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PART III
EVIDENCE-BASED
HEALTH PRACTICE
171
CHAPTER 7
Health Promotion
JILL BRADSHAW and WALDO C. KLEIN
T
HINK ABOUT IT
: health promotion; the idea of advancing good health. It
would seem that the idea of health promotion should be one of those com-
monsense notions that would be clearly understood and heartily endorsed
by all people. And yet, like common sense itself, neither the understanding of
health promotion nor the endorsement of the many ways that it can be advanced
are always readily apparent among older adults or even the professionals who
provide service to them. We labor under the myth that the genetic material re-
ceived from our parents is the most significant predictor of our longevity; in fact,
it is the decisions that we make about our social and behavioral choices that are
most influential with regard to health status and functioning (Ory, Hoffman,
Hawkins, Sanner, & Mockenhaupt, 2003).
Contemporary life is filled with circumstances that run counter to health pro-
motion. In many places, basic environmental conditions assault healthful living
through the air we breathe or the water that hydrates our bodies. Social condi-
tions, too, challenge health promotion through the stressors that manifest them-
selves as illness and injury, both physical and mental. Modern diets have moved
away from traditions of whole foods toward highly processed food that often
lacks basic nutrients. Of course, any diet cannot be evaluated without a simulta-
neous consideration of the physical exercise in which one is engaged. Work burns
fuel; even when it is pleasant, exercise is work; food is fuel. We need to attend to a
balance in this and in so many other areas to maximize health promotion.
Whether of their own choosing or externally imposed, the opportunities for
older adults to ignore or avoid good health abound. Health promotion is, in short,
the advancement of all things healthful. Health has been defined by the World
Health Organization (1948) for nearly 60 years as “a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity.”
When one considers the breadth of this definition, it is clear that although the
fundamental notion of health promotion may ring true as common sense, in prac-
tice it involves an extensive array of social conditions and personal behaviors that
interact in myriad ways.
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HEALTH PROMOTION AS PRIMARY PREVENTION
This chapter approaches health promotion as an exercise in primary prevention.
On their face, both health promotion and primary prevention seek to avoid the
untoward consequences of illness, accidents, environmental stressors, and less
than ideal personal habits. However, both health promotion and primary preven-
tion must actively consider more than these negative influences that abound in
contemporary life. Health promotion must be concerned with “well-being,” not
just the “absence of disease or infirmity.” People do not present as simply a con-
stellation of pathologies; they also bring to the table a range of important assets.
These may include influences that coexist in the social and physical worlds, as
well as the personal attributes and habits that contribute to individual well-
being. To give full consideration to the “physical, mental and social well-being”
of individuals that are incorporated into the definition of health by the World
Health Organization (1948), along with both the assets and challenges that every
individual carries, we have found it useful to apply a variation of a model of pri-
mary prevention as a mechanism for advancing health promotion.
Bloom’s (1996, p. 2) configural equation to primary prevention is based on a def-
inition of primary prevention that seeks “to prevent predictable problems, to pro-
tect existing states of health and healthy functioning, and to promote desired
potentialities in individuals and groups in their physical and sociocultural set-
tings over time.” With health promotion in mind, this model highlights the simul-
taneous importance of avoiding conditions that may be anticipated to result in ill
health, to protect those assets that individuals bring to their older adulthood, and,
though too often neglected, to attend to those possibilities for the promotion of
goals—for both individuals and macro social or physical environments—that
serve the end state of health. The model has been previously applied as a guide for
professional practice in the promotion of successful aging with older adults (Klein &
Bloom, 1997).
Beyond the tripartite definition of primary prevention, this configural equa-
tion of primary prevention incorporates consideration of five levels of function-
ing. At the lowest level, the individual is recognized as being the central focus.
The individual is embedded within a social structure that entails three additional
levels. First, virtually every individual is a member of identifiable primary
groups. These groups include family, close friends, and others for whom the rela-
tionship is characterized by face-to-face ongoing contact. The number of such
groups may vary from individual to individual; the strength and salience of indi-
vidual groups will also vary. However, most older adults have such primary social
relationships. By the nature of primary relationships, it is among members of
such groups that individuals turn for support, typically as both givers and re-
ceivers. Secondary groups exist for most older adults at a somewhat lower level of
social connectedness. Secondary groups are characterized by a sense of member-
ship but may lack regularized face-to-face contact. Larger membership organiza-
tions represent such relationships. Secondary groups are less likely to provide the
personal-level relationships of primary groups, but they may provide other bene-
fits in terms of supporting identity structures or connecting to other resources.
Finally, all older adults are embedded in the macro sociocultural environment.
Included here are the social institutions that create and define the responsibili-
ties and entitlements of societal membership. Systems of law and regulation, cul-
Health Promotion 173
tural and ethnic influences, programs intended to provide services of support,
and community values are all part of this system of influence. Above even these
three levels of social engagement, all people live in some physical environment. To
fully appreciate the role of the physical environment in health promotion, we
must look beyond the natural physical environment (air, water, solitude, or the
absence of any of these qualities) to include constructed systems of community
infrastructure such as transportation systems, housing stock, and the other cre-
ated physical realities that provide a forum for contemporary existence.
Within each of these levels, primary prevention—and, by extension, health
promotion—may operate to reduce the limits or constraints that a person experi-
ences, or to protect or enhance the positive conditions that a person carries in his
or her health-promotive repertoire. Approaching health promotion from such a
preventive orientation provides a structure for the organized study and applica-
tion of health-promotive interventions that operate at any of these five levels. By
intentionally drawing attention to the multiple levels at which life is played out,
this approach to primary prevention offers a true ecological perspective. The in-
terplay among these five levels and the opportunity for the prevention of pre-
dictable problems, the protection of existing strengths and resources, and the
promotion of future goals and potentialities create a very rich stage for the ex-
pansion and application of health-promotive opportunities and interventions.
When we conceptualize health promotion in this way, it becomes much easier
to see the relationship between modest, even subtle changes in the behavior of
people and the impact that these changes can have collectively. The same power
in numbers that has allowed the baby boom cohort to shape many other aspects
of American social life can support their collective influence on macro health is-
sues. Modest but widespread reductions in body weight, tobacco use, and alco-
hol consumption could potentially result in substantial reductions in heart
disease, respiratory disease, and myriad costs associated with alcohol misuse.
Simultaneous increases in exercise, health care screening, and stress manage-
ment can produce parallel benefits at the collective level. In short, a preventive
model of health promotion may yield huge benefits sorely needed by a dramati-
cally aging society.
The reader may notice that the structure of this chapter differs somewhat
from others in this book. Health promotion is exercised across a large number of
activity areas, and consequently, the topics of trends, incidence, etiology, and
prognosis do not provide neat and unique categories into which evidence-based
health promotion interventions might be organized. We have tried to be respon-
sive to the reasonable call for a uniform structure for the chapters of this book
while accommodating the somewhat unique requirements of the proactive field
of health promotion. To that end, each of the individual areas of health promo-
tion is presented with content reflecting the common chapter themes incorpo-
rated as appropriate.
PREVENTIVE HEALTH CARE
When one first thinks about health promotion, it is perhaps the area of preventive
health care that comes most easily to mind. After all, preventive health care is ex-
plicitly linked to health, and the idea of prevention is clearly connected to the no-
tion of health promotion. We start this survey of the various areas in which one
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might practice health promotion with preventive health care for exactly those rea-
sons. Preventive health care is about avoiding predictable problems as well as pro-
tecting the existing strengths—especially but not exclusively those of our
physical bodies—as we move through time.
Even as the notion of preventive health care makes intuitive sense on its face,
the actual practice of preventive health care within a society does not come with-
out associated costs. Too often, individual consumers, as well as policy makers,
fail to make the investment in prevention because the benefits to prevention are
seen only in the absence of the negative outcomes that otherwise may occur. Un-
fortunately, the implicit assumption that seems to operate—that what we can’t
see (the prevented disease, or fall, or other avoidable catastrophe) won’t hurt us—
leads too many of us to precisely those deleterious outcomes that we fail to pre-
vent. The opportunity to invest widely in prevention is the opportunity to avoid
the often catastrophic costs associated with our failure to do so. It is a little like
playing the lottery, but with much better odds!
There are a number of principal areas for direct action in preventive health
care, including regular health screenings, appropriate use of vaccinations, and
proper use of pharmaceuticals (prescribed as well as over-the-counter [OTC]
drugs), that fall under the general rubric of medical health care. In addition to
these, there are other areas of preventive health care that are clearly related to
health promotion (e.g., exercise, nutrition, cessation of tobacco use) but that we do
not choose to include in our narrower category of preventive medical health care.
These nonmedical areas are addressed in the topical sections that this overview
of preventive medical care provides.
V
ACCINATIONS
Clean water and vaccines rate among the top health interventions of human his-
tory. For the most part, issues of water quality have been satisfactorily addressed
for older adults in American society. Access to and utilization of appropriate vac-
cines, however, continue to provide a challenge for those concerned with health
promotion. In part, the lack of more widespread use of vaccinations stems from
their very effectiveness. Since the development of the first vaccines over 200 years
ago, their use has resulted in a radical diminution in many and virtual elimina-
tion of some diseases. With the ready threat of so many diseases removed, the
motivation for becoming inoculated against them is also reduced. After all, why
should we be vaccinated against a disease that almost nobody gets (the faulty
logic goes)? In addition, some people are moved away from seeking inoculations
by concerns about vaccination side effects or even acquiring the disease through
the very vaccination intended to provide protection.
Two vaccinations stand out as essential features of preventive health care for
older adults: influenza vaccine and pneumococcal vaccine. Influenza kills an av-
erage of 36,000 people in America each year, and over 90% of them are adults over
age 65; an additional 3,400 older adults are estimated to have died of pneumococ-
cal disease (Centers for Disease Control and Prevention [CDC], 2004b). The
Healthy People 2000 (U.S. Department of Health and Human Services [DHHS],
1991) initiative set targets for immunization of older adults to each of these dis-
eases at 60% (for flu, the target was inoculation within the past year; for pneumo-
coccal disease, it was ever having been inoculated), a goal that was successfully
Health Promotion 175
achieved. However, the Healthy People 2010 initiative targets 90% for each of these
(again, an annual inoculation for flu and ever having been inoculated for pneu-
mococcal disease; DHHS, 2000). According to the Administration on Aging (n.d.),
among non-nursing-home-residing older adults, flu shots reduce hospitalization
and death by about 70% and 85%, respectively.
H
EALTH
S
CREENINGS
Health screenings are not so much about preventing the likelihood that one experi-
ences illness or disease as they are about enabling early detection so that subse-
quent treatments might be less invasive and more effective. Quite simply, the goal
of health screenings is early detection, and early detection saves lives and re-
duces disability. The most common conditions for which older adults should be
screened are high blood pressure, high cholesterol, diabetes, and a number of
cancers. Depending on individual situations and circumstances, some of these
screenings should be conducted with relative frequency; other screenings are rec-
ommended as infrequently as every 5 years. “Only one-third of older Americans
receive all recommended screening measures. For example, 60% of Americans
over age 65 have not had a sigmoidoscopy or colonoscopy in the past 5 years—two
tests that can screen for colorectal cancer—even though Medicare covers both
services” (American Public Health Association, 2005, p. 1).
Blood Pressure Blood pressure should be screened at every health encounter for
all adults. However, it must be appreciated that the condition of high blood pres-
sure is not typically detected with a single test due to the normal fluctuations in
blood pressure that are commonly experienced. Should an elevated blood pres-
sure be detected, a second check should be performed during the same visit.
Thus, it is best for older adults to take advantage of blood pressure screenings
routinely—at least annually but more frequently if elevated blood pressure is de-
tected. Generally the diagnosis of high blood pressure should be based on two or
more elevated readings taken on two or more occasions. Through such a routine,
individual norms for blood pressure may be established and used as a compara-
tive basis to determine abnormalities. In the event that blood pressure higher
than a moderate range is detected, the frequency of screening should be in-
creased as indicated by a health professional. The combined affordability and
availability of blood pressure screening to older adults suggests that this should
be made a part of regular and ongoing preventive health care.
Cholesterol High cholesterol and lipid disorders have been associated with coro-
nary heart disease and cardiovascular disease in adults. The U.S. Preventive Ser-
vices Task Force (2001) has made a strong recommendation that screening be
conducted regularly (annually) among adults. The Task Force did not indicate an
upper age limit for such screening; however, because lipid levels are not as likely
to increase among older adults (> 65 years of age), the importance of continued
screening diminishes for that group.
Diabetes All older adults should be screened for diabetes every 3 years. The risk
of diabetes increases with age, the presence of vascular disease, family history of
diabetes, hypertension, and a body mass index of greater than 25. In addition,