EPDEMOLOGY OF HYPERTANSON

Prof.Dr.Selma KARABEYCulture, Health and IllnessIf you wish to help a community improve its health, you must learn to think like the people of that community. Before asking a group of people to assume new health habits, it is wise to ascertain the existing habits., how this habits are linked to one another, what functions they perform, what they mean to those who practice them (Paul, 1955)Culture

The sum of values and traditional ideas transmitted to individuals in a community over a period of time, or patterns of behavior acquired or learned and transmitted by human groups. Culture includes how people behave,think, and communicate their values, ideas, customs, attitudes, beliefs, and mores (Huff & Kline, 1999; Tischler, 1993).CultureShared ideas, meanings, and valuesSocially learned, not genetically transmittedPatterns of behavior that are guieded by shared ideas, meanings, and valuesOften exists at an unconsciousConstantly being modified through lived experiences(Institute of Medicine, 2002)

Health

The physical, mental, social, and spiritual well-being and fitness that individuals enjoy. Health is not just freedom from disease but is multidimensional and is to a large extent culturally defined.Health may be defined as the quality of a persons physical, psychological, and sociological functioning in a variety of personal and social situations (Bedworth & Bedworth, 1992).IllnessIllness refersto what the person feels is wrong and not what a doctor says or discovers is amiss (Bond & Clark, 2002; Crane & Martin, 2002).

Example: A person who feels ill may visit a health screening and consultationprogram where height, weight, and blood pressure measurements aretaken and blood tests and possibly an electrocardiogram are performed todiscover why she feels ill and to help plan a course of action.6Disease

The failure of an organism to adequately or appropriately counteract stresses or stimuli, which can be biological, behavioral, or environmental,resulting in sickness or disability.People mix up different medical system!A 16-country study of community perception of health, illness and primary health care found that in all 42 communities studied, people used both Western biomedical system and indigenious practices.Experience has shown that health programs that fail to recognize and work with indigenous beliefs and practices also fail to reach their goals.Examples from TurkeyUse of taharet beziIncision of forehead in jaundice. Drinking urine in urticaria.

Health DeterminantsDualismAnother school of thought among the ancient Greeks, however, proved to be more influential. The philosophy of dualism considered the body as part of the material world and therefore subject only to physical laws. In contrast, mind was non-material, much like the soul and not subject to physical laws.Consequently, for the dualists, the body is like a machine and physical illness or health is a function of physical causes. Interpersonal relationships, social context, and socialization were seen as distal, minor players in the competition between physical health and illness.Dualistic philosophy dominated Western thought for centuries.When, in the1600s, Descartes recognized that there had to be some interaction betweenthe material body and the non-material mind, his solution was to maintain thatthe mind and body were separate but were connected and could communicate.(Lacking sound knowledge Descartes thought the pineal gland wasa good candidate for this connection because it was located in the center ofthe brain.) However, the emphasis on the body as machine persisted anddominated medicine and philosophy (the precursor of psychology) until thelate nineteenth century. Physicians of that era considered physical health asquite distinct from psychological health and not affected by psychologicalfactors.The advent of germ theory at the end of the nineteenth century reinforcedthis dualistic way of thinking. Germ theory, originally proposed by Galen,argued that bacteria, viruses, and other pathogens were seen as the majorcauses of specific diseases. Evidence for germ theory awaited the developmentof appropriate technologies, such as the microscope and the experimentalmethod. Rudolf Virchow generally is credited with the first definitive evidencevalidating a germ theory that emphasized organs and, more specifically,processes at the cellular level. The success of germ theory reinforced thedualism where physical and psychosocial processes were seen as separatemechanisms. Medical scientists also tended to be reductionistic, ignoring thecomplexity of factors that influence health status, and disease-focused.In medicine at the turn of the century, health was defined as the absence ofdisease, and wellness received little attention. Dualistic thinking, physicalmechanisms, reductionism, and disease-focus characterized the biomedical modelof illness that became dominant through the first two-thirds of the twentiethcentury. Medical scientists working from the biomedical model influenced by germtheory successfully identified pathogens for malaria, pneumonia, rabies, andtuberculosis and facilitated the development of vaccines that significantlyimproved the health of the human population. Other medical treatmentsfollowing the biomedical perspective, such as new medications and surgicalprocedures, also contributed to and continue to contribute to advances ineradicating disease and prolonging life. The popularity of the biomedical approachto medicine makes sense in light of these discoveries and benefits.Whether the biomedical approach deserves all of the credit, however, isdebatable. The threat of infectious diseases began to significantly decreaseseveral decades before the advent of effective vaccines (Grob, 1983). Declinesin prevalence and mortality from infectious diseases such as tuberculosis anddiphtheria appear to have occurred as a result of preventive measures such asimproved personal hygiene, greater resistance to disease (owing to betternutrition) and public health measures such as sewage treatment (Runyon et al., 1982). Many of these changes were not prompted by medical science orthe biomedical model but represented the results of socio-cultural changes.Nonetheless, optimism about the potential for magic bullet cures inspired bythe biomedical model made its success more salient than more distal contributionsof the physical or social environment.Limitations of the biomedical model, however, have become apparent inpart because patterns of illness changed during the twentieth century. Contagiousdiseases were the leading causes of death in 1900, but, by mid-centuryand continuing to the present, non-contagious diseases such as heart diseaseand cancer are the leading killers. Success of the biomedical approach andimprovements in public health have played a role in this shift. People livelonger which makes them more susceptible to chronic illnesses. However,the major causes of death currently involve behavior or lifestyle patternsinvolving health-compromising behaviors, such as smoking, overconsumingcalories and alcohol, and not exercising. Once the role of behavior in healthwas better appreciated the biomedical model seemed incomplete. A newperspective, the biopsychosocial model (Engel, 1977), was advanced whichadmitted psychological and social factors as equal partners with biologicalfactors (cf. Schwartz, 1982).The biopsychosocial model represents a return to the holism that theGreeks, such as Hippocrates, advocated, but its contemporary form employsmodern scientific methods. Interestingly, Rudolf Virchow, the scientist mainlyresponsible for the early validation of germ theory was also a holistic thinker.While tracing the role of disease to the cell, he also was a leading exponent ofthe thesis that man is the product of his life situation. Virchow argued asvociferously for attention to environmental influences, such as occupationand social class, as to the microbes he viewed through his microscope.We should acknowledge that the social psychological foundations of healthand illness that are described in this volume probably look very different fromthe social factors that Virchow thought were important. For him, social conditionspertained mainly to social class and occupation. The scientific field ofsocial psychology, which focused on the implied, actual, or anticipated impactof people on the beliefs and behavior of others, did not emerge until somedecades after Virchows death.11Social and Psycological Foundations of Health and IllnessThe idea that social factors play a role in physical health and well-being is not a new one. Hippocrates, the father of medicine, observed that the social relationship between patient and physician was important for recovery.However, an empirically based approach that focused on the role of social psychological processes for etiology, prevention, treatment and adaptation to physical illness was only pioneered in the 1950s and did not gather full-steam until the 1970s.HASTALIK & RAHATSIZLIK(Disease & Illness)If it is recognized in biomedicine, the illness that person feels would be diagnosed as disease. Although illness exists, but if disease can not biologically detected, then, by bio-medicine, it is diagnosed as psycho-somatic.This situation is real for the client, but for phsycian? In Turkey, pschological illnesses are expressed through body language especially among women. Birinci basamakta fiziksel yaknmalarla bavuran kiilerin nemli bir blmnde psikolojik faktrlerin, kii iin stres oluturacak durumlarn var olabileceinin aklda tutulmas gerekir. Ancak bu durum tam bir fizik deerlendirmeye engel olmamal, kiinin yaknmalar somatizasyon diye kmsenerek gzard edilmemelidir. Kiinin yaad hertrl rahatszlk gerektir ve temel kkenlerine ynelik yaklamlar sunabilmek nemlidir. 13CULTURE & MENTAL ILLNESS& MEDICALIZATIONApproach to the mental ilnesses is different in various cultures. In our culture, people who have moderate mental illness would be tolerated.People who have been diagnosed, who have got medicine and clinical treatment in western cultures can maintain social life and work. Yaramaz kids in our culture may have obliged to long-life drug use as the diagnosis of Attention Deficiency Syndrome in USA. MEDICALIZATIONPerhaps, it is an expression of common and normal condition as a disorder. Post-traumatic Stress Disorder:It was defined in the American soldiers coming back from the Vietnam War. It is a fictive disorder according to some studies of medical anthropology. On the other hand, insurance companies in USA only make a payment in the conditions defined as disorders.

Savaa katlmak, lmle burun buruna gelmek, bakalarnn lmne sebep olmak ciddi bir ruhsal travmadr ve savatan dnen askerlerin bu nedenle stres yaamalar olaan bir durumdur. Bir hastalk deildir, belli bir duruma verilen normal bir tepkidir. Belki yaamamalar salkszlk belirtisi olurdu. Nasl ki yaknlarn kaybeden ve yas tutan insanlar hasta olarak grmyorsak bunlar da hasta olarak grmemek gerekir. Hindistanda unutkan olan yallar ile ABDdeki Alzheimer hastalarn karlatran antropolojik alma bu konular tartyor (Lawrence Cohen, 1998)

Bir dier rnek: Gnmzde doum normal olmaktan km, hastanede genellikle de sezaryenle yaplan cerrahi bir uygulama haline dnmtr.

15Western Medicine Fails!!!It overemphasizes to biology. However, the most important current health problems depend on human behavior and life style (e.g. COPD, diabetese, Cerebrovascular accidents, Ischeamic heart disease)..It focuses on disorders. Prevention and promotion of health are not priorities of modern, western medicine. Koroner kalp hastalklarnn en nemli risk faktrleri beslenme, sigara, yksek tansiyon, stres ve hareketsiz yaam belirlenmitir. Oysa Ankara gecekondu blgesinde yaplan bir aratrmada gen erkekler sosyalleebilmek iin mecbursun imeye diyor, kadnlar da toplu olunca daha gzel alglandklarna inanyorlar. Dolaysyla genler u andaki sosyalleme ihtiyacn belirsiz bir gelecekteki kalp veya kanser hastalna yakalanma riskinden daha ncelikli tutuyorlar. Bu durumda sigara sala zararldr diye bilgi sunmak tek bana etkili olamaz. 16Western Medicine Fails!!!It accepts only itself. It ignores the conditions those can not be defined in it. It ignores the personal requests and decisions of people/patients. It refuses the approaches besides western medicine and stigmatize them as unscientificWestern medicine focuses on the health problems defined by rich countries.

Son yllarda Dou tbb iinde yer alan uygulamalar (akupunktur, meditasyon, aromaterapi vb) Tamamlayc ve alternatif tp kapsam iinde Bat lkelerinde modern tp iinde de kabul grmektedir. 17It should be consiedered:De facto approaches would extremely change and be relative according to the time, region, conditions, institutions and people. There are pyshological, social and cultural dimensions of every health/illness behavior. If only it is well understood, then, it would be developed appropiate approaches to the people and culture. For that, medicine highly needs to social science.Social Sciences that examine cultural and behavioral parametersAnthropologyMedical AnthropologyPsycologySocial PsychologyHealth PsychologySociologyMedical Sociology

Medical anthropologists examined how illness isthought of differently and treated differently across cultures. Medical sociology emphasized the effects of the larger social structure and the structure of medical delivery systems.

Although these fields overlap somewhat, social psychology is unique in its examination of howbasic psychological principles and processes influence the individual andthe group. Furthermore, social psychology can be the vehicle by which an integration of cultural, structural, and personality factors can be achieved through its focus on the individual operating in a group and within a wider cultural context (Taylor, 1978).19

Health times are changing. Eggs are again a healthy food. Avoiding cholesterolladeneggs wont solve elevated-cholesterol problems for most people. Saltintake, however, can lead to high blood pressure, and thereby perhaps threatencardiovascular health. Except, maybe eggs are not so healthy, possibly becauseof their high levels of saturated fat. And the threat from salt intakeseems only true for certain people who are sodium sensitive. Butter is full ofsaturated fat, so you should switch to margarine. Wait. Margarine, containinghydrogenated oils, is loaded with trans fatty acids, which makes it a pooralternative to butter. Try the new and expensive kind of cholesterol-loweringmargarine.Where does all of this conflicting health advice come from? Some of thischanging advice results from new scientific discoveries. New studies constantlyaddress a piece of the puzzle of the development of chronic illness.Since cardiovascular disease is by far the greatest killer in the Western world,it and its risk factors (serum cholesterol, blood pressure, diet, stress) receivelots of research attention, usually fragmentary. Another part of this contradictoryadvice results from clinicians and reporters who overstate their findings.Individual studies are rarely multi-faceted, long-term, and definitive. So aseach finding emerges, it receives more attention than justified; then later,another, different piece of the picture is revealed.20The Blind Men and the ElephantJohn Godfrey Saxe (1816-1889)

KOLSETEROL-YUMURTA, TEREYAI-MARGARN VB VB TIBBIN DEEN MODALARI

Hintli alt adam vardrenmeye ok hevesliydilerFili grmeye gittilerHepsi kr olmasna ramenGzleme ile her biriKendi dncesini teyit etmek istedi.

Birincisi file yaklatVe olan olduOnun gl ve dar gvdesine karBarmaya balad:Allah akna! Fakat filDaha ok duvar gibi.

kincisi uzun diini hissettilkla vovvv! Burada ne var? ok yuvarlak, dzgn ve sivriok ak ve netBu harika bir zellikDaha ok bir mzrak gibi

ncs hayvana yaklatVe mutlulukla tuttuElleri iinde hortumunuBylece cesaretlendi ve konutu:Anladm dedi aynenFil daha ok bir ylan gibi

Drdncs sabrsz elleriyle dokunduDizlerini hissettiNe harika canavar ok dz tekrarlad:Bu fil, ok belliDaha ok bir aa gibi

Beincisi ansla dokundu kulanaDedi: en kr adam bile Bunun ne olduunu syleyebilir, Filin bu doast zelliiDaha ok bir yelpaze gibi!

Altncs daha abuk deildiCanavar el yordam ile yokladSonra, sallanan kuyruu yakaladOnun hissiyleAnladm dediFil, daha ok, bir halat gibi

Ve Hindistanl bu adamlarUzun ve sesli tarttlarKendi fikrinde her biriSon derece kesin ve kararlHer dnce ksmen doruyduVe tm yanlt!

The Blind Men and the ElephantJohn Godfrey Saxe (1816-1889)Dr.Sultan Tarlaci tarafndan evirilmitir.21When health-care shaked with money

22Fortunately

People have it up to their noses with conflicting medical advice.So they junk all the advice and return to eating junk food.In a study conducted in Washington, more than two-thirds of the respondents asserted that the government should not tell people what to eat, and many complained about low-fat diets. More importantly, people evidencing high nutrition backlash ate more fat and fewer servings of fruits and vegetables. (Patterson et al., 2001).

Turkey is gaining weight too!

TK, Salk Aratrmas, 2012TurkStat, Health Survey, 2012Risk BehaviorsRisk behaviors cluster in patterns that in combination influence a persons risk of disease. Sedentary life-style in industrial societies: taking little exercise, eating foods of poor nutritional value, consuming caloric drinks and smoking cigarettes. Risk behaviors rarely occur in isolation, but cluster inpatterns that in combination influence a persons risk ofdisease. Thus, a sedentary life-style in industrial societiesconnotes a pattern of mutually influencing behaviorssuch as taking little exercise, eating foods of poornutritional value, consuming caloric drinks and possiblyalso smoking cigarettes. While these factors donot determine disease in an inevitable sense, they placethe person at elevated risk of obesity, high bloodpressure, and subsequently of cardiovascular disease aswell as impairment of musculoskeletal health. Otherunhealthful behavioral patterns include the connectionsamong smoking behavior,malnutrition, and drug taking,and those among alcoholism, aggression, violenceand suicide. Each of these patterns is reinforcedby membership in a social milieu that brings similarpeople together, as well as by individual personal traits.Each pattern also trends to correspond to personal valuesand beliefs, which form the connection betweenbehavior and culture.

27Risk BehaviorsWhile these factors do not determine disease in an inevitable sense, they place the person at elevated risk of obesity, high blood pressure, and subsequently of cardiovascular disease as well as impairment of musculoskeletal health. Other unhealthful behavioral patterns include the connections among smoking behavior, malnutrition, and drug taking, and those among alcoholism, aggression, violence and suicide. Each of these patterns is reinforced by membership in a social milieu that brings similar people together, as well as by individual personal traits.Each pattern also trends to correspond to personal values and beliefs, which form the connection between behavior and culture.

The Terman CohortThe best means of ascertaining healthy lifestyles and understanding health-promoting life pathways is through longterm longitudinal study.The Terman Life Cycle Study began in 192122 when most of the 1,528 participants were in elementary school in the San Francisco and Los Angeles areas.Continued until the present, it is the longest study of a single cohort ever conducted, and the only such major study with rich data collected regularly throughout the life-span (from childhood to late adulthood and death.

The Terman CohortData have been collected and refined on the subjects social relations, education, personality, habits, careers, families, mental health, life stress, physical activities, and physical health; death certificates and coded date and cause of death.The study was originally focused on addressing such issues as whether bright children were introverted eggheads.The average birth date was 1910. The data are collected prospectively, without any knowledge of the eventual health outcome, thus avoiding several common sources of bias in the data collection phase of such studies.

The Terman Cohort Neglect of Precursors and Complex Causal Pathways,Including Self-selection into Environments Just as phototropic plants move towards a source of light, some individuals grow towards more fulfilling and health-promoting spaces while other individuals remain subject to darker, health-threatening environments.There is self-selection or pull into risk conditions. That is, people seek out healthier or unhealthier situations as a function of personality and pre-existing stress.Marriage and DivorceNumerous epidemiological studies have found that married individuals, especially married men, have a significantly lower mortality risk than single and divorced individuals.Results confirmed that consistently married people (especially men) live longer than those who are single due to marital breakupInconsistently married men had a relative hazard of mortality of almost 1.4 (40 percent greater risk), and separated or divorced men had a relative hazard of 2.2. Numerous epidemiological studies have found that married individuals, especiallymarried men, have a significantly lower mortality risk than single anddivorced individuals. It is usually assumed that this association reveals a protectiveeffect of marriage. Perhaps a spouse serves as a buffer against stress.Perhaps a spouse helps insure co-operation with medical regimens like takingpills on time. Perhaps a spouse is quick to call for emergency help whenneeded. (In fact, there is also evidence to support each of these associations Friedman, 2002.) But studies of causal mechanisms have been difficult withoutaccess to a lifelong study. The resulting advice is get married or staymarried to be healthy, an inference not justified by such data.

Using the Terman archives, supplemented by death certificates we collectedand coded, the association between marital history at mid-life and mortality(as of 1991) was studied in the sample of participants (Tucker et al.,1996) (N = 1,077). As of 1950 (when they were about 40 years old), thevast majority of the participants were alive, mature, and had married if theywere ever going to marry. We classified them as to whether they were currentlyand steadily married (N = 829), married but not in the first marriage(inconsistently married) (N = 142), never married (N = 102), or currentlyseparated, widowed or divorced (N = 70). Very few had been widowed by thispoint.

Results confirmed that consistently married people (especially men) livelonger than those who are single due to marital breakup. But intriguingly, theresults suggested that this is not necessarily due to the protective effects ofmarriage itself. Controlling for gender and self-reported health, we found (insurvival analyses) that the inconsistently married people were at higher riskfor premature mortality than the steadily married, and that the currently splitpeople were at even higher risk. Inconsistently married men had a relativehazard of mortality of almost 1.4 (40 percent greater risk), and separated ordivorced men had a relative hazard of 2.2. That is, men who were currentlymarried, but had previously experienced a divorce, were at significantly highermortality risk compared with consistently married individuals. Since bothgroups were currently married (in 1950), the marriage itself could not bethe relevant protective factor. Furthermore, controlling for number of yearsmarried had minimal effect on the association between marital history andmortality risk.32DivorceMen who experienced marital dissolution and remarried were at higher risk prior to age 70, and then their relative mortality risk declines (Tucker et al., 1999).Strong advice to get married (for social support) ironically may increase rather than decrease ones risk, since one cannot face the stress of divorce if one has not married. Part of the relationship between marital history and mortality risk in the Terman participants may be explained by childhood psychosocial variables, which were associated with both future marital history and mortality risk (Tucker et al., 1996).In sum, it is possible that the stress of divorce and its concomitants, coupledwith selection into stable or unstable married roles, are more important healthmechanisms than the sustenance provided by marriage itself. An incorrectcausal inference might be drawn from simple observation of the associationbetween marriage and health. And an invalid, simple preventive intervention(Get married to promote health) may be designed.33PrecursorsWhat are these lifelong pathways that the adults with a consistent and stable marriage are traveling?Where have they come from, both psychologically and socially? Individuals who were divorced or remarried reported (retrospectively) that their childhoods were significantly more stressful than those who got and stayed married. (They scored highly on such items as marked friction among family members during childhood.)Family stress (particularly parental divorce) is known to predict unhealthy behaviors such as smoking and drug use in adolescence as well as poor psychological adjustment.Divorce of ones parents during childhood can certainly affect ones future mental health. There is good longitudinal evidence that children of divorce, especially boys, are at greater risk for observable behavior and adjustment problems.Death of a parent had very little effect, consistent with other research indicating that parental strife and divorce is a greater influence on subsequent psychopathology than is parental death (Tennant, 1988)Terman participants who were impulsive children, grew up to be both less likely to be consistently married and more likely to die younger.Childhood impulsivity and parental divorce predicted marital instability, and these arealso predictive of earlier mortality. These variables explain some of the mortality differential between consistently and inconsistently married participants.As a key determinant of health: PersonalitySociability:A large amount of evidence establishes that people with various personal and community ties, usually termed social support, are generally healthierIt thus seems sensible that more sociable people would be healthier, and that development of sociability in children and adolescents should be encouraged.This conclusion again neglects precursors and complex causal pathways, including self-selection into environments.It turns out that there is little evidence that sociability itself predicts health and longevity.Sociability was strongly related to Extraversion but also significantly correlated with Agreeableness.The Terman children who were rated by their parents and teachers as popular, fond of large groups and social activities, and so on did not live longer than their unsociable peers.There was simply no evidence that sociable children were healthier or lived longer across many decades. In fact, sociable children were somewhat more likely to grow up to smoke and drink.To confirm this finding, we also examined Termans own grouping of themen in the sample into scientists and engineers versus businessmen andlawyers. Terman found marked personality differences, with the former groupmuch more unsociable and less interested in social relations at school and inyoung adulthood. When we analyzed mortality risk, however, we found thescientist and engineer group at slightly less risk of premature mortality(Friedman et al., 1994). Examination of the pathways and tropisms suggeststhat these studious men often wound up well adjusted, working in positionswell integrated into society.38ConclusionFirst, we need to examine individual life patterns. Rather than taking a piecemeal approach, rather than educating people about endless lists of things not to do, it may prove more efficient and effective to launch people onto healthy life paths, and intervene intensively only for those few people at special high risk.Second, we need greater focus on the social context the person in the situation, and situation selection.Third, we need to consider cultural changes, both in the medical culture and in the broader societal culture.In terms of medical culture, we also needto break down the walls between different health institutes and narrow approachesto disease. We need to include overall health (not going system bysystem or disease by disease), as well as overall quality of life, as outcomes inour research.In the broader societal culture, we need to recognize the complexities ofsocialization. As one example, there is a lot of smoking and a lot of lungcancer in Kentucky, but little smoking and little lung cancer in Utah. Shouldwe spend a lot of time and money on designing anti-smoking newspaperads in Kentucky, or might we focus more on comparing the tobacco farmsouthern culture to the LDS (Mormon) culture of Utah?How is culture changed? It is not just more education. Rather, structuralchanges are often more efficient and effective. Yet no one objects to spending billions and billions on treating cancer, and millions and millions on researchon cancer, but how about subsidizing the many public health structures thataffect behavior? But it is not only a role for government. The cruise industryis booming as people spend thousands of dollars to sit and eat 24 hours a day,but they do not have time or money to stay in shape, swim with theirchildren, cook dinners, or go to church or their yogi. These are lifelong communityvalues.In sum, when psychosocial aspects of health are considered at a deep andtime-sensitive perspective, we already know a lot about how to promote health,and it does not mainly involve campaigns against eggs, more warning labelson margarine, or even more exercise campaigns. Although we do need to keepresearching healthy behavior and nutrition, physiology, immunology, infections,safety engineering, and so on, that is not where many of the greatestpayoffs likely will come. Rather, the Terman data and many other sources ofinformation suggest that stable people, well-integrated socially and with theircommunity, living in a healthy culture a healthy lifestyle across the life-span will mostly have long, productive lives. But the context for each individualcannot be ignored. The bottom line is that psychosocial and behavioral factorslook different in their relation to health when they are considered across thecontext of the life-span, than they do when considered at one point in time.39Intrapersonal FactorsInterpersonal FactorsInstitutional FactorsCommunity FactorsPublic Policy Ecological Model of Health BehaviourPredisposing FactorsKnowledgeBeliefsValuesAttitudesConfidenceCapacity

Enabling Factors:Availability of health resourcesAccessibility of health resourcesCommunity/government laws, priority and commitment to healthHealth related skillsReinforcing factors:FamilyPeersTeachersEmployersHealth providersCommunity leadersDecision makers

Environment (conditions of living)Specific behaviour by individuals or by organizationsGeneticsHealthFig. This portion of the Precede-Proceed Model includes additional lines and arrows to outline a theory of causal relationships and order of causation and feedback loops for the three sets of factors influencing behaviour. In addition to the lines shown, an arrow from enabling factors to environment would elaborate the ecological aspect of factors that influence behaviour indirectly through changes in the environment. (Kreen&Kreater, 2005, p.149, with permission)Tanl Bora diyor ki;Nice zamandr Diyarbakrda fakirin derdiyle megul olan Dr. Mahmut Ortakaya yllar nce Ankarada bir tp kongresinde, benim halkm artk kanser olmak istiyor diyordu, bata verem, Krt halknn an oktan geride brakt hastalklardan ektiklerini dile getirirken.Ben de naizane, dnyann btn halklaradna, konuan hekim istiyorum! nsann kolunu tutan, gzne bakan, yanan okayan, Mahmut abi gibi hekimleri istiyorumEvet, saaltan, yapabildiince iyi eden ve mutsuzluu da tedavi eden hekimliin srr, konumadadr.

Memduh evket Esendaln Tp rencisi Oluna tleri (1930larn sonu, 40larn ba):unu da bil ki, adam doktor olunca ok bir ey bilmi olmaz. Hekimlik birok bilgilerin satrbalarn bilmek demektir. Alt taraflar keif olunmam ki? Kansere tutulmamak iin ne yapmal? Hi belli deil. Tutulunca ilac nedir? Bilinmiyor.Mikroplar ve beden mukavemeti? Bir karanlk i? Yalnz adamlar doktoru, biliyor sanrlar ve doktor bundan istifade ederek onlar avutur! Gene lecek olur ancak doktor da avutacan avutur. Hekimliin adam gvdesi ve onun sal hakknda insanln neler bilmediini renmek olduuna inan! Ancak adamn nabzn tutmak, ona bir gler yzle bakmak, onu dinlemek bu zavall adamlara bir byk yardmdr.

Hekim olmann birinci art, st ba temiz ve ok nazik ve sevimli olmaktr. Kaba saba, pis, eek hekim olmaz. Hekim,yrei acyan, yz glen, kendisi samimi olan adamdr. Bunu herkes kendine yaktrp yapmal. Agzl, paragzl hekim be para etmez. Para kendiliinden gelir. Az geldii olursa, ok geldii de olur.Bu hekimlikte sana iki szm, u iki eyi tutmaktr: Biliyorum deye hastay muayene etmemezlik etme. Kzp hastaya kt muamele etme. Senden eyilik umarak gelmi adam incitmek olmaz, isterse yalanc ve yapmack olsun. TEEKKRLER.