37
PRIORITIES IN EDUCATING THE PUBLIC ABOUT HEALTH* ANNE R. SOMERS Professor Department of Community Medicine Department of Family Medicine College of Medicine and Dentistry of New Jersey-Rutgers Medical School Piscataway, New Jersey
W1 rHY is health education so neglected in national health policy and in the allocation of national health resources? Does it deserve to be taken seriously? The evidence as to the relation between specific forms of individual behavior, or lifestyle, and specific diseases or disabilities justifies major educational efforts to change such behavior. For example, the association between cigarette smoking and excess death rates has consistently been demonstrated during the last 30 years. It is now established that smokers have one and a half to two and a half times the overall death rates of nonsmokers. The specific diseases involved include coronary heart disease, cancer of the lungs, larynx, pharynx, oral cavity, and esophagus, chronic bronchitis, and emphysema.' A causal relation is now accepted almost without question, for example, between alcohol abuse and cirrhosis of the liver, alcohol abuse and automobile accidents, drug addiction and hepatitis. Professional opinion is not yet in total accord on the influence of diet and a sedentary lifestyle on coronary heart disease, or obesity on diabetes,3 but the evidence is that the relation can be accepted as a guide. Tremendous differences exist in death rates between the residents of Utah and Nevada, contiguous states very much alike with respect to income, climate, number of physicians and hospital beds per capita, and other variables. For example, women residents of Nevada, aged 40 to 49, experienced during the 1960s an average death rate 69% higher than their counterparts in Utah and for deaths from cirrhosis of the liver and cancer of the respiratory system the excess was 296%.4 These differences may be explained by differences in life style, *Presented in a panel, Ideology of Health Policy, as part of the 1977 Annual Health Conference of the New York Academy of Medicine, Health Policy: Realistic Expectations and Reasonable Priorities, held April 28 and 29, 1977.
Vol. 54, No. 1, January 1978
38
38
A. R. SOMERS
A. R.
SOMERS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
because Mormons, with their antipathy to tobacco and alcohol, are concentrated in Utah. As another example, Breslow and his colleagues followed 7,000 adults for more than five and a half years, and showed that seven simple habits-three meals a day at regular intervals, eating breakfast, moderate exercise, seven to eight hours sleep nightly, moderate weight, no smoking, and little or no alcohol-were associated with significantly longer life and better health.5 Considering the validity of the connection between lifestyle and health and the desirability of emphasizing more healthy behavior, we all know alcoholics who have stopped drinking, youngsters who have kicked the drug habit, and young people who have become good and sensible drivers. Different societies emphasize differing values and lifestyles and children can be molded in one direction or another. Changes probably cannot be brought about through education alone. This has been a weakness of public health education in the past, and it has worked at odds with our affluent and hedonistic society. We now seem to be moving into a period of more limited resources and probably less discretionary income which could lead to more responsible health behavior. For example, the 1973 energy crisis produced the 55-mile-an-hour speed limit and this, in turn, is credited with a substantial reduction in automobile-accident fatalities. Some types of health education have been more effective than others. For example, patient education and health education conducted in the work setting can boast a number of carefully documented success stories6 because of high motivation and competent professional assistance. On the other hand, traditional school health education has been notoriously ineffective. Some health-education programs directed to the general public have been successful, including activities of the American Heart Association and the American Cancer Society. Although the antismoking effort, starting with the Surgeon-General's Report in 1964, suffered many difficulties, including lack of full federal commitment and full professional support, there has been improvement. For example, male smokers over 21 dropped from 52.4% in 1965 to 39.3% in 1975; women smokers from 32.5% to 28.9%.7 The amount of tar and nicotine per cigarette has decreased, and the recent decline in death rates from coronary heart disease has been in part attributed to this change in adult-smoking habits.8 Bull. N.Y. Acad. Med.
EDUCATING THE PUBLIC
39
39
Probably the most carefully controlled study yet undertaken in this field is the Stanford Heart Disease Prevention Program, sponsored by the National Heart and Lung Institute.9 This five-year inquiry undertook to teach people between 35 and 59 years of age about heart risk-factor reductions in three similar California communities exposed to different mixes of television spots, printed materials, and personal instruction. According to Institute spokesmen: For the most part, the findings have been extremely encouraging. In general, Watsonville (the maximum-treatment town) has shown substantial change; Gilroy (the massmedia-only town) has changed a little, and Tracy (the control town) has changed negligibly or in the opposite direction. Moreover, within Watsonville, the intensively instructed respondents have changed more than have their randomized controls, who received our campaign messages only through the media and their mail boxes. Data regarding triglycerides, cigarette smoking, cholesterol levels, etc., led investigators to conclude that an educational campaign directed at an entire community can produce striking increases in the level of knowledge of heart disease and risk factors and very worthwhile improvements in risk factor levels.
As a probable example of the "ripple effect" emanating from such a successful program, the Gilroy Board of Education has banned the sale of "junk foods" in the town's public schools, and a bill to extend the ban throughout the state has been introduced into the California legislature. Health education alone would probably not result in any striking economies. Those who are spared from dying prematurely of myocardial infarction, lung cancer, or cirrhosis of the liver will obviously eventually die of other diseases. Some fear that health education takes all the fun and "kicks" out of life and leads to a drab neopuritanism. Studies of different ethnic, national, and socioeconomic groups or cultures document that a healthy lifestyle is not the prerogative of any one group, and longevity is associated with a wide diversity of lifestyles.10 However, a few basic ingredients appear essential: absence of serious environmental pollutants and extremes of poverty and wealth, regular physical and mental activity which does not abruptly come to an end at some arbitrary age limit, a fair degree of moderation and regularity in daily living patterns, a diet relatively low in calories, especially in animal fats, and a fairly stable family and community support system. Health education's goal is to provide people with enough information, social reinforcement, and professional assistance where needed to help them understand the factors that promote health and those that threaten it to make informed choices in their own lives. Vol. 54, No. 1, January 1978
40
40
A. R. SOMERS SOMERS
In suggesting health-education priorities, one has to consider a number of separate but mutually dependent factors: major current behavior-related risk factors, areas where there is reasonable hope of effecting positive change, and areas of current sufficient resources to undertake positive behavior-change programs. A personal list of the major risk factors might include cigarette smoking, alcohol and drug abuse, inadequate exercise, overeating, careless driving, promiscuity and carelessness with contraception, too much television, and too much stress. One might stress: cigarette smoking, patient education for diabetics and those with heart disease, alcohol and drug problems in the occupational setting, education about sex and family planning in schools, and children's television programming and advertising. Lifestyle's role as a determinant of health and education as means to change lifestyle were not so obvious in the past. The traditional view has been that health and premature death were associated primarily with poverty and lack of access to adequate health care, and only during the past few decades have the health-threatening aspects of affluence and our sedentary lifestyle become obvious. Health policy is too often dominated by interests of the health-care industry rather than that of the public. Most physicians, hospitals, appliance manufacturers, and other providers make a living out of disease, not health. With about five million Americans employed in the "disease industry," priorities will not change overnight, but we should promote a transfer of personnel and other resources from the "disease industry" to "health promotion." Congress responds to particular interests rather than the "national interest." There is no effective constituency for health education or health promotion. Conceivably, the realization of limited resources and the necessity for greater individual and social responsibility, as opposed to the overriding recent emphasis on rights, could change the picture somewhat. Perhaps we are beginning a new period of strong national leadership. It is ironic that we should approach energy conservation and health promotion as the "moral equivalent of war," but if we mean by moral something that forces Congress to override special interests, perhaps the $150 billion 1977 health-care bill will help.
Bull. N.Y. Acad. Med.
EDUCATING THE PUBLIC
41
REFERENCES 1. Center for Disease Control, National Education and Promotion Act of 1975, Report No. 94-330 to accompany S. Clearinghouse for Smoking and Health: The Health Consequences of 1466. Washington, D.C., Govt. Print. Off., 1975; Blue Cross Association: Smoking, cited in Congressional Record, January 29,1976, p. S.773. Patient Health Education. Chicago, 1974. 2. Inter-Society Commission for Heart 7. Center for Disease Control and NaDisease Resources: Primary Prevention of the Atherosclerotic Diseases. tional Cancer Institute: Adult Use of Dallas, Am. Heart Assoc. Nat. Tobacco-1975. Atlanta, Ga., 1976, chart 1. For a comprehensive review of Center, 1972. 3. National Commission on Diabetes to research in modification of cigarette the Congress of the U.S.: Long-range smoking behavior, see Bernstein, D. plan to combat diabetes. Forecast A. and McAlister, A.: The modifica(Suppl.) 28: December 1975. tion of smoking behavior: Progress and 4. Fuchs, V. R.: Who Shall Live? problems. Addict. Behav. 1: 89-192, 1976. Health, Economics and Social Choice. New York, Basic Books, 1975, pp. 8. Walker, W. J.: Government subsidized death and disability. J.A.M.A. 230: 52-54. 5. Breslow, L.: A quantitative approach 1530, 1974. See also Stamler, J. B. in to the World Health Organization in Brodu, J. E.: Drop reported in corodefinition of health. Int J. Epidemiol. nary death rate. N. Y. Times, January 1: 347-55, 1972, pp. 347-55; Belloc, 24, 1975. N. B. and Breslow, L.: Relationship 9. Maccoby, N. and Farquhar, J. W.: of physical health status and health Communication for health: Unselling heart disease. J. Comm., 25: 114-26, practices. Prev. Med. 1:409-21, 1972; 1975; Stanford University, Institute for Belloc. N. B.: Relationship of health Communication Research: Annual Repractices and mortality. Prev. Med. ports 1973-1974 and 1974-1975. Stan2:67-81, 1973. 6. Somers, A. R., editor: Promoting ford, Calif.; Farquhar, J. W. and Health: Consumer Education and NaWood, P. D.:cited in Heart disease: tional Policy. Germantown, Md., The message gets across. Med. World Aspen Systems Corp., 1976; 94th News, p. 8, February 10, 1975. Cong., 1st Sess.: Disease Control and 10. Leaf, A.: Getting old. Sci. Am. 229: Health Education and Promotion. 44-52, 1973. Hearings before the Senate Sub- 11. Breslow L. and Somers, A. R.: committee on Health, May 1975. Lifetime health monitoring: A practical Washington, D.C., Govt. Print. Off., approach to preventive medicine. N. 1975; 94th Cong., 1st Sess.: National Engl. J. Med. 296: 601-08, 1977. Disease Control and Consumer Health
Vol. 54, No. 1, January 1978
PRIORITIES IN EDUCATING THE PUBLIC ABOUT HEALTH* ANNE R. SOMERS Professor Department of Community Medicine Department of Family Medicine College of Medicine and Dentistry of New Jersey-Rutgers Medical School Piscataway, New Jersey
W1 rHY is health education so neglected in national health policy and in the allocation of national health resources? Does it deserve to be taken seriously? The evidence as to the relation between specific forms of individual behavior, or lifestyle, and specific diseases or disabilities justifies major educational efforts to change such behavior. For example, the association between cigarette smoking and excess death rates has consistently been demonstrated during the last 30 years. It is now established that smokers have one and a half to two and a half times the overall death rates of nonsmokers. The specific diseases involved include coronary heart disease, cancer of the lungs, larynx, pharynx, oral cavity, and esophagus, chronic bronchitis, and emphysema.' A causal relation is now accepted almost without question, for example, between alcohol abuse and cirrhosis of the liver, alcohol abuse and automobile accidents, drug addiction and hepatitis. Professional opinion is not yet in total accord on the influence of diet and a sedentary lifestyle on coronary heart disease, or obesity on diabetes,3 but the evidence is that the relation can be accepted as a guide. Tremendous differences exist in death rates between the residents of Utah and Nevada, contiguous states very much alike with respect to income, climate, number of physicians and hospital beds per capita, and other variables. For example, women residents of Nevada, aged 40 to 49, experienced during the 1960s an average death rate 69% higher than their counterparts in Utah and for deaths from cirrhosis of the liver and cancer of the respiratory system the excess was 296%.4 These differences may be explained by differences in life style, *Presented in a panel, Ideology of Health Policy, as part of the 1977 Annual Health Conference of the New York Academy of Medicine, Health Policy: Realistic Expectations and Reasonable Priorities, held April 28 and 29, 1977.
Vol. 54, No. 1, January 1978
38
38
A. R. SOMERS
A. R.
SOMERS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
because Mormons, with their antipathy to tobacco and alcohol, are concentrated in Utah. As another example, Breslow and his colleagues followed 7,000 adults for more than five and a half years, and showed that seven simple habits-three meals a day at regular intervals, eating breakfast, moderate exercise, seven to eight hours sleep nightly, moderate weight, no smoking, and little or no alcohol-were associated with significantly longer life and better health.5 Considering the validity of the connection between lifestyle and health and the desirability of emphasizing more healthy behavior, we all know alcoholics who have stopped drinking, youngsters who have kicked the drug habit, and young people who have become good and sensible drivers. Different societies emphasize differing values and lifestyles and children can be molded in one direction or another. Changes probably cannot be brought about through education alone. This has been a weakness of public health education in the past, and it has worked at odds with our affluent and hedonistic society. We now seem to be moving into a period of more limited resources and probably less discretionary income which could lead to more responsible health behavior. For example, the 1973 energy crisis produced the 55-mile-an-hour speed limit and this, in turn, is credited with a substantial reduction in automobile-accident fatalities. Some types of health education have been more effective than others. For example, patient education and health education conducted in the work setting can boast a number of carefully documented success stories6 because of high motivation and competent professional assistance. On the other hand, traditional school health education has been notoriously ineffective. Some health-education programs directed to the general public have been successful, including activities of the American Heart Association and the American Cancer Society. Although the antismoking effort, starting with the Surgeon-General's Report in 1964, suffered many difficulties, including lack of full federal commitment and full professional support, there has been improvement. For example, male smokers over 21 dropped from 52.4% in 1965 to 39.3% in 1975; women smokers from 32.5% to 28.9%.7 The amount of tar and nicotine per cigarette has decreased, and the recent decline in death rates from coronary heart disease has been in part attributed to this change in adult-smoking habits.8 Bull. N.Y. Acad. Med.
EDUCATING THE PUBLIC
39
39
Probably the most carefully controlled study yet undertaken in this field is the Stanford Heart Disease Prevention Program, sponsored by the National Heart and Lung Institute.9 This five-year inquiry undertook to teach people between 35 and 59 years of age about heart risk-factor reductions in three similar California communities exposed to different mixes of television spots, printed materials, and personal instruction. According to Institute spokesmen: For the most part, the findings have been extremely encouraging. In general, Watsonville (the maximum-treatment town) has shown substantial change; Gilroy (the massmedia-only town) has changed a little, and Tracy (the control town) has changed negligibly or in the opposite direction. Moreover, within Watsonville, the intensively instructed respondents have changed more than have their randomized controls, who received our campaign messages only through the media and their mail boxes. Data regarding triglycerides, cigarette smoking, cholesterol levels, etc., led investigators to conclude that an educational campaign directed at an entire community can produce striking increases in the level of knowledge of heart disease and risk factors and very worthwhile improvements in risk factor levels.
As a probable example of the "ripple effect" emanating from such a successful program, the Gilroy Board of Education has banned the sale of "junk foods" in the town's public schools, and a bill to extend the ban throughout the state has been introduced into the California legislature. Health education alone would probably not result in any striking economies. Those who are spared from dying prematurely of myocardial infarction, lung cancer, or cirrhosis of the liver will obviously eventually die of other diseases. Some fear that health education takes all the fun and "kicks" out of life and leads to a drab neopuritanism. Studies of different ethnic, national, and socioeconomic groups or cultures document that a healthy lifestyle is not the prerogative of any one group, and longevity is associated with a wide diversity of lifestyles.10 However, a few basic ingredients appear essential: absence of serious environmental pollutants and extremes of poverty and wealth, regular physical and mental activity which does not abruptly come to an end at some arbitrary age limit, a fair degree of moderation and regularity in daily living patterns, a diet relatively low in calories, especially in animal fats, and a fairly stable family and community support system. Health education's goal is to provide people with enough information, social reinforcement, and professional assistance where needed to help them understand the factors that promote health and those that threaten it to make informed choices in their own lives. Vol. 54, No. 1, January 1978
40
40
A. R. SOMERS SOMERS
In suggesting health-education priorities, one has to consider a number of separate but mutually dependent factors: major current behavior-related risk factors, areas where there is reasonable hope of effecting positive change, and areas of current sufficient resources to undertake positive behavior-change programs. A personal list of the major risk factors might include cigarette smoking, alcohol and drug abuse, inadequate exercise, overeating, careless driving, promiscuity and carelessness with contraception, too much television, and too much stress. One might stress: cigarette smoking, patient education for diabetics and those with heart disease, alcohol and drug problems in the occupational setting, education about sex and family planning in schools, and children's television programming and advertising. Lifestyle's role as a determinant of health and education as means to change lifestyle were not so obvious in the past. The traditional view has been that health and premature death were associated primarily with poverty and lack of access to adequate health care, and only during the past few decades have the health-threatening aspects of affluence and our sedentary lifestyle become obvious. Health policy is too often dominated by interests of the health-care industry rather than that of the public. Most physicians, hospitals, appliance manufacturers, and other providers make a living out of disease, not health. With about five million Americans employed in the "disease industry," priorities will not change overnight, but we should promote a transfer of personnel and other resources from the "disease industry" to "health promotion." Congress responds to particular interests rather than the "national interest." There is no effective constituency for health education or health promotion. Conceivably, the realization of limited resources and the necessity for greater individual and social responsibility, as opposed to the overriding recent emphasis on rights, could change the picture somewhat. Perhaps we are beginning a new period of strong national leadership. It is ironic that we should approach energy conservation and health promotion as the "moral equivalent of war," but if we mean by moral something that forces Congress to override special interests, perhaps the $150 billion 1977 health-care bill will help.
Bull. N.Y. Acad. Med.
EDUCATING THE PUBLIC
41
REFERENCES 1. Center for Disease Control, National Education and Promotion Act of 1975, Report No. 94-330 to accompany S. Clearinghouse for Smoking and Health: The Health Consequences of 1466. Washington, D.C., Govt. Print. Off., 1975; Blue Cross Association: Smoking, cited in Congressional Record, January 29,1976, p. S.773. Patient Health Education. Chicago, 1974. 2. Inter-Society Commission for Heart 7. Center for Disease Control and NaDisease Resources: Primary Prevention of the Atherosclerotic Diseases. tional Cancer Institute: Adult Use of Dallas, Am. Heart Assoc. Nat. Tobacco-1975. Atlanta, Ga., 1976, chart 1. For a comprehensive review of Center, 1972. 3. National Commission on Diabetes to research in modification of cigarette the Congress of the U.S.: Long-range smoking behavior, see Bernstein, D. plan to combat diabetes. Forecast A. and McAlister, A.: The modifica(Suppl.) 28: December 1975. tion of smoking behavior: Progress and 4. Fuchs, V. R.: Who Shall Live? problems. Addict. Behav. 1: 89-192, 1976. Health, Economics and Social Choice. New York, Basic Books, 1975, pp. 8. Walker, W. J.: Government subsidized death and disability. J.A.M.A. 230: 52-54. 5. Breslow, L.: A quantitative approach 1530, 1974. See also Stamler, J. B. in to the World Health Organization in Brodu, J. E.: Drop reported in corodefinition of health. Int J. Epidemiol. nary death rate. N. Y. Times, January 1: 347-55, 1972, pp. 347-55; Belloc, 24, 1975. N. B. and Breslow, L.: Relationship 9. Maccoby, N. and Farquhar, J. W.: of physical health status and health Communication for health: Unselling heart disease. J. Comm., 25: 114-26, practices. Prev. Med. 1:409-21, 1972; 1975; Stanford University, Institute for Belloc. N. B.: Relationship of health Communication Research: Annual Repractices and mortality. Prev. Med. ports 1973-1974 and 1974-1975. Stan2:67-81, 1973. 6. Somers, A. R., editor: Promoting ford, Calif.; Farquhar, J. W. and Health: Consumer Education and NaWood, P. D.:cited in Heart disease: tional Policy. Germantown, Md., The message gets across. Med. World Aspen Systems Corp., 1976; 94th News, p. 8, February 10, 1975. Cong., 1st Sess.: Disease Control and 10. Leaf, A.: Getting old. Sci. Am. 229: Health Education and Promotion. 44-52, 1973. Hearings before the Senate Sub- 11. Breslow L. and Somers, A. R.: committee on Health, May 1975. Lifetime health monitoring: A practical Washington, D.C., Govt. Print. Off., approach to preventive medicine. N. 1975; 94th Cong., 1st Sess.: National Engl. J. Med. 296: 601-08, 1977. Disease Control and Consumer Health
Vol. 54, No. 1, January 1978
