Identifying and addressing obstacles to optimizing health education/promotion services.
Abstract: Spurred by the publication of the Surgeon General's Report Healthy People in 1979 and subsequent publications through Healthy People 2010, the importance of health education and health promotion has been well documented. As a result the importance of lifestyle habits and behaviors has received greater attention and recognition. Yet, a variety of obstacles continue to exist that prevent optimizing these services. They include the fact that some of the benefits may not accrue to the purchaser/payor. For example, worker mobility or retirement may give the employer no benefit. Policies and strategies for reducing these obstacles are discussed.
Subject: Education
Medical personnel
Periodical publishing
Author: O'Rourke, Thomas
Pub Date: 03/22/2009
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Spring, 2009 Source Volume: 24 Source Issue: 2
Product: Product Code: 8200000 Education; 8010000 Medical Personnel NAICS Code: 61 Educational Services; 62 Health Care and Social Assistance SIC Code: 2721 Periodicals
Accession Number: 308743741
Full Text: Spurred by the publication of the Surgeon General's Report Healthy People in 1979 (USDHHS, 1979) and subsequent publications through Healthy People 2010 (USDHHS, 1980, 1991, 2000) the importance of health education and health promotion has been well documented. As a result the importance of lifestyle habits and behaviors has received greater attention and recognition. Yet, a variety of obstacles continue to exist that prevent optimizing these services. This Commentary identifies obstacles and suggests policies and strategies to produce a more optimal level of health education/health promotion services than currently exist. Knowledge of the obstacles may help health professionals and professional organizations in their efforts to promote and deliver these services.

Health educators frequently, and correctly, extol the potential benefits of their activities. For example, those promoting worksite health promotion cite the opportunity for increased productivity, reduced absenteeism, greater employee loyalty and reduced medical costs. Others cite the benefits of increased and enhanced health education efforts in the area of managed care exemplified by Health Maintenance Organizations (HMOs), citing the potential for reduced and more efficient utilization of costly medical services and hospitalization. School health educators emphasize the importance of health as an essential component related to the learning process. Yet many of those same health educators lament the paucity of health education efforts in those and other settings in terms of both quantity and quality. So why does this paradox exist--the apparent benefits but also the apparent absence of these services--and what might be done to address this paradox?

One problem is that the demand for these services reflects the direct benefits real or perceived of the purchasers or payors (e.g. employers--not the program recipients who may not be purchasers or payors) when, in reality, some of the benefits may/ may not accrue in the future and not even to the purchaser/payor (Higgins, 1988; Russell, 1986). When an employer implements a worksite health education/promotion program, the costs are immediate and continuing, but some of the benefits (return on investment) may not occur for years. For example, an employer may encourage flu shots and pay the cost as well as providing time off to obtain the shot. In this case the benefit may accrue within a short time frame assuming a flu epidemic materializes in the form of reduced absenteeism or health care costs. Additionally, the employer may reap immediate benefits from the "herd immunity" that protects other employees who may not be immunized, since they experience a reduced risk of infection as the number of immunized employees' increases. In contrast, a reduction in employee blood pressure at point A in time may only show benefit to that person's employer years later. Similarly, employees who quit smoking or significantly reduce tobacco consumption may well enjoy immediate physical benefits to themselves and even to other household members, but more economically meaningful benefits, such as reduced medical costs or less prolonged absenteeism due to chronic conditions, may not be realized for decades.

This problem is compounded by worker mobility. That is, employer A who incurs the costs only benefits later if the employee remains with the organization and avoids the problems addressed by the health promotion program. If the employee leaves for another job, a distinct possibility given employment mobility patterns in many industries, then the new employer reaps the benefits without the cost.

Similarly, the employer may reap no benefit from the employee who retires in good health and who is fully capable of further productive employment. In this case the benefits of the health education/promotion program paid for by the employer may accrue to the Medicare program and may even add to employer costs in the form of additional private pension benefits because of greater longevity (Higgins, 1988). So, given the time lag for many health benefits to become manifest, if at all, and the distinct possibility of employee turnover or reduction in workforce due to the current economic problems, it is not surprising that many employers may be hesitant to implement health education/health promotion programs. If the goal of the purchaser buyer was to capture the benefit, then one would conjecture that the employer focus would be on programs that offer the possibility of short-term immediate effects and avoid programs focusing on longer-term benefits. While this may be a rational approach for the employer, it may not be one that optimizes benefits for the individual, family or society.

Nor is it likely that employers will rely heavily on health education/promotion to contain health care costs. Employers are much more likely to utilize employment screening, health plan benefit modification, cost sharing and utilization controls to address the health care cost issue. For example, employers may avoid high-risk workers, shift medical costs or reduce the range of covered services. Health education/promotion programs have the potential to influence the mix of health services and result in costs savings in the future, but again, the benefits of any future cost savings may not accrue to the party that bears the cost.

A similar scenario may play out for the health care service provider. The past two decades have seen the rapid emergence of managed care primarily manifest by the Health Maintenance Organizations (HMOs). Since HMOs are financed on a prepayment basis and then responsible for providing services to the enrolled population, one would think that they would strive to provide an optimal level of health education/promotion services. But obstacles exist similar to those faced by the employer. The costs of health education are immediate and ongoing but the health care plan supplier that incurs the full cost of the program may capture none or only some of the potential benefit. Enrollee turnover is commonplace. The employer who offers health insurance may change plans or the choice of plans to the employees. Likewise, employees who remain with the employer may change plans based on plan benefits, cost, health status, marital status, dependents or geographic convenience. Also, HMOs that do not serve the Medicare population and even those that do risk losing enrollees upon retirement and thus forego the opportunity to capture substantial potential benefits resulting from a quality health education/promotion program.

Certainly there are benefits from health education/promotion programs that accrue to those beyond the purchaser. In economic terms these are referred to as externalities. They may be positive or negative. A positive externality exists when some of the benefits accrue to those other than the purchaser. Vaccines are a classic example of a positive externality. Others in the population benefit form the "herd immunity" effect. A negative externality of a health education program to reduce smoking via increasing taxation may be that, although overall consumption may decline, the remaining smokers may smoke more of the cigarette than before and thus increase their risk due to increased exposure to carcinogens at the lower end of the cigarette. Or, while a positive outcome of an environmental awareness program may be to encourage lower gasoline consumption, a negative externality may be an increase in injuries and fatalities from the increased use of smaller vehicles. Unfortunately, markets tend to underproduce goods and services having positive externalities because there is usually no incentive to do so, since the benefits accrue to others than the purchaser and the purchaser is often not liable for the negative externality.

So, what might be done? Several options exist. States play a significant role in regulating businesses and health insurers. Laws abound relating to health and safety issues. Similarly, either with or without the force of law, rules and regulations abound affecting health care coverage. One possibility is mandating coverage of health education/promotion programs either comprehensively addressing major risk factors or specifically by program to those covered by health insurance. States already have rules about the breadth of service coverage and adding these services would not be cost prohibitive. This could be done for both employers and health service providers. Nor would the entire burden have to be on the employer or health provider. To reduce the burden on the employer or provider there could be a cost sharing arrangement with the employee assessed a portion of the cost. Employee participation in health education/programs activities would be voluntary.

Given the potential unpopularity of government mandates, especially those that are unfunded, governments at all levels could address the obstacles previously mentioned by implementing incentives in the form of subsidies to businesses, health providers and individuals. A wide range of possibilities exists in the form of direct payments, tax credits or deductions. The rationale is straightforward. Health promotion benefits accrue not only to the program recipient but also to the entire society. Healthy children have a greater opportunity to learn and become productive citizens. A healthy workforce benefits the entire economy and society. Subsidizing programs that contribute to societal benefits is commonplace. For example, businesses receive an incentive to install pollution control devices or produce biofriendly ethanol fuels. Taxpayers receive a tax credit for adding insulation to conserve energy or purchase a hybrid vehicle.

Another possibility would be to implement some form of a universal access health program. A universal access health program at the national level is an emerging issue and was included in the campaign platforms of several Presidential candidates during the 2008 primaries (Obama, 2008, Clinton, 2008) and is on the front burner of President Obama. With a universal access program there would be a built-in incentive since, unlike the present, the program would capture any current or future savings.

Implementation of a universal type program at the state level is more realistic. Already several states such as Massachusetts, New Hampshire and California have or have initiated a proposal for these programs. Regardless of the specific plan, a single payer would have a built-in incentive to integrate, support and subsidize health education/promotion in all settings including community, worksite, school and medical care settings simply because it would stand to capture the benefits at any current or future point in time. Similarly, the link between the payor and beneficiary would be clear and direct. In the process all the players now hesitant to provide health education/promotion services would benefit through improved health status as well as the recipients, families and society as a whole--a classic win/ win situation for all.

CHES Area:

Responsibilities and Competencies

V B & C VII A1, D1


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Thomas O'Rourke, PhD, CHES, is a Professor Emeritus in University of Illinois at Urbana Champaign. Please address all correspondence to Thomas O'Rourke, PhD, CHES, University of Illinois at Urbana Champaign, 1206 S. Fourth St., Rm. 127, University of Illinois, Champaign, IL 61820, Phone: 217-840-7036, Fax: 217-333-2766, Email:
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