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9. Health Promotion and Disease Prevention in Community Settings Our world-and our neighborhoods-are instrumental in determining our health status. Education, access to services, family life, and work all play a role in shaping individual health and lifestyles. The kinds of health messages that people receive close to home, in their own "world," also are among the most influential in determining their health behaviors. Many witnesses, therefore, argued that interventions in schools, the workplace, and the community at large can be powerful tools in implementing the Year 2000 Health Objectives. Many testifiers accepted this premise and focused some, if not all, of their proposed objectives on interventions within the school, the workplace, and other community settings. They addressed common health problems faced by people in these settings, as well as programs that have been implemented to deal with them. In schools, for instance, the major immediate concerns are substance abuse, AIDS, and teen preg- nancy, but testimony was also directed at the health- enhancing possibilities for education programs on nutrition, physical fitness, mental health, and general lifestyle awareness and skills to enhance behavioral change. On the worksite, the primary concerns are screening for chronic diseases and programs to deal with smoking, nutrition, and stress. In the com- munity, testifiers paid special attention to programs aimed at substance abuse and the prevention of chronic diseases, and on ways to make them culturally relevant to the community they serve. In addition to the needs and proposals specific to these three settings, a number of implementation issues cross the three areas, including the content of health education programs, financing issues, and the coordination of services. These are addressed at the end of the chapter. HEALTH PROMOTION AND EDUCATION IN SCHOOLS Many witnesses see both a great potential and a great need for school-based health promotion endeavors. 82 Healthy People 2000: Citizens Chart the Course Thirty-four of them focus their remarks on health education in schools, and another 135 mention the need for school-based health education interventions either in the context of a specific issue or in terms of special interventions for children and adolescents. The American School Health Association (ASHA) presents a detailed analysis of the needs and oppor- tunities for school health programs. Problems en- countered in school-aged children include unhealthy lifestyles, chronic and episodic illnesses, emotional and behavioral problems, visual and hearing deficits, eating disorders, nutrition problems, teenage pregnancy, sexually transmitted diseases, and dental problems. In the face of these problems, The school, as a social structure, provides an educational setting in which the total health of the child during the impres- sionable years is a priority concern." No other setting approximates the magnitude of the school in terms of the number of children that can be reached. Thus, many witnesses see the school as a focal point for health planning in the community. f~l96) Given this orientation, the ASHA proposes specific objectives regarding periodic screening for hearing, vision and dental disorders; scoliosis; high blood pressure; and fitness levels; care and health promotion programs for stu- dents with chronic illnesses or problems; professional preparation and availability of school nurses; provision of primary health care clinics in schools; school breakfast and lunch programs; health education curriculum, class time, and the professional preparation of teachers; physical education programs and testing that emphasize cardiovascular fitIless and lifetime sports; mental health programs that include the deve- lopment of prosocial behaviors, stress management skills, and control of stress and violence; provision of worksite health promotion pro- grams for faculty and staff and ~ healthful school environment. (~196)

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Implementation of School~based Health Promotion Testifiers fee! that to meet many objectives, education must begin in the schools. However, school health programs need to be significantly improved if they are to sense this purpose. More comprehensive curricula are required, along with more hours spent on health education, better teacher training, and better availa- bility of health professionals or health services to students. The involvement and support of parents are also viewed as critical to the success of many school- related activities. Texas Commissioner of Education William Kirby writes: The public schools of America bear much of the burden to educate children about the physical, emotional, social and economic dangers of such health issues as drug abuse, school-age pregnan- py, AIDS and smoking. We accept this respon- sibility, yet we know that the task is too great for education systems to bear alone. We are grateful to the federal government for its sup- port in such programs as the Drug-Free Schools and Communities Act, to the Surgeon General for his comprehensive report on AIDS, and for federal funding to assist in the education of disadvantaged and handicapped children. We appreciate the philosophical and economic support and look forward to continued cooperation and coordination of education and health efforts among federal, state, and local governmental entities. We share a common goal ensuring bright futures and long, healthy lives for our children. (~305) Many testifiers suggest ways to improve the health education system so that it deals more successfully with adolescent health problems, including such far- ranging suggestions as environmental health issues; training in how to be an active and responsible medical consumer (#105~; issues of television exposure, "latchkey children," and homelessness (#198J; suicide prevention programs (~500; #731J; and art therapy and dance to deal with stress and to foster creativity (#477; #5954. Underlying these specific programs is concern about the capability of elementary and secondary school faculty to teach health issues. Chet Bradley of the Wisconsin Department of Public Instruction writes: I am convinced that unless a significant change in the professional preparation of elementary teachers in the area of health becomes a reality, the institutionalization of quality health instruc- tion at the elementary level will never occur. I propose to you that the most meaningful and effective long-term approach toward successful school-based prevention and health promotion efforts for our young people is through an investment in outstanding teachers. His testimony includes a proposal to train elementary school teachers to earn a three-year master's degree in elementary health education. (#593) The American School Health Association supports Bradley's view and states that most health education is conducted by poorly trained, non-specialists who devote much less than the minimum of 50 hours necessary for success, and who see health education at the best as secondary to their primary functions. These teachers also are working without the benefits of the other components of a com- prehensive school health program. Thus, school health education is generally a failure. (#055) Some witnesses called for more use of tested and effective behavioral teaching models. According to the National Education Association: Attitudes and behavior are not changed by simple presentation of the factor by scare tactics. Regardless of race, creed, or socioeco- nomic status, young people believe in their own invulnerabilit~that "it" simply isn't going to happen to them. An effective preventive health curriculum must rationally counter this belief in invulnerability and build a youth culture that embraces healthful behavioral choices. (#059) Similarly, Kenneth Kaminsky of the Wayne County Intermediate School District in Michigan writes that "the most successful programs today employ the social competency or 'life skills' model." This model empha- sizes skill development in communication, assertive- ness, resistance skills, peer selection, problem solving and decision making, critical thinking, making low- risk choices, self-improvement, and stress reduction skills. (~426) According to David Groves of Comerica Incorporated, "Social competency develop- ment programs emphasizing cognitive and social Health Promotion and Disease Prevention in Community Settings 83

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problem solving skills, perspective taking, and coping skills should be provided to all children as a part of their educational opportunities." (#075) Williams argues that a comprehensive, preventive health curriculum in schools necessitates collaboration not only among "educators, parents, school boards, administrators, and communities," but also among teacher preparation institutions and the medical community. (#059) The effectiveness of a school health promotion and disease prevention program relies on the support of the entire community. Community involvement is especially important when the more sensitive issues of AIDS education and school-based or school-linked reproductive health clinics for teenagers are addressed. Kirby emphasizes the need for local discretion in all health program- m~ng. We believe that where school-based clinics exist, they must be coordinated with existing health services and should be established and main- tained to meet the specific needs and philosophy of the local community. It is imperative that school-based clinics be under the direct super- vision of the campus administrator and that considerable flexibility be allowed at the local community level. Programs not supported by and congruent with local standards are not likely to be successful. (~305) One problem with focusing on school-based pro- grams, however, is that not all adolescents stay in school long enough to benefit from them. A large percentage of school age children are disenfranchised from the nation's schools. They are in jail, on the street, working, or on the run. Thus, the health objectives regarding school aged children are not realistic and lack sophis- tication. They have only focused on those children currently attending school or available to what is called "school site health education." (#055) Specific Problems and Interventions Much of the testimony on school health issues arose in the context of interventions in specific areas. Programs aimed at improving nutrition, physical fitness, and mental health, and also at preventing AIDS, teenage pregnancy, smoking, and other sub- stance abuse were mentioned most frequently. 84 Healthy People 2000: citizens Chart the Course Nuirit~on. Testifiers proposed various nutrition objectives, many of which are designed to ensure both classroom education and cafeteria participation. Several witnesses also underlined the need for a nationwide monitoring system of school-age children's nutrition status; without this, setting objectives will be difficult. Many of those testifying about nutrition education referred to the Nutrition Education and Training (NET,) Program, which came into being by an act of Congress in 1977. Its purpose is "to teach children the value of a nutritionally balanced diet through positive daily lunchroom experience and appropriate classroom reinforcement, to develop curricula and materials, and to train teachers and school food service personnel to implement nutrition education programs." #161) Witnesses testified that this program should be supported and, in some cases, expanded. Some testifiers, such as Carol Philipps representing the Midwest Region NET Program Coordinators, advocate "integrating nutrition concepts into other curricular areas as appropriate, for example biology, elementary language arts, mathematics, home eco- nomics, and social studies." (#590) Others place great emphasis on maintaining school lunch and breakfast programs and summer food programs in public and private schools. To actually maintain a nutritionally balanced diet, they argue, many children need school meals. Physical Fitness. The discussion of physical fitness focuses on engaging children in vigorous health- fitness activity and on preparing children for healthy physical activity behaviors later in life. For instance, the American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD) believes that thoroughly and appropriately integrating physical activity into one's life is possible only with a sound educational program as a starting point. (~596) One of the current problems with physical educa- tion programs, according to Brian Sharkey of the University of Northern Colorado and others, is that physical fitness tests given to school children often dictate, at least in part, the content of the curriculum. Hence, it is important to select fitness tests that will lead to the desired behaviors. As an example, he cites the health-related fitness test developed by AAHPERD as being preferable to the athletic skills- related test of the President's Council on Physical Fitness and Sports (PCPFS). Unfortunately, he says, Well-meaning school teachers see the glitter and polish of the PCPFS award system" and forsake

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AA8PERD's fitness test. This, Sharkey feels, pre- vents the establishment of a unified health-fitness related program in U.S. schools. (#363) Others discuss the need to integrate physical education with other health-related programs. Guy Parcel of the University of Texas Health Science Center at Houston, for example, discusses a program called Go For Health that was designed to reduce cardiovascular risk factors in elementary school children. This program makes an organizational-level change in the school lunch and physical education programs to "create an environment supporting healthful diet and physical activity practices," which is then supplemented with classroom instruction and theory "consistent with the school environment. (#295) Charles Kuntzleman of Fitness Finders makes the argument that increasing the amount and time of current physical education programs as they now exist may not solve the problem of the poor physical con- dition of today's children. According to Kuntzleman, 75 percent of the time in a typical physical education class is spent on record keeping, roll call, listening to instructions, waiting to take a turn, and general management; only 25 percent of the child's time is devoted to motor activity. (~121) Mental Health. Many witnesses stressed the necessity of providing mental as well as physical health educa- tion so children. Such programs can address a wide variety of issues ranging from stress management to the prevention of adolescent suicide. The American School Health Association accents the pivotal role a school can play in fostering the mental health of a child and building skills for later life. The AS HA believes that stress management is an important part of a school health education curriculum. (#196) Gaffney speaks of suicide and the potential of a teacher for identifying a suicidal child. She argues that Teachers are the children's first line of defense because they see behaviors before even parents do on occasion." (#731J The school is also an important setting for dealing with problematic personality characteristics. Bruce Dohrenwend of Columbia University School of Public Health says that because problematic dispositions can be Laid down early in life," the school is a good place to provide "training and orientation toward mastery and control." (#729) Family Planning and Reproductive Health. Many testifiers endorse the provision of family planning programs within the general school health curricula. They also agree that reproductive health or sex education should begin early in the school years. Testifiers acknowledge the sensitivity of these issues and recognize parental concerns, but most feel that ignorance of pregnancy and AIDS outweighs the concerns about sex education. High teenage pregnancy rates indicate a failure of educational and service provision efforts, according to Deborah 13astien of Galveston, Texas. She underlines the disparity of adolescent pregnancy and abortion rates in the United States and in other industrialized countries, and concludes that the higher rates of both pregnancy and abortion here are due not to greater sexual activity but to lesser availability of contracep- tive services and sex education. Despite this, "U.S. public policy still focuses on preventing sexual activity among teens." f#236) Sylvia Hacker of the Universi- ty of Michigan supports this position: "Recognizing that adolescents are risk takers, espousing abstinence as the only choice will not work." Insteaci, she says, sex education could help adolescents realize that choices are possible in expressing one's sexuality, and intercourse is only one of them. (#4063 Jackie Rose of the Clackamas County Department of Human Services in Oregon suggests social motiva- tions for teenage pregnancy: "We see teens for whom making a baby is one thing they can succeed in." To change these attitudes, she argues: We need comprehensive, coordinated teen- parent programs and teen pregnancy prevention programs to help them realize other options. We need to devise strategies to keep teens in school, for example, teaching teens and their families techniques for success and making available health services that minimize barriers to those services; that is make services available where the teens are-school-based health clinics. We need a goal to decrease the rate of repeat pregnancies during the teenage years. (#343) When and how family planning education should begin, argues Susan Addiss of the Quinn~piack Valley Health District in Connecticut, are important ques- tions. Even though "there is controversy about the content and timing of such education in communities around the country," Addiss urges "most strongly that Health Promotion and Disease Prevention in Community Settings 85

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an objective be developed with respect to some desired percentage of the nation's school systems having comprehensive family life education curricula in place by the year 2000." (i'460) The National Parents and Teachers Association also supports school-based sex education and says that because few parents actually discuss sex education, "schools and other public agencies and organizations must undertake this education. (#5 78J Similarly, Cathy Trostmann, a community school nurse in Texas, feels that sexuality education should begin in the first year of school and be presented at a level and in a manner that relates to the level of the child's develop- ment. She argues, however, that provisions be made for parents To give their own instructions in the home with guidance provided by the school system," if they so desire. (#302) The American School Health Association calls for school-based intervention programs to reduce not only teen pregnancy, but teen alcohol and substance abuse as welt According to ASHA, these programs must encompass more than just classroom education. The best way to decrease adolescent pregnancy and the incidence of sexually transmitted diseases among adolescents is to provide multiple channels: health and educational professionals, parents, and peers. The utilization of school-based clinics, school-linked clinics, and school- and community-based education programs is an example of an intervention that complements instruction and has been shown to be effective in reducing adolescent pregnancy. (~232) Clinical services are a critical part of successful intervention programs for teenage reproductive health. As ASHA notes, In preliminary evaluation a few programs have shown dramatic efficacy in combatting teenage pregnancy. It also cites studies that show widespread support for school-based clinics; the number of clinics across the United States has risen from 1 in 1970 to 120 in 1988.3 f#232) AIDS Education. Although the ideal content of AIDS education programs is controversial, most witnesses who address this issue call for aggressive school education. Wayne Teague of the Alabama Department of Education writes that when he was asked whether parents or the school system should decide the content of an AIDS education program, "I took the position that we do not give people an option for their children to commit suicide." (#675) However, although AIDS education is now mandatory 86 Healthy People 2000: Citizens Chart the Course in Alabama state schools, across the nation-according to Ralph DiClemente of the University of California, San Francisco-few school systems currently provide AIDS education as part of a formal curriculum, and even fewer have evaluated nro~ram effectivene.c.c (#273) DiClemente believes that AIDS prevention pro- grams should "encourage health-promoting behaviors and eliminate or reduce high-risk sexual and drug behaviors. Adolescents cannot be coerced into chang- ing behavior patterns.n (#273,) AIDS education, however, is hampered by the lack of information on the epidemiology of behavior among at-risk groups. Lew Gilchrist of the University of Washington says that baseline information is lacking on the actual use of condoms among specific populations, including adolescents. To offer effective education, these programs must be grounded in an understanding of actual behaviors and attitudes in at- risk populations. (~691) r - -an Smoking, Alcohol, and Substance Abuse. Some testifiers argue for early, school-based prevention activities for smoking, alcohol, and substance abuse. For example, according to the National Association of State Boards of Education: There should be a specific focus on alcohol and drugs beginning in the fourth grade and continu- ing until graduation. Providing accurate infor- mation is essential for a substance abuse preven- tion program. This includes knowledge about physiology, high-risk populations, high-risk situ- ations, the actual prevalence of drug and alcohol use, family influence, peer pressure, stress, the role of the media, and cultural norms. (#573) Kaminsly argues that students now view schools as the leading source of antidrug information. For this reason, schools must provide a program that can give adolescents information and influence healthy lifestyle behaviors. He outlines a program for substance abuse and lists as its components a grade-specific cur- riculum, in-seIvicie teacher training, counseling services for children, parent education programs, peer leader- ship and liaison work with community seIvice pro- viders, parent groups, and the media. (#496) Many of Kaminsly's components are reiterated by other testifiers, especially peer leadership and community- w~de efforts.

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HEALTH PROMOT1061 IN THE WORKPLACE As the American Occupational Medical Association (AOMA) points out, virtually all the 1990 Objectives can be addressed effectively and efficiently in the workplace. Health problems having to do with "re- production, child-rearing, immunization, mental health, substance abuse, hazard exposure, risk-taking, and self-destructive habits" are all appropriate and pertinent material for workplace health education and health promotion programs. (~071) Many other witnesses agree. Business Roundtable spokesperson Paul Entmacher offers a sample list of health promotion programs to be found in businesses today which "amply demon- strates the extent that business health promotion activities are part of the nation's total efforts These include smoking cessation, general tobacco use abstention; coronary heart disease prevention, including nutrition education; stroke prevention and hypertension control; seat belt usage and auto crash injury prevention; diabetes screening and education; early identification and treatment of alcohol abuse; cocaine, heroin, and marijuana education and counseling; occupational safety standards and matching education; occupational toxicity education and control; weight control; physical fitness and exercise; cancer detection (cervical smears, mammo- graphy); and AIDS public education and worker counseling. (#465) A survey of 48 companies by the Washington Business Group on Health identified the five priori- ties (and some reasons for them) among workplace health issues in the 1990s: 1. Detection of, and intervention against, chronic diseases, including cancer and heart disease (32 responses): because chronic diseases account for the bulk of health care expenditures and for considerable absenteeism and productivity losses. Although solu- tions require addressing multiple risks, chronic diseases are amenable to large-scale detection and prevention programs. 2. Reduction of alcohol and drug abuse (21 responses): because alcohol and drug abuse are ~ major source of health costs, absenteeism, and lost productivity; because abuse increases legal and security costs; and because abuse reduces the morale of coworkers. 3. Improvement of mental health (19 responses): because mental health costs continue to grow. Stress- related illnesses are becoming more prevalent and contribute to overall health costs; employee assistance programs at the worksite can be effective. 4. Control of HIT infections and AIDS (15 respon- ses). 5. Prevention and control of tobacco use (14 responses): because no other single factor accounts for as much cost and loss of productivity. Smaller numbers of respondents identified physical fitness (11 responses), maternal and infant health (8), occupational safety and health (8), maintaining health and quality of life in older people (8), nutrition (6), and other topics. (#355) Many of those who addressed the question of worksite-based programs spoke of generic issues such as the need for comprehensive policies, the role of health professionals, and the special difficulties faced by small businesses. Others addressed specific activities, policies, and programs to deal primarily with smoking, nutrition, stress reduction, substance abuse, and physical fitness and exercise. Implementation of Workplace-based Programs Marilyn Rothert of Michigan State University targets three factors for developing a successful worksite health promotion program: (1) involvement of em- ployees and management in the identification and development of all phases of the program; (2) expec- tation that successful programs will be sustained; and (3) working across populations and risk areas, and using multiple strategies. (#394) Margo Gorchow of the Health Development Network at Botsford General Hospital in Michigan describes the problems encountered in a worksite risk reduction program at a General Motors plant. To put up a poster announcing a smoking cessation program will not necessarily fill your classroom with eager, expectant students willing to give up smoking and pay money to do it. Offering free introductory sessions so groups can learn what the program is about does not Health Promotion and Disease Prevention in Community Settings 87

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necessarily make people want to give up a habit of eating potato chips, chocolate chip cookies, e! cetera. Aggressive outreach and engagement strategies need to be developed and imple- mented, to reach out to the individuals, to raise their level of health awareness, and engage them in a program to support their own interests, rather than what we think is a good idea for their health, to make a lifestyle change. (#386J Gorchow maintains that her program's success comes from keeping a high profile of visibility, with our professional staff (R.N.s and R.D.s) periodically on the factory floor talking to employees and signing them up for risk reduction classes. This ap- proach is working to engage the employees into a program as well as to provide follow up to assess their progress or relapse. There are on- site wellness coordinators at the plant as well. This proves to be an expensive, labor intensive approach. Still, in the first year of this study we were able to attract approximately 10 percent of the work force into behavior change programs. (#386) A number of testifiers called for a comprehensive set of policies, interventions, and activities for work- site wellness. According to Rothert and others, these programs share three components: (1) employee edu- cation, (2) a knowledgeable and available health professional, and (3) incentives for sustained par- ticipation. (#153; #394J For example, the Adolph Coors Company provides fairly complete wellness services to its employees, retirees, and their dependents. These include preven- tive dental coverage, smoking cessation programs, exercise programs, stress prevention programs, screen- ing for high blood pressure, causes and solutions for low back pain, good nutrition, weight management, healthy pregnancy/prenatal awareness and education programs, and mammography screening for the company and the community. A cost benefit analysis of Coors' programs shows that for each dollar in- vested, the company can expect a return of $1.24 to $8e33e Max Morton, manager of the Coors Wellness Center, claims a high level of participation and success for the various programs. Morton underlines the need to reach production staff as well as manage- ment staff: four studies suggest a difference in where production and nonproduction workers get their 88 Healthy People 200Q: Citizens Chart the Course health information. Production workers reported that the majority of their information comes from tele- vision, radios, and newspapers, in contrast to non- production workers information sources, which were their M.D.'s and our Wellness Center." (~153) A similarly comprehensive health promotion program is being undertaken at Michigan State University. Rothert explains that its purpose is to "establish an institutional process to sustain health promotion as a broad-based commitment and com- ponent of the mission of Michigan State University and to develop a model of this process that can be deployed to other organizations." She adds, Health habits can be contagious, and we are attempting to create a broad-based environment supportive of individual health promoting decisions." (~394) Many testifiers who have or are developing work- site health promotion programs concluded that a knowledgeable health professional at the worksite is a necessity for success. For example, Pat Joseph, representing the American Association of Occupa- tional Health Nurses, argues that workplace health education is most successful through occupational health nurses. "Approximately 75 percent of all occupational health nurses are the sole health care provider in the workplace," she says, and for this reason, they are "among the 'movers and shakers' in the activity to eliminate preventable disease and to promote optimum health in the workplace." (~385J However, although a program under the direction of a health professional might be the ideal, it may be too expensive for most small businesses to staff and draft comprehensive workplace wellness programs. To overcome this difficulty, there are now a host of local business groups on health, community organizations, and coalitions that can aid small businesses. Companies, such as insurance providers, make programs available, and resources can be found that help provide at least some wellness information or services, according to witnesses. Jack West, President of the Puro Corporation of America, illustrates what can be done. With 47 employees of his own, he argues that small businesses Can pick the low-hanging fruit" of employee health promotion programs. These are cheap interventions such as employee self-assessment questionnaires (at $12 per person), lunchtime cancer self-screening seminars, complimentary flu shots, a company newslet- ter on health and fitness, a company subscription to a local fitness club, and providing his company's product-bottled wate~to pregnant employees or spouses. (#734)

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The New York Business Group on Health, a not- for-profit coalition of nearly 300 organizations of which the Puro Corporation is a member, tries to help businesses obtain health information appropriate to the workplace. Its director, Leon Warshaw, says, "We have published a two-volume directory of avail- able resources for health education/promotion and every issue of our bimonthly newsletter is replete with articles describing innovative and successful programs and capsule reviews of publications and educational materials suitable for use in the workplace." (#448) Warshaw also talks about providing help and direction in the adaptability of projects. One should remember that the work force is not a uniform population. Specific cohorts can be identified on the basis of age, sex, educational and ethnic backgrounds, health status, and disease predilections so that they can be targeted for specific programs. The economies of scale, ease of access, and the enhancing effects of peer pressure serve to increase the effectiveness of these programs. (#448) Specific Problems and Interventions As with school-based health promotion programs, many of those who testified on workplace wellness singled out specific health needs and programs that should be addressed effectively by employers. The most commonly mentioned programs involved screen- ing for chronic diseases, smoking, stress reduction, and nutrition. Screening for Chronic Diseases. Worksite screening for heart disease and cancer can be invaluable in identifying individuals at risk of developing either of these chronic diseases. Heart disease and cancer remain the two top killers in the United States despite the fact that, to a great extent, both can be prevented. As speaker Thomas Washam of the Aluminum Company of America (Alcoa) points out, worksite screening can save lives. For example, at Alcoa there are blood pressure monitoring pro- grams and chronic health condition monitoring programs. These programs have found individuals who were in need of medical or surgical intervention, as well as individuals for whom better compliance with recommended medication was imperative. (#307) The AOMA suggests as an objective that "90 percent of the Fortune 500 companies and 75 percent of all employers with more than 100 employees should provide for on-site blood pressure screening and follow-up." Voluntary organizations, health care providers, and other organizations will have to assist employers that do not have their own assessment resources, AOMA adds. (~071) Leslie VanDermeer, an occupational health nurse, says that "screening of total cholesterol levels should be made available to all employees who work In a company that has an on-site medical unit or nursing department." She argues that since the fingerstick method of measuring total serum cholesterol is "low cost, accurate and easily accessible," it would be Ha scientifically sound and attainable goal for the year 2000 to have 100 percent of the worksites that contain employee health seIvices offer this seIvice." (imp 7) Angelo Fosco, General President of the Laborers' International Union of North America, calls for making preventive seIvices available through company- provided health plans. He suggests that these plans give particular emphasis to occupational diseases and work-related disorders, and that they be made avail- able to retired workers as well. (~586) Worksite screening for chronic conditions also can be useful in encouraging individual responsibility and coordinating other components of a worksite wellness program. Screening for cholesterol, high blood pres- sure, and breast cancer, for example, can help ind~- viduals to monitor their own health conditions. It also enhances the connection with other wellness programs for nutritional awareness, smoking cessation, physical fitness, and stress management. The Adolph Coors Company, in addition to blood pressure screen- ing, cholesterol screening, and a cardiac rehabilitation program, provides a significant mammography screen- ing program. The company has encouraged employ- ees and their spouses to Spread the word" to the community that many breast cancer deaths can be avoided if detected early. Coors offers mammograms for $15 to all staff and dependents, and is now coordinating screening for the nearby community. (~153) Smoking. Nonsmoking programs are the most fre- quently cited worksite interventions. Many large businesses in the United States are actively and effectively reducing smoking in the workplace. According to Alice Murtaugh of New York City, 36 percent of U.S. companies with 50 or more employees have smoking control activities.4 (#159J Charles Arnold, representing the Health Insurance Health Promotion and Disease Prevention in Community Settings 89

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Association of America (HIAA), exhibited a step-by- step implementation plan as an example of what can be done for employers who want to reduce smoking among their employees. The manual entitled Non- smoking in the Workplace: A Guitle for Insurance Companies is put out by HIAA and the American Council of Life Insurers, who have "resolved to make the provision of worksite smoking cessation programs a top priority for the employees of our industry." (#440) Some in the business community are not content to limit their activities to the private sector, and address participation by the government, both as a regulator lawmaker and as an employer. "More laws to ban smoking in the workplace must be enacted," says Murtaugh. (~159) However, Robert Rosner of the Smoking Polipy Institute of Seattle adds, "Before the government can advise any other organization on the issue of smoking policy and cessation programs, it must get its own house in order." Although the government has made progress, Rosner says it still lacks consistent and comprehensive policies for its own employees and worksites. (#349) Nutrition. Because of the link between nutrition and chronic disease, a number of testifiers described nutrition goals that would be appropriate for the workplace. Providing information about sodium, cho- lesterol, fats, and sugar in foods, and including cafeteria and other food providers in worksite nutri- tion programs were viewed as good policy. However, according to Marilyn Guthrie of the Virginia Mason Clinic in Seattle, "although there exists both profes- sional and public awareness of nutrition's role in health, more concrete data on the cost versus benefit of initiating changes in eating patterns are needed to provide the impetus for more structured programs." (~077) Loring Wood of NYNEX suggests combining nutri- tion and physical fitness objectives into a single objective to bolster the effect of education in the workplace. Specifically, he says that overweight, hy- percholesterolemia, and exercise are closely related to each other and to cardiovascular risk. Thus, work- place initiatives that foster good nutritional guidelines in the cafeteria and at the same time actively encourage employees to exercise regularly either off site or in subsidized programs are likely to increase productivity, lower absenteeism, and help retain satisfied employees. Wood proposes that "by 20()0, 25 percent of companies and institutions with more than 90 Healthy People 2000: citizens Chart the Course 500 employees should actively encourage their employees to exercise regularly through subsidized programs or on their own time, and their cafeteria managers to be aware of and actively promote U.S. Department of Agriculture and Department of Health and Human Services dietary guidelines.n f#736) Stress Management. Stress management is also a common element in specific interventions suggested for the workplace. Because of its toll on productivity and the absenteeism stress produces, stress manage- ment has become a compelling health issue for the business community. James Henderson of Pacific Bell reiterates this: "Our fastest growing health care cost item is the price of stress and depression in Southern California." (#761) Harriette Zal of the Southern California Association of Occupational Health Nurses remarks, "It is predicted that 'stress' will be the occupational health disease of the 199Os." fi230) As described in testimony, employer-sponsored programs for stress management can range from lunchtime classes to long-term education and relaxa- tion classes. James Quick from the University of Texas at Arlington, representing the American Psycho- logical Association, outlines how individual and organizational stress can be dealt with without causing ~distress." He cites four basic components of a stress management program: 1. knowledge of what stress is, what causes it, and what constitutes the stress response; 2. knowledge of costs-Moth individually and collec- tively"-of mismanaged stress; 3. familiarity with how to diagnose stress and its effects; and 4. knowledge of responsible individual and organi- zational prevention strategies that are beneficial in the management of stress. (#176) Employee assistance programs (EAPs), which pro- vide counseling services and resources for employees, are another work-based method of handling stress. The benefit of EAPs for employees is that it recognizes their total environment-in and out of work-as appropriate for interventions. As the AOMA says: Such broad-based programs should provide the expertise to counsel on finances, parenting, interpersonal relations, marital discord, disloca tion support, bereavement, AIDS, substance abuse, violent crime victimization, rape, etc. It is unlikely that many small businesses will have all counseling resources within their organiza

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lion. Rather, the EAP counselor (whether con tracted or employed, on- or off-site) should serve as an advisor and should guide employees to appropriate resources. (~071) COMMUNITY-LEVEL INTERVENTIONS More than 100 testifiers argue that behavior-related health problems-for individuals or entire popula- tions~n be addressed most effectively through at least some degree of community-level intervention. Linda Randolph of the New York State Department of Health says that the increasing appreciation of The role that communities play in supporting the individuals makes it necessary not only to empower individuals in the health arena, but to empower "communities as aggregates of individuals as well. (#177J As an organization with the resources necessary to provide support for community health plans, the New York State Department of Health has devised a f~ve- step process that allows it to help communities "determine for themselves the means they will employ to realize optimal health" and to establish prevention interventions: (1) identify health problems, (2) de- termine the relative public health threat, (3) devise strategies to solve the problems, (4) implement strategies, and (5) evaluate the effectiveness of the strategies. (#1 77J Other testifiers who outline community interven- tion strategies reiterate these five steps, perhaps using different terminology. Many argue that a key element of both devising and implementing prevention inter- ventions is the realization that customs, mores, and socioeconomic status affect the health of individuals and communities. Effective programs, they say, must take these components into account. Frank Bright of the Ohio Department of Health observes that Populations whose needs are being addressed should be brought into the planning process." Forcing an intervention upon a community from without or establishing an isolated intervention within an unsupportive community will not bring the same change in health status to that community as community-owned goals will. Bright says that community ownership of health objectives offers the potential of bringing necessary services into existing structures and making them acceptable to the popula- tion. (~470J Most of those who testified about community interventions spoke about specific programs, but some addressed the opportunities that community-level programs offer to racial and ethnic minorities. Still others stressed the need to link community-level programs with wider efforts in society. Specific Problems and Interventions Witnesses mentioned a number of specific areas where community-level interventions are especially valuable. These areas include adolescent suicide and substance abuse, other adolescent issues, alcoholism, and the prevention of cardiovascular disease. Problems of Adolescents. Robert Tonsberg, Director of the Wind River Health Promotion Program, reports that a community coalition to reduce adolescent suicide was developed when a series of suicides took place in the Wind River Indian Reserva- tion in Washington State. In looking at the histories of the victims, it was found that there was a high incidence of substance abuse and depression among them. The Wind River Health Promotion Program approached this by developing stress-coping skills among young people and education programs for children and youth. The planners also decided to use the "Tupperware approach-instead of having par- ticipants coming to them, they brought the services to the community. The program relies on community- based networking and on collaboration and coordina- tion with community groups; schools; churches; and local, state, and federal organizations. It focuses on multiple targets for change and multiple strategies for intervention and evaluation. (#711) In Seattle, a citywide program to provide education and services to urban children was developed with the aid of a survey distributed to adolescents in the city. Robert Aldrich of the University of Washington says that one of the most startling discoveries of this survey was "some very major differences between what kids thought and what the adults thought the kids thought. To deal with this, says Aldrich, "we put in place a kids' board, 30 teenagers who report to the mayor and who, with the officials of the city and the private sectors began to deal with each of the issues that have been brought up by the kids, and some we thought of ourselves." Aldrich also points out that this Kids' Place program is not a medical intervention program. Instead, it is "more socially driven so that the primely things that are being dealt with are things like housing, and facilitating a day-care system." Aldrich urges others who might be interested in orga- nizing similar programs to conduct a citywide survey and then plan strategies around the results. (~689) Health Promotion and Disease Prevention in Community Settings 91

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Alcohol-related Problems. Al Wright of the Los Angeles County Department of Health Senaces de- scribes a county-level alcohol intervention program that supports "the prevention of, intervention in, and recovery from alcohol-related problems that occur at the individual, family, and community levels as a result of the relationship between alcohol, drinkers, and the environment." Among the strategies for primary, secondary, and tertiary interventions, Wright includes an "environmental approach to commun~ty- level prevention of alcohol problems," that is a counterattack on the social components of drinking. He lists price, product, place, and promotion as four areas in which there are industrial and societal pressures to drink. Los Angeles County's intervention program has developed four countermeasures: taxes, alternative beverages, planning/zoning, and norms/ policies. Wright's testimony illustrates that through coordinated activities, social habits can be changed. (#229J Cardiovascular Problems. Adrian Ostfeld of Yale University describes a statewide hypertension control program that was implemented with good results in Connecticut. After the organizers carried out a state- wide survey of both health consumers and health providers in 1978, they decided to focus their efforts on controlling high blood pressure and reducing lifestyle-related risk factors, especially in younger men whose problems were more severe. They sought and received the cooperation of physicians, other health professionals, and provider agencies such as neighbor- hood health centers, public and private nursing agencies, the Red Cross, and family planning agencies. After four years, noticeable changes occurred in two areas. First, physicians and other health professionals became more active in screening for hypertension and helping their clients control it. Second, many resi- dents of Connecticut reduced their behavioral risk factors for heart disease, including smoking and the consumption of salt and fat. (#459) For Raymond Bahr of St. Agnes Hospital in Baltimore, Maryland, active participation of the community hospital is essential in a community program to prevent heart attacks. To enhance the link between early cardiac care and the community, Bahr says, "it is going to become important for each community hospital to have a coronary care system that moves into the community with educational programs focusing on chest pain and providing an early cardiac care center in the hospital." Bahr emphasizes the hospital's responsibility in this 92 Healthy People 2000: Citizens Chart the Course program. Coronary care is a community problem because a significant number of sudden deaths and myocardial infarctions take place in this environ- ment. Before entering the hospital coronary care system, the public must interact with the emergency care delivery system as well as with the hospital emergency room. The ultimate fate of the community depends on the quality and effort available in these areas. (~511J Bahr's plan also includes strategies for informing the community at large. He argues that people must be instructed in cardiopulmonary resuscitation and must recognize the early warning signs of a heart attack. "But what is more important," he argues, "is developing the concept of having an 'executive person' in each family to deal with the chest pain patient who is experiencing procrastination and denial of the heart attack." Bahr also targets high school education as an appropriate vehicle for teaching that late entry into care causes sudden cardiac deaths. (#511) Racial and Ethnic Minorities Because of the importance of culturally related health knowledge and attitudes, as described in Chapter 6, community-level intervention is thought to be an especially effective way to implement health promo- tion and disease prevention programs. The Hispanic Agenda in Colorado, described by Rita Barreras of the Colorado Department of Social Services, is one such program that aims to develop community health objectives and programs for the Hispanic community. Its premise is that the respon- sibility "to insure that there is a coordinated, in- tegrated and systematic approach to positive change" lies with the Hispanic community itself. (~243) The steering committee for the Hispanic Agenda acted as impetus for the community-wide goal-setting process. It first identified eight component areas: education, higher education, labor and employment, economic development, housing and neighborhood, health and human services, political participation and leadership, and media. Next, experts were invited to submit papers and to draft goals for these eight component areas. Finally, criteria were developed to help planners identify and assess issues and strategies. (~243) Margaret Hargreaves and her colleagues at Meharry Medical College's Cancer Control Research

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Unit describe several cancer prevention strategies being undertaken by Meharry, Morehouse, and Drew universities for the Black community. Their aware- ness program aims to improve cancer knowledge of Blacks in the three consortium cities by developing a program to ensure the diffusion of cancer information throughout the community. The strategy will employ community organization, The mass meOla, and personal contacts. program will be provided through churches, worksites, and the community-at-large. (~615) Hargreaves stresses the need to develop strategies that are culturally specific to the Black community. Blacks have been reported to exhibit a particular pattern in availing themselves of health care, delaying in utilization of the traditional health care system, and relying upon family, friends, and even spiritualists and healers during critical stresses in their lives. Such delays are com- pounded by medical care expenses that they are unprepared to meet. With their unique value systems and problems of access, it is apparent that different health promotion strategies should be used to reach Blacks. (#615) Mario Orlandi of the American Health Foundation emphasizes the importance of designing substance abuse community intervention programs that are "culturally relevant and that address specific sociocul- tural barriers to effective cross-cultural program dissemination." He also notes, however, the need for more data and research studies in these communities. In an evaluation of two community intervention approaches and their applicability to minority cul- tures, Orlandi found difficulties and gaps in assessing the substance abuse intervention needs of Blacks, Mexican-Americans, Asian Americans, and Native Americans. For all four of these groups, he cites a lack of basic research or intervention development research projects. For Blacks, compared to other groups, although there have been a number of research studies on substance abuse, Orlandi argues that "despite this accumulated body of research, the relevant understanding of Black substance abuse is lacking," and especially absent are "the appropriate information and insight necessary to design effective preventive interventions for this population. The lack of systematic, longitudinal, multivariate studies, and the failure to employ ethnographic and other culturally-sensitive data collection procedures also has impeded progress.n Orlandi concludes that the prob- lem is not that preventive innovations are not available for planners trying to develop programs for minority populations, but rather that "programs are not available that fulfill both criteria: demonstrated efficacy and cultural relevance for particular minority or ethnic groups." (~167) Linking Community-level Programs with Larger Efforts A number of testifiers argue the necessity of linking community intervention programs with wider state, regional, and national health goals. The importance of networks, linkages, broad-based support, and above all, mass communication should not be ignored. Woodrow Myers of the Indiana State Board of Health says that state health departments have a role to play in helping communities link themselves To statewide solutions that affect other communities' problems and ultimately to national solutions, whether private or public, to address those needs." Myers describes several injury prevention programs that Indiana has undertaken, which involve both govern- ment and community components. Two examples are the Hoosiers for Safety Belts program and the Indiana Poison Control Center. The first is a statewide nonprofit coalition of private citizens, professional groups, service clubs, corporations, public agencies, and trade associations. The second program is a regional center dedicated to the prevention and treatment of poisoning. The center maintains a 24- hour, toll-free poison information line to inform citizens about household products, chemicals, phar- maceuticals, and live plants that may be poisonous. In both these interventions, the communities and the state share common goals to increase the use of safety belts and to provide statewide poison control services. (#405J In some cases, the resources for health promotion and disease prevention programs are already available, but poorly coordinated. For example, writing about adolescent health problems, Claire Brindis and Phillip Lee of the Institute for Health Policy Studies at the University of California, San Francisco note that "categorical programs that have followed traditional patterns and focused on a single aspect of an issuer family planning, drug abuse, counseling-have had limited success." Only a small portion of the adolescent population has responded to this Health Promotion and Disease Prevention in Community Settings 93

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categorical, medical-model approach. "Communities need to work toward comprehensive and coordinated services," according to Brindis and Lee. This means making health education, social services, and job- related services available in the same place, with com- bined funding from public and private sources, and conducting rigorous evaluation to document success or failure and to move away from policies and programs that are not effective. "This comprehensive approach increases the efficiency of currently available commu- nity resources; facilitates the formation of linkages among a varieW of concerned groups, such as parents, religious organizations, sentence clubs, clinics and social service agencies; and spreads funding responsibilities among several concerned parties." (#027J Karil Klingbeil of the University calf Washington recognizes that community-level education, counseling, and sentences are very important for reducing violence but calls for national-level activity, as well. Klingbeil recommends six secondary prevention steps that would be national in scope: 1. implementation of a national family violence prevention week; 2."major media campaigns utilizing billboards, newspapers, radios, buses and other public vehicles, that can be used by public and private agenciesn; 3. development and implementation of legislation on all forms of abuse; 4. mandated "training and education on all aspects of family violence in all professional schools and cross-training in substance abuse and alcohols; S.ninnovative approaches to interviewing and interrogating child as well as adult victimsn; 6.nestablishment of cross-agency committees or boards whose sole purpose it is to alleviate system barriers for victims as well as the offender groups." (#697) The array of lifestyle choices offered to individuals in today's society and the conflicting information available in the media about what constitutes healthy behavior lead some testifiers to target communication channels in their intervention programs. The National Council on Alcoholism, for instance, discusses the need to look at alcohol problems as social, as well as individual, problems. Thus, there should be process objectives for each objective on "public and community education based on the principles of sound educational theory and mass media communication." According to the council, "The alcohol and beverage industry spends two billion dollars a year on alcohol marketing that encourages and glamorizes drinking and associates alcohol use 94 Healthy People 2000: Citizens Chart the Course with maturity, success, sexuality, and high-risk activities." To counter this, it recommends that broadcasters "grant equivalent air time for health and safety messages about alcohol.n (#467) Ruth Roemer of the UCLA School of Public Health states that the most effective legislative mea- sures to reduce smoking are "~1) banning all advertis- ing and promotion of tobacco products, and (2) raisi- ng the taxes on and prices of tobacco products very substantially." Government has an obligation to protect the health of the people, and a ban on advertising would promote the social norm of a nonsmok- ing society. It would counter the negative con- sequences of advertising, which are especially pernicious in influencing young people to smoke. (#184) The American Medical Association calls for res- ponsibility in the media. The AMA believes that the media can be of Inestimable value" in attaining objec- tives, but that to do a responsible job, the medical community and the federal agencies must provide them with factual data. The AMA notes that the me- dia have made a Cooperative effort at banning or otherwise censoring counterproductive advertising and promotional practices that are harmful to the public's health n (ALAS) CROSSCU~ING IMPLEMENTATION ISSUES Michael Eriksen, representing the Society for Public Health Education, writes: As part of the effort to assure qualifier of health promotion interventions, it is important to remember that not all interventions should concentrate solely on the individual. In fact, often the most effective health promotion interventions are those directed at the changes in the behaviors of providers, environments, and systems. Organizational change is inherent in the definition of health promotion and should be considered an integral component. (#309) A number of implementation issues are common to interventions proposed for schools, workplaces, and communities. Suggestions were made about the content of health promotion and education programs, their financing, and the coordination of available services.

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Content of Health Promotion and Education Programs Recognizing the importance of health promotion activities in nonmedical settings, many witnesses had suggestions about defining the scope and content of such programs. Sunny Chiu of the Michigan Depart- ment of Public Health, for instance, calls for (1) clearly defined policies, priorities, and strategies for health promotion; (2) scientific data and the oppor- tunities to apply them through program planning and implementation; (3) the tools and resources for practitioners and the community; and (4) the informa- tion, educational processes, and a combination of motivational and supporting forces for behavioral change-both individual and collective-aimed at reducing preventable morbidity and mortality. (#395J Tl~e National Education Association suggests that health education focus on "life-enhancing" behaviors. According to Williams, "Our nation's schools must put into place health education programs that engage students, ensure that they understand the scientific and medical facts, and motivate them to choose appropriate behavior." Education mil.ct motivate young people to adopt healthful, life-saving behavior. (~059) According to the American School Health Associa- tion: The health education curriculum needs to be comprehensive and not content-specific or narrowly targeted. It should work to motivate health maintenance and promote wellness and not merely to prevent physical illness. In order to do this, it must possess the following charac- tenstics: its activities should develop effective decision-making skills; it must be well-planned, sequential, and based upon the student's health needs and interests as they relate to national and local community health priorities; it must focus on health attitudes and feelings, as well as behaviors and practices; it must integrate all dimensions of human health and not focus only on the physical; it needs specific goals and objectives in addition to effective formative and summative evaluation procedures; it requires effective management and sufficient resources. (~055) Igoe writes that "despite increasing pressure to participate in the management of their own health, consumers of all ages are often unable or unwilling to do so." Research shows, she says, that those people who strive for mastery over their own health needs and who are prepared to deal assertively with health professionals usually obtain the best health care. To overcome consumer passivity and conversational barriers between the health professional and the consumer, Igoe stresses self-responsibility and autono- my. Consumers must learn to approach health care as a "problem-solving endeavor that requires an active coping effort, rather than as a situation calling for passivity and submission." She suggests objectives to integrate "consumer activism education into all school curricula, including medical schools; to make it a responsibility of state health implementation programs to provide public service materials for consumer activism; and to do more research and survey work on outcomes of consumer activism. (~105J Charles Lange of Loyola University says that one of the greatest obstacles to improving health is the lack of understanding by the general public of science, its methods, and its accomplishments. Unless the general public becomes more conversant with science, Lange feels, the achievement of the health objectives will be impossible. (~707J Financing Health Promotion and Health Education Health promotion and health education programs often fall outside of the common fee-for-service medical system and, therefore, are especially difficult to finance. Witnesses addressed this issue in the context of schools, worksites, insurance companies, and the media. William Kirby, the Texas Commissioner of Educa- tion, says that "health services and health education are critical components of the public school program." However, no education funds are specifically earmarked in the state budget for health services. Competi- tion is steep for the funds that are provided in the form of general state aid to school districts, which must use those limited funds to meet the costly mandates of salaries, instructional pro- vis~ons, and special programs as well as require- meets for health services. With the exception of drug abuse education, no additional funding has been allotted to local school districts to help them meet these responsibilities. Those in the legislative and health arenas must understand that education cannot continue to be expected to provide services and health-related instruction Health Promotion and Disease Prevention in Community Settings 9S

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without some financial support. (#305J Gorchow feels that financial support for health promotion must be sought from the private as well as the public sector. lithe insurance model in the United States has always been based on providing illness With worksite-based Intervention and education about prevention and management of chronic problems, it is possible to reduce the burden of illness on the individual as well as on the reimbursement systems. (#386) Individuals should be encouraged to take respon- sibility for adopting and maintaining healthy lifestyles, says Jeannette Merijanian of the University of Montevallo. To do this, they need motivation to change their lifestyles, information on what and how to change, and support. Thus, "national resources and knowledge" should be linked together "with local organizations to promote, educate, and support citizens who want to improve their own health status." This will require insurance reimbursements for life- style changes and funding for health education pro- grams, she says. Insurance reimbursements could be made either on self-reporting data or on quantifiable health changes, such as lower blood cholesterol and cessation or absence of smoking. (#644) coverage rather than wellness coverage. REFERENCES Kenneth Warner of the University of Michigan addresses the question of financing advertising efforts. Television has aired one shocking documentary after another on drugs, while magazines have repeatedly featured the grim and stark imagery of crack and smack on their covers. Their front covers, that is; the back covers feature attractive, glossy ads for cigarettes and alcoholic beverages. The effect of this media hype is that teenagers believe that illegal drugs are the principal source of premature death in our society, while in fact" cigarettes kill as many Americans in a single day as cocaine does in a year. We need a profes- sionally designed paid broadcast media advertis- ing campaign against tobacco use and alcohol misuse. According to Warner, the hundreds of millions of dollars required for such an effort could not be raised voluntarily. One solution is to increase the excise taxes on cigarettes and alcohol to pay for the cam- paign. As little as one cent per pack of cigarettes would raise $300 million, he says, and the tax itself would reduce the demand for tobacco, especially among younger people.5 (#429) 1. Parcel GS, Simons-Morton BG, O'Hara NM, et al.: School promotion of healthful diet and exercise behavior: An integration of organizational change and social learning theory interventions. J Sch Health 57~4~:150-156, 1987 2. Lovick SR, Wesson WF: School Based Clinics: Update. Washington, D.C.: Center for Population Options, 1986 3. Lovick SR: School-based clinics: Meeting teens' health care needs. J Sch Health 58~9~:379-381, 1988 4. U.S. Department of Health and Human Services: National Survey of Worksite Health Promotion Activities: A Summary. Office of Disease Prevention and Health Promotion, 1987 5. Warner KE: Selling health: A media campaign against tobacco. J Pub Health Policy 7~4~:434-439, 1986 TESTIFIERS CITED IN CHAPTER 9 027 Brindis, Claire and Lee, Phillip; University of California, San Francisco 055 Eberst, Richard; Adelphi University (Long Island) 059 Williams, James; National Education Association, Health Information Network 071 Givens, Austin; American Occupational Medical Association 96 Healthy People 2000: Citizens Chart the Course

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075 Groves, David; Comerica Incorporated (Detroit) 077 Guthrie, Marilyn; Virginia Mason Clinic (Seattle) 095 Hendee, William; American Medical Association 105 Igoe, Judith; University of Colorado Health Sciences Center 121 Kuntzleman, Charles; Fitness Finders (Spring Arbor, Michigan) 153 Morton, Max; Adolph Coors Company 159 Murtaugh, Alice; New York 161 Neill, Carol; Alum Rock Union Elementary School District (California) 167 Orlandi, Mario; American Health Foundation 176 Quick, James; University of Texas at Arlington 177 Randolph, Linda; New York State Department of Health 184 Roemer, Ruth; University of California, Los Angeles 196 Seffrin, John, Allensworth, Diane, Eberst, Richard, et al.; American School Health Association 198 Sheps, Cecil; American Public Health Association 217 VanDermeer, Leslie; Hunter College (New York) 229 Wright, Al; County of Los Angeles Department of Health Services 230 Zal, Harriette; Southern California Association of Occupational Health Nurses 232 Allensworth, Diane; American School Health Association 236 Bastien, Deborah; Galveston, Texas 243 Barreras, Rita; Colorado Department of Social Services 273 DiClemente, Ralph; University of California, San Francisco 295 Parcel, Guy; University of Texas Health Science Center at Houston 302 Trostmann, Cathy; Houston, Texas 305 Kirby, William; Texas Commission on Education 307 Washam, W. Thomas; Aluminum Company of America 309 Eriksen, Michael; Universitr of Texas Health Science Center at Houston 343 Rose, Jackie; Clackamas County Department of Human Services (Oregon) 349 Rosner, Robert; Smoking Policy Institute (Seattle) 355 Jacobson, Miriam; Washington Business Group on Health 363 Sharkey, Brian; University of Northern Colorado 385 Joseph, Pat; United States Air Force, Lowly Air Force Base, Denver 386 Gorchow, Margo; Botsford General Hospital (Farmington Hills, Michigan) 394 Rothert, Marilyn; Michigan State University 39S Chiu, Sunny; Michigan Department of Public Health 405 Myers, Jr., Woodrow; Indiana State Board of Health 406 Hacker, Sylvia; University of Michigan 426 Kaminsly, Kenneth; Wayne County Intermediate School District (Michigan) 429 Warner, Kenneth; University of Michigan 440 Arnold, Charles; Metropolitan Life Insurance Company 448 Warshaw, Leon; New York Business Group on Health 459 Ostleld, Adrian; Yale University 460 Addiss, Susan; Quinnipiack Valley Health District (Connecticut) 465 Entmacher, Paul; Metropolitan Life Insurance Company 467 Aguirre-Molina, Marilyn and Lubinski, Christine; National Council on Alcoholism 470 Bright, Frank; Ohio Department of Health 477 Speert, Ellen; American Art Therapy Association 500 Medrano, Martha; University of Texas Health Science Center at San Antonio 511 Bahr, Raymond; St. Agnes Hospital (Baltimore) 573 Wilhoit, Gene; National Association of State Boards of Education 578 McGuire, Judi and Crowder, Aletha; The National PTA 586 Fosco, Angelo; Laborers' International Union of North America 590 Philipps, Carol; Wisconsin Department of Public Instruction Health Promotion and Disease Prevention in Community Settings 97

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593 Bradley, Chet; Wisconsin Department of Public Instruction 595 Leventhal, Marcia; New York University and BrooksSchmitz, Nancy; Columbia University 596 Perry, Jean; American Alliance for Health, Physical Education, Recreation and Dance 615 Hargreaves, Margaret, et al.; Meharry Medical College 644 Merijanian, Jeanette; University of Montevallo (Montevallo, Alabama) 675 Teague, Wayne; Alabama Department of Education 689 Aldrich, Robert; University of Washington 691 Gilchrist, Lew; University of Washington 697 Klingbeil, Karil; University of Washington 707 Lange, Charles; Loyola University (Chicago) 711 Tonsberg, Robert; Indian Health Service/VVind River Indian Reservation (Fort Washakie, Wyoming) 729 Dohrenwend, Bruce; Columbia University 731 Gaffney, Donna; Columbia University 734 West, Jack; Puro Corporation of America (Maspeth, New York) 736 Wood, Loring; NYNEX Corporation 761 Henderson, James; Pacific Bell 98 Healthy People 2000: Citizens Chart the Course