3. WELLNESS PROMOTION
PRACTICE: TOWARD MORE
COMPREHENSIVE APPROACHES
Part 3 extends the discussion of innovative wellness promotion strategies into the realm of making recommendations for practice. Minkler (chapter 13) discusses some of the issues that have been inadequately addressed in past wellness programs, including the role of social inequities in determining health status, the empowerment of communities to participate in health planning, and the unanticipated consequences of health promotion efforts. She provides a specific example of a program wherein the health behaviors of elderly residents in a highcrime neighborhood are enhanced by increasing their sense of personal security through community-level changes. The needs of the elderly also are addressed by Duxbury (chapter 15) and Beck (chapter 16), with the former discussing the pros and cons of cancer screening and the latter focusing on the prevention of disability through comprehensive assessment techniques. The arguments put forth by Duxbury against populationwide prostate cancer screening provide an illustration of Minkler's point concerning the unanticipated consequences of health promotion, while Beck's description of the need to include social and environmental assessments in concert with medical assessments to effectively prevent disability in the elderly exemplifies one possible effect of a “person-centered” approach on clinical practice.
Within the context of educational institutions, Slavin and Wilkes (chapter 17) present an approach toward restructuring the medical school curriculum to promote a person-centered approach among physicians,
Finally, Zhu and Anderson (chapter 14) provide an example of an intervention that melds the clinical and public health approaches into an integrated program to promote smoking cessation. The Smokers' Helpline combines the intensity of the clinical approach with the accessibility and low cost associated with the public health approach to achieve meaningful and cost-effective change at the population level. Moreover, the way that the program was conceived and the feature that allows callers to choose from a menu of preferred services reflect Minkler's point concerning the value of involving communities in the planning of programs that are designed to promote their health. Altogether, part 3 serves to illustrate some of the ways that nontraditional perspectives may lead to highly effective health promotion practice.
13. HEALTH PROMOTION
AT THE DAWN OF THE 21ST CENTURY
Challenges and Dilemmas
Meredith Minkler
Recent discussions of the challenges facing health promotion in the United States have focused heavily on the advantages and disadvantages of managed care and where health promotion and disease prevention may fit in our rapidly evolving health care system. Although such deliberations are important, little attention has been devoted in these discussions to how we as a society can make the necessary changes to significantly improve the health of the American people.1 This larger question goes well beyond the nature of our medical care system, and it raises difficult challenges, beginning with how we as a nation should be defining health promotion in the first place.
This chapter begins by briefly examining the dominant vision of health promotion in the United States, its policy level implementation, and its more recent evolution and expansion. I then highlight just a few of the health promotion challenges and paradoxes we face, as health professionals and as a society, at the dawn of a new century. These challenges include, first, the need to continue to broaden the focus of our health promotion efforts in order to better address the profound role of social inequities in influencing health status; second, the importance of giving more than lip service to the rhetoric of empowerment and community participation for health by fully embracing them as a framework for health planning; third, the need to recognize and address some of the unanticipated consequences of our health promotion efforts, for example, in unwittingly reinforcing prejudice against the elderly and disabled and
Although this chapter can do little more than scratch the surface in these areas, it is put forward in the hope of contributing to a dialogue that will help us think about the challenges we face in health promotion in some new and different ways. Toward this end, the chapter closes with a brief discussion of the recent Canadian framework for health promotion as a means of illuminating potentially useful avenues for further expanding the vision and the reality of health promotion in the United States.
THE DOMINANT VISION OF HEALTH
PROMOTION IN THE UNITED STATES
Before looking at where we might head as a society in terms of health promotion, it is important to look at where we are and where we have come from. The dominant view of health promotion in the United States today emerged in the 1970s in response to a growing disillusionment with the limits of medicine, pressures to contain health care costs, and a social and political climate emphasizing self-help and individual control over health.2,3 It is a vision that sees individual behavior as in large part responsible for the health problems we face as a society. In the words of j. K. Iglehart, editor of the journal Health Affairs, this vision suggests that “most illnesses and premature death are caused by human habits of living that people choose for themselves” (emphasis added).4
Ironically, this traditional approach to heath promotion has tended to be disease oriented rather than health oriented. As Wallack and Montgomery 5 have pointed out, it defines health primarily as the absence of disease and sees disease as being associated largely with known and controllable risk factors such as cigarette smoking, poor diet, and heavy drinking. The individual is seen as the appropriate focus for intervention to control risk factors, with those interventions typically consisting of providing knowledge and skills for changing unhealthy behaviors.5 This vision of health promotion was given institutional expression in Canada, with the publication of the Lalonde Report 6 in 1974, and in the United
In the United States, the Surgeon General's report was followed by the development of clearly articulated and measurable “Objectives for the Nation.” 11 Developed by the U.S. Public Health Service with the Office of Health Information and Promotion (OHIP) playing a facilitating role, the “Objectives” were designed to help address more specifically the broad goals set forth in Healthy People. They made a major contribution in focusing attention on prevention and health promotion and in providing clear performance indicators and serving as a stimulus to action. The listing of activities for achieving each objective was extremely thorough and included strategies on the levels of institutional change, legislation, and policy and not merely in the realm of personal behavior change. This broad approach further was in keeping with the view of health promotion put forward at this time by OHIP Director Lawrence Green and his colleagues,12 who defined health promotion as “any combination of health education and related organizational, political and economic interventions designed to facilitate behavioral and environmental changes conducive to health.”
In reality, however, implementing this broad vision, particularly in an era of fiscal conservatism, proved difficult indeed. Moreover, as Green 13 has noted, the sharp distinction drawn in U.S. policy between health promotion (focused mainly on behavior and lifestyle issues) and health protection (concerned more with the physical environment) led to a narrower interpretation of health promotion in the United States than in many European nations, which argued that both physical and social environmental factors lay within the purview of health promotion.
In the United States, fully a third of “Objectives” and a special section within Healthy People were devoted to health protection with a focus on environmental concerns within such domains as toxic agent control
As a consequence, most of the programs that grew out of the early push for health promotion in the United States tended to focus primarily on the level of personal behavior change. The programmatic emphasis on individual responsibility for health, in short, frequently was not accompanied by attention to individual and community response-ability,14 or the capacity of individuals and communities to build on their strengths and respond to their personal needs and the challenges posed by the environment.
Expanding the Vision
Health promotion in the United States has evolved in important new directions since the early 1980s. Although most work-site health promotions continue to operate primarily on the level of the individual,15 many have significantly broadened their focus. Education on parenting skills, prenatal care, and interpersonal communications is frequently included in U.S. work-site health promotion programs in addition to the more traditional smoking cessation classes and related interventions aimed at modifying objective risk factors. The “Education for Action” training program, through which workers in hospitals and other settings around the nation have been helped to identify and address unsafe working conditions, provides an illustration of the broader approach to work-site health promotion that has gained popularity.16
In the community, innovative health promotion efforts, like the schoolbased Adolescent Social Action Program (ASAP) in Albuquerque, New Mexico, are including empowerment education and community development in both their methodology and their raison d’être.17 A universitycommunity partnership, ASAP involves dozens of public schools in an effort to address alcohol and substance abuse problems on multiple levels while creating the conditions in which youth can become empowered to make healthier choices in their own lives. In the area of HIV prevention,
On another level, statewide legislative initiatives, such as California's Proposition 99, which put a 25-cent tax on cigarettes and allocated 20% of the revenue generated to tobacco education and anticigarette advertising, increasingly are seen as being within the purview of health promotion activities. Finally, as will be noted later, unprecedented new efforts to drastically curtail the power and privileges of the tobacco industry nationwide currently are being attempted and have achieved considerable public support. Such developments are encouraging and have helped widen the scope of health promotion in the United States in important new ways. For the most part, however, even these broader efforts have failed to address the profound influence of broad social inequities on health.
Addressing Social Inequities
The need for developing health promotion programs that address the role of social inequalities in influencing health status is well documented. A voluminous body of evidence, for example, has demonstrated that social class is one of the major risk factors, and perhaps even the major risk factor for disease.19–22 Studies have shown that there is a clear gradient in social class and mortality rates: Not only do people in the highest socioeconomic groups have the lowest mortality rates, but these rates increase at each correspondingly lower rung of the socioeconomic ladder.21 As Syme 22 has noted, the evidence linking social class and illness is indeed so powerful that researchers routinely control for socioeconomic status in their studies of variables influencing health since this single factor would otherwise overshadow most of their other findings.
The need for addressing social inequities in the design and implementation of our health promotion programs is illustrated in a case study from San Francisco's Tenderloin district. Twenty years ago, my students and I began a project in the Tenderloin to help reduce social isolation and powerlessness and thereby improve the physical and mental health of some of the neighborhood's 8,000 low-income elderly residents. The health problems in this area were daunting. Approximately 40% of the elderly residents were malnourished or undernourished, for example,
For residents of neighborhoods like the Tenderloin, the primary challenge often is not that of having individuals “take more responsibility” for their health” but rather of improving their “response-ability,” by ensuring an adequate income, access to nutritious foods, and, for those with significant functional impairments, access to such coping resources as homemaker services, meals on wheels, and senior escorts. Services like these routinely are made available to the disabled in Canada and western Europe. However, they are effectively rationed in this country by our grossly inadequate funding for such programs and by the fact that they are easy targets for the budget axe in times of fiscal retrenchment.23
Health promotion efforts that fail to address the social context within which people live not only minimize the possibility of success but also risk violating the ethical admonition to “do no harm.” Already alienated individuals may experience an even greater sense of powerlessness when they try to change health-related behaviors and fail, for example, and this in turn may have negative health consequences 24 (see chapter 11). While continuing to acknowledge the critical need for individuals to take more responsibility for their health, a major challenge at the turn of the century, then, is to develop health promotion efforts that include an equally compelling emphasis on changing those broader social and environmental conditions that so often constrain individual choice in matters related to health. Part of incorporating broader contextual considerations into the policies and programs we design involves placing a far greater emphasis on the principles of community participation and empowerment, and it is to these related areas that I now turn.
Community Participation and Empowerment
Empowerment is a much used and abused term, and it has often been coopted by conservative policy makers who have used the rhetoric of empowering communities as a rationale for cutting back on needed health and social services. But if power is “the ability to predict, control
The concepts of community empowerment and participation reflect a commitment to such precepts as the common good and shared responsibility for health. Acting on these concepts means enabling communities to participate, in equal partnership with health professionals, in setting the health agenda defining their health problems and helping to develop the solutions to address those problems.
This focus is critical. Sociologist John MacKinlay is reported to have remarked that professionals frequently suffer from an unfortunate malady known as “terminal hardening of the categories.” 28 We get the kinds of answers we are comfortable dealing with because we ask the kinds of questions that will give us those answers. We conduct behavioral risk surveys, for example, that will carefully document heart disease as a major community health problem but will, in all likelihood, miss the fact that very different sorts of issues, like drugs or violence, may be the major health concerns of residents.28
In contrast, an empowering approach to health promotion would “start where the people are” by having them set the health agenda and then work to address the issues they collectively have identified. Such an approach validates the community's ability to assess its needs and strengths and builds on the latter in helping to increase the problem solving ability of both individuals and the larger community. The results can be dramatic. The Tenderloin project referred to earlier is illustrative.
When my students first formed the Tenderloin Senior Organizing Project (TSOP), they organized support groups among the elderly residents of several deteriorating Tenderloin hotels and asked participants what their major health concerns were. In hotel after hotel, the residents responded, “Crime,” and the students politely said, “You misunderstood, we were asking about health problems.” The residents held their ground, pointing out that they could not safely go outdoors without being mugged and therefore could not get to the doctor's office, go for a walk, or get an evening meal. Crime, they argued, was their biggest health problem.23
The students and project staff listened. Then they helped the residents organize a community-wide meeting on the subject of crime and enlist
Residents' organizing on crime prevention was given much of the credit for an 18% drop in the crime rate that occurred in this neighborhood in the first 12 months of their mobilization.23 Their organizing efforts also translated into some effective individual-level behavior change. For example, residents' new found feelings of power, self-efficacy, and improved self-esteem led some to successfully quit smoking and cut down on problem drinking.23
Had the students and staff of the Tenderloin Senior Outreach Project failed to pay attention to and support the community's definition of need, they might still be running support groups in hotel lobbies one morning a week—if indeed they were still welcome at all. Instead, by trusting the people to determine and act on their own health agenda, they were able to contribute to something that has had a real and lasting impact on the health of that community.
The Tenderloin project is but one of a number of examples that could be cited of health promotion efforts that have actively involved local communities in identifying and addressing their health problems and in the process building on and reinforcing community strengths. The earlier mentioned ASAP program in New Mexico, through which youth, many of them Native American and Hispanic, are helped to identify and then creatively address substance abuse problems in their community, is an example of another such effort and one that has demonstrated measurable successes in terms of increasing participants' perceptions of high-risk behaviors and their sense of social responsibility.17 The Black Women's Health Project (BWHP), founded in 1981 and based in Oakland, California, is another example of an empowering approach to health promotion. A national network of approximately 100 self-help groups in approximately two dozen states, the BWHP helps African American women gain information, skills, and access to resources while enabling them to work together to identify and analyze health-related concerns and to collectively address these issues.29 On a smaller scale, an innovative
Projects like these share a commitment to helping communities identify their needs and then working with them in developing health promotion programs and approaches that truly meet those needs. Implementing such a commitment, however, is often far from easy. As Gail Siler-Wells 31 points out, “Behind the euphemisms of empowerment and community participation lay the realities of power, control and ownership.” The very real structural distinctions that exist between professionals and communities, and our very location as professionals in health agencies and bureaucracies, confer a certain power that includes the power to set the health agenda.31
As we enter a new decade and a new century, new and innovative ways must be developed to better enable individuals and communities to take the power they need to bring about health improvements. Professionals committed to facilitating this process may be aided by applying a tool developed by community organizers Herbert and Irene Rubin 32 and called the DARE criteria for empowerment. The DARE criteria would have us answer the following set of questions with respect to any health promotion project in which we are engaged:
| Who Determines the goals of the project? | |
| Who Acts to achieve them? | |
| Who Receives the benefits of the actions? | |
| Who Evaluates the actions? |
The more we can answer these questions by responding, “The community,” the more likely our health promotion projects are to be contributing to true community empowerment and self-determination.33
Public health departments, hospitals, and other health institutions also can contribute to community participation and empowerment by forming what Ron Labonte 34 describes as “authentic partnerships” with communities and ensuring that our “community based” projects are not merely “community placed.” 34 Such authentic partnerships will take on particular relevance, moreover, as new and complex areas such as violence prevention become an increasing part of public health practice.
A problem such as violence presents a whole new set of challenges, in part because it is widely viewed in this society as a problem to be addressed through law enforcement and criminal justice rather than through efforts directed at economic development, human welfare, and public health. The statistics, of course, tell a different story. As Michael McGinnis and William Foege 35 have demonstrated, firearms rank sixth (after tobacco, diet and exercise, and so on) as an actual cause of death in the United States. And although the overall homicide rate in this country began to decline in the early 1990s,36 we continue to rank first—by a wide margin—among the advanced industrialized nations.37 When we turn our attention to youth violence, an even more disconcerting picture emerges. For despite recent declines, and whether as victims, perpetrators, or witnesses, young people aged 15 to 24 continue to experience disproportionately high rates of violence. A recent comparison of the overall firearms-related deaths among children under 15 in 26 advanced industrialized countries revealed the U.S. rate to be 12 times higher than that of all the other countries combined (1.66 vs. 0.14).38 The firearmsrelated homicide rate in U.S. children was almost 16 times that of the other nations combined (0.94 vs. 0.06) 38 (see Figure 13.1).
Facts and statistics like these provide compelling evidence that the public health system should be a major force in violence prevention efforts.
The suggestion that health professionals and their institutions take on violence as a major public health problem is in no way meant to underplay the critical need for broad societal-level economic and social change if we are truly to make a lasting impact on the violence that plagues our nation. With many of the new jobs created at or below minimum wage and with the gap between rich and poor greater today than at any time since World War II and continuing to expand rapidly,39 it is not hard to understand the increase in violent crime, particularly among unemployed and underemployed youth for whom drug trafficking and related violence may be very lucrative. Similarly, with handguns and semiautomatics within easy reach of our nation's most vulnerable children, and with violence endemic on our movie and television screens, it is unlikely that significant and lasting change can be made at the community level without dramatic changes on our societal landscape.
However, communities can and do have a vital role to play, and by working in partnership with communities, local health departments can lend their resources, skills, and credibility to a frontline attack on violence.
Figure 13.1. Rates of firearm-related homicides among children aged <15 years in 26 industrialized countries. Rates are per 100,000 children aged <15 years and for one year during 1990–1995. In this analysis, Hong Kong, Northern Ireland, and Taiwan are considered countries. Source: Adapted from Morbidity and Mortality Weekly Report, February 7, 1997, Figure 1, p. 104.
A powerful illustration of an empowering and collaborative approach to violence prevention that links health institutions to local communities was developed by Deborah Prothow-Stith and her colleagues 40 at Harvard's School of Medicine and Massachusetts General Hospital. Offered to youth in high-risk neighborhoods through local housing projects, schools, churches, and YMCAs, the project teaches young people new ways of coping with their anger and aggressive feelings. But it also has them explore the root causes of violence in racism, poverty, and a culture where, in Prothow-Stith's words, the most popular heroes have
On a still larger scale, the Violence Prevention Initiative (VPI) of The California Wellness Foundation has been credited with helping to create a new social and political climate for promoting handgun control and other measures that can help reduce violence on a statewide basis.43 Initiated in 1993 with a five-year, $35 million endowment, the VPI was designed to reduce the state's high youth violence rates through a multipronged grant-making program that included community action programs, public education, research, and policy development. A central piece of this ambitious effort—the successful mobilization of a statewide effort to pressure for the banning of handguns—is described in detail by Lawrence Wallack in chapter 19. In his words, the VPI has left “a large footprint … in the legislative landscape” and has paved the way for continued dramatic policy changes in a state where murder remains one of the top two killers of children and youth.44
Empowering community and multisectoral approaches to violence prevention like those described here well illustrate how expanding our definition of health promotion and disease and injury prevention and working in broad partnerships on a wide variety of levels can help address one of the most critical public health problems of our times.
Avoiding Prejudice against the Elderly
and Disabled in Our Health Promotion Efforts
I have discussed so far the need to devote greater attention in our health promotion efforts to the social determinants of health and to do this in
With some notable exceptions, the elderly largely have been ignored in most private- and public-sector health promotion efforts. The high costs of such failure are painfully evident. Helen Schauffler and her colleagues at the University of California, Berkeley, School of Public Health,46 for example, conducted the first study ever to demonstrate a relationship between risk factors for heart disease and Medicare payments. They discovered that three triggers for heart disease—high blood pressure, high cholesterol, and cigarette smoking—are costing Medicare at least $16.6 billion per year in extra medical services, yet the program does almost nothing to prevent these conditions (see Figure 13.2).
Although Medicare's failure to cover much health promotion and disease prevention for the elderly reflects in large part a more generalized reluctance in both public- and private-sector health insurance plans to cover such services,47 it may also reflect the widespread belief that such programs have little to offer the elderly, who are deemed “resistant to change” anyway and whose “productive years” are largely behind them.48 Recent changes in the Medicare program take an important step forward in providing coverage for colorectal screening and annual mammograms, increased payments for preventive injections, and coverage of glucose monitoring and other costs associated with the management of diabetes.49 But while our health promotion efforts must include even greater efforts toward the prevention of unnecessary disability and functional impairment, a challenge for the decades ahead is to find ways of doing so that do not in the process stigmatize and devalue those elders who are or may become disabled.
The renewed emphasis on individual responsibility for health in this country has been accompanied by the reemergence of a Victorian-era notion that healthy old age is a just reward for a life of self-control and “right living.” 50 Such a notion opens the door to victim blaming of those elders who dare to become chronically ill or disabled. In David Lewin's words, “Good health has become a new ritual of patriotism, a market place for the public display of secular faith in the power of will.” 51
Figure 13.2. Increased Medicare costs per elderly person per year associated with risk factors for heart disease. Source: Schauffler et al. (1993 [46]).
Within such a vision, where is there a place for the 85-year-old man with a disabling respiratory ailment or for the obese and severely arthritic elderly woman in a wheelchair?
The unwitting tendency of some health promotion efforts to foster this kind of stigmatization can also be seen in many recent injury prevention campaigns. Once again, we are faced with a paradox. On the one hand, it is critical that health promotion include an emphasis on injury prevention, and it is heartening, too, that this has expanded to include such controversial areas as handgun control. On the other hand, we must be concerned when the messages of our prevention campaigns build
As Caroline Wang 52 has pointed out, health promotion approaches to injury prevention that carry the implicit or explicit message, “Don't let this happen to you!” often inadvertently stigmatize people with disabilities, suggesting that they are “inherently flawed” and undesirable. In her words,
If the public health perspective rightly contends that becoming disabled is an unacceptable risk in our society, it paradoxically often fails to acknowledge the stigmatizing notion that being disabled is an unacceptable status in our society.52
Heeding the physicians' admonition to “first, do no harm,” those of us concerned about health promotion and injury and disease prevention must ensure that the campaigns we design and the messages we transmit through them do not further contribute to the handicappism and gerontophobia that already plague our society.
The Continuing Challenge of the Tobacco Industry
In some of the most critical arenas within health promotion, such as alcohol and tobacco, the very success of some of our health promotion efforts is raising new problems and challenges we have only begun to tackle. Recent developments in the area of tobacco marketing and advertising provide an excellent case in point.
Accounting for over 416,000 deaths per year, cigarette smoking has been called by the Centers for Disease Control and Prevention “the most devastating preventable cause of disease and premature death this country has ever experienced.” 53 Yet despite this reality, some impressive strides have been made. Smoking rates overall have dropped from 40% of the population in 1965 54 to about 23% in 1998.55 Public health measures such as increased excise taxes, mandatory warning labels on cigarette packages, restrictions on tobacco advertising, mass-media campaigns, and public and private antismoking rules and ordinances have been given much of the credit for these declines.56
The very success of health promotion efforts in the area of tobacco control, however, has contributed inadvertently to aggressive new efforts by cigarette manufacturers to find new markets at home and abroad and to take steps to increase their ebbing legitimacy. In the United States, increased
To improve their public image, leading tobacco companies also have become major donors to both large and small nonprofit organizations including, ironically, the Partnership for a Drug Free America.60 Such money often comes with strings attached. Shortly after accepting $150,000 from Phillip Morris, for example, New York City's Coalition for the Homeless was asked to help kill a bill mandating antismoking ads by pressuring the city council to focus on more important issues like homelessness.60 In a time of dwindling public and private funding for a plethora of good organizations and worthy health and social causes, the tobacco companies' substantial role in financing raises troubling ethical dilemmas.33
A combination of developments in the late 1990s seriously damaged the already waning credibility of the tobacco industry and greatly increased political and popular support for stiff new tobacco taxes and other antismoking measures. The release and wide publicizing of credibility harming tobacco industry memos and other secret documents, public revulsion at new evidence of the industry's sophisticated efforts to hook teens and to increase the addictive content of cigarettes, state-level efforts to sue tobacco companies as a means of recovering Medicaid costs for smoking-related illnesses, and one cigarette manufacturer's break with the rest of the industry in acknowledging the addictive nature of nicotine were among the events signaling a potential watershed in antitobacco mobilization in the United States.61 Health promotion efforts such as the well-financed Campaign for Tobacco Free Kids and the earlier mentioned California Tobacco Control Program (which was credited with having helped a million smokers quit the habit in its first three years of operation)62 also began playing an important role in discouraging smoking, especially among youth.
Major legislative events have further helped change the tobacco landscape. After months of heated debate between tobacco industry representatives, state attorneys general, and other parties, a proposed $368.5 billion “tobacco settlement” was announced in June 1997 that
The tobacco settlement led to a 45-cent-per-pack increase in the price of cigarettes between 1998 and 1999, with a corresponding decline in total cigarette consumption of 7.5% over the same period.65 As some analysts have noted, however, “the welcome fall in consumption resulting from the price increase may turn out to be temporary unless it is followed up with serious efforts to dissuade kids from smoking.” 65 With just 8% of the tobacco settlement monies to states so far going to antismoking efforts and the great bulk of the funds being used for road construction, tax cuts and the like,66 early hopes for dramatic declines in youth smoking appear unlikely to be realized.
We continue to face other ethical challenges when the activities of American cigarette manufacturers are viewed within a global context. The use of tobacco world-wide has increased dramatically since the mid1960s, with much of this increase occurring in Third World countries. While cigarette smoking now is declining by 1.4% annually in industrialized nations, moreover, the habit continues to grow by 1.7% per year in the developing nations, where tobacco accounted for more than
In a provocative and troubling article “Advertising for All by the Year 2000,” Wallack and Montgomery 5 demonstrate how dwindling markets and increasing advertising bans at home have made Third World nations one of the most “promising frontiers” for our nation's tobacco industry. The United States is the world's largest tobacco exporter, with our cigarette exports growing 260% from 1986 to 1996 and two-thirds of cigarettes manufactured in the United States now sold internationally.63,69 American tobacco companies also rank among the leading advertisers in many Third World nations,5 and in Asia and Latin America, researchers have documented an association between increased cigarette advertising and both general increases in smoking and specific increases among women and children.70 Tobacco consumption already accounts for a substantial proportion of overall mortality in many Third World countries, and estimates suggest that by 2025, seven out of every 10 tobacco-related deaths will occur in the Third World.69,71
The policy implications raised by these realities are profound and suggest the need for action on multiple levels. Working through groups like the World Health Organization (WHO), for example, we might promote a massive international antitobacco advertising campaign while at home we continue to press for national tobacco legislation along the lines described previously. We further must require that U.S.-manufactured cigarettes that are marketed in other nations be held to the same standards in terms of warning labels, nicotine content, and the like as those sold domestically. Such efforts are essential if we are to achieve real success in dramatically reducing smoking rates at home while preventing the realization of the WHO's dire projection that tobacco will be the world's leading cause of death by 2020.71
Rethinking “The Public Good”
A final challenge for broadening the focus of health promotion as we begin a new century is perhaps the most difficult, for it involves rethinking conceptualizations of health issues that are deeply embedded in both
When the ethical notion of public or community good is invoked in arguments for mandatory motorcycle helmet use, for example, “common good” frequently is operationalized in terms of the economic rights of law-abiding citizens. Public or community good, in short, is defined as my right not to pay for your foolish or risky behavior.2 Economic arguments of this sort may have a place. But when we limit our conceptions of the public or common good in this way—when we suggest that “the public good is nothing more … than the protection of every individual's private rights,” 73—we miss the broader meaning of community. In Dan Beauchamp's 74 words,
By ignoring the communitarian language of public health, we risk shrinking its claims. We also risk undermining the sense in which health and safety are a signal commitment of the common life—a central practice by which the body-politic defines itself and reaffirms its values.
Motorcycle helmet laws, for example, are not simply “championing some individuals over others” but rather are upholding “the public or community interest” over the interests of individuals or groups.75 Such laws ideally are saying that when one of us engages in risky behavior, our collective well-being is affected because we are all part of the same community.
Broadening our concept of the public good to embrace a sense of our intimate interdependence, a notion that we are indeed “all in this together,” will not be easy. For in the words of Dan Callahan,76 the dominant culture in America “does not speak easily the language of community.” If we are to move toward broader, more community-oriented policies in the name of health promotion, however, our vision of public good must become considerably more than the rights and obligations of the collection of individuals who happen to occupy the same geographic space.
Contrary to witnessing an enhanced notion of the common good, unfortunately, the late 1990s heralded several new measures that further
The Canadian Framework for Health Promotion
As this chapter has attempted to demonstrate, addressing social inequities, taking seriously the rhetoric of community participation and empowerment, confronting the unanticipated consequences of our health promotion efforts, and rethinking and broadening our notion of the common good constitute major challenges for those concerned with broadening the vision and the reality of health promotion in the United States. Moreover, although health promotion has moved in important new directions since the rebirth of interest in this approach in the 1970s, recent setbacks, including importantly the failure to enact health care reform legislation and the passage of a punitive and potentially healthcompromising welfare reform bill, suggest that much remains to be done.
As we grapple with these and other challenges to health promotion during this unique historical period, a new conceptual framework must be developed that incorporates such underlying principles as a commitment to social justice, empowerment, and a broader notion of the common good. Toward this end, it is useful to review WHO's vision of health promotion and specifically how that vision has been crafted into a conceptual framework for health promotion policy and its implementation in Canada.
WHO radically revised its notion of health promotion in the mid1980s, defining it as “a process of enabling people to increase control over, and to improve their health.” 79 It went on to state that health promotion represents “a mediating strategy between people and their environments, synthesizing personal choice and social responsibility in health.” 79 The principles set forth by WHO as underlying this alternative
The Canadian approach to health promotion that was developed in the mid-1980s and refined over the subsequent decade provides an illustration of how such a broadened vision may constitute a useful framework for action. After a period of considerable preoccupation with healthy lifestyles and individual responsibility for health, the Canadian government undertook a massive restructuring of its approach to health promotion. Two important points stand out in the Canadian approach. First, the number one challenge set forth for health promotion is reducing inequities between low- and high-income groups, and this is not framed in terms of individual responsibility but of broader societal responsibility.81 Second, three levels of concern are set forth—health challenges, health promotion mechanisms, and implementation strategies—and on each of these levels there is attention to the role of broad institutional or environmental change (see Figure 13.3). Self-care, for example, is advocated within a framework that devotes considerable attention to the creation of healthy environments within which positive personal health behaviors can flourish. Canadian legislation on smoking is among the toughest in the world, with many provinces having developed “healthy public policies” on tobacco that have included changing their policies on marketing, crop substitution, and smoking in the workplace at the same time that they urge individuals to quit the habit.
In several Canadian provinces, premier's councils on health have been established through which government leaders in the different sectors provide advice on health promotion and work together in jointly setting goals for helping to address the social determinants of health.80 In the Northwest Territories, land claims and the development of First Nation's People's rights have been discussed as part of a broadly defined health agenda.82 Finally, across the nation, hundreds of cities have designated themselves “healthy communities,” stressing intersectoral planning, high-level community participation, and reciprocity between the individual and the broader society.83
Hard outcome data that would indicate whether the new Canadian approach to health promotion has resulted in actual declines in morbidity and mortality are not yet available. Further, as Irving Rootman 84 and Lawrence Green 85 predicted, increased government perceptions of a need for cutbacks in social spending have led to some redesign of social
Figure 13.3. A framework for health promotion. Source: Epp (1986 [79]).
As noted earlier, even health promotion efforts that are firmly grounded in a values base like this one may stumble as a result of continuing budget cuts, growing power differentials between rich and poor, and the structural distinctions that continue to exist between communities and health and social service professionals. At the same time, however, the Canadian framework for health promotion and the values and principles underlying it stand as an important example of a vision that offers a balanced concern for personal behavior change within the context of broader social change. In its attention to broader environmental issues, moreover, the Canadian approach explicitly addresses the connection between health promotion and the roots of public health in concerns for social justice and improved social and economic conditions as a vital part of public health.
The classic illustration of this connection lies in the well-known story of Rudolph Virchow,87 the founder of cellular pathology, who in 1848 was asked by his superiors to provide recommendations on what to do about a typhus epidemic that was raging in an impoverished area in eastern Prussia. After visiting the area and studying the situation, Virchow prepared a report in which he spoke of the need for land reform, redistribution of wealth and income, and only later of some medical reforms. The report was met with displeasure, and Virchow was accused of proposing a political rather than a medical solution to the epidemic. His often-cited reply was that “medicine is a social science and politics nothing more than medicine on a large scale.” 87
Taking a cue from Virchow, health promotion and the ways in which we define and operationalize it must be seen in inherently political and multidisciplinary terms if we are to be successful in meeting the profound challenges to the public's health that we face in this last decade of the 20th century. As health professionals, we must ask ourselves what our own responsibilities are in relation to health promotion programs and activities. Do we contribute to social equity, or do we reinforce existing inequities? Do we advance the concept of individual and community empowerment, or do we merely use the language of community partnerships and empowerment to blur hierarchical distinctions without changing the status quo? 33 Do our health promotion activities inadvertently contribute to problems such as gerontophobia and handicappism? Do they, in Marshall Becker's 88 words, equate “being ill” with “being guilty?” And finally, is our notion of community good broad enough to reflect an
The story is told of a traveler, hopelessly lost on a dusty dirt road, who stops a local farmer and asks, “Is this the road to Baduka?” The farmer replies, “Mister, if I was going to Baduka, I wouldn't start from here.” The dominant American self-image stressing individualism, self-reliance and progress, and the “ethical individualism” to which it predisposes us 72 makes our starting point on the road to a broader approach to health promotion a difficult one indeed. But as we enter a new century and a new millennium, the time is ripe for considerably broadening the ways in which we think about and approach health promotion.
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14. BRIDGING THE CLINICAL AND
PUBLIC HEALTH APPROACHES
TO SMOKING CESSATION
California Smokers' Helpline
Shu-Hong Zhu and Christopher M. Anderson
INTRODUCTION
Smoking is a major risk factor for heart disease, lung cancer, and strokes and is the most important preventable cause of premature death in the United States.1 In California alone, over 42,000 deaths each year are attributable to smoking.2 However, studies have consistently shown that smokers who achieve long-term cessation significantly reduce their risk of disability and early death.3 For that reason, efforts to persuade smokers to quit and to help them with the process have been encouraged on both the federal and state levels.4,5 In recent years, in particular, many states have launched aggressive antismoking campaigns. With revenues from a voter-approved tobacco tax initiative (Proposition 99), California has developed one of the most comprehensive tobacco control programs in the country, with a budget that includes funding for a variety of smoking cessation interventions.6–9
Such interventions have been said to fall into two categories: the clinical approach, with its emphasis on depth of intervention, and the public health approach, which emphasizes broad-based interventions.10,11 The clinical approach is characterized by intensive, multisession interventions; small populations; and high quit rates. The public health approach, on the other hand, is characterized by brief, low-cost interventions; large populations; and relatively low quit rates. There are many studies and service programs that fall within one framework or the other, but programs that successfully combine the intensity of the clinical approach with the breadth of the public health approach are few.
One that does attempt to bridge the two approaches is the California Smokers' Helpline, a telephone-based program that was established as a statewide service in August 1992. Because it is telephone based, the Helpline is accessible to nearly all smokers in the state and is thus in a position to play a strong public health role as both a referral agency and a clearinghouse for cessation materials. In addition, the Helpline also provides intensive, multicomponent, multisession behavioral modification counseling for any who need it. Though intensive, this telephone counseling intervention is focused and brief in its approach, emphasizing costefficiency in its design. In this way, the California Smokers' Helpline strives to put the benefits of a strong clinical program within reach of a much broader population than more traditional programs have been able to do.
OBSTACLES IN THE HELP-SEEKING PROCESS
One problem with the traditional clinical approach to smoking cessation is that although psychologically intensive programs are effective in helping smokers quit smoking,12 few smokers use them.13,14 One national survey has shown that only 10% of smokers who tried to quit smoking used a program to help them do so.14 The reason for this is unclear; one reasonable guess would be that the remaining 90% do not want any help. But surveys have also shown that most smokers are worried about the prospect of quitting smoking. According to the 1990 California Tobacco Survey, 77.6% of smokers believe they are addicted to cigarettes, and 85.9% consider it important that there be programs to help smokers quit.15 Moreover, there is a striking difference in help-seeking patterns among ethnic groups, with smokers of ethnic minority backgrounds less than half as likely as White smokers to seek help to quit.16
Even smokers who want to quit and who believe they need help may not know where to find that help. For example, a 1990 survey conducted in San Diego County asked 1,049 smokers to name “up to three programs that are helpful for people who want to quit smoking.” Surprisingly, only 39.4% of smokers were able to name any program at all relating to smoking cessation. Furthermore, non-White smokers were even less aware of available programs (31.3%) than White smokers were (41.2%), suggesting one reason why minority smokers are less likely to seek help.17
Even if smokers do know where help can be found, they must still
INCREASING THE ACCESSIBILITY
OF SMOKING CESSATION SERVICES
As part of an effort to redress this problem, the Tobacco Control Section of the California Department of Health Services began funding the California Smokers' Helpline in August 1992. Smokers from across the state are referred to the Helpline through a variety of means, including media advertisements and physician referral. When they call, they are offered a range of services according to their preference and their readiness to quit. Smokers who are not yet ready to quit are sent materials designed to spur them along, while those who do feel ready but who prefer to quit on their own receive self-help quit kits. Smokers who would like more intensive help can enroll in the Helpline's free telephone counseling program.
The first way in which the Helpline increases the accessibility of smoking cessation services is by educating smokers on where they can get help to quit. The Helpline is aggressively promoted by the media component of the state's Tobacco Control Section, which includes the Helpline's toll-free numbers in ads urging smokers to quit. These ads, in the six languages in which Helpline services are provided, appear on television, radio, and billboards and in newspapers across the state. The Helpline also provides detailed information about its services to health care providers and volunteer organizations so that they have a dependable referral source. Moreover, the Helpline publicizes other cessation programs by sending each caller a descriptive list of all the available programs in his or her area. In these ways, public awareness of help for smoking cessation is enhanced.
The Helpline also reduces many of the costs associated with getting help to quit smoking. The first of these is the actual financial cost. Supported
As mentioned previously, there are other less tangible costs that smokers may incur from traditional programs, including having to wait for cessation classes to form, taking time away from home to attend them, and the effort and expense of arranging for transportation and child care. Even the potential benefit of social support from attending group sessions may be outweighed, for some, by the prospect of facing a roomful of strangers. Some smokers face geographic or language barriers as well. The Helpline reduces all of these costs by enabling smokers to get help without leaving home and by providing services in six of the state's most common languages—English, Spanish, Mandarin, Cantonese, Vietnamese, and Korean. (The Helpline also has a TDD line for the hearing impaired and has recently added a line for smokeless tobacco users.)
The Helpline is also able to increase its accessibility by stretching its resources. The program operates out of a single site, minimizing overhead costs. Also, it employs a stepped-care approach; 19 that is, instead of attempting to provide every caller with its most intensive form of assistance—telephone counseling—it presents a variety of options, including simply receiving materials in the mail or attending one of the cessation groups noted on the referral list. The Helpline lets each caller select the services that he or she feels would be most useful. By allowing callers to “serve themselves” from a menu of different approaches, the Helpline is able to spread its resources among a greater number of people. In just over four years of operation, the Helpline has served more than 41,000 smokers in this way, an average of more than 10,000 people a year. An additional 2,300 nonsmokers have also called the Helpline to get help for their friends and families.
In many cases, it is smokers' own ambivalence that limits their access to programs. A study conducted in southern California when the Helpline was funded to provide counseling only in San Diego County may illustrate this point. In response to calls from more than 700 Los Angeles smokers who said they were planning to quit within a month, the Helpline sent self-help materials and a directory of all the smoking cessation programs in the Los Angeles area. Five weeks later, the Helpline staff called them back and asked if they had attended any of the programs in the directory. Only 6.2% had done so. Given that the first time they called they had appeared motivated to get help to quit, the low rate at which they actually did so suggests that, as a group, they experienced
To counteract this ambivalence and reduce the resulting attrition, the Helpline tested a proactive approach with its counseling clients. As part of a larger study, more than 3,000 smokers who said they were ready to quit within a week and who opted for telephone counseling were told by intake personnel that they would receive a packet of quitting materials in a few days, at which time they should call back to begin the counseling. Subjects were then randomized into two groups. Members of one group were left to call back as instructed; about 34.2% eventually did so and received counseling. In contrast, members of the other group were contacted directly by a counselor. In this group, 74.7% received counseling, demonstrating that a proactive approach to providing service can have a strong counteractive effect on clients' ambivalence.20
WHO SEEKS HELP FROM
THE CALIFORNIA SMOKERS' HELPLINE?
With respect to the population that uses the Helpline, two demographic dimensions deserve special attention. One is its ethnic diversity, and the other is the active participation of rural smokers.
Table 14.1 indicates the ethnic diversity of the population using the Helpline. As the table shows, the 1993 California Tobacco Survey (CTS) found that smokers of ethnic minority backgrounds were underrepresented among those who sought help in general to quit smoking. His-panic/Latino smokers, for example, accounted for 18.5% of the smokers in California but only 9.4% of those who sought help to quit. African-American smokers made up 7% of the state's smokers but only 4.3% of those who sought help. Asian-American smokers were likewise underrepresented (5% vs. 2.6%).
On the other hand, ethnic minority smokers were about as well represented among Helpline users as among smokers in general. Hispanic/Latino smokers accounted for 18.2% of Helpline users, a proportion approaching their representation among the state's smokers. African-American smokers were actually overrepresented among Helpline users (11.4% vs. 7%). Asian-American smokers were still underrepresented (2.6% vs. 5%). Taken as a group, however, smokers of ethnic minority
| Smokers in California, 1992–1993 (%) | Sought Help ≤12 Months Prior to 1993 CTS (% [±95 CI]) | Called the Helpline, 8/92–8/96 (% [±95% CI] | |||||
|---|---|---|---|---|---|---|---|
| NOTE: Because only adult smokers participated in the 1993 CTS, Helpline callers under 18 are excluded from this analysis. | SOURCES: 1993 California Tobacco Survey and the California Smokers' Helpline. Adapted from Pierce et al. (1994 [8]) and Zhu et al. (1995 [16]). | ||||||
| N | 4,078,306 | 3,425 | 39,903 | ||||
| White | 67.4 | 78.9 (4.9) | 62.3 (0.5) | ||||
| Hispanic | 18.5 | 9.4 (3.4) | 18.2 (0.4) | ||||
| Black | 7.0 | 4.3 (3.0) | 11.4 (0.3) | ||||
| Asian | 5.0 | 2.6 (1.9) | 2.6 (0.2) | ||||
| Others | 2.0 | 4.8 (3.5) | 5.4 (0.2) | ||||
The fact that the Helpline's services are available in several languages, each with its own 1-800 number, contributes to its success in recruiting minority smokers. The high proportion of Hispanic callers, for example, is due largely to the Helpline's Spanish line. In fact, 71% of all Hispanic callers use that line. Conversely, the low percentage of Asian callers may be due in part to the relatively late addition of the Asian lines, 19 months after the English and Spanish lines.
Through targeted advertising and ethnic networks, the promotion of the Helpline also encourages minority participation. Because the Helpline is not tied to any particular local base, it can be selectively promoted in underserved communities wherever they occur in the state. This feature makes the Helpline particularly useful as part of a larger public health effort to reduce the smoking prevalence wherever it is especially high.
Much of this effort is spent in rural and mixed areas, where the population is low but the smoking prevalence is higher than the state average. As Table 14.2 illustrates, the likelihood of using the Helpline varies according to the urbanization of the state's 58 counties: smokers from rural counties have been disproportionately active participants in the program. (For this analysis, the classification of counties developed by the California Senate Committee on Local Government was used.)21 This may reflect the relative scarcity in rural areas of programs to help people
| Smokers in California (%) | Called the Helpline 8/92–8/96 (% [±95% CI]) | ||||
|---|---|---|---|---|---|
| NOTE: Percentages for the state of California are estimated from the smoking prevalence rates at the time of the 1993 survey. | SOURCE: 1993 California Tobacco Survey and California Smokers' Helpline. | ||||
| N | 4,078,306 | 41,232 | |||
| Rural | 7.2 | 11.5 (0.3) | |||
| Mixed | 17.5 | 16.0 (0.4) | |||
| Urban | 75.1 | 72.5 (0.4) | |||
Interestingly, the most significant means of reaching and encouraging rural smokers to call is not—as it is with urban smokers—the mass media. Across the state, the mass media were responsible for the majority of the Helpline's callers (60.9%), while health care providers referred an additional 15.7%. But as illustrated in Table 14.3, there were substantial differences by type of county in terms of how smokers learned of the Helpline. In rural counties, health care providers were responsible for 43.3% of referrals, while the media accounted for only 18.1%. The situation was reversed in urban counties, where the media accounted for 72.6% of referrals and health care providers only 7.7%. Mixed counties fell somewhere in the middle. This pattern suggests that where intensive media advertising of an important public health service becomes impractical, there are physicians, nurses, and other community health advocates who are willing to take up the slack. In fact, the active participation of these individuals in the promotion of the Helpline is further evidence that the program addresses a scarcity of needed services in their communities. Appropriately, in counties where the smoking prevalence is high and where programs are few, rural health care professionals have been playing an important role in directing smokers to accessible help.
THE EFFECTIVENESS OF TELEPHONE COUNSELING
The greater accessibility of the Helpline format, especially among ethnic minority groups and in geographic areas that are relatively underserved
| Rural (%) | Mixed (%) | Urban (%) | Total (%) | |
|---|---|---|---|---|
| SOURCE: California Smokers' Helpline. | ||||
| N | 4,715 | 6,588 | 29,834 | 41,232 |
| Mass media | 18.1 | 38.4 | 72.6 | 60.9 |
| Health care provider | 43.3 | 32.3 | 7.7 | 15.7 |
| Family/friend | 14.6 | 12.2 | 8.9 | 10.1 |
| Nonprofit organization | 8.7 | 5.5 | 2.2 | 3.5 |
| Other | 14.7 | 10.8 | 7.8 | 9.1 |
| Don't remember | 0.7 | 0.8 | 0.9 | 0.8 |
This trial was conducted in San Diego County before the California Smokers' Helpline was established. More than 3,000 smokers who said they were ready to quit within a week were randomized into three groups. The first group received only a self-help quit kit. The second group received the quit kit plus one 50-minute session of telephone counseling preparatory to quitting. The third group received the quit kit, the prequit session, and up to five additional 20-minute sessions in the first month after quitting.
The self-help condition served as a control for the two counseling conditions, although the self-help treatment was in itself a minimal intervention. Therefore, any effect attributable to the addition of counseling on top of the self-help treatment is a conservative estimate of the in-tervention's total effect.
The rationale for testing the single counseling intervention was to discover whether a minimal counseling intervention could produce an effect. Given the frequent real-world scenario in which smokers show up for a first session and then disappear, it was important to see whether just one contact with a counselor could help smokers quit. If so, the effect of the single counseling treatment would in itself argue for a realworld application of telephone counseling.
To maximize the likelihood of its success, it was crucial that the prequit session be thoughtfully planned and executed. The design of the counseling was based on a combination of the principles of motivational
The structured counseling protocol was intended to help the counselor conduct a comprehensive session in a brief and focused manner.25 The session was to cover a wide range of clinical issues, including smoking and quitting history, nicotine dependence, motivation to quit, selfefficacy, social and environmental influences, anticipating difficult situations, planning effective coping strategies, and committing to a quit date. All these areas were to be covered in about 50 minutes.
Similarly, if the multiple counseling condition was to achieve a greater effect than that of single counseling, the follow-up sessions would have to be conducted in a therapeutic manner. Like the single counseling intervention, multiple counseling was also conceived as a brief intervention: The total time spent per smoker was intended to be short enough that, if proven effective, the treatment could later be applied in a public health setting, where efficiency and brevity are central concerns.26 For this reason it was decided that follow-up counseling should entail no more than five 20-minute postquit sessions to be scheduled in the most efficient manner possible. Thus, the total time spent per client would be under three hours.
The question of how best to schedule the follow-up sessions turned out to be critical. In most traditional multisession interventions for smoking cessation, the sessions are held weekly. Though convenient for the clinician, the weekly schedule is not necessarily optimal from a therapeutic standpoint. Why this is so can be seen by considering the shape of a typical relapse curve for smoking cessation, as shown in Figure 14.1. If relapse were a linear function of time, an equal-interval schedule of sessions, such as the traditional weekly schedule, would be most suitable. However, as the shape of the curve in Figure 14.1 makes clear, relapse is in reality a negatively accelerated function of time. In other words, relapse is most likely in the period immediately after quitting and becomes
Figure 14.1. Relapse-sensitive scheduling of counseling sessions. Source: Zhu and Pierce (1995 [34]). © 1995, American Psychological Association, Inc.
An analysis of 12-month abstinence rates for the three experimental groups showed that both counseling conditions were significantly more effective than self-help.35 Moreover, there was a clear dose-response relation between the intensity of counseling and treatment effect, as multisession counseling was significantly more effective than single-session counseling. The 12-month abstinence rates were 14.7%, 19.8%, and 26.7% for self-help, single counseling, and multiple counseling, respectively. These results are represented in Figure 14.2 as the end points of
Figure 14.2. Relapse curves for self-help (SH), single counseling (SC), and multiple counseling (MC). Source: Zhu et al. (1996 [35]). © 1996, American Psychological Association, Inc.
The multisession protocol became the basis for the telephone counseling currently provided by the California Smokers' Helpline. It has been further shaped and refined by the Helpline's collective experience of counseling additional smokers since expanding statewide. Similar statewide telephone counseling services have been established for Massachusetts and Michigan using the same protocol.
BRIDGING THE CLINICAL
AND PUBLIC HEALTH APPROACHES
After decades in which clinical approaches to smoking cessation have dominated, researchers have begun calling for more of a public health perspective in interventions to help people quit smoking.10,37,38 Although they are needed both as a resource for heavily addicted smokers and as a source of scientific innovation,39 clinical programs are not sufficient to reach the large number of smokers who are at risk for smokingrelated diseases. In contrasting the features of the two approaches to smoking cessation, Lichtenstein and Glasgow have observed that clinical
The California Smokers' Helpline is one attempt at such a bridge. On the one hand, the Helpline has developed an intensive and clinically comprehensive program that produces a long-term success rate comparable to that of traditional clinical programs. On the other hand, the Helpline is highly accessible, reaches a broad population, and uses a stepped-care procedure to maximize its reach.
The Helpline's initial research on the efficacy of telephone counseling was designed, from the beginning, to establish its suitability for largescale, real-world application. In fact, the research was conducted using paraprofessional counselors operating from a single site and drawing smokers from the community at large, just as the larger application would be expected to do. For these reasons, it was easy to translate the results from the study into a program serving smokers statewide. The duplication of the program in Massachusetts and Michigan has likewise been straightforward. For the Massachusetts Smokers' Quitline, the original researchers provided early training and program support. The Smokers' Helpline of Michigan, meanwhile, contracts with the California Smokers' Helpline to provide counseling for Michigan smokers on a per-client basis; all other Helpline services are provided from their headquarters in Lansing. This arrangement suggests the potential for a single counseling center to provide telephone counseling for a multistate region or even for the entire nation.
Just as the Helpline's early research supported a wide application of its findings, that application in turn supports increased research. The size of the Helpline's population allows opportunities for research on smoking and the quitting process that would be difficult to conduct with smaller populations of smokers. For example, a close comparison of hazard functions for relapse for different intervention groups is often infeasible in typical smoking cessation research because of insufficient sample size. But a large sample gives researchers confidence to make such comparisons, providing new information about the differential effects of interventions at different points in time.35 The size and diversity
THE FUTURE: TELEPHONE COUNSELING
AS AN ADJUVANT TO PHYSICIAN ADVICE
The California Smokers' Helpline has made an attempt to blend features of both the clinical and the public health approaches to smoking cessation with the aim of bringing a clinically effective intervention to a large and diverse population. Undoubtedly, more could be done along these lines. One possibility that the Helpline is currently pursuing is to apply telephone counseling to primary care settings.
The role of physicians in helping patients to quit smoking is one of the most active areas of research in smoking cessation. Most smokers visit their doctors at least once a year,40,41 an occasion that has been called a “teachable moment” because it is then that they are likely to be receptive to advice on behavior changes that could improve their health.42 The effect per smoker may be quite low, but if all physicians were to start doing this, they would quickly reach the majority of smokers. The overall effect, therefore, could be dramatic. For this reason, there is now a big push to urge physicians to take a more active role in helping to reduce the smoking prevalence.43 Many creative approaches to physician involvement have been proposed, such as the vital sign approach, in which smoking status is included among the vital signs that physicians assess as part of routine physical checkups.44 Such approaches are intended to create an impetus for physicians to advise their smoking patients to quit.
There are obstacles to physician involvement, however. Doctors are not reimbursed for providing behavioral modification counseling and, moreover, may feel inhibited by a lack of counselor training.45 Further, those who are inclined to advise patients on preventive health measures may have little time to do so. In managed care settings, physicians typically have about 15 minutes with each patient, during which time they must diagnose, discuss, and treat the presenting complaint; arrange needed referrals or routine screenings; and respond to other possible concerns of the patient. And given the high attrition rate in smoking cessation clinics, the physicians who refer their patients to them may quickly become discouraged with that strategy.46
Telephone counseling may work well as an adjuvant intervention
NOTE
This work was supported by grants 90-10961 and 92-15416 from the California Department of Health Services, Tobacco Control Section. Preparation of this chapter was supported by a grant from The California Wellness Foundation. This chapter follows closely the content of a Wellness Lecture presented in October 1996, when the number of calls to the Helpline had reached 41,000. At the time this volume went to print, the number of first-time calls had surpassed 120,000. For updated information on the demographic distribution of callers to this program, interested readers may wish to consult S.-H. Zhu et al., “A Centralized Telephone Service for Tobacco Cessation: The California Experience” (Tobacco Control [Suppl., August 2000]).
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15. Burns, D., and Pierce, J. P.1992. Tobacco Use in California, 1991–1992.Sacramento: California Department of Health Services.
16. Zhu, S.-H., Rosbrook, B., Anderson, et al. 1995. “The demographics of helpseeking for smoking cessation in California and the role of the California Smokers' Helpline.” Tobacco Control4 (Suppl. 1), S5–S15.
17. Zhu, S.-H., Anderson, C. M., and Pierce, J. P.1995. “Smoking cessation in
18. Von Winterfeldt, D., and Edwards, W.1986. Decision Analysis and Behavioral Research.Cambridge: Cambridge Press.
19. Abrams, D. B.1993. “Treatment issues: Towards a stepped-care model.” Tobacco Control2 (Suppl.), S17–S29.
20. Zhu, S.-H., Freeman, D., Martinez, E., and Anderson, C. M.1995. “Help seeking and active helping in smoking cessation.” Paper presented at the 16th annual scientific session of the Society of Behavioral Medicine, San Diego, March.
21. “California Legislature, Senate Committee on Local Government.” 1985. Rural Counties' Fiscal Problems.Sacramento: State Capitol.
22. Miller, W. R., and Rollnick, S.1991. Motivational Interviewing: Preparing People to Change Addictive Behavior.New York: Guilford Press.
23. Beck, A. T., Wright, F. D., Newman, C. F., and Liese, B. S.1993. Cognitive Therapy of Substance Abuse.New York: Guilford Press.
24. Marlatt, G. A., and Gordon, J. R.1985. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behavior.New York: Guilford Press.
25. Zhu, S.-H., Tedeschi, G., Anderson, C. M., and Pierce, J. P.1996. “Telephone counseling for smoking cessation: What's in a call?” Journal of Counseling and Development75 (2), 93–102.
26. Glynn, T. J., Boyd, G. M., and Gruman, J. C.1990. “Essential elements of self-help/minimal intervention strategies for smoking cessation.” Health Education Quarterly17 (3), 329–345.
27. Lando, H. A., Hellerstedt, W. L., Pirie, P. L., and McGovern, P. G.1992. “Brief supportive telephone outreach as a recruitment and intervention strategy for smoking cessation.” American Journal of Public Health82 (1), 41–46.
28. Ockene, J. K., Kristeller, J., Pbert, L., et al. 1994. “The physician-delivered smoking intervention project: Can short-term interventions produce longterm effects for a general outpatient population?” Health Psychology13 (3), 278–281.
29. Prochaska, J. O., DiClemente, C. C., Velicer, W. F., and Rossi, J. S.1991. “Standardized, individualized, interactive and personalized self-help programs for smoking cessation.” Health Psychology12 (5), 399–405.
30. Ossip-Klein, D. J., Giovino, G. A., Megahed, N., et al. 1991. “Effects of a smokers' hotline: Results of a 10-county self-help trial.” Journal of Consulting and Clinical Psychology59 (2), 325–332.
31. Orleans, C. T., Schoenbach, V. J., Wagner, E. H., et al. 1991. “Self-help quit smoking intervention: Effects of self-help materials, social support intervention, and telephone counseling.” Journal of Consulting and Clinical Psychology59 (3), 439–448.
32. Curry, S. J., McBride, C., Grothaus, L. C., Louie, D., and Wagner, E. H.1995. “A randomized trial of self-help materials, personalized feedback and telephone counseling with nonvolunteer smokers.” Journal of Consulting and Clinical Psychology63 (6), 1005–1014.
33. Lando, H. A., Rolnick, S., Klevan, D., et al. 1997. “Telephone support as an
34. Zhu, S.-H., and Pierce, J. P.1995. “A new scheduling method for time-limited counseling.” Professional Psychology: Research and Practice26 (6), 624–625.
35. Zhu, S.-H., Stretch, V., Balabanis, M., et al. 1996. “Telephone counseling for smoking cessation: Effects of single-session and multiple-session interventions.” Journal of Consulting and Clinical Psychology64 (1), 202–211.
36. Howard, K. I., Kopta, S. M., Krause, M. S., and Orlinsky, D. E.1986. “The dose-effect relationship in psychotherapy.” American Psychologist41 (2), 159–164.
37. Abrams, D. G., Emmons, K., Niaura, R. D., et al. “Tobacco dependence: An integration of individual and public health perspectives.” In The Annual Review of Addictions Treatment and Research, edited by P. E. Nathan, J. W. Langenbucher, B. S. McCrady, and W. Frankenstein. New York: Pergamon Press.
38. Winett, R. A., King, A. C., and Altman, D. G.1989. Health Psychology and Public Health: An Integrative Approach.New York: Pergamon Press.
39. Shiffman, S.1993. “Smoking cessation treatment: Any progress?” Journal of Consulting and Clinical Psychology61 (5), 202–211.
40. Gritz, E. R.1988. “Cigarette smoking: The need for action by health professionals.” CA—A Cancer Journal for Clinicians38 (4), 194–212.
41. Gilpin, E., Pierce, J. P., Goodman, J., et al. 1992. “Trends in physicians' advice to stop smoking.” Tobacco Control1 (1), 1–36.
42. Vogt, T. M., Lichtenstein, E., Ary, D., et al. 1989. “Integrating tobacco intervention into a health maintenance organization: The TRACC program.” Health Education Research4 (1), 125–135.
43. “U.S. Department of Health and Human Services.” 1994. Tobacco and the Clinician: Interventions for Medical and Dental Practice. NIH Publication 94-3693. Washington, D.C.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health.
44. Fiore, M. C., Jorenby, D. E., Schensky, A. E., et al. 1995. “Smoking status as the new vital sign: Effects on assessment and intervention in patients who smoke.” Mayo Clinic Proceedings70 (3), 209–213.
45. Sexton, M., Stine, J., and Cahill, S.1994. “Smoking intervention by providers of health care for women.” In Tobacco and the Clinician: Interventions for Medical and Dental Practice. NIH Publication 94-3693. Washington, D.C.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health.
46. Lichtenstein, E., and Hollis, J.1992. “Patient referral to a smoking cessation program: Who follows through?” Journal of Family Practice34 (6), 739–744.
47. Fiori, M. C., Bailey, W. C., Cohen, S. J., et al. 1996, April. Smoking Cessation. AHCPR Publication 96-0692. Clinical Practice Guideline 18. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research.
48. Tsoh, J. Y., McClure, J. B., Skaar, K. L., et al. 1997. “Smoking cessation: 2. Components of effective intervention.” Behavioral Medicine23 (1), 15–27.
15. DISEASE PREVENTION
VERSUS HEALTH PROMOTION
Pitfalls of Preventive Care
in the Geriatric Population
Andrew Duxbury
INTRODUCTION
Rapid gains in medical knowledge, technology, and public health measures through the 20th century have led to a demographic shift unprecedented in human history. A much larger portion of the population is surviving to old age, placing great strains on long-established social structures and concepts. The geriatric age-group, usually defined as those 65 years of age or older, has become one of the fastest-growing segments of our society in terms of both percentage and absolute numbers.1,2 At the turn of the 20th century, there were approximately five million adults over the age of 65 in the United States, or about 4% of the total population. In 1990, that number had increased to 30 million, or 12.5%. If present trends continue, by the middle of the 21st century, nearly 70 million, or more than 20%, will qualify as members of the geriatric age-group.3
This demographic change is forcing our society to grapple with multiple complicated issues related to aging. These include questions of social and medical policy that impact the lives of older adults and their caregivers. One of these questions is, How should our health system approach the subject of preventive health care for the geriatric population? Should the model we use focus on disease prevention, or is this model inadequate to deal with the normal physiologic changes of an aging population? What should be the role of screening for specific disease in a population with high prevalence of disease from the physiologic and functional challenges of the aging process? This chapter looks at some of the issues surrounding
There has been a tendency in American social and medical policy to consider all persons over the age of 65 as a homogeneous entity of “geriatric” individuals. However, such inclusiveness does not allow for the differences that may exist within the older population in terms of life expectancy, functional status, or disease burden. In order to better understand this demographic group, some sort of divisions are helpful. Some authors advocate splitting older adults into three groups based strictly on chronologic age: The “young old,” aged 65 to 75, who are physically and physiologically quite similar to younger adults; the “middle old,” aged 75 to 85, who are more likely to be impaired physically or functionally from disease; and the “old old,” those over the age of 85 who are at the highest risk for severe morbidity.4–7 Others recommend considering older adults solely on the basis of their functional status, arguing that there is little difference between a robust and healthy 65- and 85-year-old.8–10 Functional dependence, or an inability to complete basic activities of daily living such as bathing or dressing, affects less than 5% of adults 65 to 75 but approaches 40% in those over 85.11 Either way, the majority of the “geriatric” age-group is not what most would consider geriatric in either health status or functioning. The poorly functional, often the “old old,” bear the brunt of age-related disease and their associated costs, economic and human.
The decline in mortality that has led to a longer life span has not been matched by a decline in morbidity.12 Older people are in danger of severe physical and functional compromise from both acute and chronic disease states. The medical and social problems of such dependent individuals pose both a direct and an indirect economic burden to society and the health care system. Over the last few decades, Alzheimer's disease, one of the more common diseases of aging, has emerged from relative obscurity to the 16th most costly disease in our health system in direct dollar costs.13 If indirect costs such as lost productivity of patients and caregivers are factored in, it rises to third, following only heart disease and cancer.14 The direct costs of dementia care alone are expected to top $100 billion a year by 2040, most of it being spent on functional needs.15 Good medical practice and old-fashioned common sense say that the afflictions that create this frail, dependent fraction of the elderly population should be minimized, as they drain increasingly scarce health care dollars, often without hope of restoration of premorbid functioning.
Given the intense interest on both local and national levels regarding expenditures for health care, it is time to take a critical look at how our health care system goes about the task of maintaining health. Much of the current focus in gerontology is on so-called successful aging, whereby older individuals maintain lifestyles and health similar to those of younger people. The U.S. medical system is organized around acute interventions; treatment is offered for a specific illness or diagnosis. Thinking is based on the concepts of disease and cure. Preventive measures, when they are offered, fit into this model by obviating the need for a later cure. The evolving specialty of geriatrics, with its emphasis on functional status and health maintenance, requires a new paradigm of “health promotion” in which preventive measures are integrated into the full life cycle including the older age-group. The focus becomes not one of “disease” but rather one of “health.”
OLDER ADULTS AND THE HEALTH CARE SYSTEM
The average primary care physician currently spends between 30% and 40% of his or her time with patients in the geriatric age-group. It is estimated that this will increase to at least 50% early in the 21st century, given current population trends.16,17 The majority of these adults are able-bodied and independent; however, 22% require some assistance from others to remain at home, while another 5% reside in a long-term-care facility.18 These frail, dependent individuals are more at risk for morbidity and mortality from disease processes.
Medicare, the federal health program for the elderly, has an annual budget of over $170 billion.19 Its cost has been increasing at roughly 15% a year since its adoption in 1966.20 At the time of its inception, life expectancy for Americans was roughly 70 years, five years beyond the age for qualification.20 Life expectancy has increased to age 79 today, and for those who are healthy at age 65, it is now 84 for men and 89 for women.19 Medicare was designed to allow older Americans access to the acute care model of health service provision prevalent in the United States. It was never intended to be a comprehensive health insurance policy. It pays for services necessary to recover from an acute disease. For the most part, it does not pay for preventive measures, treatments for chronic conditions, or acute conditions after a specified time frame if meaningful recovery is not achieved. Because up to 80% of those over the age of 65 suffer from at least one chronic disease, there is a divergence
Many frail elderly are in need of chronic care. The need for skilled nursing facilities is expected to increase dramatically in the coming years. In 1964, prior to the creation of Medicare and Medicaid, only about 500,000 older adults lived in skilled nursing facilities. Numbers increased to about 1.5 million by 1990.21 For persons turning 65 in 1990, it has been estimated that 43% (900,000) will be admitted to a nursing home at least once prior to their death.22 Medicare pays for less than 5% of nursing home care costs. Most long-term care is, by definition, chronic and therefore outside the scope of Medicare. It is paid for by either state Medicaid programs or private funds.23 The economic burden to the federal government, states, and private individuals continues to increase and is part of the ongoing debate on health care reform. The combination of Medicare's emphasis on acute health conditions, its lack of payment for chronic health care needs, increasing life expectancy, and medical inflation have led to the ironic result that the elderly spend a larger portion of their income on out-of-pocket health expenses today than they did in 1965, prior to the introduction of Medicare.24
Despite the best efforts of the health care system, ultimate mortality for the human race remains at 100%. Death cannot be prevented, only postponed. The system can only try to control the types of disease and other morbid conditions that lead to death. There is some perception by the public that too many of our scarce resources are “wasted” on the elderly. Various studies have shown that the elderly do consume 30% to 35% of health care dollars.25,26 However, a more detailed analysis shows that the fraction of the elderly in the terminal stages of their life is responsible for the lion's share of these costs. Thirty percent of Medicare dollars are spent on individuals who die within a year; 52% of these are spent in the last 60 days of life.27 Younger people who die or have catastrophic disease also use large quantities of health care dollars.28 The bottom line is that a significant portion of the health care costs in this country goes to terminal care of those without hope of meaningful recovery.
HEALTH CARE MAINTENANCE
It is clear that the diseases of the frail elderly pose an increasing burden on society's ability to provide care. The medical specialty of geriatrics sees those patients with chronic health problems and tries to help the
Improvement in a patient's ability to meet his or her own selfcare activities of daily living is assumed to be a cornerstone of better health. In fact, frailty and an inability to care for one's self are those things most feared by the older population, not death.30 Research looking for predictors of frail health and disability among older adults has failed to demonstrate any consistent positive predictors. The most consistent risk factor noted has been that of physical inactivity.12 Inactivity, particularly if related to a disease, often starts a downward spiral from which there is no recovery. Neuromuscular atrophy, decreased aerobic capacity, and a decrease in basal metabolic rate all set in rapidly during bed rest in the geriatric age-group.31 The misconception that prolonged rest is good for the ill and the elderly adds to their morbidity.12 Functional assessment is aimed at interrupting this process.
Controlled randomized trials of geriatric functional assessment for frail patients on inpatient geriatric units have shown the benefits of this approach.32–34 The results are not so clear-cut on ambulatory patients.35,36 Medicare does not recognize functional assessment as a separate entity distinct from an office visit, so most practicing physicians limit its use.37 The growth of functional assessment and the spreading of the geriatrics gospel have increased the realization that interventions practiced now on older people may help prevent future burdens on the health care system. Two important concepts have come from this. The first is the idea of a compression of morbidity, eloquently articulated by Fries nearly 20 years ago.38 As death cannot be prevented, functional healthy life should be extended until the period just prior to death, and then all morbidity should be suffered relatively acutely. Theoretically, this leads to maximal functional life of high quality and an obvious period of sharp, irreversible decline, which should be allowed to run its course without heroic intervention. Second, the ideals of preventive health care,
| Primary prevention—Those measures designed to prevent a given disease state from occurring. |
| Secondary prevention—Those measures designed to interrupt an established disease process prior to the onset of clinical symptoms. |
| Tertiary prevention—Those measures designed to prevent complications of a symptomatic disease state. |
PREVENTIVE HEALTH CARE
Mathematical modeling of Medicare expenditures into the 21st century has shown that a decrease is expected if appropriate preventive health measures convert a majority of the population into healthy low-cost users of the system rather than strictly treating the acute disease states that create high-cost users of the system.39 These preventive health care measures can be divided into several classes, as shown in Table 15.1.
Many primary and secondary measures of preventive care have been shown to be cost-effective and therefore are the ones most intensely studied.39 Preventive health care modalities that have been looked at in the geriatric population include primary measures such as vaccination against pneumococcal pneumonia and influenza virus, counseling on proper nutrition, home safety, and cholesterol screening. Secondary measures include blood pressure measurement, smoking cessation strategies, and cancer screening modalities such as mammography or fecal occult blood testing. Many of these are now considered standard in the routine care of the older adult. These preventive measures are usually cast in terms of disease rather than in terms of health.
THE DISEASE PREVENTION MODEL
Most physicians in the United States are indoctrinated by the health care system principles of acute care medicine. The goal is to take a diseased patient and apply an intervention that renders that patient no longer diseased. The physician becomes reactive to the disease of the patient. When issues of preventive care are addressed, they are also usually considered within this acute care framework. The goal of preventive care is
The problem with this system is that the emphasis is placed on disease, not the patient and not health. The focus on disease can lead to a “can't see the forest for the trees” blindness on the part of physicians and the health care system. Physicians become so focused on disease that they are unable to deal adequately with information that does not neatly fit into a disease-based model. They tend to neglect pure preventive measures and miss proactive measures, such as discontinuing an unneeded medication.40 Research by Reed et al. has shown that the disease-based worldview is strongly ingrained in even the youngest practicing physicians. Their survey of family practice residents regarding the follow-up of recommendations from a geriatric functional assessment showed that physicians ordered additional tests for diagnosis 70.3% of the time. They ordered additional medication for treatment 85.4% of the time. They were much less likely to stop a medication (64.3%) or perform preventive measures (54.3%).41 Clearly, the goals of maximizing function and health in the geriatric population require a more encompassing view than one that deals strictly with “disease.”
SCREENING TESTS IN OLDER ADULTS
A major focus of disease prevention in the geriatric age-group is screening tests for serious medical conditions. Some, such as blood pressure screening, are so routine and easily performed that they are considered a normal part of a visit to the doctor. Others, such as screening tests for certain cancers, diabetes, or elevated cholesterol, require special examinations. Medicare, which pays approximately 50% of the health care bill for those over 65, was conceived under the acute care model.42 Medicare reimburses doctors and hospitals for the care of disease states. It was never designed to be an all-encompassing health program, and screening tests, with certain exceptions, are not covered benefits, as they do not treat acute disease.
Whether a given screening test is worthwhile in a population depends heavily on that test's sensitivity and specificity. Sensitivity is defined as the proportion of patients with a given disease whose test will be positive for that disease. A sensitive test produces few false-negative results. Specificity is defined as the proportion of patients without a specific disease
CANCER SCREENING: AN OVERVIEW
Cancer lends itself to the disease prevention model of preventive care and screening. It is the second-leading cause of death in the elderly, after atherosclerotic cardiovascular disease.45 Fully 50% of diagnosed cancers occur in the over-65 age-group.46 Awareness of the disease in older patients is high.47 The goal of most cancer screening tests is to detect early malignancies prior to regional spread and metastasis, when the chance of curative treatment is high.48 Therapy for malignancies that have spread remains problematic, particularly in older individuals who may be debilitated from other disease and unable to tolerate radical surgery or chemotherapy.49 By screening, the clinician hopes to extend additional “well” time to an individual and limit the morbidity and mortality of the disease process, thus fulfilling the goal of compression of morbidity discussed previously.
Difficulties arise in trying to determine just what type of screening is appropriate in the older age-group. Data from controlled trials is limited or nonexistent. Conflicting recommendations are issued by authoritative groups. The American Cancer Society (ACS) is perhaps the best known of these; it issues screening recommendations with periodic updates for most common cancers. Some physicians, however, find the ACS recommendations too burdensome for the average patient.16,50 Various physicians
These conflicts can leave the clinician caring for the older patient somewhat confused. Different groups make different recommendations on the basis of the same data. Patients may request specific preventive services, not caring that they may be inappropriate. There may be pressures from colleagues or the makers of equipment used in screening exams for referrals. Authoritative, rational guidelines as to appropriate care of the elderly are not uniformly distributed. The physician often uses the old paradigms of acute care medicine and orders a screening exam, assuaging his or her conscience with a feeling of “it's better to do something than to do nothing.” Two of the most common cancer screening exams, mammography and the prostate-specific antigen, can be used to illustrate the pitfalls of preventive care in the elderly, particularly if they are used without thought or rationale.
MAMMOGRAPHY
It is estimated that one out of nine American women will develop breast cancer at some point in her adult life.54 Currently, an estimated 180,000 women are diagnosed with the disease annually, and 44,000 die.46 These numbers have steadily increased; some of the increase is due to improved detection; the reason for the rest is less clear. A number of risk factors for breast cancer have been established, including increased age, family history, and not having borne children.55 Seventy-five percent of cancers, however, occur in the absence of specific definable risk factors placing all women at risk.56 Despite advances in detection and treatment, mortality rates today are similar to those of 20 years ago.57 Women in the geriatric age-group are at much higher risk for breast cancer than their younger counterparts. They constitute approximately 14% of the female population but account for 43% of the diagnoses of breast cancer.58 Breast cancer rates for older women are listed in Table 15.2.
A renewed focus on women's health issues and the commonplace nature of the disease have led to increased public awareness of the problem
| Age | Rate per 100,000 Population |
|---|---|
| SOURCE: National Institutes of Health (1991 [59]). | |
| 65–69 | 390.7 |
| 70–74 | 421.8 |
| 75–79 | 461.4 |
| 80–84 | 451.3 |
| 85+ | 411.9 |
Like all X-ray examinations, mammography is not an inexpensive procedure. Costs range from $40 to $250 for the examination, with an average charge in the United States of $120 to $150. Based on a
Mammography has a proven track record, but the elderly are among those least likely to receive screening. Risk factors for not receiving screening mammography include age over 65, low income, low educational level, living in a rural area, and ethnic minority status.74 The goal of the National Cancer Institute is an 80% screening rate of at-risk women by the year 2000.75 Currently, approximately 35% to 40% of women over age 50 are being screened.76,77 Massive trial community based intervention programs have managed to increase this to about 55% in selected areas.78 The number of women being screened continues to increase, and an individual is nearly nine times more likely to be screened now than in the mid-1980s.79 Why are women over 65, who bear the brunt of the disease burden, less likely to receive screening, which has been proven to be of benefit? The reasons for this are several. First, physicians are less likely to recommend mammography to older women.80 Seventy-six percent of women who undergo mammography have the exam at the advice of a physician and not through their own initiative.77 If an older woman's physician does not recommend the test, it usually is not done. Physicians fail to make the recommendation for many reasons: They assume older women have relatively short life expectancies and screening is not warranted, they are unaware of the data and recommendations that say older women should be screened, and they are less likely to be asked by patients for the procedure.80,81 Many physicians believe that they recommend the procedure for their older female patients, but review of their records show that their beliefs and their practices are vastly different and that mammography is underutilized.82 Older patients are less likely to believe that they need screening.83 Media attention to the disease has focused on the risks to younger women. This youth-oriented approach has lulled many older women into a false sense of security regarding their risks.84 There is also a tenacious belief, held mainly by older women, that healthy women without risk factors are not in need of mammography. In addition, women over the age of 65 have some inherent distrust of
| Age | Rate per 100,000 Population |
|---|---|
| SOURCE: Morrison et al. (1990 [89]). | |
| 65–69 | 303.0 |
| 70–74 | 487.6 |
| 75–79 | 705.6 |
| 80–84 | 949.5 |
| 85+ | 1,043.9 |
PROSTATE-SPECIFIC ANTIGEN
Cancer of the prostate gland remains a major cause of morbidity and mortality for males in the United States. It is the most commonly diagnosed tumor among men, the second-highest cause of cancer death for men,46 and the fourth most common cause of death overall.86 Prostate cancer rates in older men are given in Table 15.3. The death rate from prostate cancer has been slowly increasing since the early part of the 20th century. In 1930, the mortality rate was approximately 14 per 100,000 men, and by 1985 this had increased to 23 per 100,000.87 More than 50% of men over the age of 70 could be diagnosed with the disease if full screening were performed in this age-group.88 The American Cancer Society estimates 334,500 new diagnoses and 42,000 deaths for calendar year 1997.46
Given the high prevalence of the disease, there is an intense interest in screening and disease prevention. Mortality has changed little over the last 20 years because of the advanced nature of the disease at diagnosis in most men.90 Approximately two-thirds of newly discovered cases have extended beyond the prostatic capsule or have distant metastases at diagnosis, making them poorly amenable to treatment.91 The serum enzyme acid phosphatase, discovered in 1936, was linked to prostatic function and recognized as a marker for prostatic cancer in 1948.92,93 For the next four decades, it became a standard screening test for prostatic cancer. Acid phosphatase, however, had poor diagnostic accuracy for the disease and often reached abnormal levels only after skeletal metastasis had taken place.94,95 Another indicator was needed.
| Stage | Five-Year Extent of Tumor | Survival |
|---|---|---|
| SOURCE: Gernic (1993[102]). | ||
| A1 | Well-differentiated focal carcinoma—not clinically detectable | >90% |
| A2 | Diffuse localized carcinoma—not clinically detectable | >90% |
| B1 | Discrete nodule in single lobe of gland | 77% |
| B2 | Multiple nodules or multiple lobe involvement | 77% |
| C1 | Localized invasion of adjacent tissue; no involvement of seminal vesicles | 64% |
| C2 | Localized invasion with seminal vesicle involvement or>70-g tumor | 64% |
| D0 | Biochemical evidence of metastatic tumor without physical evidence | |
| D1 | Tumor metastatic to lymph nodes or with hydronephrosis | |
| D2 | Tumor with distant or bony metastases | Median survival 2.5 years |
Immunologists recognized the high antigenicity of the prostate gland as early as 1960.96 One of these antigens, originally identified as gammaseminoprotein and later as protein E and protein p30, has now been characterized as the prostate-specific antigen (PSA).97 It is a 30,000-dalton glycoprotein of the kallikrein family of serine proteases, produced only in the prostate gland with elevated levels being present in states of hypertrophy or carcinoma.98 It has been extensively studied, and its structure is well known. The development of radioimmunoassays for the substance has allowed the marketing of commercial tests for measurement of the PSA in serum from patients on a routine basis.97 The value of the PSA level in a patient's serum has been shown to be proportional to the size of the cancer and its stage.99–101 Prostatic cancer is usually divided into four stages, as shown in Table 15.4; early-stage cancers can be cured through surgical intervention.97
The logarithmic relationship between cancer stage and serum level of PSA, plus the relatively slow doubling time of most prostate cancers, would seem to make them easily amenable to a sensibly designed screening program.103 Unfortunately, men with benign prostatic hypertrophy (BPH) and no evidence of carcinoma will also have elevated levels 104,105 A PSA level of 4 ng/ml, taken as the upper limit of normal, will uncover many false positives from BPH. A PSA level of 10 ng/ml will
A number of uncontrolled studies of PSA measurement have been done in an attempt to define a benefit for screening of the population. Results have been controversial at best. Studies such as those of Catalona et al.,106 Brawer et al.,107 and Labrie et al.108 have shown that PSA is extremely useful in detecting cancers that would otherwise have been missed by more conventional methods, such as digital rectal examination. There are, however, no controlled studies to show that this earlier detection makes any difference in either morbidity or mortality. Such studies are currently being performed, but because of the indolent nature of the disease, results are not expected until well into the 21st century.109
This lack of proven benefit has called the use of PSA as a screening test into question. To complicate the picture further, the very nature of the disease raises serious questions about the utility of screening.110,111 Population studies suggest that approximately 30% of the male population at age 50 and 50% at age 70 have malignant change in the prostate gland.88 A vast majority of these cancers remain latent. Only one in about 400 ever progresses to clinical disease.112 This has led to the old adage that “far more men die with prostate cancer than from prostate cancer.” Prostate-specific antigen cannot differentiate which of these cancers will progress to overt disease and which will remain latent. Improved detection will lead to many more men undergoing treatment for a condition that would never have led to any clinical problems. Even the urologic literature has been polarized over the utility of using PSA as a screening test.113,114 In order to settle the debate, recent work has used sophisticated decision analysis techniques to determine if PSA is a viable screening tool. These studies have shown PSA to be of little to no benefit in the testing of unselected populations.115,116
Despite the doubts raised about PSA and the lack of consensus from the medical community on its usefulness, the American Cancer Society adopted recommendations in December of 1992 that all men over the age of 50 undergo annual PSA screening for prostate cancer in addition to the previously recommended digital rectal examination.117 Their focus of disease prevention argues that elimination of the disease is both necessary and worthwhile. As public awareness of the PSA test has increased, demand by patients has increased; arguments of a statistical or costbenefit nature are not easily used to mollify an individual who is concerned about his personal risk. The clinician is left torn between the competing imperatives of the patient and of the health care system.
Widespread screening of the male population with PSA is not without substantial risk. The current treatment of choice for early disease, stages A and B, remains either surgical removal through radical prostatectomy or radiation therapy.109 More advanced disease also usually involves either surgical or chemical castration, as the tumor tends to be androgen dependent.118 Both prostatectomy, despite improved surgical techniques, and radiation therapy can have significant sequelae.119 As a screening program, yearly PSA levels would uncover many cases of latent disease, and the estimated iatrogenic morbidity and mortality would increase astronomically.
Questions have also been raised regarding the cost-effectiveness of massive PSA screening. Optenberg and Thompson, in a detailed study from 1988 (see Table 15.5), estimated current costs to the health care system from screening and follow-up to be in the neighborhood of $255 million a year. This would increase to $11.3 billion if the population were screened and all PSA levels over 10ng/ml were followed up with biopsy and appropriate treatment. If the abnormal level were dropped to 4 ng/ml in order to better detect stages A and B cancers that were more likely curable, the cost to the system would be expected to rise to nearly $28 billion.120 This study was done using the population between the ages of 50 and 70 as a model. No analysis has been done involving only the geriatric age-group, in which the disease becomes even more common, and morbidity and mortality from surgery or radiation may be increased.
THE HEALTH PROMOTION MODEL
The examples discussed here show that the disease-based model of preventive health care may not provide the whole answer. Mammography has been proven to have a place in the health care of the older patient, but the data on PSA are not convincing, as PSA in particular looks highly problematic with potential rates of iatrogenic disease that are simply unacceptable. Geriatrics, with its emphasis on an integrated approach to the patient, offers an alternative to a disease-based model, namely, one founded on the concept of health. The goal of geriatric care is to maintain an individual at optimum health and functional status. All recommendations for treatment, screening, and other health care measures are
| Current Screening Levels | 100% PSA Screening | |
|---|---|---|
| SOURCE: Optenberg and Thompson (1990 [120]). | ||
| No. cases impotence | 3,354 | 266,671 |
| No. cases incontinence | 908 | 61,618 |
| No. colostomies | 133 | 10,522 |
| No. treatment deaths | 220 | 20,563 |
| Expense per year | $255 million | $3.8-27.9 billion |
In order to discuss a model of health promotion, it is important to define health. In the geriatric age-group, health is probably not best defined as “freedom from disease.” Most older people have chronic disease burden and continue to lead active normal lives. Health is instead a self-reported feeling of well-being and of being able to function to maximal abilities within a self-selected lifestyle. Work done on health attitudes of older people shows a strong correlation between self-reported perception of health and ultimate morbidity.121 The older patient needs to be approached with an understanding that disease may not be an overriding concern for him or her. An ability to function and undertake usual activities often is much more important. Patients may choose not to undergo treatment for disease if it would leave them functionally impaired.
These ideas of health and function may best be conceptualized within a framework of basic ecologic principles. Modern biology contains a construct known as niche theory, which is a useful analogy in understanding the approach to the older adult.122 The basic principles of niche theory are contained in Table 15.6.
In brief, a species and an ecological niche must always fit together hand in glove. If they do not, extinction is the end result. The older adult fits together with a chosen life in a similar fashion. Individuals and lives evolve together over the decades in a symbiotic relationship. When there
| Each species has a unique ecological niche within the ecosystem. | The species has adapted to fill that niche. | A change or mutation in the species requires that the niche also change in accommodation. | A change in the niche from external environmental influences requires a change in species behavior or function in reaction. |
For the health promotion model to work effectively in a primary care practice setting, the following conditions are necessary. First, there must be an expectation on the part of both the physician and the patient that such measures be addressed in an encounter. In addition, communication between physician and patient must be effective. Second, the patient must be motivated to pursue these measures outside the physician's office and to modify lifestyle choices. Patients can be educated and encouraged to become a more active partner in the information loop. Such measures as informational brochures and pocket checklists have proven beneficial to increasing compliance and awareness. Third, the physician must be knowledgeable in the principles of health maintenance and be aware of measures with proven efficacy versus those that are of more dubious value. Fourth, the health care system must regard health maintenance issues as central to health care and place priority on carrying them out and allowing adequate reimbursement.123
Health promotion, particularly in the geriatric age-group, would seem to be a rather obvious conclusion and nothing short of common sense. However, it bucks the thinking and teaching of acute care medicine to consider the patient as a complete individual rather than as the sum of diagnostic parts. Most physicians are guilty of thinking of their patients as “the lady with the breast mass” or “the colon cancer in room 302.” Simple health promotion interventions for the elderly are still in their infancy. It is well established that 10% of community-dwelling elderly are
EVALUATION OF PREVENTIVE MEASURES
The precepts of health promotion require that screening examinations, particularly those with the potential of inflicting morbidity, be studied as to their impact on the whole patient, not just the disease process. Rational criteria must be developed for the evaluation of current and future screening procedures to see if they truly fit the needs of the elderly population. Issues such as the effect of a test or service on the caregiver of an older patient are not taken into account under standard methods of evaluation.44 Cost-benefit analyses by some experts tend to be inherently biased against the elderly, as their life expectancy tends to be shorter than that of younger persons.129,130 Frame and Carlson published a set of six principles (listed in Table 15.7) for assessing screening exams that have been widely used as a method of determining their benefits.
The Department of Family Practice at the University of Michigan, under the leadership of Klinkman and Zazove, have taken these criteria and modified them to make them more representative of the special needs of the elderly. Their modified criteria are listed in Table 15.8.
The University of Michigan criteria fulfill the goals of health promotion by placing the major focus immediately on the total health of the patient. The shift from the older criteria is subtle. It includes a major stress on the concept of health, a word that does not appear at all in
| SOURCE: Frame and Carlson (1975 [131]). | |||||
| 1. The disease must have a significant effect on the quality of life. | 2. Acceptable methods of treatment must be available. | 3. The disease must have an asymptomatic period during which detection and treatment significantly reduce morbidity or mortality. | 4. Treatment in the asymptomatic phase must yield a therapeutic result superior to that obtained by delaying treatment until symptoms appear. | 5. Tests that are acceptable to patients must be available at reasonable cost to detect the condition in the asymptomatic period. | 6. The incidence of the condition must be sufficient to justify the cost of screening. |
| SOURCE: Klinkman et al. (1992 [44]). | ||||||||
| 1. The condition must have a significant effect on health. | 2. Acceptable methods of preventive intervention or treatment must be available for the condition. | 3. For primary preventive services (counseling, chemoprevention, immunizations), the intervention must be effective in preserving health. | 4. For other preventive services or interventions: | a. There must be a period before the individual (or his or her caretaker) is aware of the condition, or of its seriousness or implications, during which it can reliably be detected by providers. | b. Tests used to identify the condition must be able to reliably discriminate between cases and noncases of the condition. | c. Preventive services or treatment during this “preawareness” period must have greater effectiveness than care or treatment delayed until the individual or caretaker brings it to the provider's attention. | 5. For individuals who are cared for by caregivers, the benefit offered by the preventive service must outweigh any negative effects on the quality of life of caregivers. | 6. The relative value of the preventive service or intervention must be determined by a comparison of its costs with its expected health benefits. |
The University of Michigan criteria can be applied to the cancer screening modalities discussed previously. Mammography has been shown to be quite effective in women up to 75 years of age, and it meets all six criteria. The evidence is less clear for women 75 and older. The United States Preventive Services Task Force suggests that women who have been regularly screened up to age 75 are unlikely to develop cancer after that age and do not need to be screened further, but hard data are lacking.52 Women over 75 without previous screening should probably be screened. Prostate-specific antigen does not meet criteria 4a, 4b, or 4c because of its lack of sensitivity and potential for causing new disease related to medical treatment. It may also not meet criterion 6.112,118,132–135
HEALTH AND THE OLDER PATIENT
A focus on health requires a different mind-set from a physician. He or she must learn to inquire into a patient's individual health values. He or she must be flexible in approaching disease processes, as the textbook “cures” available for them may not be in the patient's best interest. Those physicians who are unable to see the patient for the disease leave patients with new problems created by failed curative measures, polypharmacy, and suboptimal social situations. It is estimated that 10% of hospital admissions in the over-65 age-group are due to medication reactions of one kind or another.136 A patient over 65 has a one in three chance of new problem being caused by his or her health care during a hospital stay.137 The personal and economic costs are staggering. A health-based approach might be able to make substantial inroads into these problems.
As a society, we remain ambivalent about health care for older individuals. The adoption of Medicare was a statement that we believe in the rights of older people to have access to treatment for acute disease processes. Societal thinking on preventive measures is not as clear, as there has been no formal adoption of programs or goals. There is discussion of mass screening for serious disease with the techniques discussed here, but the costs involved are considerable. We must tread very carefully in these times when disease is easily politicized and health conditions compete in the legislative and economic arenas for shrinking pools of public resources. The question we must answer is, Should we place our
Care of the geriatric patient requires a sense of the art of medicine as well as of the science of medicine. The goals of health promotion are designed to remove the blinders of disease-based thinking so that the patient is seen as a unique challenge in health maintenance. Preventive medicine is an essential part of the care of the geriatric patient, but physicians can develop an overreliance on their need to “stamp out disease” and use the precepts of preventive care in ways that may not be beneficial to the overall health of their patients. Applying rational criteria to preventive services, such as those from the University of Michigan, helps the physician understand the goals of health promotion. Physicians can and should be taught to look at their older patients in a more holistic light so that they do not pursue disease and “cure” at the expense of the patient. Doing this will help physicians, patients, and society avoid the pitfalls of preventive care.
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101. Partin, A. W., Carter, H. B., Chan, D. W., et al. 1990. “Prostate-specific antigen in the staging of localized prostate cancer: Influence of tumor differentiation, tumor volume and benign hyperplasia.” Journal of Urology143 (4), 747–752.
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16. PREVENTING DISABILITY IN OLDER AMERICANS
The Challenge of the 21st Century
John C. Beck
THE GRAYING OF AMERICA
It is often stated that we live in an aging world. This fact represents one of the major success stories of the 20th century but simultaneously presents the 21st century with one of its major challenges. As America and other industrialized societies approach the new century, the aging population is increasing rapidly, causing growing concern in the broader health care community as well as within local, state, and national legislative arenas. In the United States, persons 65 years or older numbered 33.5 million in 1995, representing almost 13% of the of the U.S. population. In that year, the 65- to 74-year age-group (18.8 million) was 8 times larger than in 1900, the 75- to 84-year group (11.1 million) was 14 times larger, and the 85-year group (3.6 million) was 29 times larger.1,2 The latter, together with centenarians, represent the most rapidly growing age-group. The growth slowed somewhat during the 1990s because of the low birth rate in the 1930s, but the most rapid increase is expected between 2010 and 2030, when the “baby boom” generation reaches age 65. By 2030, about 70 million older persons, more than twice the number in the 1990s, will be in this agegroup, representing at least 20% of the population.1 The group over 75 require more health/social care services than “younger” elderly, and concern is generated because present evidence suggests that there will be an absolute and perhaps also a relative increase in the disability burden that persons of advanced age will place on society.3 Solutions
DEFINITION OF HEALTH
Many factors that are substantially different in the elderly than in the young influence health status as well as illness behavior and the utilization of health and social services. Although the World Health Organization's (WHO's) definition of health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity” has been criticized as being too broad, the breadth of the first part of the definition is an essential concept to a definition of health in the elderly. Complex relationships exist between physical health, mental health, socioeconomic status, and the environment. Defining and measuring health as well as disability must therefore take into account these complex relationships.
The breadth of the second part of the WHO definition, however, is problematic. The traditional definition of health status as the presence or absence of disease is less usable in the elderly than in other populations because it does not include a critical concept—the impact of chronic disease on function. Impairment of function in terms of basic activities of daily living (ADLs), such as dressing, eating, bathing, and toileting, or instrumental activities of daily living (IADLs), such as shopping, cooking, and housekeeping, or advanced activities of daily living (AADLs), such as recreational exercise, gardening, and participating in social activities, has an important influence on the elderly individual's ability to cope with disease and illness as well as on their need for health and social services. The latter (AADLs) represent physical and social functions that are voluntary, the loss of which may indicate early functional decline. A reasonable, usable definition of health in the elderly therefore necessarily includes the concept of function. Such a definition would, for example, encourage providers to see elderly persons as individuals rather than as members of a homogeneous group. Because of the extreme heterogeneity of functional status at any age over 65, ranging from independence to dependency, it has been obvious for some time that functional impairment is not just a natural consequence of aging, and it deserves evaluation on an individual basis. In addition, evidence is increasing that the processes leading to impairment may be
Figure 16.1. International Classification of Impairments, Disabilities, and Handicaps (ICIDH).
MODELS OF THE DEVELOPMENT OF DISABILITY
An understanding of the impact of disease on functioning or the transition from independence to dependency has been aided by the development of new models or conceptual schemes describing this process. The first was developed by the WHO—the WHO International Classification of Impairments, Disabilities and Handicaps (ICIDH) (Figure 16.1).4 Another somewhat similar scheme was conceived and developed by Nagi,5–7 and this one embraces a more holistic approach to health and disability. It is becoming the preferred one and was adopted by the Institute of Medicine.8 I have further modified this model to include the transitional step between independence and dependency. These are illustrated in Figures 16.1 and 16.2, respectively.
More recently, the Disablement Process Model has been developed by Verbrugge and Jette.9 The model is demonstrated in Figure 16.3. It has been modified to include the independence-dependency concept. It emphasizes the pathway of the development of disability and dependency.10 In addition, the model identifies factors that are predisposing as well as introduced, that either speed up and slow down the pathway from independence to dependency. It emphasizes that there are always social, psychological, environmental, and other factors that are operating to modify the pathway. The model describes the impacts that chronic and acute conditions have on the functioning of specific body systems as well as the total organism and on people's ability to act in necessary, usual, expected, and personally desired ways in their society. These models permit the development of research addressing the mechanisms involved in
Figure 16.2. Modified Institute of Medicine model.
Figure 16.3. Modified model of the disablement process (Verburgge and Jette).
THE NEED FOR DISABILITY PREVENTION
In mid- and late life, chronic conditions dominate, and individuals often accumulate several of them. The most common chronic conditions tend to be nonfatal: For middle-aged and older women, the highest prevalence conditions include arthritis, high blood pressure, chronic sinusitis, tinnitus, hearing impairments, allergic rhinitis, chronic back conditions, varicose veins, hemorrhoids, migraine headaches, cataracts, and visual impairments.11,12 The only fatal conditions in women's top 15 rankings
| Jackson et al. (1991 [13]) | Manton (1989 [14]) | McBride (1989 [17]) | Rogers et al. (1990) | |
|---|---|---|---|---|
| Data source | 1981–86 LSOA; 1984–86 CLTC | 1984 NLTCS; 1985 NNHS | 1984 SOA; 1985 NNHS; 1976–80 AHS | 1984–86 LSOA |
| a Data exclude standby assistance. | ||||
| Projections include: Community-dwelling | Yes | Yes | Yes | Yes |
| Nursing home | Yes | Yes | Yes | No |
| No. of ADLs used in projections | 5 | 6 | 5 | 7 |
| Definition of disability | Human assistance | Human assistance (special equipment)[a] | Difficulty | Difficulty |
| Projections method | Multistate; life table | Static components | Static components | Multistate; life table |
Projections of the size of the disabled elderly population have been made by a number of groups, including our own. Data from the United States demonstrate the disability burden common to developed nations. These projections have varied substantially, depending on how the survey instruments define disability and what criteria are used by investigators to analyze disability 13–17 (Table 16.1). Manton has estimated that from 1985 to 2050, the number of disabled older persons will approximately triple in and out of institutions.14 The number of communitybased older persons with five or more limitations in ADLs will increase
| 1990 | 2000 | 2010 | 2020 | 2030 | 2040 | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| a Assumes that 10% of institutionalized population is ADL dependent. | b Age 70 and over. | ||||||||||||
| Jackson et al. (1991 [13]) | |||||||||||||
| Low-mortality assumption | 3,617 | 4,381 | 5,242 | 5,819 | 6,933 | 9,009 | |||||||
| Mid-mortality assumption | 3,752 | 4,116 | 4,631 | 5,589 | 7,130 | 7,907 | |||||||
| Manton (1989 [14])[a] | — | 4,086 | — | 5,675 | — | — | |||||||
| McBride (1989 [17]) Base case | 6,200 | — | 9,000 | — | 13,800 | — | |||||||
| Optimistic mortality | 6,200 | — | 9,900 | — | 16,300 | — | |||||||
| Optimistic mortality and health | 6,000 | — | 8,800 | — | 13,400 | — | |||||||
| Rogers et al. (1990)[b] | 5,190 | 6,300 | 6,662 | 7,480 | 9,869 | 12,014 | |||||||
There is no conclusive evidence at present as to whether older persons are becoming more or less disabled. Some argue that sociomedical advances have increased life expectancy but not changed the age of morbidity and dependency onset, thus projecting greatly increased numbers of disabled older persons. Others contend that morbidity, compressed into the very last stage of life, will increase the functional life expectancy of older adults and decrease the proportion of older persons requiring long-term care.18–22
The concept of functional life expectancy is illustrated in Figure 16.4,
Figure 16.4. Survival curve for persons dying of degenerative disease.
A number of recent reports have contributed further data that add evidence to those who believe that there are progressive declines in chronic disability prevalence rates. The long-accepted theories of Gompertz that mortality rates increase with age at predictable trajectories have been challenged because age trajectories of mortality do not follow predictable
DEMAND REDUCTION STRATEGIES
The terms functional impairment and disability imply an increase in the demand for health services (medical/social). These services with respect to the chronic disease burden in older persons are often termed long-term-care services and can include community-based, home-based, and institutional services (residential care facilities or nursing homes). (Though many definitions exist of long-term care, the implied meaning here is a broad one and includes any aspect of the care of the elderly that is provided over a long period of time. It implies that this care may occur in many settings and that an effective coordination of this care across these various settings is mandatory.) An important policy question is whether these services might actually be reduced. A number of strategies have been considered as nations begin to expand the options and seek improvements in their long-term-care system: (1) increasing provision of formal home-based long-term care (formal care), (2) increasing provision of unpaid long-term care in the community (informal care), and (3) decreasing the number of older persons developing functional disabilities requiring long-term care.11,26
The first strategy, formal home care, can supplement or substitute for
The second strategy, informal home care, has most often involved female spouses or nonworking daughters and may be infeasible in the future because women have entered the paid workforce in increasing numbers. In addition, while two-thirds of the current cohort of older persons with functional limitations live with relatives (United States), the next cohort of older persons will have families half the size of the current older cohort, limiting family support systems even more.31–34
The third demand-reduction strategy argues for extending functional life expectancy as a national policy. This strategy has only recently become feasible with increasing evidence that improvement in functional status and delay or prevention in loss of independence can be achieved by the following: (1) primary prevention, or the prevention of a disease or health problem before it occurs; (2) secondary prevention, or the early detection of a disease or problem when it may respond favorably to treatment; and (3) tertiary prevention, or rehabilitation for the residual effect of a disease or problem that has already occurred. Primary prevention aims to avert the onset of pathology, secondary prevention aims at the early detection and management of pathology, and tertiary prevention aims to maintain and restore function. In addition, it includes efforts to avoid the onset of secondary conditions and to sustain or improve the quality of life.
The next sections deal with three possible approaches to delaying or preventing the development of functional impairment and disability. These include (1) comprehensive geriatric assessment (CGA), (2) inhome assessment programs, and (3) the development of a health risk assessment system for the elderly (HRA-E). All address various steps in the Verbrugge-Jette model of the disablement process (Figure 16.3).
COMPREHENSIVE GERIATRIC ASSESSMENT
Comprehensive geriatric assessment (CGA) was developed in the early 1970s and has proliferated since that time. It was defined by a 1987 National Institutes of Health (NIH) Consensus Development Conference as being “a multi-disciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible, and in
The CGA, or multidimensional assessment process, has been primarily institution based, and controlled studies have demonstrated important benefits, the most dramatic of which were first documented in in-hospital programs.44,45 The inconsistent findings reported in some studies of CGA have been postulated as due to the following methodological limitations:
- Basic flaws in study design
- Small sample sizes
- Homogeneous settings of patient populations, such as in the Department of Veterans Affairs (DVA) or in Academic Medical Centers
- Selection criteria for study populations
- Patient gender (e.g., 96% males in DVA studies compared to 60% to 80% females in other hospital settings)
- Different levels and types of care in “control” groups, ranging from usual care by attending physicians to enhanced care similar to CGA
- Lack of adherence of participants and/or their providers
- Most recently, training and continuing competence of the professionals responsible for the assessment
In addition, there have been differences in the interventions that make comparisons of studies difficult. These include the timing of the intervention; variable patient length of stay for delivery of the intervention; assessment processes and approaches, such as geriatric assessment units versus consultation teams; strategies aimed at restorative treatment versus prevention of functional decline; and the intervention strategies themselves. Thus, some studies have offered recommendations only, while others have implemented recommendations, and still others have provided specialized follow-up care. The process of care in CGA programs has been termed the “black box” of multidimensional assessment and follow-up.
IN-HOME ASSESSMENT PROGRAMS
A more recent, alternative approach is to provide assessment, referral, and follow-up services in the home. Home outreach strategies take place before the older person seeks medical or other attention for a problem and permit early preventive interventions. Providing CGA in home settings permits insight into a person's living environment (e.g., hazards, accessibility, resources, adequacy, self-care ability, nutritional adequacy, inappropriate medications, and the nature of social relations and support) and provides an excellent social environment for communication, health education, health promotion, and reinforcing self-care activities. A small number of randomized trials of in-home assessment and prevention programs have been undertaken during the past 15 years, most of them outside the United States, with some promising results.48–52
Results of the first two randomized trials of in-home assessment were published in 1984, one from the United Kingdom and the other from Denmark. Both demonstrated that individuals visited at regular intervals had lower mortality and made greater use of community services than those who were not visited regularly.46,47 In addition, the Danish study showed a decrease in hospital days and emergency room visits, whereas the U.K. study showed improved quality of life; neither of these involved CGA as defined by the NIH Consensus Conference.33 More recent studies tend to confirm these results, although not all findings are
Kaplan, in reexamining data for Alameda County,56 develops suggestive evidence that early interventions in older persons with chronic disease may alter the risk for loss of independence. He showed convincingly that certain incident chronic diseases, in addition to behavioral, social, and demographic risk factors that are associated with chronic disease (e.g., race, income, hypertension, degenerative disease, smoking, excessive weight, alcohol), are associated with poor physical functioning.57 His data suggest that interventions reducing or delaying functional impairment associated with chronic diseases and other behavioral and social interventions may modify the impact of these multiple factors on functioning. The data also suggest that these interventions may increase the level of functioning in those who survive with or without disease.
It is also important to recognize that problems in functional impairment are often reversible. In one national study reported in 1988, 35% of those older persons with five or six problems in ADLs who survived two years improved in functioning over that two-year period,58 confirming earlier studies that we reported in 1984.59
A recent meta-analysis of CGA (including in-home assessment programs) has recently been reported by our UCLA faculty. It compared 4,959 subjects allocated to one of five CGA types (determined by location) and 4,912 control subjects. The combined odds ratio (95% confidence interval) of one of the outcomes—living at home—was 1.68 (1.17 to 2.41) for hospital-based units, 1.49 (1.12 to 1.98) for hospital-home assessment services, and 1.20 (1.05 to 1.37) for home-assessment services. The data from this meta-analytic approach demonstrated CGA to be highly effective for improving survival, place of residence, and function in older persons.49Figure 16.5 demonstrates the effects on mortality at one year for institutional programs and at the end of the intervention
Figure 16.5. End-of-study mortality odds ratios of individual and combined CGA trials.
A RANDOMIZED TRIAL OF ANNUAL IN-HOME
CGA FOR ELDERLY PEOPLE IN THE COMMUNITY
Of the 13 million Americans aged 75 and over, 91% live at home. Among those elderly with functional impairment, 80% live in the community, and 25% of these live alone. Further, older people are disproportionate users of the health care dollar. Although those age 75 and older account for only 5% of the population, they account for 15% of acute hospital admissions and nearly 25% of hospital days.60 Clearly, methods to prevent decline and to improve the health status of community-dwelling elderly may be of great importance.
We conducted a three-year randomized controlled trial of annual in-home CGA and follow-up for people in the community who were 75 years of age or older. The 215 people in the intervention group were seen at home by gerontological nurse practitioners (GNPs) who, in collaboration with geriatricians, evaluated problems and risk factors for disability and gave specific recommendations. The 199 persons in the control group received their regular medical and social care.
The program used specially trained GNPs to implement the following program components:
- Problem and risk identification by in-home comprehensive geriatric assessment
- Problem solution and recommendations
- Health education with emphasis on the role of the older person as an active agent in determining his or her own health and well-being (empowerment and self-care)
- Health promotion and disease prevention
- Regular quarterly follow-up visits to aid in adherence to the recommendations and to identify new problems
In the yearly in-home CGA and in the shorter follow-up visits every three months, the home setting facilitates shared decision making and allows the GNP to observe the older person's function in his or her own environment. The goal of the first visit was to establish a personal relationship,
After having taken action on any urgent problems, the GNP carefully reviewed the baseline findings and the generated problem list with the project geriatricians during regular case conferences and developed an individualized preventive, health educational and health promotional plan to be presented to the older person at the next visit. Each older person's plan was unique and formulated on the basis of the initial home visit. Recommendations were made for those areas in which the team felt the older person could make a positive contribution toward the management or prevention of the problem. Specifically, recommendations were either something the individuals could do for themselves (e.g., a lifestyle change) or something that required referral to a health professional or community service (e.g., seeing a physician for a medication adjustment or contacting a local senior center for a stroke support group).
Measures were taken to maximize client adherence to recommendations. Health education by the GNP provided clients with the knowledge base to understand the recommendations and institute appropriate action. Potential barriers, such as financial or memory deficits, were addressed, and recommendations were prioritized, written down, and limited in number, if necessary, to avoid overwhelming the client. When serious health questions arose, the GNP or project geriatrician contacted the primary care physician by mail or telephone after obtaining permission from the client to do so.
At follow-up visits every three months, the GNP queried the older person about recent physician and community visits, medication changes, episodic illnesses, and falls and then performed a limited assessment to determine how well the client complied with previous recommendations. The GNP noted changes in problem status and consulted the project geriatricians if necessary. The previous recommendations were reinforced, modified if they required it, or supplemented with new ones on the basis of a new finding.
Each subsequent annual home visit, in contrast to the follow-up visit, included a repeat CGA, a review of adherence with the previous year's recommendations, an update of the routine health maintenance record (which was a checklist of preventive care items, such as cancer screening), and a review of the active problems. The GNP encouraged good health behaviors and made additional recommendations for action when indicated. At the final (36-month) visit of the study period, each older person received from the GNP a written summary of that person's personal health priorities and the final recommendations from the team, a copy of his or her individualized health maintenance schedule, and information about community resources if applicable. The last visit included a full CGA and focused on the implications of completing the program and moving to what was hoped would be improved client-initiated use of appropriate health and community services. It is important to emphasize that the GNP did not perform primary care nursing.61
The main outcome measure was the prevention of disability, defined as the need for assistance in performing basic ADLs or IADLs, and the prevention of nursing home admissions.
The baseline characteristics of the participants and the results are shown in Tables 16.3 through 16.8. In summary, at three years, 20 people in the intervention group (12% of 170 surviving participants) and 32 in the control group (22% of 147 surviving participants) required assistance in performing the basic activities of daily living (adjusted odds ratio, 0.4; 95% confidence interval, 0.2 to 0.8; P 0.02). The number of persons who were dependent on assistance in performing the IADLs but not the basic ADLs did not differ significantly between the two groups. Nine people in the intervention group (4%) and 20 in the control group (10%) were permanently admitted to nursing homes (P 0.02). Acute care hospital admissions and short-term nursing home admissions did not differ significantly between the two groups. In the second and third years of the study, there were significantly more visits to physicians among the participants in the intervention group than among those in the control group (mean number of visits per month, 1.41 in year 2 and 1.27 in year 3 in the intervention group, as compared with 1.11 in year 2 and 0.92 in year 3 in the control group; P 0.007 and P 0.001, respectively). It thus appears that a program of this type can delay the development of disability and reduce permanent nursing home stays among the relatively well elderly persons living in the community.
The intervention was not a substitute for usual care (medical and social services) but instead was integrated with such care. It was therefore
| Characteristic before Random Assignment | Intervention Group (N=215) | Control Group (N=199) | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| a Plus-minus values are means (SD). Basic ADL denotes basic activities of daily living (bathing, dressing, feeding, grooming, transferring from bed to chair, and moving around inside the house). | b An annual income of $11,000 is considered the poverty line. | c The rating scale for self-perceived health ranges from 5 (excellent) to 1 (poor). | d The Geriatric Depression Scale, short form, ranges from 0 to 15, with a score above 5 indicating probable depression. | e Data are missing for 13 persons who dropped out of the study before the assessment could be performed. Assessments were not performed in the control group. Arterial hypertension was defined as 160 mm Hg systolic or 90 mm Hg diastolic. Poor vision was defined as 20/50 in the better eye. Poor hearing was defined as 1,000 or 2,000 Hz not heard at 40 dB in the better ear. Impairment in gait and balance was defined as a score 23 on a scale of 0 to 28, with 28 representing the best result (from A. E. Stuck, M. H. Beers, A. Steiner, et al., Inappropriate medication use in community-residing older persons, Archives of Internal Medicine 331(1994) : 821–827. Underweight was defined as 20% below average body weight and overweight as 20% above average body weight (from A. M. Master, R. P. Lasser, and G. Beckman, Tables of average weight and height of Americans aged 65 to 94 years, Journal of the American Medical Association 172(1960) : (658–663). | ||||||||||
| Age—years | 81.0 = 3.9 | 81.4 = 4.2 | ||||||||||||
| Women—no. (%) | 149 (69) | 141 (71) | ||||||||||||
| Living alone—no. (%) | 140 (65) | 125 (63) | ||||||||||||
| Completed high school—no. (%) | 173 (80) | 151 (76) | ||||||||||||
| Annual income < $11,000—no. (%)[b] | 82 (38) | 74 (37) | ||||||||||||
| Mean score for self-perceived health[c] | 3.2 = 1.2 | 3.1 = 1.2 | ||||||||||||
| Independence in basic ADL—no. (%) | 196 (91) | 183 (92) | ||||||||||||
| Depression score[d] | 2.8 = 2.7 | 3.1 = 2.9 | ||||||||||||
| Regular exercise— no. (%) | 142 (66) | 116 (58) | ||||||||||||
| Current nonsmoker— no. (%) | 198 (92) | 184 (92) | ||||||||||||
| No. of medications | 4.9 = 2.8 | 4.6 = 3.1 | ||||||||||||
| No. of visits to physicians in previous month | 1.3 = 1.4 | 1.1 = 1.6 | ||||||||||||
| Characteristic at Initial Geriatric Assessment[e] | ||||||||||||||
| Arterial hypertension— no. (%) | 67 (33) | — | ||||||||||||
| Poor vision—no. (%) | 34(17) | — | ||||||||||||
| Poor hearing—no. (%) | 61 (30) | — | ||||||||||||
| Impaired gait and balance—no. (%) | 20(10) | — | ||||||||||||
| Underweight—no. (%) | 14(7) | — | ||||||||||||
| Overweight—no. (%) | 54 (27) | — | ||||||||||||
| In-home hazard— no. (%) | 61 (30) | — | ||||||||||||
| Functional-Status Score | Intervention Group (N = 170) | Control Group (N=147) | Difference in Scores(Intervention Group vs. Control Group) | P Value | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean (95% CI) | ||||||||||||||
| NOTE: Data are based on reports by 287 study participants and 30 proxies (in most cases, a spouse or close relative) during the home interview at three years. Data were not available for 45 persons in the intervention group (24 died, 14 refused, and 7 moved away) and 52 in the control group (26 died, 21 refused, and 5 moved away). Results have been adjusted for age, sex, whether the subject lived alone, baseline self-perceived health, and baseline functional status. ADL denotes activities of daily living, and CI denotes confidence interval. All scores are on a scale of 0 to 100, with 100 representing the highest functional status. | a As defined in Table 16.3. | b Instrumental ADLs include cooking, handling finances, handling medication, engaging in “handyman” work, housekeeping, doing laundry, shopping, using the telephone, and using public or private transportation. | ||||||||||||
| Basic ADL[a] | 96.8 (94.8-98.8) | 95.4 (93.4_97.4) | + 1.4 (-0.3 to +3.1) | 0.1 | ||||||||||
| Instrumental ADL[b] | 72.3 (69.0-75.6) | 69.3 (66.0-72.6) | + 3.0 (+ 0.6 to +5.4) | 0.02 | ||||||||||
| Basic and instrumental ADL | 75.6 (73.2-77.9) | 72.7 (70.2-75.2) | + 2.9 (+ 0.4 to +5.4) | 0.03 | ||||||||||
The intervention was not associated with changes in the use of in-home and supportive services. Study participants in the intervention group were more likely than those in the control group to use services promoting socialization, such as college courses for older persons or a friendlyvisitor program (Table 16.7).
In the second and third years, the people in the intervention group had significantly more outpatient visits than those in the control group (Table 16.8). Exploratory subgroup analyses showed that this effect was more pronounced among the study participants with symptoms of depression (P 0.03). The intervention was also associated with a reduction in the proportion of persons who did not visit a physician in a 12month period. Nine percent of the study participants in the intervention group, as compared with 16% of those in the control group, did not visit a physician during the third year of follow-up (P 0.04).
| Functional Status | Intervention Group (N=170) | Control Group (N=147) | Odds Ratio (95% CI)[a] | P Value | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No. of persons (%) | |||||||||||||||||||
| a Odds ratios are based on a polychotomous logistic-regression analysis adjusted for age, sex, whether the subject lived alone, baseline self-perceived health, and baseline functional status, with independent persons as the reference group. The odds ratios are for the intervention group, as compared with the control group. CI denotes confidence interval. | b Dependence was defined as requiring assistance in at least one of the basic ADLs (defined in Table 16.3). | c Dependence was defined as independence in basic ADL but a need for assistance in at least one of the instrumental ADLs (defined in Table 16.4). | d Independence was defined as a need for no assistance in either basic or instrumental ADLs. | ||||||||||||||||
| Dependent on assistance in basic ADL[b] | 20 (12) | 32 (22) | 0.4 (0.2-0.8) | 0.02 | |||||||||||||||
| Dependent on assistance in instrumental but not basic ADL[c] | 39 (23) | 28 (19) | 1.1 (0.6-2.0) | 0.8 | |||||||||||||||
| Independent[d] | 111 (65) | 87 (59) | — | — | |||||||||||||||
The intervention did not have a significant effect on the number of admissions to acute care hospitals or the number of short-term nursing home stays (Table 16.6). Eighteen percent of the study participants in the intervention group and 21% of those in the control group were admitted at least once to an acute care hospital in the first year; 21% and 20%, respectively, were admitted at least once in the second year; and 24% and 25%, respectively, were admitted at least once in the third year. The mean length of stay per acute care admission was 6.3 days in the intervention group and 5.1 days in the control group (P 0.7, by the polychotomous logistic-regression analysis). With self-reported hospital admissions outside the study area added to the data in Table 16.4, the estimated number of hospital days per 100 subjects per year was 203 for the intervention group and 180 for the control group.
Although there was no overall effect of the intervention on hospital admissions, we performed an exploratory analysis to determine whether the intervention was associated with an increased or decreased number of admissions among certain subgroups of study participants. A poly
| Type of Addmission | Intervention Group (N=215) | Control Group (N=199) | Adjusted Odds Ratio or Relative Risk (95% Cl)[a] | P Value | |||||
|---|---|---|---|---|---|---|---|---|---|
| NOTE: Nursing home data are based on information reported by the study participants, with verification from secondary sources. Permanent and short-term admissions are defined in the text. Hospital data are based on systematic reviews of admissions to local hospitals. | a Results have been adjusted for age, sex, baseline self-perceived health, and baseline functional status. The odds ratio (OR) is based on a multivariate logistic-regression analysis, and the relative risks (RR) are based on multivariate analyses corrected for overdispersion. The odds ratio and relative risks are for the intervention group, as compared with the control group. CI denotes confidence interval. | ||||||||
| Permanent nursing home | |||||||||
| No. of persons admitted (%) | 9 (4) | 20 (10) | OR = 0.4 (0.2-0.9) | 0.02 | |||||
| No. of days/ 100 persons/year | 128 | 820 | |||||||
| Acute care hospital | |||||||||
| No. of persons admitted at least once (%) | 99 (46) | 93 (47) | RR = 1.0 (0.8-1.4) | 0.8 | |||||
| No. of days/ 100 persons/year | 197 | 160 | |||||||
| Short-term nursing home | |||||||||
| No. of persons admitted at least once (%) | 27 (13) | 31 (16) | RR = 0.9 (0.6-1.4) | 0.6 | |||||
| No. of days/ 100 persons/year | 89 | 111 | |||||||
We hypothesize that the lack of a significant effect on acute hospital use may reflect a balance between two opposite effects of the intervention. It is likely that among study participants with previously unrecognized or
| Type of Service | Intervention Group (N = 215) | Control Group (N = 199) | P Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| No. of persons(%) | |||||||||||
| NOTE: Data are based on reports provided by the study participants at one or more of the interviews conducted every four months during the three-year follow-up period. | a Formerly known as case management. | b Denotes a home-based program that schedules social visits by volunteers with elderly persons. | |||||||||
| In-home and supportive services | |||||||||||
| Care management[a] | 43 (20) | 33 (17) | 0.4 | ||||||||
| Home health care | 27 (13) | 17 (9) | 0.2 | ||||||||
| Homemaker | 24 (11) | 28 (14) | 0.4 | ||||||||
| Meals on wheels | 23 (11) | 18 (9) | 0.6 | ||||||||
| Personal care | 20 (9) | 24 (12) | 0.4 | ||||||||
| Services promoting socialization | |||||||||||
| College courses for senior citizens | 45 (21) | 23 (12) | 0.01 | ||||||||
| Friendly visitors[b] | 23 (11) | 7 (4) | 0.01 | ||||||||
| Community transportation | 57 (27) | 36 (18) | 0.04 | ||||||||
| Year | Intervention Group | Control Group | Adjusted Relative Risk (95% Cl)[a] | P Value | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No. of Persons | Mean No. of Visits | No. of Persons | Mean No. of Visits | ||||||||||
| NOTE: Data are based on Medicare claims data and on records of health maintenance organizations. Persons who had died, moved permanently to nursing homes, or moved out of the area were excluded from the analysis. In addition, 22 persons (8 in the intervention group and 14 in the control group) were excluded because reliable data on the number of visits to physicians were not available. | a Relative risks (based on a multivariate analysis corrected for overdispersion) have been adjusted for age, sex, membership in a health maintenance organization, baseline self-perceived health, and baseline functional status. Relative risks are for the intervention group, as compared with the control group. CI denotes confidence interval. | ||||||||||||
| 1 | 207 | 1.27 | 185 | 1.03 | 1.1 (1.0-1.3) | 0.1 | |||||||
| 2 | 199 | 1.41 | 180 | 1.11 | 1.2 (1.1-1.4) | 0.007 | |||||||
| 3 | 191 | 1.27 | 162 | 0.92 | 1.4 (1.1-1.6) | 0.001 | |||||||
The approximate yearly cost of the intervention can be derived from the costs of the program itself, including the costs for personnel (1.0 full-time-equivalent nurse practitioner and 0.1 full-time-equivalent geriatrician per 136 persons), supplies, travel, and overhead (estimated at $48,000 per 100 persons); the marginal costs for the increased number of visits to physicians (estimated at $18,000 per 100 persons); and the marginal savings from the decreased number of permanent-stay nursing home days (estimated at $42,000 per 100 persons), resulting in a net cost of $24,000 per 100 persons. Acute care hospital admissions and short-term nursing home stays are not included in this calculation because they did not differ significantly between the two groups.
The effect of the intervention on health-related outcomes can be summarized in two ways: by estimating the number of disability-free years gained by the intervention (4.1 years per 100 persons per year during the three-year follow-up) or by calculating the number of permanent-stay nursing home days avoided (692 days [820 128] per year) (Table 16.6). On the basis of these estimates, the cost for each disability-free year of life gained was approximately $6,000. The cost of preventing one day of a permanent stay in a nursing home was $35.62
As compared with the U.S. population of persons 75 years old or older living at home, our study group had a higher educational level, a lower mortality rate, and a lower rate of acute care hospital admissions, with a higher proportion of persons living alone.63,64 The first three of these factors suggest a higher health status of the study population.
During this study, we had an opportunity to examine the role that the participant's physician played in patient adherence to the recommendations given by the nurse practitioner. Although all physicians in the community had been made aware of the study, we did not wish to involve them directly except in emergency situations. This was because we were focusing our efforts on further improving the participants' ability to deal more effectively with their problems as well as their providers. We examined the factors that led to cooperation of the primary care physician with the community-based prevention program, the relationship between physician cooperation and patient adherence, and patient satisfaction with health care. The providers who were rated as cooperative were more likely to have a positive appraisal of the program (they were younger and had fewer years in practice), and their patients had higher adherence
Other studies of preventive-type home visits were reported in the literature during the study: a one-time in-home geriatric assessment with follow-up, regular telephone follow-up, or health promotion that may improve outcomes in the elderly. Also, studies show that older persons with congestive heart failure discharged from hospital benefit from regular, intensive home-care surveillance with an improvement in functional status and a reduction in hospital admission rates and duration of hospital stay.66,67 Improvement in these latter studies probably is related to better adherence with medications and diet, increased exercise, and more effective response to early signs of cardiac decompensation. A study of the long-term effectiveness of comprehensive support and counseling for spouse/caregivers and families of Alzheimer's disease patients has shown a postponement or prevention of nursing home placement.68 These latter studies, like most of the studies of CGA, have focused on tertiary prevention in persons at high risk for developing disability.
Our own trial also presented an opportunity for examining the process of care linked to the annual home CGA. Detailed data were collected prospectively on the problems detected, the specific recommendations made for these problems, and subject adherence with the recommendations made by the GNP.
These data showed that major independence-threatening problems were identified in all domains of CGA (medical, including mental health, functional, and social/environmental), although the most common problems were medical. New problems appeared at a regular rate—approximately two medical to one social per subject per year.
In the first year, three-quarters of the subjects had at least one major problem identified that was either previously unknown or suboptimally treated. One-third of the subjects had additional major problems identified during the second year. A constant number of recommendations was made each year (11.5 per subject per year). Subject adherence varied by type of recommendation; adherence was better for referrals to a physician than for referrals to a nonphysician professional or community service and lowest for recommendations involving self-care activities, including behavioral change.
The important issue of linking processes of care to outcomes requires larger studies. Such an opportunity presented itself in the EIGER project
In a further analysis of the Santa Monica database, we have been able to show that more highly functioning persons appear to benefit most. This finding appears to be confirmed in our Swiss project and raises the intriguing question of targeting preventive interventions to a younger and thus more functional and healthier population.
Development of a health risk
appraisal system for older persons (HRA-E)
To ensure reaching at-risk adults as they age in the community, surveillance needs to be directed toward a high-volume activity with broad outreach. This requirement necessitates that the service be cost-effective (i.e., prevention and treatment must be efficacious), but surveillance needs to be developed at low cost per older person screened. This is in contrast to many programs developed to date and particularly those that are inpatient based and have focused on smaller numbers of frail older persons. It was with this background that a group of senior faculty with expertise in health promotion, disease prevention, epidemiology, and geriatric medicine began developing a health risk appraisal instrument for the elderly (HRA-E) with an aim to reducing the development of functional impairment.71
Health risk appraisal in younger persons has been a promising approach for the maintenance of health. It begins with the identification of specific factors in individuals that increase the risk of impairments, disability, and premature mortality and then develops and recommends strategies for minimizing their impact. In the younger workforce, HRA alone has not been a highly effective intervention for bringing about behavior change. Traditionally, HRA is a process that entails (1) data collection about an individual, (2) use of a computerized algorithm to analyze the data, and (3) feedback designed to encourage medical and behavioral
The first phase in this project was the development of a prototype HRA-E questionnaire and feedback statements for preliminary testing. We sought to examine risk factors that could impact function, such as vision, hearing, memory, chronic diseases and their consequences, and medications. Risk factors were selected on the basis of the magnitude of the effect and potential impact on functional impairment, the feasibility of assessment, the generalizability of these assessment results, and the potential for risk reduction. Criteria for selection of survey instruments for individual items were the availability of psychometric properties in older adults, the feasibility of data collection in a self-administered questionnaire, the feasibility of self-administration, and the prior or current use in other population-based studies. Included in the initial survey instrument were items addressing functional status, although these would also be used in any more long term study addressing outcomes as important outcome variables. These included basic ADLs, IADLs, and AADLs. This process led to a selection of the domains that were in the first version of the questionnaire or survey instrument.
Algorithms and feedback statements regarding the results of the assessment of each risk factor and important risk factor combinations were developed to provide the participants with a response based on current literature. The algorithms covered all possible combinations of questionnaire responses. Computer software using these algorithms were developed and alpha and beta tested. Thus, each person completing a questionnaire received a computer-generated personalized HRA-E feedback report with a series of statements in each domain, including a generic statement about the problems identified, individually tailored suggestions for actions and the rationale for them, sources for further information and assistance, and a health care summary report, including a section dealing with how more effectively to communicate with physicians or other providers. In addition, a computer-generated summary was developed that could be sent to the health provider when requested by the participant.
The second phase of this project included further development of the questionnaire and refinement of the algorithms and feedback statements for the computer-generated personalized reports to the participants and where applicable, to their physicians. The feasibility of using the questionnaire
Preliminary findings based on early analyses of 1,924 respondents indicate that nearly all participants found the questionnaire easy to complete and were pleased with its overall length. In addition, most participants read their reports, and many planned to take action on the basis of the reports' recommendations. These findings will be presented under the categories of Health Status and Health Risk Factors, Personal Health Habits, Physiological Risk Factors, and Preventive Practices and will be followed by a brief summary of the four-month evaluation. The evaluation is based on data obtained by the participant completing a selfadministered questionnaire.
HEALTH STATUS AND HEALTH RISK FACTORS
From 25% to 30% of each of the three groups reported excellent health, 55% to 65% reported good health, and 11% to 16% reported fair to poor health. In the three groups, between 18% and 26% reported fair, poor, or no vision. Fair or poor hearing or deafness was common and ranged from 34% to 36% of each group. Between 20% and 25% of the participants reported at least a single fall in the past 12 months. Positive
A positive depression screen (a score less than 66 using the RAND MHI items from the SF-36) was found in 10% to 23% of the samples, and between 15% and 32% of the samples were either isolated or deficient in their social network. A significant percentage of each group, ranging from 10% to 12%, had a positive screen for an adverse drug event to prescription medications, and 10% were taking five or more prescription drugs.
PERSONAL HEALTH HABITS
Two-thirds to three-quarters of each group reported participation in some form of physical activity on most days, 72% to 83% consistently avoided eating high-fat food, and only 5% to 7% were current cigarette smokers. A high proportion, 90% to 98%, always or nearly always wore seat belts. Alcohol consumption patterns revealed that of the combined total of 1,127 older drinkers across the three sites, 23.7% reported alcohol problems using either the Short MAST-6 or the CAGE.
PHYSIOLOGICAL RISK FACTORS
Self-reported systolic blood pressures above 140 occurred in one-third of each group, with almost 10% reporting systolic-diastolic hypertension. Between 20% and 35% of the population reported percentage serum cholesterol levels in excess of 240 milligrams.
PREVENTIVE PRACTICES
More than 95% of the three groups reported having a blood pressure check within the last year, and a similarly high proportion reported receiving cholesterol measurements within the past year. Over 80% of the group reported having a hearing test. Immunization for influenza in the past year was reported by approximately two-thirds of the populations studied, while only 37% to 49% had received pneumonia vaccination at any time. A very high percentage of the women in all groups had mammograms
EVALUATION
Among the 65% of the participants who submitted an evaluation form immediately after receiving their individualized report, more than 90% had read all of the report, and the remainder had read most of it: 90% found it “very easy” to understand, and the remainder reported it to be “easy.” In excess of 90% found the length “right,” while 5% found it “too long” and 3% “too short.” Ninety-five percent found the format to be “excellent” or “good,” and more than two-thirds reported that they intended to take some steps as a result of the report.
Eighty percent of those who completed the questionnaire responded to a third evaluation request four months after receiving their personalized report. Preliminary examination of these data indicate a high response to the recommendations made in the participant report, especially for those recommendations pertaining to preventive health measures. Eighty-five percent of the respondents said that they had either had a blood pressure check or had one scheduled; 61% had or scheduled a cholesterol check. Over half reported having or scheduling a flu shot, and one-fourth reported the same for pneumonia vaccination. Nearly one-quarter reported having or scheduling a colonoscopy/sigmoidoscopy. Seventy-three percent had or scheduled a dental exam, and nearly 60% had or scheduled a vision exam. Only 21% had or scheduled a hearing exam. Twentynine percent reported increasing their physical activity levels, while 43% reported decreasing their intake of dietary fat. Rather small numbers reported increasing their seat belt use, decreasing their alcohol intake, or decreasing or quitting smoking since receiving their individualized report, but, as reported previously, many participants were already engaging in healthy behaviors except for alcohol use. On the basis of this experience, a revised health risk assessment for the elderly system has subsequently been developed, and the products of this work to date include the following:
- A revised questionnaire for comprehensive health risk assessment of older persons
- Revised software for processing computer-generated, personal reports to participants and their physicians from the returned questionnaire
- Findings from testing the questionnaire and software in three different populations
- Favorable experience with the HRA-E on the part of a longestablished prestigious physician group
- A substantial database consisting of information about responses, questionnaire item answers, reports to participants and physicians, participant evaluation of questionnaires and reports, and behavior changes reported four months later
- A user guide
These products are envisaged for use in further refinement of the instrument and system in order to assess its impact in a randomized controlled trial design on outcomes such as behavior, health status, medical service utilization, and costs and offer a crucial body of information to assess whether this particular strategy of prevention of disability is effective and might be implemented on a large public health scale.
RESEARCH, PRACTICE, AND POLICY ISSUES
Issues of research, practice, and policy are in part addressed in each of this chapter's sections but are more explicitly articulated in this section. However, the magnitude of the problem of loss of independence as the baby boom begins to enter the elder phase of the life span and the importance of testing promising interventions directed at preventing or delaying the onset of functional impairment/disability deserve reiteration.
The disability burden has already been addressed from the national perspective, but the demographic shift is of even greater importance in California. In 1990, there were over three million persons 65 years of age or older, ranking first in the nation and involving 10% of the nation's senior population. It is estimated that California's elderly population will increase by 52% between 1990 and 2010.
Within the elderly population nationally, certain ethnic segments are growing more rapidly than others. The proportion of African Americans 65 years of age and older increased by 26% between 1980 and 1994. Hispanic elders increased by 103% in the same time period. Asian elders represent the greatest increase, from 210,000 to 565,000 (169%) in the 14-year time frame. California reflects this increased diversity and houses the most Hispanic and Asian individuals and the second-most African Americans in the United States.72 Predictions made on the basis of the relationship
The health care system of the United States, and in particular that of California, is undergoing enormous changes, in part driven by the progressive rise in costs over the last several decades. These changes also reflect an apparent transition in the societal values of health from primarily being a “social good” to being an “economic good.”
In addressing the issues relating to the prevention of functional impairment/disability, the implication is one of moving health care policy from “dependency” services to promoting “independence” through preventative strategies. This, too, would necessitate a major culture shift from the traditional treatment paradigm to one focusing on prevention. This change in policy with respect to older persons has actually been legislated in a number of member nations of the European Union in which a variety of “system” or structural problems are interfering with the optimal implementation of these legislative efforts.
In the United States, there is a great deal of rhetoric about prevention, particularly in the emerging managed care organizations. In this country, only a few of the long-established HMOs have moved their rhetorical statements to serious implementation activities. An understanding of the factors involved in the reticence to change is timely. There are serious questions about the effectiveness of prevention efforts and the feasibility of implementing programs for older persons at acceptable costs. These can be addressed only by a concerted research strategy addressing the unresolved issues. The most important of these can be addressed only by long-term studies since the increasing evidence of the effectiveness of disability prevention programs has been obtained in short-term studies of one to three years. In a recent literature review, there are over 1,000 papers addressing risk factors for impairment and disability, and the majority of the identified risk factors are amenable to a preventive intervention.
The remainder of this chapter discusses the future research, practice, and policy issues involved in the three types of intervention strategies discussed in this chapter.
COMPREHENSIVE GERIATRIC ASSESSMENT
Comprehensive geriatric assessment (CGA) in a clinical setting has become an established practice pattern for optimal quality clinical management.
The unresolved questions from a research and programmatic point of view include the following: (1) How can the populations that respond best to this intervention be identified? (2) What are the adherence issues with recommendations in both the older person and their providers?
(3) What is the optimal frequency of the assessment? (4) What is the best way to link process to outcomes? (5) How can this process be most costeffectively introduced into a prepaid health care system?
IN-HOME PREVENTION PROGRAMS
In addition to the unresolved issues raised in the previous section, the following questions apply specifically to in-home prevention programs:(1) Which professional grouping is most appropriate for carrying out these programs? (2) Where in a seamless health care system for older persons does a program of this type fit best? (3) How much are payors prepared to contribute to a prevention program, and who is responsible for payment? (4) What is the best quality control system to maintain high standards, and where does the responsibility for such a system lie? (5) Who is responsible for developing competency criteria for the providers and supplying them with the appropriate training? (6) How can older persons most effectively be motivated to participate in a program of this type? The issue of how to most effectively develop reliable communication systems between the principals holds for both the CGA and the in-home prevention strategies for delaying or preventing functional impairment (see Figure 16.6). In this figure, GNP refers to gerontologic nurse practitioner; C/A refers to communication/adherence issues as they relate to the nurse practitioners' recommendations for problem solution directed at both the older person and the physician; M.D. (geriatrician) implies that well-trained generalist physicians especially trained in the process of in-home prevention might substitute for a formally trained geriatrician. The lower part of the model suggests that the major out
Figure 16.6. Model of in-home prevention effectiveness.
HEALTH RISK ASSESSMENT SYSTEMS
FOR THE ELDERLY (HRA-E)
The majority of the unresolved questions in the previous two sections hold also for health risk assessment systems for the elderly (HRA-E). In addition, the following represent research questions that primarily confront this particular strategy: (1) What is the effect of HRA-E and immediate feedback on participants and their providers, as compared with more extended interventions targeted at one or both of these groups, on outcomes such as behavioral change, medical care utilization, functional status change, disenrollment from a health plan, satisfaction with care, and cost of the intervention related to estimated outcomes for individuals and for health plans? (2) When is the most opportune time for moving toward a quantitative rather than qualitative risk assessment so that future feedback algorithms might include quantitative statements about risk of functional decline? (3) What is the validity of self-reported information? (4) How can systems of this type be most effectively marketed? (5) How can readiness to change be most effectively determined? (6) What are the most beneficial strategies for bringing about behavioral change and self-care capabilities? (7) How can better strategies be developed to enhance long-term adherence with induced behavioral change? (8) In this era of rapidly changing health care technologies, how can the most appropriate method of administration be addressed, the options being selfadministration, interviewer administered, computer assisted, and an interactive
Figure 16.7. Model of HRA-E effectiveness.
It is important to recognize that effects are often diluted when interventions of these types are applied to large-scale community programs in the real world. Because the interventions comprise many individualized steps, standardizing the intervention to be applied outside the research setting is difficult. Relatively subtle changes in the intervention often result in lower levels of effectiveness.73 To test an intervention's effect on reducing or preventing disability, we recommend that randomized clinical trials be conducted that are characterized by the identification of the critical risk factors for disability, clarification of the causal mechanisms behind their impact on disability, careful documentation of the components of the intervention process, linking of process to outcome, and delineation of the interplay across time between and among functional limitations and disability.
The recently published book The Future of Long-Term Care: Social and Policy Issues74 contains a summary of a modified Delphi methodology of a large number of experts in the field addressing the issues of what the long-term-care system might look like early in the 21st century.
NOTE
The author wishes to acknowledge many colleagues who have contributed to the studies referred to in this chapter: Cathy A. Alessi, Harriet U. Aronow, Lester Breslow, Christophe J. Bula, Jonathan Fielding, Jerilyn Higa, Christoph E. Minder, Alison A. Moore, Hal Morgenstern, Rosane Nissenbaum, Larry Z. Rubenstein, Andreas E. Stuck, and J. Walhart.
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17. AN EDUCATIONAL APPROACH TO ENGAGE
HEALTH CARE PROFESSIONALS
IN WELLNESS PROMOTION
Stuart J. Slavin
and Michael S. Wilkes
Health care in the United States is changing rapidly. The importance of health promotion and disease prevention has been widely recognized. To work effectively in this new paradigm for medical care, physicians and other health care professionals need to acquire a new set of skills, knowledge, and values. David Rogers, M.D., wrote,
- Our nation needs doctors with a broader and more sensitive view of the place and role of medicine in the larger society. Doctors will need more skills with which to assess the efficacy of medical interventions and the relative contribution of medicine to the health of society.
- Our nation needs doctors who are more skillful in doctor-patient relationships. We should introduce a better blend of humanism and science into our health care institutions and the students they graduate.
- Modern physicians should pay more attention to health promotion, disease prevention, and the social, environmental, and emotional factors bearing on health.
- Both the physicians who graduate and the academic medical institutions that produce them should have a strong sense of social responsibility for the health and medical care rendered in their communities.
Unfortunately, the education of health care professionals has not changed rapidly to fulfill this need. In 1991, the Pew Health Professions Commission surveyed health care professionals about perceptions of their education.2
| Topic Area | % Rating Indequate Teaching |
|---|---|
| Health promotion and disease prevention | 25.2 |
| Public health and community medicine | 30.3 |
| Role of community health and social service agencies | 39.5 |
| Nutrition | 53.1 |
| Cross-cultural communication | 38.3 |
Since 1991 there is little evidence of substantial improvement. In the 1996 Medical School Graduation Questionnaire of the Association of American Medical Colleges, medical students were asked if they believed that the time devoted to their instruction in a number of areas was excessive, appropriate, or inadequate.3 Responses for issues relating to prevention and wellness are shown in Table 17.1.
Strikingly, only 4.1% of medical students felt that the time devoted to education in the basic sciences was inadequate.
New educational initiatives are needed to teach medical students, physicians in practice, and other health care professionals about issues relating to health, wellness, and disease prevention. It is crucial, given the changing health care needs of society, that these educational interventions be effective. How can we ensure effectiveness? By considering carefully not only what we teach but also how we teach.
THE GOAL OF EDUCATION
What elements are important to consider in designing an educational intervention? What pedagogical philosophies, strategies, and learning settings are most likely to produce effective learning? What are the roles of the teacher and the student? To answer these questions, it is critical first to define the learning outcomes we seek.
Numerous educators, researchers, and philosophers have proposed definitions for the ultimate goal of education. More than half a century
Benjamin S. Bloom and a group of cognitive psychologists have classified educational outcomes, with the result that the lowest cognitive level is acquisition of knowledge. Higher levels include application, analysis, synthesis, and evaluation. The mission of education from the standpoint of cognitive psychology is thus to help students move from memorization of discrete facts to more complex and more difficult cognitive levels.6
For the most thoughtful description of the goal of education, we return to Whitehead. He viewed the mission of education as the imaginative acquisition of knowledge: “The university imparts information but it imparts it imaginatively. … A university which fails in this respect has no reason for existence. This atmosphere of excitement, arising from imaginative consideration, transforms knowledge. A fact is no longer a bare fact: it is invested with all its possibilities. It is no longer a burden on the memory; it is energizing as the poet of our dreams and as the architect of our purposes.” 4 Unfortunately, in many medical schools in the United States, little imagination is evident in the curriculum, and the students show little excitement about what they are learning. Excessive attention is paid to the acquisition of “bare facts,” and little attention is paid to the development of wisdom or understanding. However, new alternatives to the traditional fact-based, lecture-based education of medical students are beginning to emerge and spread.
PRINCIPLES OF TEACHING AND LEARNING
How then do we help students to gain wisdom, to understand, and to function at higher cognitive levels? A number of principles need to be considered in the design and implementation of effective educational interventions.
Teaching methods should focus less on the transfer of information and more on the development of higher cognitive skills. Lecturing remains the dominant method of teaching at most American medical schools.
The acquisition and development of skills, values, and attitudes by students should be emphasized at least to the same extent as acquisition of knowledge. What are the skills, values, and attitudes that we want students to develop, and how can we help students develop them? The skills important in medical practice include the more difficult and complex tasks found in the higher cognitive domains, such as analysis, evaluation, critical thinking, and problem solving. Educators have also identified other important skills that students need to acquire. One is the skill of self-evaluation. It is crucial for students, particularly medical students, to have a sense of the limits of their knowledge—what they know and do not know. Svinicki believes that students also need to develop an awareness of “how their own biases and behaviors filter the information they receive.” 8 Students also need to be able to communicate effectively with patients, families, and professional colleagues, and they need to be skilled in caring for people from diverse cultural backgrounds.
For physicians and other health care professionals, the acquisition of appropriate values and attitudes is as important as the acquisition of skills. Honesty, integrity, dedication, compassion, humanism, and an abiding concern for patients and colleagues are essential values that need to be fostered and nurtured.
Unfortunately, in traditional medical education, particularly in the first two preclinical years, little opportunity is provided for students to develop self-reflective skills, communication skills, and other appropriate values. The passive and impersonal experience of sitting in a lecture
A related approach to teaching in medical school that has received substantial attention and increased acceptance is problem-based learning (PBL), which is a systematic, structured approach to learning in which small groups of students work with faculty facilitators to solve clinical problems. Faculty have a very different role in PBL. Rather than serving as repositories of information that needs to be passed on to students, faculty act as guides to help direct student learning. The development and practice of higher-level cognitive skills is inherent in the process of problem-based learning. Students work through several steps to arrive at a solution:
- Problem definition
- Hypothesis generation
- Data analysis
- Identification of present knowledge and learning needs
- Independent inquiry
- Synthesis and reevaluation of problem
- Problem resolution
Problem-based learning has been used extensively around the country in basic science teaching, but we believe that it is particularly well suited to teaching issues such as disease prevention, health promotion, and crosscultural care.
To learn most effectively, students need to feel motivated. How are students motivated? One key factor is that learning should be engaging and enjoyable. The dominance of lecturing and the focus on the passive acquisition of vast quantities of information needed to pass the next series of exams can have a deadening and dispiriting effect on many students. There is strong evidence that students in small-group, problembased curricula are happier and enjoy the learning experience more than their counterparts in traditional lecture-based curricula. For example,
Another important factor in motivating students to learn is the bond between teacher and learner. In lecture-based courses, there is little opportunity for any meaningful connection between teachers and learners. The GPEP panel recognized this problem and recommended that “the practice of having a large number of faculty members, each of whom spends a relatively short period of time with medical students, should be examined critically and probably abandoned.” They also stated that the “anonymous relationship between students and faculty is inconsistent with a general professional education directed toward the personal development of each student.” 10 By contrast, in small-group settings, students have an opportunity for real dialogue with faculty. When faculty meet with students in small groups over the course of an academic year, meaningful interpersonal connections can be made.
Learning must be meaningful for the students. Learning can be made more meaningful for students in a number of ways:
- The content should be relevant and recognized as important by the students. The goal of medical education is to prepare future physicians for the practice of medicine. To be relevant, the content of the curriculum must therefore address important health needs in society and reflect the actual practice of medicine. Health care educators must thus help students recognize the importance of prevention in medical practice today.
- Teaching approaches should encourage easy retrieval of what has been learned. The traditional lecture-, discipline-, and fact-based curriculum does not encourage effective storage and future retrieval of information that has been learned by the student. Much of what is learned is soon forgotten, and that which is remembered cannot be easily utilized to solve clinical problems. By contrast, the educational strategies used in PBL courses facilitate this process of storage and retrieval. H. G. Schmidt termed the recall mechanism “encoding specificity.” He hypothesized that retrieval of information is enhanced when the knowledge that is learned is acquired in a context that is similar to the future setting where it will be needed to solve a problem 11—hence the theoretical strength of case- or problem-based learning: Knowledge begins to take on meaning when it is acquired in the appropriate context.
- Content should be developmentally sequenced, and planned repetition and opportunities for students to use knowledge in different contexts should be built into the curriculum. The meaning of what is learned by third- and fourth-year medical students is very different from the meaning of what is learned in the first year. By paying attention to the developmental level of medical students, learning opportunities can be constructed that provide deeper meaning by allowing students to build on what they have learned and to make connections with other curricular experiences. With planned repetition, students can use what they have learned before to solve problems in new and somewhat different contexts.
A classic example of a case for developmental sequencing is the teaching of medical ethics. Until recently, ethics at the University of California, Los Angeles (UCLA), was taught in a brief course in the first eight weeks of medical school and was never formally addressed again. Clearly, students at this very early stage in their medical education have neither the prior knowledge nor the clinical experience to develop a deep understanding or appreciation of this important subject. Ethics (and other topics, such as prevention) should be woven longitudinally throughout the curriculum. Students can then use the concepts they have learned in the first years to solve new and more complex problems as they gain experience and progress in their studies.
Students must be encouraged to develop independent learning skills. There is simply no way that medical students can be provided with all the information they will need to solve all the clinical problems they will encounter in their careers. New knowledge about diagnostic techniques and therapeutic approaches is constantly emerging and must be evaluated by physicians. Also, clinical problems do not always fit classical or typical patterns, and physicians need to be able to recognize gaps in their own understanding and know how to rectify these deficiencies.
In traditional medical education, students are not rewarded for independent inquiry and endeavor; in fact, these activities are often suppressed and extinguished by the oppressive focus on specific knowledge acquisition and the emphasis on learning what is needed to excel in the next exam. In PBL courses, independent inquiry is an essential part of the process for all students.
Student and faculty roles must change. This new paradigm for learning calls for a new partnership between students and faculty. Students must take a more active role, assuming greater responsibility for their own learning. They can no longer expect to sit passively and simply
CHANGING PHYSICIAN PRACTICE BEHAVIORS
The principles outlined here have proven helpful in designing effective undergraduate medical curricula. These and additional factors should also be considered, however, in designing better ways to change the behaviors of practicing physicians.
For some time the public has assumed that clinicians actively seek out new medical information and respond by changing their behaviors if they believe that the information will improve care for their patients. In this scenario, effective dissemination of new information is thought to be the key variable in changing physician behaviors. Dissemination is understood to involve the communication of information from one or more sources through various channels (journals, conferences, word of mouth, and popular press) to an audience of clinicians. Physicians are assumed to be active consumers of new information, eager to keep abreast of the latest developments and willing and able to devote the time necessary to ferret out sources of information for practical clinical pearls.
The task of changing clinicians' behaviors has traditionally been thought to be limited only by an inability to reach the practitioners with accurate, timely information. However, researchers have failed repeatedly to find much change in practitioner behaviors, even when all conditions for effective dissemination of information are ideal. Alternative views of clinician behavior have been suggested to explain this failure. It has been postulated that changing physicians' behaviors requires more than simply providing believable and relevant information; it requires a better understanding of the context in which clinical decisions are made.12–14 Some educators have applied social psychology—specifically, concepts of social influence—to understand methods of behavioral change,15–17 others have used cognitive psychology, and still others have invoked theories that derive from sociology. Whatever the explanation, rarely does dissemination alone change physician practice behaviors.
It could be argued that physicians will change a behavior if the information
Others might feel that physicians want their colleagues or groups of experts to endorse or recommend a given change in behavior before they incorporate it into their practice. The most extensive exercise of professional influence involves the dissemination of consensus recommendations. The dissemination strategies used by different consensus projects vary, but the dominant strategy has been publication of consensus statements both in booklet form and in medical journals. In surveys, however, only 25% to 60% of physicians in the United States report hearing about conference recommendations addressing their medical specialties.18,19 Behavioral change is thus not ensured by practitioners' reading habits, a finding that is not encouraging to those who seek to affect physicians' behaviors by written interventions.19
Physicians also rank the importance of various information sources somewhat differently. For example, different publications may hold different credibility levels for practitioners. Ideally, we would like to know how influential different channels are in changing practice behaviors, but this turns out to be difficult to measure; most studies rely on providers' self-reports through questionnaires or interviews. Providers' ability to report accurately on what influences their decisions in such circumstances is open to question.
How, then, are physician behaviors determined? A host of different factors, including environmental, organizational, clinical, specialty, patient, and provider characteristics, affect behaviors. Environmental characteristics are external influences, such as laws and financial incentives. Organizational characteristics are determinants unique to a practice setting, such as a managed care organization or hospital. Clinical characteristics are determinants of behavior based on patient disease characteristics, such as those associated with HIV infection or substance abuse. Specialty determinants are related to specialty training and socialization. Patient characteristics are factors related to the patient (age, gender, race, affect, education, and values) that determine provider behavior. A number of provider characteristics (socioeconomic background, schooling, and gender) also contribute to determine behavior. Finally, information—the form that it takes and the way in which it is delivered
CONTINUING MEDICAL EDUCATION
Continuing medical education (CME) is the primary educational forum for the acquisition of knowledge by practicing physicians. Ninety-seven percent of a random sample of physicians reported that they had participated in continuing medical education activities in the last year, many because it is a state licensing requirement.19 The purposes of CME vary. In some cases, CME results from a physician's self-recognized need for new knowledge in order to improve patient outcomes. Some courses, however, may be chosen mainly because of the attractiveness of the locale. In other cases, an organization (hospital, HMO, or state licensing board) may look to CME to increase the likelihood that physicians will implement an appropriate therapeutic or diagnostic approach under a given set of circumstances.
Continuing medical education seems to be an effective method of disseminating some types of simple factual knowledge but is not very effective in other respects, particularly in terms of influencing a behavioral change. To gain an understanding of the conditions under which CME is an effective intervention for disseminating information and thereby changing physicians' behavior, we should first recognize that there are several contextual issues. These include the characteristics and level of interest of those engaged in the CME activity, the requirement for attendance (state license, HMO mandate, or physician choice), the behavior targeted for change, and the methods of instruction employed. (As in undergraduate medical education, the standard approach of most CME courses has been to provide fact-laden lectures to the learners.)
Researchers have examined these issues and identified some attributes of successful education. For example, face-to-face contact is an especially effective way to achieve behavioral change.20–23 This and other conclusions are suggested largely by considering the shared characteristics of interventions that have been successful. Unfortunately, randomized trials in which the same practice recommendations or guidelines are promulgated through more than one intervention are practically nonexistent, so far-reaching conclusions are not possible. However, based on a careful review of the literature, additional elements of continuing medical
- Involving opinion leaders wherever possible
- Addressing real and perceived barriers to implementation of new practice behaviors
- Offering realistic alternatives to the practices being discouraged
- Repeating and reinforcing major points in the message
- Actively involving the learner, preferably with a chance to practice the behavior(s) or see others perform the behaviors
- Following the intervention with behavioral feedback to the learner
- Providing supportive materials for later use
- Using multiple teaching methods during the course of the intervention
Not surprisingly, the strategies listed here, which have been successful in changing practicing physicians' behaviors, are very similar to those that are beginning to be employed in medical schools.
THE UCLA DOCTORING CURRICULUM
A curriculum that incorporates these educational principles is Doctoring, a three-year, longitudinal program for medical students at the UCLA School of Medicine.24,25 The overarching goal of Doctoring is to ensure competencies in areas that allow our graduates to care for patients, families, and communities in a compassionate, humanistic, and competent manner. Such a daunting educational mission could not be contained within a single course, a single semester, or even a single department or discipline. Thus, Doctoring was designed as a three-year sequence, emphasizing special areas in each year, but with a cascading approach to major goals. The curriculum is coordinated by faculty from the three generalist disciplines (i.e., internal medicine, pediatrics, and family medicine) with input from multiple expert working groups. Curricular time and content for Doctoring came from a merger of previously existing courses, such as behavioral sciences, medical ethics, clinical correlates, epidemiology, and clinical fundamentals. These orphan courses, each standing alone, had little status relative to the basic science courses, but together they formed nearly a fifth of total curricular time. In addition, topics such as violence, substance abuse, and AIDS, largely absent in the curriculum before, were incorporated into Doctoring.
A major concept of Doctoring is integration, which works at three
In the first and second years, Doctoring combines an ambulatory patient care experience with a small-group, problem-based learning experience that stresses the development of communication skills and selfdirected learning. Students work in groups of eight with two faculty tutors (one generalist and one mental health professional/social scientist). Learning in both years is organized into a series of four-week modules, each driven by a particular clinical problem. In week 1 of each module, the group is introduced to a problem using a standardized patient (an actor trained to portray a patient in a reproducible manner), a videotaped vignette, an iterative paper case, or a real patient. Using an inquiry approach, students seek to define the problem, identify and acquire relevant data, formulate explanatory models and hypotheses, and identify questions for independent learning. (Preliminary evaluation has shown that the vast majority of learning issues that the faculty have designated as key are also identified by the students as important areas of study.) A protected half day for independent study in week 2 of the module allows students to pursue their special interests, build on prior life experiences, and apply their preferred learning styles. Students research their learning issues in locations such as nontraditional health care facilities (jail clinics, hospices, and homeless shelters), a patient's home, religious centers, and community-based support groups. In addition, community experts are invited to the medical center at designated times so that students can easily contact them to ask specific questions.
During week 3, students visit a generalist preceptor in the community (someone working in private practice or at an HMO or county clinic) for a longitudinal clinical experience. During these sessions the emphasis is
In the fourth and final week of the module, students again meet in their Doctoring groups and discuss learning issues in a manner that allows the group to explore the topics in greater depth, focusing on how they relate to the care of the patient.
In Doctoring 1, the first year of the Doctoring Curriculum, major themes include eliciting a patient's experience of illness, taking a comprehensive psychosocial history, promoting health through nutrition, understanding ethical issues in the context of patient care, and understanding major health care issues at different stages of life.
The major foci for Doctoring 2 are the physical examination, basic clinical reasoning skills, population-based medicine, an approach to solving ethical dilemmas, counseling for promotion of health, and an awareness of cultural and social perspectives of illness and disease.
As with nearly all U.S. medical schools, once the clinical years begin at UCLA, students tend to consider a substantial part of the knowledge acquired in years 1 and 2 as nonessential to the actual practice of medicine. Without reinforcement, the skills, knowledge, and attitudes developed in Doctoring 1 and 2 might be quickly extinguished by the culture in the clerkships, which focuses on treatment of acute disease in hospitalized patients, mechanisms of disease, memorization of lists and facts, and professionalization through indoctrination. A major goal, then, of Doctoring 3 is to reinforce and preserve concepts acquired in Doctoring 1 and 2 while at the same time introducing important new content areas not covered elsewhere in the curriculum. Throughout the third year, students in their small groups are encouraged to discuss real and perceived barriers to practice. In Doctoring 3 we do not use a four-week module system; rather, each small group manages a fictitious panel of patients for the entire year.
Doctoring deals with a broad range of wellness and prevention issues over the three years of the curriculum. An example of a wellness issue of critical educational importance that Doctoring deals with is violence, particularly domestic violence.
Violence in the United States
Over the last decade, violence has been recognized as a major threat to the health, well-being, and safety of an increasing number of Americans.
Violence against women is endemic in the United States, and the greatest risk occurs in the home. It is estimated that between two and four million women are severely physically abused each year by their partners.26 Even pregnancy offers no protection but actually appears to increase the risk of abuse: An estimated 4% to 8% of pregnant women are physically abused.27 Sexual violence against women is also widespread. The incidence of date rape has been estimated to be as high as 20% for adolescent females.28
Another group at high risk for violence is children, 1.6 million of whom experience some form of nonfatal abuse or neglect each year.29 One hundred and sixty thousand are seriously harmed, and between 1,200 and 5,000 children die each year as a result of injuries inflicted by an abusive relative.29 The elderly are equally at risk: The prevalence of elder abuse is estimated to be between 4% and 10%, which translates to 1.5 to 3.2 million Americans.30
No single approach can address or combat the problem of violence; it would be naive to think so, given the prevalence and complexity of the problem. Nevertheless, it is clear that the medical profession and clinicians must play a far larger role in defining and implementing potential solutions. Health care professionals are the ones most likely to see victims of violence or those at risk for becoming victims. As such, the medical community constitutes a front line for identification, intervention, and prevention.
Unfortunately, substantial evidence suggests that health care professionals are not fulfilling this essential role. It has been reported that between 11.7% and 35% of women visiting emergency rooms are there because of symptoms of ongoing abuse, yet only 5% of victims of domestic violence are so identified.26,31,32 In one study, 20% of domestic violence victims reported seeking medical care for injuries more than 10 times. Another 23% had seen a physician between 6 and 10 times for care of abuse-related injuries.33
In the area of domestic violence in particular, a number of barriers have been identified that may help to explain the general unresponsiveness of physicians in terms of recognition and intervention. Close identification with patients, fear of causing offense, feelings of powerlessness, an inability to control outcomes, and time constraints in practice have all been found to be significant factors.34 One of the most important factors, however, is the lack of training that most physicians have received in this area. Physicians and other health professionals are ill prepared to help their patients largely because of the absence of violence-related education in undergraduate, graduate, and CME curricula. Numerous community and professional groups have called for increased attention to violence at all levels of medical education. Yet there has been little improvement to date. In 1994, over 50% of graduating medical students in the United States rated their instruction in family and domestic violence as inadequate.35 Through the Doctoring course, UCLA was one of the first medical schools to institute an integrated substantive educational intervention relating to domestic violence.
Domestic Violence Module
The domestic violence module, which focuses primarily on partner abuse, is one of eight educational units in the second year of Doctoring. It is worth describing in detail since it employs many of the educational elements mentioned previously. Beyond the goal of developing a substantial knowledge base about the epidemiology of domestic violence, signs and symptoms of abuse, legal and ethical issues relating to violence, and resources and options for victims, the module is designed to help students develop the essential clinical skills (interviewing, counseling, and diagnosis) and values (empathy and trust) required to apply this knowledge in practice to provide sensitive care to patients.
The specific learning objectives are as follows:
Knowledge
- K1. Define domestic violence (societal and legal definitions)
- K2. Recognize the prevalence of domestic violence in the United States today; recognize how frequently women seek medical care for this problem and how frequently physicians miss this diagnosis
- K3. Identify predisposing and predictive characteristics of both victims and abusers
- K4. Recognize common presenting signs, symptoms, “stories,” and red-flag indicators of abuse
- K5. Describe reasons why a victim may not recognize a relationship as abusive
- K6. Describe reasons why a victim may be reluctant to make disclosure of domestic violence or seek help
- K7. Identify reasons why a victim may remain in an abusive relationship
- K8. Identify questions with which physicians can encourage patients to talk about domestic violence
- K9. Describe reasons why physicians may avoid inquiring about abuse or intervening when abuse is uncovered
- K10. Identify local legal requirements regarding reporting domestic violence and potential limits of confidentiality
- K11. List elements that should be included when documenting a case of abuse
- K12. Identify community resources and legal recourse available to victims
- K13. Identify steps that a victim may take to increase safety
Skills
- S1. Conduct a sensitive, empathetic, detailed history when domestic violence is suspected
- S2. Conduct a sensitive screening history for domestic violence when abuse is not suspected
Attitudes
- A1. Appreciate the central roles that physicians may play in helping victims of domestic violence
- A2. Feel a personal responsibility to identify domestic violence victims and intervene appropriately when domestic violence is identified
- A3. Appreciate the need to screen all patients for the risk or presence of domestic violence
In the first week of the module, students and faculty meet in their small groups to view a videotape of a clinical encounter. A young man brings his girlfriend to the emergency room, saying that she has some kind of
After viewing the videotape, students have the opportunity to discuss their perceptions and feelings about the encounter. What was really going on? Despite the fact that no obvious physical harm was inflicted, does this constitute abuse on the part of the boyfriend? Do our own ethnic or social backgrounds influence our perceptions and understanding of abuse? How did the doctor handle the situation? Should he have done anything differently? Why did he miss or ignore the signs of abuse? What might he have been feeling? Following this discussion, students participate in an “invent-an-interview” exercise. They explore what questions should be asked when someone is at risk for or a victim of abuse. After constructing their own list of questions, students compare their list with the recommended questions from the American Medical Association's Diagnostic Treatment Guidelines on Domestic Violence.
In the next segment of the session, students are told that they will interview a standardized patient (SP) using the skills that they have just discussed. They are then given Mrs. Rita Brown's medical records to examine prior to her arrival. The triage note states that Mrs. Brown is a “48-year-old female requesting pain medication for headaches following a car accident the day before.” In fact, she is a victim of ongoing abuse at home. Mrs. Brown's medical record (physician notes, X-ray reports, and emergency room encounter forms) chronicles a long history of different types of injuries.
The SP is then brought in, and one student begins the interview in front of the group. Time-outs can be called by the interviewer or faculty when students need guidance from their peers or when the seminar leader feels a sufficient number of teaching points have been raised. During these time-outs, the action freezes and the SP goes into “suspended animation.” The group can then assess what is transpiring. These discussions are particularly rich, as attention is paid both to what is being learned about the patient and to how it is being learned. Consideration is given to the most effective communication approach and the feelings that the interviewer experiences while talking to the patient. Finally, approaches
When initially confronted about violence at home, Mrs. Brown is reticent to discuss her circumstances and denies any problem. With a supportive and compassionate approach to interviewing, however, she eventually admits that her husband has physically abused her.
After the completion of the interview, students identify learning issues that they will pursue to help them better understand and provide care for Mrs. Brown and other victims of domestic violence. These learning issues constitute many of the objectives outlined previously. For example, one student might choose to look into ethical and legal issues surrounding the reporting of domestic violence to law enforcement; another might research resources such as hotlines and shelters.
In the second week of the module, students are given protected time to pursue their learning issues. Expert resource persons from the faculty and the community (victims, victim advocates, shelter directors, physicians with expertise in domestic violence, police officers, assistant district attorneys, and social workers) meet with the students at prearranged times. The experts are told not to give a lecture but rather to respond to students' questions and needs. In addition, students are given required and optional readings on the problem of violence. Finally, students can research their learning issues in other ways. Some students, for example, may independently arrange to visit shelters and support groups for battered women.
In week 3 of the module, the entire second-year class attends a Doctoring forum in which several women talk about their own experiences with domestic violence and the response, or lack of response, of physicians in their cases. In addition, the male director of a residential counseling center for abusers shares his perspective. The forum gives students the opportunity to hear firsthand accounts, which has proved to be a very powerful and moving experience for them—and for the panelists. During this week the students also work through a problem set concerning the epidemiology of domestic violence. In this exercise, students evaluate the reliability of data from different sources, assess the quality of data on the incidence/prevalence of domestic violence arising from hospital emergency rooms, and identify approaches to improving surveillance for this problem. In the final week of the module, students return to their tutorial groups and discuss what they have learned in the context of Mrs. Brown's case and review what advice they might offer her.
The teaching approach used in this module affords students the opportunity to begin to develop a deeper understanding of the problem of domestic violence rather than just accumulating a group of facts and statistics that are not grounded in real experience. Students are actively engaged in the educational process and can tailor their learning by pursuing independent study. There is also a substantial focus on essential clinical skills, such as communication with patients and diagnostic reasoning. Finally, students have the opportunity to compare their values with those of other students and to consider some important questions for themselves: What is abuse? Where should the line be drawn? What has been accepted as appropriate behavior in different cultures?
CONCLUSION: IMPLICATIONS FOR
THE EDUCATION OF HEALTH PROFESSIONALS
Just as it is increasingly important to teach medical students about the problem of domestic violence, many practicing physicians need to be trained in this area as well. Internists, family physicians, pediatricians, orthopedists, obstetricians, neurosurgeons, and ophthalmologists all encounter—and yet often fail to recognize—patients who suffer from injuries due to abuse. Other health care professionals, such as nurses, physical therapists, psychologists, and social workers, also need to receive formal and effective education on violence prevention and treatment. The same holds true for prevention and health promotion in such areas as smoking, drug and alcohol abuse, high-risk sexual activity, and depression.
In developing new and innovative curricula for these groups, the Doctoring Curriculum does not necessarily need to be replicated. Rather, the educational principles that underlie Doctoring should be taken and applied to the particular teaching setting. For example, in the typical CME course, the time is not available for longitudinal, PBL experiences. The teaching format could, however, make use of small groups and interactive learning techniques. A three-hour CME workshop on domestic violence could use activities similar to those of the first week of the domestic violence module: viewing a videotape of the clinical encounter with the abusive boyfriend, inventing a domestic violence interview, and interviewing a standardized patient. Instead of pursuing learning issues (as is done in a PBL approach), learners could attend a lecture that provides an overview of the key issues in providing appropriate care for the patient.
Given the great need for more effective approaches to prevention and health promotion in our society, it is more important than ever that health care educators assume a key role in effecting change. Our hope is that this chapter will stimulate others to think creatively about teaching, particularly where behavioral change is the goal.
NOTE
We wish to thank the many faculty, staff, and students who helped in the creation of the Doctoring Curriculum at the UCLA School of Medicine. In particular, we appreciate the contributions of Richard Usatine, Marjorie Covey, Elizabeth O'Gara, LuAnn Wilkerson, David Schriger, and the Curricular Working Group on Violence. Brenda Hanning provided invaluable assistance in the editing and preparation of this manuscript.
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18. UNIVERSITY-COMMUNITY PARTNERSHIPS
TO PROMOTE WELLNESS IN CHILDREN,
YOUTH, AND FAMILIES
Philip R. Nader
Wellness promotion can be defined as the enhancement of physical, mental, and social well-being and the prevention of disease and disability. Efforts to promote wellness are difficult because (1) wellness promotion does not have the “press appeal” of a dramatic cure or a high-technology advance, (2) the benefits of wellness promotion may be delayed (3) wellness promotion may encounter strong industry lobby interests (e.g., tobacco), and (4) the crisis of immediate unmet needs overshadows allocation of resources for prevention.
The enhancement of physical, mental, and social well-being and the prevention of disease and disability for all children and youth in our society will require new partnerships and collaboration among a broad range of public, private, and community organizations that interact with youth and families on a routine basis. These may be organizations that traditionally have not worked together very effectively. To form these new partnerships and collaborations, certain barriers will have to be overcome, including professional and turf issues, categorical funding, fragmentation, diverse institutional missions, bureaucracy, communication problems, and lack of involvement of the community as a source of power to solve problems (Morrill, 1992).
This chapter proposes that the university, and specifically the university medical school, along with other academic branches, become a leading force in forging the necessary collaborations and partnerships that will be required to promote wellness in a community (Nader, 1979).
A COMMUNITY APPROACH
TO WELLNESS PROMOTION
Prevention sounds like a good idea, but it will take a great deal of effort to realize the benefits of an emphasis on prevention. It has been conceptualized as primary, secondary, and tertiary. What most of medicine does on a daily basis fits into tertiary (rehabilitation) or secondary (early detection and treatment) categories. In pediatrics, primary prevention of diseases for which active immunization is possible has now become routine. However, the promotion of wellness, which includes the availability of immunizations to each and every child in the community, obviously encompasses a great deal more than strictly biologically determined issues of susceptibility, host response, and reactions to immunization. Many much broader factors, including economics, delivery systems, and education, must be considered in implementing a community emphasis on immunizing all children. One quickly realizes the complexity of the problem if one includes these additional factors.
The problem is greatly magnified when attempting to consider primary prevention of the leading causes of mortality and morbidity. These include cardiovascular disease, cancer, accidents (including motor vehicle), morbidity and violence related to alcohol and substance abuse, and morbidity related to both premature and unprotected sexual activity. Therefore, while it is true that operationalizing wellness promotion requires specific activities with measurable outcomes, the approach must
The school is a crucial site for wellness promotion for youth and a good place to gather information as well (Bruhn and Nader, 1982). The school tends to cut across many segments of society. Every school day, nearly 47 million students attend school in the United States; about six million certified and classified personnel staff these schools. Schools are the center of work activity for nearly one-fifth of the U.S. population (Green and Kreuter, 1991). While there are children who do not attend school, families with no school-age children, or newly emigrated families who may still not be comfortable with the school setting, the school does reach a large number of youth and their families at perhaps crucial times in their development of health habits and lifestyle choices. The school is also important because it offers educational resources that may be useful in planning interventions. In both projects described in this chapter, the school plays an important role.
Nationally, the leading causes of adult mortality and morbidity are cardiovascular disease and cancer. The roots of these diseases are often reflected by lifestyle habits that may be formed early, for example, diet habits, physical activity, and nonsmoking (World Health Organization, 1982). Risk-taking behaviors in youth are also directly related to morbidity and mortality in youth. Among persons ages 1 through 24, nearly 70% of all deaths are due to accidents (especially motor vehicle accidents), injuries, and violence (homicide and suicide) (Centers for Disease Control and Prevention, 1993). In addition, an estimated 2.5 million teenagers are infected with a sexually transmitted disease each year. About 20% of new AIDS diagnoses are in 20- to 25-year-olds. Given the relatively lengthy incubation period, many of these individuals become infected with HIV during adolescence.
In San Diego, the statistics are similar to national norms. In San Diego County, the big killers are heart disease, stroke, cancer, injury, and HIV (San Diego County Department of Health, 1991). Because of San Die-go's proximity to Mexico and because immigration patterns may bring
When examining demographic characteristics for San Diego County, some interesting trends for the future are revealed. The age-groups that increased the most in the decade 1980–1990 were the oldest and the very young. The 75-and-older age-group grew by 60.1%. Of tremendous impact for those interested in prevention among children, however, is that the 0- to 4-year-old age-group increased by 53.7%, adding more than 69,000 people (San Diego Association of Governments, 1990).
As this cohort ages, it will require more and more emphasis on education and prevention directed toward basic immunization, access to health care, and accident and violence prevention. We have other information on San Diego County that suggests that a broad-based approach to prevention is needed.
In 1990, there were three deaths and 985 cases due to measles in San Diego County; all of these could have been prevented with timely immunizations. Surveys in San Diego and California indicate that more than half of all pre-school-age children are behind on their immunizations (San Diego County Department of Health, 1990). A recent grocery store/mall interview survey of parents was conducted by the Maternal and Child Health Section of the Health Department in selected San Diego County census tracts with predicted difficulty in accessing health care (American Academy of Pediatrics, 1992). The results suggested that 31% of children are not covered by either health insurance or Medi-Cal; 14% said they do not obtain well-child preventive care. These figures are probably underestimated since some San Diego areas with the highest levels of poverty and highest levels of immigrant residents were not surveyed. “Financial difficulty” was given as a major reason for not accessing health care. Forty-six percent of the respondents did not have dentists for their children.
In addition to difficulty in meeting basic physical health needs, a myriad of other issues and conditions work against the chances for a child or youth in San Diego to experience total wellness. For example, national surveys indicate that 20% to 25% of parents report that their children have had some school problems (Haggerty and Roghmann, 1993). There is no evidence to suggest that San Diego is different. The current predicted four-year dropout rate (as of 1991) (San Diego City Schools, 1991) for
| Ethnicity | % Dropout |
|---|---|
| Hispanic | 41.7 |
| African American | 29.2 |
| Indochinese | 23.4 |
| White | 23.0 |
| Filipino | 17.8 |
| Asian | 15.0 |
Most dropouts occur at age 16 or after eighth grade, but a disturbing number begin as early as seventh grade. Forty percent (1,022) of the 2,679 dropouts that occurred in 1989–1990 involved eighth- or ninthgraders. Dropouts are balanced between boys and girls. Having a health problem and being held back in school have been associated with dropping out (Grunbaum and Basen-Engquist, 1993).
Since there are increasing data linking poor health, risk-taking behaviors, and academic underachievement, there is interest in examining adolescents' own self-reported health habits and behaviors.
A recent survey of student (self-reported) health was conducted in the San Diego Unified School District under the auspices of the Centers for Disease Control (Campana, 1992). The results suggest that there is room for a great deal of improvement in health education efforts with youth. It is also likely, even though the surveys are anonymous, that the levels of risk-taking behaviors may be even higher, given the fact that the survey was available only in English and that only those present in school responded to it.
The survey results indicated that San Diego youth reported that 31% had been passengers in a car driven by someone who had been drinking, 26% said that there had been at least one instance in the past month in which they had consumed five or more drinks, and 11% said that they had driven a car while under the influence of alcohol. Twenty-three percent of students said that they had carried a weapon such as a knife, gun, or club in the month prior to the survey; 4% said that they had carried a gun. Thirty-six percent said that they had tried marijuana, 3% said that they had injected illegal drugs and used cocaine or heroin at least once. Thoughts of suicide and depression were not uncommon. About
Slightly less than half the students reported that they had engaged in sex at least once. Sixteen percent said that they had four or more partners ever, and 3% percent said that they had that many partners in the past three months. Only 22% said that they or their partner had used a condom during their last sexual intercourse. However, this figure included all the respondents to the survey in the denominator. When considering only those who said that they were sexually active, 45% reported that they or their partner had used a condom during their last sexual intercourse. An interesting age-related trend emerged: Proportionately more sexually active ninth-graders (52%) reported condom use, while the proportion decreased each successive grade to only 34% of sexually active 12th-graders reporting condom use. Six percent said that they had been pregnant or had made someone else pregnant.
Fifty percent to 60% of the students reported frequently consuming high-fat foods, such as french fries, potato chips, cookies, and cake. Sixty percent reported engaging in regular vigorous exercise. Eighteen percent—lower than the national average of 36%—report smoking tobacco. This may reflect vigorous local educational programs, or it may reflect regional differences in smoking in the general population (San Diego City Schools, 1992).
All these data support the need for a broad-based approach to prevention and health promotion. Clearly, much more emphasis is required in order to improve the picture that emerges of a significant population at risk.
EXAMPLES OF A UNIVERSITY RESPONSE
In democratic countries the science of associations is the mother science; the progress of all the rest depends upon the progress it has made.
—Alexis de Tocqueville, originally published
in Democracy in America (1835)
A number of countywide effects involving the university and its community have been under way from the University of California, San Diego. Over 100 such initiatives were recently identified by a University K–12 Task Force (University of California, San Diego, 1997), and only a few that pertain to youth and schools are described here.
The San Diego Health Coalition
for Children and Youth
The San Diego Health Coalition for Children and Youth is an attempt to move from a situation in which many groups and agencies that impact and serve youth are frustrated that little is done for prevention to a situation in which an organized collaboration can actually begin to demonstrate the benefits of preventive programs.
However, there are many steps and barriers to overcome in moving from a stage of loose networks to coordination of efforts and, finally, to a real collaboration for this purpose. The process itself is worthy of study. “What we don't need is another meeting to attend.” “Another coalition?” These are commonly heard complaints during days already filled with emergency meetings to deal with fiscal and other crises. Yet there is a growing awareness among all human services personnel of an increasing pressure to intervene earlier in the stream of life events. It is believed by many, with striking new evidence supporting the conclusion, that such preventive interventions will be much more cost-effective than treating problems later. For example, a home visitor program has been shown in several studies to markedly reduce the incidence of physical child abuses to improve both health and developmental outcomes of low-birth-weight infants and to improve pregnancy outcomes and prenatal care (Hawaii Healthy Start, 1991; Olds et al., 1986; Ramey et al., 1992). Another study estimated that merely by applying preventive health strategies known to be effective—such as car safety restraints, hot water heater temperature controls, and safety bars on windows—the morbidity/mortality due to childhood injuries could be reduced significantly (Rivera, 1985). As Liz Schorr (1988) has reminded us, goals for youth are within our reach. However, there is a striking lack of a broad-based constituency to support health promotion and disease prevention for youth and families.
The recognition of the need for such a constituency led several UCSD staff to enlist the support of others in the community to develop such a coalition. The first meeting, with 10 to 12 people attending, representing five agencies, occurred on January 26, 1990. At a retreat led by a volunteer professional facilitator on September 8, 1990, 50 attendees designed a mission/vision statement and established four working groups. The mission is to achieve optimal health and development of children and youth of the San Diego region. A data group was charged with conceptualizing
The pilot project selected was a measles immunization project, targeting selected neighborhoods with known low immunization rates. These neighborhoods were predominantly low income and Hispanic. While the project actually resulted in special immunization sessions at a community clinic on two weekend days with more than 100 children immunized, the real benefit of the project was the demonstration that multiple private and public agencies, as well as government and media, could work together. The County Health Department gave specialized training to members of a Latino health education group called Por La Vida, who canvassed the target area. The Children's Hospital Public Relations Department coordinated media coverage with local Spanish print and radio media. An exit interview held at the clinic site documented that children who were brought to the clinic were significantly behind in their immunizations and that the home visitor counselors, or “consejeras,” as well as information from the school, were effective in informing the parents of the clinic. This pilot project was timely since immunizations were being targeted by national and local health officials in San Diego. As a result of Health Department initiatives and this pilot project, funding has been obtained for several additional projects that could significantly affect immunization levels in San Diego in the future.
The All Kids Count Project, which was initially a response to a Robert Wood Johnson Foundation request for proposal, fit nicely into the coalition's plans. An application was made by the Health Department with coalition support. Although not funded, its objective was the establishment of a computerized tracking system and database for immunizations for San Diego children. Once the computerized system was established, it was envisioned that a number of health and wellness indicators for youth could be continuously collected and made available to the community to serve as a status report and to serve as a database for future program evaluation. As of 1997, the All Kids Count Immunization Registry is in its final pilot phase, supported by grants from the State of California and the Anna B. Casey Foundation.
As of 1997, there are 50-plus individuals who are members of the San
University-community partnerships are also required to implement community-based research in health promotion and disease preventions. The Child and Adolescent Trial for Cardiovascular Health (CATCH) Project, funded by the National Institutes of Health, is a clinical trial of the efficacy of promoting healthy eating, physical activity, and nonsmoking by working with elementary school children and their parents via schools (Perry et al., 1990). This project is a national collaborative trial with sites in Minnesota, Texas, Louisiana, and California. The coordinating center is the New England Research Institute in Boston, Massachusetts. The University of California, San Diego, was selected as a study site in a competitive granting process. Part of the reason we were selected as a site was our previous work in the area of cardiovascular disease prevention with Mexican-American and Anglo families—Project SCAN (Study of Child Activity and Nutrition)—and our studies of the determinants of cardiovascular disease risk factor behaviors in children ages 4 to 6 and 9 to 14 years (Broyles et al., 1996; Elder et al., 1998; McKenzie et al., 1991, 1992; Nader et al., 1989a, 1995; Sallis et al., 1995b; Sallis et al., 1997; Zive et al., 1995, 1998).
There is good evidence that modifiable precursors of cardiovascular disease—namely, smoking, dietary habits, and sedentary lifestyle—lead to elevations of total and LDL cholesterol, which in turn promote premature cardiovascular disease morbidity and mortality (Luepker et al., 1996). There is also good evidence that preclinical disease processes can be detected in childhood and that, although not in every case, the various relative levels of physiologic risk factors (e.g., weight, blood pressure, and cholesterol) tend to persist through childhood, adolescence, and into adulthood (Fraser, 1986). It would seem logical, then, to attempt interventions that are not extreme, that do not label children or cause undue concern or worry, and that are hygienic from a public health perspective. As mentioned earlier, the school is an obvious site for such an intervention. The school has opportunities for adult and peer modeling of health habits and behaviors (Perry et al., 1990). The school potentially can exercise control over the environmental aspects of the school lunch program, physical education programs, and smoking policies. In addition, there are the usual opportunities to involve children and parents in curricular learning activities to reinforce healthful choices (Perry et al., 1990).
 |
CATCH was evaluated in Austin, Minneapolis, New Orleans, and San Diego among public school populations of third- to fifth-grade students that include a range of socioeconomic groups and minority students (including Blacks and Hispanics) and that are representative of the larger U.S. school population (for the study design, see Table 18.1). The results were published in 1996 (Luepker et al., 1996) and presented the effects of the three-year intervention (grades 3 through 5) compared to control schools who received only their usual health education programs. In intervention school lunches, the percentage of energy intake from fat fell significantly more (from 38.7% to 31.9%) than in control lunches (from 38.9% to 36.2%) (P < .001). The intensity of physical activity in physical education classes during the CATCH intervention increased significantly in the intervention schools compared with the control schools (P <.02). Self-reported daily energy intake from fat among students in the intervention schools was significantly reduced (from 32.7% to 30.3%) compared with that among students in the control schools (from 32.6% to 32.2%) (P <.001). Intervention students reported significantly more daily vigorous activity than controls (58.6 minutes vs.46.5 minutes; P <.003). Blood pressure, body size, and cholesterol measures did not differ significantly between treatment groups. No evidence of deleterious effects of this intervention on growth or development was observed (Luepker et al., 1996). In summary, the CATCH intervention was able to modify the fat content of school lunches, increase
Why the University?
The mission of the university is to define and investigate new knowledge, to teach the applications of knowledge to its students and its faculty, and to provide a resource and service to the surrounding community. The third of this triad has received increasing attention as public support for higher education has become more precarious and as universities strive to enrich their faculties and student populations with more people of color.
Active collaboration with the community provides rich opportunities for the university to enhance its traditional missions as well as to respond to the community and recruit and attract students from varied ethnic backgrounds. The balance provided by in-the-field, real-life experiential learning combined with more didactic and contemplative approaches within the university classroom or seminar session is exciting for both teachers and students. In medicine, recent concern has been expressed over the lack of students entering the primary care fields. This has been attributed to lack of financial rewards. It has also been attributed to lack of exposure of medical students and doctors in training to real life, primary care, out-of-the-medical-center learning activities, and relatively more exposure to predominantly subspecialty research physicians in tertiary care centers.
At UCSD, there are a number of examples of involvement of university students and trainees in community sites and programs. The Independent Study Project (ISP) frequently involves community outreach. Several years ago, one UCSD medical student conducted an ISP examining San Diego youth's knowledge and attitudes about HIV/AIDS. He compared a group of gay youth and groups of urban and suburban high school students to a group of incarcerated youth. The incarcerated group demonstrated significantly poorer knowledge and lower agreement with health guidelines, a lower perceived personal threat of AIDS, a lower personal efficacy to prevent AIDS, and the lowest perceived norms of safesex practices (Nader et al., 1989b). Another student, who was president of the American Women's Medical Student Association, based one of her ISPs on initiating and conducting a program of volunteer medical student health education teachers for local high schools. Although initiated
At the postdoctoral level of medical education, we have incorporated community and school experiences for pediatric residents. In these activities, residents become familiar with community consultation activities of the pediatrician. The resident witnesses firsthand the numerous social and health concerns buffeting families and becomes aware of resources in the community to help children and families with a wide variety of physical health, learning, and behavioral problems of children. At times, residents have been able to provide a source of ongoing health care for a child identified by the school as having special needs. Both schools and residents indicate satisfaction with these educational experiences.
Data collected on similar resident training in Texas and other settings indicate that pediatricians in practice who had such training experiences continue to be more active in school and community consultations later when they enter their practices, compared to those without such community activities during their residency training (Black et al., 1991).
Currently, UCSD is examining its medical school curriculum and is likely to expand primary care and community-based education. The desire is not to diminish the contribution and importance of basic biomedical research and teaching but rather to complement it with the richness and breadth of application of advances in the biomedical sciences using behavioral sciences and epidemiology, thereby exposing medical students to the challenge of delivering quality primary care medical services in the community.
Interaction with the community in service and educational areas leads naturally to collaboration and mutual pursuit of research projects. This fits well with the primary mission of the university. Unfortunately, too often the university is perceived by the community as coming in, doing its research, and then leaving without even sharing the results of the study with community participants. We utilize the following guidelines in approaching schools with ideas for research: (1) What benefit will the
INSTITUTIONALIZATION AND REPLICATION: A MODEL
In 1990, a project was initiated at the Harvard School of Public Health. This project undertook a nationwide examination and policy analysis of the potential contributions made by university and public K–12 schools in health promotion efforts. A first step was the review and synthesis of 25 selected panel expert group reports, including reports by the American Medical Association, the Carnegie Council, the Center for the Study of Social Policy, the Children's Defense Fund, the Congress of the United States Office of Technology Assessment, the Council Chief of State School Offices, the National Commission on Children, the National School Boards Association, the U.S. Department of Education, and the U.S. Department of Health and Human Services. Five common themes emerged:
Theme 1: Education and health are interrelated. It is accepted and well demonstrated that knowledge and skills learned by individuals can assist them in improving their health. Similarly, health influences education. Recent research documents the role of potentially preventable conditions in the development of learning impairments from birth to age five, including low birth weight, prenatal exposure to alcohol, parental smoking, prenatal drug exposure, lead poisoning, child abuse and neglect, and malnutrition. In addition, direct morbidity and mental deficits can occur if children are not immunized in a timely manner. The interrelation between academic failure and health risk behaviors has already been noted.
Theme 2: The biggest threats to health are “social” morbidities. The American Medical Association defines social morbidities as those that are primarily the result of behavior and the social environment. This is evident in the current burden on the health care system of low-birth-weight infants, alcohol-related birth impairments, drug use during pregnancy, and physical and sexual abuse. Add accidents, homicide, suicide, and the additional impact of alcohol on these morbidities, and the need for a broad-based approach to prevention is evident.
Theme 3: There is a clear need for a more comprehensive, integrated approach. Many of the reports reviewed examples of effective interventions that can be made, but all reports called attention to the fact that there is no consistent effort to apply effective interventions to the general
Theme 4: Health promotion and education efforts should be centered in and around schools. We have long attempted as a society to solve many problems by placing the brunt of the responsibility for change on the schools. At the same time, we have been unable to provide increasing resources or support from other institutions and government (or the private sector) to enable schools to respond effectively. The difference in the call today for school-centered health promotion is the realization that the school cannot, and should not, be expected to do this job alone. The stakes are high for everyone, and all must contribute. Efforts will be needed from all sectors of society—public and private.
Theme 5: Prevention efforts are cost-effective. The social and economic costs of inaction are too high and still escalating. The Children's Defense Fund estimates that every dollar spent on prenatal care saves $3 in the child's first year of life by reducing the need for remedial medical care. Every dollar spent in immunizing a child saves $10 by reducing death and disease. The costs of preventable problems are also documented by the Carnegie Council, which concluded that a year's class of dropouts would cost the nation $260 million in lost earnings and forgone taxes. Each added year of secondary education reduces the probability of public welfare dependency by 35%. Alcohol and drug abuse in the United States cost more than $136 billion in 1980 in reduced productivity, treatment, crime, and related costs.
It behooves the university to take an active role in increasing savings and decreasing costs to society by facilitating health promotion and wellness promotion programs. The university is an educational institution, and so are community schools. It makes sense to have a structure within the university that will facilitate the types of community interactions with schools that have been described. A university-wide committee with membership of departments, divisions, and colleges that could interact beneficially with K–12 schools in the area, along with school leaders as consultants to the committee, could be one mechanism for institutionalizing a university's commitment to wellness promotion for a
CONCLUSION
This chapter has described examples of how a university can promote wellness for children, youth, and families. There are many other examples that could have been described. The particular emphasis that the university brings to wellness promotion is on education and on researching the best and most effective methods of promoting wellness. Both of these contributions are important to the advancement of knowledge and practice of health promotion and disease prevention. The benefits to the university include improved responsiveness to the needs of the community surrounding the university while at the same time furthering the traditional missions of the university. The university can become an important catalyst in a community without diluting or detracting from traditional academic pursuits. The eventual bottom line should be a significant increase in investment in our nation's families and youth—an investment in time, cooperation, collaboration, and resources that will result in enhanced physical, emotional, and social well-being for all of our society.
NOTE
This chapter was initially prepared for the 1992 University of California/Health Net Wellness Lecture Series under a grant from Health Net.
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