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OCR for page 82
9. Health Promotion and Disease
Prevention in Community Settings
Our world-and our neighborhoods-are instrumental
in determining our health status. Education, access to
services, family life, and work all play a role in
shaping individual health and lifestyles. The kinds of
health messages that people receive close to home, in
their own "world," also are among the most influential
in determining their health behaviors. Many
witnesses, therefore, argued that interventions in
schools, the workplace, and the community at large
can be powerful tools in implementing the Year 2000
Health Objectives.
Many testifiers accepted this premise and focused
some, if not all, of their proposed objectives on
interventions within the school, the workplace, and
other community settings. They addressed common
health problems faced by people in these settings, as
well as programs that have been implemented to deal
with them.
In schools, for instance, the major immediate
concerns are substance abuse, AIDS, and teen preg-
nancy, but testimony was also directed at the health-
enhancing possibilities for education programs on
nutrition, physical fitness, mental health, and general
lifestyle awareness and skills to enhance behavioral
change. On the worksite, the primary concerns are
screening for chronic diseases and programs to deal
with smoking, nutrition, and stress. In the com-
munity, testifiers paid special attention to programs
aimed at substance abuse and the prevention of
chronic diseases, and on ways to make them culturally
relevant to the community they serve.
In addition to the needs and proposals specific to
these three settings, a number of implementation
issues cross the three areas, including the content of
health education programs, financing issues, and the
coordination of services. These are addressed at the
end of the chapter.
HEALTH PROMOTION AND EDUCATION IN
SCHOOLS
Many witnesses see both a great potential and a great
need for school-based health promotion endeavors.
82 Healthy People 2000: Citizens Chart the Course
Thirty-four of them focus their remarks on health
education in schools, and another 135 mention the
need for school-based health education interventions
either in the context of a specific issue or in terms
of special interventions for children and adolescents.
The American School Health Association (ASHA)
presents a detailed analysis of the needs and oppor-
tunities for school health programs. Problems en-
countered in school-aged children include unhealthy
lifestyles, chronic and episodic illnesses, emotional and
behavioral problems, visual and hearing deficits, eating
disorders, nutrition problems, teenage pregnancy,
sexually transmitted diseases, and dental problems.
In the face of these problems, The school, as a
social structure, provides an educational setting in
which the total health of the child during the impres-
sionable years is a priority concern." No other setting
approximates the magnitude of the school in terms of
the number of children that can be reached. Thus,
many witnesses see the school as a focal point for
health planning in the community. f~l96)
Given this orientation, the ASHA proposes specific
objectives regarding
· periodic screening for hearing, vision and dental
disorders; scoliosis; high blood pressure; and fitness
levels;
· care and health promotion programs for stu-
dents with chronic illnesses or problems;
· professional preparation and availability of
school nurses;
· provision of primary health care clinics in
schools;
· school breakfast and lunch programs;
· health education curriculum, class time, and the
professional preparation of teachers;
· physical education programs and testing that
emphasize cardiovascular fitIless and lifetime sports;
· mental health programs that include the deve-
lopment of prosocial behaviors, stress management
skills, and control of stress and violence;
· provision of worksite health promotion pro-
grams for faculty and staff and ~ healthful school
environment. (~196)
OCR for page 83
Implementation of School~based Health
Promotion
Testifiers fee! that to meet many objectives, education
must begin in the schools. However, school health
programs need to be significantly improved if they are
to sense this purpose. More comprehensive curricula
are required, along with more hours spent on health
education, better teacher training, and better availa-
bility of health professionals or health services to
students. The involvement and support of parents are
also viewed as critical to the success of many school-
related activities.
Texas Commissioner of Education William Kirby
writes:
The public schools of America bear much of the
burden to educate children about the physical,
emotional, social and economic dangers of such
health issues as drug abuse, school-age pregnan-
py, AIDS and smoking. We accept this respon-
sibility, yet we know that the task is too great
for education systems to bear alone. We are
grateful to the federal government for its sup-
port in such programs as the Drug-Free Schools
and Communities Act, to the Surgeon General
for his comprehensive report on AIDS, and for
federal funding to assist in the education of
disadvantaged and handicapped children. We
appreciate the philosophical and economic
support and look forward to continued
cooperation and coordination of education and
health efforts among federal, state, and local
governmental entities. We share a common
goal ensuring bright futures and long, healthy
lives for our children. (~305)
Many testifiers suggest ways to improve the health
education system so that it deals more successfully
with adolescent health problems, including such far-
ranging suggestions as environmental health issues;
training in how to be an active and responsible
medical consumer (#105~; issues of television
exposure, "latchkey children," and homelessness
(#198J; suicide prevention programs (~500; #731J;
and art therapy and dance to deal with stress and to
foster creativity (#477; #5954.
Underlying these specific programs is concern
about the capability of elementary and secondary
school faculty to teach health issues. Chet Bradley of
the Wisconsin Department of Public Instruction
writes:
I am convinced that unless a significant change
in the professional preparation of elementary
teachers in the area of health becomes a reality,
the institutionalization of quality health instruc-
tion at the elementary level will never occur. I
propose to you that the most meaningful and
effective long-term approach toward successful
school-based prevention and health promotion
efforts for our young people is through an
investment in outstanding teachers.
His testimony includes a proposal to train elementary
school teachers to earn a three-year master's degree
in elementary health education. (#593)
The American School Health Association supports
Bradley's view and states that
most health education is conducted by poorly
trained, non-specialists who devote much less
than the minimum of 50 hours necessary for
success, and who see health education at the
best as secondary to their primary functions.
These teachers also are working without the
benefits of the other components of a com-
prehensive school health program. Thus, school
health education is generally a failure. (#055)
Some witnesses called for more use of tested and
effective behavioral teaching models. According to
the National Education Association:
Attitudes and behavior are not changed by
simple presentation of the factor by scare
tactics. Regardless of race, creed, or socioeco-
nomic status, young people believe in their own
invulnerabilit~that "it" simply isn't going to
happen to them. An effective preventive health
curriculum must rationally counter this belief in
invulnerability and build a youth culture that
embraces healthful behavioral choices. (#059)
Similarly, Kenneth Kaminsky of the Wayne County
Intermediate School District in Michigan writes that
"the most successful programs today employ the social
competency or 'life skills' model." This model empha-
sizes skill development in communication, assertive-
ness, resistance skills, peer selection, problem solving
and decision making, critical thinking, making low-
risk choices, self-improvement, and stress reduction
skills. (~426) According to David Groves of
Comerica Incorporated, "Social competency develop-
ment programs emphasizing cognitive and social
Health Promotion and Disease Prevention in Community Settings 83
OCR for page 84
problem solving skills, perspective taking, and coping
skills should be provided to all children as a part of
their educational opportunities." (#075)
Williams argues that a comprehensive, preventive
health curriculum in schools necessitates collaboration
not only among "educators, parents, school boards,
administrators, and communities," but also among
teacher preparation institutions and the medical
community. (#059) The effectiveness of a school
health promotion and disease prevention program
relies on the support of the entire community.
Community involvement is especially important
when the more sensitive issues of AIDS education and
school-based or school-linked reproductive health
clinics for teenagers are addressed. Kirby emphasizes
the need for local discretion in all health program-
m~ng.
We believe that where school-based clinics exist,
they must be coordinated with existing health
services and should be established and main-
tained to meet the specific needs and philosophy
of the local community. It is imperative that
school-based clinics be under the direct super-
vision of the campus administrator and that
considerable flexibility be allowed at the local
community level. Programs not supported by
and congruent with local standards are not likely
to be successful. (~305)
One problem with focusing on school-based pro-
grams, however, is that not all adolescents stay in
school long enough to benefit from them.
A large percentage of school age children are
disenfranchised from the nation's schools. They
are in jail, on the street, working, or on the run.
Thus, the health objectives regarding school
aged children are not realistic and lack sophis-
tication. They have only focused on those
children currently attending school or available
to what is called "school site health education."
(#055)
Specific Problems and Interventions
Much of the testimony on school health issues arose
in the context of interventions in specific areas.
Programs aimed at improving nutrition, physical
fitness, and mental health, and also at preventing
AIDS, teenage pregnancy, smoking, and other sub-
stance abuse were mentioned most frequently.
84 Healthy People 2000: citizens Chart the Course
Nuirit~on. Testifiers proposed various nutrition
objectives, many of which are designed to ensure both
classroom education and cafeteria participation.
Several witnesses also underlined the need for a
nationwide monitoring system of school-age children's
nutrition status; without this, setting objectives will be
difficult. Many of those testifying about nutrition
education referred to the Nutrition Education and
Training (NET,) Program, which came into being by
an act of Congress in 1977. Its purpose is "to teach
children the value of a nutritionally balanced diet
through positive daily lunchroom experience and
appropriate classroom reinforcement, to develop
curricula and materials, and to train teachers and
school food service personnel to implement nutrition
education programs." ˘#161) Witnesses testified that
this program should be supported and, in some cases,
expanded.
Some testifiers, such as Carol Philipps representing
the Midwest Region NET Program Coordinators,
advocate "integrating nutrition concepts into other
curricular areas as appropriate, for example biology,
elementary language arts, mathematics, home eco-
nomics, and social studies." (#590) Others place
great emphasis on maintaining school lunch and
breakfast programs and summer food programs in
public and private schools. To actually maintain a
nutritionally balanced diet, they argue, many children
need school meals.
Physical Fitness. The discussion of physical fitness
focuses on engaging children in vigorous health-
fitness activity and on preparing children for healthy
physical activity behaviors later in life. For instance,
the American Alliance for Health, Physical Education,
Recreation and Dance (AAHPERD) believes that
thoroughly and appropriately integrating physical
activity into one's life is possible only with a sound
educational program as a starting point. (~596)
One of the current problems with physical educa-
tion programs, according to Brian Sharkey of the
University of Northern Colorado and others, is that
physical fitness tests given to school children often
dictate, at least in part, the content of the curriculum.
Hence, it is important to select fitness tests that will
lead to the desired behaviors. As an example, he
cites the health-related fitness test developed by
AAHPERD as being preferable to the athletic skills-
related test of the President's Council on Physical
Fitness and Sports (PCPFS). Unfortunately, he says,
Well-meaning school teachers see the glitter and
polish of the PCPFS award system" and forsake
OCR for page 85
AA8PERD's fitness test. This, Sharkey feels, pre-
vents the establishment of a unified health-fitness
related program in U.S. schools. (#363)
Others discuss the need to integrate physical
education with other health-related programs. Guy
Parcel of the University of Texas Health Science
Center at Houston, for example, discusses a program
called Go For Health that was designed to reduce
cardiovascular risk factors in elementary school
children. This program makes an organizational-level
change in the school lunch and physical education
programs to "create an environment supporting
healthful diet and physical activity practices," which is
then supplemented with classroom instruction and
theory "consistent with the school environment.
(#295)
Charles Kuntzleman of Fitness Finders makes the
argument that increasing the amount and time of
current physical education programs as they now exist
may not solve the problem of the poor physical con-
dition of today's children. According to Kuntzleman,
75 percent of the time in a typical physical education
class is spent on record keeping, roll call, listening to
instructions, waiting to take a turn, and general
management; only 25 percent of the child's time is
devoted to motor activity. (~121)
Mental Health. Many witnesses stressed the necessity
of providing mental as well as physical health educa-
tion so children. Such programs can address a wide
variety of issues ranging from stress management to
the prevention of adolescent suicide.
The American School Health Association accents
the pivotal role a school can play in fostering the
mental health of a child and building skills for later
life. The AS HA believes that stress management is
an important part of a school health education
curriculum. (#196)
Gaffney speaks of suicide and the potential of a
teacher for identifying a suicidal child. She argues
that Teachers are the children's first line of defense
because they see behaviors before even parents do on
occasion." (#731J
The school is also an important setting for dealing
with problematic personality characteristics. Bruce
Dohrenwend of Columbia University School of Public
Health says that because problematic dispositions can
be Laid down early in life," the school is a good place
to provide "training and orientation toward mastery
and control." (#729)
Family Planning and Reproductive Health. Many
testifiers endorse the provision of family planning
programs within the general school health curricula.
They also agree that reproductive health or sex
education should begin early in the school years.
Testifiers acknowledge the sensitivity of these issues
and recognize parental concerns, but most feel that
ignorance of pregnancy and AIDS outweighs the
concerns about sex education.
High teenage pregnancy rates indicate a failure of
educational and service provision efforts, according to
Deborah 13astien of Galveston, Texas. She underlines
the disparity of adolescent pregnancy and abortion
rates in the United States and in other industrialized
countries, and concludes that the higher rates of both
pregnancy and abortion here are due not to greater
sexual activity but to lesser availability of contracep-
tive services and sex education. Despite this, "U.S.
public policy still focuses on preventing sexual activity
among teens." f#236) Sylvia Hacker of the Universi-
ty of Michigan supports this position: "Recognizing
that adolescents are risk takers, espousing abstinence
as the only choice will not work." Insteaci, she says,
sex education could help adolescents realize that
choices are possible in expressing one's sexuality, and
intercourse is only one of them. (#4063
Jackie Rose of the Clackamas County Department
of Human Services in Oregon suggests social motiva-
tions for teenage pregnancy: "We see teens for whom
making a baby is one thing they can succeed in." To
change these attitudes, she argues:
We need comprehensive, coordinated teen-
parent programs and teen pregnancy prevention
programs to help them realize other options.
We need to devise strategies to keep teens in
school, for example, teaching teens and their
families techniques for success and making
available health services that minimize barriers
to those services; that is make services available
where the teens are-school-based health clinics.
We need a goal to decrease the rate of repeat
pregnancies during the teenage years. (#343)
When and how family planning education should
begin, argues Susan Addiss of the Quinn~piack Valley
Health District in Connecticut, are important ques-
tions. Even though "there is controversy about the
content and timing of such education in communities
around the country," Addiss urges "most strongly that
Health Promotion and Disease Prevention in Community Settings 85
OCR for page 86
an objective be developed with respect to some
desired percentage of the nation's school systems
having comprehensive family life education curricula
in place by the year 2000." (i'460)
The National Parents and Teachers Association
also supports school-based sex education and says that
because few parents actually discuss sex education,
"schools and other public agencies and organizations
must undertake this education. (#5 78J Similarly,
Cathy Trostmann, a community school nurse in Texas,
feels that sexuality education should begin in the first
year of school and be presented at a level and in a
manner that relates to the level of the child's develop-
ment. She argues, however, that provisions be made
for parents To give their own instructions in the
home with guidance provided by the school system,"
if they so desire. (#302)
The American School Health Association calls for
school-based intervention programs to reduce not only
teen pregnancy, but teen alcohol and substance abuse
as welt According to ASHA, these programs must
encompass more than just classroom education. The
best way to decrease adolescent pregnancy and the
incidence of sexually transmitted diseases among
adolescents is to provide multiple channels: health
and educational professionals, parents, and peers.
The utilization of school-based clinics, school-linked
clinics, and school- and community-based education
programs is an example of an intervention that
complements instruction and has been shown to be
effective in reducing adolescent pregnancy. (~232)
Clinical services are a critical part of successful
intervention programs for teenage reproductive health.
As ASHA notes, In preliminary evaluation a few
programs have shown dramatic efficacy in combatting
teenage pregnancy. It also cites studies that show
widespread support for school-based clinics; the
number of clinics across the United States has risen
from 1 in 1970 to 120 in 1988.3 f#232)
AIDS Education. Although the ideal content of
AIDS education programs is controversial, most
witnesses who address this issue call for aggressive
school education. Wayne Teague of the Alabama
Department of Education writes that when he was
asked whether parents or the school system should
decide the content of an AIDS education program, "I
took the position that we do not give people an
option for their children to commit suicide." (#675)
However, although AIDS education is now mandatory
86 Healthy People 2000: Citizens Chart the Course
in Alabama state schools, across the nation-according
to Ralph DiClemente of the University of California,
San Francisco-few school systems currently provide
AIDS education as part of a formal curriculum, and
even fewer have evaluated nro~ram effectivene.c.c
(#273)
DiClemente believes that AIDS prevention pro-
grams should "encourage health-promoting behaviors
and eliminate or reduce high-risk sexual and drug
behaviors. Adolescents cannot be coerced into chang-
ing behavior patterns.n (#273,)
AIDS education, however, is hampered by the lack
of information on the epidemiology of behavior
among at-risk groups. Lew Gilchrist of the University
of Washington says that baseline information is
lacking on the actual use of condoms among specific
populations, including adolescents. To offer effective
education, these programs must be grounded in an
understanding of actual behaviors and attitudes in at-
risk populations. (~691)
r - -an
Smoking, Alcohol, and Substance Abuse. Some
testifiers argue for early, school-based prevention
activities for smoking, alcohol, and substance abuse.
For example, according to the National Association
of State Boards of Education:
There should be a specific focus on alcohol and
drugs beginning in the fourth grade and continu-
ing until graduation. Providing accurate infor-
mation is essential for a substance abuse preven-
tion program. This includes knowledge about
physiology, high-risk populations, high-risk situ-
ations, the actual prevalence of drug and alcohol
use, family influence, peer pressure, stress, the
role of the media, and cultural norms. (#573)
Kaminsly argues that students now view schools as
the leading source of antidrug information. For this
reason, schools must provide a program that can give
adolescents information and influence healthy lifestyle
behaviors. He outlines a program for substance abuse
and lists as its components a grade-specific cur-
riculum, in-seIvicie teacher training, counseling services
for children, parent education programs, peer leader-
ship and liaison work with community seIvice pro-
viders, parent groups, and the media. (#496) Many
of Kaminsly's components are reiterated by other
testifiers, especially peer leadership and community-
w~de efforts.
OCR for page 87
HEALTH PROMOT1061 IN THE WORKPLACE
As the American Occupational Medical Association
(AOMA) points out, virtually all the 1990 Objectives
can be addressed effectively and efficiently in the
workplace. Health problems having to do with "re-
production, child-rearing, immunization, mental
health, substance abuse, hazard exposure, risk-taking,
and self-destructive habits" are all appropriate and
pertinent material for workplace health education and
health promotion programs. (~071) Many other
witnesses agree.
Business Roundtable spokesperson Paul Entmacher
offers a sample list of health promotion programs to
be found in businesses today which "amply demon-
strates the extent that business health promotion
activities are part of the nation's total efforts These
include
· smoking cessation, general tobacco use
abstention;
· coronary heart disease prevention, including
nutrition education;
· stroke prevention and hypertension control;
· seat belt usage and auto crash injury prevention;
· diabetes screening and education;
· early identification and treatment of alcohol
abuse;
· cocaine, heroin, and marijuana education and
counseling;
· occupational safety standards and matching
education;
· occupational toxicity education and control;
· weight control;
· physical fitness and exercise;
· cancer detection (cervical smears, mammo-
graphy); and
· AIDS public education and worker counseling.
(#465)
A survey of 48 companies by the Washington
Business Group on Health identified the five priori-
ties (and some reasons for them) among workplace
health issues in the 1990s:
1. Detection of, and intervention against, chronic
diseases, including cancer and heart disease (32
responses): because chronic diseases account for the
bulk of health care expenditures and for considerable
absenteeism and productivity losses. Although solu-
tions require addressing multiple risks, chronic
diseases are amenable to large-scale detection and
prevention programs.
2. Reduction of alcohol and drug abuse (21
responses): because alcohol and drug abuse are ~
major source of health costs, absenteeism, and lost
productivity; because abuse increases legal and security
costs; and because abuse reduces the morale of
coworkers.
3. Improvement of mental health (19 responses):
because mental health costs continue to grow. Stress-
related illnesses are becoming more prevalent and
contribute to overall health costs; employee assistance
programs at the worksite can be effective.
4. Control of HIT infections and AIDS (15 respon-
ses).
5. Prevention and control of tobacco use (14
responses): because no other single factor accounts
for as much cost and loss of productivity.
Smaller numbers of respondents identified physical
fitness (11 responses), maternal and infant health (8),
occupational safety and health (8), maintaining health
and quality of life in older people (8), nutrition (6),
and other topics. (#355)
Many of those who addressed the question of
worksite-based programs spoke of generic issues such
as the need for comprehensive policies, the role of
health professionals, and the special difficulties faced
by small businesses. Others addressed specific
activities, policies, and programs to deal primarily
with smoking, nutrition, stress reduction, substance
abuse, and physical fitness and exercise.
Implementation of Workplace-based Programs
Marilyn Rothert of Michigan State University targets
three factors for developing a successful worksite
health promotion program: (1) involvement of em-
ployees and management in the identification and
development of all phases of the program; (2) expec-
tation that successful programs will be sustained; and
(3) working across populations and risk areas, and
using multiple strategies. (#394)
Margo Gorchow of the Health Development
Network at Botsford General Hospital in Michigan
describes the problems encountered in a worksite risk
reduction program at a General Motors plant.
To put up a poster announcing a smoking
cessation program will not necessarily fill your
classroom with eager, expectant students willing
to give up smoking and pay money to do it.
Offering free introductory sessions so groups can
learn what the program is about does not
Health Promotion and Disease Prevention in Community Settings 87
OCR for page 88
necessarily make people want to give up a habit
of eating potato chips, chocolate chip cookies, e!
cetera. Aggressive outreach and engagement
strategies need to be developed and imple-
mented, to reach out to the individuals, to raise
their level of health awareness, and engage them
in a program to support their own interests,
rather than what we think is a good idea for
their health, to make a lifestyle change. (#386J
Gorchow maintains that her program's success comes
from keeping
a high profile of visibility, with our professional
staff (R.N.s and R.D.s) periodically on the
factory floor talking to employees and signing
them up for risk reduction classes. This ap-
proach is working to engage the employees into
a program as well as to provide follow up to
assess their progress or relapse. There are on-
site wellness coordinators at the plant as well.
This proves to be an expensive, labor intensive
approach. Still, in the first year of this study we
were able to attract approximately 10 percent of
the work force into behavior change programs.
(#386)
A number of testifiers called for a comprehensive
set of policies, interventions, and activities for work-
site wellness. According to Rothert and others, these
programs share three components: (1) employee edu-
cation, (2) a knowledgeable and available health
professional, and (3) incentives for sustained par-
ticipation. (#153; #394J
For example, the Adolph Coors Company provides
fairly complete wellness services to its employees,
retirees, and their dependents. These include preven-
tive dental coverage, smoking cessation programs,
exercise programs, stress prevention programs, screen-
ing for high blood pressure, causes and solutions for
low back pain, good nutrition, weight management,
healthy pregnancy/prenatal awareness and education
programs, and mammography screening for the
company and the community. A cost benefit analysis
of Coors' programs shows that for each dollar in-
vested, the company can expect a return of $1.24 to
$8e33e Max Morton, manager of the Coors Wellness
Center, claims a high level of participation and
success for the various programs. Morton underlines
the need to reach production staff as well as manage-
ment staff: four studies suggest a difference in where
production and nonproduction workers get their
88 Healthy People 200Q: Citizens Chart the Course
health information. Production workers reported that
the majority of their information comes from tele-
vision, radios, and newspapers, in contrast to non-
production workers information sources, which were
their M.D.'s and our Wellness Center." (~153)
A similarly comprehensive health promotion
program is being undertaken at Michigan State
University. Rothert explains that its purpose is to
"establish an institutional process to sustain health
promotion as a broad-based commitment and com-
ponent of the mission of Michigan State University
and to develop a model of this process that can be
deployed to other organizations." She adds, Health
habits can be contagious, and we are attempting to
create a broad-based environment supportive of
individual health promoting decisions." (~394)
Many testifiers who have or are developing work-
site health promotion programs concluded that a
knowledgeable health professional at the worksite is
a necessity for success. For example, Pat Joseph,
representing the American Association of Occupa-
tional Health Nurses, argues that workplace health
education is most successful through occupational
health nurses. "Approximately 75 percent of all
occupational health nurses are the sole health care
provider in the workplace," she says, and for this
reason, they are "among the 'movers and shakers' in
the activity to eliminate preventable disease and to
promote optimum health in the workplace." (~385J
However, although a program under the direction
of a health professional might be the ideal, it may be
too expensive for most small businesses to staff and
draft comprehensive workplace wellness programs. To
overcome this difficulty, there are now a host of local
business groups on health, community organizations,
and coalitions that can aid small businesses.
Companies, such as insurance providers, make
programs available, and resources can be found that
help provide at least some wellness information or
services, according to witnesses.
Jack West, President of the Puro Corporation of
America, illustrates what can be done. With 47
employees of his own, he argues that small businesses
Can pick the low-hanging fruit" of employee health
promotion programs. These are cheap interventions
such as employee self-assessment questionnaires (at
$12 per person), lunchtime cancer self-screening
seminars, complimentary flu shots, a company newslet-
ter on health and fitness, a company subscription to
a local fitness club, and providing his company's
product-bottled wate~to pregnant employees or
spouses. (#734)
OCR for page 89
The New York Business Group on Health, a not-
for-profit coalition of nearly 300 organizations of
which the Puro Corporation is a member, tries to
help businesses obtain health information appropriate
to the workplace. Its director, Leon Warshaw, says,
"We have published a two-volume directory of avail-
able resources for health education/promotion and
every issue of our bimonthly newsletter is replete with
articles describing innovative and successful programs
and capsule reviews of publications and educational
materials suitable for use in the workplace." (#448)
Warshaw also talks about providing help and
direction in the adaptability of projects.
One should remember that the work force is not
a uniform population. Specific cohorts can be
identified on the basis of age, sex, educational
and ethnic backgrounds, health status, and
disease predilections so that they can be targeted
for specific programs. The economies of scale,
ease of access, and the enhancing effects of peer
pressure serve to increase the effectiveness of
these programs. (#448)
Specific Problems and Interventions
As with school-based health promotion programs,
many of those who testified on workplace wellness
singled out specific health needs and programs that
should be addressed effectively by employers. The
most commonly mentioned programs involved screen-
ing for chronic diseases, smoking, stress reduction,
and nutrition.
Screening for Chronic Diseases. Worksite
screening for heart disease and cancer can be
invaluable in identifying individuals at risk of
developing either of these chronic diseases. Heart
disease and cancer remain the two top killers in the
United States despite the fact that, to a great extent,
both can be prevented. As speaker Thomas Washam
of the Aluminum Company of America (Alcoa) points
out, worksite screening can save lives. For example,
at Alcoa there are blood pressure monitoring pro-
grams and chronic health condition monitoring
programs. These programs have found individuals
who were in need of medical or surgical intervention,
as well as individuals for whom better compliance
with recommended medication was imperative.
(#307)
The AOMA suggests as an objective that "90
percent of the Fortune 500 companies and 75 percent
of all employers with more than 100 employees
should provide for on-site blood pressure screening
and follow-up." Voluntary organizations, health care
providers, and other organizations will have to assist
employers that do not have their own assessment
resources, AOMA adds. (~071)
Leslie VanDermeer, an occupational health nurse,
says that "screening of total cholesterol levels should
be made available to all employees who work In a
company that has an on-site medical unit or nursing
department." She argues that since the fingerstick
method of measuring total serum cholesterol is "low
cost, accurate and easily accessible," it would be Ha
scientifically sound and attainable goal for the year
2000 to have 100 percent of the worksites that
contain employee health seIvices offer this seIvice."
(imp 7)
Angelo Fosco, General President of the Laborers'
International Union of North America, calls for
making preventive seIvices available through company-
provided health plans. He suggests that these plans
give particular emphasis to occupational diseases and
work-related disorders, and that they be made avail-
able to retired workers as well. (~586)
Worksite screening for chronic conditions also can
be useful in encouraging individual responsibility and
coordinating other components of a worksite wellness
program. Screening for cholesterol, high blood pres-
sure, and breast cancer, for example, can help ind~-
viduals to monitor their own health conditions. It
also enhances the connection with other wellness
programs for nutritional awareness, smoking cessation,
physical fitness, and stress management. The Adolph
Coors Company, in addition to blood pressure screen-
ing, cholesterol screening, and a cardiac rehabilitation
program, provides a significant mammography screen-
ing program. The company has encouraged employ-
ees and their spouses to Spread the word" to the
community that many breast cancer deaths can be
avoided if detected early. Coors offers mammograms
for $15 to all staff and dependents, and is now
coordinating screening for the nearby community.
(~153)
Smoking. Nonsmoking programs are the most fre-
quently cited worksite interventions. Many large
businesses in the United States are actively and
effectively reducing smoking in the workplace.
According to Alice Murtaugh of New York City, 36
percent of U.S. companies with 50 or more employees
have smoking control activities.4 (#159J
Charles Arnold, representing the Health Insurance
Health Promotion and Disease Prevention in Community Settings 89
OCR for page 90
Association of America (HIAA), exhibited a step-by-
step implementation plan as an example of what can
be done for employers who want to reduce smoking
among their employees. The manual entitled Non-
smoking in the Workplace: A Guitle for Insurance
Companies is put out by HIAA and the American
Council of Life Insurers, who have "resolved to make
the provision of worksite smoking cessation programs
a top priority for the employees of our industry."
(#440)
Some in the business community are not content
to limit their activities to the private sector, and
address participation by the government, both as a
regulator lawmaker and as an employer. "More laws
to ban smoking in the workplace must be enacted,"
says Murtaugh. (~159) However, Robert Rosner of
the Smoking Polipy Institute of Seattle adds, "Before
the government can advise any other organization on
the issue of smoking policy and cessation programs,
it must get its own house in order." Although the
government has made progress, Rosner says it still
lacks consistent and comprehensive policies for its
own employees and worksites. (#349)
Nutrition. Because of the link between nutrition and
chronic disease, a number of testifiers described
nutrition goals that would be appropriate for the
workplace. Providing information about sodium, cho-
lesterol, fats, and sugar in foods, and including
cafeteria and other food providers in worksite nutri-
tion programs were viewed as good policy. However,
according to Marilyn Guthrie of the Virginia Mason
Clinic in Seattle, "although there exists both profes-
sional and public awareness of nutrition's role in
health, more concrete data on the cost versus benefit
of initiating changes in eating patterns are needed to
provide the impetus for more structured programs."
(~077)
Loring Wood of NYNEX suggests combining nutri-
tion and physical fitness objectives into a single
objective to bolster the effect of education in the
workplace. Specifically, he says that overweight, hy-
percholesterolemia, and exercise are closely related to
each other and to cardiovascular risk. Thus, work-
place initiatives that foster good nutritional guidelines
in the cafeteria and at the same time actively
encourage employees to exercise regularly either off
site or in subsidized programs are likely to increase
productivity, lower absenteeism, and help retain
satisfied employees. Wood proposes that "by 20()0, 25
percent of companies and institutions with more than
90 Healthy People 2000: citizens Chart the Course
500 employees should actively encourage their
employees to exercise regularly through subsidized
programs or on their own time, and their cafeteria
managers to be aware of and actively promote U.S.
Department of Agriculture and Department of Health
and Human Services dietary guidelines.n f#736)
Stress Management. Stress management is also a
common element in specific interventions suggested
for the workplace. Because of its toll on productivity
and the absenteeism stress produces, stress manage-
ment has become a compelling health issue for the
business community. James Henderson of Pacific Bell
reiterates this: "Our fastest growing health care cost
item is the price of stress and depression in Southern
California." (#761) Harriette Zal of the Southern
California Association of Occupational Health Nurses
remarks, "It is predicted that 'stress' will be the
occupational health disease of the 199Os." fi˘230)
As described in testimony, employer-sponsored
programs for stress management can range from
lunchtime classes to long-term education and relaxa-
tion classes. James Quick from the University of
Texas at Arlington, representing the American Psycho-
logical Association, outlines how individual and
organizational stress can be dealt with without causing
~distress." He cites four basic components of a stress
management program:
1. knowledge of what stress is, what causes it, and
what constitutes the stress response;
2. knowledge of costs-Moth individually and collec-
tively"-of mismanaged stress;
3. familiarity with how to diagnose stress and its
effects; and
4. knowledge of responsible individual and organi-
zational prevention strategies that are beneficial in the
management of stress. (#176)
Employee assistance programs (EAPs), which pro-
vide counseling services and resources for employees,
are another work-based method of handling stress.
The benefit of EAPs for employees is that it
recognizes their total environment-in and out of
work-as appropriate for interventions. As the
AOMA says:
Such broad-based programs should provide the
expertise to counsel on finances, parenting,
interpersonal relations, marital discord, disloca
tion support, bereavement, AIDS, substance
abuse, violent crime victimization, rape, etc. It
is unlikely that many small businesses will have
all counseling resources within their organiza
OCR for page 91
lion. Rather, the EAP counselor (whether con
tracted or employed, on- or off-site) should
serve as an advisor and should guide employees
to appropriate resources. (~071)
COMMUNITY-LEVEL INTERVENTIONS
More than 100 testifiers argue that behavior-related
health problems-for individuals or entire popula-
tions~n be addressed most effectively through at
least some degree of community-level intervention.
Linda Randolph of the New York State Department
of Health says that the increasing appreciation of The
role that communities play in supporting the
individuals makes it necessary not only to empower
individuals in the health arena, but to empower
"communities as aggregates of individuals as well.
(#177J
As an organization with the resources necessary to
provide support for community health plans, the New
York State Department of Health has devised a f~ve-
step process that allows it to help communities
"determine for themselves the means they will employ
to realize optimal health" and to establish prevention
interventions: (1) identify health problems, (2) de-
termine the relative public health threat, (3) devise
strategies to solve the problems, (4) implement
strategies, and (5) evaluate the effectiveness of the
strategies. (#1 77J
Other testifiers who outline community interven-
tion strategies reiterate these five steps, perhaps using
different terminology. Many argue that a key element
of both devising and implementing prevention inter-
ventions is the realization that customs, mores, and
socioeconomic status affect the health of individuals
and communities. Effective programs, they say, must
take these components into account.
Frank Bright of the Ohio Department of Health
observes that Populations whose needs are being
addressed should be brought into the planning
process." Forcing an intervention upon a community
from without or establishing an isolated intervention
within an unsupportive community will not bring the
same change in health status to that community as
community-owned goals will. Bright says that
community ownership of health objectives offers the
potential of bringing necessary services into existing
structures and making them acceptable to the popula-
tion. (~470J
Most of those who testified about community
interventions spoke about specific programs, but some
addressed the opportunities that community-level
programs offer to racial and ethnic minorities. Still
others stressed the need to link community-level
programs with wider efforts in society.
Specific Problems and Interventions
Witnesses mentioned a number of specific areas where
community-level interventions are especially valuable.
These areas include adolescent suicide and substance
abuse, other adolescent issues, alcoholism, and the
prevention of cardiovascular disease.
Problems of Adolescents. Robert Tonsberg,
Director of the Wind River Health Promotion
Program, reports that a community coalition to reduce
adolescent suicide was developed when a series of
suicides took place in the Wind River Indian Reserva-
tion in Washington State. In looking at the histories
of the victims, it was found that there was a high
incidence of substance abuse and depression among
them. The Wind River Health Promotion Program
approached this by developing stress-coping skills
among young people and education programs for
children and youth. The planners also decided to use
the "Tupperware approach-instead of having par-
ticipants coming to them, they brought the services to
the community. The program relies on community-
based networking and on collaboration and coordina-
tion with community groups; schools; churches; and
local, state, and federal organizations. It focuses on
multiple targets for change and multiple strategies for
intervention and evaluation. (#711)
In Seattle, a citywide program to provide education
and services to urban children was developed with the
aid of a survey distributed to adolescents in the city.
Robert Aldrich of the University of Washington says
that one of the most startling discoveries of this
survey was "some very major differences between what
kids thought and what the adults thought the kids
thought. To deal with this, says Aldrich, "we put in
place a kids' board, 30 teenagers who report to the
mayor and who, with the officials of the city and the
private sectors began to deal with each of the issues
that have been brought up by the kids, and some we
thought of ourselves." Aldrich also points out that
this Kids' Place program is not a medical intervention
program. Instead, it is "more socially driven so that
the primely things that are being dealt with are things
like housing, and facilitating a day-care system."
Aldrich urges others who might be interested in orga-
nizing similar programs to conduct a citywide survey
and then plan strategies around the results. (~689)
Health Promotion and Disease Prevention in Community Settings 91
OCR for page 92
Alcohol-related Problems. Al Wright of the Los
Angeles County Department of Health Senaces de-
scribes a county-level alcohol intervention program
that supports "the prevention of, intervention in, and
recovery from alcohol-related problems that occur at
the individual, family, and community levels as a
result of the relationship between alcohol, drinkers,
and the environment." Among the strategies for
primary, secondary, and tertiary interventions, Wright
includes an "environmental approach to commun~ty-
level prevention of alcohol problems," that is a
counterattack on the social components of drinking.
He lists price, product, place, and promotion as four
areas in which there are industrial and societal
pressures to drink. Los Angeles County's intervention
program has developed four countermeasures: taxes,
alternative beverages, planning/zoning, and norms/
policies. Wright's testimony illustrates that through
coordinated activities, social habits can be changed.
(#229J
Cardiovascular Problems. Adrian Ostfeld of Yale
University describes a statewide hypertension control
program that was implemented with good results in
Connecticut. After the organizers carried out a state-
wide survey of both health consumers and health
providers in 1978, they decided to focus their efforts
on controlling high blood pressure and reducing
lifestyle-related risk factors, especially in younger men
whose problems were more severe. They sought and
received the cooperation of physicians, other health
professionals, and provider agencies such as neighbor-
hood health centers, public and private nursing
agencies, the Red Cross, and family planning agencies.
After four years, noticeable changes occurred in two
areas. First, physicians and other health professionals
became more active in screening for hypertension and
helping their clients control it. Second, many resi-
dents of Connecticut reduced their behavioral risk
factors for heart disease, including smoking and the
consumption of salt and fat. (#459)
For Raymond Bahr of St. Agnes Hospital in
Baltimore, Maryland, active participation of the
community hospital is essential in a community
program to prevent heart attacks. To enhance the
link between early cardiac care and the community,
Bahr says, "it is going to become important for each
community hospital to have a coronary care system
that moves into the community with educational
programs focusing on chest pain and providing an
early cardiac care center in the hospital." Bahr
emphasizes the hospital's responsibility in this
92 Healthy People 2000: Citizens Chart the Course
program.
Coronary care is a community problem because
a significant number of sudden deaths and
myocardial infarctions take place in this environ-
ment. Before entering the hospital coronary
care system, the public must interact with the
emergency care delivery system as well as with
the hospital emergency room. The ultimate fate
of the community depends on the quality and
effort available in these areas. (~511J
Bahr's plan also includes strategies for informing
the community at large. He argues that people must
be instructed in cardiopulmonary resuscitation and
must recognize the early warning signs of a heart
attack. "But what is more important," he argues, "is
developing the concept of having an 'executive person'
in each family to deal with the chest pain patient who
is experiencing procrastination and denial of the heart
attack." Bahr also targets high school education as an
appropriate vehicle for teaching that late entry into
care causes sudden cardiac deaths. (#511)
Racial and Ethnic Minorities
Because of the importance of culturally related health
knowledge and attitudes, as described in Chapter 6,
community-level intervention is thought to be an
especially effective way to implement health promo-
tion and disease prevention programs.
The Hispanic Agenda in Colorado, described by
Rita Barreras of the Colorado Department of Social
Services, is one such program that aims to develop
community health objectives and programs for the
Hispanic community. Its premise is that the respon-
sibility "to insure that there is a coordinated, in-
tegrated and systematic approach to positive change"
lies with the Hispanic community itself. (~243)
The steering committee for the Hispanic Agenda
acted as impetus for the community-wide goal-setting
process. It first identified eight component areas:
education, higher education, labor and employment,
economic development, housing and neighborhood,
health and human services, political participation and
leadership, and media. Next, experts were invited to
submit papers and to draft goals for these eight
component areas. Finally, criteria were developed to
help planners identify and assess issues and strategies.
(~243)
Margaret Hargreaves and her colleagues at
Meharry Medical College's Cancer Control Research
OCR for page 93
Unit describe several cancer prevention strategies
being undertaken by Meharry, Morehouse, and Drew
universities for the Black community. Their aware-
ness program
aims to improve cancer knowledge of Blacks in
the three consortium cities by developing a
program to ensure the diffusion of cancer
information throughout the community. The
strategy will employ community organization,
The
mass meOla, and personal contacts.
program will be provided through churches,
worksites, and the community-at-large. (~615)
Hargreaves stresses the need to develop strategies
that are culturally specific to the Black community.
Blacks have been reported to exhibit a particular
pattern in availing themselves of health care,
delaying in utilization of the traditional health
care system, and relying upon family, friends,
and even spiritualists and healers during critical
stresses in their lives. Such delays are com-
pounded by medical care expenses that they are
unprepared to meet. With their unique value
systems and problems of access, it is apparent
that different health promotion strategies should
be used to reach Blacks. (#615)
Mario Orlandi of the American Health Foundation
emphasizes the importance of designing substance
abuse community intervention programs that are
"culturally relevant and that address specific sociocul-
tural barriers to effective cross-cultural program
dissemination." He also notes, however, the need for
more data and research studies in these communities.
In an evaluation of two community intervention
approaches and their applicability to minority cul-
tures, Orlandi found difficulties and gaps in assessing
the substance abuse intervention needs of Blacks,
Mexican-Americans, Asian Americans, and Native
Americans. For all four of these groups, he cites a
lack of basic research or intervention development
research projects. For Blacks, compared to other
groups, although there have been a number of
research studies on substance abuse, Orlandi argues
that "despite this accumulated body of research, the
relevant understanding of Black substance abuse is
lacking," and especially absent are "the appropriate
information and insight necessary to design effective
preventive interventions for this population. The lack
of systematic, longitudinal, multivariate studies, and
the failure to employ ethnographic and other
culturally-sensitive data collection procedures also has
impeded progress.n Orlandi concludes that the prob-
lem is not that preventive innovations are not
available for planners trying to develop programs for
minority populations, but rather that "programs are
not available that fulfill both criteria: demonstrated
efficacy and cultural relevance for particular minority
or ethnic groups." (~167)
Linking Community-level Programs with Larger
Efforts
A number of testifiers argue the necessity of linking
community intervention programs with wider state,
regional, and national health goals. The importance
of networks, linkages, broad-based support, and above
all, mass communication should not be ignored.
Woodrow Myers of the Indiana State Board of
Health says that state health departments have a role
to play in helping communities link themselves To
statewide solutions that affect other communities'
problems and ultimately to national solutions, whether
private or public, to address those needs." Myers
describes several injury prevention programs that
Indiana has undertaken, which involve both govern-
ment and community components. Two examples are
the Hoosiers for Safety Belts program and the Indiana
Poison Control Center. The first is a statewide
nonprofit coalition of private citizens, professional
groups, service clubs, corporations, public agencies,
and trade associations. The second program is a
regional center dedicated to the prevention and
treatment of poisoning. The center maintains a 24-
hour, toll-free poison information line to inform
citizens about household products, chemicals, phar-
maceuticals, and live plants that may be poisonous.
In both these interventions, the communities and the
state share common goals to increase the use of safety
belts and to provide statewide poison control services.
(#405J
In some cases, the resources for health promotion
and disease prevention programs are already available,
but poorly coordinated. For example, writing about
adolescent health problems, Claire Brindis and Phillip
Lee of the Institute for Health Policy Studies at the
University of California, San Francisco note that
"categorical programs that have followed traditional
patterns and focused on a single aspect of an
issuer family planning, drug abuse, counseling-have
had limited success." Only a small portion of the
adolescent population has responded to this
Health Promotion and Disease Prevention in Community Settings 93
OCR for page 94
categorical, medical-model approach. "Communities
need to work toward comprehensive and coordinated
services," according to Brindis and Lee. This means
making health education, social services, and job-
related services available in the same place, with com-
bined funding from public and private sources, and
conducting rigorous evaluation to document success or
failure and to move away from policies and programs
that are not effective. "This comprehensive approach
increases the efficiency of currently available commu-
nity resources; facilitates the formation of linkages
among a varieW of concerned groups, such as parents,
religious organizations, sentence clubs, clinics and social
service agencies; and spreads funding responsibilities
among several concerned parties." (#027J
Karil Klingbeil of the University calf Washington
recognizes that community-level education, counseling,
and sentences are very important for reducing violence
but calls for national-level activity, as well. Klingbeil
recommends six secondary prevention steps that would
be national in scope:
1. implementation of a national family violence
prevention week;
2."major media campaigns utilizing billboards,
newspapers, radios, buses and other public vehicles,
that can be used by public and private agenciesn;
3. development and implementation of legislation
on all forms of abuse;
4. mandated "training and education on all aspects
of family violence in all professional schools and
cross-training in substance abuse and alcohols;
S.ninnovative approaches to interviewing and
interrogating child as well as adult victimsn;
6.nestablishment of cross-agency committees or
boards whose sole purpose it is to alleviate system
barriers for victims as well as the offender groups."
(#697)
The array of lifestyle choices offered to individuals
in today's society and the conflicting information
available in the media about what constitutes healthy
behavior lead some testifiers to target communication
channels in their intervention programs.
The National Council on Alcoholism, for instance,
discusses the need to look at alcohol problems as
social, as well as individual, problems. Thus, there
should be process objectives for each objective on
"public and community education based on the
principles of sound educational theory and mass
media communication." According to the council,
"The alcohol and beverage industry spends two billion
dollars a year on alcohol marketing that encourages
and glamorizes drinking and associates alcohol use
94 Healthy People 2000: Citizens Chart the Course
with maturity, success, sexuality, and high-risk
activities." To counter this, it recommends that
broadcasters "grant equivalent air time for health and
safety messages about alcohol.n (#467)
Ruth Roemer of the UCLA School of Public
Health states that the most effective legislative mea-
sures to reduce smoking are "~1) banning all advertis-
ing and promotion of tobacco products, and (2) raisi-
ng the taxes on and prices of tobacco products very
substantially."
Government has an obligation to protect the
health of the people, and a ban on advertising
would promote the social norm of a nonsmok-
ing society. It would counter the negative con-
sequences of advertising, which are especially
pernicious in influencing young people to
smoke. (#184)
The American Medical Association calls for res-
ponsibility in the media. The AMA believes that the
media can be of Inestimable value" in attaining objec-
tives, but that to do a responsible job, the medical
community and the federal agencies must provide
them with factual data. The AMA notes that the me-
dia have made a Cooperative effort at banning or
otherwise censoring counterproductive advertising and
promotional practices that are harmful to the public's
health n (ALAS)
CROSSCU~ING IMPLEMENTATION ISSUES
Michael Eriksen, representing the Society for Public
Health Education, writes:
As part of the effort to assure qualifier of health
promotion interventions, it is important to
remember that not all interventions should
concentrate solely on the individual. In fact,
often the most effective health promotion
interventions are those directed at the changes
in the behaviors of providers, environments, and
systems. Organizational change is inherent in the
definition of health promotion and should be
considered an integral component. (#309)
A number of implementation issues are common to
interventions proposed for schools, workplaces, and
communities. Suggestions were made about the
content of health promotion and education programs,
their financing, and the coordination of available
services.
OCR for page 95
Content of Health Promotion and Education
Programs
Recognizing the importance of health promotion
activities in nonmedical settings, many witnesses had
suggestions about defining the scope and content of
such programs. Sunny Chiu of the Michigan Depart-
ment of Public Health, for instance, calls for (1)
clearly defined policies, priorities, and strategies for
health promotion; (2) scientific data and the oppor-
tunities to apply them through program planning and
implementation; (3) the tools and resources for
practitioners and the community; and (4) the informa-
tion, educational processes, and a combination of
motivational and supporting forces for behavioral
change-both individual and collective-aimed at
reducing preventable morbidity and mortality. (#395J
Tl~e National Education Association suggests that
health education focus on "life-enhancing" behaviors.
According to Williams, "Our nation's schools must
put into place health education programs that engage
students, ensure that they understand the scientific
and medical facts, and motivate them to choose
appropriate behavior." Education mil.ct motivate
young people to adopt healthful, life-saving behavior.
(~059)
According to the American School Health Associa-
tion:
The health education curriculum needs to be
comprehensive and not content-specific or
narrowly targeted. It should work to motivate
health maintenance and promote wellness and
not merely to prevent physical illness. In order
to do this, it must possess the following charac-
tenstics: its activities should develop effective
decision-making skills; it must be well-planned,
sequential, and based upon the student's health
needs and interests as they relate to national
and local community health priorities; it must
focus on health attitudes and feelings, as well as
behaviors and practices; it must integrate all
dimensions of human health and not focus only
on the physical; it needs specific goals and
objectives in addition to effective formative and
summative evaluation procedures; it requires
effective management and sufficient resources.
(~055)
Igoe writes that "despite increasing pressure to
participate in the management of their own health,
consumers of all ages are often unable or unwilling to
do so." Research shows, she says, that those people
who strive for mastery over their own health needs
and who are prepared to deal assertively with health
professionals usually obtain the best health care. To
overcome consumer passivity and conversational
barriers between the health professional and the
consumer, Igoe stresses self-responsibility and autono-
my. Consumers must learn to approach health care
as a "problem-solving endeavor that requires an active
coping effort, rather than as a situation calling for
passivity and submission." She suggests objectives to
integrate "consumer activism education into all school
curricula, including medical schools; to make it a
responsibility of state health implementation programs
to provide public service materials for consumer
activism; and to do more research and survey work on
outcomes of consumer activism. (~105J
Charles Lange of Loyola University says that one
of the greatest obstacles to improving health is the
lack of understanding by the general public of science,
its methods, and its accomplishments. Unless the
general public becomes more conversant with science,
Lange feels, the achievement of the health objectives
will be impossible. (~707J
Financing Health Promotion and Health Education
Health promotion and health education programs
often fall outside of the common fee-for-service
medical system and, therefore, are especially difficult
to finance. Witnesses addressed this issue in the
context of schools, worksites, insurance companies,
and the media.
William Kirby, the Texas Commissioner of Educa-
tion, says that "health services and health education
are critical components of the public school program."
However,
no education funds are specifically earmarked in
the state budget for health services. Competi-
tion is steep for the funds that are provided in
the form of general state aid to school districts,
which must use those limited funds to meet the
costly mandates of salaries, instructional pro-
vis~ons, and special programs as well as require-
meets for health services. With the exception of
drug abuse education, no additional funding has
been allotted to local school districts to help
them meet these responsibilities. Those in the
legislative and health arenas must understand
that education cannot continue to be expected
to provide services and health-related instruction
Health Promotion and Disease Prevention in Community Settings 9S
OCR for page 96
without some financial support. (#305J
Gorchow feels that financial support for health
promotion must be sought from the private as well as
the public sector. lithe insurance model in the United
States has always been based on providing illness
With
worksite-based Intervention and education about
prevention and management of chronic problems, it is
possible to reduce the burden of illness on the
individual as well as on the reimbursement systems.
(#386)
Individuals should be encouraged to take respon-
sibility for adopting and maintaining healthy lifestyles,
says Jeannette Merijanian of the University of
Montevallo. To do this, they need motivation to
change their lifestyles, information on what and how
to change, and support. Thus, "national resources
and knowledge" should be linked together "with local
organizations to promote, educate, and support
citizens who want to improve their own health status."
This will require insurance reimbursements for life-
style changes and funding for health education pro-
grams, she says. Insurance reimbursements could be
made either on self-reporting data or on quantifiable
health changes, such as lower blood cholesterol and
cessation or absence of smoking. (#644)
coverage rather than wellness coverage.
REFERENCES
Kenneth Warner of the University of Michigan
addresses the question of financing advertising efforts.
Television has aired one shocking documentary
after another on drugs, while magazines have
repeatedly featured the grim and stark imagery
of crack and smack on their covers. Their front
covers, that is; the back covers feature attractive,
glossy ads for cigarettes and alcoholic beverages.
The effect of this media hype is that teenagers
believe that illegal drugs are the principal source
of premature death in our society, while in fact"
cigarettes kill as many Americans in a single day
as cocaine does in a year. We need a profes-
sionally designed paid broadcast media advertis-
ing campaign against tobacco use and alcohol
misuse.
According to Warner, the hundreds of millions of
dollars required for such an effort could not be raised
voluntarily. One solution is to increase the excise
taxes on cigarettes and alcohol to pay for the cam-
paign. As little as one cent per pack of cigarettes
would raise $300 million, he says, and the tax itself
would reduce the demand for tobacco, especially
among younger people.5 (#429)
1. Parcel GS, Simons-Morton BG, O'Hara NM, et al.: School promotion of healthful diet and exercise behavior:
An integration of organizational change and social learning theory interventions. J Sch Health 57~4~:150-156,
1987
2. Lovick SR, Wesson WF: School Based Clinics: Update. Washington, D.C.: Center for Population Options,
1986
3. Lovick SR: School-based clinics: Meeting teens' health care needs. J Sch Health 58~9~:379-381, 1988
4. U.S. Department of Health and Human Services: National Survey of Worksite Health Promotion Activities:
A Summary. Office of Disease Prevention and Health Promotion, 1987
5. Warner KE: Selling health: A media campaign against tobacco. J Pub Health Policy 7~4~:434-439, 1986
TESTIFIERS CITED IN CHAPTER 9
027 Brindis, Claire and Lee, Phillip; University of California, San Francisco
055 Eberst, Richard; Adelphi University (Long Island)
059 Williams, James; National Education Association, Health Information Network
071 Givens, Austin; American Occupational Medical Association
96 Healthy People 2000: Citizens Chart the Course
OCR for page 97
075 Groves, David; Comerica Incorporated (Detroit)
077 Guthrie, Marilyn; Virginia Mason Clinic (Seattle)
095 Hendee, William; American Medical Association
105 Igoe, Judith; University of Colorado Health Sciences Center
121 Kuntzleman, Charles; Fitness Finders (Spring Arbor, Michigan)
153 Morton, Max; Adolph Coors Company
159 Murtaugh, Alice; New York
161 Neill, Carol; Alum Rock Union Elementary School District (California)
167 Orlandi, Mario; American Health Foundation
176 Quick, James; University of Texas at Arlington
177 Randolph, Linda; New York State Department of Health
184 Roemer, Ruth; University of California, Los Angeles
196 Seffrin, John, Allensworth, Diane, Eberst, Richard, et al.; American School Health Association
198 Sheps, Cecil; American Public Health Association
217 VanDermeer, Leslie; Hunter College (New York)
229 Wright, Al; County of Los Angeles Department of Health Services
230 Zal, Harriette; Southern California Association of Occupational Health Nurses
232 Allensworth, Diane; American School Health Association
236 Bastien, Deborah; Galveston, Texas
243 Barreras, Rita; Colorado Department of Social Services
273 DiClemente, Ralph; University of California, San Francisco
295 Parcel, Guy; University of Texas Health Science Center at Houston
302 Trostmann, Cathy; Houston, Texas
305 Kirby, William; Texas Commission on Education
307 Washam, W. Thomas; Aluminum Company of America
309 Eriksen, Michael; Universitr of Texas Health Science Center at Houston
343 Rose, Jackie; Clackamas County Department of Human Services (Oregon)
349 Rosner, Robert; Smoking Policy Institute (Seattle)
355 Jacobson, Miriam; Washington Business Group on Health
363 Sharkey, Brian; University of Northern Colorado
385 Joseph, Pat; United States Air Force, Lowly Air Force Base, Denver
386 Gorchow, Margo; Botsford General Hospital (Farmington Hills, Michigan)
394 Rothert, Marilyn; Michigan State University
39S Chiu, Sunny; Michigan Department of Public Health
405 Myers, Jr., Woodrow; Indiana State Board of Health
406 Hacker, Sylvia; University of Michigan
426 Kaminsly, Kenneth; Wayne County Intermediate School District (Michigan)
429 Warner, Kenneth; University of Michigan
440 Arnold, Charles; Metropolitan Life Insurance Company
448 Warshaw, Leon; New York Business Group on Health
459 Ostleld, Adrian; Yale University
460 Addiss, Susan; Quinnipiack Valley Health District (Connecticut)
465 Entmacher, Paul; Metropolitan Life Insurance Company
467 Aguirre-Molina, Marilyn and Lubinski, Christine; National Council on Alcoholism
470 Bright, Frank; Ohio Department of Health
477 Speert, Ellen; American Art Therapy Association
500 Medrano, Martha; University of Texas Health Science Center at San Antonio
511 Bahr, Raymond; St. Agnes Hospital (Baltimore)
573 Wilhoit, Gene; National Association of State Boards of Education
578 McGuire, Judi and Crowder, Aletha; The National PTA
586 Fosco, Angelo; Laborers' International Union of North America
590 Philipps, Carol; Wisconsin Department of Public Instruction
Health Promotion and Disease Prevention in Community Settings 97
OCR for page 98
593 Bradley, Chet; Wisconsin Department of Public Instruction
595 Leventhal, Marcia; New York University and BrooksSchmitz, Nancy; Columbia University
596 Perry, Jean; American Alliance for Health, Physical Education, Recreation and Dance
615 Hargreaves, Margaret, et al.; Meharry Medical College
644 Merijanian, Jeanette; University of Montevallo (Montevallo, Alabama)
675 Teague, Wayne; Alabama Department of Education
689 Aldrich, Robert; University of Washington
691 Gilchrist, Lew; University of Washington
697 Klingbeil, Karil; University of Washington
707 Lange, Charles; Loyola University (Chicago)
711 Tonsberg, Robert; Indian Health Service/VVind River Indian Reservation (Fort Washakie, Wyoming)
729 Dohrenwend, Bruce; Columbia University
731 Gaffney, Donna; Columbia University
734 West, Jack; Puro Corporation of America (Maspeth, New York)
736 Wood, Loring; NYNEX Corporation
761 Henderson, James; Pacific Bell
98 Healthy People 2000: Citizens Chart the Course
Representative terms from entire chapter:
health education
