Promoting Wellness as a Primordial Prevention Strategy for Achieving Sustainable Public Health in the Post-Covid 19 Era

Abstract

The global scenario of a contracted economy over 4% and distraught healthcare systems due to the 2019 pandemic behooves us to redesign our strategies to move towards holistic approaches that allow health and wellbeing to be uniquely viewed within their contexts, promising sustainability. World-over, communities are more aware of the connectedness with nature and the role of positive behaviors. Disproportionate investments go into secondary and tertiary cure in healthcare systems and there is a minimal uptake of primary prevention. Investments in primordial prevention (PP) that can help achieve sustainable health are inadequate. PP is defined as an approach that prevents the risk factors for disease conditions from manifesting through maintenance of good health by embracing healthy environment, diet, and lifestyle behaviors, to function optimally. We propose integration of wellness as a primordial prevention strategy for sustainable public health using the 3 Ps: People, Places, and Policies/Programs. Wellness is holistic and multi-dimensional and is a primordial prevention concept as it focuses on people thriving based on a positive approach to health. The authors point out that the stumbling block in public health is due to unsustainable behavior as a result of misplaced priorities.

“The healthcare providers have a moral obligation to maintain a continued awareness of our patient’s beliefs, background, and values.”

Introduction

There is general consensus worldwide that it is imperative to move healthcare services outside of the hospital into homes and communities, particularly post-pandemic. ¹ Incremental exposure to stress, culturally discordant and unsustainable anthropocentric behaviors, and a polluted environment have pushed humans to require higher levels of care during and post COVID-19 pandemic.

This article highlights the earnest need in redefining people’s (providers, patients, and the population) view of health from absence of disease to health being holistic, multi-dimensional, life-course centered, culturally relevant, underpinning wellness centered care conceptualized as a PP strategy. Primordial preventive and preservative behaviors include activities that build health through positive individual and social obligations that can be achieved through the wellness approach. COVID’s milder impact among the Japanese revealed behaviors and culture that are fundamentally encoded in their way of living. Ikigai of the Japanese is in concept primordial prevention in action.

A common thread is the underlying immunity and vitality built through consumption of locally and seasonally available, traditional, non-processed food; exposure to less polluted, greener environment; fostering a culture of strong networks and practicing stress-free living while having a deep belief in local and traditional ways of living. Practicing these health promotive and health-sustaining behaviors throughout their life-course would lead to a status of zero-risk factors introducing the concept of a high-level of wellness previously expounded by Halbert L Dunn ² as well as established by traditional systems of medicine since time immemorial.

Wellness as Primordial Prevention Strategy

We posit that wellness is a suitable primordial prevention strategy. The underlying premise of Dr. Dunn’s concept is that of vitality, and high-level of wellness and was defined as an integrated method of functioning oriented towards maximizing the potential of the individuals within the total lived environment. Strategies to promote Wellness can be achieved by focusing on the 3 Ps: (1) The People (2) The Places and (3) The Policies/Programs.

The People who should be involved in promotion of wellness as the primordial prevention strategy include Family members, teachers, physicians/healthcare providers, and policy makers to name a select few; however, everyone in this ecosystem can be a catalyst in primordial promotion.

Transgenerational transfer of knowledge about ways of life is critical in sustaining health practices that have served communities and countries over time, encompassing cultural practices of each Household and norms of the local community regarding food and nutrition, exercise, circadian rhythm, respect for people and the planet to list a few. For example: During COVID 19, the importance of turmeric as a protective factor was promoted among many households in India.

Also, the importance of individual health and social education cannot be underrated in facilitating opportunities for students. Increasingly the teaching workforce is being recognized as crucial in promoting health and wellbeing with WHO joining the effort by recommending a Health promotion framework, integrating holistic health education goals.

Physicians and other allied healthcare workers need to be indoctrinated about primordial and primary prevention while in medical school and also learn about alternate systems of health which would mainstream wellness as a primordial prevention strategy. Furthermore, there is a need to change the prevailing perception among physicians about being part of a “health” care system and not a “medical” care system by paying as much attention to health and wellbeing as it is done to disease and for doctors to learn more about food as medicine ³ and promote medical education that fosters a collaborative inter-professional environment across different healing systems.

Finally, Policy Makers are pivotal in transforming our health ecosystems and advocate for wellness as primordial prevention strategy. Wellness promotion should be prioritized as a national strategy followed by dedicating outlay of funds which will convey the magnitude of its significance to the different stakeholders including the population, thereby mainstreaming primordial prevention. It is well documented in Vision China 2030 on the role of government in shifting from a systems thinking approach to action oriented approach.

1) The Places: The various locations where wellness can be operationalized forms the context for implementing the programs and policies.

The places that become the context for these programs are a) Home: Behavioral norms both positive and negative are learned at home, a social setting where simultaneous group and individual process takes place. Being an organized and valued physical space, home provides people with specific environmental cues, opportunities, and obligations. ⁴ Research studies have highlighted the role of the cultural practices that were followed during COVID that helped respective communities to stay COVID free.

b) Schools and Colleges are critical to learning positive behaviors through peer interaction and through influencers in the form of teachers and mentors. For example, the social norms about smoking and tobacco use were successfully combated through tobacco prevention programs in Schools.

c) Workplaces: Workplaces can be a crucial space where screening for risk factors can become an annual routine for the employers. Peer learning and social support is instrumental in the success of the program. Many employers, through corporate wellness programs offer gyms, yoga therapy etc. that are effective in reinforcing preexisting ideal behaviors and through peer influence help sustain optimal behaviors.

d) Places of recreation/worship: These are spaces that can help connect people with the power of nature. These serve in deepening bonds with the land and the environment. In Japan, the practice of shinrin-yoku, “taking in the forest” or “forest bathing,” first appeared in public health in the 1980s and is promoted for mental health nowadays. Furthermore, studies have established that religious involvement and spirituality are associated with better health outcomes, including greater longevity, coping skills, and health-related quality of life and less anxiety, depression, and suicide.

e) Wellness centers and Hospitals: These places can serve as opportunities to rebrand health and reiterate wellness behaviors through every encounter with a patient and their family. Hospitals as secondary and tertiary care centers can be complemented with wellness centers which ideally can provide Primary Healthcare and reiterate primordial care where applicable. In India, there has been a push towards mainstreaming health and wellness with Ayushman Bharat (https://ab-hwc.nhp.gov.in/) which will deliver Comprehensive Primary Health Care, with a focus on wellness and the delivery of an expanded range of services closer to the community.

f) The Natural Environment: Research findings reveal that urban green and blue areas aid in stress recovery and promote physical activity. They offer spaces for social interactions in the neighborhood and places for children’s play. In an urban space, a tree canopy cover reduces the urban heat island effect while it helps prevent further environmental damage by reducing use of Air Conditioning.

3) The Policies and Programs: Considering the multi-dimensionality of Wellness, documenting the generational practices with regard to Maternal and Child health has helped in understanding the influence at the family level as highlighted by the grandmother project in African communities and there is merit in promoting local traditions for, they are sustainable and in time of crises people always resort to the tried and tested.

Policies and programs to integrate wellness and PP in the systemic functioning of schools and colleges will help children and young adults to appreciate the value and adopt them in their future lives. Programs such as the University Wellness Program (UWP) offer structured pedagogical methods to apply learning to designing and implementing appropriate programs for better wellness outcomes for young adults.

Workplace wellness programs when designed by the employees, offering smart incentives, building accountability by measuring the right things while building a culture of health endorsed by management will encourage behavior change while sustaining positive behaviors Organizational policies such as no smoking, using helmets on campus, promoting physical activity through gyms and programs such as yoga, dance etc. offer a health promoting ecosystem coupled with promotion of leisure and work-life balance will steer the working population to health and wellness.

Conclusion

Initial efforts in promoting wellness require overcoming major challenges such as changing perceptions among healthcare workers including physicians followed by the general population about Illness and Wellness. There is concurrence among physicians and patients that the goal of healthcare is to promote health and well-being. However, these concepts of “health” and “wellness” are individually understood in the light of their social, cultural, spiritual, and interpersonal connotations and towards achieving the monumental task of patient-centeredness. There is a need for medical practice to reflect on having a more inclusive and holistic pursuit of healthcare goals and definitions. Furthermore, the healthcare providers have a moral obligation to maintain a continued awareness of our patient’s beliefs, background, and values.

The culture of wellbeing in healthcare cannot be separated from the culture of food, housing, politics, and every other culture. We need a new scheme which will see people in a holistic way and create appropriate mechanisms to ensure care is delivered in a personalized, effective, and sustainable manner where each of us is an investor in our own wellness thereby contributing to societal/global wellness.