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5
Health Promotion and Disease Prevention
INTRODUCTION
Health promotion and disease prevention are a major emerging
theme in geriatric medicine and health care generally. Although
efforts have typically been targeted at younger persons, there is
growing evidence that this approach is both appropriate and feasible
for those age 65 and over (Office of Technology Assessment, 1985b).
The health promotion and disease prevention approach is one of
a number of possible strategies to deal with what has increasingly
become a hallmark of current times: the prevalence of chronic illness
and multiple chronic illnesses or functional impairments among the
elderly. While it will not replace medical care either for the treatment
of acute diseases or for acute flare-ups of chronic illness, this approach
has promise for reducing the incidence and prevalence of chronic and
acute disease among both the general population and the elderly. (See
Office of Technology Assessment, Chapters 4 and 5, 1985b; and Kane
et al., 1985, for a review of the state of the art in health promotion
and disease promotion in the elderly.) In addition, of course, both
long-term medical treatment and care for many diseases and illnesses,
as well as research to improve diagnosis, treatment, and prevention
of chronic and acute disease, are a continuing need.
Selected policy questions relating to health promotion and dis-
ease prevention include:
Should more resources be allocated to increasing our scientific
and clinical knowledge base on the efficacy of many health
108
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HEALTH PROMOTION AND DISEASE PREVENTION
109
promotion and prevention activities for the elderly popula-
tion?
To what extent should public and private programs be devel-
oped to motivate older persons who are still asymptomatic to
health-maintaining behavior?
What success rate in modifying health behavior can we antic-
ipate for older patients with various forms of chronic illness
or disability?
What institutions and what professions should be responsible
for health promotion? Should health professionals be trained,
and should their training be publicly supported?
How can we move toward a more balanced relationship be-
tween the minuscule national investment in health education
and other aspects of preventive medicine and the overwhelm-
ing resources devoted to medical care directed to reducing
the duration and severity of disease and disability?
Should public and private health insurance programs pay for
health promotion and disease prevention interventions?
DEFINITIONS, FEDERAL INITIATIVES, AND GOATS
What is health promotion and disease prevention? Simply stated,
health promotion involves "the development of behaviors that im-
prove bodily functioning and enhance an individual's ability to adapt
to a changing environment" (Ward, 1984:6~. Disease prevention in-
volves actions to reduce or eliminate exposure to risks that might
increase the chances that an individual or group will incur disease,
disability, or premature death. Some risk factors for disease and dis-
ability are mutable or amenable to change (such as personal habits),
while others (such as genetic endowment and family history) are
not (Kane et al., 1985~. A major goal of the health promotion and
disease prevention approach both for individuals and for an entire
population is "to identify the health problems for which preventive
efforts can result in more appropriate utilization of health services
and improvements in health status" (Lee, 1985:784~.
This approach to health emphasizes the importance of lifestyle
and personal behavior in improving personal health status and in
maintaining health and functioning, both physical and mental. It
also recognizes that the extent to which health care interventions
and behavior change or channeling can be effective in promoting
health and preventing disease depends in part on current health
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AGING POPULATION IN THE TWENTY-FIRST CENTURY
status and the stage in the life cycle in which particular interventions
are introduced. Both concepts underscore the need for individuals
and family units to accept personal responsibility for their own health
and to take the initiative in managing their health care.
Three types of prevention activities can affect health and well-
being of the elderly. Primary prevention refers to efforts to eliminate
health or functional problems at their source-that is, preventing
their occurrence or to procedures (such as immunizations, improv-
ing nutritional status, and increasing physical fitness and emotional
well-being) that reduce the incidence of disease or render a popula-
tion at risk not vulnerable to that risk. Secondary prevention involves
efforts to detect adverse health conditions early in their course and
to intervene promptly and effectively, or to curtail the spread of
disease to others. Tertiary prevention aims to reduce the duration
and severity of potentially disabling sequelae of disease and disabil-
ity, to reduce complications of disease once established, to minimize
suffering, and to assist the individual in adjusting to irremediable
conditions (see Lowy, 1983; Office of Technology Assessment, 1985b;
World Health Organization, 1986; and Chapter 6 of this report).
Federal Initiatives
Interest in health promotion and disease prevention activities
nationwide, and in particular for older Americans, has been stimu-
lated by federal initiatives. The first major step was publication of
the report by the U.S. Department of Health, Education, and Wel-
fare entitled Healthy People: The Surgeon General's Report on Health
Promotion and Disease Prevention in 1979. Noting that individual
behavior and lifestyle, as well as the environment, are major deter-
minants of health and illness that are amenable to change, the report
contends that health promotion and disease prevention are critical
to further improvements in health status. The report laid out a set
of 5 broad national goals and 15 priority areas for improving the
health of the American people during the 1980s. Each goal targeted
an age group of the population, from infants to older adults. Health
promotion activities initiated before people become elderly would
tend to improve their health status in old age. For older adults, the
stated goal was "To improve the health and quality of life for older
adults and, by 1990, to reduce the average annual number of days of
restricted activity due to acute or chronic conditions by 20 percent,
to fewer than 30 days per year for people aged 65 and older" (U.S.
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HEALTH PROMOTION AND DISEASE PREVENTION
111
Department of Health, Education, and Welfare, 1979~. Among the
15 priority areas were high blood pressure control, immunization,
surveillance and control of infectious diseases, smoking control, im-
proved nutrition, and physical fitness and exercise. All of these have
relevance for the elderly. The perspective for health promotion and
disease prevention obviously extends far beyond these goals for 1990.
Subsequent to the publication of the surgeon general's report,
the Public Health Service published Promoting Bealth/Preventing
Disease: Objectives for the Nation (U.~. Department of Health and
Human Services, 1980a), which included separate reports on each
of the 15 priority areas. A total of 226 measurable national objec-
tives were presented under 5 major headings: improved health sta-
tus, reduced risk factors, increased public or professional awareness,
improved services or protection, and improved surveillance and eval-
uation systems. Implementation plans for achieving these objectives
were presented in the supplement to the September-October 1983
issue of Public Health Reports, entitled Promoting Heatth/Preventing
Disease: Public Health Service Implementation Plans for Attaining
the Objectives for the Nation. (U.S. Department of Health and Hu-
man Services, 1984~.
A more recent federal initiative in the area of health promo-
tion and disease prevention is the establishment in 1984 of the U.S.
Preventive Services Task Force within the Public Health Service
to develop recommendations for the appropriate use of preventive
services in clinical settings (see U.S. Department of Health and Hu-
man Services, 1984~. Another initiative was mandated by the U.S.
Congress under P.~. 98-551. This law authorized the Department of
Health and Human Services, through its Centers for Disease Control,
to establish, maintain, and operate centers for research and demon-
stration with respect to health promotion and disease prevention
(U.S. Congress, 1984~. In accordance with this congressional man-
date, the Centers for Disease Control in spring 1986 approved the
creation of such centers at the Schools of Public Health of the Univer-
sity of North Carolina, the University of Texas, and the University
of Washington. In contrast to the other two schools, the Univer-
sity of Washington's center is to focus on the elderly. Although the
preceding discussion emphasizes federal initiatives, there are obvious
implications for the private sector, for example, in the organization
and delivery of services and the financing of medical care.
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112
AGING POPULATION IN TlIl3 TWENTY-FIRST CENTURY
Goals
Most statements of health promotion and disease prevention
goals for the elderly acknowledge that expected outcomes for older
persons especially those who already have chronic illnesses or dis-
abilities may be different from those for younger persons who do
not yet have such illnesses or disabilities. Cure, or full restoration
of health or function, may not be a realistic general goal for the
elderly. More realistic goals might involve tertiary prevention efforts
such as maintenance or stabilization of existing health and function,
amelioration of the effects of disease and disability, and postpone-
ment or delay of further disability and functional lirn~tation. Even
small gains in the ability to maintain current health and to reduce
functional disability may make a major difference in the quality of
life experienced by an older person. For the elderly population as
a whole, shifting or delaying the average age of onset of particular
diseases and disabilities, such as hip fracture, may make survival
to old age more pleasant, as active life expectancy is increased and
morbidity is shifted to the end of the life span. Preservation of per-
sonal independence and avoidance of institutionalization may also
be viewed as legitimate goals of a health promotion and disease pre-
vention strategy for the elderly, as they are so intimately related to
quality of life.
Broadly stated, the goal of health promotion and disease pre-
vention for the elderly may be viewed as the avoidance or delay of
"the potentially reversible . . . physical, mental, or social factors that
lead to unnecessary functional dependence and institutionalization"
(Filner and Williams, 1981~.
HEALTH PROMOTION AND DISEASE PREVENTION FOR
THE ELDERLY
A note of caution is required before the development of health
promotion and disease prevention strategies for the elderly popula-
tion is enthusiastically endorsed. Attempts to improve the quality of
old age require an understanding of the risk factors for common dis-
ease among the elderly and the efficacy of strategies to decrease the
risk of morbidity. Simplistic generalizations from studies of young
and middle age adults to the elderly in this realm are frequently
invalid. Middle aged adults and the elderly differ in their patterns of
disease and disease presentation.
Furthermore, the elderly represent a select group of survivors,
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HEALTH PROMOTION AND DISEASE PREVENTION
113
with physiologic alterations that may influence pathophysiologic
processes. For instance, the widely cited Alameda County study
(Wingard et al., 1982) reported reduced mortality in young and
middle-aged adults who never smoked, drank little alcohol, were
physically active, and slept seven or eight hours nightly. In con-
trast, however, ~ a similar analysis of elderly Massachusetts residents
(Branch and Jette, 1984) it was found that five-year mortality rates
were not influenced by alcohol intake, physical activity, or sleeping
habits, indicating the age modification of risk factors. Similarly, a
recent study suggests that more overweight elderly subjects have a
lower rather than a higher mortality rate from coronary disease (Ja-
jich et al., 1984~. This controversial finding is difficult to explain in
view of the known adverse ejects of obesity on diabetes, hyperten-
sion, and hyperlipidemia and indicates a need for detailed evaluation
of the potential protective effect of moderate overweight in old age
(the two preceding paragraphs closely parallel Rowe, 1985:8283.
There are several reasons for adopting a health promotion and
disease prevention approach for the elderly, despite legitimate cau-
tions. Among them are the plasticity of the aging process; the
possibility of modifying physiologic or pathologic conditions that,
although associated with so-called normal aging, also entail risks to
health; and the high incidence of chronic disease among the elderly,
which increases the importance of pi stponing additional disability.
Furthermore, life expectancy is increasing and it is desirable to en-
hance health status during these additional years of life.
The Plasticity of the Aging Process
The health ejects of deleterious habits and lifestyles are typically
cumulative, and for this reason often viewed as nonremediable-
making primary prevention among younger members of the popula-
tion appear as a preferable strategy for improving the nation's health.
There is, however, increasing evidence to suggest that some harmful
habits and behaviors are capable of modification and even reversal,
sometimes when interventions and changes occur late in life. Recent
studies on osteoporosis, for example, indicate that moderate exer-
cise can retard age-related bone loss and even in some cases increase
bone density in elderly women, including women in their nineties and
those living in institutions (Aloia et al., 1978; Smith and Reddan,
1976; Smith et al., 1981~.
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114
AGING POPULATION IN THE TWBNTY-FIRST CENTURY
Risks Associated With Normal Aging
There is evidence to suggest that physiologic or pathologic chang-
es so common with advancing age as to be considered normal by
clinicians may not be without risk. Although systolic blood pressure
increases with age among the American elderly population, it is also
clear that increases in systolic blood pressure are associated with
marked increases in the risk of stroke and coronary heart disease
(Rowe, 1983~. Just because a finding is considered normal among
the elderly does not mean that it is also harmless. Perhaps the term
usual aging should be substituted for normative aging, to recognize
the possibility of adverse effects associated with typical age-related
change and the importance of considering techniques to modify these
usual, but not necessarily harmless, characteristics.
The High Incidence of Chronic Disease and BInese
Among the Elderly
While persons of any age may have chronic disease or disabil-
ity (e.g., both children and adults become deaf or blind, acquire
permanent orthopedic disabilities and develop degenerative diseases
requiring continuing treatment and care), the elderly are particularly
vulnerable to chronic disease and disability. An estimated 86 per-
cent of persons over age 65 have one or more chronic diseases (Office
of Technology Assessment, 1985b). Among the noninstitutionalized
elderly, who have a much lower prevalence of severe limitations and
dependency than the institutionalized elderly, some 46 percent had
arthritis, 37 percent had hypertension, 28 percent had a hearing Toss,
and 28 percent had a heart condition in 1981 (Office of Technology
Assessment, 1985b; Rice, 19863. Therefore, efforts to maintain ex-
isting health and well-being, to ameliorate the effects of illness and
disability, and to delay or postpone further disability are particularly
important for the elderly population.
Increases In Average Life Expectancy and Individual Variability
The life expectancy of the elderly is increasing. Those currently
age 65 can expect on average to live another 16 years (more than
14 for men and 18 for women) (Office of Technology Assessment,
1985b:10~. With increasing longevity, current elderly cohorts, as
well as younger age groups, can be expected to live through longer
periods of exposure to risk factors, including those posed by the
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HEALTH PROMOTION AND DISEASE PREVENTION
115
environment, diet and nutrition, and personal behavior and lifestyle,
and will have more time to develop symptoms than past generations.
Furthermore, as with other age groups, there is great variability in
the health and functional status of older persons. While some are
severely debilitated or ill and can benefit minimally if at all from
preventive interventions, others are thriving and show no evidence of
disease or disability.
CRITICAL ISSUES
Five issues are of current concern in the health promotion and
disease prevention approach to health care: (1) the inconclusiveness
of the scientific and clinical evidence of the efficacy of many promo-
tion and prevention activities, (2) the need for additional knowledge
concerning factors that facilitate behavior modification among per-
sons of all ages, (3) the shortage of health care personnel trained
in this approach, (4) the potential impact that accelerating growth
in the number and utilization of health maintenance organizations
and other systems with prepaid capitation fees will have on this ap-
proach to health care, and (5) the effect that prospective payment
systems, as exemplified by diagnosis-related groups for the elderly
under Medicare, will have on the services received.
The scientific basis for many of the health promotion and disease
prevention activities currently in vogue is inadequate. With respect
to the elderly in particular, there is only modest evidence that par-
ticular behaviors and interventions can prevent disease or retard the
impact of illness and disability, once established. For example, the
role of exercise in reducing the risk of coronary heart disease and
stroke for women and the elderly is not yet known (Office of Technol-
ogy Assessment, 1985b). Similarly, it is not yet understood whether
current obesity or a history of chronic obesity is a risk factor for coro-
nary heart disease (Office of Technology Assessment, 1985b). And
the relative risks and benefits of different levels of exercise for older
persons particularly those with chronic disease have not yet been
established (Office of Technology Assessment, 1985b). Nonetheless,
a variety of activities and behavior changes have been widely adver-
tised as health promoting and disease preventing- as ways to avoid
everything from cancer to heart disease. Private-sector initiatives
in the area of physical fitness, nutrition, and diet counseling have
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AGING POPULATION IN THE TWENTY-FIRST CENTURY
been largely responsible here, although the scientific and clinical ev-
idence on which much of the popularized advice to the public and to
individuals is based is often inconclusive or conflicting.
A related issue is the need for increased knowledge of the factors
that facilitate attitude and behavior change among the population
as a whole and among segments of it, including the elderly (Franks et
al., 1983; Sanazaro, 1985~. An effective national strategy of preven-
tion and promotion, such as that established by the Public Health
Service initially with the publication of Healthy People: The Surgeon
General's Report on Health Promotion and Disease Prevention (U.S.
Department of Health, Education, and Welfare, 1979), depends not
only on knowledge of scientific and clinical efficacy of particular in-
terventions but also on the ability and willingness of individuals to
modify their behavior.
A third issue is the shortage of physicians and other health
personnel who are trained to provide health promotion and disease
prevention services to their patients (Lee, 1985~. One reason for this
shortage is the passive structure of the U.S. health care delivery sys-
tem, which generally relies on individuals to present themselves to
physicians and other providers when and if they have a problem. Un-
ti! very recently, health care coverage for most people, and Medicare
reimbursement policies for the elderly, have reinforced a system of
health care that creates no demand for health promotion and disease
prevention practitioners. Medicare has not generally covered individ-
uals or compensated providers of care for prevention and promotion
activities.
Two developments that may affect the rate at which the health
promotion and disease prevention approach gains widespread accep-
tance are the recent dramatic growth in the number and utilization of
prepaid health plans by the general public and by the elderly and the
provision of coverage and rennbursement for Medicare enrollees and
providers of care involved in health plans that are paid prospectively
according to a fixed rate capitation formula. HMOs, one type of cap-
itated plan, provide a comprehensive range of medical or health care
services within a single organization in exchange for a fixed monthly
or annual fee. As their name suggests, HMOs might be expected
to encourage their enrollees to maintain health and prevent disease
through the particular variety of services they offer and the gatekeep-
ing functions they perform to reduce utilization of more expensive
forms of care (such as hospitalization). Information on the extent to
which these functions are carried out would be important. From June
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HEALTH PROMOTION AND DISEASE PREVENTION
117
1983 to June 1985, enrollment in HMOs increased by 20 percent per
year, with an estimated 8 percent of the U.S. population or some
19 million persons enrolled as of June 1985 (TarIov, 1986:29-303. In
1985 the Health Care Financing Administration issued regulations
that encourage HMOs to enroll Medicare beneficiaries on a capitation
basis (Ginsburg and Hackbarth, 1986~.
DATA NEEDS
This portion of the chapter discusses existing federal surveys
that provide data relevant to health promotion and disease preven-
tion for the general population and for the elderly. These surveys
are reviewed from two perspectives: the extent to which they pro-
vide information about the health promotion and disease prevention
knowledge and activities of the general population (including the
elderly), and the extent to which they provide information about the
health promotion and disease prevention activities of providers of
care (such as physicians and nurses). Population-based surveys yield
information by surveying samples of individuals selected from the
general population or certain segments of it, such as minorities, the
elderly, or women of childbearing age. Provider-based surveys sur-
vey individual or institutional providers of care, such as physicians
or nursing homes.
Public Enawledge About Health Promotion and Disease Prevention
The success of a health promotion or health maintenance and dis-
ease prevention program depends on many things. One is an informed
and knowledgeable public, which in turn depends on widespread dis-
semination of the known benefits and harmful effects to health and
well-being of particular behaviors. Also necessary is a willingness on
the part of individuals to change attitudes, habits, and behaviors-
often long-standing ones- and the initiative to undertake responsi-
bility for one's own health and the health of one's family.
More information is needed about the techniques and strategies
that are likely to be effective in inducing and maintaining attitude
and behavior change, not only among the elderly, but also among
the general population. In fact, there is a considerable amount of
research in the area of behavior modification techniques under way
at present and planned for the future some of it experimental,
involving controlled clinical trials, and some of it less rigorous in
nature (see, for example, Russell, 1987~.
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A GING P OP ULA TI ON IN THE T WENTY-FIRS T CENTURY
There is also concrete evidence demonstrating that successful
campaigns to educate the public, increase its awareness of the harm-
ful effects of particular practices, and motivate individuals to take
action can be mounted. A prominent example is the successful Na-
tional High Blood Pressure Education Program launched by the
National Heart Institute in 1972 to spread the word to physicians,
their patients, and to ordinary citizens (U.S. Department of Health
and Human Services, 1985~.
In 1985, the National Health Interview Survey (National Center
for Health Statistics, 1985a) described in Chapter 3 included a health
promotion and disease prevention supplement as an effort to obtain
information on the knowledge and behaviors of the general public.
The supplement includecl questions pertinent to various age groups
including the elderly. For example, adult respondents were asked
about their knowledge of factors that increase one's chances of de-
veloping heart disease and stroke, about foods associated with high
blood pressure, about diseases caused by smoking and alcohol, and
about activities that prevent tooth decay and gum disease, among
others (National Center for Health Statistics, 1985a). The supple-
ment thus provides data relevant to the Public Health Service's goals
and objectives for promoting health and preventing disease (U.S.
Department of Health and Human Services, 1980a) and the imple-
mentation plans for attaining the objectives for the nation (U.S.
Department of Health and Human Services, 1983~.
Despite the obvious importance of health maintenance and dis-
ease prevention, data are not routinely available through national
data systems on the extent to which the population is informed as
to the causes of preventable illnesses and conditions and the actions
they might take to reduce their own risks of developing such illnesses
and accompanying impairments.
As noted earlier, the health needs and concerns of the elderly
are somewhat different from those of younger persons, because of
their stage in the life cycle, their social circumstances, and the fact
that the risk of particular diseases and disabilities changes with age
and with the existing health and functional status of the individual.
Separate health promotion and disease prevention modules (clusters
of items on specific topics) should be developed that are appropriate
to the elderly and subgroups of this population, since risk factors
and expected health and functional outcomes for particular diseases
and disabilities among the elderly vary. Modules should be designed
to reflect special conditions among racial and ethnic minorities, the
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HEALTH PROMOTION AND DISEASE PREVENTION
119
poor, residents of rural areas, women, the oIclest-old, the impaired
and institutionalized, and those elderly who are at high risk for or
who have particular diseases or disabilities. The panel also believes
that such modules and items that have a more narrow focus on a
particular disease or disability for which the elderly are at greater
risk than the rest of the population should also be developed, to be
administered in or along with selected population surveys. It would
be useful to develop modules and information items for subjects such
as breast self-examination and screening, pap tests, and osteoporosis
prevention and retardation for women; issues of falling (including
items on hip fracture ant] broken bones); primary prevention ac-
tivities such as influenza and tetanus shots for the institutionalized
and other immunizations and their purposes; incontinence; adverse
effects of drugs; social isolation, depression, and other potentially
preventable and/or remediable social and emotional conditions; the
role of diet, nutrition, and exercise in the prevention or retardation
of particular illnesses; and the use of preventive safety measures in
the home.
Both the National Health Interview Survey and the National
Health and Nutrition Examination Surveys would be good vehicles
for health promotion and disease prevention items and modules for
the general population and for the elderly. Both surveys are de-
scribed in Chapter 3 of this report. The NHANES, scheduled to be
fielded again in 1988 (NHANES ITI) is a unique opportunity because
of its inclusion of physiologic measures in addition to self-reported
(interview) information on health and nutrition status and practices.
A major policy issue is whether the federal government should
fund health promotion and disease prevention activities and, if so,
which ones. To clarify this issue, information is needed on the extent
to which population subgroups of the elderly are informed about
health promotion and disease prevention practices and the degree to
which persons of all ages behave in ways known to promote health
and prevent illness. Such information is also needed to assess changes
in the extent of such activities resulting from public and private
initiatives.
Recommendation 5.1: The panel recommends (a) that mod
ules of health promotion and disease prevention items (in
cluding those concerned with attitudes, knowledge, and be
havior) be developed that are appropriate for the elderly
and subgroups of the elderly population that are at risk
for particular diseases, illnesses, disabilities, or conditions,
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AGING POPULATION IN THE TWENTY-FIRST CENTURY
which can be used with a variety of population-based sur
veys; (b) that these health promotion and disease prevention
survey modules be tested on relevant segments of the elderly
population; and (c) that successful modules be incorporated
in population-based surveys such as the National Health
Interview Survey and the National Health and Nutrition
Examination Survey, or as supplements to them.
Development of these modules will require cooperation and coordi-
nation of effort by several agencies, including the Office of Health
Promotion and Disease Prevention, the National Center for Health
Services Research and Health Care Technology, the National Center
for Health Statistics, and institutes within the National Institutes of
Health.
The Role of Physicians
Once the scientific basis for particular health promotion and
disease prevention interventions and behaviors has been established,
and the medical and health care technology to implement them has
been developed, physicians and other health care personnel can play
important roles in promoting health and preventing disease, with
patients of all ages, including the elderly.
The elderly, on average, make more visits to physicians annually
than middle-aged persons. In 1985, for example, persons ages 65-74
averaged 7.7 physician visits per year, and those age 75 and over
had an average of 9.3 visits per year, in contrast with 6.1 visits per
year for persons ages 45-64 (National Center for Health Statistics,
1986b). In 1979 elders (age 65 and older) with chronic activity
limitation averaged 8.7 physician visits per year, in contrast with
4.3 visits per year for those without activity limitation. Only 5
percent of the elderly had not seen a physician for five or more
years (Rice, 1986~. The sheer frequency with which the typical older
person visits a physician, particularly since the elderly tend to see
the same physician (Rice, 1986), enhances the possibility of physician
influence.
Although some patients, including elderly patients, do not adhere
to physician-prescribed regimens such as drug regimens, it has been
shown that in the area of promoting and maintaining attitude and
behavior change, physicians-particularly primary care physicians-
can be effective (German et al., 1982; U.S. Department of Health ~.nd
Human Services, 1986c; GiTson et al., 1984~. This is especially true
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HEALTH PROMOTION AND DISEASE PREVENTION
121
when other intervention techniques, such as providing the patient
with written material on the issue in question, are used in conjunc-
tion with physician-initiated discussion. This was demonstrated in
a recent study conducted at a large Seattle-area health maintenance
organization in which researchers examined the relative impact of
strategies involving physician-patient discussions and other interven-
tion methods on compliance with colorectal screening and smoking
cessation (Gilson et al., 1984~. For colorectal screening compliance,
the most elective intervention was a three-step strategy consisting of
a physician-patient talk about the importance of the screening test,
sending a postcard as a reminder, and calling those who failed to
return the test within 10 days. With respect to smoking cessation,
experimental interventions involving physician discussions with pa-
tients, together with the provision of sel£help material, achieved a
higher rate of compliance with trying to quit smoking than did other
interventions. None of the interventions, however, were notably suc-
cessfu] in achieving smoking cessation (Gilson et al., 1984~.
A major drawback to fully exploiting the potential influence of
physicians in health promotion and disease prevention among their
patients has been the paucity of data on the extent to which physi-
cians currently do engage in prevention activities. Such activities
might include screening examinations and inoculations, discussion
and counseling, and therapeutic measures and follow-up where effi
cacy measures have been scientifically and clinically established.
The mechanism being used to determine some aspects of physi-
cian behavior in this area is the National Ambulatory Medical Care
Survey (also discussed in Chapter 9~. This survey, conducted an-
nually from 1973 through 1981, and again in 1985, with three-year
periodicity planned for the future, collects data on office visits made
by ambulatory patients to nonfederal physicians who are principally
employed in office-based patient care practice. The nature of the
physician-patient encounter is recorded for a sample of patient vis-
its to a sample of such physicians in the coterminous United States.
The physician sample is drawn from files maintained by the American
Medical Association and the American Osteopathic Association. In
1985, the latest year for which data are available, some 3,500 physi-
cians (70.2 percent of those sampled) participated in the survey.
Of the 71,594 physician-patient visits sampled and recorded, 14,700
(20.5 percent) were by people age 65 and over (National Center for
Health Statistics, 1987b).
At present, the data collected on the physician-patient encounter
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AGING POPULATION IN THE TWENTY-FIRST CENTURY
include the date and duration of the visit, the reasonts) for the visit
(the patient's presenting complaints or symptoms), the physician's
diagnoses, whether the major problem Is new or previously addressed
by this physician, the diagnostic and therapeutic services ordered or
provided, and the action at the end of the visit. The patient record for
this survey provides a checklist for the physician that distinguishes
between medication and nonmedication therapy (including among
other things psychotherapy, diet counseling, and other counseling).
The 1985 patient record report of the visit also contains checkoff items
on specific tests, e.g., blood pressure, glucose tolerance, visual acuity,
and breast examination. These sections need to be reexamined to
increase their usefulness in identifying specific health promotion and
disease prevention activities. At present, such activities cannot be
distinguished from those carried out as a follow-up for previously
diagnosed disease or because of suspected disease.
The pane! recognizes the space constraints of the form currently
being used for the National Ambulatory Medical Care Survey, but
we believe that changes can be accommodated in the items currently
included and a distinction made between prevention and treatment.
The recommendation below recognizes that:
.
physicians and other health care providers play a critical
role in influencing the behavior of their patients,
the health needs of the elderly often diner from those of the
remainder of the population, and
some diseases and illnesses of old age can be modified through
prevention and health promotion.
Recommendation 5.2: The pane] recommends that the Na-
tional Center for Health Statistics: (a) develop questions
pertaining to the health promotion and disease prevention
practices of health care providers that include categories
with special relevance for the elderly to be used in provider-
based surveys and that (b) these questions be included in
the National Ambulatory Medical Care Survey to obtain
information on physician-patient encounters.
These questions should ascertain: (1) the activities that physi-
cians undertake to change patients' behavior and increase their
awareness and understanding of health promotion and disease pre-
vention, (2) the specific preventive measures (such as dietary advice
and screening for hypertension) taken during the patient visit, and
(3) information obtained on changes in patient's behavior.
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HEALTH PROMOTION AND DISEASE PREVENTION
123
A recommendation in Chapter 9 to expand the sampling frame of
the National Ambulatory Medical Care Survey to include additional
physician types and practice settings is pertinent here as well.
Providers of Health Maintenance and Disease Prevention
Services to the Elderly
Many different kinds of physicians, for example, family prac-
titioners, pediatricians, internists, psychiatrists, and cardiologists,
engage in some kinds of health promotion and disease prevention ac-
tivities with their patients, but the extent to which they do so varies
and is currently unknown. A recent report on the 1980-1981 Na-
tional Ambulatory Medical Care Survey (National Center for Health
Statistics, 1984b) points out some differences by type of physician
and age and condition of patient, for instance, in the extent to which
a blood pressure reading is taken during an office visit and whether
medication or nonmedication therapy (e.g., counseling) is provided.
However, this survey, as currently constituted, does not attempt to
fully document physician practices in health promotion or mainte-
nance and disease prevention. Nor is this survey designed to ascertain
the extent to which different physician specialties and other providers
of care consider health promotion and disease prevention concerns as
among the services they should provide to their patients.
Many other types of practitioners, such as nutritionists and social
workers, also provide health and health-related services to persons of
all ages, including the elderly. Furthermore, health promotion and
disease prevention services are also provided in a variety of nonmed-
ical settings, including physical fitness centers and senior centers by
professional, paraprofessional, and nonprofessional support person-
nel.
Comprehensive information on the numbers of professionals and
allied health personnel who provide health promotion and disease
prevention services to the elderly in a variety of settings does not
exist. While some federal agencies such as the Bureau of Health
Professions of the Health Resources and Services Administration
(U.S. Public Health Service) collect data on health manpower and/or
health manpower training (see, for instance, Fifth Report to the Pres-
ident and Congress: U.S. Department of Health and Human Services,
1986a), none of them collects information on professionals and allied
personnel who render health promotion and disease prevention ser-
vices to the U.S. population at large or to the elderly. Although some
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124
AGING POPULATION IN THE TWENTY-FIRST CENTURY
data exist on members of health maintenance organizations and their
enrollment figures (which are in flux because of rapid growth in this
area), there are no comprehensive data on the services HMO s pro-
vide and the numbers of elderly who receive these services as HMO
enrollees.
The Health Research Extension Act of 1985, Section 8, called
for a study of personnel for health needs of the elderly. It directed
the secretary of the U.S. Department of Health and Human Services
to "conduct a study on the adequacy and availability of personnel
to meet the current and projected health needs (including needs for
home and community-based care) of elderly Americans through the
year 2020." The National Institute on Aging, in a joint effort with
the Health Resources and Services Administration, conducted the
study, with its director acting as chair of a committee that includes
representatives from several federal agencies (see National Institute
on Aging, 1985, and Chapter 9 of this report for more information).
The secretary's report, submitted to Congress in fall 1987, includes
recommendations related to the number of primary care physicians,
dentists, and other health personnel needed to provide adequate care
for the elderly; the education and training needs of other physicians,
dentists, and health personnel to provide care responsive to the par-
ticular needs of the elderly, and the financing of geriatric and training
activities (U.S. Department of Health and Human Services, 1987~.
While the study addresses the manpower and training needs for many
different types of health personnel who provide care to the elderly, it
does not focus explicitly on the area of health promotion and disease
prevention, although it recognizes it as a special issue area. The
Office of Disease Prevention and Health Promotion within the De-
partment's Public Health Service also does not routinely collect data
on the numbers of health personnel involved in health promotion and
disease prevention services to the elderly or on their training in this
area. The panel believes such information is important to determine
whether there is need for additional trained personnel and training
programs for health promotion and disease prevention among the
elderly.
Recommendation 5.3: The panel recommends that the Bu-
reau of Health Professions collect information on health care
personnel (including professionals and support staff such as
nurse's aides) who focus on health promotion and disease
prevention activities and services to the elderly in a variety
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HEALTH PROMOTION AND DISEASE PREVENTION
of medical and nonmedical, and institutional and noninstitu-
tional, settings. Estimates of the numbers of such personnel
and their health promotion and disease prevention activities
should be ascertained.
125
Representative terms from entire chapter:
disease prevention
