HEALTH PROMOTION AND HEALTH STATUS

Health promotion, a general term, refers to a wide range of health-enhancing activities that seek to maintain health and functional ability, increase longevity, and reduce the prevalence and consequences of disease. These diverse activities include distributing free needles to substance abusers, identifying and modifying genes such as those linked to the development of Alzheimer's disease, proposing laws that seek to deter cigarette smoking, and offering blood pressure and cholesterol screening. They also include personal health practices whereby individuals engage in healthy lifestyles, consume vitamins, and the like. Therefore, these wide-ranging activities are conducted by persons trained in the field of public health, traditional health care workers, practitioners of complementary medicine, basic science researchers, politicians, health policy experts, and the individuals who practice health-enhancing behavior, to name but a few.

Long ignored in favor of medical, surgical, and pharmaceutical treatments that seek to cure or arrest health problems, health promotion information is now a prominent feature of popular magazines and nightly newscasts. Indicative of its rising importance, the United States Public Health Service has expanded the official title of the Centers for Disease Control to the Centers for Disease Control and Prevention.

The significance of health promotion activity is well known to the medical community. It offers the best, if not cheapest, method of reducing the burden of life-threatening conditions and maintaining a healthy, well-functioning, long-lived population (Pope and Tarlov 1991). As has been stated, "many of the most serious disorders. . . can be prevented or postponed by immunizations, chemoprophylaxis, and health life-styles. To an unprecedented extent, clinicians now have the opportunities, skills, and resources to prevent disease and promote health, as well as cure disease" (Office of Disease Prevention and Health Promotion 1994). Thus, health promotion is the ounce of prevention to avoid the pound of disease/disability/decline.

THE RANGE OF HEALTH PROMOTION ACTIVITIES

Activities that constitute health promotion are conducted on macro and micro levels. They address many spheres of society including: (1) the physical environment, (2) political/economic institutions, (3) health and medical care systems, (4) the social environment, (5) the fields of human biology, molecular medicine, and genetics, and (6) human behavior.

Macro-level efforts range from the international arena (e.g., drafting treaties about water safety), to the national level (e.g., policies about smoking and air pollution standards), and further to the local level (e.g., offering services of the city or county public health agency). They also include the private sector. Some of these activities address the training of medical personnel, the financing and delivery of medical care at private and public sites, the provision of health screening services, the development of active surveillance systems about disease threats, the provision of immunization programs, the offering of health education programs, and the scientific discovery of pathways to disease.

Micro-level health promotion involves individuals and small units. A single person's actions to maintain a healthy body, forestall the development of disease, achieve a longer life, or reduce emotional stress are micro-level health-promoting activities. Also included in this category are behaviors of the patient–health provider dyad. Such behavior often pertains to establishing a set of health-promoting practices and complying with this plan.

In a narrower approach to health promotion, disease control is the focus. This has resulted in distinguishing health promotion activities according to their potential for primary, secondary, and tertiary prevention of disease. The terms are used in relationship to the stage of a disease or condition; thus primary prevention includes the predisease phase and applies to the period prior to onset or diagnosis of a disease. In contrast, secondary and tertiary prevention occur after a disease has manifested itself. Efforts to detect the disease and keep it controlled, contained, and manageable are included (secondary prevention) as well as medical treatment activity addressed to preventing disability, improving life quality, and delaying death during the course of well-established disease.

Primary prevention can begin at any time during the life course. Directed toward individuals without disease manifestations, it seeks to help them maintain well-functioning, disease-free bodies. One of the oldest primary prevention practices is handwashing to prevent spread of communicable disease. One of the newest is testing women for the BRCA1 gene for breast cancer. If it is detected in an individual, she may be prescribed a drug that has been observed to have cancer-prevention potential. This type of primary prevention activity reflects cutting-edge medical technology from the fields of molecular medicine and genetic therapy. It is growing exponentially as a health promotion strategy. Indeed, $25 million of macro-level prevention efforts were recently announced to prevent or curb the spread of infectious diseases by using state-of-the-art technology (New York Times, December 27, 1998).

Avoiding exposure to agents that cause disease, injury, or defects is clearly the focus of much of the primary prevention activity. Public health agencies achieve this by offering immunization programs to children and adults alike. Health policy and health law personnel propose laws to prohibit cigarette advertisements. Physicians offer general and condition-specific health education, such as teaching patients about the value of weight control. Laboratory personnel seek to develop new vaccines or analyze the genetic characteristics of bacteria linked to certain infectious diseases.

Personal behavior is often the target of primary prevention efforts. Individuals with a family history of heart disease may be advised about dietary change from fatty foods or the need to engage in exercise, stress reduction, smoking cessation, and/or weight reduction programs. Given recent data, these activities appear to be quite important in preventing the development of a heart attack (myocardial infarction) and blockage of the coronary arteries. Even reducing one of the modifiable risk factors for heart disease (smoking, high blood pressure, obesity, physical deconditioning, high lipid count, impaired glucose tolerance) significantly reduces the risk of developing this disease (Herd et al. 1987; Kannel et al. 1987). Since more than half of the men and women over age 65 currently die of heart disease, such activity could have profound effects. Indeed, the development of a major heart condition may take fifty years, beginning in childhood with unhealthy food and exercise habits (Fries and Crapo 1986). Therefore, the individual is responsible for this type of primary prevention, which can actually begin with parental efforts to offer low-fat diets to their children. The idea is that the person would then carry on healthy living behavior throughout the life cycle.

The importance of personal behavior in health promotion and disease prevention was established in a recent effort to reconceptualize the causative factors for death (mortality). Previously, mortality data listed specific diseases as primary or secondary causes of death. The new approach designates specific health-risk behaviors (e.g., smoking and exercise behavior, food habits, alcohol use) as actual causes of death (McGinnis and Foege 1993). These behaviors accounted for half of all U.S. deaths in 1990. The three leading risk behaviors were tobacco use (400,000 deaths) and diet and activity patterns (300,000 deaths). By now considering this health-risk behavior to be the cause of death, the prevailing disease-centered approach is diminishing in importance. Reducing the prevalence of these behaviors is becoming a goal of interventive efforts and can facilitate the shift to primary prevention efforts.

Secondary prevention is undertaken after a disease has been detected. This may occur a half century after the causal agent or offending behavior initiated the disease process (Fries and Crapo 1986). For example, a heart attack at age 70 may have as its etiology poor dietary habits beginning at age 15, smoking behavior that started at 20, and at ages 30, 40, and 45, respectively, physical deconditioning, job stress, and the development of hypertension.

In contrast to primary prevention, secondary prevention involves control of a disease or condition. Aims are to ensure early detection, follow this with prompt and effective treatment, and educate the individual about risk-reduction behavior. Such efforts seek to halt, slow, or possibly reverse the progression of a condition and to prevent secondary effects or complications. Therefore, the heart patient would not only receive medication that might improve functional capacity of the heart but also receive referral to a smoking-cessation program.

Secondary prevention efforts are addressed to all acute and chronic conditions, but five chronic diseases account for most of the deaths, hospital care, and disability of the U.S. population. In order of prevalence they are arthritis, high blood pressure (hypertension), heart disease, chronic bronchitis, and diabetes. These chronic diseases are readily amenable to preventive action (Pope and Tarlov 1991). Physicians can treat these conditions medically, pharmaceutically, and surgically to prevent complications or arrest disease progression. The individuals suffering from these conditions can engage in a series of health behaviors and modify their lifestyles. For example, persons with diabetes can be asked to visit their doctor regularly, have frequent tests of blood and urine to detect disease progression, and visit specialists for control of diabetes complications involving eyes, kidneys, nervous system, skin, and so forth. Simultaneously, they can be taught to monitor and control their conditions, engage in dietary change, and actively pursue weight-control and exercise programs.

One of the most important tools for secondary prevention is health screening. This procedure seeks to detect disease, abnormal body states, and sensory loss. It comprises activities as diverse as mammography; Pap smears; and blood pressure, glaucoma, blood sugar, prostate specific antigen (PSA), and hearing tests. These secondary prevention services may be offered in physician's offices, at community sites (such as health fairs or churches on Sunday), or at work sites.

Secondary prevention procedures are immensely valuable, especially if they allow a disease to be detected in its early stages. Through early detection, medical and personal care can begin before the disease has progressed. Complications may be avoided, dangerous clinical thresholds may be averted, and the downward trajectory to disability and death may be prevented. For example, mammography that detects a small breast tumor may be responsible for saving a woman's life, preventing disfigurement from mastectomy (seldom performed in the early stages of cancer), averting the need for chemotherapy and its severe side effects, and enabling the patient to have hope for complete remission. In contrast, if a tumor is detected by clinical breast examination by a physician or breast self-examination, it will be larger than one identified through mammography. A tiny tumor or precancerous breast tissue change will not be apparent, through clinical breast examination and the cancer detected may be larger or have metastasized.

Physicians and nurses are the predominant practitioners of secondary prevention. Physician assistants, pharmacists, nutritionists, health educators, and physical therapists are among others who form the secondary prevention medical team. Unfortunately, there is much less use of this health promotion strategy than is optimal, or even desirable. Studies have shown that fewer than half of all physicians indicated they schedule proctoscopic examinations and chest x-rays for asymptomatic patients with no personal history of cancer (American Cancer Society 1990). This study also showed that specialists in internal medicine offer their patients the most cancer screening relative to other medical specialties (Pap tests; mammograms; stool blood determinations; chest x-rays; and breast, digital rectal, and proctoscopic examination).

Tertiary prevention is the last type of diseasefocused prevention. It seeks to provide good health care to persons with diseases that have progressed beyond their initial stages. Therefore, since it is too late to prevent illness or arrest its progression to a more serious phase, tertiary prevention includes medical and surgical interventions that can prevent functional decline, improve life quality, or delay death.

The U.S. medical care system has focused on tertiary prevention and uses an increasingly large medical and surgical armamentarium. Breakthrough technology is at the basis of these efforts. It features replacement of organs with mechanical, animal, or other human parts; using genetically engineered products to alter disease agents; and cloning or otherwise duplicating disease-free cells to replace unhealthy tissue. These efforts are unprecedented and unique to the U.S. health care system. No other nation offers a comparable level of advanced medical care. Unfortunately, these tertiary prevention services have made our health care system the most costly in the world on a per capita basis but have not improved our life expectancy to the level of most of the industrialized world. In 1994 life expectancy at birth in the United States was 75.9 years, compared with 80.1 years in Hong Kong, 79.3 in Japan, 78.2 in France, and 78.1 in our neighbor, Canada (U.S. Bureau of Census 1994). Men, in particular, have failed to experience major gains in life expectancy. Women of all racial groups have outlived men since 1900, and white females currently have a seven-year advantage in length of life (U.S. Bureaus of Census 1994).

The fact that the gender gap in survival is occurring simultaneously with a major decline in mortality from conditions such as heart disease may speak to the limitations of tertiary prevention. Some attribute lower mortality from heart disease to procedures such as replacing valves and arteries, heart transplantation, removing blockages in coronary arteries and introducing stents, or offering pharmacological treatment in the form of clot-reducing drugs. Yet others suggest that medical measures have been less effective than those that involve change in health-risk behavior. It is proposed that the reduction in heart disease mortality has been achieved mainly through primary and secondary prevention practices. Since males are less likely to have good dietary practices, and more likely to ingest foods that contribute to artery blockages, use tobacco and have poor exercise habits, this may be affecting their mortality rates. Men may not be living as long as women because they fail to engage in health-promoting behavior, relying instead on medical treatment for an existing condition.

Tertiary prevention is clearly important. The vast majority of individuals suffering from cancer, severely debilitating disease, or life-threatening heart problems seek, or await the development of, advanced medical care. Medical journal articles about life-saving, and sometimes life-enhancing, treatments, are reported regularly on evening news programs. Only a small number of people refuse to have organ transplants or kidney dialysis, and many wait for new AIDS or cancer drugs to be offered for clinical trials. Canadian citizens routinely cross the U.S. border to avail themselves of medical, surgical, and technological procedures that are unavailable in their country or subject to waiting lists.

As stated in a classic medical sociology article, medical care in this country has not been responsible for a decline in mortality rates; rather, the primary causes of the reduction are public health measures that lessen the risk of acquiring disease (McKinlay and McKinlay 1977). We need to refocus our efforts toward heavier emphasis on primary and secondary prevention, and reduce our reliance on costly and technology-heavy tertiary interventions.

THE ROLE OF THE INDIVIDUAL IN HEALTH PROMOTION

As presented above, the responsibility for health promotion rests with several agents; the national and international health care systems, health law and health policy experts, public and private health facilities, health professionals, and individuals. However, the individual is often the center of attention as the burden of health promotion is shifted to the person.

This approach rests on the premise that a person's actions account for whether he or she remains healthy and does not experience progression of or complications from disease. The corollary to this is that persons who fail to exert control over health behaviors are contributing to disease, disability, and death. Movements to empower people and help them take charge of their medical conditions reflect this emphasis on the person's responsibility for health.

Indicative of this trend is that patient noncompliance with the medical regimen is considered to be a cause of medical treatment failure. Clearly, many people fail to adhere to the treatment plan prescribed by their physician. They may fail to have their prescriptions filled, take the amount of medication prescribed, keep medical follow-up appointments, or adhere to a dietary program necessary for a controlling a condition. Only 57 percent of persons with elevated cholesterol levels actually visited a physician after being notified of their state. Gender is an important part of compliance. Women visit physicians more than men, especially for preventive care (Verbrugge 1990). They also act as gatekeepers to the medical system for children and husbands, offering suggestions and advice, and sometimes making medical appointments without the consent of the latter.

This line of reasoning—patients are largely responsible for poor health outcomes because they do not follow the doctor's advice—ignores the fact that health professionals may create situations that foster noncompliance. Presenting an ultimatum about smoking cessation to heart patients, informing people with diabetes they must avoid sugar for the rest of their lives, or telling people diagnosed with hypertension they must fill a costly prescription for a condition that does not cause them physical distress seldom results in compliance. People do not like to be given lists of do's and don'ts. If reasons for the recommended procedures, medications, or behavioral changes are not given, compliance may fail to materialize. Asymmetric models of the patient–physician encounter (Bloom 1974) pose physician authority on the one hand and childlike response on the other. These models have lost their impact, especially among educated middle-class patients, and compliant behavior as an automatic response by the patient is becoming much less widespread.

Another reason that health promotion should not be considered the sole responsibility of the individual is that knowledge is the foundation for action. However, individuals may have little knowledge of appropriate health-promoting behavior. They are consumers of health information. As such, they must either depend on others for information or take the initiative for self study. While knowledgeable, enlightened patients can certainly help to control and/or contain their medical problems, only medically trained persons familiar with that patient's health problems can offer appropriate recommendations! To illustrate, the heart patient's physician is responsible for educating the patient about specific exercises to reduce the risk of a second heart attack because it is the physician who is intricately familiar with the functional and/or anatomical state of that person's heart. Physicians must educate their patients and, in doing so, carefully explain the regimen. It is only when patients receive adequate information and careful explanation about a particular regimen that they can be held accountable.

BARRIERS TO HEALTH PROMOTION

Reducing barriers to health service use helps considerably to promote health and reduce disease prevalence (Orlandi 1987). Analysis of the major barriers to health service utilization shows that they are both societal and individual. Societal impediments are known as structural barriers and refer to variables that originate in the economic, political, and medical organizational spheres of society. Individual, or personal, barriers refer to behavioral variables that seek to avoid, delay, or underutilize health care.

Structural barriers limit access to health promotion programs, as they do to medical service utilization. They can act at several levels. At the economic and health insurance level, absence of such resources make it unlikely that patients will receive some recommended screening or early detection tests. Even for those persons with health insurance coverage, policies may not cover the recommended tests. Constraints on health promotion services are also due to policies or factors that reflect how health care services are organized. To illustrate, political decisions that reduce the availability of public transportation in turn reduce access to sites offering health promotion services. Another example would be health policies that encourage medical sites with state-of-the-art equipment to proliferate in suburban areas. If the newest mammography equipment is available only to women in affluent areas, while inner-city sites have machines that may be old and of poor quality, clearly mammography screening will be less likely in these latter areas.

Personal barriers to health promotion activity include several factors that relate to an individual's perceptions, beliefs about cause and cure, and/or attitudes toward use of formal health care services. These barriers influence whether people will seek health care, follow the advice of medical professionals, and comply with a health promotion regimen and are reflected in the health belief model (Rosenstock 1974). This model of health services utilization proposes that people seek medical services according to: (1) perception of the threat posed by a health problem, and beliefs about their susceptibility to it (e.g., "heart attacks are serious but no one in my family died of heart disease"); (2) the possible inconvenience of the health-related activity versus potential rewards ("I can't manage without a morning cigarette, and besides my heart can't be in such bad shape since I only smoke half a pack a day"); and (3) response cues ("Did you have your annual prostate cancer checkup?").

Cultural factors affect the likelihood that persons will engage in recommended health promotion activity. Beliefs and practices handed down through the generations prescribe alternative health behaviors and nutrition habits. Some are harmless, others may be beneficial (chicken soup for colds, for example), and still others may exacerbate illness or even cause death (refusing blood transfusions on religious grounds). Beliefs also affect primary prevention; for example, some cultural traditions associate obesity with beauty or strength, not risk for chronic disease.

Denial is a particularly important personal barrier that can be added to this model, since denial of illness is directly related to avoidance of medical care. Many women fail to have a mammogram or delay the procedure because they seek to deny the possible threat of cancer. Some of these women have intense fear of the disease, others believe it is incurable, still others fear the surgical or chemotherapeutic treatment involved (Young 1998). In either case, they avoid thinking about it and feel they are better off not knowing whether they have a breast tumor. Delay in scheduling mammograms is a current interest of people seeking to improve rates of mammography compliance (Rimer et al. 1996).

Belief in one's own ability to control one's life also relates to health promotion. Health locus of control measures indicate whether individuals are internally controlled or whether they believe control is due to chance or the actions of powerful others (Wallston et al. 1978). Thus, individuals with internal health locus of control are the best candidates for health promotion programs because they believe in exerting control over their health status. They represent, on a conceptual level, the action stage of Prochaska and DiClemente's (1984) transtheoretical model of health behavior. Using this same framework, persons who are not engaging in risk-reduction behavior might be considered to be in precontemplation or contemplation stages and may never move to action.

HEALTH PROMOTION FOR OLDER PEOPLE

Health promotion and disease prevention programs generally target working-age people rather than older adults (Young 1994). This is quite unfortunate, since approximately 85 percent of people aged 65 and over suffer from chronic disease and the three most prevalent conditions are arthritis, high blood pressure, and heart disease (National Center for Health Statistics 1996). When considered simultaneously with the three leading causes of death in this population (heart disease, cancer, and stroke), the need for preventive care is quite apparent. These five conditions are largely amenable to risk-factor reduction practices. Indeed, readily available and well-known health promotion and disease prevention practices can alter the course of most, if not all, chronic and killer diseases of older people. There is great potential for improving the health of older adults by including them in health promotion programs (Pope and Tarlov 1991).

Health promotion efforts for older people should certainly involve risk-reduction behavior. As they are taught about behavioral and lifestyle changes, these efforts can result in a sharp drop in the medical consequences of chronic disease. Heart disease provides an important example. Rates of coronary heart disease are at least ten times as high in persons aged 65 and over as among their counterparts under age 45. Women as well as men show a dramatic rise in heart disease rates after they reach age 65. It has clearly been shown that much heart disease can be prevented by diet, exercise, smoking cessation, and similar healthy living practices. Furthermore, some of these same practices can reduce the likelihood of death, development of secondary complications of heart disease, and occurrence of a second heart attack (Kannel et al. 1987). Such behavioral change also brings psychological and social benefits to heart patients and results in gains in several areas of their lives. Yet older people recovering from heart attacks have been found to be significantly less likely to receive preventive behavior advice than their younger counterparts (Young et al. 1987). Particularly absent for persons aged 60 and over is advice to cease smoking and enroll in a cardiac rehabilitation exercise program. The question then emerges, "How can older people engage in health-promoting behavior that may prevent another heart attack, if not given the proper information from their physicians?"

Another way health promotion can be achieved is through following recommendations of major authorities for periodic administration of specific tests, examinations, and immunizations. The guidelines for adult preventive care offered by the U.S. Preventive Service Task Force (1989) include specific age-related tests. The set of recommendations for people aged 65 and over includes annual influenza shots; breast, thyroid, mouth, skin, ovarian, testicular, lymph node, rectal, and prostate cancer examinations; and dental examinations. Tests to determine blood pressure and visual ability should be conducted every two years. There are also recommendations for periodic tests of urine, hearing, estrogen levels in women, and cholesterol. Of course all of these recommendations apply to persons without specific health problems (those who are asymptomatic and of normal risk). Cholesterol and blood pressure tests for older people with heart disease would need to be performed frequently.

Thus, health promotion for older people can be achieved if (1) physicians conduct specific examinations and tests at defined periods of time and (2) if older people engage in risk-reduction behavior. For either to be successful, the older person must follow a recommended plan for medical visits and for individual behavior. This plan must be carefully explained to the older patient. However, studies show that patient-physician interaction in later life is poor (Coe 1987), and physicians may communicate poorly with their older patients and fail to offer a recommended illness-management plan (Young et al. 1987). Clearly, if older people are to change poor dietary habits, they must first be informed about good food choices. Since this information is condition-specific, it needs to be provided by the physicians who treat the individuals or their medical agents, such as nurses or physician assistants.

Older individuals also bear responsibility for behavioral change. They must be willing to engage in health behaviors that prevent illness or modify high-risk profiles. Even when these behaviors represent change in lifelong habits, they must be willing to pursue them. However, for effective risk-reduction practices to be targeted to older people, patient–physician partnerships must be formed (Hess 1991). Including the older patient in the health promotion program is essential.

HEALTH PROMOTION FOR MINORITIES

Significant advances in understanding, managing, and treating chronic disease have failed to eliminate the excess death and disability found in older minorities. African Americans, for example, have a five-year deficit in life expectancy (U.S. Bureau of the Census 1994). They have higher mortality rates for cancer and heart disease (Polednak 1989) and twice the risk of severe complications from diabetes, such as blindness, neurological decline, and illnesses that require dialysis or amputation (Lieberman 1988). Other ethnic minorities such as Hispanic Americans, Native Americans, and some Asian Americans also have a major gap in mortality and morbidity, compared with whites; death rates for heart disease and stroke, two leading causes of death, are twice as high for older minorities as for whites (Polednak 1989). Indeed, the health gap of minorities in the United States is wide and shows no signs of being bridged.

This bleak prognosis is certainly a call for massive efforts at treatment, on the one hand, and extensive health promotion efforts, on the other. Yet despite the fact that health needs vary across populations, health promotion efforts have usually been generic (Young and Olson 1993). Often they focus on the needs of white, middle-class adults (Gottleib and Green 1987).

Programs to target ethnic minorities must be culturally sensitive; they must also be specific to a particular population (Tseng and Ellyne 1990). One-size-fits-all programs will not fit ethnic minorities as a whole, or individual ethnic groups. The cultural background of the particular target population must be taken into account, along with educational level, health beliefs, and attitudes toward health providers (Young and Olson 1993).

The need to modify generic health promotion program for minority groups is increasingly recognized. Without targeted programs, it is doubtful that health promotion efforts can achieve high success. Knowledge about and appreciation of specific cultural norms, values, and beliefs should be a major component of health promotion programs for minorities (Leavitt 1990).

An example of a health promotion program that targeted a particular ethnic minority was conducted among African Americans with coexistent diabetes and hypertension (Waller et al. 1994). Sixty subjects were randomly assigned to an educational/self-care intervention group or an observation group. The former were instructed by a health educator, using culturally relevant materials. Diet and food preparation information were specific to the food habits of lower-income African Americans and focused on culturally acceptable food and cooking changes. Materials prepared reflected the average educational level of the target population. After one year, high-risk behavior among the intervention group was significantly less than among the observational group. Risk for complications of diabetes, heart disease, and stroke all declined. Furthermore, the diseases were considered to be controlled.

The determinants of success of health promotion programs are clearly their effect on (1) health-risk behavior and (2) medical outcome (control over the condition, laboratory test values within acceptable ranges, etc.). Programs that can change behavior and also effect better outcome for ethnic minorities cannot be generic. They must be culturally sensitive and appropriate to the population they seek to serve. Otherwise, there will be little effect on the mortality and morbidity status of the minority group.

HEALTH STATUS ASSESSMENT

Health promotion goals are often measured in terms of reduction in the prevalence of specific diseases or decline in death rates for a particular condition. The sciences of epidemiology and biostatistics and the field of medical sociology propose several ways to determine health status. They use measurements and statistics for populations, subgroups, and individual cases.

Health status data are collected by epidemiologists, agencies, and medical professionals. Among multiple strategies used are disease surveillance, population surveys, and conducting probability and nonprobability studies of the health of subpopulations (Friedman 1988). Surveys that assess health-risk behavior (e.g., Behavioral Risk Factor Surveys from the Centers for Disease Control and Prevention) are well accepted means of collecting health status data.

Measurements often used to assess health status include rates, ratios, counts, proportions, distributions, ranges, and quantiles. These measurements may indicate prevalence of a particular disease (number of persons with the disease in proportion to the total number in the group); incidence (number of new cases in a given period); or number of persons of a particular age, gender, or ethnic group with the disease. They can also indicate ranking systems and represent change over time in disease or death rates.

Rates are often calculated as the number of cases per 1,000, 10,000, or 100,000 persons. They are also standardized to take factors such as age into consideration. Therefore, since age increases risk of lung cancer, epidemiologists can eliminate this potential bias by using appropriate statistical techniques. They may use age adjustment or age standardization procedures to calculate the expected rate of lung cancer (Friedman 1988). This enables them to assume nonsmokers are the same age composition as smokers.

After rate comparisons are made, the relative and attributable risks of a disease can be determined. In these calculations, biostatisticians evaluate prevalence or incidence of a disease in a particular population and may then compare risks of two different populations. Other analyses may be of change in risk over time, or the lifetime risk of acquiring a disease such as cancer.

A frequently encountered health indicator is the proportion of cases that fall into a particular quantile. This generic term refers to several tiers, each representing a proportion of the population. To illustrate, people may be categorized into four quartiles, representing cholesterol levels. Each 25 percent segment of the population may then be compared. In these analyses, the association of an outcome variable, such as a second heart attack, with membership in a high-cholesterol-level group (quartile 1, for example) is clearly shown.

From a public health perspective, important indicators of health status are infant mortality and life expectancy rates. Low infant mortality and high life expectancy are considered to represent good health in a society. The premise is that societies that can reduce unnecessary maternal and child deaths and increase the average life expectancy at birth have established good medical care procedures and may have health practices that reduce the burden of illness and premature death.

In the United States, infant mortality rates have declined over the past century. In 1991 the overall infant death rate in the United States was 8.9/1,000 births (National Center for Health Statistics 1996). This represented a decline from 20/1,000 in 1970. Among certain subpopulations infant mortality was much higher than for the population at large. Blacks, for example, had infant death rates of 17.6, versus 7.3 for whites.

Life expectancy at birth is approximately 76 years in the United States. However, it is close to 80 years for white women and 73 years for white men. These figures represent a rise in life expectancy for men and women alike, and although there is a major racial gap, nonwhites have also shown an increase over the past 90 years.

In comparison with industrialized countries that offer all or most of their citizens publicly funded health care, U.S. men and women show up to a four-year gap in life expectancy (U.S. Bureau of Census 1994). U.S. infants are also more likely to die than those in several industrialized nations.

Sociologists use a different approach to assess health status than epidemiologists or biostatisticians They measure functional ability, perceived health status, emotional and psychological health, and quality of life, to name a few. Medical measures are used infrequently, and statistics are seldom expressed in rates. Rather, sociologists assess health status by tabulating scale scores of health-specific indices and/or calculating frequency distributions of individual health status questions. In the case of the latter, the investigator might determine presence/absence of a specific health problem (e.g., Do you have arthritis?) and measure central tendencies and variance in the data.

Functional ability is considered to an important indicator of health status in a sociological context. While the level of functioning can be measured as physical, mental, or social impairment, most of the interest is in physical functioning. This approach conceptualizes functional ability as ability to conduct activities of daily living (ADLs) or instrumental activities of daily living (IADLs) without assistance from others. Instruments used include measures suitable for older people (e.g., the OARS instrument of Duke University 1978), disease-specific measures (e.g., the arthritis functioning measure of Patrick and Deyo 1989), and instruments that assess cognitive functioning as a component of physical functioning (e.g., Keller et al. 1993).

The individual's perception of his or her health is often measured. In these investigations, the concern is with how the person assesses general health status at the present time or in reference to other people and other times. Thus, they may be asked "Is your health generally excellent, good, fair, poor, bad?" or "How does your health compare with that of people your own age?" or "Is your health better or worse than one year ago?" They may also be asked about perceived functional ability (Duke University 1978; Lawton et al. 1982).

Emotional and psychological health are also measured. Well-validated instruments such as the CES-D of the Center for Epidemiological Studies or the Zung Depression Measure are used for depression (DeForge and Sobal 1988). Investigators also seek to determine mood (Profile of Mood States of McNair et al. 1971), positive and negative effect (Bradburn 1969), morale (Lawton et al. 1982), and subjective well-being (Dupuy 1984).

Quality of life indicators are among the least well validated instruments used to assess health status. There are many different approaches to quality of life that represent medical, psychological, and social models of illness. Since sociologists prefer a multidimensional view, Levine and Croog (1984) presented five components of quality of life: social-role performance, physiologic state, emotional state, intellectual function, and general satisfaction or feeling of well-being. Also considered to measure quality of life are some subscales of the Sickness Impact Profile (Bergner 1984). The full 134-item instrument assesses physical, social, psychological, and interactional aspects of illness, but some scales are specific to pain or impairment level and tend to reflect a medical, rather than psychosocial, view of quality of life. Indeed, the medical approach may concentrate exclusively on disease-specific or treatment-specific variables. It may measure, for example inability to eat or excessive fatigue among cancer patients undergoing chemotherapy, or frequency of urination among individuals with hypertension who are prescribed medications to expel fluids from the body. Still other medically focused approaches to quality of life may focus on the experience of pain, as in the previously mentioned Sickness Impact Profile.

Health status assessment is clearly a broad field. It includes measurement of disease patterns in a population, self-reports by individuals of generalized health status, and middle-level health measurements. These latter measurements are neither macro level, like population-based mortality and morbidity statistics, nor micro level, like individual reports. Rather, they include validated scales, indices, or series of questions that may be widely used among general or specific populations. Many, if not most, measures have been found to be reliable and valid indicators of health status. The medical sociologist or related researcher thus has a wide range of instruments to assess health status.

CONCLUSION

Health promotion includes a wide-ranging set of activities that (1) enhance health status, (2) prevent disease, (3) seek to control the spread of chronic or infectious disease, and (4) attempt to arrest or delay deterioration that occurs as the result of these conditions. Health-promoting activities occur at the societal and individual levels and include a long list of agents. Essentially, health promotion represents the principle that maintaining health, preventing disease, and avoiding decline or complications of progressive illness are all achievable goals. For any society to have a healthy, vital citizenry, it must reduce the financial, social, and medical burdens of illness. All these are accomplished with health-promoting practices.

references

American Cancer Society 1990 "1989 Survey of Physicians' Attitudes and Practices in Early Cancer Detection." Ca-A Cancer Journal for Clinicians 40:77–101.

Bergner, M. 1984 "The Sickness Impact Profile (SIP)." In N.K. Wenger, M. Mattson, C. Furberg, and J. Elinson, eds., Assessment of Quality of Life in ClinicalTrials of Cardiovascular Therapies. New York: Le-Jacq.

Bloom, S. W. 1974 The Doctor and His Patient. New York: Free Press.

Bradburn, N. 1969 The Structure of Psychological Well-Being. Chicago: Aldine.

Coe, R. M. 1987 "Communication and Medical Care Outcomes: Analysis of Conversations Between Doctors and Elderly Patients." In R. Ward, and S. Tobin, eds., Health and Aging: Socioissues and Policy Directions. New York: Springer.

DeForge, B.R., and J. Sobal, 1988 "Self-Report Depression Scales in the Elderly: The Relationship Between the CES-D and Zung." International Journal of Psychiatry in Medicine 18:325–338.

Duke University Center for the Study of Aging and Human Development 1978 Multidimensional Functional Assessment: The OARS Methodology. Durham, N.C.: Duke University Medical Center.

Dupuy, H. J. 1984 "The Psychological General Well-Being (PGWB) Index." In N. Wenger, M. Mattson, C.Furberg, and J. Elinson, eds., Assessment of Quality of Lifein Clinical Trials of Cardiovascular Therapies. New York: Le-Jacq.

Friedman, G.D. 1988 Primer of Epidemiology, 3rd ed. New York: McGraw-Hill.

Fries, J. F., and L. M. Crapo, 1986 "The Elimination of Premature Disease." In Ken Dychtwald, ed., Wellnessand Health Promotion for the Elderly. Rockville, Md.: Aspen.

Gottlieb, N. H., and L.W. Green, 1987 "Ethnicity and Lifestyle Health Risk: Some Possible Mechanisms." American Journal of Health Promotion 2(1):37–51.

Herd, J. A., J. J. W. Alastair, J. Blumenthal, J. E. Daugherty, and R. Harris, 1987 "Medical Therapy in the Elderly." Journal of the American College of Cardiology 10:29–34.

Hess, J. W. 1991 "Health Promotion and Risk Reduction for Later Life." In R. Young and E. Olson, eds., Health, Illness, and Disability in Later Life: PracticeIssues and Interventions. Newbury Park: Sage.

Kannel, W. B., J. T. Doyle, R. J. Shepard, et al. 1987 "Prevention of Cardiovascular Disease in the Elderly." Journal of the American College of Cardiology 10A:25–28.

Keller, D. M., M. G. Kovar, J. B. Jobe, and L. G. Branch, 1993 "Problems Eliciting Elder's Reports of Functional Status." Journal of Aging and Health 5:306–318.

Lawton, M. P., M. Moss, M. Fulcomer, and M.H. Kleban, 1982 "A Research and Service-Oriented Multilevel Assessment Instrument." Journal of Gerontology 37:91–99.

Leavitt, R. 1990 "The Appreciation of Cultural Diversity. How to Integrate Content into Curriculum." In G. Price and P. Fitz, eds., Issues in Aging: Cultural Diversity and the Allied Health Curriculum. Hartford, Conn.: University of Connecticut.

Levine, S., and S. H. Croog 1984 "What Constitutes Quality of Life? A Conceptualization of the Dimensions of Life Quality in Healthy Populations and Patients With Cardiovascular Disease." In N. Wenger, M. Mattson, C. Furgerg, and J. Elinson, eds., Assessment of Quality of Life in Clinical Trials of Cardiovascular Therapies. New York: Le-Jacq.

Lieberman, L. S. 1988 "Diabetes and Obesity in Elderly Black Americans." In J. S. Jackson, ed., The BlackElderly: Research on Physical and Psychosocial Health. New York: Springer.

McGinnis J. M., and W. H. Foege, 1993 "Actual Causes of Death in the United States." Journal of the AmericanMedical Association 270(18): 2207–2212.

McKinlay, J.B., and S.M. McKinlay, 1977 "The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century." Health and Society 55(3):405–426.

McNair, D., M. Lorr, and L. Doppleman, 1971 Manualfor the Profile of Mood States. San Diego: Educational and Industrial Testing Service.

National Center for Health Statistics 1996 Vital Statisticsof the United States 1991, vol. 2. Hyattsville, Md.: U.S. Government Printing Office.

New York Times. "Clinton Plans 125 Million Initiative on Infectious Disease." December 27, 1998.

Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services Public Health Service 1994 Clinician's Handbook ofPreventive Services. Washington D.C.: U. S. Government Printing Office.

Orlandi, M. A. 1987 "Clinical Perspectives. Promoting Health and Preventing Disease in Health Care Settings: An Analysis of Barriers." Preventive Medicine 16:119–130.

Patrick, D. L., and R. A. Deyo 1989 "Generic and Disease-Specific Measures in Assessing Health Status and Quality of Life." Medical Care 27 (Suppl. 3):S217–S232.

Polednak, A.P. 1989 Racial and Ethnic Differences inDisease. New York: Oxford University Press.

Pope, A. M., and A. Tarlov 1991 Institute of MedicineDisability in America. Washington, D.C.: National Academy Press.

Prochaska, J. O., and C. C. DiClemente 1984 TheTranstheoretical Approach: Crossing the TraditionalBoundaries of Therapy. Chicago: Dow Jones/Irwin.

Rimer, B. K., J. M. Schildkraut, C. Lerman, T. H. Lin, and J. Audrain, 1996 "Participation in a Women's Breast Cancer Risk Counseling Trial: Who Participates? Who Declines? Journal of American CancerSociety 77(11):2348–2355.

Rosenstock, I. M. 1974 "Historical Origins of the Health Belief Model." Health Education Monographs 2:344.

Tseng, R. and D. Ellyne, 1990 "Perspectives on Developing a Course in Multicultural Health Promotion." Issues in Aging, 44–48.

U.S. Bureau of Census 1994 Current Population Reports. Washington, D.C.: U.S. Government Printing Office.

U.S. Preventive Services Task Force 1989: Guide to Clinical Preventive Services. Baltimore: Williams and Wilkins.

Verbrugge, L. M. 1990 "The Twain Meet: Empirical Explanations of Sex Differences in Health and Mortality." In M. G. Ory and H. R. Warner, eds., Gender,Health, and Longevity. New York: Springer Publishing Company.

Waller, J. B., R. Young, and J. R. Sowers, 1994 FrailElderly (Report to National Institutes of Health, NIA No. 10428). Washington, D.C.: U.S. Government Printing Office.

Wallston, K. A., B. S. Wallston, and R. DeVellis, 1978 "Development of the Multi-Dimensional Health Locus of Control MHLC Scales." Journal of Health Education Monographs. 6(2):160–170.

Young, R. F. 1994 "Older People as Consumers of Health Promotion Recommendations." Generations 18(1):69–73.

——1998 "Delay in Breast Cancer Screening." Report to Karmonos Cancer Institute.

——, E. Kahana, and M. Rubenfire, 1987 "Preventive Health Behavior Advice: A Study with Older Myocardial Infarction Patients." Evaluation and the HealthProfessions. 10:4394–4407.

Young R. F., and E. A. Olson, 1993 "Health Promotion Among Minority Aged: Challenges for the Health Professions." Journal of Continuing Education in theHealth Professions 13:235–242.

Rosalie F. Young