If we want more evidence-based practice, we need more practice-based evidence.*
Table of Contents
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
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.
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
Depression Related to Poor Health After Bypass Surgery. Feb. 4, 2003
Stressful Feelings May Influence Vaccine Effectiveness. Nov. 25, 2002
New Protocol for Administering Pneumonia Vaccine Could Save Lives, Dollars. February 14, 2002
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 atwww.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.
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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.
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:
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.
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.
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.
McHorney, C. A. (1999). Health Status Assessment Methods for Adults: Past Accomplishments and Future Challenges. ANNUAL REVIEW OF PUBLIC HEALTH 20: 309-336.
McNeil, C. (1999). Can Guidelines Be Integrated Into Everyday Practice? The NCCN in Year 4. JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 753-755.
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.
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.
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.
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.
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.
Reynolds, T. (1999). Declining Breast Cancer Mortality: What's Behind It? JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 750-753.
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.
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:
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.
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:
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, 1991-1997Morbidity 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?
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.