Gender Equity, Focus on High-Risk Reduction and the Future of Health Promotion

 The New Gender Gap 
A recent issue of Business Week¹ has a fascinating story which describes how girls and young women are consistently outperforming boys and young men in educational achievement. For example, ''in every state, every income bracket, every racial and ethnic group, and most industrialized nations, women reign, earning an average of 57% of all BAs and 58% of all masters degrees in the US alone.'' The article cites National Center for Education statistics showing higher participation rates for girls in virtually all extracurricular activities, including the following: student government (27% of girls vs. 19% of boys), performing arts (46% vs. 35%), publications (29% vs. 21%), and academic clubs (36% vs. 28%). Boys continue to dominate sports (49% of girls vs. 63% of boys), prescriptions for stimulants (1% vs. 4%), and suicide rates (3/100,000 vs. 17/100,000). Boys are also 2.7 times more likely to have learning disabilities and 3.2 times more likely to be diagnosed as being emotionally disturbed. 

How did this occur? The reasons are complex, but are in part due to the improved achievements of girls and the stagnation of boys. In response to men's dominance of society and boys' dominance in school, education experts launched the ''Girl Project'' thirty years ago, with the objectives of eliminating girls' weaknesses in math and science, enhancing their self esteem, and creating new opportunities for growth. This occurred at the same time as the Women's Movement, Title IX (sports equity legislation), and the Gender and Equity Act, all of which created a legal and social environment which reduced discrimination against girls. Few new programs were created to support boys and young men. 

If the impact of this trend was a leveling of the playing field and equal opportunities for men and women, there would be a net gain to society. However, the Business Week article cited some unintended negative artifacts of these trends, including increasing unemployment rates and imprisonment rates for men, a drop in eligible men for women to marry, and a loss of hope for many boys in the current generation. 

The solution to this problem is not to end programs that support girls, but to add programs that support boys. In a broader sense, the solution is to provide intensive support for the groups and individuals in greatest need, as well as ongoing support to continue helping those who are doing well. This issue is fascinating and troubling in and of itself, but there is a connection to health promotion. 

The Perils of Focusing on High-Risk 
During the past two decades, the focus of health promotion has shifted from helping the whole populations we serve stay healthy to reducing the risks among those with the most health risks. The shift has been driven by humanitarian and economic factors. We want to help those with the greatest needs, and we want to control medical costs for the 20% of the population who account for 80% of the costs. Hundreds of risk-reduction and cost-containment success stories have been published, but what about the failures this high-risk focus has caused? By focusing weight control programs on helping obese people lose weight, and neglecting those at ideal weight, population prevalence of obesity or overweight increased from 47% in 1976-1980 to 64% in 1999-2000.² Rather than providing programs to help all people manage the daily stresses of life, the vast majority of our mental health services are directed to helping emotionally disturbed people. Will this strategy increase or decrease the prevalence of people with emotional distress? 

Focusing on high risk and failing to keep healthy people healthy may also be costing us money. Dee Edington and his team have found that reducing one risk saves an employer approximately $153 in medical costs per risk per employee per year, but failing to prevent an increase in risks costs approximately $350 in medical costs per risk per employee per year.³ Another advantage of providing programs to help healthy people maintain their health is the ease with which these programs can be implemented. Participation and success rates are higher, and costs and attrition rates are lower. We can also take a lesson from the most successful organizations. How do the most successful organizations, be they universities, research institutes, sports teams, consulting firms, or manufacturing organizations, make themselves great? They do it by grooming their most talented people. 

If our goal is to build the healthiest population, we need to serve all its members. We need to devote concentrated resources to help those with the greatest health needs, and we need to devote sufficient resources to help those who are already healthy remain healthy. 

References 

1. Conlin, M. The new gender gap. Business Week. May 26, 2004. 

2. National Center for Health Statistics. Prevalence of Overweight and Obesity Among Adults: United States, 1999-2000. Available at: http://www.cdc.gov/ nchs/products/pubs/pubd/hestats/obese/obse99.htm#Table%201.Accessed June 4, 2003. 

3. Edington, D. Worksite Wellness: 20 Year Cost Benefit Analysis and Report: 1979- 1998. Ann Arbor, Mich: University of Michigan Health Management Research Center; 1998. 

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