Car Thefts and Health Promotion Science

Today I was reading a story in the Washington Post regarding the ten most commonly stolen cars.  The article was formatted so that readers would breathlessly page through the tenth most widely stolen, the ninth, all the way through the car with the number one distinction.  I was waiting for the drum roll when it was finally revealed that the Honda Accord is the most frequently stolen vehicle.  The insurance accountants who provided the rankings further stipulated that the 1994 model was the single most widely stolen in 2011.  This caught my attention because I happen to own a Honda Accord, though not that model.

I would like to think that every reader immediately thought of many questions about this ranking. First and foremost, wouldn't the Accord be at or near the top of theft numbers simply because it has been the most widely sold vehicle for many years?  In addition, because these cars are so well made, each vehicle is in service for more years than less reliable cars, and therefore are at risk for theft for a longer period.  The key issue for consumers and risk managers alike is whether a specific vehicle has a greater risk of being stolen, but the data reported in this article do not answer the question.  This reminds me of the joke about the man who decided he needed to move when he was told that he was most likely to have an accident within 25 miles of his home.

What does all this have to do with health promotion?  It is just this.  In popular culture and conversation, people often express the extent and proportions of the intellectual challenge of something by saying "It is not rocket science" or "It is not brain surgery."  No one ever says "It is not health promotion!"  This is unfair I suppose, but my point is that health promotion doesn't get credibility and trust by divine right.  We have to earn it, and we do so by asking hard questions about health claims, by insisting that our strategies and methods are based, not on good intentions, but on evidence and standards of best practice.  The nature of health and disease is such that people can and will make claims about prevention or treatment that are based on well-intentioned wishful thinking.  We cannot drink this particular cool aid.

In our academic programs we are working hard to do a better job instilling in students a habit of critical thinking.  We are driving home the lesson that program plans must be based on research and evaluation evidence, and when there is no such evidence, evaluation of our efforts is of the first order of importance.  Never can we use the rationale "Well, it can't hurt...."

Of course we assume that the lay public, as a group, is quite vulnerable to fuzzy thinking about the causes of health and illness.  No matter how hard we strive to correct misconceptions, it is hard to keep up.  The public is probably more interested today in not losing their cars, but we also must keep helping them to understand the real things that are likely to steal their health.

Is Big Sugar on a Downward Spiral?

Many years ago I visited a museum and exhibit maintained by the Coca Cola company in Atlanta; it is still operating and is heavily promoted in the Atlanta area.  This museum is quite large and it takes the visitor through the history of the company, from the early days in the 1800s to the present.  When I was there it was a very happy place, celebrating the success of a great company and the status of Coke as an American cultural icon.  O how the mighty have fallen!  While Coke is still highly respected, it is a fact that the soft drink industry is now in a defensive stance.

Maybe it is me, but it seems that public alarm regarding too much sugar in our food and beverages is becoming like the venerable snowball out of control.  PSAs, media stories, and general scrutiny regarding the hazards of excess sugar, and efforts to limit our sugar consumption in total have become almost as ubiquitous as the political ads during the election season. Recently I came across a new video presentation from the Center for Science in the Public Interest, regarding sugared-beverages.  See what you think about it.  Recently a lot of attention has gone to what New York City is doing to restrict large serving sizes of sugar-rich beverages, and people are waiting to see how successful that effort  becomes.  Even Big Sugar is getting into the act by announcing the coming use of soda machines that provide calorie information.  See the video from ABC news.  By the way, I'm including under the umbrella of "Big Sugar" the soft drink companies and high-sugar candy and junk food makers, because these products are not really food, but delivery devices for sugar, as well as caffeine in the case of many soft drinks.  The population is hooked on sweet.

The adjective "Big" is often used to cast aspersions on the thing it modifies.  The label Big Tobacco doesn't just refer to market share, economic power, or number of employees.  It also whispers that because of the size and clout of those entities, they are up to no good.  Other examples are Big Pharma (e.g. Pfizer, Merck, GlaxoSmithKline), Big Food (e.g. Tyson, Nestle, Kraft), Big Medicine (insurance companies and provider chains) and so forth.  While we are painting with a broad brush, there is no question that many of these powerful firms have pursued their narrow interests against the best interest of the public, especially the most vulnerable.

So what is behind this recent change regarding Big Sugar?  Why are we talking so much about sugar, and specifically sugar-flavored beverages, as opposed to fat or alcohol, or other nutritional issues such as too few fruits and vegetables?  For one thing, it is a fairly simple idea: cut down on sugar and you can decrease obesity and other health problems.  It is a simple media message - the best kind.  It is easy to act on this message, whether you are a consumer or a food and beverage producer.  There are lots of options already available, and consumers have access to more and more data to alert them when a lot of sugar is a key ingredient.

The anti-tobacco campaign is young, really just taking shape.  It remains to be seen if the extended tug of war that public health has had with Big Tobacco over the last 50 years will be replicated as we tackle the health consequences of sugar-laden diets.   We now have a  play book for public health advocacy, but so does Big Sugar.  Stay tuned.

Reflections on BRFSS

This week I participated in an annual task of making decisions about the question items that will be included in the annual Behavioral Risk Factor Surveillance System (BRFSS) data collection.  Before I write about this process, some background would be helpful.

Shortly after the publication of the watershed document "Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention" in 1979, it became more apparent that, as in all public health work, better data for planning purposes was critical.  The important role played by behavior had certainly been recognized for quite some time, but health related behavior and lifestyles as causes of our dismal health status came to a prominence not seen before.  Public Health leaders in the federal Health & Human Services and CDC set about building a data infrastructure for behavior change efforts, and so in the early 1980s, the BRFSS project was born.  It started with only 15 states; since the mid 1990s, all states and the District of Columbia are participating.  The system provides a standardized set of questions, with data reported on a national basis, data for each state, as well as to some local communities.  Comparisons among levels as well as time trends are possible.

Survey items include a set of "core" questions that are uniform throughout all jurisdictions, and from year to year.  There are then questions called "optional modules" that will be used less frequently, such as every other year.  There are also "state-added" questions that will be inserted only in the questionnaire used for the data collection in a specific state.  State-added questions may be standardized CDC questions not being used in the national survey, but for local reasons are thought important enough to be included in the state-specific survey instrument.  States can also add questions not from CDC, but that address a local concern.

In addition to the importance of the actual questionnaire content, there also has to be thought given to survey administration.  The data collection method is telephone survey, with most interviews being done on land-line phones.  A growing proportion of phone interviews is done with cell phone numbers, since an ever larger segment of the population is shifting to cell phone use only.  Kentucky's cellphone sample in 2013 will be 25% of the total sample.  In addition to the cell phone interviews, states can mail questionnaires to people who either have no phones or for other reasons cannot be interviewed by phone.  In Kentucky, about 300 mailed questionnaires have been completed in recent years.  Survey administrators and interviewers must be concerned about the length of interviews and questionnaires, as well as the nature of sensitive questions.  A typical BRFSS phone interview will take about 20 minutes, including about 140 questions - a lot to ask from busy householders who receive no specific benefit.  In addition, some questions might be considered too personal or perhaps offensive to some respondents.  For example, in the HIV module respondents are asked to indicate whether "You have given or received money or drugs in exchange for sex in the past year."  Not everyone is pleased to get that questions from a complete stranger on the other end of the telephone.

At the state level, Departments of Public Health will typically have an administrator who manages the state BRFSS data collection.  In Kentucky, an RFP process is used, so that individuals and groups are invited to submit requests for individual or groups of questions to be added to the data collection for the following year.  As mentioned at the beginning, I was part of a group that reviewed the question proposals that came to our BRFSS administrator.  The proposals must demonstrate three things: 1) need for questions, based on the importance of the issue (e.g. oral health, adolescent sexuality); 2) a demonstrated data gap, with information not available through other existing state-wide data collection; 3) validity and reliability of the proposed questions, and capability to use data findings.  Agencies successful with their question requests are charged, in Kentucky, $2500 per question added.

The reviewers considered seven question proposals - three were rejected.  In one case, the question requested, about people buying fruits and vegetables in nontraditional venues such as farmer's markets and you-pick farms, seemed to the reviewers to be not important enough information to justify inclusion.  In the second case, a set of questions about adverse childhood experiences, such as being physically or sexually abused, left doubts about the practical value of the information.  In the third case, a set of questions about parental support for various aspect of school-based sex education, was considered too hot politically by a majority of reviewers, and of dubious value for community interventions.  Decision makers strive to be evidence-based and guided by critical thinking, but there are undoubtedly some subjective considerations.

While I left the BRFSS meeting feeling satisfied about making a small contribution to health promotion and the public's health, I also felt as though I had seen some health promotion sausage being made.

Health Promotion In Your Face

Recently ABC news had a story about public school students complaining because the cafeteria lunches are too healthy and too low in calories.  A whole serving of new school lunch policies has pushed food service directors to provide less fries, pizza and chicken nuggets, and more fruits, vegetables, and low fat milk.  This comes on the heels of most schools eliminating junk food vending machines, and some schools putting stricter limits on food sales (such as bake sales) as fund-raising tools.  While the lunch lady was never the most popular person in school communities, this raises a whole new regimen of rancor.  Some students are resentful that they can't have burgers and fries for lunch every day, while other students are aggravated by what they see as force-feeding of vegetables.  On top of these conflicts, some conservative parents object to the "nanny state and nanny school" interfering with the views and traditions of parents who believe they should be the driver of nutrition for kids.  The health promoters behind the push for schools to be focal point in the fight against obesity perhaps feel isolated and unappreciated at best.  It is much easier to produce and disseminate congenial PSAs, encouraging families to eat more fruits and vegetables.

Also this week there has been news coverage about a media campaign produced by Blue Cross / Blue Shield of Minnesota, highlighting the influence of parent's bad food habits as a developmental influence on kids.  The campaign has become controversial because it is seen by some to shame and humiliate adults who are overweight.  The producers felt that the extreme urgency of the obesity epidemic justified pushing the envelope of social decorum because many of the media messages used in the past were not working.

The issue is not a new one.  During the 50 years of the anti-tobacco campaign, we've seen media messages making women blame-worthy for smoking while they are pregnant.  We've also seen media pieces connecting cigarette smoking with male impotence.  Such messages don't rely on guilt or shame, but are  certainly provocative, deserving at least a PG-13 rating.  Other messages have overtly associated marijuana use with a somnolent lifestyle leading to a dead end - a message some would find insulting or offensive.

So the question is, do health promoters have an obligation to be nice?  How do we deal with the tension between respect and cultural sensitivity and the driver of our profession, helping people obtain and maintain better health?  This is a professional dilemma shaping our identity.  It is also an ethical issue, regarding recognizing a line demarcating effective practice versus guilting and manipulation.


Why do health promoters sometimes use these in-your-face tactics?  Sometimes it is a lapse in judgement to resort to controversial approaches, because the epidemiology screams so loud, whether it is obesity, smoking or HIV prevention.  Sometimes these messages are intentional as a way to break through the media clutter.  Only provocative messages get more than a nanosecond of attention some times.  In addition to grabbing peoples attention with health promotion ideas, controversial messages and approaches have a chance to create "buzz" leading to further discussions at home and at work.  Most of the time, people talking about a health promotion theme is a good thing, moving people ahead in readiness to change.

Of course we have an obligation to treat clients and communities with respect and compassion.  Overweight children and adults are part of a cultural minority group, facing their own set of discrimination and ridicule.  We certainly don't want to perpetuate this, but neither do we want to be a Nero, fiddling while Rome burns.  Much thought and wisdom are required.

Health Promotion Behind Bars

In the last few days, two unrelated cues came my way, both inspiring me for a blog posting. In my building we have a closed-circuit information TV screen system, that scrolls through announcements, birthday notices, a vocabulary “word of the day”, and inspirational quotes. This week the quote was from Nelson Mandela: “It is said that no one truly knows a nation until one has been inside its jails. A nation should not be judged by how it treats its highest citizens, but its lowest ones.” Of course Mandela has credibility as a first-hand witness.

The other item that stopped my forward progress momentarily was an op-ed in the Washington Post, by Elton John, regarding the treatment of HIV positive individuals in U.S. jails and prisons, particularly in Alabama and South Carolina. John documents examples of unfair treatment experienced by these prisoners, particularly in those two states.

The Mandela quote and the John article both come together on the topic of prison health. Most societies make some effort to provide medical care and more generally, ethical and humane treatment for those persons incarcerated.

In all developed nations there is a social agreement, supported by some legal safeguards, that people locked up by society should be provided with basic resources to support life: air, food, shelter from the elements, personal hygiene facilities, and medical care. The principles that provide a rationale for the provision of these and similar services are several, but general in nature. They create an expectation for these basic provisions, but don't specify components and extent of services. For example, we agree that prisoners should be fed, but at what quality level? There is a lot of distance between the most inexpensive, barely adequate food and first quality protein, fresh produce, and whole grains. In most places this is simply a short-term budget issue, managed by bureaucrats in the correctional system, with no thought to long-term implications. However, society has a stake in these decisions, in the same way that all have a stake in the public school system, even those who don't have school-aged children.

Incarceration is mostly about punishment for misdeeds, some of which are truly heinous. However, there is a hope, for most prisoners, that prison time is the first step in personal rehabilitation. Spending time in a "correctional" institution is supposed to get people back into the community, making contributions in a pro-social way. Prison programs are judged, in part, by their recidivism rates: the frequency with which freed prisoners return with subsequent offenses and sentences. While there may not be much evidence that health promotion for prisoners decreases the recidivism rates, we can construct a limited extrapolation: healthier children perform better in school, and healthy workers are more productive for their companies.

The dilemma is how to apply health promotion practice principles within the unique setting of corrections. Prisoners are an interesting challenge for education programs. It can be predicted that the average resident of a state prison was not a model student. A large portion (23 %) of prisoners report learning disabilities. We would expect health literacy to be a particular concern, but this is only speculation because of a lack of definitive data. Prisoners have limited control over their health behavior, compared to other adults. For example, opportunities for a physically active lifestyle are narrow, and healthy nutritional choices are confined to foods provided by the warden. They also have limited opportunities to secure social support, and health promotion professionals will have limited prisoner exposure time and a much smaller range of tools. For example, social media would not generally be a feasible tool in the prison population.

The other type of intervention, policies, are also uniquely challenging. In this sense, prisons are parallel to corporate health promotion. Companies will only implement health promotion, including health policies, if there is real evidence that the investment will reap a return of increased productivity and improved profit. In the same way, prisons would be interested in health promotion only if it had a desirable impact on a few key things; 1) Does health promotion for prisoners have a positive impact on recidivism? 2) Does health promotion make for more contented, easily manageable inmates? 3) Does health promotion save money on healthcare, which amounts to billions of dollars nationwide?

The above questions represent a research agenda. Many answers are yet to be found. In the end, we have to find consensus regarding what is appropriate treatment for incarcerated criminal offenders. Does their criminal penalty also include having their medical problems neglected, no provisions for health promotion, and to be victimized by sexual assault and violence? President Mandela is challenging our national conscience, but for most people, prisoners are locked away where we don't have to glance at them. Perhaps it is time to think about health for all, including those on the other side of bars, walls and razor wire.