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Scientific base of health promotion
PREVENTIVE
MEDICINE
15, 439-441
(1986)
Forum: The Health Promotion Sciences in Chronic Disease Prevention The Scientific
Base of Health
DONALDC. Cancer Control Institute, Blair
Science Building,
Program, Room
Promotion
IVERSON, PH.D.
Division of Cancer Prevention and Control, 432. Nationul Institutes of Health, Bethesda,
Nutionul Marylund
Cancer 20892
Interest in, and support for, health promotion has grown steadily since the release of two landmark reports-A New Prospective on the Health of Canadians (5) and Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (9). Together, these reports outlined the philosophical, scientific, and economic rationale for health promotion and identified specific research and program priorities. For example, the five priority areas identified in Healthy People were smoking cessation, reducing misuse of alcohol and drugs; improved nutrition; exercise and fitness; and stress control. Health promotion research and program activities in both the public and private sectors continue to receive significant support, and as a result, the scientific base of health promotion continues to expand. It is possible to consider the scientific base of health promotion as comprising three rather distinct components. The epidemiological component largely consists of studies that demonstrate a relationship between a health status measure and a behavior or condition. For example, the Framingham Study (3) provided evidence of the relationship of elevated blood pressure, elevated serum cholesterol levels, and cigarette smoking to coronary heart disease incidence, while the Alameda County Study (1) found that five (initially seven) health habits were predictive of longevity. Health education and health behavior studies primarily constitute the behavioral component of the scientific base. This component provides evidence that a behavior (e.g., smoking) or a condition (e.g., elevated serum cholesterol levels) can be altered. While epidemiological studies provide the rationale for the behaviors targeted for change, there is often a paucity of evidence to demonstrate that the behavior changes result in an actual versus a statistical change in health status. For example, until the completion of the Lipid Research Clinics Coronary Primary Prevention Trial, there was no conclusive evidence that reduced serum cholesterol levels resulted in lower coronary heart disease incidence (6). On the other hand, while there are many epidemiological studies demonstrating a relationship between a high-fat diet and breast cancer incidence (4), no controlled studies have shown breast cancer incidence rates to decrease when a low-fat diet is adopted. The theory component of the scientific base includes studies in the basic, clinical, and social sciences that provide explanations for the “why” and “how” of 439 0091-7435186 Copyright All rights
$3.00
0 1986 by Academic Press, Inc. of reproductmn in any form reserved.
440
DONALD
C. IVERSON
the recommended changes. Studies describing how saturated fat intake affects low-density lipoprotein levels (2), how dietary fiber alters the risk of colon cancer (7), or how stressful situations affect the endocrine system are all examples of studies that contribute to this component of the scientific base (8). Obviously, the certainty of the evidence in the three components varies significantly and changes dynamically as new evidence emerges. In February 198.5, a seminar was held at the National Cancer Institute (NCI) to review the status of the behavior component of the health promotion science base. Selected papers from that seminar comprise this issue of Preventive Medicine. Cullen provides an overview of the research strategy that the Division of Cancer Prevention and Control, NCI, uses to guide its research and programmatic efforts, including those in health promotion. Flay examines this strategy, especially as it pertains to the role of efficacy and effectiveness studies in guiding the development of health promotion programs. Together these articles provide a systematic approach for health promotion research. Bettinghaus, Syme, and Green et al. address the issue of behavior change. Bettinghaus analyzes the knowledge, attitude, and behavior continuum and suggests how it contributes to the design of health promotion programs. Syme proposes use of environmental strategies as the basis of health promotion programs and provides examples of their use. Green, Wilson, and Lovato suggest how health promotion programs can be designed to increase the likelihood that behavior change will be initiated and sustained. The articles by Orlandi and by Nutting address the problem of diffusion of successful health promotion programs. Orlandi examines worksite health promotion programs from the perspective of how these programs can be more effectively diffused throughout the country, while Nutting, from a different perspective, describes the practical problems of having health promotion integrated into the usual office practices of primary-care physicians. The issue of health promotion and economics is addressed by Schelling. Using cigarette consumption and production data, he discusses the complexities of considering health promotion from an economic perspective. While these articles do not fully address the behavioral component of health promotion’s scientific base, they do identify many such aspects. As new data emerge from the many ongoing health promotion studies, the range, depth, and specificity of health promotion’s scientific base will continue to increase. REFERENCES 1. Berkman, L. F., and Breslow, L. “Health and Ways of Living: The Alameda County Study.” Oxford Univ. Press, New York, 1983. 2. Brown, M. S., Kovanen, P. R., and Goldstein, J. L. Regulation of plasma lipoprotein receptors. Science 212, 628-635 (1981). 3. Dawber, T. R. “The Framingham Study.” Harvard Univ. Press, Cambridge, Mass., 1980. 4. Kabar, F., and Henderson, M. Diet and breast cancer. C/in. Nutr. 4, 119-130 (1985). 5. LaLonde, M. “A New Perspective on the Health of Canadians: A Working Document.” Health and Welfare Canada, Ottawa, 1974.
FORUM:
HEALTH
PROMOTION
IN DISEASE PREVENTION
441
6. Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results. I. Reduction in incidence of coronary heart disease. JAMA 251, 351-364 (1984). 7. MacLennan, R., Jensen, 0. M., Mosbech, J., and Vuori, H. Diet, transit time, stool weight, and colon cancer in two Scandinavian populations. Amer. J. C/in. Nuts. 31, S239-S242 (1978). 8. Rose, R. M. Endocrine responses to stressful psychological events. Psychiatr. C/in. N. Amer. 3, 251-276 9.
(1980).
U.S. Department of Health, Education, and Welfare. “Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention.” U.S. Govt. Printing Office, Washington, D.C.. 1979.
MEDICINE
15, 439-441
(1986)
Forum: The Health Promotion Sciences in Chronic Disease Prevention The Scientific
Base of Health
DONALDC. Cancer Control Institute, Blair
Science Building,
Program, Room
Promotion
IVERSON, PH.D.
Division of Cancer Prevention and Control, 432. Nationul Institutes of Health, Bethesda,
Nutionul Marylund
Cancer 20892
Interest in, and support for, health promotion has grown steadily since the release of two landmark reports-A New Prospective on the Health of Canadians (5) and Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (9). Together, these reports outlined the philosophical, scientific, and economic rationale for health promotion and identified specific research and program priorities. For example, the five priority areas identified in Healthy People were smoking cessation, reducing misuse of alcohol and drugs; improved nutrition; exercise and fitness; and stress control. Health promotion research and program activities in both the public and private sectors continue to receive significant support, and as a result, the scientific base of health promotion continues to expand. It is possible to consider the scientific base of health promotion as comprising three rather distinct components. The epidemiological component largely consists of studies that demonstrate a relationship between a health status measure and a behavior or condition. For example, the Framingham Study (3) provided evidence of the relationship of elevated blood pressure, elevated serum cholesterol levels, and cigarette smoking to coronary heart disease incidence, while the Alameda County Study (1) found that five (initially seven) health habits were predictive of longevity. Health education and health behavior studies primarily constitute the behavioral component of the scientific base. This component provides evidence that a behavior (e.g., smoking) or a condition (e.g., elevated serum cholesterol levels) can be altered. While epidemiological studies provide the rationale for the behaviors targeted for change, there is often a paucity of evidence to demonstrate that the behavior changes result in an actual versus a statistical change in health status. For example, until the completion of the Lipid Research Clinics Coronary Primary Prevention Trial, there was no conclusive evidence that reduced serum cholesterol levels resulted in lower coronary heart disease incidence (6). On the other hand, while there are many epidemiological studies demonstrating a relationship between a high-fat diet and breast cancer incidence (4), no controlled studies have shown breast cancer incidence rates to decrease when a low-fat diet is adopted. The theory component of the scientific base includes studies in the basic, clinical, and social sciences that provide explanations for the “why” and “how” of 439 0091-7435186 Copyright All rights
$3.00
0 1986 by Academic Press, Inc. of reproductmn in any form reserved.
440
DONALD
C. IVERSON
the recommended changes. Studies describing how saturated fat intake affects low-density lipoprotein levels (2), how dietary fiber alters the risk of colon cancer (7), or how stressful situations affect the endocrine system are all examples of studies that contribute to this component of the scientific base (8). Obviously, the certainty of the evidence in the three components varies significantly and changes dynamically as new evidence emerges. In February 198.5, a seminar was held at the National Cancer Institute (NCI) to review the status of the behavior component of the health promotion science base. Selected papers from that seminar comprise this issue of Preventive Medicine. Cullen provides an overview of the research strategy that the Division of Cancer Prevention and Control, NCI, uses to guide its research and programmatic efforts, including those in health promotion. Flay examines this strategy, especially as it pertains to the role of efficacy and effectiveness studies in guiding the development of health promotion programs. Together these articles provide a systematic approach for health promotion research. Bettinghaus, Syme, and Green et al. address the issue of behavior change. Bettinghaus analyzes the knowledge, attitude, and behavior continuum and suggests how it contributes to the design of health promotion programs. Syme proposes use of environmental strategies as the basis of health promotion programs and provides examples of their use. Green, Wilson, and Lovato suggest how health promotion programs can be designed to increase the likelihood that behavior change will be initiated and sustained. The articles by Orlandi and by Nutting address the problem of diffusion of successful health promotion programs. Orlandi examines worksite health promotion programs from the perspective of how these programs can be more effectively diffused throughout the country, while Nutting, from a different perspective, describes the practical problems of having health promotion integrated into the usual office practices of primary-care physicians. The issue of health promotion and economics is addressed by Schelling. Using cigarette consumption and production data, he discusses the complexities of considering health promotion from an economic perspective. While these articles do not fully address the behavioral component of health promotion’s scientific base, they do identify many such aspects. As new data emerge from the many ongoing health promotion studies, the range, depth, and specificity of health promotion’s scientific base will continue to increase. REFERENCES 1. Berkman, L. F., and Breslow, L. “Health and Ways of Living: The Alameda County Study.” Oxford Univ. Press, New York, 1983. 2. Brown, M. S., Kovanen, P. R., and Goldstein, J. L. Regulation of plasma lipoprotein receptors. Science 212, 628-635 (1981). 3. Dawber, T. R. “The Framingham Study.” Harvard Univ. Press, Cambridge, Mass., 1980. 4. Kabar, F., and Henderson, M. Diet and breast cancer. C/in. Nutr. 4, 119-130 (1985). 5. LaLonde, M. “A New Perspective on the Health of Canadians: A Working Document.” Health and Welfare Canada, Ottawa, 1974.
FORUM:
HEALTH
PROMOTION
IN DISEASE PREVENTION
441
6. Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results. I. Reduction in incidence of coronary heart disease. JAMA 251, 351-364 (1984). 7. MacLennan, R., Jensen, 0. M., Mosbech, J., and Vuori, H. Diet, transit time, stool weight, and colon cancer in two Scandinavian populations. Amer. J. C/in. Nuts. 31, S239-S242 (1978). 8. Rose, R. M. Endocrine responses to stressful psychological events. Psychiatr. C/in. N. Amer. 3, 251-276 9.
(1980).
U.S. Department of Health, Education, and Welfare. “Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention.” U.S. Govt. Printing Office, Washington, D.C.. 1979.