Promoting Good Health

Efforts to promote good health and to prevent disease always are preferred strategies over efforts to treat disease. Yet, we spend far too little time, attention, and effort on either of these strategies. Both remain very underdeveloped in behavioral health. This reality persists despite the fact that both are included in the Essential Health Benefit and the Medicaid Alternative Benefit mandated by the Affordable Care Act (ACA).

We must begin with some basic distinctions. First, health and disease are two different personal states rather than two features of a single state. For this reason, health promotion and disease prevention imply different interventions, even though these interventions may have cross-effects. Second, because health promotion, per se, not only can improve personal health, but also prevent or delay disease onset, it is very important that we engage in both types of interventions at the same time. Ideally, both should be started very early in life. Third, because our current “health care” system is oriented principally toward disease treatment, we will need to make major modifications to our current health care infrastructure in order to incorporate health promotion and disease prevention.

This commentary will focus on health promotion; a future commentary will focus on disease prevention. The World Health Organization defines health promotion as the “process of enabling people to increase control over their health and its determinants, and thereby improve their health.”

Our concepts of positive health and how to promote it are emerging rapidly from the field of positive psychology. Intuitively, we understand the basic features of positive health: healthy people are happy, engaged, energized, and living life fully in their communities. They also have positive regard for themselves, and they have positive regard for family members, friends, co-workers, and neighbors. They have control over their health. 

The things in peoples’ lives that determine one’s life chances also can foster or inhibit positive health. For example, a supportive family and community can contribute to one’s positive health; poverty and social exclusion can detract from it. Disease and disability can detract as well. Thus, we speak of “disability-adjusted life years”, i.e., total expected years of life minus years of life lost to premature mortality minus years of life diminished due to disease and disability. Thus, gaining control over the determinants of health is equally important in promoting good health.

What actions will be required to develop the interventions needed to promote good health? Several obvious steps would include:

• Summarize Available Health Promotion Interventions. An urgent need exists to produce a practical summary of the clinical and public health interventions known to promote good health. Because good mental health and good health are closely related, the interventions used to promote good mental health can be deployed to promote good overall health as well.  At this time, because the field is so new, the summary should include both practice-based evidence and evidence-based practices.
• Undertake a Longitudinal Cohort Demonstration. A longitudinal demonstration is needed to test the best of these interventions in a cohort of persons without any known diseases; a cohort of persons with long-term physical diseases, such as heart disease, diabetes, and cancer; a cohort of persons with mental and substance use conditions, such as schizophrenia, bipolar disorder, and illicit drug use; and a cohort of persons with co-occurring physical and behavioral conditions. Each cohort should be carefully stratified by condition and age.
• Embed the Cohorts in Medical and Health Homes. The cohorts should be assigned to primary care medical homes and behavioral health-health homes so that we can begin to develop an understanding of how to incorporate health promotion from both the clinical and public health perspective into the day-to-day practices of integrated care.

Almost 35 years ago, we developed the concept of a health promotion organization to reduce mortality and to delay and mitigate disease. This concept was never implemented on a broad scale. More recently, peers have led the way in developing wellness interventions for persons with mental and substance use conditions. Now, the ACA has created an opportunity to greatly expand this work.

Promotion of good health does represent an exceptional opportunity for behavioral health going forward. It is a first in two very important ways: it will foster an entirely new field of endeavor, and it will foster linkage with all population groups. In fact, I speculate that behavioral health will be central to health promotion in the future. How very exciting!