Forces Shaping the Future of Health Promotion

This issue contains only two manuscripts. It is very unusual for two manuscripts to fill an entire issue or for this journal to publish such long manuscripts. We are publishing these manuscripts because we believe they will both be very important in shaping the future of health promotion. One is important because of who released it; the other is important because of the topic. Additional perspectives on these manuscripts are below.

Promoting Health: Institute of Medicine Perspectives

"Promoting Health: Intervention Strategies from Social and Behavioral Research" is authored by Drs. Brian D. Smedley and S. Leonard Syme and is released by the Division of Health Promotion and Disease Prevention within the Institute of Medicine. It is the introduction to a book of the same title which will be released by the National Academy of Sciences. This is an excellent article, but it is important because it was released by the Institute of Medicine. Understanding how I discovered this manuscript illustrates this point. I was meeting with one of the legislative aides of Senator William Roth of Delaware. At the time Senator Roth was chairman of the Senate Finance Committee. The Finance Committee controls funding for Medicare and other large budget items. I was extolling the virtues of health promotion when this aide interrupted me and said, "This health promotion idea sounds all nice and good, but on the Finance Committee, we wouldn't take something like this seriously until the Institute of Medicine says it is a good idea." As I listened to this legislative aide's comments, I was reflecting on the likelihood of my being successful in trying to persuade the Institute of Medicine that health promotion is a good idea. The Institute of Medicine is part of the National Academy of Sciences. The National Academy of Sciences is an independent think tank which the Congress and President draw on for advice in setting policy. Being invited to join the National Academy of Sciences is a crowning achievement in an academic career, and few ever receive such an invitation. I was thinking that it would be easier to persuade the Finance Committee not to worry about what the Institute of Medicine thought than it would be to persuade the Institute of Medicine to come out with a position statement supporting health promotion. Not one to be easily discouraged, I picked up the telephone to try to figure out what this would entail. After many telephone transfers and visits to the Web, I discovered that the Institute of Medicine had just written a report called Promoting Health: Intervention Strategies from Social and Behavioral Research." The essence of this report is expressed in the following sentence, which appears on the first page of the introduction: "Behavioral and social interventions therefore offer great promise to reduce disease morbidity and mortality, but as yet their potential to improve the public's health has been relatively poorly tapped." I contacted the authors and they were very happy to publish the introduction of this report in our journal.

Does publication of this report mean that we will see the federal government shift its health care focus toward health promotion and disease prevention? Certainly not. However, publication of this report does give the field the credibility required to persuade the government to do so. It provides one of the levers we have been seeking to persuade the government to head our "Building Health Promotion into the National Agenda" efforts.

I would like to offer health promotion professionals few cautions as they read this report. First, the report does have some limitations. The authors were very gracious in listening to my constructive criticisms, and they agreed with all of them. The most serious limitation is that this report was written by academics who have an impressive command of the published literature and noteworthy ability to articulate the role health promotion can play in society. However, neither of the main authors and few of their advisors have any practical experience in delivering health promotion outside of a limited number of research projects. The report does not reflect the successes achieved in the thousands of workplace, community and clinical programs that have not been documented in the literature. As I have preached for repeatedly, the "science" of health promotion will be most effective when it is able to draw on the unrecorded "art" of health promotion created by thousands of practitioners over the past three decades.

Second, a central tenet of this report is the importance of breaking from the predominate clinical model of addressing disease at the individual patient level and shifting to a strategy which addresses multiple levels of influence including the individual, interpersonal, institutional, community and policy levels. Emphasis is placed on the need to improve the socioeconomic status of individuals and the social support structures which exist within communities. The authors are correct when they assert that a person's socioeconomic situation is one of the most important, if not the most important, predictor of an individual's health. However, we need to be cognizant of what we, as health promotion professionals, can and cannot control. We can help individuals make individual lifestyle changes. We can help employers, schools and small communities develop norms and physical environments that promote health. We can even help to pass local, state and national laws related to tobacco, substance abuse and other areas that promote health. As CITIZENS, we can support policies and elected officials who fight for ending health and economic disparities, but as health promotion professionals, we must focus on what we do best. If new federal funding causes health promotion to focus too much on these admittedly critical social issues, the danger is that too few new efforts will be focused on developing the core science and practice of health promotion. It is important to clarify that the authors of this report call for focusing on many levels of change. They ask for a shift of attention toward changes at the societal level versus the individual level. They do not ask for discontinuation of focus at the individual or small group level. I would like to further suggest that efforts to change social units will probably be most successful if they are focused on cohesive social units like families, schools, businesses, faith communities, small towns and so on. Affecting change in large cities, or at the state or national level is usually much more difficult to achieve.

Third, this report calls for funding for a wide range of research efforts. If these research efforts are dominated by federal agencies, research centers or universities as the authors suggest, and do not draw on existing health promotion infrastructures that have been developed in clinical settings, workplaces and community organizations by not-for-profit and for-profit health promotion providers, they run the risk of being less successful and damaging the existing infrastructure. As a field, we need to make sure linkages are established between the research and practice groups which have historically not communicated very well or often. This will empower the existing health promotion infrastructure rather than erode it.

Fourth, this report tends to focus more on the disease prevention vs. the health promotion side of the prevention spectrum. Both are very important, but disease prevention continues to receive a disproportionately large amount of funding relative to health promotion, and this must be brought into balance. The concept of improving quality of life, or having a sense of joy in life are hardly mentioned.

These comments notwithstanding, this article and the larger book from which it is drawn will provide an excellent framework for the field of health promotion and the federal government to support efforts of Building Health Promotion into the National Agenda.

Disease Prevention, Health Promotion and Productivity

In contrast to the first article, the second article, developed by the Center for Disease Prevention and Heath Promotion within the Institute for Health and Productivity Management, is important not because of who released it, or what it says, but because of what it represents. It represents the first systematic effort to create a focus on productivity within health promotion. Subsequent efforts by the Health Enhancement Research Organization (HERO) have contributed to this effort.

Why is this important? To quote a comment in a personal conversation with Dr. Jonathan Fielding of UCLA, "productivity is the holy grail of health promotion". If employers and federal policy makers understand the effect that health has on productivity, lack of funding for health promotion will not be an issue. This has always been true; why is it so important now? Timing. To explain this, we need a short review of economics and current events. First the economics review.

When this issue went to press, the United States was experiencing the longest economic expansion in its history, from March, 1991 to December, 2000; a period of 118 months and possibly still counting. During this time, Bureau of Economic Research figures showed that the economy grew at rates ranging from 2.7% in 1991-1995, 4.3% in 1996-1999 and 6.0% from July 1999 to June, 2000. Bureau of Labor Statistics figures showed the unemployment rate dropped from 4.9% in 1990 to 4.0% in January of 2000, and 3.9% in September, 2000. Traditional economic thinking has postulated that annual growth above 2.0% or unemployment below 6% will cause an increase in inflation rates. Much to the economists' surprise, core inflation (this excludes food and energy costs) actually dropped from 4.9% in 1990 to 3.0% in 1995 to 1.9% in 1999. By August of 2000, it reached 2.5% and seems to be still increasing slightly. How could inflation stay so low, for so long, despite these conditions of rapid growth and low unemployment? One answer is lack of inflation itself. With low overall inflation rates, and deflation in some areas, there was not strong pressure to increase wages. Employees saw prices continue to fall for computers, cell phones and other high technology products and could continue to afford their usual purchases with existing wages. However, Bureau of Labor Statistics show that wages finally did increase, at a rate of approximately 1% each quarter in 1999 and 1.4% in the first quarter of 2000. Despite these increases, unit labor costs actually DECREASED .4% between mid 1999 and mid 2000. How did this occur? Increases in productivity, caused primarily by application of computer technology, progress in other sciences, and efficiency caused by improved manufacturing and management processes, allowed this to occur. The increases in productivity were not huge in absolute terms. Annual increases averaged 1.8% between 1991 and 1995, and 2.6% between 1996 and 1999. Economists have always known that increased productivity will temper the effects of growth on inflation....they just did not know how much. And business executives have always known that increased productivity is good for business. But there are two more chapters to explain why productivity enhancement is so important As labor costs decrease, profit margins increase. As profit margins increase, stock prices increase. As stock prices increase, executive bonuses go through the roof. In very simplified terms, this is what we saw happen.

So why is productivity so important now? Because productivity is a salient issue. The basic relationships between productivity, profits and muted inflation have not changed, but because of the of this recent economic experience, business leaders, economists and government policy makers are very aware of productivity. When medical care costs started to skyrocket in the 1970's this relatively obscure element of health care and our economy took center stage and has held it for over two decades. When the Presidential Election between Al Gore and George W. Bush was held in the balance by a few votes in Florida, the term "chad" became part of the lexicon and people realized that the president was indeed chosen not by the popular vote, but the uncelebrated Electoral College. Productivity now has that same prominence among business leaders, economists and government policy makers and they will be more inclined to spend money to raise productivity than they have in recent years. This inclination may last a few months, or it may continue for decades.

A brief review of the link between health promotion and productivity is necessary to close the loop. To cover the cost of a health promotion program, productivity needs to be increased only .33%. For example, if an employee in a factory earns $30,000 per year, this employee probably needs to produce at least $60,000 worth of product to cover the basic salary, employee benefits, equipment and facilities, marketing costs, administration, and profit. If that employee is 1% more productive, his or her increased output would be worth $600 ($60,000 x 1% = $600). An excellent health promotion program might cost $200 per year per employee, so the program would need to increase productivity only .33% to pay for itself ($200 ÷ $60,000 = .33%). This is a very conservative example. This 2 to 1 ratio between employee output and employee costs is not unusual for factory workers in small manufacturing settings, but in high technology fields a 10 to 1 ratio is common; and among sales people, scientists and managers, the ratios are even higher, so productivity increases are even more valuable in those settings and with professional employees. Is it reasonable to expect a health promotion program to increase productivity .33%. This seems reasonable given the limited findings of the review published in this special issue, but a more important question is what would a top manager think. To find out, pose the following question a top manager: "How much more productive are employees who are physically and emotionally able to work and motivated to work because they know their employer cares about their health?" In my own experience, scientists are reluctant to make an estimate, but top managers respond without hesitation, and none has answered less than 20%. When I ask top managers how much more productive they are under these circumstances, the most common response is "at least 100%."

To put this in perspective, to pay for a health promotion program through medical care cost containment, medical care costs must be reduced approximately 5%. This example assumes that medical care costs average $4,000 per employee per year and that a health promotion program costs $200 per employee per year ($4,000÷$200 = 5%). As any regular readers of this journal knows, most research on the financial impact of health promotion has focused on the relationship between health risks and medical care costs and the ability of health promotion programs to reduce those risks and thus reduce the costs. We are finally making good progress in that area of study. A review of the literature which will be published in this journal in a few months, shows that savings do seem reasonable, but at a gut level, increasing productivity one third of one percent will seem more achievable to most high level decision makers. If we are going to be successful in advancing the concept of health promotion, we must be aware of the relative contributions of medical care cost containment vs. productivity enhancement on the bottom line. We must also remind ourselves that medical care costs will never be more than a nuisance to top management. A health promotion program tied to medical care cost containment will never be more than an appendage to a nuisance. In contrast, productivity enhancement is directly related to the core outcomes of the business, and a health promotion program tied to that core will have a much greater chance of surviving and thriving.

We must strike now, while productivity enhancement is a salient issue, to create the science necessary to establish the link between health promotion and productivity. This review makes an important contribution in that direction. The most striking finding in this review is the relative absence of much good research on the link between health promotion and productivity. If the authors had not limited the review to recent years, they may have uncovered some additional high quality work. The authors do an excellent job of synthesizing the research that has been published and in articulating a conceptual framework within which we can develop this new area of study.

I encourage our readers to work with the Institute for Health and Productivity Management

and the Health Enhancement Research Organization to advance this new area of study. The future growth and survival of health promotion will certainly be impacted by this work, and its survival may depend upon it.

References

1. Business Week. 2000 (August 28)

2. Business Week. 2000(February 14)

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