If we want more evidence-based practice, we need more practice-based evidence.*

Chapter 7
Adult Health

Table of Contents


Health  Headlines, Timelines, and Milestones
REFERENCES - since publication of 8th edition




Adult health builds on the disease prevention and health promotion successes and failures achieved in maternal, infant, child, and adolescent health. The previous chapters have outlined principles and strategies for a community and population approach to health that apply similarly to an approach to adult health. One philosophical principle that increases in importance as we progress through the life span is the principle of participation. With infants and children, paternal guidance and discipline is unavoidable and essential but with adolescents, it begins to backfire as teenagers rebel against authority. With adults, the will of others tends to be ignored unless it is clearly understood to correspond with the self-interests and needs of the adults themselves. Besides the technical objectives outlined for this chapter, we attempt to illustrate approaches that apply principles of adult education and democratic decision-making to community self-determination in matters of health.


Most of the risk factors for adult health involve the pleasures of life and will be indulged by the public regardless of the admonitions of health professionals. The risk factors for heart disease, stroke, cancer, and lung disease are reviewed epidemiologically and behaviorally to illustrate this point, which will be developed further in Chapter 12.


Annual Physical Exam Fails Evidence-Based Test (New York Times, Aug 12, 2003) - Studies of the effectiveness of annual physical examinations and many of the routine tests associated with them show that they do not yield benefits in improved health nearly as useful as counseling on lifestyle problems of smoking and diet.

Hodgkin's Patients at Risk for Breast Cancer.  (USA Today, July 21, 2003).

Many People Ignore Warning Signs for Colorectal Cancer July 15, 2003

Social Factors Loom Large in Men's Poor Health.  April 29, 2003

Cancer Mortality Rates Remain Higher for Blacks Than Whites, Study Says.   Apr 15, 2003.

Diabetes Costs Soar.  (Associated Press, February 28, 2003) - The cost of diabetes rose in the United States to $92 billion last year.  This is increase is double the cost reported in 1997.

WHO Report Favors Cutting Salt from Food Supply.  (Reuters Health, February 28, 2003) - According to United Nations officials, government actions to decrease the amount of salt in processed foods (along with other measures) may reduce the global rate of cardiovascular disease by 50%.

Picking a Bone With Vitamin A.  (Washington Post, Feb. 3, 2003) - According to a newly published study in the New England Journal of Medicine, high levels of vitamin A are linked to bone fractures.

New U.S. Guidelines Stress First Colon Screening.  (Reuters Health) - New U.S. guidelines on colon screening stress the importance of the first screening after the 50th birthday, over 3 year follow-up screening after the removal of polyps.
 Prevention: Avoiding Obesity, With Breakfast.  (The New York Times  Mar 10,2003)

Behavior Changes Could Sharply Cut Cancer Death Rates, Says Institute of Medicine.  March 10, 2003

Caregiving Raises Risk of Heart Disease in Women.  Feb. 11, 2003

Family History Doesn't Predict Colon Cancer Genes, Behavior.  Feb. 10, 2003

Family History Has Little Predictive Value for Asthma.  Feb. 7, 2003

Cultural Values May Explain Low Vaccination Rates for Diabetic Minorities.  Feb. 5, 2003

A Lifetime of Poking Pays off. YELLOW SPRINGS (AP, Mar. 10, 1999). Over the past 32 years, Suzanne Bosl has been pierced with large-bore needles, held her breath in an underwater tank, spit into test tubes and even endured ice-cold cakes of glycerin on her skin. But Bosl says any discomfort was worth being part of the "Fels family," a group of test subjects for perhaps the largest and longest-running study of human growth, body composition and risk factors or heart disease. The Fels Longitudinal Study began in 1929 in this southwest Ohio village. The study was initially funded by Samuel Fels of the Fels soap company in Philadelphia at the request of his friend Arthur Morgan, then president of Antioch College in Yellow Springs.

Test May Cut Colon Cancer Deaths. WASHINGTON (AP, Mar. 3, 1999) The death rate from colon cancer, the second leading cancer killer in the United States, could be reduced by up to a third if more people over 50 started using a simple screening test that detects bleeding in the bowel, researchers say. In a study published Wednesday, Minnesota researchers say a study of the long-term health of 46,000 volunteers shows that people who take an annual fecal occult blood test have 33% fewer deaths from colon cancer than do people who do not take the test. Among those who are tested every other year, the death rate is reduced by 21%, the study found. The study is published Wednesday in the Journal of the National Cancer Institute.

PAP Screening Result May Lead to New Guidelines. WASHINGTON (AP, Feb. 5, 1999)  A large study of Canadian women says very few cases of mild cervical abnormalities detected by Pap smears progress to cervical cancer, a finding that may affect how women with the condition are treated. Some 50 million women in the United States get a Pap smear every year, a simple test that can detect precancerous cell changes before they turn into cervical cancer. Paps detect mild abnormalities, called "mild dysplasia," as well as severe lesions that are poised to become cancerous imminently. Regardless of the degree of dysplasia, women often are referred for more in-depth testing called colposcopy, or even a biopsy. But doctors have questioned how necessary the extra - and expensive - care is for women whose dysplasia is mild.

U.S. Surgeon General Launches Men's Health Resources at Healthfinder.Gov WASHINGTON D.C. (June 8, 1999) - Surgeon General David Satcher today unveiled new features and services oriented to men's heath at www.healthfinder.gov, the government gateway Web site for health information. Healthfinder(r) brings under one umbrella the vast health information resources of the federal government and its many partners. Healthfinder(r) offers a broad range of reliable consumer resources and serves, on average, more than 350,000 consumers each month - more than 5.3 million visitors since it was launched.

For related stories, please click here.


Statistics on Cancer in 1998 http://www.hc-sc.gc.ca/hpb/lcdc/bc/facts_e.html

Health Canada has just released figures on the estimated number of cases of cancer in Canada in 1998, as well as the estimated number of deaths caused by the different forms of the disease. The statistics are issued by the Cancer Bureau, which conducts and is developing cancer surveillance programs and risk assessment networks. 

The Heart: A Virtual Exploration

Students explore the heart's develop-ment and structure, blood circulation, the history of the heart science, and health. Includes quizzes, lesson plans, resources, activities, and a glossary.

National Women's Health Information Center

This site provides answers to many frequently asked questions about women's health as well as news releases, links to Federal government and other sites that deal with women's health, and access to several online medical resources including Medline and online medical dictionaries.  The database, which you can search by topic, will point you to publications of interest and link you to their download site if available.

National Cancer Institute -Office of Cancer Comm.
Building 31, Room 10A24
9000 Rockville Pike
Bethesda, MD 20892
Phone: (301) 496-5583

Responds to written requests and telephone inquiries. Prepares a wide variety of publications on cancer-related topics. Publications lists available for both patients/consumers and health professionals.

Food and Nutrition Information Center
National Agricultural Library
10301 Baltimore Boulevard, Room 304
Beltsville, MD 20705
Phone: (301) 344-3719

Provides print and audiovisual materials for consumers (including children) and professionals on topics in human nutrition, including cancer and heart disease.

National Arthritis and Musculoskeletal and Skin
Diseases Information Clearinghouse
P.O. Box AMS
Bethesda, MD 20892
Phone: (301) 468-3235

Assists health professionals to identify patient education materials and serves as an information exchange for individuals involved in public, professional, and patient education.

National Diabetes Information Clearinghouse
Bethesda, MD 20892
Phone: (301) 468-2162

Provides consumer information on diabetes-related topics. Professional materials include bibliographies of patient education materials.

National Eye Institute -Information Officer
Building 31, Room 6A-32
9000 Rockville Pike
Bethesda, MD 20892
Phone: (301) 496-5248

Supports and conducts research aimed at improving the prevention, diagnosis, and treatment of eye disorders. Answers information requests and distributes consumer and professional materials.

American Lung Association
1740 Broadway
New York, N.Y. 10019 http://www.lungusa.org/index.html

Can provide information about chronic lung disease, smoking, and asthma.

National Coalition for Cancer Research

The National Coalition for Cancer Research website aims to educate the public on policies that support and foster the U.S. position in medical research into cancer. It includes position papers and links to other resources.

The Vanderbilt Cancer Center

The Vanderbilt Cancer Center (VCC) website is a resource guide for patients, health care professionals and scientists. It gives information about specific types of cancer and treatment options, physicians and their services; scientists and research.

New Women's Health Web Site From the U.S. Public Health Service http://www.4woman.gov

Link obsolete

Please see additional links below for resources covering women's healthcare

toll-free hotline: 1-800-994-WOMAN.

Database and links to more than 1,000 federal agencies, publications, and hundreds of government-screened private sector organizations related to women's health.



Information on such things as diet, news, support groups, discussion groups, and complications of the disease.

Website for Type 2 diabetes - Healthline 


Healthline gives a very comprehensive overview of Type 2 Diabetes and is a critical starting point for individuals and/or their loved ones.

All Allergy Web Site http://www.allallergy.net/allallergy  


The All Allergy website provides everything intolerance, allergy, and hypersensitivity sufferers and health-care professionals need to know about this complex and rapidly-developing field. They provide the only allergy & intolerance gateway site, only site with an allergen database, only allergy site with article grading and allergy and intolerance information.

Lesbian Health
A report from the National Academy of Sciences, Institute of Medicine, available from November 1998: 178 pages, paperback, $19.95; hardback, $34.95

To order, call National Academy Press 1-800-624-6242 or go to NAP web site

What are the unique health issues for lesbians? Are lesbians at higher or lower risk for such health problems as AIDS, sexually transmitted diseases, breast cancer, mental disorders, and substance abuse? How does homophobia affect the funding of research on lesbian health? How do lesbian health needs fit into the current heath care system?

Lesbian Health takes a frank look at the political pressures, community attitudes, and professional concerns uniquely affecting the study of lesbian health issues. The book explores many other issues and offers a closer look at this important topic.

Gender, Science and Technology for Equitable and Sustainable Development.  


This web site is modeled on the seven areas for "Transformative Actions" outlined by the Gender Working Group Report to the UNCSTD which was ratified by UNCSTD and accepted by ECOSOC. Gateway information areas include gender equity in science education, advancement in scientific careers, recognition of local knowledge systems, science & technology (S&T) for the needs of society, ethical issues, collecting gender-disaggregated data, and gender equity in S&T decision-making.

Canadian Women's Health Network http://www.cwhn.ca/

American Heart Association web site http://www.americanheart.org/presenter.jhtml?identifier=1200000

National Cancer Institute of Canada: Canadian Cancer Statistics 2002. Canadian Cancer Society, 2002. http://www.cancer.ca/files/stats2002_e.pdf

Web Sites For Effective Nutrition Education Resources

Web Sites For Effective Nutrition Education Resources: http://arborcom.com

For Summaries of Effective Interventions:

Module for First Year Medical Students:

CME Conference Transcripts:

Complete Personal Dietary Assessment Using:


Women's Health
www.feminist.org/ (International Links)

(International Links)

sawweb/sawnet/health.html (South Asian Site/Links)




American Heart Association Web Site

Canadian Women's Health Network

Resources covering women's healthcare



Two books on women caring for men's health. NY Times book reviews. July 20, 2004.

Prevalence of Diabetes and Impaired Fasting Glucose in Adults --- United States, 1999--2000. (2003). MMWR Weekly Report, 52, No. 35, Sept 4, 2003. 

Public Health Dispatch: Multistate Outbreak of Hepatitis A Among Young Adult Concert Attendees --- United States, 2003. (2003). MMWR Weekly Report, 52, No. 35, Sept 4, 2003.

Cigarette Smoking-Attributable Morbidity --- United States, 2000. (2003). MMWR Weekly Report, 52, No. 35, Sept 4, 2003.  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5235a4.htm

Public Health Dispatch: Multistate Outbreak of Hepatitis A Among Young Adult Concert Attendees --- United States, 2003. (2003). MMWR Weekly Report, 52, No. 35, Sept 4, 2003.

Cocco, P., Heineman, E.F., & Dosemeci, M. (1999). Occupational Risk Factors For Cancer Of The Central Nervous System (CNS) Among US Women. AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 36 (1): 70-74.
    ABSTRACT: Background: In a recent report, we found an elevated risk of cancer of the central nervous system (CNS) in several occupations and industries, and-a modest association with exposure to solvents and to contact with the public. Results: Overall, CNS cancer risk showed a 20-30% increase among women exposed to electromagnetic fields methylene chloride, insecticides and fungicides, and contact with the public. Risk for meningioma was elevated among women exposed to lead (OR = 1.9; 95% CI 1.0,3.9). CNS cancer did not show a clear pattern of risk increase by probability and intensity of exposure to any of the explored risk factors, Cross-classification by probability and intensity of exposure did not reveal any significant trend Cases were too few to explore trends of meningioma by probability and intensity of exposure to lead. Conclusions: We did not find evidence of a strong contribution of 11 occupational hazards to the etiology of CNS cancer. However; limitations of the occupational information might have reduced our ability to detect clear patterns of risk.

De Grasse, C. E., O'Connor, A. M., Boulet, J., Edwards, N., Bryant, H., Breithaupt, K. (1999). Changes In Canadian Women's Mammography Rates Since The Implementation Of Mass Screening Programs. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 927-929. The Journalís Home Page is: http://www.ajph.org/.
    ABSTRACT: Objectives. This study reports on Canadian mammography rates between 1990, when mass screening programs were launched, and 1994/95. Methods. Mammography rates from 2 national surveys were compared according to the presence of a provincial screening program. Results. Mammography rates among women aged 50 to 69 years (the targeted group) increased significantly, by 16%; increases were twice as high in provinces with screening programs, Among women in their 40s (nontargeted group), the changes were insignificant and independent of screening program status. Conclusions. Screening programs appear to have influenced the mammography rates of targeted women aged 50 to 69 years.

Glasgow, R.E., Fisher, E.B., Anderson, B.J., LaGreca, A., Marrero, D., Johnson, S.B., Rubin, R.R., Cox, D.J. (1999). Behavioral Science In Diabetes - Contributions And Opportunities.  DIABETES CARE 22 (5): 832-843.
    ABSTRACT: Objective - To summarize the current status of behavioral research and practice in diabetes and to identify promising future directions. Conclusions - Changes are required on the part of behavioral scientists in how they organize and present their research and on the part of potential users of this knowledge, including other health professions, organizations, and funding agencies. Integrating behavioral science advances with other promising genetic, medical, nutritional, technology health care, and policy opportunities promises not only to broaden our understanding of diabetes but also to improve patient care, quality of life, and public health for persons with diabetes.

Graham, H., & Der, G. (1999). Smoking And Women's Health. Influences On Women's Smoking Status. The Contribution Of Socioeconomic Status In Adolescence And Adulthood. EUROPEAN JOURNAL OF PUBLIC HEALTH 9 (2): 137-141.
http://www3.oup.co.uk/eurpub/hdb/Volume_09/Issue_02 .

Jeffery, R.W., & French, S.A. (1999). Preventing Weight Gain In Adults: The Pound Of Prevention Study. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 747-751.
    ABSTRACT: Objectives. This study examined whether weight gain with age could be prevented through the use of a low-intensity intervention. Results. Individuals in intervention groups reported favorable changes over time in frequency of weighing and healthy dieting practices relative to those in the control group. These behavior changes were in turn related to a reduced rate of weight gain over time. However, weight gain over 3 years did not differ significantly by treatment group. Conclusions. This low-intensity educational approach to weight gain prevention sustained interest over a lengthy time period and was associated positively with behavior change, but it was not strong enough to significantly reduce weight gain with age.

McHorney, C. A. (1999). Health Status Assessment Methods for Adults: Past Accomplishments and Future Challenges. ANNUAL REVIEW OF PUBLIC HEALTH 20: 309-336.
    ABSTRACT/Full-Text: Abstract.

McNeil, C. (1999). Can Guidelines Be Integrated Into Everyday Practice? The NCCN in Year 4. JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 753-755.
    ABSTRACT: http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;91/9/753.

Michaud, D.S. et al (1999). Fluid intake and the risk of bladder cancer in men. THE NEW ENGLAND JOURNAL OF MEDICINE 340 (18): 1390-1397. 
    ABSTRACT: http://content.nejm.org/cgi/content/short/340/18/1390. A study that followed nearly 48,000 men over a 10-year period, showed that those drinking over 6 cups (1440 ml) of water per day had up to a 50% lower rate of bladder cancer than those who drank less than 1 cup (240 ml) per day.

Moens, G., van Gaal, L., Muls, E., Viaene, B. & Jacques, P. (1999). Body Mass Index And Health Among The Working Population. Epidemiological Data From Belgium. EUROPEAN JOURNAL OF PUBLIC HEALTH 9 (2): 119-123.
http://www3.oup.co.uk/eurpub/hdb/Volume_09/Issue_02 .

Mosca, L., McGillen, C., Rubenfire, M. (1998).  Gender Differences in Barriers to Lifestyle Change for Cardiovascular Disease Prevention. JOURNAL OF WOMEN'S HEALTH 7 (6): 711-716.

Nelson, N. J. (1999). Purple Carrots, Margarine Laced With Wood Pulp? Nutraceuticals Move Into the Supermarket. JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 755-757.
    ABSTRACT: http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;91/9/755.

Noseworthy, J. H. (1999). Progress in determining the causes and treatment of multiple sclerosis. NATURE 399 (6738).

Pollan, M., & Gustavsson, P. (1999). High-risk occupations for breast cancer in the Swedish female working population. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 875-881.
    ABSTRACT: The purpose of this study was to estimate, for the period 1971 through 1989, occupation-specific risks of breast cancer among Swedish women employed in 1970. For the complete abstract, go to: http://www.ajph.org/cgi/content/abstract/89/6/875.
    The Journalís Home Page is at: http://ajph.org/.

Ramirez, A.G., Villarreal, R., McAlister, A., Gallion, K.J., Suarez, L., & Gomez, P. (1999). Advancing The Role Of Participatory Communication In The Diffusion Of Cancer Screening Among Hispanics. JOURNAL OF HEALTH COMMUNICATION 4 (1): 31-36.
    ABSTRACT: Based on previously demonstrated methods, a cancer prevention program combining media and interpersonal communication was conducted in a Texas border city (Brownnsville) in 1995-1996. To evaluate the program a quasi-experimental panel design study followed 107 women in a program site and 105 women in a comparison site from 1994 to 1996. Women in the program site reported an increase in levels of Pap screening adherence.

Reynolds, T. (1999). Declining Breast Cancer Mortality: What's Behind It? JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 750-753.
    ABSTRACT: http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;91/9/750.

Rylander, R., Axelsson, G., Megevand, Y., Dahlberg, C., Lijeqvist, T., & Sundh, V. (1999). Dietary habits for non-smoking females living with smokers or non-smokers. EUROPEAN JOURNAL OF PUBLIC HEALTH 9 (2): 142-145.
http://www3.oup.co.uk/eurpub/hdb/Volume_09/Issue_02 .

Schwartz, M.D., Rimer, B.K., Daly, M., Sands, C., & Lerman, C. (1999). A randomized trial of breast cancer risk counseling: The impact on self-reported mammography use. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 924-926. The Journalís Home Page is: http://www.ajph.org/.
    ABSTRACT: Objectives. We evaluated the impact of individualized breast cancer risk counseling on mammography use among women at risk for breast cancer. Methods. Participants (n = 508) were randomized to the breast cancer risk counseling intervention or a general health education control intervention, and 85% completed follow-up. Results. in multivariate modeling, a significant group-by-education interaction demonstrated that among less-educated participants, standardized breast cancer risk counseling led to reduced mammography use. There was no intervention effect among the more-educated participants. Conclusions. These results suggest that standard breast cancer risk counseling could have an adverse impact on the health behaviors of less-educated women.

Toobert, D.J., Strycker, L.A., Glasgow, R.E.  (1998). Lifestyle Change in Women with Coronary Heart Disease: What Do We Know?  JOURNAL OF WOMEN'S HEALTH 7 (6): 685-700.

Veenstra, G. & Lomas, J. (1999). Home is where the governing is: Social capital and regional health governance. HEALTH AND PLACE 5(1): 1-12. http://www.elsevier.nl/locate/jnlnr/03092

Wannamethee, S.G., & Shaper, A.G. (1999). Type Of Alcoholic Drink And Risk Of Major Coronary Heart Disease Events And All-Cause Mortality. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 685-690.
    ABSTRACT: Objectives. This study examined the effects of beer, spirits, and wine drinking on coronary heart disease (CHD) events (fatal and nonfatal) and all-cause mortality. Results. Regular drinkers showed a significantly lower relative risk of CHD, but not all-cause mortality, than occasional drinkers, even after adjustment for potential confounders. The benefit for CHD of regular drinking was seen within both beer drinkers and spirit drinkers but not among men who reported wine dl inking. However, all men who reported wine drinking (both occasional and regular) shelved significantly lower age-adjusted risks of CHD and all-cause mortality than men drinking beer or spirits; beer and spirit drinkers showed similar risks. Conclusions. The findings suggest that regular intake of all alcoholic drinks is associated with a lower risk of CHD, but not all-cause mortality, than occasional drinking. A large part, but not all, of the greater benefit seen in wine drinkers relative to other drinkers can be attributed to advantageous lifestyle characteristics (e.g., low rates of smoking and obesity).

Other References

Prevalence of Diabetes --- U.S. Virgin Islands, 1999-2001.  Morbidity and Mortality Weekly Report, 52(27), July 10, 2003.

Update:  Cardiac and Other Adverse Events Following Civilian Smallpox Vaccination --- United States, 2003.

Adults Who Have Never Seen a Health-Care Provider for Chronic Joint Symptoms --- United States, 2001 Morbidity and Mortality Weekly Report, 52(18), May 9, 2003.

Colorectal Cancer Test Use Among Persons Aged greater than or equal to 50 Years --- United States, 2001.  Morbidity and Mortality Weekly Report, 52(10), March 14, 2003.    

At Home HCV Test Gains FDA Approval. JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 908, 1999. The first over-the-counter test of its kind, called "Hepatitis C Check," has been approved by the U.S. Food and Drug Administration. It is made by the Home Access Health Company of Hoffman Estates, Ill., and will be sold nationwide at pharmacies in the United States. Abstract:

Stat Bite: Melanoma Incidence in U.S. Whites. JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 912, 1999. Abstract:

Stat Bite: Breast Cancer Mortality Rates: U.K., Canada, and U.S., 1950-1994. Journal of the National Cancer Institute 91: 752, 1999. http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;91/9/752

National Arthritis Month --- May 1999. Morbidity and Mortality Weekly Report 48 (17), May 7, 1999. http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4817a1.htm Colorectal Cancer Test Use Among Persons Aged greater than or equal to 50 Years --- United States, 2001.

May is National Arthritis Month. Arthritis and other rheumatic conditions are among the most common chronic conditions and constitute the leading cause of disability, affecting an estimated 42.7 million persons in the United States. The prevalence of arthritis is expected to increase to 60 million by 2020 (1). On May 18, the Arthritis Foundation is sponsoring Arthritis Action Day to draw national attention to this public health problem. In addition, the Arthritis Foundation is working with CDC and other organizations to implement the National Arthritis Action Plan: A Public Health Strategy (NAAP) (2) and to promote progress toward proposed arthritis health objectives for 2010 (3). Additional information about arthritis, National Arthritis Month, Arthritis Action Day, NAAP, and ongoing local Arthritis Foundation programs and services is available from the Arthritis Foundation, telephone (800) 283-7800, or on the World-Wide Web, http://www.arthritis.org .  References cited:
1. CDC. Arthritis prevalence and activity limitations--United States, 1990. MMWR 1994;43:433-8.
2. CDC. National Arthritis Action Plan: a public health strategy. Atlanta, Georgia: Arthritis Foundation, Association of State and Territorial Health Officials, and CDC, 1999.
3. Office of Disease Prevention and Health Promotion. Healthy people 2010 objectives: draft for public comment. Washington, DC: US Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 1998.

Impact of Arthritis and Other Rheumatic Conditions on the Health-Care System --- United States, 1997. Morbidity and Mortality Weekly Report 48 (17), May 7, 1999. http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4817a2.htm
    Arthritis and other rheumatic conditions are the leading cause of disability in the United States (1), affecting approximately 43 million persons (2) and costing $65 billion in 1992 (3). By 2020, these numbers will increase as the population ages (4). This report examines several measures of the impact of arthritis on the U.S. health-care system; the findings indicate that arthritis and other rheumatic conditions have a large impact on hospitalizations, ambulatory-care visits, and home health care, with women accounting for most of this impact and all persons aged less than 65 years accounting for a substantial portion. References cited:
1. CDC. Prevalence of disabilities and associated health conditionsóUnited States, 1991-1992. MMWR 1994;43:730-1,737-9.
2. CDC. Prevalence and impact of chronic joint symptoms--seven states, 1996. MMWR 1998; 47:345-51.
3. Yelin E, Callahan LF. The economic cost and social and psychological impact of musculoskeletal conditions. Arthritis Rheum 1995;38:1351-62.
4. CDC. Arthritis prevalence and activity limitations--United States, 1990. MMWR 1994;43:433-8.

Screening for Colorectal Cancer --- United States, 1997. Morbidity and Mortality Weekly Reports, 48 (6), February 19, 1999. Go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/00056494

Trends in Sexual Risk Behaviors Among High School Students--United States, 1991-1997 Morbidity and Mortality Weekly Report, 47 (36), September 18, 1998.
The percentage of sexually experienced high school students decreased from 54.1 percent in 1991 to 48.4 percent in 1997, while the proportion of sexually active teens using condoms increased from 46.2 percent to 56.8 percent in the same time period. These finding represent a reversal in the trend toward increased sexual risk among teens that began in the 1970s and point to the success of comprehensive prevention efforts to both delay first intercourse among teens and to increase condom use among young people who are sexually active.

Reforming Medicare: The Gramm Plan. THE NEW ENGLAND JOURNAL OF MEDICINE  339 (11): 777, SEP 10 1998.

Diet, Lifestyle, and Colorectal Cancer: Is Hyperinsulinemia the Missing Link. NUTRITION REVIEWS  56 (9): 275, SEP 01 1998. 
    ABSTRACT: http://www.ilsi.org/pubs/v56-sep98.htm#275.   The Journal's website is located at: http://www.ilsi.org/pubs/nrlist99.html.   Also of interest: http://www.ilsi.org/


1. The Tragedy of the Commons revisited. The Tragedy of the Commons, first introduced in Chapter 3, is applied here to adults who engage in the short-term gratification of indulgent, sedentary or reckless behavior. The intent in this activity is to help you understand that short-term gains can result in long-term losses not just for the individual involved. On the surface, sedentary or reckless behaviors appear purely self-destructive. However, when these individual behaviors are considered in the context of family and community the scene changes. Children whose parents smoke learn to imitate this dangerous behavior and are subject to the hazards of passive smoking. The husband who dies of a heart attack due to obesity and uncontrolled hypertension leaves his wife a grieving widow. Employers feel the impact of self-indulgent behaviors when these activities result in employee sick days and disability days. The community suffers when it must attend to the treatment of individuals with illnesses were easily preventable. Pick a health- related behavior, such as smoking, alcohol use, or over eating, and explore the different ways in which individual and social rights and responsibilities have been drawn with respect to this behavior.

2. Mass media. Campaigns and public service announcements are used to inform the public about the health consequences of alcohol, smoking, hypertension and diet. What would you include in a report which addresses the effectiveness of mass media campaigns. Can such reports be used successfully to change behavior?

3. Community resources. Voluntary, government, and private agencies and organizations play varying roles in offering assistance to those seeking to change life-style related behaviors. Pick a health-related behavior, such as smoking, over or under eating, alcohol abuse, and explore the various community resources available to assist in lifestyle change. Gather materials from these agencies and compare them by message, cost, feasibility, and appropriateness for different segments of the adult population. What recommendations would you make as community workers to various segments of the population regarding these different resources?

4. Family health history. Develop a family health history that explores as far back as you can go and with as extended a view as possible, the following questions: How long did people live? From what did they die? What current health problems/strengths to adults (over age 21 years) have? Pull this information together in a "family tree" chart. How does your family compare with national or local statistics with regard to longevity? Mortality? Morbidity? What implications are there for your own health-related behaviors?

5. Social determinants of health. Explore the broader social contexts within which lifestyle behaviors exist. Either pick a lifestyle behavior, such as smoking or drug use, or a disease, such as cancer or heart disease, and explore the statistics of these through the lenses of gender, socioeconomic status, and ethnicity. For example, how are women who present with heart attack symptoms treated in comparison with men? How is it that those in lower socioeconomic strata are more likely to be obese? What contributes to different smoking rates among ethnic groups?

6. Making changes. Changing lifestyle behaviors is difficult. Interview an adult who has either been successful or unsuccessful in making a lifestyle change such as quitting smoking or loosing or gaining weight. Explore with the person the history of this behavior, the factors that contributed to it, and the factors that facilitated or hindered them in making changes. Explore these influences on behavior using the PRECEDE model introduced in Chapter 4, with particular focus on the educational diagnosis. Categorize influences on behavior (facilitators or barriers) using the predisposing, enabling, and reinforcing factors. Such diagnosis often reveals that people trying to make lifestyle changes have sufficient knowledge, but lack other kinds of support necessary for sustained change.

Consider issues of confidentiality and ethics in conducting research, such as interviews. What do you need to learn about interviewing in order to ask the right questions? How will you treat the data with confidentiality? Consider using participatory research in which you would take your data analysis of the predisposing, enabling, and reinforcing factors back to the person interviewed for comment and input. 

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