Reflections on the 25th Anniversary of Publishing the American Journal of Health Promotion: People, Scientific Progress, and Missteps

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People

As in any endeavor, people have been the most important element of my work on the Journal. In paging through the 141 issues and nearly 2000 articles we have published, I thought about the thousands of authors who have published their work in our pages, even more who have submitted their work and had it rejected, and the hundreds of scholars who have served on our editorial team as editors and reviewers. Tens of thousands of hours have been donated by our editorial teams in reviewing manuscripts. Scholars donate this time as a service to fellow scholars, with the goal of enhancing the scientific foundation of our field, which of course is dedicated to enhancing the health and quality of life of people of the world. When I selected the initial members of our editorial team, my primary criteria was to recruit the most talented up-and-coming experts in each of the many disciplines of health promotion.  I was 32 years old and most of our editorial team members were in their 30s or 40s. Well, I was either really lucky or really smart in my choices, because so many of our team members went on to become deans and presidents of colleges or universities, heads of major government agencies or professional associations, award-winning scientists, founders or leaders of major health promotion companies, or authors of best-selling books. Most of them also became spouses, parents, grandparents, and friends; some of them are among my closest friends, and unfortunately, several have passed away. Fourteen of those who  joined our team in the first 18 months have stuck with us through the current day. Those 14 are David Anderson, Judd Allen, Allan Best, Bill Baun, Steve Blair, Larry Chapman, Michael Eriksen, Jonathan Fielding, Barry Franklin, Ron Goetzel, Larry Green, Gil Omenn, Dean Ornish, and Ken Pelletier. All of them have shared some thoughts about what has transpired in those 25 years. Their comments can be found in our online edition at this link (http://www.ajhpcontents.com/toc/hepr/25/4). Reflecting on the past 25 years has also helped me appreciate the small staff that has made the Journal a reality. They have put up with me through all my travels, ups and downs, and changes in the business of publishing. One of them, Valerie James, has stuck with me for 15 years!

Scientific Progress

In 1986, ours was a field of hope and possibility. The Surgeon General’s report of 1964¹ had removed any doubt about the link between tobacco and death, and the Surgeon General’s Healthy People report in 1979² provided a conceptual framework to guide the growth of the field. However, there was insufficient empirical evidence that quitting smoking reduced premature death, or that exercise enhanced health. Obesity was not a visible public health problem, with only 6% of children³ and 20% of adults overweight⁴ and 5% of adults obese.⁵ It was logical that employees who practiced healthy lifestyles had lower medical care costs, but there were no data to prove this. There was an emerging research literature showing that workplace health promotion programs improved health, but the rigor of these studies was poor, and there were no studies demonstrating that workplace health promotion programs saved money. Theoretical frameworks to guide the structure of programs were sparse. The Health Belief Model⁶ had been articulated 20 years earlier and was popular among academics, but was virtually unknown by practitioners, and did not prove to be very useful in developing effective programs. Dr. Albert Bandura had published his book on social cognitive theory⁷ in 1986, but his theories had not yet reached practitioners. In short, health promotion was an emerging art with minimal scientific foundation. At the time, very few journals published research on this emerging science. My dream in establishing the American Journal of Health Promotion was to help make a contribution to enhancing the scientific foundation of the field by providing a publishing forum for the many disciplines becoming involved in health promotion and to narrow the gap between research and practice

In the past few months, I have thought about the evolution of our field throughout the past quarter century and have been astounded to see how far we have come. I reviewed the tables of contents of the Journal since our inception, and did an informal review of the other journals I normally read. My goal was to pull out a dozen or so articles that documented important developments of the past quarter century. Not surprisingly, I found several hundred articles that could have been included. I disciplined myself to choose 25 major developments, one for each of our 25 years of existence (but then added three more that I just could not drop). Each of these critical development is documented by one or more articles. Some are landmark articles that were the first to document the development. Others were not the first article published, but have special significance to me because they were published in the American Journal of Health Promotion, were authored by a member of our editorial team, or were the article that first captured my attention about an important issue. It is gratify to see that 13 of these important developments were documented in articles published in the American Journal of Health Promotion, and an additional 9 were authored by members of our editorial team. Each of the developments is classified as an approach or concept (C), relationship between behaviors or conditions and health or financial outcomes, or epidemiology (E), impact of programs on health or financial outcomes (I), or analysis of specific methods, or what works best (W). Given the emerging nature of our field, it is not surprising that 17 of the developments are related to concepts or epidemiology, while only four are related to program impacts and seven to what works best. I suspect that we would find a similar pattern if we did a systematic review of the literature and classified all of the important developments. Going forward, our field needs to focus more attention on what works best if we want our programs to have the greatest effect. These developments are listed and described below in chronological order.

1986—Secondhand Smoke Kills People (E). The Health Consequences of Involuntary Smoking: A Report of the Surgeon General.⁸ This report of Surgeon General C. Everett Koop, with David M. Burns serving as senior scientific editor, erased any doubts about secondhand smoke’s killing people. It had three primary conclusions: (1) Involuntary smoking is a cause of disease, including lung cancer, in healthy nonsmokers. (2) The children of parents who smoke compared with the children of nonsmoking parents have an increased frequency of respiratory infections, increased respiratory symptoms, and slightly smaller rates of increase in lung function as the lung matures. (3) The simple separation of smokers and nonsmokers within the same air space may reduce, but does not eliminate, the exposure of nonsmokers to environmental tobacco smoke. This report led to several decades of research quantifying the health impact of secondhand smoke and stimulating changes in policy that now protect most people from secondhand smoke exposure at work, people in many states from exposure in all public places, and many children from exposure at home even when their parents smoke.

1989—Being Fit Reduces Mortality Rates (E). “Physical Fitness and All-Cause Mortality. A Prospective Study of Healthy Men And Women.”⁹ This 1989 longitudinal study of 10,224 men and 3120 women was the first large-scale longitudinal study with objective measures of fitness that showed a connection between baseline fitness and future mortality rates. The most fit men and women at baseline had mortality rates died 8 years later and had mortality rates that were about one-fifth of those in the least fit category. The lead author, Dr. Steven Blair, is a founding member of the American Journal of Health Promotion editorial team.

Health Promotion Should Be Integrated Into National Health Policy (C).  “Health Promotion Must Be Incorporated Into National Health Insurance Proposals.” ¹⁰ This editorial marked the beginning of efforts of the American Journal of Health Promotion to engage the health promotion community in advocacy efforts to integrate health promotion into national health policy. These efforts eventually resulted in creating a nonprofit organization (Health Promotion Advocates) that was successful in working with members of the U.S. Congress to craft legislation to create a national health promotion plan, enhance health promotion research, and help employers implement and evaluate health promotion programs. These provisions were incorporated into the Patient Protection and Affordable Care Act that became law in 2010.

1992—Changing Beliefs Is Not Enough to Change Behavior (W). “A Meta-Analysis of Studies of the Health Belief Model With Adults.”¹¹ This meta-analysis of the Health Belief Model, the most prominent model shaping design of health promotion programs at the time, showed that the components of the model explained only .1% to 9% of the variance in behavior change and that beliefs were one of the weakest predictors. This article was important because it was one of the first to help health promotion professionals understand that making people aware of health risks and changing their beliefs is not enough to change behavior. One of the coauthors, Dr. Lawrence Green, is one of our founding editors.

Excess Television Viewing Is Associated With High Cholesterol (E). “Relationship Between Serum Cholesterol Levels and Television Viewing in 11,947 Employed Adults.”¹² This study of 11,947 adults was one of the first large-scale studies of a growing literature showing that excess television viewing is associated with adverse health outcomes. It was published in the American Journal of Health Promotion.

Social Ecological Approach to Health Promotion Is Articulated (C). “Establishing and Maintaining Healthy Environments. Toward a Social Ecology of Health Promotion.”¹³ This manuscript was the first to articulate the social ecological approach to health promotion in a way that could help practitioners develop programs and scientists design studies to test the approach. The social ecological approach emphasizes the transactions between individual or collective behavior and the health resources and constraints that exist in environmental settings. This article was important because it helped push the field from a classic health education approach toward comprehensive and systematic solutions. This approach was consistent with the approach advocated by American Journal of Health Promotion in the definition of health promotion published in our premier issue in June of 1986,.¹⁴  The definition was updated in the fall of 1986,¹⁵ in 1989,¹⁶ and in 2009.¹⁷  In the 2009 definition, we  defined optimal health as a “dynamic balance of physical, emotional, social, intellectual and spiritual health” and suggested that changing health behaviors required a combination of efforts to enhance awareness, build skills, and provide opportunities to make healthy choices the easiest choices. The author, Dr. Daniel Stokols, is a long-standing member of the American Journal of Health Promotion editorial team.

1993—Financial Incentives Increase Participation but Don’t Change Health Behavior (W). “The Impact of Incentives and Competitions on Participation and Quit Rates in Worksite Smoking Cessation Programs.”¹⁸ This systematic review of the literature on workplace quit-smoking programs was one of the first of many to conclude that financial incentives are very effective for increasing participation in health promotion programs but probably have little if any impact on actual health behavior change. It was published in the American Journal of Health Promotion.

1996—Workplace Health Promotion Programs Improve Knowledge, Health Behavior, and Health Conditions but Little Evidence Exists for Long-Term Change (I). Also, Personal Goal Setting Doubles Success Rates in Workplace Health Promotion Programs (W). “A Comprehensive Review of the Effects of Worksite Health Promotion on Health-Related Outcomes.”¹⁹ This was the first systematic review of the literature on the health impact of workplace health promotion programs, and was prepared in conjunction with the Centers for Disease Control and Prevention. It included critiques of the methodological quality of the literature and summaries of the health impact of programs from 381 studies on 14 topics (alcohol, cholesterol, exercise, health risk assessment [HRA], human immunodeficiency virus/acquired immune deficiency syndrome, (HIV/AIDS) hypertension, nutrition, seat belt use, smoking cessation, smoking policy, stress management, weight control, and multicomponent programs) and resulted in 14 manuscripts by 22 authors. It showed that the methodological quality of studies was approaching acceptable standards, and that workplace health promotion programs improved knowledge, health behavior, and health conditions, but that there was very little evidence of lasting change, in part because most programs and studies were of short duration. This series of articles was published in the American Journal of Health Promotion. Within this set of reviews, the review of multicomponent programs²⁰ was especially important because it was one of the first to show that including goal setting in a program doubles the program success rates.

1997—Applying the Stages of Change Construct Improves the Impact of Programs. (W) “The Transtheoretical Model of Health Behavior Change.”²¹ The Stages of Change concept from the Transtheoretical Model was the first empirically based theory that provided practitioners with a practical framework to guide construction of health promotion programs. It has become the basis of most high-quality workplace health promotion programs. The special issue of the American Journal of Health Promotion in which this article appeared was the first compilation of studies that apply the construct. Dr. James Prochaska, the codeveloper of the model and coeditor of this issue, is a long-standing member of the American Journal of Health Promotion editorial team.

Self-Efficacy Predicts Likelihood of Attempting Changes, Maintaining Effort, and Time to Relapse, and Self-Efficacy Can Be Enhanced (W). Self-Efficacy: The Exercise of Control.²² Self-efficacy is one of the most powerful concepts in health promotion because it is easy to measure and relatively easy to enhance, and because it is one of the most powerful cognitive factors that predicts likelihood of attempting change, maintaining effort, and time to relapse. Although Dr. Albert Bandura started discussing this concept in the 1970s,²³ his 1997 book made these concepts tangible to practitioners.

1998—Health Promotion Can Reverse Heart Disease and Possibly Prostate Cancer (I). “Intensive Lifestyle Changes for Reversal of Coronary Heart Disease.”²⁴This study, one of a series published by Ornish and colleagues starting in 1990, provided persuasive documentation that regression in coronary atherosclerosis could be maintained and even improved for 5 years through a comprehensive health promotion program. This type of regression had not been achieved with traditional medical care. Subsequent studies by Ornish and colleagues have shown that heart disease risk factors can be reduced in large populations in multiple settings in programs conducted by trained professionals,²⁵ and that it may be possible to slow the progression of prostate cancer with similar interventions.²⁶ Dr. Dean Ornish is a founding member of the American Journal of Health Promotion editorial team.

Healthy Lifestyle in Early and Mid Adulthood Delays Onset of Disability by 5 to 9 Years (E). “Aging, Health Risks, and Cumulative Disability.”²⁷ This 30+--plus-year longitudinal study of 1741 university alumni supported the compression of morbidity hypothesis²⁸ put forth by Dr. James Fries 18 years earlier that suggested healthy lifestyle would result in people having a shorter period of disability at the end of life. Dr. Fries is a long-standing member of the American Journal of Health Promotion editorial team.

Unhealthy Lifestyle Practices Are Associated With Higher Medical Costs for Employers (E). “The Relationship Between Modifiable Health Risks and Health Care Expenditures. An Analysis of the Multiemployer HERO Health Risk and Cost Database.”²⁹ This 1998 study of 46,026 employees from six employers was the first large-scale study to demonstrate that employees with unhealthy lifestyle practices have higher medical costs. Dr. Ron Goetzel, lead author of the study, is a long-standing member of the American Journal of Health Promotion. A follow-up study published in the American Journal of Health Promotion showed that lifestyle factors accounted for approximately 25% of medical costs for these employers.³⁰

2000—People Who Eat Nutritious Foods Have Lower Mortality Rates (E). “A Prospective Study of Diet Quality and Mortality in Women.”³¹ This prospective cohort study of 42,254 women showed that women who ate nutritious foods had 79% lower risk of death from all causes, heart disease, and cancer. A similar study of 40,837 men found that men with more nutritious diets had lower risk of death rates from all causes and heart disease but not cancer.³²

2001—Workplace Health Promotion Programs Save Money and Produce Returns on Investment (ROI) of More Than $3.00 to $1.00 (I). “Financial Impact of Health Promotion Programs: A Comprehensive Review of the Literature.”³³ This was the first systematic review of the literature on the financial impact of workplace health promotion programs and the methodological quality of the studies. It included 72 qualifying studies and showed that 88% of 32 programs reduced medical costs and 100% of 18 programs reduced absenteeism, with ROI’s of $3.93 to $1.00 and $5.07 to $1.00 respectively. This was part of a special issue that included 2 other reviews, 2 manuscripts on methodological challenges, 2 manuscripts on applications, and 15 commentaries. Copies of this special issue were delivered to all members of the U.S. Senate and House of Representatives, and launched formal support by the American Journal of Health Promotion of efforts to integrate health promotion concepts into national health policy. Many of the authors were members of our editorial team.

Keeping Employees Healthy May Save More Than Helping Them Improve Bad Habits (E and I). “Emerging Research: A View From One Research Center.”³⁴ This report of preliminary findings revealed several important trends. First, it showed that numbers of health risks and medical costs are closely related, and that costs change as risks change. Second, it showed that there seems to be a natural flow of level of health risks and related medical costs among employees. For example, employees with low risk (0–2 risks, 0–$999 costs) can remain low risk or can move to moderate risk (3–4 risks, $1000–$4999 risks) or high risk (5 or more risks, $5000+ costs). Third, among employees who reduced risks, medical costs dropped an average $150 per risk/year, whereas among employees who increased risks, medical costs increased an average of $350 per risk/year. This work was important because it provided the first empirical evidence to support a population health approach in which the goal is to keep healthy employees healthy and to help at-risk employees reduce their health risks. This accelerated the shift of programs’ focus from employees with high health risks to all employees. It was published in the American Journal of Health Promotion.

Productivity Enhancements May Produce More Savings Than Medical Cost Reductions (E). “The Effect of Disease Prevention and Health Promotion on Workplace Productivity: A Literature Review.”³⁵ This was the first systematic review of the literature on the impact of workplace health promotion programs on productivity. Its primary contribution was to identify weaknesses in how productivity is measured and how the relationship between health promotion programs and productivity was studied. This provided a foundation on which to build this important emerging field of study. This area of study is important because savings from productivity may occur faster and be greater than savings from medical costs. This review documented encouraging preliminary findings that the payback from productivity enhancements will come before medical cost savings; exercise programs reduce absenteeism and turnover, especially when they reduce low back pain; smoking cessation programs reduce time away from work for smoking breaks; vaccination programs reduce absenteeism; and stress increases absenteeism and performance. It was published in the American Journal of Health Promotion.

2002—Health Promotion Prevents Onset of Diabetes Better Than Drugs or Medical Care (I). “Reduction in the Incidence of Type 2 Diabetes With Lifestyle Intervention or Metformin.”³⁶ This study randomized 3234 obese prediabetic men and women into usual medical care, metformin, or lifestyle (exercise and weight control) treatments with an average follow-up of 2.8 years. The lifestyle intervention reduced incidence of diabetes by 58% whereas the metformin group reduced it by 31% compared to the usual-care group. This study captured the attention of Tommy Thompson, the Secretary of Health and Human Services, and was instrumental in making Congress and the White House interested in integrating health promotion into national health policy.

2003—Urban Sprawl Is Associated With Amount of Walking, Obesity, and Hypertension (E). “Relationship Between Urban Sprawl and Physical Activity, Obesity, and Morbidity.”³⁷ This study of 206,992 adults in 448 U.S. counties was the first large-scale study to establish a link between the physical structure of communities and obesity. It was featured in more than 350 TV shows and in every major newspaper in the United States. It was one of the articles in a special issue of American Journal on Health Promotion on “Health Promoting Community Design” that documented the emergence of active living as a field of study and practice.

Medical Costs for Smokers Increase When They Quit Because They Were Already Sick (E). A pair of articles published in the November/December 2003 issue of American Journal of Health Promotion provided the solution to the nagging mystery of why medical costs usually increase for people in the year after they quit smoking. The article by Martinson et al³⁸ showed that people with higher medical costs or with chronic disease were more likely to quit smoking than those with lower costs or no chronic disease. The article by Musich et al³⁹ showed that it takes 10 years after quitting for medical costs of smokers with chronic diseases to return to those of nonsmokers and 5 years for those with no chronic diseases. The first authors of both studies were members of our editorial team.

2004—Smoking Tobacco Reduces Life Expectancy 10 Years, and Quitting Early Restores All Of Those Years (E). “Mortality in Relation to Smoking: 50 Years’ Observations on Male British Doctors.”⁴⁰ This 50-year longitudinal study of 34,439 U.K. physicians showed that smoking doubled the death rate for most age ranges and reduced life expectancy about 10 years, but quitting by age 60, 50, 40, and 30 restored 3, 6, 9, and 10 years of life respectively. This was the largest and longest-lasting study of this kind and was one of the most perfectly executed studies ever conducted. It involved two-thirds of all the physicians in the United Kingdom at the time of inception and had an annual attrition of less than .025.

Motivational Interviewing Can Be Applied to Health Promotion (C). “Motivational Interviewing in the Service of Health Promotion.”⁴¹ This article, authored by one of the cocreators of motivational interviewing, was one of the first to describe how an interviewing technique developed for addiction treatment could be applied broadly to health promotion programs. It was important because motivational interviewing has become one of the important techniques in health promotion. It was published in the American Journal of Health Promotion.

Senator Tom Harkin Is a Champion for Health Promotion (C). “Health Care, Not Sick Care.”⁴² This editorial in the American Journal of Health Promotion announced Senator Harkin’s intentions to introduce a bill called The Healthy Lifestyles and Prevention (HELP) America Act. The bill had four major sections: Healthy Kids and Schools, Healthy Communities and Workplaces, Responsible Marketing and Consumer Awareness, and Reimbursement for Preventive Services. Many of these provisions were incorporated into the Patient Protection and Affordable Care Act signed into law March 23, 2010. I worked with Senator Harkin’s staff for more than a decade to advance these concepts, and hundreds of American Journal of Health Promotion editors and subscribers were active advocates in these efforts.

2007—Tailoring Messages Improves Outcomes (W). “Does Tailoring Matter? Meta-Analytic Review of Tailored Print Health Behavior Change Interventions.”⁴³ This review drew data from 57 studies to yield a sample of 58,454 used in a meta-analysis on the effects of tailoring messages on health behavior change. It showed sample size–weighted mean effort size of r = .074 and found that the following variables moderated effect: (1) type of comparison condition, (2) health behavior, (3) type of participant population (both type of recruitment and country of sample), (4) type of print material, (5) number of intervention contacts, (6) length of follow-up, (7) number and type of theoretical concepts tailored on, and (8) whether demographics and/or behavior were tailored on. This article was important because it was the first systematic review of tailored messaging. The concept of tailoring has evolved beyond messaging to a broader approach in which our entire interventions are tailored to meet the needs of specific populations or individuals. Tailored approaches are one of the most promising strategies available to enhance outcomes.

Fitness Is More Important Than Obesity in Predicting Mortality (E). “Cardiorespiratory Fitness and Adiposity as Mortality Predictors in Older Adults.”⁴⁴This longitudinal study of 2603 older adults who completed a maximal exercise test and series of measures of adiposity in 1979–2001 showed that most measures of adiposity were independent predictors of all-cause mortality, but not after controlling for fitness level. This study is important because of its potential to help shift the focus of health promotion interventions from weight control (which usually fails), to enhancing fitness (which is often successful), and because it was coauthored by Dr. Steven Blair, who was the first to raise this issue more than a decade earlier, and is also one of our founding editors.

2008—Friends, Especially Good Friends, Influence Weight Gain, Quitting Smoking, Quitting Drinking, and Happiness (E). “The Spread of Obesity in a Large Social Network Over 32 Years.”⁴⁵ A series of studies by Nicholas Christakis and James Fowler and colleagues examined the social relationships documented among 12,067 people involved in the Framingham Study between 1971 and 2003 and discovered that friends, especially close friends, have a powerful influence on weight gain,⁴⁵ quitting smoking,⁴⁶ quitting drinking,⁴⁷ and levels of happiness.⁴⁸ These studies were important because they illustrated an innovative method to draw important findings from existing data sets and because they are the first series of large-scale longitudinal studies on the impact of relationships on a wide variety of health behaviors. They help us understand the powerful impact of social relationships on health behaviors and will hopefully shape how programs are designed.

2009—90%+ HRA Participation Rates Can Be Achieved With Financial Incentives Integrated Into Health Plans, Effective Communication, and Strong Culture (W). “The Role of Incentive Design, Incentive Value, Communications Strategy, and Worksite Culture on Health Risk Assessment (HRA) Participation.”⁴⁹ This study of 36 employers and 559,988 employees was the second large-scale study (the first⁵⁰ was published in 2008) explaining the predictors of HRA participation rates. It showed that HRA participation rates were in the 70% to 90% range when employers offered financial incentive, integrated incentives into the health plan design, and had effective communication campaigns and a supportive culture, compared to 30% to 40% for those that did not. This study is important because it illustrates that employers can determine the level of participation they wish to achieve in HRA programs and implement efforts to achieve those rates. This study was published in the American Journal of Health Promotion.

2010—Health Assessment + Feedback Is Not Enough; Skill Building Is Also Needed (W).
“What Works in Worksite Health Promotion: Systematic Review Findings and Recommendations From the Task Force on Community Preventive Services.”⁵¹ The core finding of this systematic review of the literature on the health impact of workplace health promotion recently completed for the Centers for Disease Control and Prevention’s (CDC) Community Guide by the Task Force on Community Preventive Services was that workplace health promotion programs that include health assessment plus feedback are not very effective in changing behaviors, but programs that include health assessment plus feedback plus skill building are effective. Many of the members of the task force are members of the editorial team of the American Journal of Health Promotion.

Missteps and Future Challenges: Probably Inability to Communicate

I may be naïve, but my general sense is that the field of health promotion has developed wonderfully. I think that part of its success is because of the fact that it was always an orphan industry and branch of science. Because of this, it attracted dedicated people who were passionate about helping others and refining the methods in a new field rather than attracting people whose primary motive was to make money or achieve notoriety. Being an orphan field led to slow growth. (Total annual revenues for the entire field of workplace health promotion are probably in the $2–$3 billion dollar range. To put this in perspective, there are 54 hospitals in the United States with gross revenues of more than $3 billion and 149 with revenues of more than $2 billion.) Slow growth allowed us to test strategies before applying them widely. It also forced us to be innovative in thinking about how we could have the greatest impact on people’s health with limited funds. With no core philosophy or technology to dominate thinking, diverse perspectives were allowed to flourish, and diverse scientific and practice groups worked together to incorporate health promotion into their basic approaches. This in turn helped us realize that our society will be most healthy when health promotion concepts are integrated into transportation, agriculture, city planning, education, recreation, and other aspects of society, in addition to health care. If we had taken a different course, the outcome could have been disastrous. For example, if my early dreams of integrating health promotion into medical care had come true, and medical organizations became the primary provider of programs, the health promotion field might have followed the same course as the medical field in the United States, a field that has attracted highly talented and dedicated people who are guided by sophisticated science and supported by elaborate technology, but that has resulted in a medical care system spending twice as much as any other nation and producing medical outcomes that are sometimes miraculous, but with overall population health outcomes, like infant mortality, that are worse than those in Cuba.⁵² I don’t mean to imply that health promotion concepts should not be integrated into medical care; in fact, I believe that health promotion can significantly enhance medical outcomes and reduce costs in many cases. I also believe that the extensive network of hospitals and doctors can help us reach a huge slice of the population that we would not otherwise reach. However, if this integration had occurred before we had three decades of experience and before a well-developed scientific foundation had evolved, we might never have developed the very effective strategies in place today.

Ironically, the path of our evolution, which led us to the wonderful place we have reached, has also caused us to be highly fragmented. This fragmentation is the likely cause of what I think is one of the biggest setbacks the field of health promotion has experienced to date, and may also present our biggest challenge going forward. Because our field is so fragmented, it is very difficult for all the diverse professions involved in health promotion to communicate with each other. A perfect and unfortunate illustration of this problem occurred with the implementation of the Genetic Information Nondiscrimination Act (GINA).⁵³ The GINA legislation was advanced by genetic scientists who were having trouble recruiting people for their studies because people were concerned about the confidentiality of their genetic information. This bill created safeguards to insure the confidentiality of genetic information, was widely supported by the scientific community, and passed in the U.S. Congress with broad bipartisan support. However, when the regulations were written to guide the implementation of this bill, a coalition led by the American Heart Association (AHA) and the American Cancer Society (ACS) suggested some provisions that have little connection to genetic information and significantly reduce the effectiveness of health promotion programs. These regulations state that HRA questionnaires cannot ask questions about family history (of heart disease, cancer, etc.) if a financial incentive is offered to complete the HRA. As a result, most workplace health promotion programs removed questions about family history because the only effective way to get high participation rates is to provide a financial incentive (as we learned from the study by Seaverson et al.⁴⁹). Unfortunately, removing information about family history significantly reduces the ability of an HRA to estimate an individual’s risk of developing a lifestyle-related disease, and of developing the most effective strategy to prevent that disease from developing. Because of the efforts of the AHA/ACS coalition, genetic scientists have access to information on family history, but health promotion program counselors do not. The real irony is that family history is a more effective predictor of disease than genetic information,⁵⁴ probably because family history is closely related to family norms related to eating, smoking, physical activity, alcohol use, etc and so forth. The further irony is that the AHA and ACS are not adversaries of the health promotion field; on the contrary, they may be the most effective advocates of healthy lifestyle in the entire nation. Similarly, many health promotion professionals support their efforts as volunteers and staff members. Furthermore, I have no doubt their intentions were to help patients in some way. In short, these are our good friends. This problem occurred because communication between the health promotion community and the policy leaders at AHA and ACS were inadequate. That does not bode well for our future. The era of slow growth of the health promotion field is over; demand for health promotion programs is growing in the United States and globally in workplace, clinical, and community settings, and integration into national policy is accelerating in many countries, especially the United States.⁵⁵ With this growth, it is inevitable that the field will attract people who are more interested in making money than helping people. Its growth will divert resources for scientific funding and spending on services from other fields, and those fields will fight to retain their resources.  In short, we will have powerful adversaries for the first time. Therefore, our biggest challenge is to learn how to communicate effectively with both our friends and our adversaries.

Michael P. O’Donnell, MBA, MPH, PhD
Editor in Chief

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