term ill health is used. Ill health is therefore an
umbrella term used to refer to the experience of disease plus illness.
Health is the normal functioning of the body as a biological entity.
Health is both not being ill and the absence of symptoms.
Social scientists view health and disease as socially constructed
entities. Health and disease are not states of objective reality waiting
to be uncovered and investigated by scientific medicine; rather, they
are actively produced and negotiated by ordinary people. Cornwell’s
(1984) study of London’s Eastenders used three categories of health
problems.
1. Normal illness, e.g. childhood infections.
2. Real illness, e.g. cancer.
3. Health problems, e.g. ageing, allergies.
Illness has often been conceptualized as deviance – as a different
state from the healthy norm and a source of stigma. Goffman (1968)
identified three sources of stigma.
1. Abominations of the body, e.g. psoriasis.
2. Blemishes of character, e.g. human immunodeficiency virus
(HIV)/acquired immunodeficiency syndrome (AIDS).
3. Tribal stigma of race, nation or religion, e.g. apartheid.
The subjective experience of feeling ill is not always corroborated by
an objective diagnosis of disease. When this lack of corroboration
happens, doctors and health workers may label sufferers
‘malingerers’, denying the validity of subjective illness. This can have
important consequences. For example, a sick certificate, and therefore
sick pay, may be withheld if a doctor is not convinced that someone’s
reported illness is genuine. The acceptance of reported symptoms as
signs of an illness leads to a debate about how to manage the illness.
Several conditions, such as chronic fatigue syndrome and repetitive
strain injury, have taken a long time to be recognized as legitimate
illnesses.
Lear ning Activity 1.4 The medicalization of

health
What examples are there of a condition or behaviour where its
medicalization has led to its acceptance or otherwise?
It is also possible for an individual to experience no symptoms or

signs of disease, but to be labelled sick as a result of medical
examination or screening. Hypertension and pre-cancerous changes to
cell structures are two examples where screening may identify a
disease even though the person concerned may feel perfectly healthy.
Figure 1.2 gives a visual representation of these discrepancies. The
central point is that subjective perceptions cannot be overruled, or
invalidated, by scientific medicine.
The Western scientific medical model of health
In modern Western societies, and in many other societies as well, the
dominant professional view of health adopted by most healthcare
workers during their training and practice is labelled Western
scientific medicine. Western scientific medicine operates within a
medical model using a narrow view of health, which is often taken to
mean the absence of disease and/or illness. In this sense, health is a
negative term, defined more by what it is not than by what it is.
FIG. 1.2 The relationship between disease and illness.
This view of health is extremely influential, as it underpins much of

the training and ethos of a wide variety of health workers. Its
definitions become powerful because they are used in a variety of
contexts, not just in professional circles. For example, the media often
present this view of health, disease and illness in dramas set in
hospitals or documentaries about health issues. By these means,
professional definitions become known and accepted in society at
large.
The scientific medical model arose in Western Europe at the time of
the Enlightenment, with the rise of rationality and science as forms of
knowledge. In earlier times, religion provided a way of knowing and
understanding the world. The Enlightenment changed the old order,
and substituted science for religion as the dominant means of
knowledge and understanding. This was accompanied by a
proliferation of equipment and techniques for studying the world. The
invention of the microscope and telescope revealed whole worlds
which had previously been invisible. Observation, calculation and
classification became the means of increasing knowledge. Such
knowledge was put to practical purposes, and applied science was
one of the forces which accompanied the Industrial Revolution. In an
atmosphere when everything was deemed knowable through the
proper application of scientific method, the human body became a key
object for the pursuit of scientific knowledge. What could be seen, and
measured and catalogued was ‘true’ in an objective and universal
sense.
This view of health is characterized as:
• biomedical – health is assumed to be a property of biological beings
• reductionist – states of being such as health and disease may be
reduced to smaller and smaller constitutive components of the
biological body
• mechanistic – this conceptualizes the body as if it were a machine, in
which all the parts are interconnected but capable of being
separated and treated separately
• allopathic – this works by a system of opposites; if something is
wrong with a body, treatment consists of applying an opposite force
to correct the sickness, e.g. pharmacological drugs which combat
the sickness
• pathogenic – this focuses on why people become ill
• dualistic – the mind and the body can be treated as separate entities.
Health is predominantly viewed as the absence of disease. This
view sees health and disease as linked, as if on a continuum, so that
the more disease a person has, the further away he or she is from
health and ‘normality’.
The pathogenic focus on finding the causes for ill health has led to
an emphasis on risk factors, whether these are health behaviours or
social circumstances. Antonovsky (1993) called for a salutogenic
approach which looks instead at why some people remain healthy. He
identifies coping mechanisms which enable some people to remain
healthy despite adverse circumstances, change and stress. An
important factor for health, which Antonovsky labels a ‘sense of
coherence’, involves the three aspects of understanding, managing
and making sense of change. These are human abilities which are in
turn nurtured or obstructed by the wider environment.
The medical model focuses on etiology, and the belief that disease
originates from specific and identifiable causes. The causes of
contemporary long-term chronic diseases in developed countries are
often ‘social’. Medicine and medical practice thus recognize that
disease and the diseased body must be placed in a social context.
Nevertheless, the professional training of many healthcare workers
provides an exaggerated view of the benefits of treatment and pays
little attention to prevention. In part this is due to the dominant
concern of the biomedical model with the organic appearance of
disease and malfunction as the causes of ill health.
Resear ch Exam ple 1.1 Carers’ health

An ageing population means that caring for the elderly will become
a more common experience for younger adults or even children.
This has significant implications for the health of the population as
a whole. Research studies have reported a clear association between
caring and care givers’ poor mental and physical health, emotional
distress and increased mortality. A more intense caring role (e.g.
having to provide 24-hour cover, or caring for someone with both
mental and physical ill health) is associated with poorer health
outcomes on the part of the carer. Yet evidence also shows that not
all carers report poor health. Indeed, caring has the opposite effect
on some carers, conferring positive benefits through feelings of
altruism, fulfilment of familial obligations and personal growth. It is
likely that the impact of caring on the health of carers will be to
some extent dependent on the existence, or lack, of a supportive
environment, including, for example, community activities and
respite opportunities. It also seems likely that the existence of
personal religious and faith beliefs is associated with improved
health and caring, as religion provides an overarching rationale for
existence, even if this is compromised by poor health. Religious
centres often provide supportive and caring activities for members
of their faith, enabling carers to cope better with their burden of
care, and providing some respite care for people with disabilities.
See for example Awad et al., 2008; Rigby et al., 2009; Vellone
et al., 2008.
Table 1.1 contrasts the traditional views of a medical model with

those of a social model of health.
A critique of the medical model
The role of medicine in determining health
The view that health is the absence of disease and illness, and that
medical treatment can restore the body to good health, has been
criticized. The distribution of health and ill health has been analysed
from a historical and social science perspective. It has been argued
that medicine is not as effective as is often claimed. The medical writer
Thomas McKeown (McKeown, 1976) showed that most of the fatal
diseases of the nineteenth century had disappeared before the arrival
of antibiotics or immunization programmes. McKeown concluded
that social advances in general living conditions, such as improved
sanitation and better nutrition made available by rising real wages,
have been responsible for most of the reduction in mortality achieved
during the last century. Although his thesis has been disputed, there is
little disagreement that the contribution of medicine to reduced
mortality has been minor when compared with the major impact of
improved environmental conditions.
Table 1.1
The medical and social model of health
Lear ning Activity 1.5 The impact of medicine

• What effects do medical advances in knowledge have on death
rates?
• What other reasons could account for declining death rates?
The rise of the evidence-based practice movement (see Chapter 20)

is attributed to Archie Cochrane (1972). His concern was that medical
interventions were not trialled to demonstrate effectiveness prior to
their widespread adoption. Instead, many procedures rest on habit,
custom and tradition rather than rationality. Cochrane advocated
greater use of the randomized controlled trial as a means to gain
scientific knowledge and the key to progress.
The role of social factors in determining health

Most countries are characterized by profound inequalities in income
and wealth, and these in turn are associated with persistent
inequalities in health (see
www.who.int/social_determinants/sdh_definition/en/). The impact of
scientific medicine on health is marginal when compared to major
structural features such as the distribution of wealth, income, housing
and employment. Tarlov (1996) claimed that medical services
contributed only 17 percent to the gain in life expectancy in the
twentieth century. As Chapter 2 shows, the distribution of health
mirrors the distribution of material resources within society. In
general, the more equal a society is in its distribution of resources, the
more equal, and better, is the health status of its citizens (Wilkinson
and Pickett, 2009).
Medicine as a means of social control

Social scientists argue that medicine is a social enterprise closely
linked with the exercise of professional power. Foucault (1977) argues
that power is embedded in social organizations, expressed through
hierarchies and determined through discourses. Medical power
derives from its role in legitimizing health and illness in society, and
the socially exclusive and autonomous nature of the profession. The
medical profession has long been regarded as an institution for
securing occupational and social authority. Access to such power is
controlled by professional associations that have their own vested
interests to protect (Freidson, 1986). The 1858 Medical Act established
the General Medical Council, which was authorized to regulate
doctors, oversee medical education and keep a register of qualified
practitioners. The Faculty of Public Health Medicine opened
membership to non-medically qualified specialists in 2003, becoming
the Faculty of Public Health.
Medicine is a powerful means of social control, whereby the
categories of disease, illness, madness and deviancy are used to
maintain a status quo in society. Doctors who make the diagnoses are
in a powerful position. The role of the patient during sickness as
conceptualized by Parsons (1951) is illustrated in Table 1.2.
Increasingly, too, doctors are involved in decisions relating to the
beginning and ending of life (terminations, assisted reproduction,
neonatal care, euthanasia). The encroachment of medical decisions
into these stages of life subverts human autonomy and, it is argued,
gives to medicine an authority beyond its legitimate area of operation
(Illich, 1975).
Table 1.2
The sick role
Medicine as surveillance
Public health medicine has been concerned with the regulation and
control of disease. Historically this included the containment of
bodies, such as those infected with the plague, tuberculosis or
venereal disease. Mass-screening programmes have given rise to what
has been called medical surveillance. The wish to identify the
‘abnormal’ few with ‘invisible’ disease justifies monitoring the entire
target population. Another critique of the pervasive power of
medicine suggests the mapping of disease and identification of risk
have subtly handed responsibility of health to individuals. This may
invite new forms of control in the name of health, e.g. random drug
testing or linking deservingness for surgery to lifestyle factors. The
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sino á la honra y á la fama que
ganaban, teniendo por cierto,
conforme á su fe que ellos tenían,
que lo que hacían era también
para ganar la gloria del otro
mundo, como la tenían en éste
por cierto; y esta es la segunda
manera de honra, la cual en su
manera está fundada y tiene
cimiento sobre la virtud, pues que
conforme á su ley, las cosas que
hacían eran lícitas y en provecho
suyo ó de sus repúblicas ó de
otras personas particulares. Pero
los que somos christianos todo lo
hemos de tener y creer al
contrario, porque la honra que
perdemos en este mundo estando
en medio la humildad y el amor
de Christo y temor de ofenderle,
es para acrescentar más en la
honra de nuestras ánimas,
aunque hay pocos que hagan
esto que digo.
Albanio.—¿Y quién son esos
pocos?
Antonio.—A la verdad el día de
hoy mejor dixera que ninguno. El
mundo cuanto á esto está perdido
y estragado sin sabor ni gusto de
la gloria del cielo; todo lo tiene en
la pompa y vanagloria deste
mundo. ¿Quereislo ver? Si hacen
á un hombre una injuria y le
ruegan é importunan que perdone
al que se la hizo, aunque se lo
pidan por Dios y le pongan por
tercero, luego pone por
inconveniente para no hacerlo:
¿cómo podré yo cumplir con mi
honra? No mirando á que siendo
christianos están obligados á
seguir la voluntad de Christo, el
cual quiere que cuando nos
dieren una bofetada pasemos el
otro carrillo estando aparejado
para rescibir otra, sin que por ello
nos airemos ni tengamos odio con
nuestro prójimo. Si alguno ha
levantado un falso testimonio en
perjuicio de la buena fama ó de la
hacienda y por ventura de la vida
de alguna persona, por lo que su
conciencia le manda que se
desdiga luego, pone por
contrapeso la honra y hace que
pese más que la conciencia y que
el alma, y así el premio que había
de llevar de la virtud por la buena
obra que hacía en perdonar ó en
restituir la fama, en lo cual
ganaba honra, quiere perderle
con parescerles que con ello la
pierde por hacer lo que debe,
quedando en los claros juicios
con mayor vituperio por haber
dexado de hacerlo que su
conciencia y la virtud le obligaba.
Absolvió Christo á la mujer
adúltera, y paresce que por este
enxemplo ninguno puede
justamente condenarla, pero los
maridos que hallan sus mujeres
en adulterio, y muchas veces por
sola sospecha, no les perdonan la
vida.
Jerónimo.—Pues ¿por qué por
las leyes humanas se permite que
la mujer que fuere hallada en
adulterio muera por ello?
Antonio.—Las leyes no mandan
sino que se entregue y ponga en
poder del marido, para que haga
della á su voluntad. El cual si
quisiere matarla, usando oficio de
verdugo, puede hacerlo sin pena
alguna cuanto al marido; pero
cuanto á Dios no lo puede hacer
con buena conciencia sin pecar
mortalmente, pues lo hace con
executar su saña tomando
venganza del daño que hicieron
en su honra; y si se permite este
poder en los maridos, es por
embarazar la flaqueza de las
mujeres para que no sea este
delito tan ordinario como sería de
otra manera. Y no pára en esto
esta negra deshonra, que por
muy menores ofensas se
procuran las venganzas por casi
todos, y es tan ordinario en todas
maneras de gentes, que ansí los
sabios como los necios, los ricos
como los pobres, los señores
como los súbditos, todos quieren
y procuran y con todas fuerzas
andan buscando esta honra como
la más dulce cosa á su gusto de
todas las del mundo, de tal
manera que si se toca alguno
dellos en cosa que le parezca que
queda ofendida su honra, apenas
hallaréis en él otra cosa de
christiano sino el nombre, y si no
puede satisfacerse ó vengarse, el
deseo de la venganza muy tarde
ó nunca se pierde. Los que no
saben qué cosa es honra, ni
tienen vaso en que quepa,
estiman y tienen en mucho esta
honra falsa y fingida. Si no, mirad
qué honra puede tener un
ganapán ó una mujer que
públicamente vende su cuerpo
por pocos dineros, que á estos
tales oiréis hablar en su honra y
estimarla en tanto, que cuando
pienso en ello no puedo dexar de
reirme como de vanidad tan
grande; y no tengo en nada esto
cuando me pongo á contemplar
que no perdona esta pestilencial
carcoma de las conciencias á
ningún género de gentes de
cualquier estado y condición que
sean, hasta venir á dar en las
personas que en el mundo
tenemos por dechado, de quien
todos hemos de tomar enxemplo,
porque los religiosos que, allende
aquella general profesión que
todos los christianos en el sancto
bautismo hecimos, que es
renunciar al demonio y á todas
sus pompas mundanas, tienen
otra particular obligación de
humildad por razón del estado
que tienen, con la cual se obligan
á resplandecer entre todos los
otros estados, pues están puestos
entre nosotros por luz nuestra,
son muchas veces tocados del
apetito y deseo desta honra, y
ansí la procuran con la mejor
diligencia que ellos pueden,
donde no pocas veces dan de sí
qué decir al mundo, á quien
habían de dar á entender que
todo esso tenían ya aborrecido y
echado á un rincón como cosa
dañosa para el fin que su sancto
estado pretende; de donde
algunas veces nacen entre ellos,
ó podrían nascer, rencillas,
discordias, discusiones y
desasosiegos que en alguna
manera podrían escurecer aquella
claridad y resplandor de la
doctrina y sanctidad que su
sancto estado publica y profesa,
lo cual ya veis que á la clara es
contra la humildad que debrían
tener, conforme á lo que
profesaron y á la orden y regla de
vivir que han tomado.
Jerónimo.—Conforme á esso no
guardan entre sí aquel precepto
divino que dice: el que mayor
fuese entre vosotros se haga
como menor; porque desta
manera todos huirían de ser
mayores, pues que dello no les
cabría otra cosa sino el trabajo.
Antonio.—Verdaderamente, los
que más perfectamente viven,
según la religión christiana, son
ellos, y por esto conoceréis cuán
grande es el poder de la vanidad
de la honra, pues no perdona á
los más perfectos.
Jerónimo.—No me espanto
deso, porque en esta vida es cosa
muy dificultosa hallar hombre que
no tenga faltas, y como los flaires
sean hombres, no es maravilla
que tengan algunas,
especialmente este apetito desta
honra que es tan natural al
hombre, que me parece que no
haya habido ninguno que no la
haya procurado. Porque aun los
discípulos de Jesu Christo
contendían entre sí cuál había de
ser el mayor entre ellos, cuanto
más los flaires que, sin hacerles
ninguna injuria, podemos decir
que no son tan sanctos como los
discípulos de Jesu Christo que
aquello trataban. Pero quiero,
señor Antonio, que me saquéis de
una duda que desta vuestra
sentencia me queda y es: ¿por
qué habéis puesto enxemplo más
en los flaires que en otro género
de gente?
Antonio.—Yo os lo diré. Porque
si á ellos, que son comúnmente
los más perfectos y más sanctos
y amigos del servicio de Dios, no
perdona esta pestilencial
enfermedad de la honra mundana
y no verdadera, de aquí podréis
considerar qué hará en todos los
otros, en los cuales podéis
comenzar por los príncipes y
señores y considerar la soberbia
con que quieren que sea
estimada y reverenciada su
grandeza, con títulos y cerimonias
exquisitas y nuevas que inventan
cada día para ser tenidos por otro
linaje de hombres, hechos de
diferente materia que sus
súbditos y servidores que tienen.
Los caballeros y personas ricas
quieren hacer lo mesmo, y así
discurriendo por todos los demás,
veréis á cada uno, en el estado
en que vive, tener una presunción
luciferina en el cuerpo, pues si las
justicias hubiesen de hacer
justicia de sí mesmos, no se
hallarían menos culpados que los
otros, porque debajo del mando
que tienen y el poder que se les
ha dado, la principal paga que
pretenden es que todo el mundo
los estime y tenga en tanto cuasi
como al mesmo príncipe ó señor
que los ha puesto y dado el
cargo, y si les paresce que alguno
los estima en poco, necesidad
tiene de guardarse ó no venir á
sus manos.
Albanio.—Justo es que los que
tienen semejantes cargos de
gobierno sean más acatados que
los otros.
Antonio.—No niego yo que no
sea justo que así se haga; pero
no por la vía que los más dellos
quieren, vanagloriándose dello y
queriéndolo por su propia
autoridad y por lo que toca á sus
personas, y no por la autoridad de
su oficio. Y dexando éstos, si
queremos tomar entre manos á
los perlados y dignidades de la
Iglesia de Christo, á lo menos por
la mayor parte, ninguna otra cosa
se hallará en ellos sino una
ambición de honra haciendo el
fundamento en la soberbia, de lo
cual es suficiente argumento ver
que ninguno se contenta con lo
que tiene, aunque baste para vivir
tan honradamente y aún más que
lo requiere la calidad de sus
personas, y assí, todos sus
pensamientos, sus mañas y
diligencias son para procurar
otros mayores estados.
Albanio.—¿Y qué queréis que se
siga de esso?
Antonio.—Que pues no se
contentan con lo que les basta, y
quieren tener más numerosos
servidores, hacer grandezas en
banquetes y fiestas y otras cosas
fuera de su hábito, que todo esto
es para ser más estimados que
los otros con quien de antes eran
iguales, y assí se engríen con una
pompa y vanagloria como si no
fuesen siervos de Christo sino de
Lucifer, y este es el fin y paradero
que los más dellos tienen. Puede
tanto y tiene tan grandes fuerzas
esta red del demonio, que á los
predicadores que están en los
púlpitos dando voces contra los
vicios no perdona este vicio de la
honra y vanagloria cuando ven
que son con atención oídos y de
mucha gente seguidos en sus
sermones y alabados de lo que
dicen, y así se están
vanagloriando entre sí mesmos
con el contento que reciben de
pensar que aciertan en el saber
predicar.
Jerónimo.—Juicio temerario es
este; ¿cómo podéis vos saber lo
que ellos de sí mesmos sienten?
Antonio.—Júzgolo porque no
creo que hay agora más perfectos
predicadores en vida que lo fué
San Bernardo, el cual estando un
día predicando le tomó la
tentación y vanagloria que digo, y
volviendo á conoscer que era
illusión del demonio estuvo para
bajarse del púlpito, pero al fin
tornó á proseguir el sermón
diciendo al demonio que lo
tentaba: Ni por ti comencé á
predicar ni por ti lo dejaré. En fin,
os quiero decir que veo pocos
hombres en el mundo tan justos
que si les tocáis en la honra, y no
digo de veras, sino tan
livianamente, que sin perjuicio
suyo podrían disimularlo, que no
se alteren y se pongan en cólera
para satisfacerse, y están todos
tan recatados para esto, que la
mayor atención que tienen los
mayores es á mirar el respeto que
se les tiene y el acatamiento que
les guardan, y los menores el
tratamiento que les hacen, y los
iguales, si alguno quiere
anteponerse á otro para no perder
punto en las palabras ni en las
obras. Y medio mal sería que esto
pasase entre los iguales, que ya
en nuestros tiempos, si una
persona que tenga valor y méritos
para poderlo hacer trata á otra
inferior llanamente y llamándole
vos, ó presume de responderle
como dicen por los mesmos
consonantes, ó si no lo hacen van
murmurando dél todo lo posible. Y
no solamente hay esto entre los
hombres comunes y que saben
poco, que entre los señores hay
también esta vanidad y trabajo,
que el uno se agravia porque no
le llaman señoría y el otro porque
no le llaman merced; otros,
porque en el escribir no le trataron
igualmente, y un señor de dos
cuentos de renta quiere que uno
de veinte no gane con él punto de
honra. Pues las mujeres ¿están
fuera desta vanidad y locura? Si
bien lo consideramos, pocas
hallaréis fuera della, con muy
mayores puntos, quexas y
agravios que tienen los hombres.
La cosa que, el día de hoy, más
se trata, la mercadería que más
se estima, es la honra, y no por
cierto la verdadera honra, que ha
de ser ganada con obras buenas
y virtuosas, sino la que se compra
con vicios y con haciendas y
dineros, aunque no sean bien
adquiridos. ¡Oh cuántos hay en el
mundo que estando pobres no
eran para ser estimados más que
el más vil del mundo, y después
que bien ó mal se ven ricos,
tienen su archiduque en el
cuerpo, no solamente para querer
ser bien tratados, sino para
querer tratar y estimar en poco á
los que por la virtud tienen mayor
merecimiento que ellos! Si vemos
á un hombre pobre, tratámosle
con palabras pobres y desnudas
de favor y auctoridad; si después
la fortuna le ayuda á ser rico,
luego le acatamos y
reverenciamos como á superior;
no miramos á las personas, ni á la
virtud que tienen, sino á la
hacienda que poseen.
Jerónimo.—Si esa hacienda la
adquirieron con obras virtuosas,
¿no es justo que por ella sean
estimados?
Antonio.—Sí, por cierto; pero el
mayor respeto que se ha de tener
es á la virtud y bondad que para
adquirirlas tuvieron, por la cual yo
he visto algunos amenguados y
afrontados, que usando desta
virtud gastaron sus patrimonios y
haciendas en obras dignas de
loor, y como todos tengamos en el
mundo poco conoscimiento de la
honra, á éstos que la merecen,
como los veamos pobres, les
estimamos en poco; así que los
ricos entre nosotros son los
honrados, y aunque en ausencia
murmuramos dellos, en presencia
les hacemos muy grande
acatamiento; y la causa es que,
como todos andemos tras las
riquezas procurándolas y
buscándolas, pensamos siempre
podernos aprovechar de las que
aquellos tienen, los cuales van
tan huecos y hinchados por las
calles, que quitándoles las gorras
ó bonetes otros que por la virtud
son muy mejores que ellos,
abaxándolos hasta el suelo con
muy gran reverencia, ellos
apenas ponen las manos en las
suyas, y en las palabras y
respuestas también muestran la
vanidad que de las riquezas se ha
engendrado en ellos. ¡Oh vanidad
y ceguedad del mundo! que yo sin
duda creo que esta honra es por
quien dixo el Sabio: Vanidad de
vanidades y todas las cosas son
vanidad. La cual tan poco
perdona los muertos como á los
vivos, que á las obsequias y
sacrificios que hacemos por las
almas llamamos honras, como si
los defunctos tuviesen necesidad
de ser honrados con esta manera
de pompa mundana; y lo que peor
es que muchos de los que
mueren han hecho sus honras en
vida llamándolas por este
nombre, tanto para honrarse en
ellas como para el provecho que
han de recibir sus ánimas. Es
tanta la rabia y furor de los
mortales por adquirir y ganar
honra unos con otros, que jamás
piensan en otra cosa, y harto
buen pensamiento sería si lo
hiciesen para que se ganase la
honra verdadera. Lo que tienen
por muy gran discreción y saber
es aventajarse con otros en
palabras afectadas y en obras de
viva la gala, y cuanto se gana en
lo uno ó en lo otro entre hombres
que presumen de la honra, ¿qué
desasosiego de cuerpo y de
ánima nace dello? Porque si es
tierra libre, luego veréis los
carteles, los desafíos, los gastos
excesivos, pidiendo campo á los
reyes ó á los señores que pueden
darlo; de manera que para venir á
combatir han perdido el tiempo,
consumido la hacienda,
padescido trabajo, y muchas
veces los que quieren
satisfacerse quedan con mayor
deshonra, por quedar vencidos. Y
lo que peor es que el que lo
queda, por no haber sido muerto
en la contienda, pierde la honra
en la opinión de los parientes, de
los amigos y conoscidos, que
todos quisieran que perdiera
antes la vida y aun la ánima que
la honra como cobarde y
temeroso. Y es el yerro desto tan
grande, que si muere (con ir al
infierno) los que le hacen se
precian dello y les paresce que en
esto no han perdido su honra. Y si
es en parte donde no se da
campo á los que lo piden, ¡qué
desasosiego es tan grande el que
traen en tanto que dura la
enemistad, qué solicitud y trabajo
insoportable por la satisfacción y
venganza! Y muchas veces se
pasan en este odio un año, dos
años y diez años, y otros hasta la
muerte, y algunos se van con la
injuria y con deseo de vengarla á
la sepultura.
Jerónimo.—Bien ciertos van
éstos de la salvación, quiero decir
de la condenación de su ánima;
poco más me diera que murieran
siendo turcos y gentiles, y aun en
parte menos, porque no dieran
cuenta del sancto baptismo que
no hubieran recibido.
Albanio.—Decidme, señor
Antonio, ¿hay alguna cosa que
pueda ó tenga mayor fuerza que
la honra?
Antonio.—El interesse es
algunas veces de mayor poder,
aunque no en los hombres de
presunción y que se estiman en
algo, y si por ventura en éstos se
siente esta flaqueza, pierden el
valor que tienen para con los que
tienen presunción de la honra, y
luego son dellos menospreciados.
Albanio.—¿Y cual tenéis vos por
peor, el que sigue el interés ó la
vanagloria?
Antonio.—Si el interese es bien
adquirido, por mejor lo tengo,
porque con él pueden venir á
hacer buenas obras y usar de
virtud, lo que no se puede hacer
con la honra vana sin el interese.
Albanio.—Pues decidnos en
conclusión, ¿qué es lo que
queréis inferir de todo lo que
habéis alegado contra la honra,
que según habéis estado satírico,
creo que ha de ser más áspero
que todo lo antecedente. ¿De
manera que queréis desterrar la
honra del mundo para que no se
tenga noticia della?
Antonio.—Si tenéis memoria de
todo lo que he dicho, por ello
entenderéis que yo nunca he
dicho mal de la que es verdadera
honra, conforme á la diffinición
della y al verdadero
entendimiento en que habemos
de tomalla, y si á los virtuosos, los
sabios, los que tienen dignidades
ó officios públicos honrados, los
esforzados, los magníficos, los
liberales, los que hicieron
notables hechos, los que viven
justa y sanctamente también
merescen esta honra y
acatamiento que el mundo suele
hacer como ya arriba dixe y lo
dice Sancto Tomás. Y es razón
que sean honrados y estimados
de los otros, y la honra que ellos
procuran por esta via, justa y
sancta es, y nosotros estamos
obligados á dársela. Pero si la
quieren y piden con soberbia,
queriendo forzarnos á que se la
demos, ya pierden en esto el
merecimiento que tenían por los
méritos que en ellos había.
Jerónimo.—Desa manera
ninguno habrá que pueda forzar á
otro á que le reverencie y acate.
Antonio.—No es regla tan
general ni la toméis tan por el
cabo, que el padre puede forzar á
los hijos, los hermanos mayores á
los menores, y más si les llevan
mucha edad, los señores á los
vasallos y á los criados, los
perlados á los súbditos; pero esto
ha de ser con celo de hacerlos
ser virtuosos y que hagan lo que
deben, y no con parescerles que
les puedan hacer esta fuerza por
solo su merecimiento, porque assí
ya va mezclada con ella la
soberbia y vanagloria, y en lugar
de merescer por ello, serán
condenados en justicia.
Jerónimo.—Al fin lo que entiendo
de vuestras razones es que la
verdadera honra es la que damos
unos á otros, sin procurarla los
que la reciben; porque las obras
virtuosas que hicieron las obraron
por sola virtud y sin ambición ni
codicia de la honra, y que
cualquiera que procurare tomarla
por sí mesmo, aunque la
merezca, esto solo basta para
que la pierda.
Antonio.—En breves palabras
habéis resumido todos mis
argumentos; ahí se concluye todo
cuanto he dicho, siendo tan
contrario de la común opinión de
todos los que hoy viven en el
mundo. Y lo que he hablado entre
vosotros, como verdaderos
amigos, no lo osaría decir en
público, porque algunos no
querrían escucharme, otros me
tendrían por loco, otros dirían que
estas cosas eran herejías
políticas contra la policía, y otros
necedades; no porque diesen
causa ni razón para ello, ni para
confundir las que digo aunque no
son gran parte las que se podrían
decir, lo que harían es irse
burlando dellas y reyéndose de
quien las dice, aunque á la verdad
esto es decir verdades, y
verdaderamente lo que se ha de
sentir de la honra que tan fuera
nos trae del camino de nuestra
salvación. Y porque ya se va
haciendo tarde y por ventura el
conde habrá preguntado por mí,
es bien que nos vamos, aunque
algunas cosas quedarán por
decir, de que creo que no
recibiérades poco gusto.
Jerónimo.—Ya que no las digáis
agora, yo pienso persuadiros que
las digáis hallándoos
desocupado, porque quiero
entender todo lo que más hay que
tratar desta honra verdadera y
fingida, porque si alguna vez
platicare esta materia con mis
amigos, vaya avisado de manera
que sin temor pueda meterme á
hablar en ella, como dicen, á
rienda suelta.
Albanio.—No quedo yo menos
codicioso que Jerónimo, y assí
pienso molestaros hasta quedar
satisfecho.
Antonio.—Pues que así lo
queréis, mañana á la hora de hoy
volveremos á este mesmo lugar,
que yo holgaré de serviros con
daros á sentir lo que siento. Y no
nos detengamos más, porque yo
podría hacer falta á esta hora.
COMIENZA LA
SEGUNDA PARTE
Del colloquio de la honra, que

trata de las salutaciones
antiguas y de los títulos y
cortesías que se usaban en el
escrebir, loando lo que se
usaba en aquel tiempo, como
bueno, y burlando de lo que
agora se usa, como malo.
INTERLOCUTORES
Albanio.—Antonio.—Jerónimo.
Albanio.—Á buena hora

llegamos, que aquél es Antonio,
que agora llega á la puerta del
jardín. No ha faltado punto de su
palabra.
Jerónimo.—Paréceme que,
dexando la calle principal de los
chopos, se va por otro camino
rodeando.
Albanio.—El rodeo es tan
sabroso que no se siente, porque
toda esta arboleda que veis es de
muy hermosas y diferentes frutas,
las cuales no tienen otra guarda
más de estar aparejadas para los
que quisieren aprovecharse y
gustar dellas. Toda esta espesura
que miráis produce fructo en muy
gran abundancia, y los más de los
árboles que están en este tan
hondo valle son provechosos.
Mirad qué dos calles estas que
parescen dos caminos hechos en
alguna cerrada y muy espesa
floresta, y de la mesma manera
va otra calle por la otra parte. Por
cierto deleitosa y muy suave cosa
es gozar en las frescas mañanas
deste caloroso tiempo de tan
grande y agradable frescura como
aquí se muestra.
Jerónimo.—¿Qué puerta grande
es ésta que aquí vemos?
Albanio.—Una puerta trasera por
donde se entra al jardín, y es la
mesma que vimos cabe la
fuentecilla, cerca del estanque.
Jerónimo.—Agora entiendo lo
que decís; porque lo he visto,

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Foundations for Health Promotion 4th

Edition Jennie Naidoo

Principles and Foundations of Health Promotion

Worksite Health Promotion 3rd Edition

Worksite Health Promotion Third Edition

Planning Health Promotion Programs: An Intervention

(eTextbook PDF) for Health Promotion in Nursing

Health Promotion in Multicultural Populations: A

Health promotion throughout the lifespan eBook

Foundations for Population Health in Community/Public

Chapter One. Concepts of health

Defining health, well-being, disease, illness and ill health

The Western scientific medical model of health

A critique of the medical model

Lay concepts of health

A unified view of health

Chapter Two. Influences on health

Social class and health

Income and health

Housing and health

Employment and health

Gender and health

Health of ethnic minorities

Place and health

Explaining health inequalities

Tackling inequalities in health

Chapter Three. Measuring health

Why measure health?

Measuring health as a negative variable (e.g. health is not being diseased

Measuring health and disease in populations

Measures of health as an objective attribute

Subjective health measures

Physical well-being, functional ability and health status

Social capital and social cohesion

Chapter Four. Defining health promotion

Foundations of health promotion

Origins of health promotion in the UK

The World Health Organization and health promotion

Defining health promotion

The argument for health promotion

Chapter Five. Models and approaches to health promotion

The medical approach

The educational approach

Models of health promotion

Theories in health promotion

Chapter Six. Ethical issues in health promotion

The need for a philosophy of health promotion

Consequentialism and utilitarianism: The individual and the common good

Chapter Seven. The politics of health promotion

The politics of health promotion structures and organization

The politics of health promotion methods

Part Two. Strategies and methods

Chapter Eight. Reorienting health services

Promoting health in and through the health sector

Primary healthcare and health promotion

Primary healthcare principles

Primary healthcare: strategies

Primary healthcare: service provision