HOW TO DEVELOP THE BASIC AND APPLIED SCIENCE OF HEALTH PROMOTION

Part of the Health Promotion FIRST (Funding Integrated Research, Synthesis and Training) legislation we are advocating¹calls for development of a strategic plan on how to best develop the basic and applied science of health promotion. This plan might include three basic elements:

1. A research agenda identifying the important research questions to be answered,
2. Review of the resources required to answer these questions, and
3. An outline of the optimal mix of state, federal, and private organizations to provide these resources. Each of these elements is briefly discussed below.

Research Agenda

The research agenda would identify the important questions that must be answered for us to understand how to provide effective health promotion programs to all segments of society and the extent to which we know the answers to those questions. Basic questions might include the following:

1) What are the relationships between health practices and health outcomes? A large and rigorous body of literature has demonstrated that behaviors such as tobacco use, overeating, substance abuse, etc lead to negative health outcomes and that other behaviors such as physical activity, eating nutritious foods, relaxation, etc. lead to positive outcomes.² However, the mechanisms for these relationships are sometimes not clear. For example, the interaction of genetics, behaviors, and social influences is not clear. Why does one smoker contract cancer and another does not? Why can some societies consume higher fat diets and smoke more cigarettes yet have lower rates of heart disease? The direction of causality is also not well established in some epidemiological studies. For example, the prevalence of diabetes, hypertension, cholesterolemia, and other conditions is higher among obese people, but the extent to which those problems are caused by obesity, rather than the problems leading to inactivity which in turn leads to obesity, must be clarified.

2) What strategies are most effective in producing lasting health behavior change among all the different segments of society? Hundreds of studies have shown that health promotion programs can help people quit smoking, manage stress, eat more nutritious foods, exercise on a regular basis and in turn improve cardiovascular conditioning, muscle strength, reduce body fat, blood pressure, cholesterol, and improve other health conditions.³ Furthermore, the theoretical basis of behavior change efforts has evolved significantly in the last two decades. However, we still do not know the optimal combination of education, skill building, social unit transformation, policy change, and environmental change necessary to produce short term or lasting change, let alone the most cost-effective combination. Our knowledge is even weaker in addressing the needs of children and older adults, different ethnic and racial groups, and different education and income levels. We also do not have clear protocols on the most effective strategies for workplace, school, clinical, family, or neighborhood-based programs. Many programs have drawn on the disciplines of health education, psychology, exercise physiology, nutrition, medicine, and nursing, but most have not drawn on the disciplines of agriculture, anthropology, child development, environmental planning, organization development, tax policy, transportation engineering, and other disciplines that study how physical and social environment are shaped.

3) What are the relationships between health conditions and medical costs, productivity, academic and professional achievement at the organizational and societal level, and what are the impacts of health promotion programs on these outcomes? A growing body of literature has demonstrated that a large portion of medical costs can be attributed to tobacco use, stress, obesity, inactivity, and other lifestyle behaviors and conditions, and that health promotion programs can reduce these costs.⁴ The number of these studies needs to increase and the rigor must be improved. Outcome measures need to include the full spectrum of productivity, academic and professional achievements and other factors important to organizations and society. Furthermore, the unit of analysis needs to be expanded; most of these studies have focused on organizational level costs, and very few have focused on societal- or individual-level relationships. For example, if lifestyle-related health conditions impact employer profits through medical utilization, employee productivity, and a person's retirement age, how does this impact federal receipts from individual and corporate income taxes, and Social Security and Medicare payroll taxes? How do health conditions impact Medicare utilization and Social Security payments? How do all of these factors impact the federal deficit and related interest payments, as well as global competitiveness, the unemployment rate, and the national trade deficit? Understanding the answers to these questions is important for the nation to determine the amount of resources to devote to health promotion. At the other end of the scale, how do health conditions impact the individual financially or professionally? The answers to these questions will help us understand how motivated people will be to change.

Resources Required to Answer the Questions

Once we understand the questions that need to be answered, we can determine the resources required to answer those questions. An important part of the answer is that we need more money to directly fund research, but this is only part of the answer. Do we have the human resources we need to conduct this research? Do we need more experts in health promotion content, program management, program evaluation, or research methods? Do we have sufficient educational institutions and faculty to train them? Are there sufficient financial rewards and career opportunities to attract students and faculty to these programs? Do we have access to validated measurement tools, and knowledge of appropriate analysis methods? Do we have access to research subjects in the form of employees, patients, students, community residents, and organizations and communities in which they are based? What needs to be changed to secure all of these resources?

In answering these questions, we need to have a sense of the level of societal will to answer these questions. Leading scientists and the health agencies of the federal government have known that lifestyle is the primary cause of death for over 25 years.¹ They have also known that the United States spends more than twice as much per capita on health care as virtually every nation of the world, yet ranks near the bottom of the developed nations in life expectancy, portion of life that is disability free, infant mortality and other measures of good health.^6,7 Nevertheless, as a nation, our investments in health promotion are so small they are not even tracked. The U.S. Department of Health and Human Services has identified “Reduce the major threats to the health and well-being of Americans” as its number one priority,⁸ yet its investments in health promotion have remained flat. In fact, newly announced programs including "Steps to a Healthier U.S.", and the expanding smoking quit lines⁹ have been funded by cutting existing health promotion budgets at CDC and National Cancer Institute. It is clear that national health policy is not driven by the goal of investing resources in efforts that will have the greatest impact on improving health. What does drive the policy? Is it the financial interests of the medical field, or the educational and research communities? Is it the political influence of these or other groups? Is it ideology? Until we know the answer to this question, we will not be able to gather the resources required to develop the basic and applied science of health promotion.

Optimal Mix of Research and Educational Organizations and Disciplines

Once we have a clear sense of the questions that need to be answered, and the resources needed to answer them, we can identify the optimal combination of public and private organizations most able to fund and conduct the research, as well as train researchers and practitioners. Funding should probably come from a combination of federal and state governments, foundations, and the employers and other organizations that will benefit from the programs. A wide range of federal health research and service organizations should be involved in conducting the research, including but not limited to the National Institutes of Health, Centers for Disease Control and Prevention, National Science Foundation, Health Resources and Services Administration, the Agency for Healthcare Research and Quality, the Centers for Medicare & Medicaid Services, and the Substance Abuse and Mental Health Services Administration. Other federal departments might include the Departments of Agriculture, Transportation, Interior, Education, and others. A wide range of schools of business, city planning, education, exercise science, nursing, public health, public policy, psychology, medicine, nursing, transportation, and social work, as well as private research institutes, need to be involved in conducting research and training students. All of these organizations should draw on the most talented health promotion experts. Health promotion is largely an art, versus a science, and that art has been developed by practitioners, not scientists. As such, the primary expertise of health promotion resides in the practice community, not the research community, so it is critical that the practice community serves a central role in all research efforts.

A comprehensive plan of this nature is an important first step in developing the basic and applied science of health promotion. With that science base in place, we can transform the art of health promotion into a well-grounded and effective science, and provide effective health promotion programs to the nation and the world.

References

1. Health Promotion Advocates. Available at: http://www.HealthPromotionAdvocates.org. Accessed March 30, 2004.
2. US Department of Health and Human Services. Healthy People 2010 Objectives. Washington, DC: US Government Printing Office; 1999.
3. Wilson M, Holman PB, Hammock A. A comprehensive review of the effects of worksite health promotion on health-related outcomes. Am J Health Promot. 1996;10:6.
4. Aldana SG. Financial impact of health promotion programs: a comprehensive review of the literature. Am J Health Promot. 2001;15:296–320.
5. US Department of Health Education and Welfare. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. Washington, DC: US Government Printing Office; 1979.
6. Anderson GF, Hussey PS. Charts from multinational comparisons of health systems data, 2000. Charts VIII1–VIII11 and IX1–IX2 available at http://www.cmwf.org/ programs/international/comp_chartbook_charts4.asp#chart8-1. Accessed March 30, 2004. Also see Reinhardt UE, Hussey PS, Anderson GF. Cross-national comparisons of health systems using OECD data, 1999. Health Affairs. 2002;21:169–181.
7. World Health Organization. The World Health Report, 2001. Healthy life span data is located in Annex Table 4. Available at: http://www.who.int/whr2001/ 2001/main/en/annex/annex4.htm. Accessed March 30, 2004.
8. Department of Health and Human Services. Strategic Plan for FY 2001–2006. Goal one is available at http://aspe.hhs.gov/hhsplan. 9. Tommy G. Thompson, February 18, 2004, Conference on chronic disease prevention and control. Available at: http://www.hhs.gov/news/speech/2004/040218.html. Accessed March 30, 2004.

Michael P. O'Donnell, PhD, MBA, MPH
Editor in Chief, American Journal of Health Promotion