Ee 014718 ,AUTHOR Larshall, Carter L

DOCOeEVT.Bissuaz-

OM 151 51% -eE 014718 ,AUTHOR larshall, Carter_ L. Toward as Edidated- Health, Consumer; Masa -CoMainitatida and Quality -Medical Care. Pogarti. /iteriatiCail Series on the Teadhinq of Preventive Medicine. NO lap&-7.

INSTITUTION Pogaity International. Center lbativpitt) , Bethesda,

:REPORT NO kti-178-817 ,i)(16 DATE 77 iipTE, 70p41Buperintendent' Of Documents,,'W.S. ,Goverment printingtiffice, -Naihington, D.C. .440: /Btoci *amber 017-040-00406-1) 0 :BOBS,' PRICE MP-46483 HC-$3'..0',Plus:-Postage. ,DJIscrtz,PToBs ehavior Patteint; c64414ty Health:. CoPOMer

BCOnaiiCs; Consumer---Education;- *Consumer, Protection; Consumer Bdience;.-IdadatiOnal,:0004; "Wide tiOnal Strategies_; Bditcational Federal iegiSiatiOn; *Health idticatid14 -Bea InforMatiOn, DiSseiiaationl- instruction -Media:- *Mats Media: iedidal Cari,4valiuition: *Prevent Preventive-..kedicine"; _Prilarf -Health Caret- Public Health; iPublid: potion ; Publis Television_t Ittitud'eS; Social Values- ;_ 'State of the Art ReVieirs; TeledomiuMidatiOnl TeleviSion. IDENTIFIERS United States

ABSTRACT _Focus in this preventive Medicine monograph for :health- prOfessionals is on consumer health. education and the current andpotential -effects of mass-dOsianidatiOn, on the 4140X-iti of medical -Caiei, -Following an introduction, the content is presented in fOUr :.chapters.- Chapter 1 covers the state\of the art in consumer. health . -; education and discUsaes three- Models \of lealth, edadation, the bases, of health edacatiOn4 attitudes ,and-knd.010d4fiabout :both -health and illness, Allneas Tbehaii.cLand, ii010140tii4 Programs ',of preventive Medicine. The second chapter ,W704---z-611-0000A-#Ous7 revolution first _presents an aireiview Of: the cdaiunication- prodess laSs media and then disOuSses rise -of specialise, consUmerisiv_ and the Message of the media (particulatlY television), and health behavior and mass commerication.LChapter 3 on- quality medical care covers the origins of the health 'consumer;. legislatiie. such as national health insurance, professional Standard& review ;organizations, and health maintenance Otgaiiiiations;- and quality. ',assessment including the establishment of a phySician-constimer alliance and outcome measures. The last chapter briefly preientsa strategy for health education. Each of the four chapters concludes with an extensive bibliography. (EN:

4**********,*********************************************************** Reproductions supplied by pRs are the best that .can be made froi the original document. 1********************************************************************** AN ED:OPTED CONSUMER:

MASS COMMUNICATIONAND I QUALITY.INMEDICAL CARE By

Carter L. Marshall, M.D. S.

-- It'A Report of Conferences Sponsored by the John E. Fogarty International Center for Advanced Study in the Health Sciences

National-Institutes of Health Bethesda, Maryland

U.S DEPARTMENT OF HEALTH, EDUCATION & WELFARE NATIONAL INSTITUTE OF EDUCATION THIS DOCUMENT HAS BEEN REPRO" DUCED EXACTLY AS aECEIVEO FROM THE PERSON OR ORGANIZATION ORIGIN, ATING IT POINTS OF VIEW OR OPINIONS STATED DO NOT NECESSARILY REPRE. SENT OFFICIAL NATIONAL INSTITUTE OF EDUCATION POSITION OR POLICY

DHEW Publication No. (NIH) 77-881 U.S: -DEPARTMENT OF HEALTH, EDUCATION, AND WELF/ARE Public Health Service \National Institutes of Health \.)s

2 This monograph is the seventh in a serieson the TEACHING OF, PREVENTIVE MEDICINE

sponsored by the

JOHN E. FOG ARTY :INTERNATIONAL CENTElOar"--g- ,; ADVANCED STUDY IN THE HEALTH SCIENCES

- For sale by tb:-. SUperintendent of Dovments, U.S. Government Printing Office, Washington, D.C. 20402

Stick Number 017:040-00406-1 -141E.FACE-4.

TheFogarty -Internatiiinal Center was established in-.1968- as a Memorial the late. Congressman lohnr.H._,FOgarty from Rhode had been Mr. -Fogarty's desire to create -Within the National Institutes of-, Health a center for research in hiolOgy and/ inedicine-.dedicated_ to international cooperation and collaboration in the interest of the health_ of mankind The Fogarty InternatiOnal Center is a unique resource within the:Federal -lisinnen4.1provid in& a i?,iie.,for expansion of Amerioa's health research- and health bringing the, talents- and resources of other nationa.to ...beartupon* Many-and varied,liealthprobiems of the=tnited States. As an institution` for-.advanced stiidy;The 'Fogarty _Intemitional -Center has einhracid,:thei major themes of mediCal education; .envitOnmental-health, societal factors influencing. health and disease, geographic hedlth. Problenis, international= 'health -iesearch and education; and preventive medicine. Our commitment -to the Study, of _Preventive aapeCts of human disease 'Is expressed in the forthcoming Fogirtyjiiternitional Center Serieson Preventive Medicine. InipiOyernept in the health status of _the-Amerizan.peOple will depend, in 'great measUre;,_.on the design and application of programs whiCh place major:emphasis on the-Preventive- aspects of human disease: Although- health authorities generally- agreei,I,ith-ithia--thesis; there is need-for more precise definition of effective methods and programs of prevention, financial resOurfes required to implement these -prograrntjand_priotities to be assigned to research in preventive methodology. The need-toes` expertise in this field to elucidate mecha_nisnis whereby the full *Pact of preventive medicine maybe brought to\bear on the solution of America' ,Major health:problems has been expressed repe,dly in publip :statement' by leat-ders throughout the health field. /In to this need; the -Fogarty International Center initiated a series of ,comprehensive studies-of.preventive medicine in order, to review and evaluate. the Istate of the art' of prevention any control of human diseases, to identify deficiencies in knowledge requiring further research,-inclifdingran.alysis of financial resources, preventive techniques, and manpower, and to recognize problems in 'application of -preventive methods and suggeSt corrective action. This monograph, Toward an Educated Health Consumer, is one in the Fogarty International Center series on the Teaching of Preventive Medicine. It deals with health education and the current and potential effects of mass communication on the-quality Of Medical care. The growth of the consumer movement is dismissed 41, along with-the technological advancements which have Occurred, in the communications field- and the interplay betv.-;en_ the two (that is, consuerism and mass le media) as They affect the adoption of preventive measures for` maintenance of lifetime well-being. As the need for individuali to take. greater responsibility for their own-health is increasingly recognized, prosvider-consumer-coritinintication and -':"----oroeration,become ._eker more- important. It is hoped that this monograph will-be .influential not only in producing e 1-14-fed-health-consumers, but in promoting an -alliance-,between consumer interest groups and health professional---niftlirattain------ment of their mutual goal: high-quality medical care for everyone; iii 4 Aw' ,.1

:CONTENTS

PREFACE

ACKNOWLEDGMENTS vii

ODUCtON ix

Chapter 1CONSUMER HEALTH EDUCATION: THE STATE OF THE ART 1 - . Reiearch Bases -of Health Education- 4 Attitudes and ICnowledge'Abotit.Hepith 4 Attitudes and Knowledge AbOtit Illness 5 , illness Behavior. 7 Implementation , 10-

'7-Chapter 2 THE COMMUNICATIONS 'REVOLUTION 15 An Overview.of the Communication Process and Mass Media 15 The Rfi,,c. of Specialism . 18 Consumerism: The Message of the.Media 19 Health.BehaViiirand,Mass Communication 24

Chapter 3 QUALITY IN MEDICAL CARE: CONSUMERISM AND CADUCEUS 33 Origins of the Health Conlumer 33- . The Legislative Initiative 38

Quality-Assessment: Toward a Physician-Consumer Alliance 42 re'

Chapter 4 A STRATEGY FOR HEALTH EDUCATION 55

INDEX _61 MIIMEMM=1!

ACKNOWLEDGMENTS

J. ;In may 1973, -the Subcommittee- on -Cornmunications in thvEducation of .the Public for Health of the 'Association ofTeachers of Preventive*Tiviedichie:.(ATPM) -met at- the-Mbunt- Sinai- School' of:Medicine of the City University of New York fOra Symposium Coordinated by-the Medical School's Department of Community 'Mediaine-and=fUndeci by =the.,Fogarty International tenter. The Symposium dealt with-_bqth theoretical. and practical-issues in health education via prekentationk on .health iaucation; for the public and :physicians, advertiking, mask media, and Terson-to-person-Prograins in health education-. It concluded withia recognition by participatkthat_effectiVe Lea lth education-requires improvcdievaluation of current efforts- as well as establiihinent of Priorities for the iOttire.. This -- monograph' grew .Mit of-someOahe issues raised by-the ATPM Syriipoiium,--foauSinLo) the currnt- .nitil potential. role' of communications tun!: Of consuiiiaiisncNeeffective health education for our tithes. In, the preparation, of this docuient; .the author, was assisted by Helen. A. Bronheim,_who prepared Chapter -1 and edited the overallmanuscript,and by all -members of the Division-of Cominunication of the Department of Community Mediebie, who _read; reread, cffered advice abbut; and debated 'the substantive issues and recommendations embodied in the manuscript. I- am indebted to all of 'them for their.tintiting= efforts and unflagginenthusiasm.,The wisdom and interest of Dr. Kurt Densehle, -Chairman of the Department of Community Medicine, were invaluable assets in the preparation of the- final manuscript. In additiOn, intensive discussions of the Task Force on Consumer Health Education of- thethe June 1975 National Conference on-Preventive Medicine, of which I was a member, have helped immeasurably in clarifying and furtheing my efforts. Finally, I wish to -thank the -Fogarty Center for the generous support which made possible the preparation of this manuscript. INTRODUCTION'

As we enter the third quarter of, the 20th_cenitiry, a number, of factors have -come together that-make it,necessary: for us to take a new look at the' was'- we -handle -conspmet health educationin the United States. These factors are -the increasing prevalence -of-chionic disease and the need for individuals totake more responsibility for their own health, the search for effective methods to assess and assurethe, quality of health care;_technolOgical,advances in mass communication, and, of _course, the growth of the consumer movement itself This monograph does not attempt to deal exhaustively with:these-Object_ areas, but ;rather tocuies, on -health education and thewayltinflueilees_andlis-inilliendeci-bY-each,of-, the four factors For example, a _special, effort *been- made to define the important role of communication both: in the genesis 'Of consiiiiierism, and in:`,the; recent TA. emphasis on the use of outcome ineasures intre \eyaluation of medical care quality. , Lhave also tried to .point out, ways in which mass -COnunitniCation can and cannofbe-used-iii the -service-of-health education. I have treated-health-education as A-keneral -subject area and have 'avoidedoccupational breakdowns and role assiginnents.. Some of my suggestions may be surprising, perhaps- even contra. versiall. If so; this is to be welcomed, because controversy :can lead- to -further -clarification of -the goals we should be setting in the area of coniAuner health education. The need 'for an educated health consuiner'has grown considerably during the 'past 75- years. For example, 19th centurY public health authorities had to do little more than inforin- the public cif sanitation-measures taken in their behalf. The development of techniques for immunizing people against infectious diseases-added another dimension. It became necestary.not only to inform the publie, but also to a exhort them to take advantage of the, measured: offered. With_ the emergence of chrbnic disease as- a major- health problem, however, the situation has changed dramatteally. There are no simple techniques for the prevention or cure of chriMie diseases, which require 'long-term medical management. and a .high degree .of patient cooperation. Such preventiontechniqUes as- do exist foehronic illness do not lend themselves to the information "and simple behaviOr models of the _past becauseihey- require the individual to convert habits and lifestyles that increase his susceptibility to disease into habits and lifestyles that promote health. This is a difficult process that takes years to effect and then requires the individual to maintain his new behavior for life. The develOpment of what we have called a chronic disease model in consumer health education is complicated further by the fact that we must deal to a large extent with people who are not patents. If our-efforts are to succeed, anumber of challenges must be, met. First, we must persuade people that health maintenance is a realistic and, achievable gOal. Second, we mu,stpersuade people to regard health maintenance as- a personal obligation rather than as the responsibility ofthe health care system. Third, we must-make it easy for people toadopt beneficial behaviors; for example,if we ..want people to exercise,facilities for exercise .must be it 7

-1 x/Toward an Educated Health COnsumer

available. Fourth, we must.help people avoid .suchsocially approved but harmful behaviors as smokingi excessive use of alcohol, and overeating. Meeting. these challenges will require.a coordinated- effort of a type not yet demonstrated in health education. It will also requireparticular attention to low- income people whose aggregate health behavior isthe least satisfactory,, whose; attitudes toward. medicine are the most negative,whose knowledge of'health is the' least well developed, and whose healthstatus leaves the Most room for improvement' Five hundred years- ago, Gutenberg/inventedmovable type, and 150 years' ago, the-telegraph ushered in the eraioqlectroniccommunication. These two develop7, ments produced a still - accelerating- expansion of informationand knowledge and _led to the development of,,oeciipational specialismin all areas of human activity, including medicine. As specialties generate additional knowledge,still more -specialties emerge; cOnsurrier health educationis, one of the more recent. /The growth of ,pecialisin precededa related developthent-7-the -emergence- of electrpnic mass communications, particularly television. While,much canCein has been expressed' over the Trogram ,.;.ntent of'television, itsgreater significance lies perhaps in its technical capacity to disseminate information. Televisionha's made, possible for the first -time the Creation ofa general.data-base shared by, allsegments of die society, including low-income people whoseprimary sources of infortnation rarely include print media. One important effectof the creation of this general data base is that it has riducedr,the gene"ial informationgap between society as a whole and the specialists, who' have tended to focuson ever- narrower specialties with the result that the specialist often knowsa great deal about a small area and relatively little about the general fieldto which his specialty belongs. Tele- vision can also serve to spark a viewer's interestin a partichlar subject and inspire him to seek additional information fromnewspapers, magazines, or other publications specializing in'the subject. As people learn more about a particular subject, theytend to coalesce into what we have called a community of interest. The communityof interest develops 'information by following the specialtyor specialties which subsume the -subject. The juxtaposition of specialism and coMmunity of interestproduces consumerism, pert* The most Powerful force 4nour society today. Essentially, consumerism is a device to close the informationgap between-the specialty and its community of interest. Consumerism, specialism, and communitiesof interest all generate information which is homogenized, simplified, anddisseminated by television. Television has a bad reputation among those interested in health education priMarily because of the close ties of television to the advertising industry. Too often, deceptive claims and misleading information exerta negative influence on health consumers and health ',providersalike. Aside from the valuablebut limitedpublic service advertising, use of mass communication techniques in consumer health education has been difficult in the past becauk of the enormous funding levels required. However, an examination of television advertisingreveals much that is relevant to consumer health education, notably the fact that adver, tisers invest large sums to gain very small-increases, usuallyon the, order of 1 or 2 percent. Health education efforts using television rarelyseem to meet the extraordinarily high expectations of health professionals, yetmost do far better ,!lian even the most heavily backed advertising campaign. For example,a .television-based health education program aimed 'aran elderly population in New 'York City successfully Introduction/xi

induced 8 percent of its target population to participate in screening programs and followups. It is proposed that health providers who use television should, \to be more realistic, limit their expectations. The 4-year antismoking campaip, which relied primarily on television, and the less well defined but ,continuous effort, to educate people to the dangers of cholesterol and saturated fats are cases in poiiitz Because information presented on television cannot be retrieved, frequent brief' messages have more impact than 30- or 60-Minute programs. Frequent .repetition is alto necessary because television cannot be directed with great precisionat a particular audience. Since the availability of public service time is limited and the costs involved in normal television advertising are high, one effective way for health -providers to use television might be to lend their prestige in return for the development of producti that are either beneficial to health or at least less harmful than those presently in use. This might be achieved through the use or product endorsement by 'medical specialty societies. Such endorsement would, of course, be conferred on the product only after exhaustive review of its beneficial claims and careful consideration of any potentially negative effects on health. While this approach may. seem unusual to many health workers, it merits careful consideration since use of television is the only way, short of face-to-face contact, to reach all segments of the population, including the poor who are, perhaps, most susceptible to the negative effects of false advertising. Those who would educate. the public in matters of health must educate themselves in the use of mass communication techniques. Particular attention must be paid to evaluating health education materials formatively as well as summationally. As chroniC diseases have achieved primacy in the catalog of human ills, they have led *o ever-rising costs without yielding a proportionate increase in longevity or decrease, in morbidity. High costs and a variety of other complaints, have contributed to the growth of health consumerism. On One leyel, we have the trend to do-it-yourself medicine and the publication of such consumer-oriented documents as patients' bills of rights and consumer guides to health insurance or local practitioners. At the Government level, we have had discussions of national health insurance and the passage of several pieces of legislation including bills creating professional standards review organizations (PSROs) and health maintenance organizations (HMOs). HMOs are free to advertise and to be advertised once they achieve Federal certification, while the PSRO Act will ultimately have the effect of placing professionally developed norms and criteria of care into consumer hands. Once such norms and criteria become available to the public, the information gap between-consumer and professional will be closed still further. -Medicine is covered so extensively in the media that it is no longer unusual for the public to learn of medical news before the professional. As health-related information accumulates in the public domain, demands for the assurance of quality become increasingly frequent and it seems clear that eventually the consumer will be satisfied with nothing less than quality standards based on outcomes. For the consumer, there can be no success in surgery if the patient dies. False positives, inadequate followup, ineffective therapies, and poor patient compliance are the major causes of outcome failures. In most cases, the physician's success is measured by the extent to which he succeeds in influencing patient behavior. The physician proposes but the patient disposes. The development of outcome measures must take into account not only the

9 alt /Toward an Educated Health Consumer

health care process itself, but also patient behavior (that is, the degree to which the patient complies with the physician's recommendations).. This may well require a new kind of provider-consumer alliance, one that places the patient in a new relationship with the physician. The use of outcomemeasures should also stimulate consumer interest in and support for such forms of researchas clinical trials. In addition, a provider-consumer alliance around outcomes mill) probably provide effective resistance to 'efforts to impose budgetary restrictions that do not take into account the cost effectiveness of the programs involved. The establishment of outcome measures is an act of incalculable educational importance, and itis high timethislong-neglected activity was incorporated into the process of medical care. The goal of consumer health education isto encourage people to adopt preventive behavior, and become knowledgeableself-reliant healthconsumers., Three objectives are necessary if this goal ii to be achieved. Each objective reinforces and augments the community of interest concerned with health and increases the popular-constituency of health education. first objective is to protect both consumer and provider against misinforma-misinformation. The consumer needs protection from misleading advertisements and \oneway to do that might be to encourage high school students to examine critically the claims of television advertisements they see. Physiciansare subject to similar pressures, particularly with regard to drug advertising, and they must be able to select the most efficacious therapy from the choices offered. T e second objective is to demonstrate and reinforce preventive behavior. Here, an irhportant resource might be-the 3 million low-level service workers (primarily women and minorities) employed in the health industry who, with a little training, could comprise an army of peer health educators to low-incomegroups. In addition, the trend to do-it-yourself medicine should be encouraged and will probably be s imulated by a growing number of self-help books, the increasingpresence of family practices, and, perhaps, the advertising effects of HMOs. The involvement of the consumer in his own health maintenance can also be encouragedamong the poor by the use of health advisers drawn from. the same socioeconomic group. A final objective is to support the generalconsumer movement. Consumer health education is part of the broader consumer movement and is dependenton consumerism for the political power necessary to produce changes beneficialto health. The role of television in the context of consumer health education isto generate interest and provide the information base required to stimulate the search for indepth specialized information whether from print mediaor via face-to-face consumer interactions. Television, we believe, is the technological base for the development of consumerism. It is not, however, its ultimate instrument. Gun control, facilities to promote. physical fitness, certain kinds of restrictionon television advertising, and a host of other changes all require legislative action best approached through an- alliance of health professionals and consumer interest groups. CARTER L. MARSHALL, M.D. Professor of Preventive Medicine Director, Office of Primary Care College of Medicine and Dentistry of New Jersey New Jersey Medical School Newark, New Jersey 07103 1 In addition to chronic and degenerative diseases, today's Amerizan is also subject to the long-term CONSUMER HEALTH EDUCATION: effects of individual lifestyles and to the cumulative THE STATE OF THE ART effects of a highly industrialized society, neither of which is susceptible to direct medical intervention. To deal effectively with the problems created by this situation, we need a consumer health program that The ont,, way to keep your health is to eat Wu.: you will not only make Americans aware of. the health don't want, drink what you' don't like, and do Alai consequences of 20th-century living, but will also you'd driaher not. make them aware that they, personally, can and must Mark Twain, Following the Equator begin to take. more responsibility for the maintenance of their own health and the prevention of illness. The concept of medical self-help is comparatively new to modern medicine. Indeed,, until the develop- Changes in the health status of Americans and in ment of the germ theory of disease in the late 19th the state of the art of contemporary health care have century, public health efforts to control disease were produced a need for a new theory and strategy for limited almost exclusively to quarantine measures to dealing with consumer health educationinthe isolate the victims of diseases such as leprosy and United States. plague and, in the18th and 19th centuries, the At the turn of the century, the average patient was removal of dirt and other suspected disease carriers a relatively passive reciprt of whatever treatment to improve living conditions. For the rest, the sick was available for his particular problem. That situa- had to rely on home remedies or on the fairly primi- tion has changed dramatiCally over the years, and tive skills of the medical,profession. today's patient is much more a participant in the It was only after the development of specific health care system. One reason is that the average immunizations to control communicable diseases that American now lives longer than his grandparents health providers became aware of their responsibility thanks largely to advances in the medical art and to educate the public in matters of health. Subse- ;s, therefore, more susceptible to chronic and de- quently, as effective disease prevention tools oecame generative diseases, the management of which re- available in the late 19th and early 20th centuries: quiresincreasinglevelsof participation bythe bbth governmental and voluntary health agencies patient himself. An idea of the degree of change that assumed the mission of implementing them for the has taken place over the past 75 years can be gauged general good,inline with our Western culture's from the following situation. \ "highly developed sense that whatever is possible In 1900, there *ere approximately 3 million for one should be available to all."(2) Americans over 65 years of ageabout 4 1 percent Not surprisingly, perhaps, the overall development of thepopulation. By 1970, their number had of consumer hc..lth education, from its beginnings swelledto 20 million, and older Americans ac- in the early 20th century, has moved from broad- counted for almost 10 percent of the population. 1n scale measures matched to the broad-scale technol- thethe death rates per 100,000 populion from ogy of primary prevention to individualized measures tuberculosis, influenza and pneumonia, and, certain tailored to the available technology of individual diseases of early infancy were 194.4, 202.2, and care in the prevention of illness. The primary pre- 62.6, respectively. By 1965, the death rate from vention techniques of the early sanitatic. movement tuberculosis had been reduced considerably, while relied on such indirect measures as pasteurization, deaths frominfluenza ,ad pneumonia had de- water purification, and other environmental manipu- creased by 85 percent, and from certain diseases of lations and required little more than public accept- childhood by ,54 percent. (1) By contrast, the death ance. Immunization, on the other hand, required rates from heart disease and cancer increased by the delivery of preventive technology directly to 268 percent and 240 percent, respectively, between at-risk populations and this demanded active indi- 1900 and 1965. vidual participation. This duality of technology in 2/Toward an Educated Health Consumer

the control of communicable diseases gave rise to a programs to eradicate communicable disease. (3) paiallei duality between cofssumet health education Too often, however, public response has been dis- programs of public information, on the one hand, appointing, even when efforts have been madeto stir and those seared tc stimulate or promote individual up popularinterestand to make participation action, on the other. Easy. (4) Even now, while the U.S. populationas This split in consumer health education_ iT..no- a whole is protected against communicable disease, where more evident than in the controversy sur- significant sectors of the populationare not. For rounding the fluoridation of drinking water a decade example, despite public information efforts regarding' ago. The fluoridation effort exemplifies the develop- the ready availability of immunization against early meni of consumer education techniquesfrom the 'childhood diseases, a recent study conducted for the beginning of the'sanitation movement, when imple- Center for Disease Control indicated: that almost 40 mentation of environmental measures was accom- percent of 14 million American children under age plished by straightforward administrative or govern- 4 have not received adequate protection. (5) Simi- mental fiat, to the period when immunization made larly, continuing and highly sophisticated educational possible the control of communicable diseases, at efforts are required to, assure publicuse of readily which time it became necessary to, develop infor- Mailable diagnostic and controlmeasures against mation programs to persuade people that immuniza- venereal diseases, which have established themselves tion was both safe and effective. in epidemic proportions inmany parts of the United The addition of fluoride to public water supplies States. is a broad-scale prevention technique requiring only The control of chronic diseases greatly increases public acceptance (that is, individuals need only the complexity of health education. To begin with, continue to' drink available water to receive fluoride since the specific causes of most chronic diseases therapy). The topical application of fluorides, /how- are unknown, it has not been; possible to develop ever,is a preventive measure requiring individual the primary preventive techrsology that has been participation (that is, individuals must crder the available for the control of communicable disease. health care system to receive fluoride therapy). The Further, the course of chronic disease is gentrally active resistance to fluoridationin a number of progressive, long term, incurable, and irreversible. States focused on tile issue of "individual rights" Treatment, too, is prolonged, and there isno quick, and on the contention that the addition of fluoride to short-term prophylaxis comparable tosimmunization. public water supplies created an unavoidable danger A "clean bill of health" forcancer or high-blood to the public. Countering this opposition required a pressure today is no guarantee against the onset two-pronged public information campaign, consisting of symptoms in the future: Chronic disease control of (a) programs to enhance public acceptance of requires ongoingindividualparticipationinthe fluoridation and (b) programs to encourage indi- health care system, both for diagnosis andtreatment. vidual action via directvisits to the dentist for From the fOregoing, it is possible to discern three fluoride therapy. models of health education, each of which depends Another factor in the development of hearth edu- forits impetus upon the available technology of cation includes the nature of the diseases to be con- health care. trolled and the control measures available:, . example, the course most communicable diseases Model I: Information. The public is informedof take is fairly straightforward: They are usually self- things already accomplished in the control of com- limited in duration and the patient either lives or municable disease through such environmental ma- dies. Prevention,, too, is straightforward in that it is nipulations as chlorination of water supplies or quick,relativelysimple,foolproof, and painless. pasteurization of milk. (As noted earlier, this may These factors convinced early 20th-century public also require mass persuasion.) health authorities that simply providing the public Model II: Simple Prevention. Individuals are en- with information about the availability of quick, couraged to undergo a simple procedure to remove painless, guaranteed preventive or diagnostic meas- the risk of communicable disease, that is, immuni- ures would assure large-scale public participation in zation. Consumer Health Education/3

Model III: Chronic Disease Control. Individuals 3 months for a breast cancer screening at New York are encouraged to engage in (a) life-time participa- City's Gutman Institute prior to the Ford/Rocke- tion in the health care system toward the early diag- feller surgery, the lead-time for appointments by nosis and control of chronic, degenerative disease January 1975 had risen to 4 or 5 months, with a and (b) life-time concern with the possible health wiltter. request required. Because daily public ex- consequences of lifestyle. - hor:ations to followup on suspected signs of breast The prevalence of chronic disease in the aggre- cancer are given,itisclearly essential that the gate health profile of the American people requires prov'der system meet its obligations to make fol- continuing refinement of approptiate chronic: disease lowup possible. models for health education. Recent definitions of In addition to technological accessibility, barriers health educationrecognize and encapsulatethis such as cost, transportation, language difficulties, need: and, sociocultural factorsespecially among the Health education is a process that bridges the gap poor, the uneducated, black, Spanish-speaking and between health information and health practices ... other ethnic minoritiesmust also become a con- it motivates the person to take the information and do tinuing concern of the health care provider system. something with it. (6) ' Cervantes' comment that "costs, inaccessibility, social Health education is a process with intellectual, psycho- circumstances, prejudice, and inconsiderate treatment logical, and social dimensions relating to activities which by health -professionals virtually force Chicanos to increase.' the abilityof people to make informed deer- slow affecting their personal, family, and community use their own immediate 'resources for health or wdl.being. (7) meckal treatment..." (6) can be applied to many These, and similar definitions, place health edu- othlr subgroups of the population. cation in the behavioral sphere 'and, by so doing, For the individual, 'health behavior in response they assign new' kinds of responsibilities to health to the risk of chronic disease requires new kinds of responsibilities,particularly the educators,providers,andconsumersofhealth perceptions and following: services. To- health educators, the challenges are twofold. I Perceived Susceptibility, that is, awareness of Successful communication, of the belief that ,vulnerability to a variety of chronic disease the 'inintenance, of good health is an appro- entities. priate and achievable individual goal and re- 2.Perceived Severity, that is, understanding of sponsibility; and the threat or risk factor even in the absence of Establishment of viable "bridges" to the health immediate symptoms. care provider system to encourage appropriate 3.Perceived Benefits and Costs, based on'knowl- individual behavior with regard to the screen- edge of the preventive and long:term behaviors ing, diagnosis, and control of chronic disease. required to reduce Or, ameliorate the risk. (9),- The challenge to health care providers is to facili- In a dicussion of the behavioral requireffients tate increased consumer participation in the health for preventive health, Baric has formulated a model care system, primarily by assuring the accessibility of "at-risk" behaviortothethreatof, chronic and availability of their services. To encourage pre- diSease. (10) Contrasting Talcott Parsons' model ventive behaviors without medical backup to meet of the "sick role" with "at-risk" behavior concern- increased demand for service is counterproductii,e ing chronic disease, Baric suggests the following.` at best. The publicity and information campaigns While the sick role offers "gains" in term; of surrounding the recent breast cancer surgery of the exemptions from social responsibility, the at- wives of the President, and Vice-President of the risk model only imposes duties. "The person United States, for example, created unprecedented is expected to fulfill all his` social obligations, demand on available screening facilities nationwide. to change some existing behavior and to do it In November 1974, the American Cancer Society on his own without any right to social recogni- renorted an increase of 400 to 700 percent in re- tion for his achievement. (11) ques,c for breast cancer examinations Natits27 For the vast majority of illness episodes, the national screening centers. From an average wait of sick role has a limited time span and promises 13 : 4/Toward an Educated Health Consumer

an eventual reward in terms of a return to large scale for selected population groups, it is esti- health. On the other hand, there is n6 time mated that Only: half the'people who have this con- limit iirthe...atrEisk role; behaVior acquired is di.ion are even aware of it. (15) While cigarette expected to be Ontinuous and the reward is consumption for the population as a whole-has de- far less certain. clined, its incidence among young people has risen:. Thp sick role is reinforced by the medical pro- In short, the- glass is only half full. Americans\ fession and society. The at-riskindividual, aSa wholel are concerned about -health and show hoWever, often has tofightoff temptations encouraging tendencies to act in behalf of the pres- forced on him by members of society (for vrvationof health and the prevention of illness. As example, the offer -of cigarettes or alcohol), will be ;discussed. below, however, in thisas in The sick role is based on real symptoms. "An most aspectst American lifethe poor,, the un:- at-risk role, relies on the .abstract quality of educated, and Minorities arefurthest froM the cognitive processes through which a person achievement of optiuum. -health behaviors, even perceives a health threat: (12) though feat of illness and denial of -bOth symptdms `!'lit ,,attire of the challenges and the possibilities and susceptibility cut across socioeconomic ,lines in health education at the present time is best toaffect aspects of the health behavior of all expressed in the record of Americans' behavior con- Americans. cerning'individual health maintenance and diagnoiis. ,7 There is' noquestion that Americans are interested in, and concerned about, health. Health food, RESEARCH BASES OF HEALTH EDUCATION 'once an esoteric oddity confined to food faddists, is now-widely available and sold in supermarket chains A vast and continually increasing literature on-, throughout the nation. Special health magazines, like health attitudes, knowledge, and behavior attests to Psychology Today and_ Prevention, report ever- the growing recognition and importance of these increasing subscriptionrates. Our Bodies,Otir- factors in consumeiUaTth .edifeatrein.---The -Mita selves, a publication of the Boston Women's Health.,Medicus lists 24 journal articles in health education Collective, has become a best seller on college cam- in 1964, 35 in 1970, and 54 in the first 8 'months puses (see Chapter 3). of 1974- alone. The monograph Series of the Society In some instances, behavioral indicators are also of Public Health Educators (SOPHE), the single encouraging. Between 1968 and 1972, coronary most detailed and useful resource for the study_ of death rate for white males, ages 35 to 64, fell 8.7 health education in the United States, recently added,. percent, and similar downward trends were seen for as a regular feature, a section on "Current Litera- black males and for all women in this age group. ture Related to Health Education." The first such Cigarette smoking among the adult male population bibliography cited 169 references for 1973. (16) declined from 60 percent in 1955 to 40 percent in Detailed reviews of this literature are regularly in- 1970. The average level of blood cholesterol has corporated in the SOPHE health education mono- also begun to decline, from 240 mgs/100 mgs of graph series. For our purposes, a brief ,review of blood in the I950s to about 220 mgs/100 mgs at the some major areasof research and investigation present time. (13) The massive public response to should be enough to indicate the trends affecting the For breast cancer surgery noted health education and its efforts to meet the challenge earlier also bespeaks 'a high level of public interest of behavioral change. in ,available prevention (see Chapter '3). On the other hand, while it has been known for ATTITUDES AND KNOWLEDGE ABOUT . years thalcervical cancer/canebe reliably detected HEALTH Ay' ..*** t! !ugh a simple Pap smear, only half of1,11 Ameri- can women ovtr age 18 havehad Pap smears once ,.,. and only 5 percent of all wcmen over age 20 Definint.ns of health vary: Physicians see it as a Ndergb annual Pali wears, as recommended. (14) reflection of the normal functioning of the body and Similarly, while hyperlinsion can be controlled on a the mind, but the World Health Organization views 4 Consumer Health Education/5

it more abstractly as "a state of complete mental, health knowledge can only have increased in the physiCal, and social 'well-being." (17) The average decade since the NORC study. person's perception of his own health depends on a On the basis of a secondary analysis of national variety of subjective and cultural judgments of well- survey research data for the period 1951-.1962,,Wade being or illness. In Spanish-speaking villages of New (22) concludes that "education is so powerful an Mexico and Colorado, for example, where a well- indicator (c# health knowledge) that from it alone fleshed body is a significant criterion of health, a one can usually predict as much as from all other thin man with toothache was regarded as more ill demographics." Wade also found that: than a fat man with TB. A recent British study A positive relationship exists between health showed that persons who had not seen a physician knowledge, income, and occupational status. for up to 10 years tended to consider themselves An inverse relationship exists between health healthy, even' though they had a similar number of education and age. recent trivial ailments as another group of persons Controlling for education, differences in hea" who hadrecently seen a physician. (18) knowledge related to. income and age occur Whatever the definition of good health, survey chiefly in the lower edticational group. research data indicate that it is an iteni of great Knowledge about health is widely assumed to be importance to Americans. In comparable Gallup a prerequisite' for successful health education. In- polls of random samples of American adults over deed, the Information Model described earlier has a I2-year period personal good health ranked first been a major component in the public health edu- for 40 percent of;.respondents in 1964 and for 29 cation efforts of almost all voluntary health agencies. percent of respondents in 1971. In the 1971 poll Th's model has been described as one in which "the (19), the impodance of good health was seen to be role of health education is the transmission bf in- conversely related to education and income, which formation about health and disease from the expert is consistent with the widely observed finding that professional to the lay client." (23) It assumes that: the poor paiticipate differently in the health care Humans_are rational. system than do wealthier members of the popula- The client is captive. tion. For the poor, the emphasis is on emergency Didactic methods will reach the client. care and the episodic treatment of diagnosed ill- The essential disciplines required are pedagogy nessesTwhile-higher-iricome-groups-usually-partici-:- --and-educatiOn. pate.in the health care system on a continuing basis, Despite, or perhaps because of, the simplicity of with regular check-ups and preventive screenings. the Information Model, it is severely limited in its A study of a random sample of 935 predomi- effectiveness in several significant health areas. (24) nantly lower-income households in East Harlem in As we have seen, the Information Model provided 1970 emphasizes the special importance of health a highly appropriate method of informing the public to the poor. The study found that the importance about primary prevention activities undertaken in of health among the East Harlem population out- its behalf. When applied to behavioral outcomes, ranked other concerns by more than two to one, with however, the Information Model is, at best, a base- half of allrespondents ranking health as ,"most line for the development of education programs to important to have from life," with 18 percent for promote desired individual outcomes. the next most important item, "family."* (20) The fact that most Americans are interested in ATTITUDES AND KNOWLEDGE ABOUT and knowledgeable about health was well demonstrated by a National Opinion 'Research Center ILLNESS (NORC) study in 1966. (21) It seems likely that Studies of knowledge, attitudes, and behavior concerning specific disease entities add another dimen- The overwhelming importance of health in this study is, sion to the research base for health education. In a in part, an artifact of the known sponsorship of the study by now-classic study of participants and nonparticipants 9. the medical school affiliated with a large voluntary hospital in the area. in a TB screening program,' Hochbaum (25) sought' 5 612' award an Educated Health Consumer

to investigate the reasons that people accept or . . under specified social and situational conditions reject opportunities to discover their health status. . . . public response to a health program will be maximal In a random sample of roughly 12AO:tr.:lulls in; three when the target population feels ir high degree ofper- cities, Hochbaum found a high degfee b'faiformation sonal involvement with the disease under attack and also feels -that it is a socially acceptable diseaseover which about tuberculosis and the role of X-raWia diag- science has a high degree of mastery. (29) nosiszAbbut 85 percent a the respondents were certain that TB is contagious. Nearly 97 percent were Antonovsky (30), in recent research basedon aware' of the, importance of early treatment;more Jenkins' methodology, studied four dimensions ofd than 80 percent understood that chest X-rays could the image; of several diseases among the urban detect symptoms or the disease before the affected Jewish population of Israel. The diseases studied individualthimself could do so. were cancer, heart disease, mental 'illness,and Correlating X-ray behavior with knowledge base, cholera. Respondents were asked to rate each illness Hochbaum concluded: from "least" to "most" with respect to seriousness (mortality and recovery), social and personalcon- People learn to gise correct answers to questions before trol, susceptibility, and salien4. Cancerwas rated they learn to believe what they say and long before the most serious of the illnesses, with 65 percent of they use this information to guide their behavior.... Information alone is, not a motivating force, although it is respondents believing that death was, the outcome basic to most behavior. Without knowing what to do of cancer, while only 3tYpeL cent felt heart disease and how to do it, one cannot act.,But only when this was the most serious. However, Antonovsky found knowledge is related in some way to one's needs will it a fairly low perception of individual susceptibility actually be translated into action. (26) to all diseases; closely related to their actual Preva- From these and other findings, Hochbaum hy- lence among the population. For example, heart pothesized a three-step model of health behavior: disease took first place as a possible pdrsonal afflic- tion, followed by cancer and cholera (then epidetriic 1.People know the facts. 2.People know the facts and believe them, but in Israel). Becker, in a review of studies of _pre- ventive health behavtorjound that; do-We-think the racts/apply to them. , 3.People know, believe, and act on the facts. /It' least six retrospective and four prospective studies of The Hochbatim paradigm can be viewed as a preventive health behavior have yielded positive correla- Simple_Prev_ention_Mods1;of_Health_Education. In tions between relatively higher levels of subjective vulnerability and compliance with- recommendations to: 1) this case, information ,or knowledge about TB obtain screening for cervical, briast, or other cancer; for screening-was -seen in context of lifestyle factors tuberculosis; for heart disease; for Tay-Sachs disease; militating against TB screenings. It was found, for and for dental problems; and 2) engage in preventive example, that people often will-avoid taking actions health actions such as obtaining immUnizations and they feel will create more problems than they are accepting accident- preventive measures. (31) likely to solve and that they are more concerned Attitudes and knowledge about cancer have been with immediate suffering than with distant cure. (27) subject to a massive. research effort, documented in Numerous investigators have studied the attitudi- detail in a recent SOPHE health education mono- nal limits that transform knowledge and information grar:1,Review of Research and Studies Related to into salience (that is, the belief that knowledge about Delay in Seeking Diagnosis of Cancer. (32)The illness has personal applicability). For example, authors point out that a major effort in cancer edu- Jenkins and Zynaski(28)studied polio, career, and cation has been to educate the public about the mental illness using Osgood's semantic differential warning symptoms of be expected, to construct bipolar scales for ,public and personal however,_ the literaturesuggests suggests that thereis no susceptibility, public and personal salielice,_severity, linear, relationship between knowledge and attitudes preventability, and other factors. For Hechbaum's about cancer and rearm ndedt preventive behavior. formulation of the interaction of knowicde. with For example, one stutc f persons with knowledge perception of severity and salience, Jenkins and about cancer symptoms ,found that a high level of Zynaski hypothesizea a more basic dimension, anxiety led to greater ddlay in seeking medical help personal involvement. They suggest that: than\ did a low level (4 anxiety. (33) 16 O Consumgr Health Education/7

On the other hand, spective, they suffer from the inherent weaknesses, of each methodology: There islittlecorrelation --- thejtar.of being told the suspected truth may lead between what people say they will do and-what they ?odelay, whilenondelayers present their symptoms partly because they fear the consequencees ?! further actually do in a given situation; recollections of the procrastination. The latter has been found particularly __process of behavior cannot always be relied on. among thosehavingthemost knowledgeabout Seconds studies_ ittthis area generally analyze the cancer.(34) attitu6-zs and actions of -persons_ with a diagnosed illti6ss. We have no comparable data about-the proc- Widespread fear and fatalities from cancer are . belieyed to be major detriments to optimum diagnos- ess by,which persoqs diagnosed as disease-free come tic behaviors. With an information Campaign to to a diagnostic situation or behave thereafter. (39) counter fear and pessimism leading to inaction, a Other questions are definitional. Where, for ex- British,program-chinged *public opinion about can- ample, does. health end and illness begin? With cer curability.(35) The .percentage of respond- physiological changes? In the individual's percep- ents who beli6ed-that cancer could usually or some- tion that something is wrong? With the physician's times be cured rose from 30 in 1953 to 60 in 1966. discovery. of asymptomatic disease? With the phy- Reviewing the role, of fear in, attihides about sician's confirmation of presenting symptoms as a illnesses, Leventhal(36.)differentiated "danger" departure from normal limits? Similarly, where does from "fear" and described differential control mech- illness end? Professionals define chronic illness as anisms. Danger control,. he argues,iscognitive, continuous, but there is no reason to believe that while fear control derives from (1) mnbiguity, of the people perceive such asymptomatic conditions as danger agent, (2) lick of information about it, hypertension or diabetes as significantly omnipresent. and (3) inability to devise action in response to It is also unclear whether physicians' assurances of danger. He suggested that health education programs rod health signify a return to health for self - that Kecognize the existence of fear and attempt to perc "ived symptomatic individuals. halp_the...subjeeLcoPe_with_his_emotional. xesponse MainTaY (40); i"n a review otfhe liteTature oar could "decrease the occurrence of fear and facilitate healthutilization,has categorized the numerous a task-oriented approach in which the subject focuses investigationsofhealth Behavioraseconomic, on the danger and its control." (37) socinclemographicgeographie;_ sociopsychologieal, s GoTdon ht as dikt-gibarners to learning sociocultural, and organizational or ,delivery-system and action:. concerning health and illness in terms approaches. Each of these approaches provides useof "proceptions"-=the individual'sspecific poten- ful, albeit partial, insights to the factors affecting tials forseeing,hearing,doing,andthinking, individual health behavior. For example, it has been derived from life experiences. In view of the indi- generally assumed that since knowledge and attitudes vidualized nature of these proceptive directions, he affect behavior, attitude change (through health edu- stated: cation per se, peer influence, or communication) It is hard to know how to present our invitation to would create desirable changes in health behavior. learning to students or clients who... have a need for However, efforts to correlate attitudes and specific safety and freedom from threat, a need for simple and health behaviors have proved contradic- gratifying rubrics to reinforce their own prejudices; who are emotionally fearful and cognitively self-centered. tory. (41, 42, 43) In a New York City study, for It is usually approval they want and 'not fact, reassur- example, Suchman found evidence linking socio- ance and not alarm.... (38) cultural characteristics and medical orientations in a model which appeared to.,predict health behavior. ILLNESS BEHAVIOR A recent effort to repliCate the Suchman model in The arrayof definitionaland methodological another urbansetting produceddirectlycontra- problems that can be found in the literatureon dictory results, with data suggesting that "reliance actual health behavior reflects the inherent concep- on either sociodemographic or community orienta- tual complexity of bodi health and illness.First, tion variables as predictors of medical orientation is because 'most studiesare either prospective or retro- a weak procedure ....further .... therelation- 17 8/Toward an Educated Health Consumer

shipbetween medicalorientations/ andhealth function in teems of personally perceivednorms of behaviors remains to be established." (44) adequacywe can divide health behaviors into self- Some proportion of every population group, how- maintenance and prevention and healthcare mainte- ever stratified, exhibits desirable health-related be- nance and prevention. Thus, an individualmay en- haviorsa fact which requires continuing indepth gage in one, several, or all of the following types of investigation.In general, however, almostevery behaviors: random sample study of health` behavior hasfound Maintenance of functional ability (forexam- that lower-income, less-educated, and olderpersons ple, sleep, diet, exercise). tend to tarn to the health care system primarily for Prevention of functional disability (for acute episodes of illness and, to a lesser degree, for example, avoiding smoking, heavy drinking, reducing continuing treatment of diagnosed chronic disease. cholesterol intake). Minority groups and al e n (as special population Validation of functional ,ability. (for-example, groups) usually do not visit a doctor unless they are regular visits to physician or dentist). unable to work or look -after their family. These,- Validation of functional disability (for example, groups rarely make use of programs of prevention seeking diagnosis of perceived dysfunctions). unless free services are available. (45) Prevention of impairment of functional ability In a study of general. influenceson illness behavior (for example, diagnostic screenings, early treat- among a subsample of applicants for social security ment, and therapeutic control). disability benefits whose self-reported health, was A number of studies have investigated the relation- poor, Ludwig et al. (46) found that 26 percent had ship among combinations of these factors.The Uni- not seen a doctor in the past 6 months, regardless of versity of Michigan surveyed Approximately 1,500 the nature or number of reported symptoms (includ- adults in 1963, and a subsample 15 months later,to e ing arthritis, colds, dizziness, chest pains, shortness studyfour preventive behaviors:'toothbrushing, \)f breath, headaches, frequent upset stomach, and prophylactic dental visits, routine visitsto physicians tiredness). It was found that, in additionto respond- for "checkups," and participation in screenings. The ents' inzome level, medical scientific orientationin- study found that those who exhibited any of the four fluenced their use of the medicalcare system': 31.5 behaviors were also most likely to exhibit all and, percent of tho se with strongly negative attitudes in addition, that those who tooka particular action toward medicscience had not beento a physician during a specified time period were more likely to despite feelings of poor health, comparedwith only repeat, the action. Here, too, less educated, lower-4 6.9 percent of those with positive medicalscientific income persons displayed less preventive behavior orientations. (47) regardless of cost factors. (49). After interviewing first-timepatients in the out- An earlier' study by King and Leah (50) also patient eye and general medicine clinics ata metro- found individuarconsislency over tink.irr general politan Boston hospital, Zola (48)- identified five patterns of illness management. Patients witha his- patterns df nonphysiological triggers causing indi- tory of physician consultation for anything unusual viduals to seek medical aid. Theywere: (1) inter- or not 'understood, regardless of severity, also de- personal crisis, (2) perceived interference with social layed less with cancer symptoms. The authorscon- or personal relationships, (3) external sanctioning clude that the interrelationship of behaviors wasso by peer validation; (4) perceived interference with close as to indicate that "reaction patternswere es- vocational or physical activity,, and (5)temporizing tablished before the onset of cancer." Goldsenet al. of symptomatology. (51) also found that those who delayed inpresent- Zola concluded that it is not at their "physically ing cancer. symptomS had similar histories of delay with respect to prior medical problems. sickest" that people become patients, but when their Multivariate analysis, on the other hand, reveals accommodation to their symptoms breaks down. numerous anomaliesintherelationships among Health behavior varies widely. For example, if we health behaviors. Williams and Wechsler (52), for view health behavior in terms of lay definitions of example, divided preventive behaviors into those healththe continuing ability of the individual to which reduce ur increase susceptibility, those which 1s . consumer Health Education/9

reduce seriousness of disease or accidents, and those odic behavior that would interfere only occasionally which reduce susceptibility to financial loss. with established behavioral patterns of the participays. The actions involving personal living habits, however, Factor analysis revealed a number of primarily involved altering presumably well-established and fre- independent and unrelated dimensions of preventive quently repeated patterns of action. For modifying such health behavior. For example, while obtaining medi- actions, merely changing the participants' beliefs about cal checkups 'was reliably correlated with higher health was not enough. (55) socioeconomic status, obtaining medical checkups While it is clear that knowledge, awareness, and was not correlated with not smoking, getting ade- attitudes toward health are related to individual be- quate sleep and exercise, limiting cholesterol intake, havior, the relationships are fugitive and variable and and not being cotese. The six variables associated appear to increase in complexity in relationship to With heart disease(checkup, smoking,exercise, the complexity of the health behavioys sought. The obesity, calorie, and cholesterol control) were not increasing worldwide effectiveness of World Health interrelated; regular'dental checkups were not corre- Organization progranis in infectious disease control lated with the matching preventive belavior, that is, (56) bespeaks the potential for health educators to regular toothbru'shini. involve large population groups in simple preventive Steele and McBroam (53) studied the interrela- behavioral change. However, Where long-term be- tionship of three health behaviorsphysical check- havior or behavioral change is sought, multivariant ups, dental visits, and eye doctor visits in associa- explorations are required. Research around -;?tther tion with ownership of health insurance. They found aspects of human ,behavior reveals similar complai-, relatively weak association of the health behavior ties: As the variables and options for voluntary indicators, concluding that the respondents' actions behavior increase, prediction bZcomes less reliable. were not "focused on health as a general condition (57) It is in this context that bel-Kivioral modifica- to be achieved through prescribed preventive action." tion, a recent trend hlbehavioral research onlyaltb, With several others, Steele and Mc Broom conclude' should be viewed. that "health behavior is multidimensional rather than __ Behavior modification is based primarily on the unidimensional in the_sense that persons who engage' development of the animal learning research of the in one behavior tend to engage in others." (53) once-discredited I. P. Pavlov and its elaboration by A before and after study of the effectiveness of B. F. Skinner to problems of human behavior. (58) media in health education (54) confirms the multi- Contingency management (reinformationviare- dimensionality of health behaviors. Contro: and ex- wards, punishments, or voluntary contractual agree- perimental groups were interviewed about beliefs and malts) and stimulus analysis and manipulator arc behavior .concerning health and illness. One week the primary concepts employed. (59) Combinations later, the experimental group was exposed to sep- of rewards and/or punishments, on the vac hand, arate films on heart disease, cancer, and tubercu- and identification and manipulation of the stimuli- losis. Each of the films recommended regular pro- to maladaptive behavior, on the ether, are applied fessional examinations; those on heart disease and by external agents, in an individual or group process cancer recommended personal preventive health be- with the goal of eventual individual adaptation of havior. Followup studies of both groups revealed desired new behaviors. that the experimental group had visited physicians To some extent'. behavior modification can be for checkups related to the disease entities under seen to 'shortcut the social,psychological, and cul- study significantly more often than those in the coll.\ tural effects on health behavior, substituting a direct trol group who had not been exposed to the educa- interventive program of behavioral change and com- tiultalfilms. On the other hand, the two groups I pliance. The partii ating jndividual is in effect iso- showed no significant differences with respect to lated from his peels a his past, except as they health behaviors involving personal living habits. relate diPectly to the healsbehavior under study, The authors concluded: Sand is assisted in developing behavioral suppOrts to resist everyday pressures encouraging maladaptive Apparently, then, Effectiveness of the beliefs about behavior. Cigarette, smokers, for wignple, may be health in modifying behavior is specific to the kinds of behavior proposed. The medical actions required peri. helped toidentify thestimuli for lighting up 19 10/Toward an Educated Health Consumer

nervousness, boredom, hunger, and so forthand IMPLEMENTATION to substitute other responses and other loci for the behavior. (60) Similarly,. the obese are assisted in It is a principle of preventive medicine that pre- identifying and 'controlling the cues to detrimental food consumption. (61) ventive behavior, early detection, and early intervention are essential for the .Optimum treatment and Some impressive short-term behavioral changes control of chronic disease. It is believed "apparent have been noted in .rigorous behavior modification that surveillance can be maintained and intervention experiments aimed at the control of obesity (62), can be made in (at least) five health parameters so alcoholism (63), smoking (64), and cardiovascular that much disability and premature death can be disease (65). The long-termsuccess rate is disap- prevented." (67) If, then, cervical cancer can be pointing, however, and because' small, selected,or detected through a simple Pap smear, why is it that self-selected populationsareinvolvedinthese only 5 percent of women over 20 years of age under- studies, it is impossible tomeasure the relative- suc- go annual Pap meats, as recommended? If recur- cess of behavior modification against other socio- rence of rheumatic fever can be prevented,. why is behavioral factors. For example, itis not known it that only 5 percent of those who have had .rheu- whether behavior modification techniqueswilliprove fever are under appropriate preventive treat- equally effective among all socioeconomicgroups, ment? If hypertension is susceptible to control, why or how age, sex, education level, and othervaria- is it that only half the people with hypertensionale, hies will correlate with successful behaviormodifica- even as much as awate_of_their-conditif0 (68) tion programs. One thing that is known,however is =While -befilvioral research?rovides clues to the that because the most effective behaviormodification individual's resistances to appropriate 'preventive and -techniques-"iiitiii involveintensive, "sustaine,, d inter- medical behavior, there are as yet no programs-to------vention in preventive health behavioi;'theirbenefits transform tEis data into the-requiredpOsitive moti- in'relation to costare no better than the apparently vational and educational approaches for the; public random successes of the populationas a whole to as a whole or for target audiences at partidular risk adopt recommended preventivehealth behaviors. to specific chronic diseases. The research bases of healthbehavior thus pro- Despite continued assertions of the benefits of vide a broad range of dataon individual responses prevention, the low level of financial support for the to. health and illness. The challengeto' health edu- health education of the American public suggests its low actual priority in the health care system. Of $83 cation is that of identifying the reachablemoments billion spent for' health in the complex processbs of individualbehavior as :are in the United States in 1973, according to the President's Committeeon, the starting points for motivatingpeople's active par-, Health Education, 92 to 93 percentwas spent on ticipation in the preservation of healthand the prevention of illness. Horn's medical care for the sick; 4 to 4.5 percent on bio= summary of the relation medical research; 2 percent- on such public health of health education to everyday life best expresses measures as rodent control; and less than one-half this challenge: of 1 percent for health education. (69),Ina Nation with more than 5,800 short-stay When it comes to behavior by those whoare basically hospitals, with well, both primary and secondarypreventive actions-are 350,000 physicians, with more than 4.7 millionper- frequently ignored by large segments ofthe population. sons employed in the delivery of health services, the Instead of saying that such peopleare ignorant or President's Committee was able to identify only 111 Illogical, we will make muchmore progress if we ac- ongoing health education programs during its 1971= cept the idea that there Issome sense to their behavior 1972 investigations. Health information abounded. from their point of view. Furthermore, that large num- The Committee found that the five major voluntary bers of people are not only .willing, buteager to do health 'agencieS were spending things in their own sell-interest and in theinterests of more than $100 pil- those who are dear to them. But theirconcept of what lion annually for pamphlets, brochures,. films,film- is in,their own sell-interest dependson their values, not strips, and other informational materials. Ina 10- ours, their p;rceptions, not ours, their feelings, not year period, however, the Committee could identify ours.(66) only two instances in which the agencies attempted 0 Consumer Health Education/11

to evaluate the motivational and educational effec- upon to add health education to their skills, and tiveness of those materials. (70) school health education has beenin the mainthe It is a thesis of the present monograph that wide- responsibility of the gym department ever since. (73) spread mass media dissemination of health informa- Despite an increasing awareness on the part of tion has positive implications for the creation of school educators that health education requires spe- increased health consciousness and for the eventual cial curricula, and teaching skills, it still remains an creation of ar effective ,consumer constituency for amorphous area and is Tarely viewed as an inlegral health and Ilea lth education (see Chapter 2). At or even essential part of the curriculum. (74) this time, however, no particular public constituency With other critics of school health education, exists to represent the needs of consumers for effec- Aubrey identifies its programmatic weaknesses as: tive health education programs (see Chapte: 3). (1) inadequate training of teachers, (2) lack of en- In the absence of significant public health educa- forcemeat of mandatory state regulations, (3) re- tion efforts on the part of providers, and in the sistance and apathy of teachers, (4) indifference absence of a demand for such efforts by consumers, among school administrators,(5)difficultiesin the task of health education has been borne pri-, building _student- interest arr-cl-ifivolireinent, and (6) madly by the public education_establislunenn-lu-st parental resistance and indifference. _as...public health. education has been secondary to The variety of State teacher certification require- health care delivery, however, school health educa- ments and the curricular autonomy of 16,70P indi- tion has been secondary to other school goals and vidual school districts throughout the Nation also objectives. hi essence, it is because good health is militate against the adoption of innovative health considered a requisite for the achievement of the education curricula beyond their point of origin in general goals of education in democracy that the a singleingle State or school district. As public education schools have assumed this task at all. (71) In turn, is currently organized in the United States, each school health education is but one aspect of the State and/or school - (strict tends to reinvent the overall official health responsibilities of the schools, wheel for most aspects of curriculum; health educa- which include health protectior and improvement tion is no exception. and are a composite of: (1) healthful school living, A number of conceptual, goal-oriented approaches (2) health and safety education, (3) direct health to health ?ducation have been suggested. (75, 76) services, (4) physical education and athletics, and Hoyman, for example, his identified a number of (5) education and care of the handicapped. (72) approaches to health curriculum planning and teach- In this welter of responsibilities for the health and ing based on existing data about how and why peo- safety of its charges, and in competition with the ple relate to health and illness. To replace traditional schools'awesomeoverallresponsibilities,itis 'textbook teaching on such traditional health educa- hardly surprising that health education, as such, has tion topics as first aid, consumer health, and so on, achieved the same low priority in schools as it has Hoyman suggests the organization of school health in the larger society. A society that relates to health education to deal with such concepts as: the life primarily in terms of crises around illness is unlikely cycle as it extends from generation to generation and to expect a creative emphasis on health and on from conception to deaih; America's lifestyles and prevention of illness from its schools. their relation to health and n.ortality; the ecological School health education programs developed from causal web of health, disease, and longevity; and the classical Greet linkage of health, hygiene, and so forth (see Chapter 4). physical activity to become the physical education Several States, notably New York and California corryonent of the elementary and secondary school (77), have instituted new health echicat:on curricula curricula. Health educationitselfisa relatively at both the elementary and secondary levels. Los recent addition to the curriculum and was given Angeles' Project Quest reorganized the course of formal encouragement in 1917 by the identification health education from topicsto learner-centered of health as the first of Seven Cardinal Principles of goals and objectives, with preidentified behavioral Education. At that time, physical education teachers, outcomes for each learning goal. Foliowup studies trained formally in exercise and hygiene, were called of the effectiveness of the Project Quest approach 21 12 /Toward an Educated HealthConsumer

found overall increases ranging from 14.8 percent 3. Rosen, G. 1958. A History of PublicHealth. MD to 23.6 percent in all goals andat all grade levels. Publications, New York, p :194. On the other hand, evaluationof a `similar cur- 4. Hochbaum G. 1958. Public Participationin Medical riculum approach yielded less Screening Programs. DREW, Public HealthService encouraging results. Publication #572, p 1. Employing a standard healthbehavior inventory to 5. New York Times. October 10, 1974. compare (1) student? self-reported healthbehavior 6: The Report of the, President's Committeeon Health in traditional andconceptual health education sys- EdUcation. 1973. DREW, Washington,-D.Cp 17. tems and (2) longitudinal changeafter a .period of 7. New definitions: report'of the 1972-73 jointcommittee instruction on health education terminology. January 1974JountarA among bothgroups,researchersin .of SeLocti Health, 44, p 34. Florida found that the approachdid not produce 8: Cervantes, R....p_ecember-19717Thefailureof cbmpre-- any significant changes in studentreported-health--- 'Cervices to serve the urban Chicano. behavior patternsr--(-78)-ltideeda followuP-study -Health ServiCeiReperts 939. 9. Becker, M. and L. Maitnan. Jam ---- revealed that studentswho-had-Fein exposed ary 1975. 8ociobe- to the havioral determinants of Compliande with health experimental approachwere no more knowledgeable and medical care recommendations, MedicalCare 13, pp -titan theaverage student. (79) 10-24. Research finding about preventivebehavior point 10. Bade, L. 1969. Recognition of the--"aTrisk7\ rote:a to the implicit difficulty of means to influence health behavior, International Jour- school nal of Health Education 12,pp 24-34. io potentially killingillness 11.ibfd, p 32. lend to ignore these realthreats to life in the face of ,12.ibid, p 33. a variety of public information campaignsand ex- 13. New York Times. January 24, 1975; 14. hortations to action. Symptomaticadults often delay Simonds,,,S. 1974. Health educationas social policy in in the presentation of G. Reader, ed:, proceedings Of the Will Rogersconfer- those symptoms to physicians. ence on health education, Hearth EducatiSn Mono- Painless procedures--such as X-rays, Pap smears, graphs 2, supp. 1. SOPHE, Inc., San Francisco,p 3s and blood pressure readings-arebypassed by sub- .5., ibid. - stantial proportions ofthe population, even when 16. Current literature related to health education,op cit. accessibility and costare not issues. Why, then, Health Education Monographs 2,,pp 178-0,1. should children and 17.Brooks, E. Boothroyd. 1972. The contributionof so- youthto whom the threats ciology in L. Baric, Behavioral sciences fin of illness can be of only health and minimal personal relevance disease, International Journal of HealthEducation, -be expected to respondwith interest and/oren- Geneva, Switzerland,i) 48. thusiasm to schoolprograms and suggested behaviors 18.ibid. 19. Erskine, H.,Spring 19Th. The polls-hopes, only occasionally supportedin.their home and family fears and life and nowhere validated regrets, Public Opinion Quarterly 37, pp 132-45. : by the- larger society? 20. East Harlem community health study,final report on School health educationhas become the whipping Contract HSM 110-71-149. Depadtnent of Corifinunity post for critics of 'health educationin the United Medicine, mount Sinai School of Medicine, New York, States. Whilemany of the specific criticisms of Table 4-2. 21. Feldman. J. 1966. The Dissemination a school health educationare justified, Health Infor- its inherent mation. National Opinion ResearchCenter, Chiciiio, conceptual failings relateto a far broader problem- p 155. the perceived relevanceand importance of health 22. Wade, S. March 1970.1Public knowledge abouthealth, and illness in the societyas a whole. American Journal of Public Health,60,pp 458-91. 23.Steuart, G. 1269. Planning and evaluation inhealth education, International Journal of Health Education 12, pp 65-76. REFERENCES 24.ibid, p 74. 25. ochbaum, G. op. cit. 26.ibid, pp 16-17 27. Hochbautr 1968. What they believe and how they 1. Marshall, C. 1972. Dynamics ofHealth and Disease. behave, International Journal of Health Education11, Appleton-Century Crofts, New York,p 124. p.46. - 2. Vickers, Sir 9: 1965.What sets the goals .of public 28Jenkins, C. and S. Zynaski. September 1968. Dimensions health? in A. Katz and S. Felton, Health and the Com- of belief and feeling about threediseases, Behavioral munity. The Free Press, New York,p 853. Science 13, pp 372-81. 22 Consumer Health Education/13

29. ibid, p 380. 53.Steele, J. and W. McBroom. December 1972. Conceptual 30. Antonovsky, A. July 1972. The image of four diseases and empirical dimensions of health behavior, Journal held by the urban Jewish population, Journal of Chronic of Health and Social-Behavior 13, pp 382-92. Diseases 25. pp 375-84. 54.Haefner, D. and J. Kirscht. June 1970. Motivational and 31. Becker, M. and L. Maiman, op cit. p_13. behavioral effects of modifying health beliefs, Public 32. Kalmer, 11.,,_ed._1974r-Review of research and studies Health Reports 85, pp 478-84. relatertii delay in seeking diagnosis of cancer, Health Education Monograph 2. SOPHE, _Fr nc i sco ,- 56. World Health Organization. 1974. Health Education: A p 17T-- P.rogramme Review, report by the director-general of 33 "ibid,p 116. the WHO to the fifty-third session of the executive 34. ibid, p 117. board, WHO, Geneva, Switzerland, p 78. 35. Davison, R. May-June 1973. Cancer and education for 57. Crespi, I. Fall I971. What kinds of attitude measures life, Commu,nity Health 4, pp 315-20. are predictive of behavior? Public Opinion Quarterlii '36. Leventhal, H. June 1971.:Fear appeals and persuasion, _35,,pp 327-34. American Journal of Public Health 61, pp 1208,24. 37. ibid,pp 1220-21. _,- . 58. Skinner, B.F.1953-Science and Human Behavior. '38.Allport, G. :i'erception and public health in A. Katz, op. Macmillan Company, New York, p 461. . cit. p 504. 59. ibid. 39. Kegles, S. 1973. Behavioral science data and approaches 60. Ober, D. May 1972. The modification of smokihg be- relevant to the development of education programs in havior, Journal of Consulting and Clinical Psychology,. cancer, proceedings of the conference on cancer public 38, pp 542-49. education, Health Education "onograph 36. SOPHE, 61. Stuart, R. March 1967. Behavioral control of overeating, Inc., San Francisco, pp 18-33. Behavior Research and Therapy 53, Pp 357-65. 40. McKinlay, J.June 1972. Some approaches and problems 62. PAR !-k, S. et.al. January-February 1971. Behavior mddi- in the study of the use of services--an rerview, Journal ficationin the treatment of obesity, Psychosomatic of Health and Social Behavior 13, pp 115-52. Medicine 33, pp 49-55. 41. Health Education Monograph 2.1974. op. cit. 42. Health Education Monograph 36.1974. op. cit. 63.Miller, P. and D. Barlow. January 1973. Behavioral 43. King, Stanley H. 1972: Social-psychological factors in approaches to the treatment of alcoholism, Journal of illness in Howard E. Freeman et al., eds., Handbook of Nervous and Mental Disease 57, pp 10-20. Medical SociOlogy (second edition). Prentice-Hall, Inc., 64. Schmahl, D. et al. January 1972. Successful treatment Englewood Cliffs, New Jersey, pp 129-47. of habitual smokers with warm smoky air, and 'rapid 44. Reeder, L. and E. Berkanovic. June 1973. Sociological smoking, Journal of Consulting and Clinical Psy4hology concomitants of health orientation-a partial replication 38, pp 105-11. of Suchmar,, Journal of Health and Social Behavior 14, 65. Meyer, A. and J. Henderson. June 1974. Multiple risk pp 134-42. factor reduction in the prevention of cardiovascular 45. Mazelis, S. op. cit. Characteristics of special population disease, Preventive Medicine 3, pp 225-36. groups and subcultures which affect public education 66.Horn, D. op..cit. Public attitudes and beliefs relative to measures, Health Education Monograph 36, p 54. cancer prevention, Health Education Monograph 36, 46. Ludwig, E. and G. Gibson. June 1969. Self-perception of p 16. sickness and-- the-seeking of medical care, Journal of 67.Simonds, S. op. cit.

Health and Social Behavior1-10 pp 125-34. 68.ibid. ..*

ibid, p 133. _ 69.Weingarten, V. op. cit. Report of findings and recom- 48. Zola, I. October 1973. Pathways to the doctor-from mendations c: the President's Committee on Health person to patient, Social Science and Medicine 7, pp Education, Health Education Monograph 2, supp.1, 677-89. pp 11-19. 49. Haefner, D. et al. May 1967. Preventive actions in 70.ibid. dental disease, TB and cancer, Public Health Reports 71.Wiechmann, G. December 1970. Education for health 82, pp 451-59. behavior-a philosophical model, College Health 19, 50. King, R. and J: Leach. July 1950. Factors contributing p to delay in seeking diagnosis for cancer symptoms, 72.Schneider, R. 1966. Methods and Materials of Health Cancer 10, pp'571-19. Education, W.B. Saunders, Philadelphia, p 8. 51. Goldsen, R. et al. January-February 1957. Some factors 73.Simon, J. September 1971. An .historical and philo- related to patient delay in seeking diagnosis for cancer sophical analysis of dual professional preparation in symptoms, Cancer 10, pp. 1-7. health and physical education, Jourral of School Health S2. Williams, A. and H. Wechsler. December 1972. Inter- 41, pp 365-72. relationship of preventive actions in ,health and other 74.Aubrey, R. May 1972. Health education: neglected child areas, Health Services Reports 87, pp 969-76. of the schools, Journal of School Health 42, pp 285-88.

a ....rm.,

14/Toward an Educacd Health Consumer

75. Nagel, C. May 1970. A behavioral objectiveapproach 78. to health instruction, Journal of School_Htalth-40, j___Men._R.-and-OrHoljraili.- February 1972.Eiilualitig the conceptual approach to teaching healtheducation: a 151) summary, Journal of School Health 42, pp 118-19. _76. Ho an, . September 1973. New frontiers in health 79.Allen, R. and 0. Holyoak. May k1973. Evaluatingthe education, Journal ofSchool.Health 42, pp 423-30. 77. Nagel, C. op. cit. conceptual approach to teachinghealth education: a second' look, Journal of School Health43, pp 293-94.

.10

24 111CMIEL close, General Yamashita's army was well estab-

lished on the islatkd of Singapore. The British con-- THE COMMUNICATIONS tinued to resist, and as the Japanese,sammunition REVOLUTION supply dwindled, Yamashita reluctantly considered 'withdrawing his forCps across the narrow causeway 11 to the Malay peninSula. The British Commander, General Percival, knew nothing of this, however, Specialism ... has fragmeuted the specialties them- and believing himself `outnumbered and fearing the selves. ... The workers lose all sense of proportion in loss of his water supply, he surrendered. So it was a maze of minutiae. that on February 15, 1942, "the Tiger of Malaya" Sir William Osier, 1910 secured for Japan the greatest military victory in her history. (3). What, it might be asked, do these. three historical ANt OVERVIEW OF THE COMMUNICATION episodes have in common except the involvement PROCESS AND MASS MEDIA of the British? In each case, the outcome was devtr- mined by communication; the process of transmit- ... On January 8, 1815, Andrew Jackson and a rag- ting and receiving information. The process can be tag army of irreplar troops defeated the British represented in the paradigm which appears in Fig- at New Orleans to give the United States her greatest ure 2-1. This model was proposed by Shannon in land victory of the War of 1812. Impressive though 1948 and most subsequea 'communication theory is it was, the battle of New Orleans was superfluous: derived in part from his ideas. (4) Shannon identi- The war had ended on Christmas Eve, 1814-2 full fied a message, transmitted' as a signal and trans- weeks before Jackson's triumph. (1) ported via a channel. The channel might-be a news- Six months later, in London, Nathan Rothschild paper, lelevisia, radio, filni, or any of the other was the first to learn that Nalio leen Bonaparte had channels known collectively as media. The phrase been defeated at Waterloo. However, rumors of a mass media usually refers to those channels that are British defeat had sent prices on the London ex- aimed at a general audience. change to extraordinarily low levels. Rothschild In January of 1815, the U.S. Government was the bought up stock at rock bottom prices, greatly en- information source important to Andrew Jackson. larging his fortune. (2). The Government message said that peace became As the second week of February 1942 drew to a effective on December 25, 1814. It was encoded in

THE COMMUNICATION PROCESS ACCORDING TO SHANNO-N.

Tronsenitler Receiver

ENCODER CHANNEL DECODER DESTINATION Signal Received Message signal A

NO SE SOURCE

FIGURE 2-1. 25 15 16/Toward an Educated Health Consumer

written English and sent to the General byP man model along lines depicted in Figure 2-2. (7)The on horseback,' the fastest communication channel model now shows that when the fields ofexperience then known. In this instance, however, the channel sharea large common area, communicationis was not able to reach the receiver-destination (Gen- readily achiived. On the other hand, if thereis no eral Jackson) in time to prevent the battle with the overlap or common experience, communication is British. impossible. Rothschild, in contrast, benefited fromaccess to Neither of these comnuaication models, however, an "advanced" communication system (mid to in- provides for feedback: Thesource has no direct, clude carrier pigeGns) that provided him withinfor- rapid means of finding out how or whether hismes- mation about the battle,of Waterloo before the infor- sage is received. This problem of feedback accounts mation reached the British Government. for the endless audience research efforts of the mass The Yamashita-Percival episode ismore complex. media, particularly the extraordinary influenceon Each wanted to know as muchas possible about his television of the famous Nielsen ratings. On the basis opponent, while preventing the opponent from find-. of the continuous monitoring of 1,200 families, these ing out anything about him. Good intelligence would ratings are teed by all three networks and form the have provided both men witha sounder basis for b?sis of decisions to retain or drop individualpro- their command decisions and, in Percival'scase, grams. (8) The Nielsen approach provides very lim- might have altered thecourse of the campaign. ited feedback; itreveals what people watch, but Obviously, Yamashita would have worried lessabout sheds little light on what people might watch if their his ammunition supply had he known ofthe water choices were less restricted. At thesame time, the shortage facing Percival. In Percival'scast, however, Nielsen ratings play a major role in restricting view- his decision to surrender was based on the erroneous ers' choices because the show that produceshigh assumption that he was outnumbered. Nielsen ratings invites imitators. Thuswe have the All messages are mediated by the respective fields cyclical domination of the televisionscreen by shows of experience of transmitter and receiver, including of one particular type. As theseasons pass, west- social,cultural, conomic, and political influences. erns give way to medical stories which are replaced De Chardin (5) has defined these fields of experi- by courtroom dramas which yield to police adven- ence as the "noosphere"; in Shannon's model (Figure tures which inevitably will surrender their dominance 2-1) they appear as noise. Noisecan be defined as to yet another round of westerns. Meanwhile, the the discrepancy between the transmittedmessage changes are rung on the variety show and the situa- and the received message. (6) While noisemay be tion comedy, with varying degrees ofsuccess. considered' analogous to the field of experience of Communication models have been developed to the receiver, it does not account for the field ofex- incorporate feedback and to account for allcom- perience working on the origin of themessage. To municative acts from simple person-to-personcon- account for this, Schramm has modified Shannon's versation to the complex interactions ofgroups of

THE COMMUNICATION PROCESS AS MODIFIEDBY SCHRAMM

Field of experience Field of experience

SOURCE ENCODER SIGNAL DESTINATION ...)

FIGURE 2-2. 26 Communications Revolution/17

people, and the still more complicated: process c tion _ommunicated material and that' they are mass communication, which imposes an - enormous most likely to retain information they believe to be organization on the communication chain. Osgood's congruent with the views of individuals with whom model (Figure 2 -3) is a relatively simple one which they will communicate at sonic future time. Bauer stresses feedback and the unity of sender and re- presentei additional 'evidence for what he called, cipient in,the sense that each encodes, interprets, and the "obstinate audience" in a later paper. (17) decodes messages. (9) The importance of the selective, active.audience is Each of these models is of alusin analyzing the paramount. If people .retain information congruent _content of communication. Shannon( was firstto with their own conceptions and views, communica- delineate the essential elements which.he saw inter- tion techniques, cannot in and of themselves induce acting...in a transport process. Schramm added the behavior. Once robbed of its fabled omnipotence, the very important uotion of fields of experience while Communications process can be seen realistically as Osgood's model', stresses feedback and the essential one which relates people to each-Oilier and in which bidirectionality At the communication process. In people engage for reasons that Schramm has cate- mlother model, Westley and MacLean (10) empha- gorized in Table 2-1. (18) Table 2-2, from the sized the different roles. inherent in the process and same source, relates these objectives to the communi- added the.important idea that the receipt of a mes- cation tasks of any social organization. sage by a receive, does not necessarily depend on the Research interest in communication accelerated sending of thai message by a single' advocate. There coincident to American involvement in World War /,are a number of alternative models one might con- II, along with the widespread fear of subversion sider (11-15), but those presented here seem to through enemy propaganda. This fear stemmed from be sufficient to p: aide both a conceptual context and a view of the media found in the work of Lazarsfeld a ptspective for considerationofmass communica- and Merton. (19) Their belief that once in control tion. In particular, eachfk of the modifications of of the media, powerful interest groups could use Shannon's work adds to the importance of the re- them, to further thc,r pyin ends, led to the so-called ceiver ur audience in the communication process. "hypodermic" view of media. This view held that While Shannon's paradigm implies a passive audi- once the message was injected, the audience was ence, each of the ethers provides a dimension which ..upposed to respond as if drugged. The theory does tends to I.-?h__ the audience indmore active posture. not .hold up, of course, but As Klapper (20 pro- The idea of the active audience was forcefully pre- posed in 1960, mass communication may not have sented.by Zimmerman and Bauer. (16), who demon- a direct effect, but it does exert a significant influ- strated that people are highly selective in the reten ence through various mediating factors. For example, the health education message urging people to rrsE OMMuNICATION PROCESS AS SEEN BYOSG001:2 have their blood pressure taken is mediated by individual perceptions of personal susceptibility, the severity 'of the disease, the benefits to be derived from acting, the barriers to such action (21), and probably a vague concept of the prevalence of hypertension. In concluding this overview of the communication .process and.mass media, it is jmportant to note that

TABLE 2-1. The Objectives of CoMmutdcatIon

Sender's Viewpoint Receiver's Viewpoint -

Source C Osgood eta+ .the Meosuremen1 of Meomng. 1957 I. Inform I. Understand 2. Teach 2. Learn 3. Please 3. Enjoy, FIGURE 2-3: 4. Propose or persuade 4. Dispose or decide 27. 110 Toward an Educated Health donsunier

TABLE 2-2. Methods of Communication in Traditionaland Modern Societies.

' Communication Traditional Modern Task MOde rn Society Society Society Inteipersonal Mas's Pattern

1. Share Watchman Informed News media., knowledge of person environment - 2.Socialize Parent or , Parent, older new members School system, tribal elder children, publishing, 'edu- professional cational media teacher .0. 3. Entertain Dancer, Storyteller, Entertainment ballad artists of all industry, including , singer, kinds entertainment storyteller media an publishing 4.Gain Tribal chief Influential . Government, and all .consensus, or council leader, salesman, the organizational persuade, L. agitator and media structure control for forming public opinionand exerting social control, including advertising and propaganda

the discussion thus far has been restricted entirelyto chariot or a horse and rider, the standard of tele- the content or message of -communication and how_ cohimunication was the camelcaravan, which began it is transported, received, and respondedto. In the crossing desert afeas around 6000 B.C. ata speed discussion,, which follows,itis proposed that the of 8 miles per hour. was A.D. 1784 before this effect of mass communication is deiivednot pri- speed was regularly exceeded with the advent of marily from its content but rather from its capacity the horse-drawn mail coach, which averagedap- to accelerate the transmission of information. proximately 10 miles per hour. (22) In 1837 the invention of the telegraph ushered in theage of elec- THE RISE. OF SPECIALISM tronic media and the speed of communication took an exponential -leap from 10 miles per hour to 186,000 miles per second. The Greeks communicated the nevvs of their vic- - The telegraph and its electronicsuccessors not tory at Troy by lighting fires on mountaintops. only Sparked an explosion of information butalso African tribes used drums as a medium, the Amer- greatly enhanced our ability to store and retrieve ican Indians perfected the smoke signal, andmany knowledge, An endeavor that began with the devel- youngsters will remember th t the Count of Monte opment of the renowned library at Alexandria during Cristo defeated one of his co s With the' aid of a the Hellenistic period (323-331 B.C.). Through the semaphore Yet these creative ansrs to the prob- Middle ,Ages, the laborious process of producing lem of human communication when.sender andre- books was undertaken by the church. Thisgave the ceiver were 'beyond earshot simply footnote the gen.- church vRrtual monopoly on reading skills and eralization that from man's firsappearanceon earth made the clergy the dominant profession until well until about 150 years ago, telecommunication and into the modern era (considered to begin with the transportation were one and, the, same thing. Sve discovery of the New World at the beginning of the for very short distances.. covered in a spvint by 16th century). This brigan to change, however, when

1 Communications Revolution/19

exactly. 400 years before the invention of the tele- est is probably the sports an the follower of a team, graph, 'Gutenberg' invented movable type. Books the spectator. Baseball was the first mass spectator could now be mass produced, and even circulated at sport and the Spread of professional eams in the 10 miles an hour, they soon entered the public major leagues followed the 'availability of s domain as familiar and.affOrdable items. The book rail transpoftation which made it feasible for teams offered every individual knowledge without an inter- from different cities to play each other on a. regular mediary and efforts to preserve the. theocratic in- basis. Electronic communication played an equally formation monopoly through censorship and repres- important role in baseball's development by letting sion did not ,prove effective. Europe was turning out the home fans know how their team was doing on about a-thousand titles per year by the middle ofthe the road. This sustained interest in the game and 15kcensury. By the middle of the 20th century the stimulated the sales of newspapers carrying the 'figurekwas nearly 120,000 titles annually. (23) results.' - The, emergence of the book as a prime source of Thersports writer emerged as a specialist within public information touched all areas of intellectual journalism; an expert to keep the fans informed and life--in-cluding, and perifaps particularly, science. to interpret the events he reported. Yet when one 'Although scientific knowledge was comparatively seeks to-identify the basefall fan; hefrcantiot be cate- meager until well into the present century, it was gorized by educational level, union membership, a nevertheless a potent stimulus to those exposed to particular skill, or any specific point of view. This it for the first time, and the ability of the cognoscenti is so because the fan population cuts across demo- to share information resulted in a rising level of graphic lines and is ever changing. scientific knowledge which, among other things, led People develop and lose interest over time so the to still more efficient methods of storing and dis- community of those interested in the sport is quite seminating knowledge. With the rapid expansion of fluid. Groups of people find in baseball different the frontiers of knowledge came the need for spe- points of interest: Amateur statisticians love its ca- cialization.(24) The pursuit Tiknowledge and pacity to generate trivial data; small boys find in it ideas is a never-ending process. The more one knows a source of heroes; and increasingly it has become a Of a field, the more there is to know. As a result, lucrative occupational model for black and Latin specialties become narrower and narrower and rep- ycuth. (26) Small boys, data buffs, and blacks may resent an even smaller proportion of the total fund have little in common except baseball,: but this data of knowledge. As this process continues the spe- interest alone identifies them as a community, a cialist comes, as it were, to know more and more target consuming population for those who sell news- about less and less, and over time the gap between papers, publish sport magazines, or manufacture his general knowledge and tlAt of the lay public be- athletic equipment. - comes smaller. As his relative knowledge 'decreases, Itis a central argument of this essay that the so doe the overall' societal value of the specialist, development and proliferation of communities of since his field of work applies to an ever smaller interest since the end of World War II are functions segment of the population. of the growth of mass communication, especially In the last 30 years, however, there has emerged television, and that the juxtaposition of interest com- a variant of specialism based not on occupation but munities and oc,,Apational specialties creates c9n- on groups of people brought together from various sumerism. occupations around a common interest: what Pierce refers to, appropriately enough, as "communities of CONSUMERISM: THE MESSAGE OF THE interest.,"(25) Obviously, thereisnothing new about people .having interests outside of their work. MEDIA What is new, however, is the appearance of such people in ever larger numbers, the variety of their Nearly all the households in the United States interests, and the breadth and depth of information have at least one television and these receivers are re?dily available about these interests. in operation some 6 hours per day or 42 hours per The most clearly identifiab:e community of inter- week. A typical citizen spends 15 hours each week 20 /Toward an Educated HealthConsumer

exclusively watching television, more time than he entertainmentat best harmless escapism (36),at 'spends doing anything else except sleepingor work- worst an opiateorthe people controlled by powerful ing.(27)On any -given day, 65 percent of the forces intent on defending theirown interests.(37) U.S. population spends some time watching tele- Nevertheless, in spite of theiedisclaimers, people vision, and over a 1-week period the figure rises to continue to behave as though misscommunication, 87 percent.(28)The 1975 Super Bowl football particularly television, does indeedexert a great in-; game attracted no less than one-half, of the entire fluence on human behavior.Advertisers happily population between 5 and 65years of age(29),and spend $214,000 for each minute of commercial,time an average prime time (8 p.m. to 11 p.m.) viewing during the Super Bova broadcast.(38)Politicians audience approximates 40 million people. Children jockey with each other for televisioncoverage and spend an inordinate amount of time in frontof the spend millions on 7'Sspots. Parents and psychia- small scieeii. It is estimated that by the time a child trists have been fighting a running battlewith the graduates from high school, heor she will have de- networks for yearsover the content of commercial voted some 22,000 hours to television but only messages directed at _children.(39) 12,000 hours to formal education.(30) Debate over the effects of television is blurredby V Not only do people spend vast amounts of time a tendency to equate television with advertising; watching television, their viewing habitsseem. to Thus, politicians try to buy elections throughclever have little to do with education, income,race, or useof. television;advertisersattempt to subvert other demographic characteristics. Indeed,one of children by means of endless commercials;and the the most remarkable things about television:isits banal content of. televisionprograms is attributed uniform penetration of all segments ofthe popula-1to the dictates of Madison Avenue. While eachof tion. In an extensive survey carriedout in 1970, these arguments is backed by muchsubstantiating Bower(31)found that lower-income people watch evidence and each is probably correct tosome degree, more television than the affluent but that ifone con- thispreoccupation withcommercialism .obscures trols for income, viewing habits donot vary sig- what undoubtedlyistelevision's most important nificantlywith education(alth6ughthebetter- contribution. Television, for betteror for worse, has educated complain more about what theywatch). given the entire American populacea common data Theie findings.are supported by the workof Green- base: All Americans bank presidents, stevedores, berg and Dervin(32),who found also that apparent and rural tenant farmers alikenow sharea vast racial differences in viewing habits vanishonce in- pool of ubiquitous identical information. come is held constant. Other findings: Television In Understanding Media, Marshall McLuhan y10) ownership is unrelated to income '('Unlike otherforms argues that the growth of political units spanning' of media), and lower-income persons are more likely large geographic areas is dependenton a communi- to rely on television as their principal source of cation system capable of keeping the seat ofgovern- information. Others have pointedout that. disad- ment informed of happenings at the periphery. The vantaged children spend twiceas much time watch- acceleration of information flow tendsto reinforce ing television as more affluent children.(33)The centralism. Influence begins to shift fromcenter to preference for television among low-income people periphery, however, when informationmoves so substantiates the claim that televisionisunique fast that there is no knowledgegap between the among the mass media in that it does not disfranchise periphery and the central authority. The simultane- the poor%(34) ous existence of the same information everywhere Television's .critics have blamed it .for allkinds at the same time creates a world "whose center is of social ills, but its proponents regard it as the everywhere and whose margin is nowhere... on puTic's only meangol keeping abreastof the infor- Spaceship Earth thereare no passengers, everybody mat explosion.(35)Those who argue that the is a member of the crew." (41) effects o ass -communication (are trivial point to . Television seems to have created such a universal studies that demonstrate that people are more likely information system largely becauseitis, thefirst to be persuaded by other people than by media and medium to appeal to those whose normalsources of that the role of mass communication is essentially information are nonprint sources, almostalways 30 7' Communications Revolution/21

word-of-mouth. However, the system falls somewhat guished by the extent to which if dilutes serious sub- short of McLuhan's description. Up to now, because ject matter, the peripheral nature of the problems it of high production costs and the need for large depicts, the superficiality and foolishness of its per- audiences to attract advertisers, television program- ceptions, and itsall but total lack of subtlety. .ing has been designed to appeal to what its critics Despite this, one must agree with Shils' position that refer to as "the lowest common denominator." As a mass culture brings to the bulk of the population a result,the general data base provided might be dimension not present before television's emer- likened to the Rio Grande River: It is a mile wide gence. (43) In addition to its silly programs and and an inch deep. For example, the women's rights offensive commercials tele' ision exposes people to movement is brought to public attention in news- ideas and concepts thekAwould not otherwise expe- casts and programs that portray the issues in the rience. simplest possible terms. Advertisements deal with In the. midfdrties, Laiarsfeld (44) postulated a thesubjectindirectlyalmostsubliminallyby two-step theory of communication, suggesting that showing father changing diapers (the product adver- the effect of mass communication is mediated by tised) while mother is at work, or by eXtolling the intervening opinion leaders who, in turn, influence benefits of life insurance for working women. those who look to them, for cues. There is general In addition to the need to appeal to a broad, gen- agreement among students of communication that eral audience, television is also limited by its inability this theory is greatly oversimplified (45, 46) and to transmit information that does °not lenditself to that people seek information from different sources visual presentation. Television is incapable of trans- for different 'problems. Beal and Bohlen (47) per:. latin, much of what appears in the print media. formed a major service when they summarized three Novels may lend themselves to a televisidn treat- dozen studies dealing with the process of adoption ment, but many, if not most nonfiction works are of new ideas or new products: They identified five difficult to present in a visual form. Another serious progressive steps, including the most relied upon limitation is the problem of information retrieval source of information at each step.This was pie- and portability. The television image appears on the sented as a table by Laze!' and Bell (48) and modified here as Table 2-3. The-table demonstrates that screen for 1/30 of a second,and thenis.lost fOrever a fr.all practical purposes.* Information cannot be the primary role of mass media-is RI create aware- . - retrieved; it can only be repeated. By contrast, books, ness and to generate interest, and that-people rely periodicals, and newspapers are easily stored, and principally on the influence of peers and friends- in the information they contain is readily available. The the evaluation and adoption of information. It should book isalso portable. One takes a book along; be remembered, however, that notwithstanding the one must go to the television receiver. superficial ,level of its effect, it is television's ability to generate awareness and.provide someinforafiation In spite, or perhaps because, of theseconstraints which has resulted in the rising data base of society and limitations, television has been-enshrined asthe fountainhead of mass culture. If one acceptsthe as a whole. definition of high culture offered by Shils (42),it When television became the dominantgeneral isitlear that mass culture as it comes through the medium, eachof its predecessors assumed amore small screen is an aberration,, the retardedchild of a specialized role.* Radio has tr come a background sophisticated parent. Shils says "refinedculture is medium devoted to musicaril news. The general distinguished by the seriousness of its subject mat- interest periodicals like Life, Look, and theSaturday te; the centrality of the problem withwhich it deals, the acute penetration and coherence ofits percep- McLuhan observed that obsolete media ten_ tobecome tions, [and) the subtlety and wealth of itsexpressed art forms (1964.Understanding Media.Signet, p ixff). taring." Television, on the other hand, is distin- Comic books are now quite acceptable as "pop art"and old, invariably black and white, films are regarded aspinnacles of the cinematic art. Similarly, black andwhite television of enter- This should .not be interpreted to meanthat such will shows from the late fifties are cited as paragons tainment. Yet those same shows prompted NewtonMinnow's always be the case. Better retrieval methodsexist today but characterization of television as a "wasteland." are not in wide use. 31 woi Toward an Edu&aed Health Consumer. 19,K

TABLE,2 -3. The Importance of InformationSources During the Adoption Procne

Information Source Awareness Interest Evaluation Thal Adoption

Mass media (radio, 1 .4 television, newspapers) 4

tiends, peers 2 .2 1 1 1

ti Expert sources (books, 3 3 2 .school periodicals, 2 2 newspapers),

Salesmin . 4 4 3 3 4

Evening Post vanished and were replaced by such minorities represent the coalescence of communities highly `specialized magazines as Psychology Today, of interest formed aroundmore specific issues, such Ms., and Money. It is to these specialized.periodicals -as jobs, education; br segregation of public buses. that people look, after friehds andpeers, for infor- The existence of a community of interest mation in depth. Newspapers play does not a dual role. A imply universal or even majorityacceptance of its few, like the NewYorlc Times, provideinformation point of view. The Movement to change children's in considerable depth. Most localpapers, howeve, television is backed- by one of the most 'po.werfol provide little more than advertisements, gossip, fea- communities of interest even though, accordingto tures, sports, and comics. (49) the Association of National Advertisers, 82percent Information in depth characterizes the evaluation of mothers like- children's television just theway and trial stepsof the adoptionprocess. Evaluation it -is. (50) What matters is the relative neutrality and trial -represent a testing of the ideato see if it or indifference of those outside the community of conflicts with the beliefs of one's friendshipand peer interest. Even if we are to believe the advertisers, groups. In this sense, such individuals andgroups the finding has relevance only if this 82 percent were represent the opinion leaders of Lazarsfeld.How- actively opposed to the desires of the active minority. ever, the evaluator influences friends and peers per- The development of communities of interest isa haps as much as they influence him. Inother'words, major stimulus to the growth of all media. Thecar- every group has its innovators and early adopters. riers of information play an important role in keep- Once adopted, the idea becomesa part of the in-"ing consumers in touch with each othei. Between dividual's set of attitudes, opinions,and beliefs, 1950 and 1970, telephone use surged upward, with ObviouSly, the friendship-peer complex isdominant the steepest increase in toll calls and overseas calls., here since ideas that deviate stronglyfrom those of The mails grew steadily but less spectacularlyover \ The:ference group imply a shift to anothergroup the same period. (51) The community of interest whose ideas are:closer to the newly adoptedones. demand for information and the emergence of the The friendship-peer complex of shared opinions paperback greatly stimulated the publishing business. and ideas can be the beginning of the communities Almost 6000 new books in new editions appeared of interest which tend to develop inareas that affect in 1945, a figure which had increased sixfold by large numbers of people. There isnot much of a 1970; (52) Today a succaul book need reach community of interest relating to Physical chemistry only a small segment of the population. Its appeal or biophysics but these subjectareas might be to a particular community of interest will usually affected by the community of interest whose interest assure sufficient sales to realip a profit. The number) lies in social welfare and the allocation ofresources. of periodicals rose from about 6800 in 1950 to more Social movements such as civil rights forwomen and than 9000 in 1970. (53) While magazines like Time 32 Communications Revolution/23

and Newsweek captured the more affluent piofes- , As communication between them increases so does sional and managerial heads of household (54), the public's expectation of government. The public there were plenty of readers of the more specialized becomes Jess tolerant of government secrecy and, periodicals such as Black Enterprise (with a circu- in the face of increasing demand for information by lation of 1.6 million)Aparunent Life (2.0 million), the various communities of interest, secrecy is diffi- Scientific American (2.3 million), and Prevention cult to achieve. The Watergate scandal is a case in (4.6 million). (55) The growth of these various point. Far from being satisfied by the almost daily media occurred coincident with thespectacular revelations concerning this unfortunate episode, the growth...Of television, which began around 1950. public continued to demand more and more infor- Indeed, Maisel (56) has pointed out that the maxi- mation until finally the specific demand arose that mum growth of television occurred between 1950 the president be impeached.. At this point, the com- and 1955 and that between 1955 and 1970 the munity of interest became a consumer interest group. growth rate of television was actually less than that Consumer interest grOups deve,lop from commu- of other media. (56) nities of interest and theik goal is to alter the serv- The fundamental role, of television in our society ices or products produced by a.specialty group in a has been to provide all segments of the population way that benefits the consumer. They evolve natu- with uniform exposiire to new ideas and information. rally from the data base built up by the parent in- This process facilitated and was itself facilitated by terest community. The suaesses of the consumer rising educational levels which increasingly included movement, although less than some would have minorities and women as .well as traditional white hoped, have been impressive. In the late 1960s, male constituents. (57-59) Television has revolu- ab u 10 years after the rise of television, a number tionized communication by letting people see events of, major consumer bills were passed by the Con- for themselves rather than learn about them only gress and signed into law. These included:. the Fair through the deFriptions (which may or may not be Packaging and Labeling Act, the Child Protection objective) of others. This, plus the ubiquity of the Act, and the Traffic Safety Act (1966); the Flam- medium and its electronic speed of transmission, mabi.e Fabrics Act (1967); the Wholesale Meat Act, makes it increasingly difficult for Government, in-.the Consumer Credit Protection Act, the Interstate dustry, or other interest groups to promote a uni- °Land Sales Full Disclosure Act, and the Wholesale lateral point of view with any degree of success. P-ultfy .Products Act (1968); the Radiation Control The ,rime example of this is the war in Vietnam. for Health and Safety Act (1969); and the Poison Even though government achieved partial control P-evention Packaging Act (1970). In 1960 no State over what would appear on television by restricting had an office of consumer affairs; in 1973._all 50 the geographic bounds of onsite camera crews, it States had such offices as did 25 counties and 110" proved impossible in the end to convince the public cities. (60) that involvement in Southeast Asia was vital to our Bills introduced into Congress in 1975 include national, security. How could Washington talk of legislation to create a Federal consumer protection ending the war when each nightly newscast showed agency, to provide a national no-fault auto insur- rice fields, villages, and provincial capitals changing ance law duplicating those now operating in15 hands on a regular, almost ritualized basis? States; to facilitate class-action legislation; to require As communities of interest develop from infor- proof of advertising claims; to require public dis- mation first seen on television and complemented closure of results of mandatory testing of manufac- by specialized media, they usually begin to use the tured products; and to assist States and local gov- same. media channels in their attempt to influence e-rments in the establishment of better consumer the behavior of government. For example, the pur- rievance machinery to handle small claims. (61) pose of many, if not most, demonstrations is to get The most venerable of our institutions have come television coverage. Newspapers, periodicals, and under consumer scrutiny. No school may deny stu- books deal with the issue.in depth while telephones dents or parents access to student records under the and the mails are used to maintain contact between so-called "Buckley Amendment" which took effect individuals on both sides. January 1, 1975. (62) College athletics are under 33 24/Toward an Educated Health Consumer

presSure for slighting women.(63)Students file and there is much to suggest that it is well founded. suits against their colleges on grounds of deceptive In a study of fifth- and sixtblgrade children, 'Lewis advertising, to reverse expulsion orders,or to fake and Lewis(72)found that 208 children 'believed the rescheduling of canceled courses. (64) Educa- 70 percent of 781 commercials and that low-income tional program requirementsare changing to make children were, mire credulous thantheir more things easier for the student-consumer. A ,television afflueht classmates. series called "The Ascent of Man" became in effect Televisiorimessages rarely ifever mention health. an off -campus course as more then 200 colleges They are directed instead at incorporating offered 'credit to 25,000 viewer-students. (65-) the de- A sired behaviof, for example,se of vitamins, 'into major New York college offered' 'a program short- the prevailing stbreotypes of the child's world. Thus, ening the time it takes to become a physician from ads aimed at girls focus On beauty and popularity 8 years to 6 years after high school graduation and while those directed at boys stress size\,..power, promptly followed this w h a similar noise, program to and speed.(73)Small children have no conpept of shorten the pathway into law. (66)Ori'Septembei commercials and tend to regard themas part of the 20, 1974, an Albany, New York,man became the program.(74) Jiro American to While credence in commercials de- earn a bachelor's degree without clines-rapidly as the viewer gets older (75), the any college credits at all. The degree was awarded- potential foi deception is...alwayspresent in the tele- by the State University of New York after 9years vision commercial. Schwartz(76)points out that of .self-study and successful completion of various the visual dimension of television adscan produce qualifying examinations. Total costto the student an effect quite inrelated to. their- verbal message was only $400.(67) when, for example, they leavea child with ',.the Not surprisingly, television its.1 isa perpetual impression that aspirin is something he shouldtake . target of consumer attack. A program dealing with to have a good time. A public service ad cpansoted the sexual molestation of a 14-year-old boywas by Mars candy in a children's show correctly iden- rejected by several stations not, because irate parents tified plaque as the cause of tooth decay andurged 4* .objected to the subject matter but becausehomo- the viewers to team up with the toothbrush andthe sexual rights groups felt the programwas unfair. dental floss, the enemies of Rlacpie. About $300,000. (68) The Federal Communications Commission was invested in the ad .which never mentionedany (FCC) voted in 1974 not to renew the licenses of connection between the formation of plPque and, v three Alabama television stations because of citizens' the consumption 9f candy.(77)Diet soft drinks, *charges that the stations discriminatedagainst blacks advertised as having only two caloriesper ,Irounce, in biting and programming. (69) In the UnitedNa= can also contain up to 108 mg. of sodium.(78)The tions, Communist and Third World countrieshave latter fact is never mentioned, but has serious impli- called for-worldwide regulation of television because cations far the obese hypertensiveon a low-salt diet. of the global implications of satellite communica- The health behavior of lay people is heavilyin- tion.(70)' fluenced by the physician, who is himself thetarget of advertisers ishing to persuade himto endorse a particulat product.,Over a 10-year period, McNeil HEALTH BEHAVIOR AND MASS . COMMUNICATION Laboratories (a subsidiary of Johnson and Johnson) has promoted' the analgesic Tylenol to physicians who often 'recommend the product byname to their Most health professiolials regard mass commuhi- patients. (79) As a result thisonce obscure over- cation as antithetical .to beneficial health behavior. the-counter prep. ition is now a serious challenger Somers stateditsuccinctly when she wondered to such sales leaders as Anacin and Bag= Aspirin. whether lifestyle modification was possible with "so What makes this technique so advantageous isits many 'value-producing forces, including television cost: Tylenol spent less than $2 million in adver- advertising...lined up on the other side."(71) tising in contrast to Anacin's $29 million andBayer's The close identification of television with the ad- $20 million. No doubt 'encouraged by Tylenol'ssuc- vertising industry is largely responsiblefor this. view, cess, Pfizer has established a new division to focus its 34 Communications Revolution/25

effOrts on the phaimacist rather than the public. (80) for example, spent $186 million in 1973. Fast-food Studies linking bad habits of one kind or another chains are rapidly expanding their advertising efforts, to television have not taken the controversy out aswitness, McDonald's $47million promotion of television's rile in either health or the society as budget for 1973. (86) Much, if not most, food a whole. For' example, does television really induce advertising is devoted to high carbohydrate snack reliance on medication when the medication adver- foods which can be properly considered antihealth. tised is aimed either at such trivial complaints as Television advertising can cost as little as $100 dandruff or baoLbrealh, or such non-illnesses as or less for a 30-second local spot or as much as "tiredblood" the old one-two"? No one really,' $30,000 to $50,000 for,a 30-second national spot in knows, but the value of the information. can be prime time. (87) For that prim e, however, the adver- judged by the results of a week-long study of health.tise; is virtually guaranteed an audience of 10 to 14 jnformation on television in which Smith et al. (81) million, It is indeed a sobering thought that the entire found that while only 7.2 percent of time was de- $7 million first-year_ authorization for .the -National. voted to health-relatecj content, 70 percent, of the Health Information and Promotion Act would pur- material presented was inaccurate, misleading, or chase only 70 minutes'Of prime time television. both. One might ask what manufacturers hope to lain One of the, most impressive things about adver- from adverth....,;. The answer is, less than might be tisingis the amount of money spent on it. The expected. For example, Winston, the best - seeing United States spent $23 billion on advertising in cigarette, commands only 16 percent of the total 1972, 'nearly 21/2 times more than the combined market and spends more thin $22 mi,lion annually total of the next five countries. (82) Of this total, just, to maintain that position. With more than 20 $4 billion went to television advertising. This jos 1.4 competing brands, Winston does not aim for an times the combined television advertising expendi- increase in market penetration of 25 percent, 10 tures of the other 62 countries in the survey. At percent, or even 5 percent. The manufacturers are $110, per capita advertising expenditures in the in fact delighted with a 1 to 2 percent sales increase. United States approximate the per capita income of (88) A 1percent gain is worth $16.5 million in so Third World nations. sales. Even for the slowest seller in the R.J. Rey- In 73, almost $200 million was spent on cigar- nolds' line, Vantage, a, 1 percent increase will pro- ette advertising. Yet sales were sufficiently high that duce $1.3 million in additional sales. Similarly a 2 advertising expenditures of $22 million for Winston, percent increase inthe market for the assorted the leading brand, cost the R.J. Reynolds Company products of Schering-Plough means more than $7

only 5 cents per carton sold. (83) During 1973, million.in sales. These modest sales increases re- Warner-Lambert and Warner-Chilcott ' spent $142 quire only that about 1 percerit of the Nation's miilion to promote such products as Super Anahist, 52,000,000 smokers respond favorably the adver- Eromo-Seitzer,Listerine,Gelusil,and Sinutabs. tising campaign. With such a respon._ the ad cam- Schering-Plough spent $52 million on Pi-Gel, Cori- paign will be considered a success, even if it offends cidin, St: Joseph Aspirin, A. & D Hemorrhoidal the vast majority of the viewing audience.. SuppositOries, and other products. (84) All to- The modest return expected from product adver- gether the 21 leading drugs and cosmetic manufac- tising is in marked contrast to the expectations of turers spent $1.2 billion on advertisintin 1973. those who have used media to alter health-related In contrast, the first year authorization of $7 behavio,, Seidenfeld (89) expressed disappointment million for the National Health Information and that even after Government information campaigns, Promotion Act of 1975 is approximately 30 percent only 25 percent or the public had received the entire the amount spent to advertise Anacin tablets. Even series of four polio shots while 60 percent had had in the Most ambitious health education campaign at least the first of the series. In a similar vein, ever launched, antismoking, television commercials O'Keefe (90) administered questionnaires to 621 were outnumbered four-to-one by cigarytte adver- college students and 300 people from a general tisements. (85) Food manufacturers ka processors popujation to explore attitudes toward smoking re- also spend vast sum, on advertising. General Fesils., sulting from, the antismoking commercials on tele- 0 t.) 26 /Toward an Educated,Health Consumer

vision. He-, too, was disappointed. He found that 34 More smokers (80 percent) have triedto stob smok- percent of students were smoking less as a result ing than ever before, and there is a marked Vend- -of the commercials and that 22 percent had stopped toward assuring nonsmokers a 'smoke -free environ- smoking altogether, at- least temporarily. Robertson ment. New. York CIty and the Ctati of Oklahoma et al. (91) mounted a television campaign to en- have recently passed ordinances banning smoking in courage automobile seat beltuse. Five different elevators, ;Supermarkets, and other public buildings, commerci -Is were shown in three communities over and nonsmoking sections are ,now ,a regular part of a 9-monperiod. The five commercials were broad-.air transportation. There were so many contributory cast a tal of 943-times. When compared. with the factors in the smoidtt,iituation that it is folly to controls, the group which had been exposed to the ascribe all of these chantes to the televiiion cam- commercials, showed no increase whatever in seat paign. Yet the importance of this most ambitious belt use; this' was in spite of_tpe fact_that.the corn- -effort cannot be-overlooked: The "fact- remains: that Mercials were written and produced by an advertising smoking was in a decline while the antismoking agency which "had a record of success in advertising were riming and began to increase again only after commercial products." they Stopped. , Thelailurg of mass communication to please these The antismoking Campaign exemplifies the im- viewers is related to advertisers' failure to recognize portance of the dose-duration relationship. The ads two fuadamental principles of using the media to begin in 1967 and continued for almost 4 years, induce behavior change. First, one's goalsmust be accompanied by stories and articlesifi the print realistic (eind therefore limited). Second,one must media. As advertising campaigns go, this is not very not lose sight of the interrelationship behveen dose iOng, and the impacCof the commercialswas becom- and duration. If advertisers are pleased with 1 and ing apparent only as they were leaving the air. The 2 percent sales gains, it seems unreasonable for health only health education campaign that approaches the people to expect a 100 percent success rateor even antismoking effort is the continuing publicity about a 25 percent success rate. Indeed, our knowledge cholesterol and heart .disease. This effortis largely of this area is so meager that it is probably inappro- inadvertent; uncoordinated, diffuse, and general, but priate to define success at all until trial anderror it-has been in existence for almost 10-years now suggest what is and is not possible. In this regard,, and has played an important, part in steering dietary the sustained use of television and other mediato habits away from foods with high saturated fat con- encourage behavior change relating to weight, diet. tent. They: dietary changes probably played same smoking, and exercise has shownsome promise in a rose in the recently observed downturn in deaths due health education experiment being conducted by to heart disease, although' the specific causes of this Farquhar and MacCoby. (92) After 1 year, their decline are unknown. results suggest that use of media, though far; less .How long must a campaign be continued to be effective than face-to-face contact, does helpto effective? Again, we do not know. Sustained efforts stimulate beneficial behavior change. O'Keefewas ha.e been few and there is simply not enough data dissatisfied with reactions to antismokingcommer- available to allow the kind of analystrneeded cials, but he never identified what percentage he reach a rational conclusion. The five messages used would have considered adequate, and it is difficult in the 9-month seat belt campaign may well have to define success without a clear idea of failure. In failed because of dose, duration, or both. First, 9 addition, his survey was carried out before the anti- months is probably not long enough to,induce seat smoking campaigh reached its peak. In fact,one can belt use no .matter how persuasive the software. make a strong case for the success of the antismoking Second, actual exposure during. the 9-month period commercials. Whiteside (93) points out that at their was rather marginal. The commercials were shown peak in 1970, the antismoking commercials were 943 times but only 187 or 20 percent were shown accompanied by ,a noticeable decline in per capita during prime evening time when males are most cigarette consumption. In addition, cigarettes contain likely to watch. In fact, male use of seat belts was somewhat less tobacco now than they did in 1970 even less satisfactory. than that of females in this and tar and nicotine content have also declined.' study.

-36 CoMmunications R'evo7ution/27

It is also likely that the use'Of five very' different provide, price supports.1*tobacco in amounts lhat messages over the relatively brief 9-month period have greatly increased over. the past 10 years. (0.5 allowed too little time for the full impact of any one This contradiction was pointed out tit an editorial meskage to manifest itself. Television is pqrly spited appearing in the Journal of fhe American Medical for information fetrieval,..and for thisTeason the Association. (98) In thrniidslittfes,.each dollar same' message mus;_ be repeated over and over spent on cigarettes was divided in ap.Proxintatelyi the again.* No doubt different messages appeal to dif- following way: tobacco" companies 34g Federal feient groups:withini the target population:In other Government 19¢ -State and local governments 110; words, there is a pool of susceptibles for each mes- distributors and retailers 110; wage earners in fac- sage, and the optimum use. of a message calls for tories 13¢; foreign producers 40; domestic tobacco its -repetition until the susceptiblepooliiexhausted. farmers 7¢. (99) Aside from the-tObacco cofopanieS Wliile _scare techniques, are no doubt lest Effective themselves,therefore, thousands of 'farmers and than .peer pressure, itidoes not follow that peer wage earners depend on the use of, tobacco products. pressure is the right approach for the entire popula- The tax monies generated by tobaccotales at_the tion. In all probability, each of the five aPproaches local, sate and Federal levels would presumably to encouraging seat belt use reached a egment of have to be raised elsewhere if the tobacco source the population; the question is, How long does a ceased to :exist. One might argue that if we were message have to ,run to exhaust its particular audi- free of the cost of sickness arising, from cigarette- ence? This is not kndivn, but when the message is induced diseases, the tax money would not be missed shown and who is watching at that time obviously anyway. Perhaps. But monies saved because of a have some bearing. lower incidence of disease would not 'necessarily or _\ Assessing the effeets of a television advertising even probably find their way to the services and ',campaign on alcohol misuse, Louis Harris and As- activities now supported by tobacco taxes. ociates (94) pointed ouLthat one of the problems The cholesterol ,publicity ,mentioned, above has f television advertising is that 'only 60 percent of produced a marked decline in egg-consumption. Be- ddUlts drink but ads.cannot be placed to reach only tween 1972 'and 1973, for example, a 5 percent d'rinkers. This is anotherway of stating a fourth decline in egg consumption reduced the. pr,fiis of principle: Television is a general medium and can- egg producers by $30 million. (100).. Blaming biased not be directed with great precision at a particular researchers employed by their rivals,thecereal population group. Particular television programs do manufacturers and the producers of polyunsaturated have identifiable constituent audiences. (95) It is oils (101), the egg -producers counterattacked with possible to separate out viewers of specific programs advertisements containing the somewhat misleading by age and sex, sometimes by race and Income, but statement that "there is absolutely no scientific evi- not by health risks. Do alcoholics watch different deuce that eating eggs in any way increases the risk shows from nondrinkers or do they watch what of heart disease." (102) It should be remembered, other people of their age and sex watch? It would however, that this is the response of people who be of great value to know more about the specific must balance a very real threat to their livelihood television habits of the poor in view of the fact that against someone else's estimate of a possible health television is their vpreferred medium and the best threat to a statistical population. way to reach them short of face-to-face contact. Removing harmful products from the market by The American people spend 311.5 billion annu- means of publicity campaigns or Congressional pres- ally for health problems arising from cigarette smok- sure is not easy, and the enormous sums of money ing: (96) Yet Congress, which is obviously con- required to make the most effective use of television cerned with the costs of health care, continues to would seem to put this communication tool beyond the means of public health agencies. Direct pressure In advertising directed at children, the repeu:ion of the on the television networks probably would involve message is a positive advantage, because the childhood view- constitutional problems that are best avoided, but ing population is continually changing through the addition cf nev) viewers to tin audience base, and the subtraction of one successful approach is that already carried out those entering older age groups. in the antismoking campaign. The Federal Con; 37 28/Toward an Educated Health Consumer

munications Commission decided that the fairness less of the strength of its statistical associationwith doctrine applied to cigarettes and that because of disease. the health hazard antismoking messages were needed Perhaps the best w ay for health agencies toen- to counterbalance cigarette -advertising. This, how- hance the cause of consumer health education ever, was a special situation and the FCC. cannot.,through the resources of advertising is to provide be expf...!ed to take such action when matters less'the advertiser with an endorsement usable inpro- . clear-cuf than smoking are at issue. Public service,rooting the product. The endorsement.. of Crest messages' are a valuable tool, but their value is toothpaste by the American Dental Association limited. For example, the $570 million made avail-'helped make 'Crest the, best-selling toothpaste and able for public service campaigns in 1974 by the stimulated the manufacture of other toothpastescon-, Advertising Council(103)was about 14 percent taining fluoride. If such a system wore to bemore of the total amount spenton television advertising widely used, enderstd products would have to be . in 1972. Also, public service time must, be divided reviewed periodically as a requirement for continued among a host of public service interests such as pre- endorsement. Endorsement would dependon the vention of farest fires, cleaning up, the environment, validation of beneficial claims and a determination and solicitation of funds for a number of nonprofit that the product was free Of other harmIul ingre- concerns. There is no doubt that health workers dients. Most diet sodas, lot example, would' becer- should regard the Advertising Council as a source tified with qualifications because their high sodium of assistance; butwith the need for sustained effort Content is a hazard to hypertensives and thus dimin- over many years, the utility4;of this assistance is ishes the value of the fact that they contain only strictly limited. , two calories per can. Recently introduced choles-; A solution to this problem might be the creation terol-freeegg subititutes would seem to deserve en- of a mechanism through which the people who dorsement unless they are found to contain some spend $23, billion on advertising annually will simul- harmful ingredient. In addition to egg white, vita- taneously pay for the dissemination of health.infor- min D, and nonfat dry milk, egg substitutes contain mation. In the fall of 1974, the U.S. Congressen- some 14 other ingredients, each of which would acted legislation that liberalized regulations concern- require evaluation. ing the development of tax-sheltered retirement plans The concept of realistic goals suggests thaten- for the self-employed. Banks immediately began to dorsements be given not only for beneficial products, advertise on television and in the print media to but also for those that are less harmful than others. inform the public about the new legislation and to For example, smokers who cannot quit should be urge them to use their banks in setting uparetire- encouraged to smoke br,nds low intar and dcotine. ment plan. The Federal Government had no need to It is tree that there is little hard evidence atpresent publicize the new law; the banks who stood to that low tar and nicotine cigarettes reduceany of profit from the raw readily undertook the task of the health hazards associated with smoking, but lack disseminating information about it. of evidence is no excuse for paralysis. As Chalmers This brings us to a fifth principle. Because ofthe so aptly puts it, "Once a physician believes that nature of media in the United States, it is easierto therapy may be effective...or. that its ben ficial introduce a beneficial product into theeconomy than effects definitely outweigh its deleterious side effects, it is to remove one that is harmful.Removing such he is compelled... to use such therapy until con- aproduct is difficult when it affects the economic vinced that it does not or will not work."(104) 0 well-being of a special interestgroup;. itis even The endorsement approach could Havea number more difficUltwhen those who would benefit from of beneficial effects: It could stimulatethe devel- its removal cannot be identified readily. Forex- opment of beneficial products and put harmfulcom- ample, most smokers do notget lung cancer and peting prOducts at a disadvantage; it could increase while those who arc destined to do so would perhaps general knowledge about healthas new products 'benefit from the removal of cigarettes fromthe related to health were ,introduced; and it couldhelp market, these individuals cannot be identified be- to enlist previously unavailable monetaryresources forehand. Risk is tantamount to uncertainty regard- in .the cause of health.

38 . Communications Revolution/29 J

.The ideaidea of product endorsement is similar to thing. In other words, they are selling eggs, not legislation presented to the 94th Congress which health. would authorize the National Bureau of ,Standards The fact is that we do not know the most effec- to test products and release the results to consumers. tive way to bring specific health messages to public Manufacturers would be permitted to use the re- attention, and the experience of general advertising sult's in advertising if they so desired.(105)Pre- is probably of limited value. Advertisements often sumably some of the products tested under this pro- promise easy solutions for everything from greasy posed legislation would be health related. .dirt to bad- breath. Muchhealth,education, on the Meeting the costs of the certification process de- other hand, often asks people to change their life- serves careful study. It is certain, however, that a style and give up ingrained habits to reduce risks direct, transfer of funds from the potential advertiser and perhaps forestall or prevent events that Might to the certifying body is highly undesirable. Instead, or might not o...zur at 'some future time. To cope the endorsing agency should be one which enjoys with this problem, we n.eed to experiment with a the highest possible prestige and is totally free of number bf approaches and, as has been suggested ties to advertising or business interests. The medi- (106), evaluate them formatively as well as sum- cal specialty societies scum to be the best choice, matively. By carrying out sample surveyS using al- primarily because, as we will see in the next chapter, tcanative messages, we could determine the best the forces of consumerism tend to move the con- approach to various population subgroups before sumer closer to the physician and the endorser role the campaign ends. In this way, effective techniques in this context becomes another way to overcome could be introduced into general use as soon as they the adversary stance of organized medicine and are identified. consumer groups. The final principle is thattelevision is the most effective communication technologyavailableto REFERENCES health education because it is one of the best ways to reach low-income groutps,The importance of television implies that optimization of its potential should 1.Morison, S. 1965. The Oxford History of the Ameri- be one of the highest prioritiee of health providers. can People. Oxford, New York, pp 392-93. This is far from the case at present. Much of the 2. Columbia Encyclopedia. 1963. Columbia Univ:rsity problem has been financial, but even with a system Press, New York, p 1839. of endorsements,better useof theAdvertising 3.Toland, I. 1970. The Rising Sun. Random House, New Council, Federal intervention, or some other mecha- York, pp 268-77. 4. Shannon, C. July and October 1948. The mathematics.: nism to help health agencies make more use of theoryof communication,BellSystem Technical television, health providers will need greatly im- Journal. proved communication techniques. 5.de Chardin, P. Teilhard. 1961. ThePhenoCtimonof If health education is ever to have a major in- Man. Harper Row Torch, New York, pp 110-83. fluence on the health status of the American popu- 6.Mortensen, C. 1972. Communication. McGraw-Hill, New York, p 38. lation, it must use television, particularly if it is to 7. Schramm, W. 1955. How communication works in W. reach those people who have the most to gain from Schramm, ed., The Process and Effects of Mass Com- additional knowledge of beneficial health behavior. munication. University of Illinois Press, Urbana, Illi- Much cah,be learned from the advertisers who long nois, pp 3-26. 8. New York Times. September 1, 1974. ago learned that telling peoplethat a product is good 9. Osgood, C. et al. 1957. The Measureiitent of Mean- for them is not always the best approach to safes. ing.University of Illinoistress, Urbana, Illinois, For example, the only reason for the existence of p 228. a cholesterol -free egg product is that the absence of 10.Westley, B. .and' M. MacLean Winter '1957. A con- cholesterol is beneficial to the consumer and yet the ceptual model for communication, Research Journal Quarterly 34, pp 31-38. adVertisements downplay this aspect and emphasise 1 t.Barlund, A. 1970. A transactional model of -commu- the similafity between, their produci and the real nication in K. Soreno and D. Mortensen, eds., Foun- 39 30 /Toward an Educated Health Consumes

dations of Communication Theory. Harper & Row, 36.Schramm, W, op. cit. Men, Mesuges, and Media, New York, pp 83-102. p 234. 12. Dance, F.1967. Human Communication Tbiory. 37.Lazarsfeld and Merton, op. cit. Holt, Rhinehart & Winston, New York, pp 288-309. 38.New York Times. January 12, 1975. 13. Fearing, F. January 1953. Toward a psychological 39.Barthel, J. January 5, 1975. Boston mothers agaiist theory of human communication, Journal of Person- kidvid, New York Times Magazine. , ality 22, pp 71-88. 40.McLuhan. M. 1964. Understanding Media. Signet, New. 14: Peterson, a January 1958. Speech 'and hearingire- York, p 90 ff. search, Journal of Speech and Hearing Research 1, 41.McLuhan, M. Winter 1974. Global theater, Journal of pp 3-11. Communication 24. pp 48-58. \ 15. Ruesch, J. and G.- Bateson. 1951. Communication: 42.Jacobs, N., ed. 1961. Culture for"Millions. Van Nos- \ The Social Matri:: of Psychiatry. Norton, New York. trand, New York, p 508. 16. Zimmerman, C. 'Arid R. Bauer. Spring 1956. The effects 43.ibid, p 510. - on an audience of what is remembered, Public Opin- 44.Lazarsferl, P. atal.1944. The People's Choice. Harper ion Quarterly 20, pp 238-43. & Row, New York. 17. auer, R. March 1964. The obstinate audience: the 45.Scbrinun, W. op. cit. Men, Messages and Media,pp ihfitience process from the pointof view of social '120 -125. communication, American Psychologist 19, pp 319-28. 46.Katz, E. Spring 1957. The two-step now of communi- 18. Schramm, W. 1971. The nature of communicajion cation: an up-to-dale report on an hypothesis, Public between humans in W. Schramm and D. Roberts, eds., -Opinion Quarterly 2i1, pp 61-78. The Process and Effects of Mass Communication 47.Beal, G. and J. Bohlen. 1957. The Diffusion Process, (second edition). University of Illinois Press, Uibana, Special Report No. 18. Agricultural extension Service, Illinois, pp 3-53. Iowa Suite College,(Ames,Iowa. 19. Lazarsfeld, P. and R. Merton: 1971. Mass communi- 48.Lazer, IV. and W. II. September 1966. The commu- cation, popular taste, and organized social actions in nications process and innovation, Journal of Advertis- W. Schramm and D. Roberts, eds., The Process and ing Research 6, pp Effecti -of Mass Communication (second edition). 49.Sandman, P. et al.972. Media. Prentice-Hall, Engle- University of Illinois Press, Urbana, Illinois. wood Cliffs, New Jey, pp 237-56. 20. Klapper, J. 1964. The Effects of Mass Communication. 50.New York Times. Se tember 5, 1974. Free Press. New York, p 8. 51.Pierce. op. cit. 21. Rosenstock,I.July1966. Why people 'use health 52. services, Milbank Memorial Fund Quarterly 44, Part 53,ibid. 2, pp 94-127. 54.Advertising Age. Oct,...ber.21, 1974. 22. Toffier, A. 1971. Future Shock. Bantam Books, New 55.Target Group Index. 1974. York, p 26. 56.Maisel, R. Summer 1973.,Tbe.decline of mass media, 23.ibid, p 30, Public Opinion Quarterly 37, pp 159-70. 24. Pierce, J. Septembe. 1972. Communication, Scientific 57.Chronicle of Higher Education. November 25, 1974. American 227, pp 31-41. ... 58.ibid. Dtcember 2, 1974. 25.ibid. 59.ibid. November 11, 1974. 26: New York Times. January 12, 1975. ' 60.Gartner, A. and Riessman, F.1974. The Ser;ice 27, San Francisco Examiner. January 19, 1970. Economy and the Consumer Vanguard. Harper & Row, 28. Broadcasting Yearbook. 1968, p, 22. New York, pp 76-77. . 29. New York Times. January 12, 1975. 61.Changing Times. January 1975. 30. Looney, G. August 1971. Television as a major factor 62.Association of American Medical Colleges. January in the ecology of childhood, Clinical Pediatrics 10, 13, 1975. Weekly Report 75:2. pp 445-48. 63.Chronicle of Higher Education.-January 13, 1975. 31. Bower, R. 1973. Television and the Public. Holt, 64.National Observer, January 25, 1975. Rhinehart & Winston, New York. 65.New York Times. January 7, 1975. 32. Greenberg, P and B. Deryin. Summer 1970. Mass 66.New York Times. Jamstry 10, 1975. communication among the urban poor, Pablic Opinion 67.New York Times. September 21, 1974. Quarterly 34, pp 224-35. C8.New York Times. September 28, 1974. '33. Schramm, W. 1973. Men, Messages and Media. Harper 69.New York Times. November 30, 1974. & Row, New York, p 234. 70.New York Tithes. November 3, 1974. 34. Gerbner, G. September 1972. Communication and the 71.Somers, A. .August 22,1974. Recharting national socialenvironment,ScientificAmerican227,pp health priorities: a new Canadian perspective, New 153-60. England Journal of Medicine 291. 35. Singer, A. April 1969. Effects of different types of 72.Lewis, C. and M. Lewis. March 1974. The impact of programs, Proceedings of the Royal Society of Medi- television commercials in health related beliefs and cine 62, pp 10-11. behaviors of children, Pediatrics 53, pp 431-35. 40 Communications RevOlution/31

n 73. Sheikh, A. et al, Autumn 1974. Children'sTV com- 41. Robertson, L, A. Kelley, et al. Novembei 1974. A mercials: a review of research, Journal of Contmuni- uintrolled study of the effect of television messages on Cation 24, pp 126-36. safety belt use, AmeriCan Journal of Public Health 64, 74. Waal, S. et al.-1972. Children's perception, explana- pp 1071-80, tions and judgments of 'television advertising: a fur- 92. Institute for Communication Research. October 1974. ther explanation in E. Rubenstein et al., eds., Televi- Annual Repiirt, 1973-1974. Stanford University. sion and Snciat Behavior, volume 4. U.S. Government 93, Whiteside, T. November 18, 1974. Report at large: Printing Olfide, Washington D.C., pp 468-90. smoking still, New. Yorker, pp. 121 ff. 75. Blatt, 1. at al. 1972. A cognitive developmental study 94. Louis Harris & Associates. February 1974. Public of children's reactions to television advertising in E. Awareness of the NIAA7 Advertising Campaign and Rubenstein et'al., eds., Television and gocialliehavLor, Public Attitudes Toward Drinking and Alcohol Abuse. volume 4. US: GOvernraept Printing Office, Washing= -% 95. Advertising Age. November 1974. ton, D.C., pp 452-67. /6. National Center for Health Statistics. March 1974. ' 76. Schwartz T. 1974. The Responsive Chord. Doubleday/ Mortality Trends for Leading Causesof-Death: United ArichorMaiden City, Nevi York, p 22. States, 1950-1969. Department of Health, Education, 77. Advertising,Age. October 7, 1974. and Welfare. 78Diabetics Departmant. Mount Sinai Hospital, New 97. US. Department of Agriculture. April 1974. Statistical , York.' Bulletin No. 528: Annual Report on Tobacco Statistics 79. Advertising-Ace. pctobet 28, 1974. 1973. 80. Advertising Age. January 6, 1975. 98. Walker. December 16, 1974. Government subsidized 11. Smith, F. et al. March 9, 1972. Health information death and disability, Journal pf the American Medical during.a week of television, New England Journal of Association 230, pp 1529-30. Medicine 286, pp 516-20. Marshall C. 1972. Dynamics of ,Health and Disease. 82. Advertising Age. February 17, 1975. .4 Appleton-Century-Crofts, New York, p 264. 83, AdVeril.k:ng AgF. November. 25, 1974. 100.Medical World News. March 15, 1974. 84. Advertising Age. August 24, 1974. 101: New York Times.anuary 7, 1974. 85.\Smikop. cit., 102. Medical World News. March 15, 1974. 86, Advertiiing Age. August 24, 1974. 103. Barnum; H. January 1975. Mass media and health 87. ,Mcgfillen,*H. Janu 975. Portrait of a can- communications, Journal of Medical Education 50, , didate,14V Guide. pp 24-26. 88Bauer, R_ March 1964 The o- 'natc audience, Amer- 104. Chalmers. T. June 1964. Mortality rate versus funeral lean Psychologist 19, pp 319-28. rate in clinical medicine, Gastroenterology 46, pp 89. BaSer, R. op. cit. . 788-,91. 2.. 90 O'Keefe, 'M. Summer 1971. The anti-smokingcom- 105. Changing Times. January 1975. - mercials- a study of television's impact of behavior, 106.libel!, E. March 1972. Health behavior; change: Public Opinion Quarterly 35, pp 342-48. political model, Preventive Medicine 1, pp 209-221.

41'' 4:3 3 often lifelong in duration, largely progressive and irrevers iblez..clitstemong middle age -.and older QUALITY IN MEDICAL *CARE: personand,atJo.ve ally require long-term continuous CONSUMER/SM. AND CAQUCEUS care. They are further characterized by high incidence and prevalence and by high,mortality and morbidity. They are treated on a symptomatie because causation,is poorly understood. The goal of "1 die by the help of too many physicians." therapy isto- control, maintain', and. rehabilitate; Alexander the Great,,323 B.C. cure is rarely possible.. The rise of scientific medicine and the emergence ORIGINS OF THE HEALTH CONSUMER. of chronic 'disease' required the development of sup- "Our immediate problem has therefore two as- port personnel to assist in patient care and in re-. pects,': wrote Abraham Flexner, "on the one hand, search. By late 1§60s,0hYsicians comprised only to strengthen these .(better] institutions ... onthe 10 tiercent of the Nation's 'health workers; physic other. to crush out the mercenary concerns that trade clans, dentists, and nurses together accounted fir on ignorance and disease." (1) Flexners 1910 re- less thAn 40 percent ofthe otal.'(4) Support per- port to the Carnegie Friuntion led to the closing of sonnel became increasingly specialized as the hospi- proprietary medical s and to the establishment tal beeam,e the epicenter of health care. If one con- of a scientific_ aor medical education. Flexner siders birth, marriage, the birth of children, and emphasized high standards. ofaccreditation,the death to be the signal events of life, the hospital's interdependence of clinical medicine and the basic role in all but niatriage Sestides to its importance sciences,. and the desirability otmedical school affilia- in the community. Until very recently, the historic tyhti universities. robts of the hospital in the inteiconnected trilogy The closing. 9f Aroprietary institutions and ,the of religion, charity, and philanthropy permitted these rapid de4elopment of the university -based medical institutions to pay very low wages to all personnel,' school had far-reaching effects. Medicine became includihg physiciansininternship and residency he dominant arn: of biological science, and its New training programs. In consequence, there developed tonian approach 'to the workings of living organisms a very wide gap between earnings of the top health produced a vast amount of new knowledge of health professionals(physicians,dentists,administrators, and disease. In the field of therapiutics, the on- and so on) and middlc-level personnel and a smalla slaught against bacterial diseases led to their eclipse gap between the middle and the relatively unskilled as the major killers and the ...,,ceasing availability of lower levels. Of the 4.7 million workers in the health vaccines meant that at least some of the therapeuti- industry, about 60 percent fall into this lower level cally intractable viral diseases could be prevented of service and clerical workers. (5) altogeTher. Infants and small children were the prin- The establishment of the American Medical As- cipal beneficiaries of success against infectious dis- sociatjon (AMA) in 1847 marked the completion eases and the decline in death rates among the 'ery of the .professionalization of the American physician. young led to spectacular increases in average life In a running battle against quacks and competing expectancy from 54 years in 1920 to slightly more therapeutic systems which has never ended,the -_titan .71 years by the 1970s. (2) AMA emerged as the nation's most prestigious and The trend to specialization greatly accelerated as powerful health organization by the beginning of ,knowledge expanded. By 1973, the once- predomi- the 20th century. By the time of the Flexner report, nant general practitioner comprised less than15 it was promoting higher standards in medical edu- percent of the total physician population and, in cation together with a reduction in the number of addition, was less well trained and older on aver- practitioners. (6) The movement of the medical age than his colleagues. (3) schools to a university base was accompanied by a Meanwhile, the eclipse of infectious diseases left reduction in the numbers of blacks and won .n medicine to grapple with conditions of a chronic enrolled. (7) Moreover, the growth of ancillary nature which, in contrast to infectious diseases, are personnel resulted in d colic,mtration of blacks in

42 34/Toward an Educated Health Consumer

low paying health service jobs. Blacks accounted for became, tragically and horribly, a one-line item in a 22 percent of the practical nurses, 25 percent of the category lacking accurate statistics... whose ... orderlies, and 19 percent of the health aides in 1970. victims have given rise to the saying: 'The surgery In contrast, only 3.7 percent of physicians were was a great successL-lant the patient died.' " (12) black 'and the figure for registered nurses was even The author had been an observer of the health worse at 2.1 percent. (8) Although the vast majority scene for years and had written a book entitled of health workers are women, they comprise only The Plot Against the Patient 8 years earlier. His 10 percent of the physicians and over 90 percent article in a popular periodical expressed the view that of the nurse's,dieticians, dentalhygienists,- and his wife's case had been bungled largely because of health workers, (9)White women thus occupy the medicine's lack of interest in patients and its ex- middle-level jobs -while black women are concen- cessive interest in technolggical virtuosity. trated at the lower 'levels. This critical article is characteristic of a prevailing Rising admission standards and limited medical view of-the health industry presented by the media. school seats meant that physician .output did not The general dissatisfactionis augniented by the keep pace with demand as hospital utilization soared. seemingly endless- upward spiral' of costs,as insli- The number of shdrt-term general hospitals increased mica in Table 3-1 (13, 14), coupled with discour- only 14.percent between 1950 and 1972 while ad- aging data on mortality and morbidity, as shown in missions per 1,000 population increased 50 percent. Table 3 -2. Although per capita expenditureson (10) To meet- the manpower deMands- of -chronic health rose some i 350 percent between 1960 and disease care, the United States became an importer 1974, the change in health status of the population of physicians. In 1973, 44.5 percent of all newly was minute. The crude death rate hardly budged, . licensed physicians were foreign medical gradu- from 9.5 per'1,000 in 1960 to 9.4 in 1972. (15) ates and the number of licenses issued in that year To make matters worse, the stability of the crude exceeded by 35 percent the .total number of living death rate during this period obscured the fact that black physicians ever licensed. (11) Adthission of the death rate for young adults (ages 15 to 44) minorities and women to medical school has greatly actually rose slightly. (16) Each dollar spent for increased since 1969, but less progress has been health buys less and less in terms of longer lives made by minorities in nursing and other middle- and less illness. Indeed, on the basis of data from level professions. In most large urban centers, hospi- the 1960 census, Auster and his colleagues (17) tals represent a major source of employment for concluded that each 1 percent increase in quantity the poor and the poorly educated. Existence of a of medical services brought a reduction in mortality vast number of low-level support personnel drawn of 0.1 percent. The situation is summarized graph- from marginal elements of the population surrounds ically in Figure 3-1. the physicians and other high-level professionals with This graph is slightly modified from one presented a large, but often restless and dissatisfied, labor by Fuchs. (18) It suggests that we are presently at force in a relationship of total interdependence. point A, where additional dollars spent have very This large nonprofessional group of low-level litt14 effect on health statusas measured in terms of employees is an impoftant source of specific health mortality and morbidity. Growing concern with this Information to the communities from which they state of affairs has focused interest on efforts to come. Needless to say, in an industry as vast as achieve a higher benefit-to-cost ratio than is cur- health, the content of information flow often has rently the case. The fact that much higher levels of little or nothing to do with disease hit dealS also productivity are possible, as experienced at point B withfacilities,organization, financing,utilization, at lower levels of health status and expenditure, has and manpower as well as communication between in- intensified the sense of frustration among Govern- dividuals relating to decrepit hospitals, long- waits, ment officials, health planners, and informed con- high costs, or crowded waiting rooms. sumers. At point B, one realized greatest incremental A prominent journalist recently described the change in health status for each dollar spent, that is, death of his wife after cardiac Furgery. "My wife, maximum benefit per unit of cost or maximum mar- Julia,is dead," he wrote, "...last summer she ginal product. Itis worth noting that maximum Quality in Medical Care/35,

TABLE 3-1: Health Expenditures for Selected Years, 1950 -74

Consumer Per Capita' I Year Total Amount* Expenditures* Expendit#e GNP

1950 12.01 8.4 $78 4.6 1960 25.9 18.8 X,42 5.2' 1965 38.9 28.0 198 5.9 1970 68.1 40.9 /328 7.1 1974 105.2 50.0" 496 7.8

In billions of dollars. °S1972.

TABLE 3-2.Trends in .Mortaliey and MOrbidify, 1960-72

Average. Life Expectancy at 1960 1965 1970 1972

age 20white male 50.3 50.3 - 50.5 black female 50.1

age 40white male 31.7 31.9 32.1 black female 32.2 34.2 34.0 age 50. white male 23.2 23.4 23.6 black female 24.3 26.3 26.1 restricted activity days" 16.2 16.4 14.6 16.7 bed disability days" 6.0 6.2 6.1 6.5 work loss days" 5.6 5.7 5.4 5.3

Mortality data are for 1971. 'Days per person per year. benefit -pier -cost is not equivalent to maximum health point A. Obviously, we would prefer the level of status, the latter being the point at which the line BC productivity represented by point B, and this desire turns flat, that is, point C, where no further increase to achieve improved health status with lower ex- in health status is possible (given current technology penditures is widely reflected in the mass media and and practice). Fuchs points out that from the stand- in Government debate over legislation related to pdint of the allocation of societal resources,- dollars health. spent should not go beyond the point at which the With health expenditures approaching 10 percent social value of an additional increment to health of gross national product with no visible improve- equals the value to society of the additional dollars ment in health status, it is not surprising that health reqvired to obtain that increment. Since such social has attracted public notice as never before. Health optima are exceedingly difficult to identify in the is news and no health matter is too private for full real world (especially in the health care indus.ry, public disclosure. It was not always so. President where perfectly competitive markets do not exist), Grover Cleveland underwent surgery for oral cancer the relationship of our actual health expenditures to in July 1893. The procedure was carried out in ut- their optimum level is unclear. In any case, the data most secrecy aboard a yacht owned by one of his cited above indicate that we are approximately at friends. The extreme secrecy was justified because 44 36/Toward an Educated Health Consumer

CONCEPTIONAL RELATIONSHIP BETWEEN HEALTH STATUS AND HEALTH EXPENDITURES, the New York Times. (21) Throughout most of MIDDLE NINETEEN SEVENTIES the fall of f974, the public was given lengthynews coverage of the breast surgery of two famous cancer patients, the wives of the President and theVice President. The trencrto reveal all types of health problems for public view has been deplored'as "medical voyeurism," (22) but breast surgery had hardly left the front pages before the NO ,York Times followed' up with an article concerning the extent of unnecessary surgery.(23),. This article appeargl in the press 4 days before its publication in the New England Journal of Medicine. (24) In- deed, it is no longer uncommon for medicalnews to reach the public before it reaches the scientific community. The results of a study finding that two drugs used to lower serum cholesterol hadno effect on the mortality experience of victims of previous DOLLARS SPENT myocardial infarction appeared in the lay press al- Source: Modified from V. Fuchs, Health Core and the most a week before their publication in the Journal United States Economic System, 1972 of the American Medical Association. (25, 26) ,Increasingly, the press and television look to the health area as a fertile source of news. Featurear- FIGURE 3-1. ticks desqk low cholesteroldiets for children (27); news articles cover such itemsas artificially

...... inflated antibiotic prices (28), efforts to increase enrollment of women and minoritiesin medical ) "Whattheconsequnces would have been had it schools (29), and intramedical debates over the been known at once we can only surmise and allocation of research monies. (30) Psychiatry is shudder." (19) When rumors \appeared in the press criticized for its high costs and meager'successes 2 months later, they were vigorously denied by the (31); fraudulent research is fully described (32); principals involved, including the chief surgeon. and a television show covers primate research in the During the last year of his presidency, Woodrow field. (33) Above all, coverage of healthcare costs Wilson was mentally incapacitted\ by a stroke for is a constant theme in all print media and intele-- 2 months during which time a cloaof secrecy was vision. wrapped around the White House, and the country The cost question is the stuff around whichcom- was run by Mrs. Wilson and the President's physi- munities of interest develop. Rising health insurance cian. (20) The secrecy surrounding illnesses en- rates, increased out-of-pocket expenses, and apparent dured by national leaders was peeled away in the abuses in various sectors of the health care system 1950s when President Eisenhower's health prob- make `ealth a major concern of the American lems were widely publicized. However, during the people. Even the poor and the uneducatedare better presidency of John F. Kennedy, unconfirmed rumors informed than ever on the subject by virtue of the of his various illnesses were ignored by the admin- fact that vast numbers of them are employed in the istration and de-emphasized by the press. In con- health industry and because of the constant televi- trast, the mental health problems of the wives of sion coverage td which they are exposed. Senator Edward Kennedy and Prime Minister Pierre Consumer interest in health takes three forms:a Elliott Trudeau of Canada were openly discussed in noticeabletrendtodo-it-yourself medicalcare, the press, along with the phlebitis of former Presi- efforts to orient medicine more toward thecon- dent Richard Nixon. Even a perfectly normal presi- sumer, and demands for legislation to contain cost dential physical examination appears on page one of at no sacrifice to quality. 45 Quality in Medical Care/37

Young people have led the do-it-yourself move- Medicaid reimbursemeht. Physicians who refused ment. At one large New York City bookstore, more to provide- this information were listed as "unco- than 70 titles were on display in January 1975, all operative"'(39)Similarpublicationsexistfor bearing titles like The People's Handbook of Medi- Hawaii; Springfield,Illinois; and Prince Georges cal Care, The liome Health Handbook, or How to County, Maryland. (40) A major news magazine Understand and Treat Your Child's Symptoms. Most ran a forceful story wanting.the reader against in- are lull of anatomical diagrams, lists of symptoms, competent practitioners, lax State licensing boards, and sections on amateur diagnosis. Some are very and unnecessary surgery, concluding with advice on successful. In 1970, the Boston Women's Health how to choose a physician. (41)- Book Collective prepared Our Bodies, Ourselves, Beginning in 1972 and extending throughout most a compendium on female health ,an&sexuality. It of 1973, public attention was focused on a 40-year_ proved so popular that it was bought by Simon and study of 431 poor black men from rural Tuskegee, Schuster in 1973 and may well become e perennial Alabama, who were denied treatment. for syphilis seller. between 1932 and 1972 to enable researchers to Meanwhile, general interest in healtkis so strong learn more about the natural history of this disease. that, do-it-yourself blood pressure machines devel- They were denied treatment even after,a simple oped by a California manufacturer are scheduled for reliable cure for the disease, penicillin, was intro- installation in drugstores, schools, department stores, duced in the midforties and in spite of an -Alabama banks and supermarkets. (34) The Metropolitan' law enacted in 1927 which required treatment for all Life Insurance Company is now promoting, forsome citizens suffering from syphilis. (42-45) The Tus- kinds of insurance, a doctorless, virtually all-elec- kegee study generated much discussion, inside and tronic physical examination that takes only 20 min- outside the medical profession, on theethics of utes. (35) An interest in cardiopulmonary resusci- human experimentation-. Other studies came under tation (CPR), growing out of increasingawareness public scrutiny, including a hepatitis study that used of the value of emergency assistance to heart attack mentally retarded children as subjects (46), and the victims, is increasingly'irected to gaining compe- public learned that such studies while not the rule tence in CPR. Thoushnus of Americans, including were far from being exceptions. (47) Ip the scientific housewives and high-school students, have taken .literature, Curran (48) pointed out the need foran CPR courses in recent years. (36) adequate system of regulation for long-term studies Efforts to orient medicine more to the position and Weinstein (49) questioned the ethics of random- of the consumer take several forms. First andfore- ized clinical trials. Bok (50) challenged thevery most is a qbest for information useful to the con- basis of drug trials by raising doubts about the sumer-patient. Denenberg's A Shopper's Guideto ethics of placebo use, and Ingelfinger mentioned the Health Insurance, compiled while hewas Insurance desirability of the nonphysician ethicist in medicine Commissioner of Pennsylvania, rates the 25 largest "in view of the ethicist's increasing influence with health and accident insurance companies doing busi- jurists and legislators dealing in medical matters." ness in that State. Using a rating system basedon (51) 'financial stability and loss ratios, Denenberg down- Questions of ethics led quite naturallyto con- graded 15 of the 25 with the simple conclusion that sideration of assurances of quality andcompetence. they "do not rank as good buys." (37) Themost As early as 1965, the courts had establishedthd prominent of consumer periodicals, Consumer Re- principle that the administration ofa hospital can ports, has published numerous major articles re- be held responsible for the competence,of the staff, lating to health in recent years. Subjects seldomcov- and even the American Medical Association is in- ered before, such as laboratorytests,are now creasingly critical of the apathetic performanceof described 'and their high cost criticized. (38) The State boards of medical examiners in guarding the New York Public Interest Research Group issueda public.(52) In California, where theconsumer pamphlet during 1974 listing physicians inone of movement is strongest, the State board is part of New York's boroughs and stating 'their fees, house the State's Department of Consumer Affairs. Here, call policy, hospital affiliation, andacceptance of between 1969 and 1973, 387 physicians lost their 46 38/Toward etti Educatid Beath Consumer

licenses, had them suspended, or were otherwise promises to be as profound as Flexner's report of disciplined. In contrast, New York, with about 2,000. 1910. The legislative climate was set with ,th more physicians than California, took action against actment of Medicare ancl Medicaid in 1965. Thos only 58 during the same period. (53) Oh ly15 two amendments to the Social Security Act (Titles Statesidentifyincompetence ormalpracticeas XIX and XVIII, respectively) now cover approxi- grounds for revocation of licensure, while 28 States mately 30 million people, and the Federal Govern- make no mention -of either. (54) Yet times are ment pays more than half of all their health the rapidly changing. Several State medical societies costs. Medicaid, was to cost $258 million annually require evidence of continuing education forre- according toits proponents in the Johnson Adminis- newal of membership; New Mexico and Maryland tration. In 1974, however, Medicaid cost 10.5 bil- require proof of continuing education for relicensure, lion dollars, half of which was paid by the Federal and others are considering similiar legislation. (55) Government. (58) Faced with the cost problem Pressure is growing for the inclusion of lay members noted, and under increasing pressure-from the voters, on State boards, and no State is free of the growing Congress has nom enacted legislation which goes far influence of consumer activism. beyond Medicaid and Med:care to address the'health In 1959, the National League for Nursing pro- delivery system per se. duced the first declaration of the rights of patients. The need for some kind of cost conirol mechan- (56) In the climate of the seventies, it is not sur- ism that would not compromise the quality of care prising tliat such bills of rights are now common. was apparent in the early seventies and the clamor The American Hospital Association brought out its for accountability was growing within medicine as version in 1972 (57) and many hospitals have well as outside it. (59) While a -detailed discussion adopted it, often in somewhat modified form. These of the following legislative acts is beyond the scoPe rights, -12 in number, have been criticized as being of this paper, each is relevant to the consumer, to. paternalistic, unrealistic, and drawn up without suf- consumer health education, and to quality of care, ficient consumer input. Nevertheless, five of these and will be briefly presented from these person.; rights are of crucial importance to consumer and tives. 'professional alike. These assure the palent's rights In late 1972, legislation establishing- professional to: standardsrevieworganizations( PSROs)was Obtain information on diagnosis, treatment, and signed into law (PL 92-603, Title XI, Social Secu- prognosis in terns he cr she can understand. rity' Amendments of 1972). When They are all in Obtain information necessary to give informed place, PSROs will comprise a national network of consent priorto operations,procedures, or about 1,000 physician-sponsored and -controlled treatment. organizations to review care provided in facilities Refuse treatment. receiving Federal reimbursement under Medicaid or Be assured of privacy. (Patient consent must be hled:care. The idea of peer review has been likened obtained if he or she is to be the subject of any to the FCC turning over regulation of television conference or teaching exercise.) broadcasting to NBC, 03§, and ABC (60), but the Refuse to participate in human experimenta-. experience of the San Joaquin Foundation for Medi- tion. cal Care, after which the PSRO idea is modeled, gtig- gests that such an approach can indeed reduce the unnecessary hcspitalization, unnecessary surgery, and THE LEGISLATIVE INITIATIVE redundant laboratory and radiologic examinations which have plagued Medicaid and Medicare. (61) In the present climate of consumer activismit In the San Joaquin situation, the costs of the peer seems certain that some form of national health review system are lower than monies saved through insurance will be enacted within the next few years. review of hospitalization and diagnostic procedures, Legislative initiatives related to national health in- and the changes in praWce patterns.this review proc- surance have already produced significant new laws essncourages. (62) It remains to be demonstrated, in the past 3 years, and their ,combined impact how rier, that the estimated $330 million the na-

- . Quality in Medical Care/39

tional PSRO system will cdst will be exceeded by TABLE 3-3. An Example of savings realized from reducing utilization of hOspi- Patient Care Criteria tals, especially since no one has any idea to what CORONARY HEART DISEASE WITH ACUTE extent underutilization of hospitals is a problem in MYOCARDIAL INFARCTION some parts of. the country. (63) Indication for.Admission PSROs may also initiate reviews of hosp*ization A. Suspected or proven acute myocardial infarction covering pre-entry (prospective review), the hospital B. Sustained anginal type.pain period itself (concurrent review), and the post- C. Increasing. frequency and severity of anginal at- ,' tacks hospital period (retrospective review). (64) The D. Angina with development of new cardiac. rhythm review procegs must be based on the establishment E. Congestive.heart failure in, the presence of angina by each PSRO of norms, criteria, standards, and II.Length of Stay s:reens. A. Ringof 12-32 days B. Average 18.1 days- From the standpoint of consumer informatipn, the III.Essential Services Consistent with Diagnosis most significant portion of the PSRO law is the ex- A. History tent to which norms and criteria will.be subject to 1. Typical chest pain with typicalpatterns of public disclosure.. He're, the law is ambiguous. Sec- radiation tions 1155.a.3, 1156.c.1, and 1166.a all deal with 2. Change in ar7inal patterns 3. pevelgpment of symptoms of congestive heart publicationanddistributionofdatagenerated failure through PSROs, but what information the public B. Past History will bee Vitled to, if any, is the subject of much 1. History of angina pectoris debate.1nsumergroups have been joined by the 2. History of previous myocardial infarction 3. Family history of coronary heart disease American Public Health Association in insisting on 4. History of diastolic hypertensipn public access to all quality of care data. The AMA, 5. History of diabetes mellitus in contrast, filed suit against the Federal Govern- C. Physical Exam ment to block implementation of the entire PSRO 1. Hypotension or shock Act. (65) In all likelihood the real question is not 2. Significant change in heart rate 3. Pailcr what will be withheld but how secrecy will be main- 4. Diaphoresis tained. With 1,000 PSROs and growing consumer 5. Evidence of congestive heart failure demands, itis a virtual certainty that both norms D. Laboratory Tests and criteria will become public knowledge. They 1. Usual Tests . . will 'surely come out in malpractice actions and public disclosure may be required under the Free- a clamor for adoption of a single set of criteria dom of InformationAct. While release of informa- nationwide. The existence Of public criteria will open tion about individual patients cannot be condoned, the entire PSRO mechanism to extraordinary scrutiny public disclosure of norms and Criteria will have and probably represents the source of potentialdis- far-reaching effects. Physicians complain that PSRO satisfaction that could deprive physicians of masters leads to "cookbook medicine," but thedoctor's of their own destinies. In the end,it will be the cookbook is the consumer's encyclopedia. Consider collective patient that dictates terms. Table 3-3, which lists patient care criteria for acute In 1932, the Committee on the Costs of Medical myocardial infarction. It is a preliminary guideline Care recommended the creation of voluntary, hos- developed by the American Society forInternal pital-based, prepaid group practice plans (67); the Medicine and published in the AMA News. (66) health maintenance organization (HMO) concept Regardless of the specifics of the criteria and varia- was thus stated for the first time. The growth of pre- tions from region to region, this information pro- paid group practice in the UnitetJ_States has zbeen vides he public with a standard against which medi- relatively slow. Only about 5 millioliAaericans are cine cn be judged, a standard promulgated by the enrolled in HMOs; mare than half of these are sub- doctors themselves. scribers to the various Kaiser plans.in Oakland, Los Consumer groups will compare criteria from dif- Angeles, Portland, Honolulu, Cleveland, and Den- ferent regions and it would not be surprising to see ver. What they lacked in members,however, the 48 40/Toward an Edm-ated Health Consumer

. _ 4 group practIct people compensated for by contri- services. Most important, certified HMOs must be \ buti to the kedical care literature. The basic idea offered as an alternative health care package toem- i at prepayment creates inceptives to control costs, ploYee groups in any business employingmore than - .theliminating unnecessary services while providing 25 persons. In effect, this provision requires that em- high-quality care equal to nd perhaps better than ployers advertise the existence and benefits offered that provided under a fee-f-service arrangement. by any and all local HMOs. This "mandatory dual A vast literature has ,accumula d, almost always choice" provision is an incentive to the HMO to taken from the plans, themselves or their sympa- seek Federal certification. thizers, testifying to the ability of prepaid plans to According to Dorsey (74), the. original HMO provide qualityat anaffordablecost. "(68773) legislation went too far and not far enough all at Congress was sufficiently impressed to pass the HMO the same time. He felt that the requirements were Act of 1973 (PL 93 -222). so stringent that they would have the effect of dis- -Medicaid and Medicare provided fundsto cover couraging the development of HMOs because they the cost of care; PSRO providesa mechanism were required to. prOvide .services not provided by through which costs and4ality are to be reviewed; private competing insurance carriers. Because of the and the HMO Act goes e giant step forward in disparity of services, the monthly IMO premium is attemptingtoalter the organization of medical often in excess of the rate charge: by competitors practice. There are two HMO models recognized offering fewer services, and there is much experience by 'the Federal legislation: the Kaiser model and to demonstrate that the premium charges of prepaid the San Joaquin Foundation model. The latterwas group practiCe must be competitive with existing established in 1954 in response to Mier plans coverage to attract members. This problem was also to establish a prepaid group practice in the San noted by consumer periodicals and in the profes- Joaquin Valley. The San Joaquin Foundation also sional literature (75) and, in 1976, led to a reduc- provided the., model around which the PSRO Act tion in required benefits. MacLeod and Prussin was developed. It is sponsored by the county medical expressed concern over the potential manpower society and combines consumer prepayment with demand implied by the growth of HMOs. Their con- fee-for-service practice. The medical society collects clusion was that a projected increase of HMO en- the premiu and reimburses the participating physi- rollees to 40 million people by 1980 would require cian on a fefor-service basis from a premium pool. almost 40,000. physicians, or 50 percept of the Once the pois exhausted, the fees stop and the medical school output during the next 4 years. (76) HMO must cor its own deficits. The incentive is An additional problem is that the wider range of obvious. Under the Kaiser model, physiciansare benefits will tend to attract high-risk persons for salaried and most, if not all, care is provided ina .:whom the higher premiums are a bargain. Although single facility. The framers of the HMO legislatiop ,it has been modified to protect the compedtimposi- left out very little. All HMOs must provide such' don of the AMOs, the 30-day open enrollment benefits as physician services, in- and outpatient hos- period ande;community rating requirement mean pital services, necessary emergencycare, diagnostic that existing third party providers can offer lower- laboratoryandradiologicservices,therapeutic risk groups lower premiums based on experience radiolo2ic services, and a range of preventive serv- rating, and leave the HMO with an overabundance ices including family planning and infertility assist- of high-risk persons who can always buy. inte the ance. Beyond this basic bend package, each HMO plan because of the required open enrollment period. niust operate on a prepayment basis ufiinga corn- In short, the very provisions of the HMO Act which munity rating system and offer for at least ,30 days would do most to reform the delivery system and each year a period oropen enrollment. HMOs that benefit the consumer have the effect of impeding the meet these requirements areeligible for Federal growth of HMOs as long as the competition is not certification. Such certification frees the HMO flom bound by similar requirements. In this context, the any and allrestrictive State laws governing the estab- HMO Act is a case of consumerism working against lishment or operation of group practice plans includ- the consumer. It actually rewards the provider of ing those which prohibit advertitiniZrcosts and fewer benefits whose lower premiums 'serve to re- ,----- 49 Quality in Medical Care /41

.\ strictthereal advantages inherentin, the HMO Senator Edward Kennedy has been connected with concept. a number of proposals. The Kennedy-Mills plan In January 1975, President Ford signed \into law would have extended Medicare downward to persons the National Health Planning and Developtrient Act below tho age of 65, while the more expensive (PL 93-641) which combines the functions cf the Kennedy-Griffiths plan would have provided "womb- Comprehensive Health Planning, Regional MedIcal, to-tomb" coverage under a single involuntary insur- and Hill-Burton programsinasingleplannl g ance program financed from general tax revenues agency. A system of local planning agencies no and covering the entire population. By January 1977, oversees the flow of Federal health monies into each Kennedy was promoting a third bill, somewhat simi- planning area and is responsible for the development lar to Kennedy-Griffiths, known as the Kennedy- of long-range plans to meet needs identified through Cohn, an bill. Supported by organized labor, this bill the planning process. It is still difficult, even after e mbines extensive benefits with a financing scheme 2 years of health systems agencies (HSAs), to know th ties dollars available for health care directly to what kind of impact this legislation will have, but it the 'fate of the economy as-a whole. All of the pro- was clearly written to prevent unnecessary hospital posaiare probably more expensive than the $133 construction and to encourage consumer participation billion ent on health under the existing system in in the planning process. Consumers, government offi- 1974. heLong-Ribicoffcatastrophicproposal cials, and professional planners are to be a majority would ,cotleast; the Kennedy - Colman' bill would on State and local planning boards, with providers pe.hap st the most. All would reduce out-of- forming a distinct minoriiy. If the legislation proves poa-t costs, and all but the two Kennedy bills rely effective, control of construction of health facilities heairily on private insurance participation. Whatever will pass out of the hands of health providers and emerges as the final bill will no doubt contain various into the hands 0' a 'consumer-government partner- features of its predecessors, and, like its predecessors, ship The chances are good, however, that like the no doubt will be inflationary and stimulate congres- Comprehensive Health Planning program which pre- . sional efforts to further control, costs. Depending on ceded it. these H$As will sooner or laser become the co:nsutance provisions, Newhouse and his colleagues captives of medical and hospi_al interests, (77) From (73` estimate that national health insurance wiii the consumer viewpoint, the HSA approach repre- increase demand for ambulatory care from 30 to sents an attempt to prevent future waste but does 75 percent. Such an increase in demand will drive nothing to correct A-sting failures. It is consumer manpower costsup dramatically,especiallyfor involvement without content. physicians, whc, some feel, are already in short sup- It seems apparent that some kind of national ply.It is fruitless to speculate further on national health insurance is coming but when and in what health insurance. Itwill provide more and better form is unclear. Dozens of bilis have been introduced coverage for more people, it will be compatible with in Congress in recent years. The AMA proposes to HMO, PSRO, and HSA legislation, and it should rely on voluntary health insurance with G..ernmant be of value in rendering moot some of the restric- subsidizing premium costs for the poor. The more tions that presently impede the development of pre- affluent would receive a tax credit under the AMA paid grout- practice. plan and a tax deduction under a variant offi,ed Federal legislation has been passed to encourage by the Health Insurance Association of America. th, education of more physicians and allied health The Nixon-Ford Administration favored voluntary personnel. The Health Manpower Act of 1968 re- insurance withStates paying premiims forthe quireexpansion of medical school enrollment. Its Medicaid eligible, employers paying or employees, 197: successor provided capitation grants to those and Social Security picking up the tab for the Medi- schools meeting certain Federal criteria related to care population. national physician manpower needs. This act (HR Catastrophic insurance is advocated by Senators 2956) was to be renewed in 1974 but was delayed Long and Ribicoff. Under this plan, illness requiring until 1976. Among other things, this bill downplay., more than 50 hospital days or $2,000 in medical direct enrollment increases in medical schools, while bills would be covered by social Security. facilitating the transfer to America medical schools 50 . a. .1

42/Toward an Educated Health Consumer

of Americans enrolled in foreign medical institutions. firmed th. reductioc of this gap by encouraging one The medical schools have protested this on grounds type of prxtice at the expense of another in the that it strips them of control of their own admis- HMO Jaw and by requiring, through PSROs, the sions; but their dependence on Federal support development of niarths and criteria oi pre which makes it difficult tor them to do anything about this aredestined for public diclosure. In pissine.st4 ...violation of their autonomy. legislation Congress and itsconsumer constitubnts Legislation coeceming health is rarely initiated by are saying that health is too important to be. left to ° the medical profession. Similarly, the pressures for physicians alone and that the wisdom necessary to expanded medical school enrollment, reentry of make beneficial changes exists largely outside the Americans attending foreign medical schools, limi- profession. tations on licensure, restriction of theentry of for- It seems apparent' that the availability of criteria eign medical graduates,'HM0s, PSROs, HSAs, and such as those presented in Table 3-3 will lead quite national health insurance all arose outside. of or- naturally to the ultimate consumer question: What ganized medicine. To a great extent, neither the do the criteria have to do with the fate of the patient? profession nor its institutions' have effective control When consumers ask what they can expect from over consumer-backed legislation. Increasingly the medical care, they are asking about what is com posture of medicine is reactive. Medicine negotiates, monly referred to as "quality assessment" or "quality modifies, and accommodates; it no longer initiates. of care." Quality is wt. lt investigators promise consumers more of when they ask for public money to , support their research. 'Cis also what HMO advo- Quality Assessment: Toward a Physician- Consumer cates claim can best be attained through prepaid Alliance group practice, while fee-for-service practitioners warn that it will be lost if'they are paid in any other Although the instrument was known previously, it way. was William Chamberlain (1540-1596) who first Quality assessment is a central issue in medical used the forceps extensively in obstetrics. The device care, and an understanding of its components is was employed with great secrecy and passed from essential for consumerism. Without involving our- father to son to grandson. (79) William Chamber- selves in debate over a definition of quality, we will lain's great grandson, Hugh (1630-c. 1703), was instead begin our discussion with Donabedian (80), hauled before the Royal Society of Medicine, where who identifies three basic variables in quality assess- it was demanded that he display the forceps for the ment: structure, process, and outcome. inspection of his colleagues. So great was Hugh Structure refers to the facilities, organization, fi- Chamberlain's desire to maintain his competitive nancing, and manpower components that make up advantage that he produced but one blade of this the health care system. It is assumed that care is two-bladed instrument. Although such intraprofes- better when certain. arbitrary standards, such as sional secrecy is frowned upon today (and probably lici_asure of physicians and accreditation of hospitals would be impossible in any case), the story of the and medical. schools, are reached. Structure is thus Chamberlains illustratesthe point that thevery directed to the attainment of an arbitrary standard existence of the professional provider depends on the of resource availabilityso many board certified differential in knowledge which separates him from physicians, so many acute care beds, requirements the consumer. Theconsumer who achieves knowl- for a specified number of continuing medical educa- edge parity with the physician stands in a new tion hours, and so forth. The great attraction of relationship with him. structural considerationsis that data are readily It has been a principal argureent of this mono- available. Disadvantages are many. For one thing, graph that the narrowing of the 'knowledge gap be- availability of resources does not mean that theyare tween physician and consumer is a result of con- accossible. For another, their existence in no way sumerism arising from mass media, on the one hand, implies that the patient is likel, .3 benefit from them. and the tread to ever narrower medical specialties, Finally, belief in the assumed value of structural on the other. Recent congressional action has con- components can le: id to the conclusion that all that 51 . ,

Quality in Medical Care /43

is needed to achieve some desirable outcome is more When a patient consults a physie;an, there are

4 .4 research, more doctors, more technology, more train- four possible results. ing, or more rules. The recent emphasis on required 1. The sick patient can be diagnosed as sick by cOrAinuing medical education of physicians is based the physician (true positive). largely on structural assumptions, as is the perceived 2. The sick patient can be diagnosed as well need for more physicians and a different specialist (false negative). mix. 3. The well patient can be correctly diagnosed as There are two uses of structural considerations. well (true negative). Structure assures that the necessary components of 4. The well patient can be misdiagnosed as sick the health care system exist and by so doing provides (false positive). a very crude measure of quality. In other words, in False negative and false positive diagnostic errors either/or situations, structure has obvious value. are harmful to the patient: false negatives because Without automobiles there would be no auto acci- they miss something which might be treatable; false dents; with no doctors there would be no patients, positives because they may frighten the patient for no process, and no outcome. Thus, it is safe to say no good reason, lead to unnecessary restriction of that the quality of health care in the United States activity or unnecessary surgery, Ordepending 'On is superior to that in Zaire. The utility of structural the conditionplace a social stigma upon the pa- considerations breaks down when one tries to identify tient. The professional view that false negatives.,,, how much or how many of something lead to a de- are worse than false positives, is consistent with the fined outcome; studies relating structure to outcome history of the medical profession,.which until quite have shown, at best, a weak correlation.(81-86) recently offeredlittle except diagnostic accuracy. In discussing the medical care process, it is neces- Historically, diagnosis has tended to become an cnd sary to keep in mind that health status depends on in itself, quite separate from therapeutics. This bias genetic makeup, environment, and behavior, as well toward the false positive has long been apparent and. as on the medical care process. The medical care constitutes a major problem in assessing quality process is defined by Donabcdian as "the evaluation based on process.(93, 94)This tendency is aug- of physicians and other health professionals in the mented by the limitations of most diagnostic tests. management of patients."(87)It deals with diag- For example, if the disease suspected affects 2 per- nosis, therapy, andallof the things th.. doctors do cent of the population from which the patientis to or for their patients. Process itself can be harm- drawn, even an extremely sensitive test is likely to ful, as indicated by the fact that 18 to 30 percent of produce false positive results.(95) all patients suffer a drug reaction while in the hos- The propensity of the physician to diagnose and pital.(88, 89) treat is often reinforced by the patient's desire to Process assessment was first proposed in 1933 by assume a sick role. Placebo effect alone relieves Lee and Jones(90),who sought to define those symptoms in about 35 percent of cases (96) and components of process which made for good medi- favorable feedback from patient to physician en- cal care. More recently, interest in process has been-- courages further use of drugs which may be ineffec- directed at cost containment. New Jersey Blue Cross tive in the treatment of a dis%:aselhe patient does not and the Commission on Professional and Hospital have. Patient feedback too often substitutes for a Activities have both developed process evaluation predefined therapeutic end point. In the atence of methods designed to allow individual hospitals to such an end point., therapeutic effect becomes sub- compare their handling of certain diseases with the jective and the doctor's belief in his therapy reduces techniques used in other institutions. Lewis(91) the likelihood that he will suspect drug toxicity.(97) has pointed out the tendency for such methods to False positives confound the medical care process equate quality with quantity, and Brook(92)makes by leading to what Dykes (98) calls"uncritical the point that any method which deals primarily with thinking," that is, the substitution of clinical opinion medical records, such as process evaluation, may for knowledge. A disease such as hypertension, conclude erroneously that the quality of the record which depends on defining normal limits, is char- i3 tantamount to the quality of the process. acterized by legions of mislabeled patients, both

52 44/Toward an Educated Health Consumer

positive and negative, and even though it isone of outcome i$ patient '-oriented, .and is strongly influ- the most important and most prevalentdiseaSes, enced by patient behavior, genetic. Makeup, there is still no adequate process for and the many of these sociophysical environment: Genetics is largelybe- patients: (99) It may be that false positivityaccounts yond manipulative control, and the in part for the tendency of physicians environment to be overly issue is more a social policy matter thana medical sanguine in prognostic judgments. (100)In addition, one. there are no process criteria for thecommon minor Unfortunate, the use of outcome illnesses which account for the measures in vast majority of quality assessment isas problematical as the use or physician visits. (101) The upper respiratoryinfec- structure or process. To begin with, the false positive tions, upset stomachs, headaches, trivial''skin prob- bias inherent in antecedent piocess tendsto inflate lems, and such vaguer entitiesas fatigue and weak- favorable results by the adding of peoplwho were ness lie beyond quality assessment, eiargely because not sick in the first place. Second, it is they are handleil by the practitioner without. cult to' recourse identify appropriate measures ofoutcome. bite to hospitals, and the record keeping ofthe prac- (104) has proposed the so-called 5 D's titioner by and large does not offer, as units of a data base outcome: death, disease, disability,_ discomfort, atik sufficient for evaluation. dissatisfactiori.TaiiShel and Bush (105) preferprog- \ In. spite of the limitations, the PSROconcept nosis and function, while Burdetteet al. (106) opt \ bases quality assessmenton process. T c use of for disease status, symptomaticstatus, and functional empirical standards derived from usualpra e in status. With the exception of dissatisfaction, Bur- a community is one way to assess process. Tother dcite's measuresare similar to White's but dissatis- is the establishment of normative standardsbased on faction is a most important omission in viewof its explicit criteria developed by panelsof experts. importance in patient behavior. (107, 108) Neither is free of problems particularto elf and The most serious problem with. whicheverset of both suffer from the false positive bias'discussed measures .one adopts relates to their temporal rela- above. Also, while themore implicit, less rigorous tion to process. In other words, whenintime-- empirical approach is more easily attained, it may should outcomes be related to process? Thirtyyears fail to reflect full exploitation of existingknowledge may be appropriate but impractical and 1 year is anti there may be very great regionaldifferences. The oftenpracticalbutusuallyinappropriate. When explicit criteria, approach also hassome obvious process includes therapy extending over manyyears, drawbacks. petailedcriteria, which may be un- outcomes arc confounded by patient behavior. At realistic in some geographic areas, also -tendto tic best, compliance rarely exceeds 70percent; among costly in that t1he procedures specifiedoften require lot.- income groups it usually fails to reach 40per- expensive equipment. There is also the riskthat cent. (109, 110) In long-term therapies, compliance these procedures' will multiply withoutany propor- as le...! as 20 to 35 percent seems to becommon. tionate positive effect on the patient. Inboth meth- (///, 11') If therapy is effective, noncompliance ods, errors constitute between andamong observers can be c .pected to have a negative effect on out- a factor of some importance in determining reliabil- come. Oa the other hand, ineffective or harmful ity and validity. therapies will appear more effective (andeven bene- Since the purpose of medical care isto maintain ficial)when noncomplianceishigh. Thisisa_ or improve health, the logic in favor of outcome neglected area of research, although it is knownthat measures is overwhelming. Outcome (that is, what patients tend to overestimate their compliance. (113) happens to the patientas a ,result of medical care) The results of a recent study of oral hypoglycemic is of central interest to theconsumer and it is the agents suggest that the noncompliant patient isnot anticipation of outcome benefits which usually leads necessarily the one with the worstoutcome. Com- the individual to the healthcare system ;n the first pliance is further influenced by structuralchanges place (102, 103) The great advantage of usingout- such as movement of a facility, increased waiting- come as a basis for assessment is the fact that it time, and the departure of a favorite physician. (114) takes into account a variety of factors, including Brook (115) has pointed out other problems with structure and process. Unlike structure andprocess, outcome measures. One is the.lack of knoWledge of 53 Qualiiy in Medical Care/45

the natural history of most diseases, especially with expert physiciansestablish hypothetical outcome regard to symptoms and disability. Obviously one standards against ,which actual outcomes would be needs to know what outcome would occur without measured.Process would be investigated when processto determine theinfluenceofprocess. actual outcome compares unfavorably with the out- Another is the difficulty of obtaining outcome (late. come standards. (127) Repetition of this cycle would They are not entered in the patient's record and permit poor process to be corrected and prognostic can usually be obtained only through interview. judgment sharpened. Williamson's approach focuses Functional status and symptomatic status may be on all determinants of outcome simply by virtue of difficult to interpret as patient perceptions of these its demands for predetermined outcome standards. are related to sociocultural factors. Finally, there Because this approach looks beyond the physician is in important variant of the time poblem. Out- and his technology, it identifies patient educational ci.r.te evaluation must be based on short -reininter- needs and must take into account Socideillthial ele- mediate outcomes such as lower blood pressure or ments as well. It is an attractive approach because reduced blood sugar. Again, the diabetic drug study it is relatively simple. However, it suffers from all illustrates the danger of equating short-run success of the problems already mentiLaed, especially prog- with long-term benefits. Starfield (116) adds the nostic inaccuracy. important observation that outcome measures de- Kcssner (128) advocates the use of "tracers." pend in the end on following patients over time. A tracer is a condition (for example, hypertension, Most o: the problems relate in some way to this visual disorder, or cervical cancer) which can affect difficulty ;11 followup. function,iseasily diagnosed and prevalent, and The concept of outcome-based assessment goes whose natural history can be influenced by a well- back to Flo.ince Nightingal; who utilized compare- defined medical care process. In addition, the effects . tive deat}. rates to demonstrate the need for better of socioeconomic and behavioral factors on each health services in the British Army. (117) Sixty tracer should be understood. This is a tall order, years ago, Codman (1/8) suggested that hospitals even for mundane conditions. Nevertheless, tracers conduct tyearly end result assessment of their do permit one to identify the strengths and weak- labors which would help them determine what was nesses of a particular physician, hospital, or even an effective and what was not. More recently, advocates entire system of health care. They also account for of prepaid group practice began conducting studies the interaction of physician, patient, and both the relating eutcomcs to structure to promote the ad- social and physical environments. However, while vantages of their delivery mechanism. (119-121) the structural, process, and outcome factors exam- Similar studies relating structure to outcomes have ined by this approach may be regarded as representa- been carried out comparing teaching and nonteach- tive of the way all illness is handled, it may well inghospitals.(122,123)Thesestudiesrelied be that tracers are not representative of anything heavily on death as an outcome measure. other than themselves. There is no particular basis Appendectomy has been a favorite condition of for the assumption that the level of physician skill, researchers investigating surgical outcomes. These structural supports, and favorable outcome apply in results :end to confirm the prevalence of biasin toto or in part to nontracers. The search for truly favor of false positives. (124,125) The Professional representative tracers may be long and frustrating, Activity Study (126) report on appendectomy is although six tracers have been used to the satisfac- representative. It reported that pathological con- tion of Kessner and his colleagues. firmation of appendicitis ranged from 100 percent Brook favors a more complex approach which all the way down to 10 percent among individual relates outcome to both of the essential dimensions, surgeons and from 30 to 90 percent in different hos- of process, diagnosis and therapy. In a Mos: im- pitals. pressive study, Brook (129) used five methods to These early structure-outcome studies were. all examine each of three medical conditions. hyptr- relatively straightforward since the vastly Compli- tension, gastric or duodenal ulcer, and urinary tract cated process 'variable was not considered. In a infection. Por each disease, he studied process, out- variation of this approach, Williamson would have come, and process and outcome combined. Each of . 54 . 46/Toi,ard an Educated HealthConsumer

-, THE HEALTH,GOAL OF THE liNITED STATES IS , 1 . TO ADVANCE FROM BC-TO SIC' these was analyzed using both, implicit(empirical).- ...... and explicit (normative) criteria. Accordingto the method used, care was judged adequate forbetween .--"-a 1.4 percent and 63.2 percent of patients,Explicit criteria accounted for the lowestrate Of adequacy. Implicit criteria proved lessseve, buk there' was a wide gap between the adeqn of process (23.3 percent) and that of .outcome ( 3.2 percent)using implicitcriteria.Interestingly, processwas often adequate but outcome was adverselyaffected'. by deficient followup. Brook'S work points out very clearlythe dependence of quality assessment on the method used. The implicit approach process 'correlated poorlywith 'outcome in his experience and therewas much variation dependingon the lition. This suggests that similar variatjon may be expectedto affect the tracer approach. Implicit or explicit, outcomes left much to be desired. This finding is supportedby Brook's earlier work on emergencyroom care. (130) Here, care was judged satisfactory only inabout 31 DOLLARS SPENT percent of cases, and theig problem again was poor foPowup, often as a ses It of patient misunder- BC = Correll relationship between healthstatus standing of provider expec tiOns. Starfield (131) and dollars spent studied 53 pediatric patients with lowhemoglobin B`Citt Potential relationship between health values and found that half of.thern stillhad similar status and dollars spent at current tech- hemoglobins 6 .months later.Surprisingly, in 24 nological base. percent of the 53 children thissimple diagnosis was New technology overlooked altogether. Among those treated, followup 'again left much room for improvement. These studds suggest that fel:owup is thegreatest weakness in the medical care process, and it is wortha brief pause to observe that followup is a doctor-patient collaboration involving efforton both sides. , a Improving the provider system (that is,the Figure 3-1 presented a graph which related dol- efficacy of diagnostic and therapeuticprocesses lars spent on health to healthstatus in contemporary now in use might be improved through modi- Ametka Figure 3-2 repeats the originalcurve of fication to reduce followup failure, to reduce Figure 3-1(line.- BC) and adds a second cunt the use of ineffective therapies, and to reduce (line LK"). It may make economists wince, hitt it the rate of false negative and false positive attempts to demonstrate graphically that we are try- diagnoses). ing through new legislation, new consumer initiatives, Incorporating the consumer-patient into tthe and new interest in quality assessment to findour medical care process in such a way that human way from BC to WC': in other words,to 'obtain behavior complements rather than contradicts more health for the 'sane or fewer dollars spent. process. Moving from the lower to the higher curvecan be Reducing the incidence and prevalence of ma- achieved in a number of ways: jor chronic diseases by modifyingconsumer - lifestyles and eliminating known disease risks. Two of these. genetic. and environmental manipulation, Research discoVeries that improve the efficacy of will not be discussed here. the' medical care process would also affect there- Quality in Medical Care/47

lationship between health expenditures and health One approach that seems particularly appropriate status The potential effect of technological change is Blum's suggestion for combining Williamson's ap- appears as line XY in Figure 3-2. proach, which he calls "prospective outcome analy- Until very recently,. effortsto improve health sis," with what he refers to as "past-focused ar.aly- stcus focused almost exclusively on the scientific sis." An expert medical committee for a given breakthrough (curve XY), and the research effort specialty area selects the most important diseases on this implies has burgeoned in the three decades the basis of such factors as prevalence, effect on since World War IL Improv ement in process dates function or life expectancy, ability of process to con- back to the PSRO legislation of 1972 and the HMO trol the disease, the costs involved in care, ease of Act of 1973 and neithtr is as concerned with im- diagnosis, and the likelihood that present care for provement as with cost containment. (132) If this the disease is less than optimal. The committee then were not the case, logic would focus the attention establishes outcome standards and samples actual of PSRO on outcomes rather than process. Enhanced outcomes. Wh....1 outcomes differ significantly from consumer involvement, which involves consume, standards, a case-by-case review isinitiated. An health education, has never been tried on a large. effort is, made to identify elements principallyre- coordinated scale. While the idea of health education sponsible for the poor outcome. the doctor, the goes back atleastto the estat:shment of the patient, the facility, the health care delivery system, American Medical Association in 1847 and profes- lack of knowledge, or some unusual element. The sional health educators have been trained since 1921, idea is to pinpoint the lesion in the elements of only about one-half of 1 percent of the $.116 billion process so that subsequent failures can be prevented. spent per year in health finds its way into either Past-focused analysis concentrates on the status prevention or health education. (133) In addition, of the patient when he or she first comes under care State and territorial health departments allocate less to identify the determinants of patient status when than one-half of 1 percent of their budgets to health the medical care process begins. Then an expert education. (134) committee again identifies the most important con- Improvement of the medical care process, as we ditions and samples a number of cases to identify have seen, requires that process be related to out- failure of one or inore of the process elements. come. This is difficult to achieve because of the need enumerated above; Having identified the source or to follow patients ov..r long periods of time. This sources of outcome failure,the committee next problem can be partly overcome by the useof attempts to eliminate the problem. person-years and life table techniques, but perhaps While this prospective-retrospective approach is the best approach isDile that establishes a defined subjectto most of the problems encounteredin populationPrepaid group practices have this ad- quality assessment, its strength lies in. its ability to vantage, but a regional approach to health services identify and perhaps correct problems in areas often delivery might accomplish much the belle thing, 2,-ir- regarded as peripheral to the medical care process. ticularly in areas with few health care facilities. The Strenuous efforts to reduce costs through PSRO, financial stakes are sufficiently high now to make a HMO, and, no doubt, other means yet to be devised regional approach attractive and regions are at the might greatly reduce the inputs of the medical care heart of the PSRO concept. Such regions permit one process. Instead of too much surgery we might find to study a given population and to compute various ourselves with tolittle, overutilization of hospitals rates based on this population denominator. Obvi might be replaced by underutilization. Needless to ously, no region will be airtight since people un- say, we seek instead a golden mean without being doubtedly will crossregional boundaries to seek able to separate precisely the excessive from the in- care elsewhere. In spite of such crossovers, however, sufficient. The prospective outcome analysis Blum regional data are dearly preferable to what is pros suggests would begin to relate outcome and process entlyavailable. As norms of care evolve under in d manner which would get increasingly precise PSRO, the regional approach will greatly facilitate user time. The boundaries between too much and the identification of outcomes derived inpart on too :title would become increasingly clear, as would process within the region. the role of particular kinds of patients in producing 56 48/Toward an Educated Health Consumer

particular outcomes for specific diseases. Meanwhile, extraordinarily difficult to dilute the impact of this past-focused analysis points out not only thesuccess legislation. Public knowledge ofnorms and criteria and failures of past encounters with the structure alone will generate newconsumer interest and result and process of medicalcare but also helps clarify in new pressures on medicine. Eventual insistence the influence of the patient in determining his own on outcome measures seems inevitable. Whatwe outcome. have to recognize is that the physician-consumer With the exception of surgical patients and those complex is the core of the medicalcare process, and who are anesthetized, comatose,or otherwise acutely together they constitute the unit of production ill, the physician's effect of on outcome is dependent on outcome. What is missing in the present situation is the ability of the physician to influence patient be- the crucial idea that the consumer usually hasmore havior. (136) This complicates thestudy a process control over his health than the physician. The because physician researchers tendto separate the dissemination of this notion and the related idea hard data from laboratory tests, electrocardiograms, that one's health is primarily one'sown responsibil- and drug trials from the soft data of behavioral ity will emerge more clearly once outcomemeasures studies (for example, patient compliance).Most have been adopted. physician researchers are uncomfortable with soft The more the consumer knows, the more likely he data, which they regard as the province of the social 'is to cooperate with the physician, not only in a com- scientists. We have alreadyseen that compliance pliance sense but also in terms of increasing the becomes a particular problem when the therapyis efficiency of the medical care system. The publica- complex or must be continued indefinitely or over tion of outcome studies and their coverage in the extended periods of time. Even the best ofdrugs is mass media will do much to dispel unduly optimistic ineffective if not used or if used improperly. Unfor- or pessimistic expectations of the medicalcare tunately, the response of physicians to the compli- process. In addition, norms and criteria of care that ance problems is unsatisfactory. (137) Having diag- differ from region to region will gradually be altered nosed and prescribed, the physician often feels that to resemble the norms that correlate best with out- complianceis someone else'sresponsibility.But comes. If the prospective-retrospective method is whose if not his? Davis found that 67 percentof used, there will be no question of the importance of senior physicians regarded noncomplianceas result- patient behavior as an outcome determinant. Public ing from an "uncooperative personality." Only 26 awareness of results of this kind is so important that percent felt that the doctor was responsible,or, pre- new norms- that are expected to result in better sumably, that compliance was a physician responsi- outcomes should be reviewed in terms of the ability bility.(13'e) The great advantage of Blum's com- of the media to disseminate to the consumer the bined prospective- retrospective approach to quality information he needs to benefit fully from improve- assessment is that the detejmination of outcome is ments. News media should be given information re- focuied on the patient. lating to susceptibility and seriousness of various With norms of care and defined populations, illnesses, as well as what medicine has to offer.* either through HMOs or regionalization, Blum's Since patient behavior is largely a trade-off between method seems well suited to pinpnint and correct perceived benefits and perceived barriers, this kind 'other important failings -f the medicalcare process, of information is important to compliance. (140) for example, followup inadequacies and the false Unlike the automobile, medical care is pfoduced, negatives and false positiies arising from inaccurate in immediate proximity to the consumer, so much so diagnoses Indeed, the past-focused approach pro- that the process, becomes a part of his experience. vides an opportunity to identify those false negatives The consumer is not only part of the unit of produc- of previous process encounters and to get some idea, tion, he is in fact the product of a "consumer-inten- of how these people will do with the wrong therapy or with no therapy. In spite of physician hostility to the notion of, "Diseases largely beyond medical control would be ap proached from a preventive standpoint or ignored. Ability to qualityassessment (139) and negativism about control the disease is one of the factors to be considered in PSRO, the pressure of consumerism will make it identifying important diseases. Quality in Medical Care/49

sive" process. (141) Once the consumer is sc re- and the central nature of the patient role, the phy- garded and so regards himself, some of the hostility sician has an interest in educating his patients, and to clinical trials, may disappear, at least in cases the patient can see clearly how compliance is in his where the standard therapy leaves much to be de- best interests. Sehnert (145) stresses the concept of sired. For example, the prognosis in operable car- the "activated patient," by which he means people cinoma of the lung is very bad and for inoperable who are specifically trained to meet the simple health cases even worse. (142) Cochrane perhaps sass it hazards of everyday life, including use of such basic best: instruments as the stethoscope, otoscope, and sphyg- Such trials would necessarily involve denying the rou- nomanometer. He reports that such patients are high tine procedure to half a group of patients and at this compliers. Etzwiler has developed a written contract stage are nearly always termed unethical. It can he between doctor and pafient in the treatment of dia- argued that it is ethically questbnable to use on patients betes. Each knows what to expect of the other and a procedure where value is unknown, but the answer Etzwiler (146) reports a compliance rate of 62.5 is that it is unethical no; to do so if the patient will otherwise die or suffer severe disability and there is no percent using this method. Both of these devices alternative therapy.(143) involve patient self-selection, but in spite of this bias each represents an innovative approach to involving As the limitations of modern medicine become thr patient in his own care. Healy (147) reported more apparent with the use of outcome measures, thatpreoperativepatientinstructionresultedin the cousumer's stake in better outcomes will make earlier discharge when compared to those not so him more tolerant of the clinical trials necessary to instructed. Patient education is also reported effec- optimize therapeutic results. After all,ineffective tive in reducing postoperative narcotic use, in de- science is nothing more than ritual mysticism masked creasing emergency room utilization, and in reducing by technical jargon. Indeed,it is the high'cost of totalhospital admissions. (148-150)Resultsof ineffective therapies that aroused consumer interest this kind have aroused the interest of third party in the first place. Other costly but perhaps ineffective payers such as Blue Cross who view patient educa- therapies should also be subjected to clinical trials. tion as a potential cost-cutting technique. (151) Psychotherapy and psychoanalysis would seem to be Interestingly,itis prime candidates, in part because of cost and in part at least conceivable thatthe because the psychiatric literature is already largely alliance of physician and consumer around out- popularized and nonpsychiatric professionals and in- comes will redound to the disadvantage of the indeed nonprofessionals as well feel increasingly com- surance carriers. Outcomes represent an effective petent to administer its techniques. (144) defense against cost-cutting third parties because Emphasis on outcome implies changes in struc- process is derived from outcome and is less subject ture as well as process. A specific desirable outcome to arbitrary regulations intended to discourage utili- or group of outcomes js a consumer-oriented objec- zation. PSROs may be a case in point. PSRO is a tive in that attention must be directed to the clientele manifestation of consumerism. The same politicians to be served. An outcome is a central objective who voted for this legislation will have difficulty around which various existing eisciplines can be resisting demands from consumer and physician for organized. Clinical medicine, epidemiology, admin- more services as long as, these are firmly based on apotential point of collision istration, biomedical research, medicai care research, outcomes.PSRO is thus between the ,cost-effective approach and political behavioral science, and health education canall relate to a common problem requiring a multidisci- reality. Prepaid group practice will also have to plinary solution. Over time, this kind of close col- prove itself. The old outcome-structure approach is laboration might lead to more or less permanent rbsolete. Only, outcome measures related to process multidisciplinary task force structures, which would and patient behavior will enable one to judge whether seriously challenge the existing departmental organi- the lower costs of such prepaid group practice rep- zation of hospitals, medical schools,.and other health resent an acceptable level of quality. The alliance institutions. between physician and consumer will be greatly Will theinformed consumer transform himself facilitated by national health insurance which will into an educated patient? Given outcome emphasis go far to remove cost as a matter of contention. 50/Toward an Educated Health Consumer

The fundamental difficulty which has plaguedcon- 17.Auster, R. et al. Fall 1969. The production of health: sumer health education since its inception isthat an exploratory study, Journal of Human Resources 4, it has always lacked a specific tie -in toprocess, the pp 412-436. mainstream of medicine. Outcome measures bring 18.Fuchs, V. April 1972. Health care and the United States economic system, Milbank Memorial Fund such education into process and provide a field for Quarterly 50, Part I, pp 211-237. productive research:thefurther elucidation and 19.Keen, W. 1928. President Cleveland's Operations in quantification of the effect of educationon process 1893 and Other Essays. Lippincott, Philadelphia, p 16. and thus on outcome. 'Consumer health education 20Morrison, S. 1965. The Oxford History of the Ameri- can People. Oxford University Press, New York, p 882. has no meaning and no direction in the absence of 21. New York Times,January 26, 1975. quality assessment based on outcomemeasures. 22.ibid. December 7, 1974. Quality assessment is the very basis of health educa- 23.ibid. December 15, 1974. tion. The content of health education is, therefore, 24 McCarthy, E. and G. Widmer. December 19,1974. behavior known to be beneficial through outcome Effects of screening by consultants on recommended elective surgical procedures, New England Journal of measures. The context of health education is that Medicine 291, pp 1331-1335. health services structure which best integratescon- 25. New York Times. January 23, 1975. sumer health education into the medical care process. 26American Medical Association. January 27, 1975. Cor- onary drug project research group: clofibrate and nia- cin in coronary heart disease, Journal of the American Medical Association 231. pp 360- 381. 27. New York Times. January 6, 1975. REFERENCES 28. New York Times. January 15, 1975. 29. New York Times. January 6, 1975. 30. New York Times. October 10, 1974. 31. New York Times. January 12, 1975. 1.Flexner, A. 1972. Medical Education :n the United 32. New York Times. December 29, '1974. States and Canada. Carnegie Foundation for the Ad- 33.National Educational Television. December 5, 1974. vancement of Teachijig, Bulletin No. 4 (1910). Science 34.Newsweek. October 14, 1974. Health Publications,'Washington, D.C., p 89. 35.ibid. 2. The U.S. Factbook: The American Almanac for 1975. 36. Med':al World News. September 27, 1974. 1975 Statistical abstract of the United States. Grosset 37.Denenber, H. 1973. A Shopper's Guide to Health In- and Dunlop, Table 80, p 58. surance. Pennsylvania Insurance Department, Harris- 3.ibid, Table 109, p 74. . burg. 4.Health Manpower Source Book. 1970. Public Health 38.'Thanging Times. January 1975. Service, Publication No. 263. U.S. Government Print- 39.N. Y. Public Interest Research Group. 1974. NYPIRG ing Office, Washington, D.C. Consumer's Guide to Queens Doctors. 5. U.S:Factbook. op. cit. Table 116, p 76. 40. Newsweek. November 18, 1974. 6.Stevens, R. 1971. American Medicine and the Public 41. Newsweek. December 23, 1974. Interest. Yale University Pres", New Haven, p 60. 42.Medical World News. August 18, 1972. 7.Gartner, A. and F.Riessmin. 1974. The Service 43.Medici' World News. March 30, 1973. Society and the Consumer Vanguard. Harper and Row, 44. New York Times. March 4, 1973. New York, p 155. 45. New York Times. March 29, 1973. 8. Minorities and Women in the Health Fields.1974. 46.Medical World News. June 8, 1973. DREW PublicationNo. 75-22. U.S. Government 47. New York Times. July 9, 1973. Printing Office, Washington, D.C. 48.Curran, W. October 4,1973. The Tuskegee syphilis 9.ibid. study. New England Journal of Medicine 289, pp 10.U.S. Fictbook. op. cit. Tables 120 and 123, pp 78, 80. 730-731. II.ibid, Tabl- I 1 I and 115. pp 74...76. 49.Weinstein, M. December 12, 1974. Allocation of sub- 12 Cook, F. November 18,1974. The operation was a jects ifi medical experiments, New England Journal of success but the patient died. New York Magazine. 111w Medicine 291, pp 1278-1285. York. 50. Bok, S. November 1974. The ethics of giving placebos, 13.American Medical News. September 30, 1974. Scientific American 231, pp 17-23. 14, U S. Factbook, op. cit. Tables 99 and 100, Tables 80, 51.Ingelfinger, F. January 2, 1975. Ethics and high blood 81, 131, and 132, pii 58, 84. 'pressure, New England Journal of Medicine 292, pp 15.ibid, Table 85, p 61. 43-44. 16.Klebba, A. et al. 1973. Mortality Trends: Age, Color, 52.Derbyshire, R. April I, 1974. Medical ethics and dis- Sex, United States 1950-69. DHEW, National Center cipline, Journal of the American Medical Association for Health Statistics Series 20, No.' IS., 228, pp 59-62.

.% 5 9 Quality in Medical Care/51

53.Medical World News. March 15, 1974. 74. Dorsey, J. January 1975. The Health Maintenance 54.Derbyshire. op. cit. Organization Act of 1973 (PL 93-222) and prepaid 55.Medical WorIciNews. March 15, 1974. group practice plans, -Melical Care 13, pp 1-9. 56. Quinn, N. and A. Somers. April 1974. The patient's 75. Consumers' Union. October 1974. HMO's: are they bill of rights, Nursing Outlook 22, pp 240-244. the answer to your medical needs, Consumer Reports, 57. American Hospital Association. 1972. A Patient's Bill pp 756-762. of Rights. American Hospital Association, Chicago. 76. MacLeod, G. and J. Prussin. March. I, 1973. The con.' 58Shapley, D. November I, 1974. National health insur- tinuing evolution of health maintenance organizations, ance. will it promote costly technology? Science 186, New England Journal of Medicine 288, pp 439-443. pp 423-425. 77. Shapley, D. January 17,. 1975. Health planning: new 59,Densen, P. August 23, 1973. Public accountability and program gives consumers, Uncle Sam a voice, Science reporting systems in Medicare aod other health pro- 187, pp 152-153. grams, New England Journal of Medicine 289, pp 78. Newhouse, J. et al. June 13, 1974. Policy options and 401-406. the impact of national health insurance, New England 60.Bellin. L. December 1974. PSRO-quality control? or Journal of Medicine 290, pp 1345-1359. gimmickry? Medical Care 12, pp 1012-1018. 79. Mettler, C. 1947. History of Medicine. Blakiston Co., 61.Dale, M. July 8, 1974. PSRO: a primer, Journal of the Philadelphia, p 952. the American Medical Association 229, pp 157-158. 80Donabedian, A. July 1966. Evaluating the quality of 62.Buck, C. and K. White. October 24, 1974. Peer review: medical care. Milbank Memorial Fund Quarterly 44, impact of a system based on billingclaims, New Part 2, pp 166-206. England Journal of Medicine 291, pp 877-883. 81 Peterson, 0. et al. 1956. An analytical study of North Carolina general practice 1953-1954, Journal of Medi- 63.Welch. C. August 9, 1973. Professional standards re- cal Education 31, Part 2, pp 1-165. view organizations-problemsandprospects, New 82.Clute, K. 1963. The quality of general practice, The, England Journal of Medicine 289, 291-295. General Practitioner.University of Toronto Press, 64. American Medical Association. July 8,1974. PSRO's Toronto. pp 262-340. and norms of care: a report by the Task Force on 83. Blankenhor, M. 1957. Standards of practice of internal Guidelines of Care, American Medical Association medicine and methods of assessing the quality of Advisory Committee on PSRO, Journal of the Ameri- practice in hospitals, Annals of Internal Medicine 47, can Medical Association 229, pp 166-171. pp 367-374. 65. New York Times. February 21, 1975. 84. Morehead, M. et al. 1964. A study of the quality of 66. AMA News. May 20, 1974. hospital care secured by a sample of Teamster family 67. Committee on the Costs of MedicalCare.1970. members in New York City. Columbia University Medical Care for the American People (1932). U.S. School of Putlic Health and Administrative Medicine, Government Printing.Office, Washington, D.C. New York. 68.Perrot, G. May 1971. The Federal Employees' Health 85Price, P. et al1971. Measurement and Predictions of BenefitsProgram.EfirollmentandUtilizationof Physician Performance, Two Decades of Intermittently Health Service, 1961-1968. DHEW, HSMHA, Wash- Sustained Research. Lynn Loyd Reid Press, Salt Lake ington, D.C. City. 69. Shapiro, S. et al. Jane 1967. Patterns of medical use 86Richards, J. et al. 1965. An investigation of the cri- by the indigent aged under two systems of medical terion problem for one group of medical specialists. care, American Journal of Public Health57, pp Journal of Applied Psychology 49, pp 79-90. 784-790. 87. Donabedian, A. 1969. A Guide to Medical Care Ad- 70.Dozier, D. et al. June 1964. Report of the Medical and ministration, VolumeII.Medical Care Appraisal- Hospital Advisory Council to the Board of Adminis- Quality and Utilization. American Public Health Asso- tiation of the California State Employees Retirement ciation, Washington, D.C., p 3. System. Sacramento. 88.Seidl, L. etal. April 1966. Studies on the epidemi- "1.National Advisory Commission on Health Manpower. ology of adverse drug reactions III reactions in patients 1967. Report of the National Advisory Commission on on a general medical service, Bulletin of the Johns Health Manpower, Vol. 2. U.S. Government Printing Hopkins Hospital 119, pp 299-315. Office, Washington, D.C. pp 197-228. 89.Hoddinolt, B. et al. October 1967. Drug reactions and 72. American Medical Association.January17,1959. errors in administration on a medical ward, Canadian Report of the Commission on Medical Care Plans. Medical Association Journal 97. pp 1001-1006. Journal of the American Medical Association169, 90.Lee, R. and L. Jones.1933. The Fundamentals of Supplement, pp 1-96. Good Medical Care. University of Chicago Press, 73.Sparer, G. and A. Anderson. No date Utilization and Chicago. Cott Experience of Low Income Families in Four 91.Lewis, C. October 1974. The state of the art of quality Prepaid Group-Practice Plans. assessment-I973, Medical Care 12, pp 799-806. 60 52/Toward an Educated Health Consumer

92.Brook, R. April 1973, Critical issues in the assessment patients at home, American Journal of Public Health of quality of care and their relationship to HMOs, 57, pp 452-459. Journal of Medical Education 48, Part 2,pp 114-134. 113. Gordis. op. cit. 93.Bakewin, H. June 1945. Pseudod9xia pediatrica, New 114. Newhouse. op.. England Journal of Medicine 232,pp 691-697. 115. Brook. 6p. cit. 94. Scheff, T. Winter 1973. Decision rules,types of error, If& Starfield, B. Jul f 19, 1973. Health services research:a andtheir consequences inmedicaldiagnosis,Be- working model, New England Jqurnal 'of Medicine havioral :science 8, pp 97-107. "289, pp 132-13u. 95.Katz, M. No amber 21, 1974. A probability graph 117.,,,Woodham-Smith, C. 1950. Florence Nightingale 187,0- describing the predictive value ofa highly sensitive 1910. Constable Press, London, pp 296-596. diagnostic test, New England Journal of Medicine 291, 118. Codman, E. 1914. Product of hospital; Surgery, Gyne- pp 1115-1116. cology, and Obstetrics 18, pp 491-496.2 96.Bok. op. cit. 119. Shapiro, S. et al. 1960. Further observations 97.Melmon, K. June 17, 1971. Preventable drug reactions on pie- n,aturity and prenatal mortality in a general popula- -causes and cures, NeEngland Journal of Medicine 284, pp 1361-1368. tion and in the population of a prepaid group practiee 98.Dykes, M. March 18, medical care plan, American Journal of Public Health 1974.Uncritical thinking in 50, pp 1304-1317. ' medicine, Jpurnal of the American Medical Associa- tion 227, pp 1275-1277. 120. Williams, J. et al. September 1966. Patterns of Medical 99.Brook. Op. cit. Utilization by the Indigent Aged Under Two'Systems of Medical Care. Health Research'Council, New York. 100.Linn, B. et al. September-October 1973. Correlatesof prognosis: a study of the physician's clinical judg.nent, 121.Shapiro, S. April 1967. End result measurements of Medical Care 11. pp 430-435. quality of medical' care, Milbank Memorial Fund Quarterly 45, Part I, pp 7-30. 101.Dingle; J. September 1973. The ills ofman, Scientific American 229, pp 76-89. 122.Lee, J. et al. October 19, 1957. Fatality from three 102.Kege.les, S. June 1969..`_ n..ki experimentattempt to common surgical conditionsinteaching and non- change beliefs and behavior of women inan urban teaching hospitals, Lancet 2, pp 785-790. ghetto, Journal of Health and Social Behavior 10,pp 123Lee, J. et al. January 16, 1960. Case-fatality in teach- 115-123. ing and bon-teaching hospitals, Lancet 1, pp 170-171. 103 Johnson, A. et al. 1962. Epidemiology of Polio Vac- 124 Lembke, P. March 1952. Measuring quality of medicine Acceptance: A Social and Psychological Analysis. cal care through vital.statistics based on hospital floridaState Board of Health, Jacksonville. service areas I: comparative study of appendectomy 104 White, K. 19f" Improved medicalcare statistics and rates, American Journal of Public Health 42, pp 276- the health services system, Public Health Reports 82, 280. pp 847-854. 125. Commission on Professional and Hospital Activities. 105.Fanshel, S. and J. Bush. November-December 1970. A March 3, 1958. Medical Audit Study Report 5, Pri- health-status index and its application to healthserv- mary Appendectomies. Commission on Professional ices outcomes, Operations Research 18, pp 1021-1066. and Hospital Activities, Ann Arbor, Michi6n, p 17., 106. Burdett, J. December 23, 1974. Primary medical evalu- 126,- Commission on Professional and Hospital Activities. ation, Journal of the American Medical Association December 1956. Professional Activity Study (PAS), 230, pp 1668-1673. Report 15, Primary Appendectomies. Commission on 107.Charney, E. May 1972. Patient-Doctor Communica- Professional andHospitalActivities, Ann Arbor, tion, Pediatric Clinics of North Americ 19,p. 263. Michigan, p 10. 108.Davis. M. 1968. Physiologic, psychologic-il, and demo. graphic factors in patient compliance with doctors' 127.Williamson, J. October 25, 1971. Evaluating quality orders, Medical Care .5, p 115. of patient care, Journal of the American Medical Association 218, pp 564-569. 109,Advis, M. November 1966. Variations inpatients' compliance with doctors' orders; analysis of congru- 128 Kessner, D. 1973. A Strategy for Evaluating Health ence between survey responses and results of empirical Services Institute of Medicine, National Academy of investigations, Journal of Medical Education 41, pp Sciences, Washington, D.C. 1037-1048. 129.Brook, R. and F. Appel. June 11,1973. Quality-of- 110.Becker, M. and L. Maiman. January1975. Social careassessment: choosing a riethod for peer review, New England Journal of Medicine 288, pp behavioral determinants of compliance with health and _- medical care recommendations, Medical Care 13, pp 1323-1329. 10-24. 130.Brook, R. and R. Stevenson. ()matter 22, 1970. Effec- I 1 1 Gordis, L. et a:. January-February 1969. The inaccu- tiveness of patient care in an emergeni,y room, New racy in using interviews to estimate patient reliability England Journal of Medicine 283, pp 904-907. in taking medications at home, Medical Care 7, pp 131.Starfield, B. and D. Scheff. April 1972. Effectiveness 49-54. of pediatric care: the relationship between process 112.Watkins, J. et al. March 1967. A study of diabetic and outcome, Pediatrics 49, pp 547-552. 61 Quality in Medical.Care/53

132. Myers, B. and R. Graham. 1973. Quality assurarce: Journal of the American Medical Ass 'anion 231, HSMHA interest and role, Quality Assurance in p 562. Medical Care, DREW Monograph 73-7021. Depart- 143. Cochrane, A. 1972.Effectiveness and efficiency: ment of Health, Education,.and Welfare, Washington, random reflections on health services. The Nuffield D.C., p 445. Provincial Hospitals Trust, London, p 23. 133. President's Committee .on Health Education.1973. 144. Greenblatt, M. January 30, 1975. Psychiatry: the bat- . Report. Department of Health, Education, and Wel- tered child of medicine, New England Journal of fare, Washington, D.C., p 24. Medicine 292, pi 246-249. 134.ibid, p 31. 145. Sehnert, K. November 14, 1974. Testimony before 135. Blum, H. December 1974. Evaluating health care, Task Force on Health Promotion and Consumer Medical Care 12, pp 999-1011. Health,Education. Chicago. 136. Szasz, T. and M. Hollander. May 1956. A contribul 146. Etzwiler, D. November 14, 1974. Testimony before -tion to the philosophy of medicine: the basic models task force on health promotion and consumer health of the doctor-patient relationship, Archives of Internal education. Chicago. Medicine 97, pp 582-592. 147. Healy, K. January 1968. Does preoperative instruction 137. Gillum, R. and A. Barsky. June 17, 1974. Diagnosis really make a difference? American Journal of Nurs- and Management of Patient Noncompliance, Journa: ing, pp 62-67. of the American Medical Association 28, pp 1563- 148. Egbert, L. et al. April 16, 1974. Reduction of post- 1567. operative pain by encouragement and instruction of 138. Davis, M. op. cit. 1966. Journal of Medical Educa- patients, New England Journal of Medicine 290, pp tion. 825-827. 139. Starfield, B. et al. September 1973. Private pediatric 149. Miller, L. and J. Goldstein. )une 29, 1972. More practice: performance and problems, Pediatrics 52, efficient care of diabetic patients in a county hospital pp 344-345. setting, New England Journal of Medicine 286, pp 1388-1391. 140. Becker, M. and L. Maiman, op. cit. 150. Rosenberg,S.September1971.Patienteducation 141. Gartner, A. and F. Riessman. December 1974. The leads to better care for heart patients, HSMHA Re- consumer: a hidden resource for improving health prts 85, pp 793-802. service, Urban Health, p 13 ff. 151. McNerney, W. January 1975. The missing link in 142. American Medical Association. February10,1975. health services, Journal of Medical Education 50, pp Outlook in lung cancer remains as bleakas ever, 11-23.

62 is a _middle-class.phenomenand _middliass people have access to inlrmation fibril each other, A STRATEGY FOR HEAI:TH from private practitioners, from print media, and EDUCATION finally, from television. However, as we have seen, lower-income people rely prim y on television

and verbal communication for 1 ormation. Infor- mation transmitted ve bally may incorrect or "Education is civil defense against media fallout." distorted by cultural di erences while television is Marshall McLuhan,Understanding Media a double-edged sword: It\ is a source of information and misinformation, and the poorly educatedare An underlying premise of this monograph is that more likely to believetitlatter than- are better in the future, individuals will have to accept greater educated persons. responsibilityforthe maintenance of their own The following objectives ust be realized if we health. To that end, we have stressed the positive are to have self-reliant health consumers. They are potential of television in the development of con- designed tor\reinforce and auent the community sumer constituencies for health and in consumer of interest concerned with hen h andto build a health education (see Chapter 2) and the importance broader constituency for consume health education. of the development of a base for consumer-provider They are equally applicable to alsegments of the collaboration (see Chapter 3). Specificrecommen- population, but in the following disc \tssion, emphasis dations for the achievement of enhanced individual is placed on ways to meet theseo ,jectives among consciousness and responsibility for health include: low-income people. '1 I.Development of a system of product endorse- The first objective is toinsulate the provider and ment to maximize the potential :of television the consumer against misinformation.The health - advertising as a source of positiveconsumer care provider must search for ways to promite the health information. diffusion of ,information on bothnew and established 2 Inclusion of therapeutic outcomes in the stand- therapeutic modalities to assure that medicalprac- ards used to judge medical care qualityas a tice incorporates the most efficacious therapies and meansofincludingthepatient-consumer discards those found to be less effective. While directly in the evaluation and assessment of PSROs will probably eliminategross faults,itis care likely that prevalent but ineffective therapieswill This final chapter draws upon the previous discus- become part of regional criteria. Indeed,one of the sion to specify a strategy for consumer health edu- greatest dangers of the PSRO program lies in the cation based on the current and projected lifestyle tendency for norms and criteria to become rigidly and health status of the American people. fixed, committing all member practitipersto cer- Until very recently, health edu,...ition efforts were ta;n therapies which may prove ineffectiveor harm- directed toward the recognition of symptoms and ful Guarantees against malpractice whennorms are signs as cues to be followed by consultation with., followed will produce stillmore rigidity by making physician. The now-famous "seven danger signals" the threat of malpractice action part of thecost of cancer exemplify this approach. The television of :iinovation. The effect of practicepatterns on campaign against smoking, on the other hand,rep- consumer health education is of major importance resents an attempt to alter behavior. As such, it because the consumer will evaluate hisown care emphasizes what the individual can do for himself in terms of the same norms used by the physician. rather than what the doctor can (or perhaps cannot) By insisting on rigid norms, theconsumers nuy be do once illness occurs. Efforts of this kindto develop induced to act unwittingly against theirown best enlightened self-reliance are well suited to the..on- interests In other words, norms which do notpre- temporary climate of consumerism. scribe the most effective therapies may in themselves How issuchenlightenedself-relianceto be become sources of consumer misinformation. achieved, especially with regard to the hard-to-reach For the consumer, however, a more important low-income groups? The entire consumer movement current source of misinformationisadvertising

63 55 . 56 /Toward an Educated Health Consumer

which encourages dietary habits leading.to obesity reliever, but this is not stated. The product could be and atherogenesis, promotes the use of drugs for the a bar of soap or a box of cereal; we are never told. most trivial of complaints, and reinforces cigarette Having examined the ad, the class could proceed smoking and alcohol consumption as Highly desirable to examine the product and discuss analgesics and social norms.Health-relatedtelevision program- their use. Rival claims could be studied to point out ming, too,is an importants urce of inaccurate the absurd_ty of itall. Anacin contains twice the factual information, especially for children, who pain reliever doctors recommend \most, but why often fail :o make a distinctionetween commercial should doctors recommend it if Excedrin has "more messages'and program content. pain reliever (and] more total strength than any To encourage children to thinmore about what other leading tablet"? Arthritis Pain Fdrmula may they see on television, we shouldelude the study ye "the doctors' choice," but for 23 years St. of television commercials and television programs Joseph Aspirin for children has been "trusted by aspart of new school health curricula.Health- more mothers and more doctors." related programs should be presented for classroom Advertisements can be juxtaposed in the class- discussion of the questions they raise. Are most phy- room with some of the better programs dealing with sicians like those portrayed? Why can't real physi- health, such as the much-maligned "Feeling Good" cians spend all day with a single patient as they do or almost any of the program series developed by on most television medical dramas? What could the Tandem PrOductiors (for example, All in the Fam- patient on this show have done to prevent illness? ily, Maude, Good Times, and Sanford and Son),. What prevents the patient from taking medicine? D9 Various individual shows in these series have dealt real -life male doctors fall in love with their /dying with health subjects, including mental health, vener- female patients' Similarly, the study of comMtrcials eal disease, breast examination, and hypertension. would explore the content of.)television advertising. While these shows are primarily entertainment, they Does the phrase "helps prevent cavities" mean the portray people trying to cop: with common health same thing as "prevents cavities"? What does it problems and are both informative and accurate in %ean that product X "works to help prevent dan- handling the fear, ignorance, and denial which so druff" What does "fortified with twice as much often prevent beneficial health behavior. If the health vitamin D" mean' Is twice as much of something product endorsement idea became a reality, these always good' Have women really "come a long way, programs would provide additional points of com- baby"? If they have, what does it have to do with parison with usual advertising practice. cigarettes° Should you be impressed that "Certscon- This approach to school health education has the tains a sparkling drop of retsyn"? Is it a good thing advantage of building on knowledge the child pos- that "Anacin (contains) twice as much of the pain sesses when he or she first enters the classroom. It reliever doctors recommended most"? proceeds to develop a meaningful education process The Anacin ad is illustrative of the kind of dis- frcm a central event relevant to the lives of virtually i-,ssion one can develop arounda commercial. The allAmerican children(thatis,television). The adis pure noninformation. Many eliliciren would idea is not so much to put information into a pre- know that the "pain reliever" in questionis aspirin. viously' unused head, but to rearrange and reorder What is unidentified, however,is that product which what the child already knows. With almost 17,000 contains only half the aspinn in Anacin. The impli- autonomous school districts in the United States, cation is that this unfortunate product is a rivalpain universal implementation of this approach may be impossible, but if it were successful it a few places, The listis endless. Consider, Tor example, "Visine gets it would perhaps spread to others and possibly exert the red out," "Pertussinsoothes your throat with a blanket considerable influence. of warmth." "Only Sines has penetrating medicated vapors," The second objective is the demonstration and "Silenceis Goldenfor people who believe in modern reinforcement of preventive behavior. Preventive be- .medicine and grandma," "Do you think about your health? Bufferin does." A more complete hst and a %cry humorous havior may be general, as in physical fitness, or disussionan be found in C. Wrighters book I Can Sell specific, as in not smoking, using prescribed medi- You Anything 1972 (Ballantine Books, N.Y.). cation, or moderating alcohol intake. The purposes Strategy for Health Education/57

of preventive behavior are to reduce mortality, mor- and larger numbers of more informed individuals bidity,disability, and costs to individuals of to who can be expected to have a beneficial effect on society as a whole, as well as to increase consumer their communities. From the hospital standpoint, satisfaction. Any of these is sufficient justification it is logical to assume that this minimal involvement for attempting to reinforce preventive behavior. of unskilled personnel will pay dividends in terms There is little to distinguish behavior that benefits of better service and better patient care. the general population from that which benefits at- Workers should be encouraged to enroll in ad- risk groups. For one thing, the dividing line between vanced courses, several of which would make the general and at-risk is often blurred. In general, the employee eligible for a certificate conferred by the poor are at greater risk for most of the chronic hospital, providing recognition of growing health diseases, but the affluent are far from immune. In knowledge. The course work need not be complex; addition, the demonstration of preventive behavior creative use of audiovisual techniques would enable is reinforcement for those who alrea4 behave in a the hospital to provide such training at modest cost preventive manner and instructive for those who do and effort. Courses should stress the recognition of not. relevant antecedent behavior-as well as signs and Finally, the most beneficial of behaviors is per- symptoms of the more important problems such as haps the most general. Numerous studies have shown, heart disease, cancer, stroke, accidents, diabetes, for example, that the number of years of formal cirrhosis, and hyptrtension, and suggest ways that schooling is the most important correlate of good they can be avoided. The employees should be health. (1-5) Itis not known whether thisdif- trained to take blood pressure readings, to use the ferenceisaccountedfor by specific knowledge thermometer, to understand the dangers of accumu- about medicine and health or by general knowledge lating drugs from past illnesses for future use, to and ability. However, until more is known about recognize common accident hazards aroundthe this relationship, those whose concern is health can home, and to appreciate the advantages of prenatal do little but continue to promote the kinds of specific care. The list is not complete, but illustrative. Pre- behaviors which can be expected to have a preven- ventive, rather than medical, care should be stressed tive effect on specific diseases. and the course should be designed to make the The kty to reaching the poor and the less well trainee a pro-elyte to the importance of preventive educated with information about health seems to be health behavior an,: notion of personal health face-to-face transfer of information and the provi- responsibility. It is expected that these "converts" sion of role models. The available resource is the would, in turn, proselytize their peers. underutilized army of nearly 3 million low-level Along the same lines, existing ideas and con- service and clerical workers in the health industry. sumer achievements should be used a' the basis for These people receive little or no training from their new approaches in health education. The trend to employers(overwhelmingly hospitals)andtheir do-it-yourself medicine should be encouraged rather knowledge of health and personal health practices than discouraged. and existing patients' bills of rights closely resembles that of the low-income population should be used to introduce the Idea that the rights from which they come. Yet they are 3ften regarded of patients are closely related to the obligations of by their peers as repositories of useful health infor- consumers to preserve their own health. Do-it-your- mation. If, in fact, they had such information, they self medicine is far more than training people in the might become a potent positive force for health, techniques of cardiopulmonary resuscitation and first particularly when supplemented by television cover- aid.Itimplies not only self-medication butself- age, health news, ands the type of television-based evaluation and personal risk assessment. In addition, school health program described above. do-it-yourself medicine is easily extended to family A formal, brief training, program for all service- units in which one individual, most likely the mother, 'level employees should produce a large number of assumes the role of health ..wiser. This roleis rather effective health educators at the grass-roots already well established but poorly formulated in level. Even the rapid turnover of such personnel is many households. Concurrent developments such not a loss since it results in the production of larger6 was the training of more family practice physicians 58/Toward an Educated Health Consumer

and the public availability of medical care norms and patient and emphasize the crucial, role of the and criteria should further encourage the do-it-your- patient in the production of health. Admittedly the self movement. Obviously, endorsement of beneficial diffusion of these concepts among the poor will be products by a blue ribbon health body would also slow, halting, and perhaps never as complete as have a stimulating effect. health workers might hope, but it must be remern:- Major impetus to self-medication and self-assess- bered that consumer health education is more a ment might be expected from the continued develop- journey than a destination, and slow progress should

ment of health maintenance organizations, but the not be used as an excuse to abandon the effort. . role of these prepaid group practice plar, far Although the idea of health education can be from certain. Existing legislation permits .only fed- found in Plato; it should be regarded in contempo- erally certified HMOs toadvertise regardless of rary America as a part of the consumer movement. State laws. However, the incentive to keep patients The activities described in this chapter are designed healthy is a part of all prepaid group practice plans, to expRnd the community of, interest focused on and HMOs should be free to advertise. Such adver- health *d medical care and help achieve the third tising should stress health education and self-assess- objective,the general supportofthe consumer movement Local television and newspaper ads are rela- ment for heaTth education.The need for consumer tively inexpensive and provide media channels to supportreflec the need for political power to middle- and low-income people alike. HMO ad- achieve conditions favorableto health education. vertising could be an important mechanism for the This is due to the, fact that many of the concerns effective use of media in promoting health. of health education lie within health but outside of The ability to deal with the aches and pains of medicine Control ofand guns, for example, would everyday life and the ability to use medical care in reduce the incidence of homicide, but pasaagc of gun a more appropriate and effective manner are the dual control legislation would require the support of a goals of existing attempts to educate the public in constituency big enough to counterbalance, the power self-medication and self-assessment. The former is of the gun lobby. Health providers cannot do it stressed in Sehnert's "activated patient" idea while aloneSimilarly, it would be helpful if restaurants the latter seems to underlie the contractual approach listed the calorie content of various menu items. but of Etzwiler and the health hazard appraisal tech- restaurants would probably be reluctant to do so nique of Robbins.(6-8)Each of these approaches without public pressure. It is fine to advocate physi- is presently oriented heavily to middle- and upper - cal fitness as sound health promotion but where income people. Indeed, the idea of self-assessment are the facilities to come from that will permit people is probably more applicable to the affluent than to w exercise' The bike paths, jogging trails, and skat the poor because it involves a financial outlay (S85 ing ri^tcan be obtained only through legislative for Sehncrt's curse), a future orientation, and a action prompted by consumer pressure propensity to recognize symptoms and signs at an The same kind of providerconsumer cooperation early stageSelf-assessmentmight be promoted will be needed to overcome special interest opposi- among the poor by the inculcation of the idea of tion to health relatedlegislation. For, example,if self responsibility in lower-level hospital employes. tilt. antismoking campaign were to be reinforced by A formal course might begin with a variant of the the imposition of higher taxes on cigarettes, or if advertising approach to school health, pointing out pre'surc were needed to assure third party reim- the limitations of drugs and leading to a discussion bursement for patient health education, the political of the limitations of modern medicine. The impor- process would-r9uhe data on which to bas, deci- tance of preventive behavior becomes apparent once sions and a I:wipe-al Lase sufficiently strong to resist the limitations of medicine are understood. Again, the .tobacco conic insurafi, carriers, and rival this indirect use of media is important becauseit claimants fur research monies. The health profes- assures that the course will proceed from a data sional would provide the fist, the consumer move- base shared by all taking it. The emphasis of con- ment, the second. A case in point is the controversy sumerism on outcome measures will serve to publi- over what will and wilt not be publican) disclosed cize the importance of collaboration between doctor under the PSRO Organized medicine 6 6 Strategy for Health Education/59

would prefer minimum disclosure of data generated it seems clear that some way must oe found to reduce under PSRO. The American Public Health Associa- the influence of advertising over programming,or tion (APHA) favors full disclosure, but it cannot at the very least to make sure that television com- succeed alone. With the support of the consumer mercials are factual and free of distortion. This movement, however, full disclosure eventually will would make it easier to fulfill television's potential be secured. In this Situation, the support of APHA as an educational tool and would benefit the con- legitimizes the consumer position by reinforcing it sumer in ways quite unrelated to health. The achieve- with the weight of expert opinion. ment of such change requires the collaboration of Elsewhere in this monograph we have discussed many consumer interest groups to solve a common the problem of the use of mass media for purposes problem. Similar collaboration in the past has proof health education and have noted that health duced long-term alliances of health providers with promoters are financially overwhelmed by the adver- the forces seeking to reduce poverty and improve tising industry. The root of this problem is the public education. Sustained efforts will be needed financial structure of the broadcast television indus- to achieve these objectives, and, while both would try. Under the present system, advertiserseither confer major benefits on health, neither is theex- directly through sponsorship or indirectly by de- clusive concern of health providers. manding the largest possible audience fortheir prime time advertisingexert a great deal of influence over television programming. Broadcasters fear small audience shows, even, when sponsored, because REFERENCES once viewers switch to another channel, they may not return for hours, or even days, and the ratings for subsequent shows will suffer. Even the noncommer- I.Auster, It. et al. Fall 1969. The production of health, cial Public Broadcasting System is not immune to an exploratory study, Journal of Human Resources 4, this pressure. Although they accept no ads, the edu- pp 412-36. cational channels cannot afford to run shows that 2 Stockwell, E. June 1963. A critical examination of the do not appeal to their upper middle-class viewers. relationship between socioeconomic status and mortality, American Journal of Public Health 53, pp 956- networks Loss .of viewers to the jeopardizes the 64. grants-in-aid that keep :hese channels in business. 3.Hinkle, L. et al. July 19, 1968. Occupation, education, Material that provides health information and and coronary heart disease, Science 161, pp 238-246. demonstrates beneficial health behavior often is kept 4.Breslow, L. and B. Klein. April 1971. Health and race off the commercial networks because of low auc'lence ,n California, American Journal of Public Health 61, appeal and sometimes because of content offensive pp 763 -775. to potential sponsors. At the same time, shows like 5 Kitagawa, E and P. Hauser Education differences in "Feeling Good," which should reach a low-income mortality by cause of death: United States 1960, Dem- ography 5. pp 318-353. audience where its message is most needed, fail 6.Sehnert, K. October 1974. The activated patient, Con- on public television because the poor are not watch- tinuing Education 2, pp 437-42. ing; affluent, well-educated people who do wa:ch 7.Etzwiler, D. November 14, 1974. Testimony before task find the approach patronizing. force on health promotion and consumer aealth promo- It has been suggested that the interest of health tion and consumer health education. Chicago. education and other consumer causes would be well 8 Robbins, L and J. Kali. :970. How To Practice Pro- prohibiting spective Medicine. Methodist Hospital of Indiana, In- served by the passage of legislation dianapolis. sponsors from specifying where and when their ads 9.Sandman, P.etal.1972.Media: An Introductory will appear during a day's programming. (9) This Analysis of American Mass Communications. Prentwe- may be impractical, for a number of reasons, but Hall, Englewood Cliffs, New Jersey.

67 Cirrhosis, 57 Communication, history of, 15-19 INDEX Communication models, 15-16 Communities o &interest as a function of mass media, 19 Advertising as a stimulus to media grovivt.h, 22 antismoking, 25-26 use of media by, 23 concepts of success in, 25-26 Comprehensive Health Planning program, 41 effect of, on seat belt use, 26 Consumer interest groups, 23 influence of, on physicians, 24 Consumer legislation, 23,-38-50 influence of, on programming, 59, potential for health education, 55 Consumer movement, 19-24, 55 See also Health education, and television. Consumerism, 19-24 Advertising Council, 28-29 Consumer Reports, 37 Alcoholism, 10, 27 Contract between doctor and patient, 49 American Hospital Association, 38 Costs of Medical Care, Committee on, 39 American Medical Association, 33, 37, 41 Deception in television commercials, 24 attitude of, to PSROs, 39 establishment of, 47 Diabetes, 57 American Public Health Association (APHA), 39, Do-it-yourself medical books, 37 59 Endorsements. Sec Product endorsements. American Society for Internal Medicine, 39 Experimentation, on humans, 37 Appendectomy, 45 At-risk behavior, 3-4 Federal Communications Commission, 24, 27-28 Flexner, Abraham, report to the Carnegie Founda- Behavior modification, 9-10 tion, 2, 33 Behavior, preventive, 56-57 Fluorides, 2 Blood pressure readings, 12, 57 Followup, in medical care, 46, 48. Blue Cross, 49 Gutman Institute, 3 Cancer, 6, 55, 57 fear of, 7 Health knowledge and behavior, 6-7 and education, 57 surgery, publicity about, 3 as a source of news, 36 Cardiovascular Iiscase, 10 attitudes and knowledge about, 4-5 Center for Disease Control, 'L consumer interest in, 36-37 Chamberlain, Hugh, 42 definitions of, 4-5 Chamberlain, William, 42 Health behaviors, 8-9 Cholesterol Health care system and egg consumption, 27 access to data on, 39 decline of, in blood level, 4 costs of, 36 outcomes of, 44-50, 55 Cigarette smoking, 10 participation in', 5, 8 health costs of, 27 process of, 43, 47-49 television campaign against, 55 structure of, 42-43, 48 trends in, 4 weakness of, 46

68 61 62Toward an Educated Health Consumer

Health education McLuhan, Marshal!, 20-21,-55 and consumers, 11, 58 Magazines, 4, 20-23 and television:17, 24-29, 56 Mass media, 15-32 development of, 1 "hypodermic" view, 17 ' difficulties with, 50 use of, to changebehavioi\26 financial'supporfof, 10 Medicaid, 38; 40 in schools, 11-12 Medical care. See Health care system. literature-on, 4 Medicare, 38, 40-41 models of Mental health problems, 36 chronic disease control, 3 Mental illness,6 information, 2, 5 Myocardial infarction, 39, 57 simple prevention, 2 oil symptom recognition, 55 National Health Information and Promotion Act of providers' efforts on, 11 197,5; 25 research bases of, 4 National health insurance, 38, 41-42, 49 Hee!th Education, President's Committee on, 10 National.Health Planning and Development Act, 41 Health educatok, challenges to, 3 National League for Nursing, 38 Health Insurance, A .74noper's Guide to, 37 National Opinion Research Center (NORC), 5 Health insurance, national; 38, 41-41, 49 Newspapers, 21 Health Insurance Association of America, 41 Nov York Public Interest Research Group, 37 Health maintenance organizations (HMOs), 39-42, Nielsen ratings, 16 48 Noosphere, 16 advertising of, 58 in reduction of costs, 47 Obesity, 10 Health Maintenance Organization Act of 1973, 40 Our Bodies, Ourselves, 4, 37 Health Manpower. Act of 1968, 41 Health personnel, 34, 57 Pap smears, 4, 10, 12 Health systems agencies (HSAs), 41-42 Patient education, 49 Heart disease, 4, 39, 57 Patients, rights of, 38 Hemoglobin, 46 Peer review, 35 Human experimentation, ethics of, 37 See also Professional standards review orgpniza- Hypertension, 4, 10, 17, 43-46, 57 tions. Illness Placebo effect, 43 attitudes and knowledge about, 5-9 Polio, 6 management of, 8 Prepaid group practice, 49 of national leaders, 35-36 See also Health maintenance organizations. Index* Medicus, 4 President's Committee& Health Education, 10 ane, national health, 38, 41-42, 49 Product endorsements, 28-29, 55, 58 nterest communities. See Communities of interest. Professional Activity Study, 45 Professional standards review organizations Kaiser plans, 39-40 (PSROs), 38-42, 44, 47-49, 55,'58 -59

Legislation, consumer, 23, 38-50 Quality.assessment, 42-46, 50 69 Index /63

Radio, 21 sr. 1 effects a, 20 Rheumatic fever, 10 growth of, 23 '

F yal Society of Medicine, 42 in school curricula,56, lin1itations of, 21 ..4, San Joaquin Fouqdation for Medical Care, 38, 40 potential of, in health education, 17, 24-29,56 Sick role, 3-4 role of, 23 Skinner, B.F., 9 time spent at, 19-20 Smoking. See Cigarette smoking. 'Television commercials, credence in, 24 s .- Social Security,41 Tracers,45 ../- , Tuberculosis, 6 I Society of Public Health Educators (SOPHE),4,6 Stroke,57 4. Ulcers,45-46 Urinary tract infection,45 Tandem Productions,56 . Television a as a general medium,27 World Health Organization (WHO) definition of health by,4-5 iv target of consumer attack, 24 infectious disease control by, 9 children's, 22 commercials, credence-in, 24 X-rays, 12

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