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Developing a Health Promotion Program

CHAPTER 1 Health Promotion in the New Century

CHAPTER 2 Epidemiology as the Catalyst in the Development of Health Promotion Programs

CHAPTER 3 Needs Assessment

CHAPTER 4 Program Development

CHAPTER 5 Health Promotion Program Marketing Techniques

CHAPTER 6 Program Evaluation

I PA R T

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Health Promotion in the New Century Bernard J. Healey, PhD Robert S. Zimmerman Jr., MPH

C H A P T E R O B J E C T I V E S

1 C H A P T E R

After reading this chapter, you should

• Understand the value of prevention efforts in medical care delivery • Define and explain the components of our current health care system • Become aware of the various problems found in our current medical

delivery system • Understand the problems associated with our health insurance system

Chronic diseases Health promotion Determinants of health High-risk health behaviors Epidemiology Social insurance

Introduction

Throughout the twentieth century and into the first years of the twenty-first century, there have been dramatic changes in the health of individuals and populations. A complex array of factors has contributed to these changes and their pace, and complexity will no doubt increase and significantly shape health in the future.

The Centers for Disease Control and Prevention (CDC, 1999) reported that the average lifespan of individuals in the United States has lengthened by greater than 30 years since 1900. At least 25 of these years are directly attributable to advances in public health. The CDC listed ten great public health achievements for the period 1900–1999. The list is not ranked in any

K E Y T E R M S

O B J E C T I V E S

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4 Chapter 1 Health Promotion in the New Century

particular order and was chosen based on the opportunity for prevention and the impact on death, illness, and disability in the United States.

Ten Great Public Health Achievements—United States, 1900–1999 • Vaccination • Motor-vehicle safety • Safer workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods • Healthier mothers and babies • Family planning • Fluoridation of drinking water • Recognition of tobacco use as a health hazard Source: Centers for Disease Control and Prevention. Ten great public health achievements—United States. 1900–1999. MMWR. 1999, 48:241-243.

These and other achievements of the twentieth century span what Breslow (2004) and others call the epidemiologic transition that occurred about mid- century as we moved from the first era, during which there was significant progress in addressing the presence and control of communicable diseases, to the second era marked by the prominence of noncommunicable or chronic diseases. Very significant public health progress was made against chronic dis- ease (particularly in mortality) during the second half of the twentieth century.

This brings us to the twenty-first century to what Breslow (2006) refers to as The Third Era in Health—The Pursuit of Health. He believes that one indica- tor of this era is the tremendous increase in longevity—a roughly 50% increase in longevity in the last century. This has led to a different view and idea of health or what you might call a spectrum of health. Breslow (2004) points out that increasing numbers of people are not only living longer (into their 80s, 90s, and beyond) but living with less disability than in the past. He and others call this decreased disability in later decades “the compression of morbidity.” He says this compression of morbidity can be advanced (as he and others have proven) by adherence to seven health practices: not smoking, drinking alcohol moderately or not at all, exercising regularly, getting regular sleep, maintain- ing moderate weight, eating regular meals, and eating breakfast. These may ring a bell (along with many others such as hand washing, eating more fruits and veggies, and so on) as the words of wisdom we have been hearing from our mothers (and wives, sisters) for generations. Think about it—a familiar, trusted, wise, and nurturing person with your best interests at heart with the authority and proximity to repeatedly reinforce the message. It does not get any better than the original and best health educators of all.

Stallworth and Lennon (2003) note the development of the Alameda Human Population Laboratory in 1965 and the follow-up health survey and studies establishing the benefit of these seven practices as perhaps Breslow’s greatest public health achievement. He tells them that although the evidence

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Introduction 5

points to the importance of individual initiative in health behavior change, people do have choices to make.

In Health, United States, 2007 (National Center for Health Statistics, 2007), the National Center for Health Statistics (NCHS) points out that the progress made in life expectancy and longevity is accompanied by increased prevalence of chronic diseases. Unfortunately, progress in this area is slowing down or trending in the wrong direction. They note that the improvements that have been made are not shared equally depending on income, race, ethnicity, edu- cation, and geography. They express concern about the high prevalence, among all Americans, of unhealthy lifestyles and behaviors, such as insufficient exercise and being overweight, which are risk factors for many chronic diseases and disabilities including heart disease, diabetes, hypertension, and back pain. The obesity epidemic among our youth is very troubling. I remember learning about a wonderful prevention program that set out to address the childhood ori- gins of the diseases of adulthood and realizing that we are now actually seeing adult diseases in childhood. The NCHS (2007) also notes the high prevalence of risky behaviors among children and young adults.

The State of Aging and Health in America 2007 (CDC/Merck, 2007) report makes several calls to action to encourage individuals, professionals, and com- munities to take specific steps to improve the health and well-being of older adults. They include the following recommendations:

• Address health disparities among older adults, particularly in racial and ethnic minority populations.

• Encourage people to communicate their wishes about end-of-life care. • Improve the oral health of older adults. • Increase physical activity among older adults by promoting environmen-

tal changes. • Increase adult immunizations, particularly in racial and ethnic minority

populations. • Increase screening for colorectal cancer. • Prevent falls, a leading cause of hospitalization and injury deaths among

older adults.

The Future of the Public’s Health in the 21st Century by the Institute of Med- icine (IOM, 2002) also notes the great national achievements in health dur- ing the twentieth century but expresses concern about the government public health infrastructure’s ability to meet future challenges without sub- stantial changes. It reaffirms the vision of Healthy People 2010—healthy people in healthy communities (discussed more below)—and recommends six areas of action and change in the government, private, and nonprofit sec- tors to meet future challenges:

1. Adopting a population health approach that considers the multiple deter- minants of health.

2. Strengthening the governmental public health infrastructure, which forms the backbone of the public health system.

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6 Chapter 1 Health Promotion in the New Century

3. Building a new generation of intersectoral partnerships that also draw on the perspectives and resources of diverse communities and actively engage them in health action.

4. Developing systems of accountability to assure the quality and availabil- ity of public health services.

5. Making evidence the foundation of decision making and the measure of success.

6. Enhancing and facilitating communication within the public health sys- tem (e.g., among all levels of the governmental public health infrastruc- ture and between public health professionals and community members).

The report also makes 34 detailed recommendations to what it sees as 6 pub- lic health system actors: governmental public health infrastructure, health care delivery system, community, businesses and employers, media, and academia (public health and health sciences).

A Look at Costs

The days of free health care and the waste of scarce resources on a health care delivery system that is destined to fail at keeping people healthy are also chang- ing. The rising cost of health insurance premiums (including employer- and government-financed care), the escalation in self-induced chronic diseases, and the inability to provide health care services for millions of people in the richest country in the world, are clear signals that something is radically wrong with our current health care system.

According to Price Waterhouse Coopers Health Research Institute (2009), health care spending will reach $5.2 trillion dollars by 2020 and consume 21 percent of GDP. These increased costs for health insurance are forcing employers to ask their employees to pay more for their health insurance. There has been a 6% increase in the share of premiums paid by workers in recent years. Business owners contacted in the same survey indicated that there will probably be an increase in health care expenditures for employees every year into the future.

This same study revealed that 20% of these employers plan to hire fewer workers this year because of rising health insurance costs. As health care costs continue to rise above the inflation rate, everyone from state and federal leg- islators to the owners of businesses are struggling to reduce the costs associ- ated with delivering health care services to their respective constituents.

On the government side, the Congressional Budget Office (2007) calcu- lates that in 2006, Medicare benefit payments totaled $374 billion, account- ing for 13% of federal spending, and they project net spending on Medicare to increase to $564 billion in 2012. The Kaiser Foundation (Kaiser Com- mission, 2007) cites many financing challenges to Medicare in the future due to the aging of the U.S. population, declining ratio of workers to benefi- ciaries, increasing health care costs, and other economic factors. The Kaiser

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Changes in the Concept of Health Insurance 7

Commission Medicare Primer (2007) quotes the total federal and state spending on Medicaid in 2005 at $316.5 billion and that although federal government funds about 57% of those expenditures, the remaining 43% is funded by the states and amounts to about 18% of their general funds sec- ond only to education.

Breslow (2006) questions how we spend our money in relationship to its impact and influence on health. He says that many of the best studies show that access to medical care is seen to have about 10% of the influence on health status but 88% of the money goes to Medicare. Whereas health behaviors indicate about 50% of the influence but only 4% of the money is spent on health behaviors.

Changes in the Concept of Health Insurance

The health insurance industry is also changing in the early years of this new century. Feldstein (2003) argues that individuals buy health insurance to pass risk on to others because of the uncertainty of illness and the inability to pay the costs if long-term illness occurs.

More and more employers are asking whether they can afford health insur- ance for their employees and whether this health insurance is worth what it costs. The cost of the insurance does not seem to be as important as the fact that the current health care delivery system is plagued by failures in prevent- ing the development of expensive chronic diseases in the insured population.

The health care system must face radical change in the next few years or the best health care delivery system in the world will go broke. This sounds very similar to the crisis we face in social security over the next several years. Trust for America (2009) argues that health insurance costs are rising at such a rapid rate that if not stopped, they will eliminate all profits for the average Fortune 500 company in the next several years. It seems like an opportune time for employee wellness programs to be considered by employers as a potential solution to the crisis.

Insurance is generally classified as casualty or social insurance. Casualty insurance is found in car or home insurance and has worked very well as long as most people practice safety measures concerning automobile and home use. Social insurance usually ignores risks and shares the costs equally among participants. Enthoven and Fuchs (2006) argue that a change from the con- cept of social insurance, where excess costs of high-risk behaviors are shared collectively, to health insurance based on actuarial principles, where the price for insurance is based on predictable risky behaviors undertaken by some indi- viduals, is going to be the norm. In other words, you will be charged a higher premium for health insurance if you practice high-risk health behaviors.

Legislators are focusing on the tremendous number of Americans with- out access to the health care system. Barton (2003) states there must be incremental changes to health insurance plans if access to health insurance by the uninsured is ever going to happen.

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The problems faced by the health care system in this country are not sim- ply access issues. The ability to enter the health care system is not what is required to keep people healthy. It is the ability to avoid behaviors that cause illness that is the real problem for Americans. This ability to choose healthy behaviors is not currently provided by a collection of health care facilities. It is a question of access to information at an early age that can potentially shape the development of better health behaviors and carry them through the process of aging.

Busch, Barry, Vegso, Sindelar, and Cullen (2006) found one way of deal- ing with the escalation in the cost of health insurance entailed in an innova- tive approach by Alcoa. In order to reduce costs of health insurance, Alcoa increased employees’ cost sharing. In January 2004, this company increased enrollees’ cost sharing for many outpatient and hospital services while simul- taneously eliminating all cost sharing for a large number of preventive ser- vices. This move by a large employer indicates their awareness of the value of preventive care as an investment in the future health of their employees.

These developments in the escalation of health care costs and the chang- ing health insurance industry to provide incentives to practice healthy behaviors or to pay more for the insurance are providing an atmosphere of opportunity for well-developed health promotion programs for the school, the community, and the workplace.

State and federal governments are beginning to increase the use of incen- tive payments to providers of government sponsored care along with a variety of other initiatives designed to incorporate health promotion and disease pre- vention services and principles. The National Governors Association (2007) notes that states, impatient with lack of progress at the national level, are increasingly pursuing health care reform as a priority and seeking ways to achieve quality improvement in health care delivery by incorporating preven- tion and wellness into their health plans, and using information technology to further improve health care. The Healthy States Initiative, a partnership among the CDC, the Council of State Governments (CSG), the National Black Caucus of State Legislators, and the National Hispanic Caucus of State Legislators, has produced an excellent work titled State Official’s Guide to Wellness (CSG, 2006) among other resources to help provide state leaders with information upon which to make sound public health decisions.

The Healthy People Concept

There has always been an interest in the prevention of health problems by many in this country. This interest is evident when we look at the strong sup- port for the elimination of childhood diseases through the funding of vaccine development and distribution by public health departments. Unfortunately, there has been a reluctance to move past children and young adults with well-developed prevention programs.

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The Healthy People Concept 9

The concept of healthy people began in 1979 as the result of a report by the Surgeon General of the United States titled The Surgeon General’s Report on Health Promotion and Disease Prevention. This report was respon- sible for the start of a national discussion on the relationship of personal health behaviors in the development of many serious diseases and injuries. Healthy People 2010 is a set of health goals and objectives for the nation to achieve by the year 2010. It includes 467 health improvement objectives in 28 focus areas. The focus areas established for Healthy People 2010 are shown in Table 1-1 (U.S. Department of Health and Human Services [DHHS], 2000).

Table 1-1 Healthy People 2010 Source: U.S. Department of Health and Human Ser- vices. Healthy People 2010 (2nd ed.). With Under- standing and Improving Health and Objectives for Improving Health (2 vols.). Washington, DC: U.S. Gov- ernment Printing Office.

Healthy People 2010 Objectives at a Glance

Healthy People 2010 consists of 467 target objectives organized into 28 broad focus areas, as follows:

• Access • Arthritis, osteoporosis, chronic back • Conditions • Cancer • Chronic kidney disease • Diabetes • Disability and secondary conditions • Environmental health • Educational and community-based programs • Family planning • Food safety • Health communication • Heart disease and stroke • HIV–AIDS • Immunization and infectious diseases • Injury–violence prevention • Maternal, infant, child health • Medical product safety • Mental health and mental disorders • Nutrition and overweight • Occupational safety and health • Oral health • Physical activity and fitness • Respiratory diseases • Public health infrastructure • Sexually transmitted diseases • Substance abuse (including alcohol) • Tobacco use • Vision and hearing

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10 Chapter 1 Health Promotion in the New Century

Determinants of Health

Improving the health of the population requires consideration and a better understanding of the various components that determine good or poor health. Although one of the major influences on health is the receipt of health services, it has become very clear to those in public health that there are other factors that determine good health that are of equal, or perhaps greater, importance than the health care system. Topics covered by the objectives in Healthy People 2010 reflect the array of critical influences that determine the health of indi- viduals and communities. For example, individual behaviors and environmen- tal factors are responsible for about 70% of all premature deaths in the United States (DHHS, 2000). Developing and implementing policies and preventive interventions that effectively address these determinants of health can reduce the burden of illness, enhance quality of life, and increase longevity.

Individual biology and behaviors influence health through their interac- tion with each other and with the individual’s social and physical environ- ments. In addition, policies and interventions can improve health by targeting factors related to individuals and their environments, including access to quality health care.

Biology refers to the individual’s genetic makeup (those factors with which he or she is born), family history (which may suggest risk for disease), and physical and mental health problems acquired during life. Aging, diet, physical activity, smoking, stress, alcohol or illicit drug abuse, injury or vio- lence, or an infectious or toxic agent may result in illness or disability and can produce a “new” biology for the individual.

Behaviors are individual responses or reactions to internal stimuli and external conditions. Behaviors can have a reciprocal relationship to biology; in other words, each can react to the other. For example, smoking (behavior) can alter the cells in the lung and result in shortness of breath, emphysema, or cancer (biology) that then may lead an individual to stop smoking (behav- ior). Similarly, a family history that includes heart disease (biology) may motivate an individual to develop good eating habits, to avoid tobacco, and to maintain an active lifestyle (behaviors), which may prevent his or her own development of heart disease (biology).

Personal choices and the social and physical environments surrounding individuals can shape behaviors. The social and physical environments include all factors that affect the life of individuals, positively or negatively— many of which may not be under their immediate or direct control.

Major Determinants of Health • Individual behaviors • Environmental factors

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Determinants of Health 11

Social environment includes interactions with family, friends, cowork- ers, and others in the community. It also encompasses social institutions, such as law enforcement, workplaces, places of worship, and schools. Hous- ing, public transportation, and the presence or absence of violence in the community are among other components of the social environment. The social environment has a profound effect on individual health, as well as on the health of the larger community, and is unique because of cultural cus- toms; language; and personal, religious, or spiritual beliefs. At the same time, individuals and their behaviors contribute to the quality of the social environment.

Physical environment can be thought of as that which can be seen, touched, heard, smelled, and tasted; however, the physical environment also contains less tangible elements, such as radiation and ozone. The physical environment can harm individual and community health, espe- cially when individuals and communities are exposed to toxic substances; irritants; infectious agents; and physical hazards in homes, schools, and work sites. The physical environment also can promote good health, for example, by providing clean and safe places for people to work, exercise, and play.

Policies and interventions can have a powerful and positive effect on the health of individuals and the community. Examples include health promo- tion campaigns to prevent smoking; policies mandating child restraints and safety belt use in automobiles; disease prevention services, such as immu- nization of children, adolescents, and adults; and clinical services, such as enhanced mental health care. Policies and interventions that promote indi- vidual and community health may be implemented by a variety of agencies, such as transportation, education, energy, housing, labor, justice, and other venues, or through places of worship, community-based organizations, civic groups, and businesses.

The health of individuals and communities also depends greatly on access to quality health care. Expanding access to quality health care is important to eliminate health disparities and to increase the quality and years of healthy life for all people living in the United States. Health care in the broadest sense not only includes services received through health care providers but also health information and services received through other venues in the community (DHHS, 2000).

The determinants of health—individual biology and behavior, physical and social environments, policies and interventions, and access to quality health care—have a profound effect on the health of individuals, communi- ties, and the nation. An evaluation of these determinants is an important part of developing any strategy to improve health.

Our understanding of these determinants and how they relate to one another, coupled with our understanding of how individual and community health affects the health of the nation, is perhaps the most important key to achieving our Healthy People 2010 (DHHS, 2000) goals of increasing the quality and years of life and eliminating the nation’s health disparities.

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Value of Healthy People 2010

The healthy people process allows for continuous feedback regarding progress toward short-term and long-term goals and objectives toward better health for constituents. The determinants of health and the health status of the population allow communities to focus on the real cause of the health problems rather than wasting resources on the symptoms of the problems. The key to the healthy people concept is the premise that the personal habits and behaviors of individuals are the key determinants in whether or not that individual will remain well or become ill later in life.

Dever (2006) argues that support for using this framework to address health problems is based on the fact that the objectives must be supported by scientific evidence and also be prevention oriented. Therefore, the program is driven by sound epidemiological principles that can withstand criticism. It allows prevention to go beyond health systems and gate keepers, and into the community or workplace.

The healthy people approach utilizes expertise from many disciplines in dealing with diseases and their complications that are primarily the result of lifestyle behaviors. Dever (2006) also points out that because individual behaviors and environmental factors are responsible for about 70% of all pre- mature deaths in this country, it stands to reason that the health care system will deal with these problems “downstream” after they have already occurred because that is where they see patients. In order to prevent these problems “upstream,” there needs to be a concentrated effort of prevention supported by the community partnerships. In public health, the upstream approach looks for the cause of disease and disability and attempts to prevent the prob- lem rather than treat it downstream. These prevention efforts over time can reduce the burden of illness and enhance the quality of life.

High-Risk Health Behaviors

Turnock (2004) believes that a synonym for public health is prevention, which he defines as actions that are taken to reduce the possibility that something will happen.

Prevention can also minimize the damage if something bad does hap- pen. The main problem with prevention activities is found in the fact that

Three Levels of Prevention • Primary • Secondary • Tertiary

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High-Risk Health Behaviors 13

it is difficult to know if you were successful in your prevention activities. How do you measure something that did not happen?

One of the things that a public health system should be doing is promot- ing healthy behaviors. This activity includes behavioral risk factor monitor- ing, school and work site health promotion, community-wide risk reduction programs, health education, and media involvement. Public health depart- ments attempt to do all of these things with a very limited budget, limited staff, and many other mandated programs to manage at the same time.

Satcher (2006) points out that the World Health Organization published a report in 2000 on the “health system efficiency,” comparing the United States with 189 other countries. Despite spending more than any other country on health care, the United States was ranked seventh in overall health system efficiency. One of the major reasons for this poor performance was the fact that this spending lacked balance with population-based prevention. How ironic it is that a country that is so generous in sharing its public health exper- tise with third world countries does not practice the same public health knowledge in most of its own sectors.

The escalation of chronic diseases as America grows older is placing high- risk health behaviors in the forefront of any attempt to deal with the rapid costs found in our current health care delivery system. McGinnis (2006) argues that these costly chronic diseases require behavioral interventions involving public health incentives and education with strong reinforcement and constant monitoring by health care providers. This intervention ideally should begin very early in life, long before the behaviors begin.

McGinnis and Foege (1993) point out that daily habits like smoking, inactivity, diet, and alcohol use and their consequences contribute to the development of virtually all of morbidity and mortality in industrial nations. Adopting healthy behaviors such as eating nutritious foods, being physically active, and avoiding tobacco use can prevent or control the devastating effects of these diseases.

Figure 1-1 offers a very good example of the use of epidemiology as a necessary adjunct to developing a better understanding of the need to sepa- rate the symptoms from the real problem when dealing with disease and dis- ease causation. These figures also reveal the behavioral aspects of chronic disease development.

McGinnis, Russo, and Knickman (2002) point out that we know behavioral choices are responsible for at least 900,000 deaths annually. These deaths are

Leading Causes of Mortality • Tobacco • Physical inactivity • Diet

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usually premature and preceded by loss of quality of life because of illness. These daily choices of the practice of high-risk health behaviors account for the vast majority of chronic diseases that are manifested in the individual later in life. According to Turnock (2009), despite all the health improvements achieved through prevention efforts, the country is still plagued by large numbers of premature diseases, disabilities, and deaths that could have been prevented.

We have developed a health care delivery system in the United States that is designed to respond to a medical emergency. The system is predisposed to wait for an uninformed patient to enter the system after a medical event has occurred. There should also be aggressive intervention even after the high-risk behaviors have been practiced for many years. There is strong epidemiological evidence that stopping high-risk behaviors can prevent or lessen the long-term complications that usually result from practicing high-risk health behaviors.

Diseases of the heart

All cancers

Stroke

Chronic obstructive pulmonary disease

Unintentional injuries

Diabetes mellitus

Alzheimer’s disease

Nephritis and nephrosis

Influenza and pneumonia

0 10 20 30 40

Causes of death in the United States Most common, 1999

Percentage of all deaths

Actual, 1990

Tobacco use

Alcohol use

Infectious agents

Poor diet / lack of exercise

Ollutants/toxins

Firearms

Motor vehicle crashes

Illicit drug use

Risky sexual behavior

0 10 155 20

Figure 1-1 Comparison of Most Common Causes of Death and Actual Causes of Death Source: Centers for Disease Control and Prevention, National Center for Health Statistics. (1997). National Vital Statistics System and unpublished data.

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Chronic Diseases 15

Chronic Diseases

The diseases facing Americans have changed dramatically since 1900. According to Brownson, Remington, and Davis (1998), the disease state in the United States has shifted from communicable diseases to chronic diseases that pose different threats to the public health. Although life expectancy has increased by over 40 years since 1900, the chronic diseases are capable of affecting the quality of life as one ages in this country.

Dever (2006) argues that the use of epidemiology has become very important among the methods of advancing the concept of risk in the cau- sation of chronic diseases. He believes that in many cases high-risk health behaviors virtually guarantee the future development of expensive and deadly chronic diseases. These diseases are usually a result of one’s lifestyle, which may include high-risk health behaviors.

Figure 1-2 shows the progression of the disease state for a communicable dis- ease. Once you adjust for a longer incubation period for most chronic diseases,

TIME

Susceptible Host Subclinical

Disease Stage

Clinical Disease Stage Stage of Recovery, Disability, or Death

Diagnosis sought

Onset of symptoms

Serious cases hospitalized

Point of exposure Beginning of

pathological process and changes within the body

Figure 1-2 Natural Course of a Communicable Disease Source: Merrill, R. M., & Timmreck, T. C. (2006). Introduction to epidemiology (4th ed.). Sudbury, MA: Jones Bartlett Publishers.

Chronic Diseases • Long incubation period • No cure • Caused by high-risk health behaviors

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the same model can be used for studying a chronic disease. Following this model, a susceptible host would be anyone who practices high-risk health behaviors. In the case of tobacco use, it would also include anyone exposed to secondhand smoke from the tobacco user. The incubation period begins at first exposure and continues until the clinical disease stage. The last stage can include the same potential outcomes as a communicable disease—recovery, disability, or death.

Chronic diseases are noncontagious, have a long latency period, and are usually not curable. These diseases are usually caused by human behaviors, which, once developed, are very difficult to change. Tobacco use, poor nutrition, and physical inactivity are the main causes of chronic diseases. Once these diseases develop, they are virtually impossible to eliminate. They just continue to get worse as the individual ages and eventually become the catalyst in the individual’s disability or death.

The CDC (2007) reports that today, chronic diseases, such as cardiovas- cular disease, cancer, and diabetes, are among the most prevalent, costly, and preventable of all health problems. Each year, 7 out of 10 Americans die from a chronic disease, and the costs associated with these diseases represent over 75% of our health care bill every year.

Because the incubation period of chronic diseases is usually years before onset of illness, it is very difficult to always determine the cause of these dis- eases. The best that can be done is to look at known risk factors and draw conclusions from the available data. It seems certain that most of these chronic diseases were acquired during the work years and could have been prevented in many cases at the workplace.

Brownson et al. (1998) argue that the concept of control has a different meaning when attributed to a chronic disease than it does for a communica- ble disease. A chronic disease interferes with good health long before this type of disease interferes with the length of life. Along with the direct costs associated with this type of disease, one must consider the indirect costs of pain, suffering, and disability that are also part of the chronic disease before it causes death.

Health Promotion

Health education is defined as the way that individuals and groups of people learn about good and bad health behaviors. Health promotion represents an enabling process to help people increase their control over their health by going beyond lifestyles to everything that can possibly affect one’s health. There has always been a rising expectation concerning the value of health services, especially treatment for conditions that already exist. This belief has helped to shape our health care delivery system in this country into a provider of care after illness occurs. Because the individual has a primary role in deter- mining his or her wellness before entering the health care system, the critical ingredient for good health in this country has become information.

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Health Promotion 17

McGinnis et al. (2002) argues that a major factor affecting investment in health promotion initiatives has been gaining consensus in decisions on what should be done to change high-risk health behaviors and how to mea- sure the effectiveness of these new initiatives. Another reason for reluctance to embrace health promotion as a potential strategy to reduce both the inci- dence and complications of chronic diseases has been a misunderstanding, by even those in public health, of the real meaning of health promotion.

According to Timmreck (2003), the concept of health promotion was an outgrowth of several disciplines, including school health education, public health, medicine, and psychology. Timmreck (2003) defined health promo- tion as the “science and art of helping people change their lifestyle to move toward a state of optimal health.” O’Donnell (1989), in his expanded defini- tion, goes on to define optimal health as a balance of physical, emotional, social, spiritual, and intellectual health. The prevention of disease is the over- riding concern in the evolving concept of health promotion as a discipline.

Laverack (2005) believes there is a great deal of disagreement among health educators as to the best definition of health promotion. It seems most authorities on the subject of health promotion believe it involves a struc- tured effort to prevent disease and to promote good health rather than an attempt to fix health problems after they develop. Others focus on prevent- ing the complications that usually arise from the disease once it occurs.

For example, type 2 diabetes is a chronic disease, but it is the complications from this disease that causes disability and premature death. The high-risk health behaviors that caused the disease are also responsible for causing the complications that ultimately result in disability and death from the disease.

Anspaugh, Dignan, and Anspaugh (2000) point out that health promo- tion programs usually spend a great deal of attention and focus on individual responsibility for their health. Easterling, Gallagher, and Lodwick (2003) argue that health promotion is a prevention strategy that needs to involve the community in the prevention effort.

Barton (2003) believes that the goal of health promotion is the achieve- ment of optimal health, but that goal is not a very great concern to a health care system that spends the majority of its resources on curative medicine. In fact, the current system of health care services is not even trained in pre- venting things that have not happened. The system is educated to respond to crisis intervention when a patient is very ill.

Barton (2003) believes that two factors affect the success of health pro- motional activities. They are the individual’s awareness of the danger associ- ated with a poor lifestyle choice and the aggressiveness of the individual in seeking healthier behaviors.

According to McGinnis et al. (2002), about 95% of health care expenses go to direct medical services while only 5% goes to population-based health improvement. It seems that the major reason that our current health care system is not delivering high-quality good health is because the expenditures are being spent on individuals who are already ill and not on preventing that illness from occurring in the first place.

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McGinnis (2002) argues that human behavior contributes to approxi- mately 40% of premature mortality in this country. It seems obvious that more attention and resources need to be made available to the behavioral aspects of disease, disability, and premature death.

Laverack (2005) argues that there are five approaches to health promotion discussed in the literature: the medical approach, the behavioral–lifestyle approach, the educational approach, the client-centered approach, and the socioenvironmental approach. Anspaugh et al. (2000) describes health pro- motion in terms of purposeful activities that are designed to improve personal and public health. The focus in this definition is on individual responsibility after health information is provided. The individual workplace and commu- nity become empowered through the availability of accurate understandable information about how to maintain good health and to avoid disease. Health education requires individuals to be educated about their health. The health educator uses specific educational strategies to enlighten individuals and even communities about their health.

McKenzie, Neiger, and Smeltzer (2005) argue that health promotion is a larger concept than health education. Thus, health promotion includes many more concepts that are important to good health along with the edu- cational piece of the puzzle. McKenzie et al. (2005) also points out the involvement of change, individual responsibility, and motivation in the assumption of a potentially successful health promotion program.

After review of arguments about whether individuals of society bear pri- mary responsibility for individual health, Minkler (1999), like Breslow (2004), Stallworth, and Lennon (2003), strikes a balance between individual and social responsibility. The World Health Organization says that health promotion is the process of enabling people to increase control over, and to improve, their health. It goes on to state the following:

Health promotion represents a comprehensive social and political process, it not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmen- tal and economic conditions so as to alleviate their impact on public and indi- vidual health. Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. Par- ticipation is essential to sustain health promotion action. The Ottawa Charter identifies three basic strategies for health promotion. These are advocacy for health to create the essential conditions for health indicated above; enabling all people to achieve their full health potential; and mediating between the different interests in society in the pursuit of health (WHO, 1998, p. 11–12).

The Institute of Medicine publication, Promoting Health—Intervention Strategies from Social and Behavioral Research (IOM, 2000), found the diffi- culty of any one intervention or set of interventions to address all behavioral and social influences and encouraged the use of multiple approaches.

Health promotion is therefore a mechanism to empower large numbers of people in the school, workplace, and community to remain healthy and to

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avoid illness and disease. This goal is accomplished through the sharing of accurate information about the long-term effects of high-risk health behav- iors. Health promotion is not a panacea and will never change everyone, but in time, it can change the majority and that will postpone, if not end, the health care crisis in America. This helps to identify targets where the most effective intervention measures can be applied.

CONCLUDING R E M A R K S

The health care delivery system in the United States has reached the crisis stage. The escalating costs of health care insurance and the employer’s desire to pass these costs on to employees have increased the incentives for action on this crisis. This crisis and the advancements in the art and science of health promotion make it imperative to reduce the escalation of resources being devoted to illness and disease and to increase attention and resources to wellness.

There is an increasing body of evidence of the real value of health promotion for individuals and society, and that without it society will be increasingly plagued with chronic diseases. These chronic diseases with their disability and loss of quality of life as we age have the ability to turn the newly acquired length of life for Americans into a nightmare of pain and suffering that is largely avoidable.

We have a responsibility to insist on, deliver, and support sound evidence- based health promotion strategies and programs and to affect public and private sector policies and decisions to improve on both longevity and quality of life for all Americans throughout the twenty-first century. The text that follows in this book provides both instructions on process and technique and substantive examples of how they are being put into practice.

DISCUSSION QUESTIONS

1. What is the difference between health education and health promo- tion programs?

2. Name and explain the three levels of prevention. 3. What are the major determinants of health in the United States? 4. What do we mean by upstream and downstream health care delivery?

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