UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Assessment and communication strategies for health promotion Peters, Heidi Freya 1983

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1983_A6_7 P47.pdf [ 10.34MB ]
Metadata
JSON: 831-1.0095811.json
JSON-LD: 831-1.0095811-ld.json
RDF/XML (Pretty): 831-1.0095811-rdf.xml
RDF/JSON: 831-1.0095811-rdf.json
Turtle: 831-1.0095811-turtle.txt
N-Triples: 831-1.0095811-rdf-ntriples.txt
Original Record: 831-1.0095811-source.json
Full Text
831-1.0095811-fulltext.txt
Citation
831-1.0095811.ris

Full Text

C- I ASSESSMENT AND COMMUNICATION STRATEGIES FOR HEALTH PROMOTION by HEIDI FREYA PETERS B . H . E . , The U n i v e r s i t y of B r i t i s h C o l u m b i a , 1978 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES ( H e a l t h S e r v i c e s P l a n n i n g Programme) We accept t h i s t h e s i s as conforming to the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA November, 1983 © H e i d i F r e y a P e t e r s , 1983 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department Of Health Care & Epidemiology The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date September 19, 1983 i i A b s t r a c t Many of the major c h r o n i c d i s e a s e s , a c c i d e n t s and premature deaths in Canada are p r e v e n t a b l e , i n d e e d , by a c t i o n s w e l l w i t h i n the c o n t r o l of each i n d i v i d u a l . T h e r e f o r e , the c e n t r a l theme of h e a l t h p r o m o t i o n , a p p r o p r i a t e l y , i s to i n f o r m , educate and m o t i v a t e people to take p e r s o n a l r e s p o n s i b i l i t y for t h e i r own h e a l t h , and i n p a r t i c u l a r , to undertake r e l e v a n t programs for l i f e s t y l e change. The i n t e n t of t h i s t h e s i s i s to make recommendations for the i n t e g r a t i o n of h e a l t h r i s k assessment and communicat ion s t r a t e g i e s i n the p l a n n i n g of e f f e c t i v e h e a l t h promot ion programs for the people of B r i t i s h C o l u m b i a . A review of the d i v e r s e l i t e r a t u r e examines what i s a l r e a d y known about these t o p i c s , and draws c o n c l u s i o n s . A l s o , i n t e r v i e w s and correspondence have been conducted w i t h C a n a d i a n , American and A u s t r a l i a n e x p e r t s in the f i e l d s of h e a l t h p r o m o t i o n , h e a l t h r i s k assessment and communicat ions . The main t o p i c s of t h i s study have been: 1 . The d e f i n i t i o n of h e a l t h and h e a l t h p r o m o t i o n , the o b s t a c l e s and b e n e f i t s i n v o l v e d i n promot ing h e a l t h f u l l i f e s t y l e b e h a v i o r s , and the c u r r e n t f e d e r a l and p r o v i n c i a l h e a l t h promot ion p o l i c i e s are addressed in Chapter 1 . 2. H e a l t h r i s k assessment , an approach to s c r e e n i n g , i i i e d u c a t i n g and m o t i v a t i n g people to change b e h a v i o r s in o r d e r to improve t h e i r h e a l t h , i s reviewed i n Chapter 2, u s i n g a matr ix of s e l e c t e d c h a r a c t e r i s t i c s . 3. S i n c e a l l a v a i l a b l e pathways sh ou ld be used to reach i n d i v i d u a l s of d i f f e r e n t p o p u l a t i o n s , Chapter 3 addres se s the need for a c o n s u m e r - o r i e n t e d market ing approach to h e a l t h p r o m o t i o n . A model for p l a n n i n g communicat ion s t r a t e g i e s f o r h e a l t h promot ion aimed at i n f l u e n c i n g a t t i t u d e s , knowledge and l i f e s t y l e b e h a v i o r s i s p r e s e n t e d . T h i s p l a n d i s c u s s e s in p a r t i c u l a r , the use of i n t e r a c t i v e computer t echno logy and mass communicat ion s t r a t e g i e s for the promot ion of l i f e s t y l e r e f o r m . 4. A major means of i n i t i a t i n g h e a l t h promot ion p o l i c y , d i r e c t i o n s i s through c o o p e r a t i v e e f f o r t s between f e d e r a l , p r o v i n c i a l and l o c a l governments , and w i t h p r o f e s s i o n a l and v o l u n t a r y a s s o c i a t i o n s , b u s i n e s s and l a b o u r . Thus Chapter 4 a t tempts to marry the concepts of r i s k r e d u c t i o n and communicat ions by p r o p o s i n g f i v e p o l i c y i n i t i a t i v e s for h e a l t h promot ion i n B r i t i s h C o l u m b i a . These i n i t i a t i v e s attempt to address the f o l l o w i n g o b j e c t i v e s : - to d e v e l o p a c o o r d i n a t e d p u b l i c / p r i v a t e s e c t o r e f f o r t and fund ing mechanisms for h e a l t h promot ion ; - to d e s i g n , implement and e v a l u a t e a package of comprehensive h e a l t h r i s k assessment ins truments for i v use w i t h d i f f e r e n t t a r g e t p o p u l a t i o n s ; and - t o d e v e l o p , implement and e v a l u a t e a sound marke t ing s t r a t e g y which uses these ins truments i n v a r i o u s h e a l t h promot ion s e t t i n g s . A h e a l t h promot ion c o o r d i n a t i n g agency i s p r o p o s e d , c o m p r i s i n g a p a r t n e r s h i p of consumers , p u b l i c and p r i v a t e h e a l t h c a r e p r o v i d e r s , and the mass media . C r i t e r i a for d e s i g n i n g comprehensive h e a l t h assessment ins truments are d e v e l o p e d . I t i s a n t i c i p a t e d tha t t h i s study w i l l o f f e r p l a n n e r s and p o l i c y - m a k e r s r e l e v a n t and u s e f u l recommendations and g u i d e l i n e s for the i n t e g r a t i o n of r i s k r e d u c t i o n and communicat ion s t r a t e g i e s i n t o e f f e c t i v e h e a l t h promot ion programs. V TABLE OF CONTENTS A b s t r a c t . i i Acknowledgements ix CHAPTER ONE Promoting H e a l t h : An Overview 1 1.1 D e f i n i n g H e a l t h Promotion 2 1.2 Promoting H e a l t h : O b s t a c l e s And B e n e f i t s 4 1.3 Towards A H e a l t h Promot ion P o l i c y For C a n a d i a n s : O b j e c t i v e s Of H e a l t h And W e l f a r e Canada And The B . C . M i n i s t r y Of H e a l t h 21 CHAPTER TWO H e a l t h Assessment S t r a t e g i e s For H e a l t h Promot ion 28 2.1 H e a l t h Hazard A p p r a i s a l / H e a l t h Ri sk Assessment: An I n t r o d u c t i o n 29 2.2 S t a t u s Of H e a l t h R i s k Assessment In Canada 34 2.3 The H e a l t h R i s k Assessment C o n t r o v e r s y : What R i s k E s t i m a t i o n Is And What I t Is Not 36 2.4 Component C h a r a c t e r i s t i c s Of H e a l t h R i s k Assessment Instruments 43 H e a l t h R i s k Assessment Instrument Components . . . . 44 Format C o n s i d e r a t i o n s 44 Des ign C o n s i d e r a t i o n s 45 Feedback C o n s i d e r a t i o n s 46 Measurement C o n s i d e r a t i o n s 46 Computer -Ana lyzed Q u e s t i o n n a i r e s 48 Computer I n t e r a c t i v e Q u e s t i o n n a i r e s 49 S e l f - S c o r e d Q u e s t i o n n a i r e s 49 R i s k Reduct ion Resource Guides 57 2 .5 E v a l u a t i n g R i s k R e d u c t i o n Programs 58 2.6 The Role Of H e a l t h Assessment S t r a t e g i e s In H e a l t h Promotion 67 CHAPTER THREE Communication S t r a t e g i e s For H e a l t h Promot ion 73 3.1 G u i d e l i n e s For P l a n n i n g Communication S t r a t e g i e s For H e a l t h Promotion 74 STEP I Assess C h a r a c t e r i s t i c s And H e a l t h Needs Of T a r g e t P o p u l a t i o n 79 STEP II Develop H e a l t h S t a t u s O b j e c t i v e s 80 STEP I I I Deve lop Content O u t l i n e 81 STEP IV S e l e c t H e a l t h Promotion Message 82 STEP V S e l e c t / P r o d u c e A p p r o p r i a t e Communication Media 92 STEP VI Use Of Communication Media . . 106 TECHNOLOGICAL STRATEGIES FOR HEALTH PROMOTION 106 The Microcomputer : T e c h n o l o g i c a l R e v o l u t i o n In The 80' s • 110 Microcomputers In H e a l t h C a r e : From H i g h -t ech M e d i c i n e To H i g h - t e c h H e a l t h Promot ion 113 H e a l t h R i s k Assessment: Software Packages For H e a l t h Promot ion 117 v i MASS MEDIA STRATEGIES FOR HEALTH PROMOTION . . . 1 2 0 P r i n t Media 125 Radio 127 T e l e v i s i o n : The Medium Of The E i g h t i e s . . . . 1 2 9 The T e l e v i s i o n Audience Of The 1980's 142 STEP VII E v a l u a t e Communication S t r a t e g i e s 145 3.2 Summary 149 CHAPTER FOUR Towards P o l i c y - M a k i n g For H e a l t h Promot ion 151 4.1 Framework For The I n t e g r a t i o n Of Assessment And Communication S t r a t e g i e s Into A H e a l t h Promotion P o l i c y For B r i t i s h Columbia 152 P o l i c y I n i t i a t i v e (1) : Development Of A H e a l t h Promotion C o - o r d i n a t i n g Agency 158 P o l i c y I n i t i a t i v e (2) : H e a l t h Promotion Funding. Mechanisms 163 P o l i c y I n i t i a t i v e (3) H e a l t h R i s k Assessment: A S t r a t e g y That Deserves A t t e n t i o n 165 P o l i c y I n i t i a t i v e (4) : M a r k e t i n g L i f e s t y l e Reform 168 P o l i c y I n i t i a t i v e (5 ) : E v a l u a t i o n S tandards For H e a l t h Promot ion 173 4.2 On D e s i g n i n g A Comprehensive H e a l t h Assessment Q u e s t i o n n a i r e For Use With D i f f e r e n t T a r g e t P o p u l a t i o n s 175 H e a l t h R i s k Assessment Instrument Component C r i t e r i a 180 Des ign 180 S t y l e , 181 Content 184 4.3 Assessment And Communication S t r a t e g i e s For V a r i o u s H e a l t h Promotion S e t t i n g s . .192 REFERENCES 196 APPENDIX A HHA/UBC QUESTIONNAIRE 210 APPENDIX B HHA/UBC PRINTOUT 213 APPENDIX C HEALTH & WELFARE CANADA: YOUR L I F E S T Y L E PROFILE 218 APPENDIX D SAMPLE OF CURRENTLY AVAILABLE HEALTH ASSESSMENT INSTRUMENTS 220 APPENDIX E HEALTH RISK ASSESSMENT RESOURCES 225 APPENDIX F RESOURCE GUIDES FOR COMMUNICATION MEDIA . . . . 2 2 7 APPENDIX G CURRENTLY AVAILABLE COMMUNICATION MEDIA 229 APPENDIX H FORMATS AND DEFINITIONS OF COMMUNICATION MEDIA FOR HEALTH PROMOTION 237 APPENDIX I SPHERE PARTICIPANT ASSESSMENT 239 APPENDIX J SPHERE MICROCOMPUTER INFORMATION 244 APPENDIX K TV ONTARIO CATALOGUE 246 APPENDIX L GUIDE TO QUESTIONNAIRE CONSTRUCTION AND QUESTION WRITING 248 v i i LIST OF TABLES 1.1 B r i t i s h Columbia M i n i s t r y Of H e a l t h Budgets (1975-1983) 12 2.1 B a r r i e r s To Us ing H e a l t h R i s k Assessment S t r a t e g i e s 40 2.2 Demonstrated B e n e f i t s From U s i n g H e a l t h R i s k Assessment S t r a t e g i e s 41 2 .3 (a ) Instrument Component M a t r i x : Computer -Ana lyzed Q u e s t i o n n a i r e s 51 2 .3 (b) Instrument Component M a t r i x : Computer I n t e r a c t i v e Q u e s t i o n n a i r e s 53 2 . 3 ( c ) Instrument Component M a t r i x : S e l f - S c o r e d Q u e s t i o n n a i r e s 55 3.1 Communication Media S e l e c t i o n M a t r i x 105 3.2 Mass Media Communications S t r a t e g i e s For H e a l t h Promot ion And H e a l t h R i s k Assessment 123 v i i i LIST OF FIGURES 1.1 B r i t i s h Columbia H e a l t h E x p e n d i t u r e s 1982/83 Gr o s s Est.-$2832.5 M i l l i o n 11 3.1 G u i d e l i n e s For P l a n n i n g Communication S t r a t e g i e s For H e a l t h Promotion 78 3.2 Framework For The S e l e c t i o n , P r o d u c t i o n And E v a l u a t i o n Of Communication Media For H e a l t h Promot-ion 99 3.3 Market Share Of D a i l y Usage Times For The L e a d i n g Forms Of Mass Communications 124 3.4 Model Of Campaign P r o c e s s 145 4.1 Framework For The I n t e g r a t i o n Of Assessment And Communication S t r a t e g i e s I n t o H e a l t h P r o m o t i o n P o l i c y 157 ix Acknowledgements The c o m p l e t i o n of t h i s t h e s i s marks an end , a c o n t i n u a t i o n , and a new b e g i n n i n g : an end to the academic requ irements for a M a s t e r ' s of S c i e n c e , a c o n t i n u a t i o n of a l i f e - l o n g adventure i n l e a r n i n g , and the b e g i n n i n g of a new c a r e e r . T h i s work c o u l d not have been a c c o m p l i s h e d a lone and I wish to express my a p p r e c i a t i o n and g r a t i t u d e to those who o f f e r e d t h e i r support and encouragement, e s p e c i a l l y : - John Raymond P e t e r s , whose love p r o v i d e d t i m e , space and u n d e r s t a n d i n g ; -John M i l s u m , my t h e s i s s u p e r v i s o r and mentor in the path of p r o s p e c t i v e m e d i c i n e , whose i n s p i r a t i o n and encouragement made c o m p l e t i o n of t h i s u n d e r t a k i n g p o s s i b l e ; -Roy Rodgers for d i r e c t i n g me towards t h i s p a t h , and for h i s c o n t i n u i n g good c o u n s e l ; - t h e s i s a d v i s o r s Pe ter Grantham and Malco lm W e i n s t e i n f o r t h e i r work on my b e h a l f and for the q u a l i t y of t h e i r input towards s t r e n g t h e n i n g t h i s t h e s i s ; -Wayne Jones f o r h i s a s s i s t a n c e in t h e . p r e p a r a t i o n of t h i s t h e s i s u s i n g a " f r i e n d l y " computer , and to K e l l y M c L a u g h l i n whose g e n t l e n e s s and t y p i n g s k i l l s h e l p e d produce the f i n a l pages; -Rose Mar ie F o u r n i e r for f r i e n d s h i p and p r o d d i n g . And g r a t e f u l acknowledgement and love to my f a t h e r , P a u l S o h n e l , and i n memory of my mother, F r i e d a S o h n e l , f or i n s t i l l i n g i n me a sense of c o n f i d e n c e , a s p i r i t of a d v e n t u r e , a moderate l i f e s t y l e and s t r o n g work e t h i c , a de termined independence , and the joy of accomplishment which have gu ided me throughout my l i f e and he lped prepare me for t h i s work. 1 CHAPTER ONE Promoting H e a l t h : An Overview h e a l t h i s more than j u s t a b i o m e d i c a l phenomenon; i t i n v o l v e s a s o c i a l b e i n g f u n c t i o n i n g i n a s o c i a l environment w i t h s o c i a l r o l e s he must f u l f i l l . ( B e r g , 1976) 2 1.1 D e f i n i n g H e a l t h Promotion The g r e a t e s t c u r r e n t p o t e n t i a l f or improv ing the h e a l t h of the American people i s to be found i n what they do and d o n ' t do for themse lves . (Fuch , 1974) An e f f e c t i v e h e a l t h promot ion p o l i c y shou ld be expected to a c c o m p l i s h two t h i n g s : (1) to d e l a y premature deaths among the p o p u l a t i o n ; and (2) to improve the q u a l i t y , of l i f e of the whole p o p u l a t i o n by improv ing i t s h e a l t h (Dav idson , 1979). However, the term "hea l th" must f i r s t be d e f i n e d i n order to d i s c u s s what an " e f f e c t i v e h e a l t h promot ion p o l i c y " means. The problems a s s o c i a t e d wi th d e f i n i n g h e a l t h are o f t e n d i s m i s s e d as s emant ic , and the i s s u e s obscured by the assumption tha t h e a l t h i s s i m p l y the absence of i l l n e s s (Davidson et a l , 1979). " B u t , " argues Kelman (1975), "the problem of d e f i n i t i o n i s i n f a c t o p e r a t i o n a l , n o n - t r i v i a l and h i g h l y r e l e v a n t to the d e t e r m i n a t i o n of h e a l t h c a r e p o l i c y . " A c c o r d i n g to the World H e a l t h O r g a n i z a t i o n (WHO) (1948), h e a l t h i s d e f i n e d as a "state of complete p h y s i c a l , mental and s o c i a l w e l l - b e i n g , and not mere ly the absence of d i s e a s e or i n f i r m i t y . " A l t h o u g h the WHO d e f i n i t i o n i f somewhat u n r e a l i s t i c , p i c t u r i n g h e a l t h as a s t a t e of p e r f e c t w e l l - b e i n g , r a t h e r than a c o n t i n u a l l y changing and e v o l v i n g p r o c e s s , i t conveys the h o l i s t i c na ture of h e a l t h ( C a p r a , 3 1982) and o f f e r s an o p e r a t i o n a l framework for u n d e r s t a n d i n g the phenomenon of h e a l t h and the p l a n n i n g and e v a l u a t i o n of our h e a l t h care system. Antonovsky (1979) , on the o ther hand, i s c o n v i n c e d tha t the WHO d e f i n i t i o n of h e a l t h deserves severe c r i t i c i s m . He argues tha t i t i s " i m p o s s i b l y a b s t r a c t , p h i l o s o p h i c a l l y U t o p i a n and m i s l e a d i n g , and s t a t i c " and makes the p o i n t that "by d e f i n i n g h e a l t h as c o e x t e n s i v e wi th the many o ther d imens ions of w e l l - b e i n g , one makes the concept of h e a l t h meaning less and i m p o s s i b l e to s t u d y . " He suggests tha t w h i l e i t i s " f o l l y to deny the i n t e r a c t i o n between h e a l t h w e l l - b e i n g and o ther d i m e n s i o n s , " h e a l t h w e l l - b e i n g s h o u l d be measured s e p a r a t e l y so that we can " c l a r i f y the f o r c e s tha t shape the i n d i v i d u a l ' s or g r o u p ' s l o c a t i o n on the h e a l t h e a s e / d i s - e a s e continuem" (Antonovsky, 1979). The WHO r e a f f i r m e d i t s p o s i t i o n in the 1978 D e c l a r a t i o n of A l m a - A t a , by d e c l a r i n g the d e f i n i t i o n to r e p r e s e n t a "goal whose r e a l i z a t i o n r e q u i r e s the a c t i o n of many other s o c i a l and economic f a c t o r s in a d d i t i o n to the h e a l t h s e c t o r " (Davidson et a l , 1979). T h i s contemporary v i ewpo in t f o r c e s a broaden ing of our h o r i z o n s as we seek to e s t a b l i s h h e a l t h promot ion p o l i c y g u i d e l i n e s which are an i n t e g r a l p a r t of an o v e r a l l h e a l t h care p o l i c y for a l l C a n a d i a n s . Once an o p e r a t i o n a l d e f i n i t i o n of h e a l t h has been r e a c h e d , i t i s then important to d e f i n e h e a l t h promot ion in terms of a d o p t i n g a c u l t u r a l l y and e n v i r o n m e n t a l l y based 4 s t r a t e g y which focusses on l i f e s t y l e v a l u e s . The Center for D i sease C o n t r o l , in i t s r ecen t p u b l i c a t i o n , Source Book for  H e a l t h E d u c a t i o n M a t e r i a l s and Community Resources (1982), d e f i n e d h e a l t h promotion as a "combinat ion of m o t i v a t i o n a l , o r g a n i z a t i o n a l , p o l i t i c a l a n d / o r economic suppor t s des igned to promote b e h a v i o r changes that are conduc ive to h e a l t h . " T h i s framework assumes t h a t h e a l t h c a r e consumers are i n h e r e n t l y i n v o l v e d in a p p r o p r i a t e ways to i s o l a t e problems and d e v e l o p s o l u t i o n s . I t r e q u i r e s a new approach to h e a l t h promot ion p l a n n i n g and p o l i c y - m a k i n g , to a s s e s s i n g m o t i v a t i o n a l c a p a b i l i t i e s , to f o r e c a s t i n g r e s o u r c e r e q u i r e m e n t s , and to d e v e l o p i n g c r i t e r i a f o r e v a l u a t i o n of these s t r a t e g i e s . 1.2 Promot ing H e a l t h : O b s t a c l e s and B e n e f i t s What we need i s a new a t t i t u d e toward h e a l t h - the idea t h a t i n d i v i d u a l s and communit ies have a major r e s p o n s i b i l i t y for t h e i r own h e a l t h , tha t i l l n e s s and i n j u r y represent a d e p a r t u r e from the norm, the r e s u l t of an o m i s s i o n or commiss ion; and tha t med ic ine i s an a r t and a s c i e n c e concerned as much w i t h p r e s e r v i n g h e a l t h as wi th r e s t o r i n g i t . ( A s s i s t a n t S e c r e t a r y for H e a l t h , U . S . H e a l t h E d u c a t i o n and W e l f a r e , 1977) A c c o r d i n g to the head of the R u s s e l l Sage F o u n d a t i o n , the c a r e d e l i v e r e d by p h y s i c i a n s accounts for l e s s than 10% of the d i f f e r e n c e in h e a l t h between any two A m e r i c a n s ; the o ther 90% i s determined by f a c t o r s beyond the p h y s i c i a n ' s 5 c o n t r o l , i n c l u d i n g e a t i n g , smoking, and e x e r c i s e h a b i t s , and the h e a l t h f u l n e s s of a i r , water , food and work environments (Swinehar t , 1979). To that l i s t shou ld be added the s o c i a l h e a l t h f a c t o r s of p e r s o n a l , f a m i l y and economic s t r e s s e s tha t may mani f e s t themselves i n p h y s i c a l - a n d mental breakdown. There seems to be l i t t l e cure for the major malad ie s of modern man. P r e v e n t i v e medic ine and h e a l t h promot ion may o f f e r a b e t t e r l o n g - t e r m answer. Indeed, based on c u r r e n t procedures for r e d u c i n g m o r t a l i t y and m o r b i d i t y , Dever (1976) argues that "unless t h e r e i s a dramat i c s h i f t in h e a l t h p o l i c y , l i t t l e or no change in p r e s e n t d i s e a s e p a t t e r n s w i l l o c c u r . In f a c t , " he adds , "with our a g i n g p o p u l a t i o n , we might very w e l l see dramat i c i n c r e a s e s in m o r t a l i t y and m o r b i d i t y . " In the contex t of the New P e r s p e c t i v e on the H e a l t h of  Canadians ( L a l o n d e , 1974), an i n c r e a s e d emphasis on h e a l t h promot ion and p r e v e n t i o n of i l l n e s s would l i k e l y y i e l d the same end r e s u l t for the e l d e r l y as advances i n m e d i c a l t e c h n o l o g y . For example, there may w e l l be a r e d u c t i o n of the i n c i d e n c e of hear t and c e r e b r o v a s c u l a r d i s e a s e among o l d e r p o p u l a t i o n s , due to i n t e r v e n t i o n s which focus on p r e v e n t i n g , or at l e a s t i n h i b i t i n g , the l i f e s t y l e and e n v i r o n m e n t a l f a c t o r s which c o n t r i b u t e to these c o n d i t i o n s (Rombout, .1 975) . A l though some people g i v e l i t t l e thought to the r o l e that p e r s o n a l l i f e s t y l e s p l a y in t h e i r w e l l - b e i n g , c u r r e n t 6 p r e - o c c u p a t i o n wi th l i f e s t y l e i s r e f l e c t e d in the l i t e r a t u r e and in the mass media which document ev idence t h a t an i n d i v i d u a l ' s l i v i n g h a b i t s , c o l l e c t i v e l y d e s c r i b e d as " l i f e s t y l e , " can e i t h e r improve or d i m i n i s h tha t p e r s o n ' s chances f o r l e a d i n g a long and u s e f u l l i f e . U s i n g the Canadian framework, A New P e r s p e c t i v e on the  H e a l t h of C a n a d i a n s , a group of American e x p e r t s conc luded tha t as much as h a l f of the U . S . m o r t a l i t y i n 1976 was due to unhea l thy behav ior or l i f e s t y l e , 20% to e n v i r o n m e n t a l f a c t o r s , 20% to human b i o l o g i c a l f a c t o r s and on ly 10% to i n a d e q u a c i e s in h e a l t h c a r e . The 250-page 1st Surgeon  G e n e r a l ' s Report on H e a l t h Promotion and D i s e a s e P r e v e n t i o n which took two years to compi l e s t a t e d : "The h e a l t h of t h i s ( U . S . ) n a t i o n ' s c i t i z e n s can be s i g n i f i c a n t l y improved through a c t i o n s i n d i v i d u a l s can take themse lves , and through a c t i o n s d e c i s i o n - m a k e r s in the p u b l i c and p r i v a t e s e c t o r s can take to promote a s a f e r and h e a l t h i e r environment for a l l Americans at home, a t work and at p l a y . " The r e p o r t d e c l a r e d : "Prevent ion i s an idea whose time has come" ( M c C o n n e l l , 1979). O b s t a c l e s to Promoting H e a l t h I t i s r e c o g n i z e d , however, tha t acceptance of the r e l a t i o n s h i p between l i f e s t y l e and h e a l t h i s h a r d l y u n i v e r s a l . The major o b s t a c l e s to g r e a t e r acceptance of c u r r e n t knowledge c o n c e r n i n g p r e v e n t i v e medic ine and h e a l t h 7 p r o m o t i o n , as d e f i n e d by Swinehart (1979), are a n a l y z e d here from a Canadian p e r s p e c t i v e . These b a r r i e r s to the p l a n n i n g and implementat ion of h e a l t h promot ion e f f o r t s i n c l u d e the f o l l o w i n g c o n c e r n s : 1. Nega t ive a t t i t u d e s among p h y s i c i a n s At the t u r n of the c e n t u r y , two out of three persons employed in the h e a l t h care f i e l d were p h y s i c i a n s . A l t h o u g h today t h a t r a t i o i s a p p r o x i m a t e l y one out of twelve ( U . S . f i g u r e s ) , the p h y s i c i a n c o n t i n u e s to be looked upon as the c a p t a i n and key d e c i s i o n - m a k e r i n the h e a l t h care team, a view r o o t e d i n law, custom, and m e d i c a l t r a i n i n g (Randt , 1983). A c c o r d i n g to Knobel (1983) "organ ized m e d i c i n e , w i t h a few n o t a b l e e x c e p t i o n s , has shown l i t t l e i n t e r e s t in h e a l t h p r o m o t i o n . " One of the major reasons why p h y s i c i a n s may be u n i n t e r e s t e d i n , or even h o s t i l e t o , the whole idea of h e a l t h promot ion i s tha t they f i n d l i f e s t y l e c o u n s e l l i n g f i n a n c i a l l y u n r e w a r d i n g . Another i s l a c k of v a l i d data t h a t warrant f i r m o p i n i o n s . M o s t l y , p h y s i c i a n s s t i l l d e a l w i t h o p i n i o n and hope and anecdote (Grantham, 1983). A p o s i t i v e s t ep towards encourag ing the p e r s o n a l and p r o f e s s i o n a l commitment of p h y s i c i a n s would be to change the c u r r e n t reimbursement system i n order to p r o v i d e them w i t h economic i n c e n t i v e s to do p r e v e n t i o n and h e a l t h p r o m o t i o n . However, many p h y s i c i a n s do attempt to encourage t h e i r p a t i e n t s to change n e g a t i v e b e h a v i o r s , a l t h o u g h some 8 encounter p e r s o n a l f r u s t r a t i o n s in t h e i r a t t e m p t s , and c o n c l u d e . t h a t such a d v i c e i s n e i t h e r wanted nor e f f e c t i v e . The r e p o r t of the Canadian Task Force on The P e r i o d i c H e a l t h  Examinat ion (1979) p r o v i d e s an e x c e l l e n t guide for p h y s i c i a n s i n t e r e s t e d in i n c o r p o r a t i n g c l i n i c a l p r e v e n t i v e s e r v i c e s i n t o t h e i r p r a c t i c e s . I t a l s o e x p l a i n s how p h y s i c i a n s can set an example of h e a l t h l i v i n g for t h e i r p a t i e n t s (Jonas , 1982). G a i n i n g p h y s i c i a n support for h e a l t h promot ion e f f o r t s i s e s s e n t i a l f o r a number of reasons : 1. 75% of the p o p u l a t i o n v i s i t p h y s i c i a n s a n n u a l l y ; 2. because p h y s i c i a n s i n f l u e n c e the d i r e c t i o n of two-t h i r d s of the t o t a l h e a l t h c a r e d o l l a r s (Jonas , 1982), p a t i e n t s r e q u i r i n g p r e v e n t i o n and h e a l t h promot ion s e r v i c e s not p r o v i d e d by p h y s i c i a n s c o u l d b e n e f i t from r e f e r r a l s to s e r v i c e s a v a i l a b l e e lsewhere in the community; 3. p h y s i c i a n s ' input i n t o the p r o c e s s of d e c i d i n g which programs to o f f e r , as w e l l as a s s i s t a n c e in c e r t a i n a s p e c t s of program development d i r e c t l y r e l a t e d to the c l i n i c a l problems encountered by p h y s i c i a n s on a d a i l y b a s i s , would h e l p s t r e n g t h e n b e h a v i o r a l o b j e c t i v e s or r i s k r e d u c t i o n programming; and 4. s i n c e the p u b l i c c o n t i n u e s to look to p h y s i c i a n s as the f i n a l a u t h o r i t i e s on h e a l t h , t h e i r e n t h u s i a s t i c endorsement of h e a l t h promot ion programs i s e s s e n t i a l 9 i f these programs are to be accepted by the community (Randt , 1983). However, the e n t i r e burden of improving the p r a c t i c e of p r e v e n t i o n and h e a l t h promot ion cannot , and sh ou ld n o t , be p l a c e d s o l e l y upon the m e d i c a l p r o f e s s i o n . There are m u l t i p l e causes of i l l n e s s , d i s a b i l i t y and premature d e a t h , and t h e r e are m u l t i p l e pathways a v a i l a b l e for h e a l t h p r o m o t i o n . 2. Inadequate funding for h e a l t h promot ion Only 1% of the U . S . n a t i o n a l h e a l t h e x p e n d i t u r e s goes towards h e a l t h e d u c a t i o n (Davidson et a l , 1979). Canadian s t a t i s t i c s on e x p e n d i t u r e s f o r h e a l t h promot ion are j u s t as poor as those in the U n i t e d S t a t e s . I n B r i t i s h C o l u m b i a , that f i g u r e i s even l e s s : o n l y 2% of the annua l h e a l t h c a r e budget which i s over 30% of the t o t a l p r o v i n c i a l o p e r a t i n g budget i s a l l o c a t e d to a l l P r e v e n t i v e S e r v i c e s , i n c l u d i n g .04% to h e a l t h promot ion s e r v i c e s . For example, in 1982/83, the t o t a l h e a l t h c a r e budget was $2 ,832 .5 m i l l i o n , of which $1.2 m i l l i o n was a l l o c a t e d to h e a l t h p r o m o t i o n . F i g u r e 1.1, " B r i t i s h Columbia H e a l t h E x p e n d i t u r e s " (1982/83 E s t . ) i l l u s t r a t e s these a l l o c a t i o n s g r a p h i c a l l y . In T a b l e 1.'1, B . C . ' s h e a l t h promot ion e x p e n d i t u r e s have been e s t i m a t e d by r e v i e w i n g the budgets of the M i n i s t r y of H e a l t h over the past few y e a r s . Bes ide the obv ious inadequacy of f u n d i n g for h e a l t h 10 p r o m o t i o n , the debate c o n t i n u e s over whether or not h e a l t h promot ion r e s u l t s in a net c o s t - s a v i n g , or i s merely an add-on to the r a p i d l y r i s i n g t o t a l c o s t s of a l l h e a l t h s e r v i c e s (from $8 b i l l i o n in Canada to about $14 b i l l i o n i n the 5-year p e r i o d 1976-81). Given the r a p i d l y r i s i n g c o s t s of m e d i c a l c a r e , h e a l t h promotion programs must demonstrate that they h e l p to c o n t r o l the i n c r e a s e i n these c o s t s , as w e l l as improve the h e a l t h and w e l l - b e i n g of Canadians ( K n o b e l , 1983). F i g u r e 1 . 1 11 B r i t i s h C o l u m b i a H e a l t h E x p e n d i t u r e s 1 9 8 2 / 8 3 G r o s s E s t . - $ 2 8 3 2 . 5 M i l l i o n Hospital Programs (47.2%) S p e c i a l Care Grants (.3X) Forensic (.4X) Alcohol and Drug (.6X1 Emergency Health (1.6X) Preventive Services (2%) Buildings.Admin. (2.3X) Mental Health (2.3X) M e d i c a l Services (2B.7X) Long T e n Care (14.6%) PROGRAM Hospital Programs Medical Services Plan Long Tarm Cara Mental Haalth Buildings, Admin..Supplle Preventiva Haalth Emergency Haalth Alcohol / Drug C o m m . Forantic Special Cara Grant* 1 9 8 1 / 8 2 1 9 8 2 / 8 3 E s t i m a t e s E s t i m a t e s 1199.6 (• (1337.8 811.9 413.7 65 8 63.8 56.8 46.0 17.0 12.3 7.4 2 4 4 3 . 4 2 8 3 2 . 5 653.8 333 7(. ) 65 6 66.9 52.7 4 4 3( . ) 18.4 11.1 7.3 Percent Chang* + 11.5% • 24.2% (. ) + 2 4 0 % ( i) + 0.3% 412.2% (s ) + 7.7% + 3.8% - 7.8% + 10.4% ( « | + 0.8% +15.9% Increased premium rates. Increased number of facilities In Long Tarm Cara. Increases in building occupancy charge)*, in relocation costs and In merit Increments. Start up of th* secure unit for psychotic luveniles. 1981/82 estimates Include 10.2 million In recruitment FUNDING ANALYSIS Voted Estimates (Blue Book) Medical Service Premiums Hospital Charges/Fees,etc. Long Term Cara User Charges Special Warrant 1981/82: Hospital Programs 42.7 Long Tarm Cara 14.4 Medical Services 4.6 61.7 Health Cost Stabilization 1982/83: Hospital Programs 48.0 Long Term Car* 16.6 Medical Services 13.2 77.8 Recoveries Alcohol and Drug Employment Dev. Account TOTAL 1 9 8 1 / 8 2 1 9 8 2 / 8 3 1985.1 (• 1 2 2 3 6 . 6 203.1 114 5 60.6 61.7 18.4 313.5 122.3 77.2 77.8 3.3 1.8 + 12.7% +54.4% | i ) + 6.8% •27.4% (• ) 2 4 4 3 . 4 2 8 3 2 . S + 1 5 . 9 % 12 T a b l e 1.1 B r i t i s h C o l u m b i a M i n i s t r y of H e a l t h B u d g e t s (1975-1983) PREVENTIVE HEALTH TOTAL (millions) SERVICES (millions) PROMOTION** (millions) 1975/76 $ 892.3 $ 17.8 $ .3 1976/77 976.0 19.5 .4 1977/78 1,094.4 21.9 .4 1978/79 1,315.0 26.3 .5 1979/80 1.490.6 29.3 .6 1980/81 2,000.0 40.0 .8 1981/82 2,443.4 52.7 1.0 1982/83 2,832.5 56.8 1.2 Preventive Services Budget is approximately 2% of total budget for Ministry of Health Health Promotion portion of Preventive Services Budget is estimated at 2%, or .04% of total Ministry of Health Budget. 1 3 3. Negat ive a t t i t u d e s among the p u b l i c Many people t h i n k p r e v e n t i o n means g i v i n g something up now in order to ach i eve some h e a l t h ga in many y e a r s in the f u t u r e . There i s a l s o widespread apathy about any e f f o r t to s u s t a i n "hea l th" as long as one has i t . In a d d i t i o n , u n r e a l i s t i c e x p e c t a t i o n s e x i s t about the a b i l i t y of medic ine to cure i l l n e s s . Gel lman (1974) emphasizes that the most d i f f i c u l t o b s t a c l e w i l l be to c o r r e c t p u b l i c a t t i t u d e s , and he recommends that s teps be taken to change the p u b l i c ' s e x p e c t a t i o n s of s i c k n e s s s e r v i c e s - "a good b e g i n n i n g might be to c a l l these s e r v i c e s what they a r e ! " 4. M e d i c a l i n s u r a n c e systems S i n c e the s t a r t of the p u b l i c h o s p i t a l and m e d i c a l i n s u r a n c e in the 1950's , and u n i v e r s a l medicare in 1968, Canadians have grown c o m f o r t a b l e w i th the c u r r e n t g o v e r n m e n t - c o n t r o l l e d h e a l t h c a r e system, and complacent w i t h i t s p e r c e i v e d "free" s e r v i c e s . However, most "hea l th i n s u r a n c e " i s r e a l l y "disease i n s u r a n c e , " and most p r i v a t e and government i n s u r a n c e pay p h y s i c i a n s and h o s p i t a l s f or d i a g n o s i s or t r e a t m e n t , but r a r e l y f o r . p r e v e n t i v e medic ine and h e a l t h p r o m o t i o n . The new O n t a r i o H e a l t h Act has p lanned to implement a fee s t r u c t u r e for p r e v e n t i v e and h e a l t h promot ion s e r v i c e s , however, the M e d i c a l S e r v i c e s P l a n of B r i t i s h Columbia (MSP) pays on ly for l i m i t e d p a t i e n t c o u n s e l l i n g ( four v i s i t s per year and not f o r the s o - c a l l e d 1 4 " a n n u a l " ) . F u r t h e r , i t pays on ly for c o u n s e l l i n g p r o v i d e d by p h y s i c i a n s , not tha t which i s p r o v i d e d by o ther h e a l t h p r o f e s s i o n a l s . 5. M e d i c a l t echnology S o c i e t a l i n f l u e n c e s - of c u l t u r e , e t h n i c i t y , economics - as d i s t i n c t from p o l i t i c a l power, change a s p e c t s such as the v a l u e p l a c e d on the h e a l t h c a r e system. P o l i t i c a l power may make t h i n g s happen, but as Newman (1982) a r g u e s , t h i s power i s bounded by t i m e . It d o e s n ' t l a s t l ong enough and so the more v i s i b l e p o l i t i c a l promises l i k e , f or example, new h o s p i t a l s , more h i g h t e c h n o l o g y , e t c . w i l l win votes over the r e d i r e c t i n g of h e a l t h c a r e d o l l a r s i n t o h e a l t h promot ion e f f o r t s u n l e s s there are more v i s i b l e r e s u l t s . Indeed , as C r i c h t o n (1980) p o i n t s o u t , "despi te the u n d e n i a b l e l o g i c of d e v e l o p i n g a h e a l t h c a r e d e l i v e r y system emphas iz ing p r e v e n t i o n and s e l f - c a r e p r o m o t i o n , i t was h o s p i t a l s that were wanted in the l a t e f o r t i e s in Canada by people l i v i n g i n communi t i e s , by d o c t o r s , by businessman and by p o l i t i c i a n s . " Indeed , i t c o u l d be a r g u e d , Canada's h o s p i t a l c o n s t r u c t i o n p o l i c y "had as much to do w i t h Canadian economic development as w i th d i r e c t h e a l t h outcomes" ( C r i c h t o n , 1980). The h i g h cos t of m e d i c a l t e c h n o l o g i e s l i m i t the amount of the l i m i t e d h e a l t h c a r e d o l l a r s which can be a l l o c a t e d to h e a l t h p r o m o t i o n . For example, Swinehart (1979) p o i n t s out 1 5 that twice as much i s spent each year in the U n i t e d S t a t e s on d e v e l o p i n g an a r t i f i c i a l h e a r t as on the most expens ive program to prevent hear t d i s e a s e . The g r e a t e s t p u b l i c i t y g iven to such s p e c t a c u l a r m e d i c a l procedures as open-hear t s u r g e r y and organ t r a n s p l a n t s tends to make us f o r g e t that many of these p a t i e n t s might not have been h o s p i t a l i z e d in the f i r s t p l a c e i f p r e v e n t i v e measures had not been s e v e r e l y n e g l e c t e d ( C a p r a , 1982). However, that i s not to say tha t advances in technology cannot be e f f e c t i v e l y and e f f i c i e n t l y used i n p r e v e n t i v e medic ine and h e a l t h p r o m o t i o n . In p a r t i c u l a r , t h e i r use i n new t e c h n o l o g i e s for h e a l t h r i s k assessment and communication s t r a t e g i e s i s d i s c u s s e d in d e t a i l i n Chapter 3. 6. O p p o s i t i o n from i n d u s t r y Some l i f e s t y l e and e n v i r o n m e n t a l c h a r a c t e r i s t i c s which are a t h r e a t to h e a l t h are a source of p r o f i t , through s a l e s or reduced c o s t s , to p a r t s of the p r i v a t e s e c t o r (Evans , 1982). Thus , the Canadian government has imposed r e s t r a i n t s on a number of p r o d u c t s and i n d u s t r i a l p r o c e s s e s i n order to p r o t e c t the p u b l i c ' s h e a l t h , as have the governments of the U n i t e d S t a t e s and A u s t r a l i a . However, some i n d u s t r i e s have managed to a v e r t c o n t r o l s that would reduce consumption of t h e i r p r o d u c t s : "The c o n f l i c t between p u b l i c h e a l t h , on the one hand, and tobacco farmers and c i g a r e t t e companies on the o t h e r , i s the most o b v i o u s , and extends i n t o the government 16 i t s e l f - p i t t i n g Department of A g r i c u l t u r e , or I n d u s t r y , a g a i n s t Departments of H e a l t h . In t h i s f i e l d , the pathogens are not m i c r o - o r g a n i s m s but p e o p l e , and they lobby and vote" (Evans , 1982). As an example, Binns (1983") r e l a t e s how the A u s t r a l i a n tobacco i n d u s t r y h a l t e d a m u l t i - m e d i a s t o p -smoking experiment i n that c o u n t r y . S i m i l a r l y , Swinehart (1979) notes tha t as of 1978, the U . S . Government was spending ten t imes more on r e s e a r c h to deve lop a "safer" c i g a r e t t e than on e f f o r t s to c u r b smoking. (We c o u l d ask whether t h i s i s not r a t h e r the r e s p o n s i b i l i t y of the tobacco  i n d u s t r y . ) In a recent p r e s s r e l e a s e , the Canadian f e d e r a l H e a l t h M i n i s t e r Monique Begin (1983) s t a t e d that e f f o r t s to con-vince Canadians of the b e n e f i t s of a v o i d i n g tobacco are f i n a l l y hav ing an e f f e c t . T h i s was shown by a t r e n d towards s l i g h t l y decreased c i g a r e t t e s a l e s d u r i n g 1982 f o l l o w i n g f i f t e e n years of s t e a d i l y i n c r e a s i n g tobacco consumpt ion . T h i s t r e n d may w e l l be due to the c u r r e n t economic c o n d i t i o n s s i n c e s a l e s of tobacco for r o l l - y o u r - o w n c i g a r e t t e s have i n c r e a s e d s l i g h t l y . The l a t e s t smoking h a b i t s survey r e l e a s e d on January 25, 1983 showed that the t r e n d away from c i g a r e t t e s c o n t i n u e d to d e c l i n e to an e s t i m a t e d 33% of the p o p u l a t i o n (age 15+) i n 1981 from 34.2% in 1979. However, i t should be noted tha t Canadians s t i l l smoke more c i g a r e t t e s per c a p i t a than any o ther people except the Swiss ( B e g i n , 1983). 17 Pos ing another p o i n t of v iew, Canadian h e a l t h c a r e economist Robert Evans argues tha t "taxes c o l l e c t e d from c i g a r e t t e s a l e s more than cover the h e a l t h care c o s t s of c a u s a l l y l i n k e d i l l n e s s s p e c i f i c a l l y a t t r i b u t a b l e to c i g a r e t t e smoking" (Evans , 1983). Even i f t h i s were so , and not a l l economists a g r e e , we might very w e l l q u e s t i o n whether or not i t i s in s o c i e t y ' s i n t e r e s t to spend i t s tax d o l l a r s in t h i s way. 7. C o u n t e r v a i l i n g a d v e r t i s i n g messages A l t h o u g h some mass media a d v e r t i s i n g can be c o n s i d e r e d p r o - h e a l t h , the promot ion of unhea l thy l i f e s t y l e s o c c u p i e s a prominent p o s i t i o n i n c o n v e n t i o n a l market ing s t r a t e g i e s . In many i n s t a n c e s , h e a l t h promot ion appea l s appear in a c o n t e x t of c o u n t e r v a i l i n g messages promot ing such p r o d u c t s as c i g a r e t t e s , a l c o h o l i c beverages , sweets and n u t r i t i o n a l l y inadequate foods . However, the mass media , used i n t e l l i g e n t l y can a c h i e v e p o s i t i v e r e s u l t s as w i l l be o u t l i n e d i n Chapter 3. 8. D i f f i c u l t i e s in m o t i v a t i n g people to adopt h e a l t h i e r  l i f e s t y l e s Swinehart (1979) c i t e s a Ch icago survey in which 40% of the respondents s a i d they were overwe ight , but on ly 25% s a i d they were t r y i n g to reduce ; 85% s a i d that e x e r c i s e was i m p o r t a n t , but on ly 32% f o l l o w e d an e x e r c i s e program; and 18 a l l agreed tha t c i g a r e t t e s were damaging, but 42% smoked. On these , and some other h e a l t h t o p i c s , i t seems c l e a r that l a c k of i n f o r m a t i o n i s not the major b a r r i e r to b e h a v i o r a l change. Many people who have c o r r e c t i n f o r m a t i o n f a i l to ac t on t h a t i n f o r m a t i o n . A d a p t i v e a c t i o n s are l i m i t e d by such f a c t o r s as h a b i t s , c o s t s , f ear of outcomes, non-a v a i l a b i l i t y of s e r v i c e s , i n c o n v e n i e n c e , and l a c k of s o c i a l support f o r c e r t a i n a c t i o n s . Few of these f a c t o r s can be i n f l u e n c e d d i r e c t l y by e d u c a t i o n a l programs (Swinehar t , 1979) . 9. Competing "heal th" messages The p u b l i c i s asked to g ive t ime or money to a v a r i e t y of causes such as the U n i t e d Way, the Red C r o s s , and dozens of o ther worthy o r g a n i z a t i o n s . In the h e a l t h area a l o n e , people are urged to get r e g u l a r checkups , have t h e i r c h i l d r e n immunized, c o n t r o l s t r e s s , get f i t , and so o n . They are e x h o r t e d to f i g h t c a n c e r , h e a r t d i s e a s e , m u l t i p l e s c l e r o s i s , d i a b e t e s , h i g h b lood p r e s s u r e , lung d i s e a s e , and o ther p r o b l e m s . It i s t h e r e f o r e not s u r p r i s i n g tha t some p e o p l e , c o n f r o n t e d wi th an a r r a y of a p p e a l s , s u f f e r from i n f o r m a t i o n o v e r l o a d , d e c i d e they c a n ' t p o s s i b l y do e v e r y t h i n g and consequent ly do n o t h i n g . 19 B e n e f i t s A s s o c i a t e d wi th Promoting H e a l t h D e s p i t e a l l the b a r r i e r s to s u c c e s s , our e f f o r t s to extend and e n r i c h l i f e deserve to c o n t i n u e , and they w i l l . (Swinehar t , 1979) D e s p i t e the a forement ioned and o ther o b s t a c l e s to promot ing h e a l t h and w e l l n e s s , there i s ev idence that p r o g r e s s i s be ing made. For example, deaths from c a r d i o v a s c u l a r d i s e a s e s have been d e c l i n i n g s i n c e 1968 i n Canada, the U n i t e d S t a t e s and A u s t r a l i a . Most e x p e r t s a t t r i b u t e t h i s r e d u c t i o n to changes in smoking, e a t i n g , and e x e r c i s e h a b i t s , and to e f f o r t s which d e t e c t and t r e a t people w i t h h i g h b l o o d p r e s s u r e . Swinehart (1979) c i t e s ev idence t h a t the percentage of people i n the U n i t e d S t a t e s w i t h a d e q u a t e l y c o n t r o l l e d h y p e r t e n s i o n has i n c r e a s e d from 12% to a t l e a s t 20%. A c e n t r a l theme of h e a l t h promot ion i s e d u c a t i n g i n d i v i d u a l s so they w i l l take p e r s o n a l r e s p o n s i b i l i t y for t h e i r own h e a l t h , and in. p a r t i c u l a r , w i l l undertake r e l e v a n t programs f o r l i f e s t y l e change. S e v e r a l examples of e f f o r t s to promote h e a l t h which have proved e f f e c t i v e i n c l u d e : - the S t a n f o r d Heart D i sease P r e v e n t i o n P r o j e c t in the U . S . which showed t h a t c o r o n a r y h e a r t d i s e a s e r i s k f a c t o r s c o u l d be cut by 15% to 20% in two y e a r s through a combinat ion of i n d i v i d u a l i z e d i n s t r u c t i o n and mass media i n f l u e n c e ; - the s i x - y e a r p r o j e c t i n Nor th K a r e l i a County , F i n l a n d 20 produced a s i g n i f i c a n t change i n c a r d i o v a s c u l a r r i s k f a c t o r s , a drop in h e a r t a t t a c k s , and reduced the number of s t r o k e s n e a r l y by h a l f ; - the K a i s e r - P e r m a n e n t e M e d i c a l Care P lan i n the U . S . found that p e r i o d i c h e a l t h s c r e e n i n g of m i d d l e - a g e d men produced a s a v i n g of $800 per person over a seven-year p e r i o d because of reduced i l l n e s s and d e a t h s ; - i n d i v i d u a l i n s t r u c t i o n of p a t i e n t s w i th c o n g e s t i v e h e a r t f a i l u r e at a C a l i f o r n i a h o s p i t a l r e s u l t e d in p a t i e n t s spending o n e - t e n t h the number of days i n h o s p i t a l as compared to p a t i e n t s not g i v e n such i n s t r u c t i o n (Swinehar t , 1979); and - the " F e e l i n g Good" t e l e v i s i o n s e r i e s on the PBS Network in the U . S . , which at tempted to i n f l u e n c e a v a r i e t y of h e a l t h - r e l a t e d b e h a v i o r s , produced a number of s i g n i f i c a n t e f f e c t s in such areas of s e l f - c a r e as b r e a s t s e l f - e x a m i n a t i o n , v i s i o n checkups , and improved n u t r i t i o n (Swinehar t , 1979). A p a r t from these k inds of e f f o r t s , there i s another e n c o u r a g i n g development tha t deserves c o n s i d e r a t i o n as p a r t of an o v e r a l l h e a l t h promot ion s t r a t e g y : the growing use of h e a l t h r i s k assessment t e c h n i q u e s . H e a l t h r i s k assessment has been r e c o g n i z e d as a u s e f u l h e a l t h promot ion approach to s c r e e n i n g , e d u c a t i n g and m o t i v a t i n g i n d i v i d u a l s to change t h e i r b e h a v i o r s for r e s u l t a n t improvements i n h e a l t h . Chapter 2 addresses the scope of the development , the 21 c o n t r o v e r s i e s s u r r o u n d i n g t h e i r use , and the proven b e n e f i t s of h e a l t h r i s k assessment s t r a t e g i e s which are o r i e n t e d towards promot ing w e l l n e s s and w e l l - b e i n g . 1.3 Towards a H e a l t h Promotion P o l i c y for C a n a d i a n s : O b j e c t i v e s of H e a l t h and W e l f a r e Canada and the B . C .  M i n i s t r y of H e a l t h The H e a l t h Promotion D i r e c t o r a t e of the H e a l t h S e r v i c e s and Promotion B r a n c h , was e s t a b l i s h e d by the M i n i s t e r of N a t i o n a l H e a l t h and Wel fare i n 1978, w i th r e s p o n s i b i l i t y for implementing the h e a l t h promot ion s t r a t e g y o u t l i n e d in the 1974 d e p a r t m e n t a l paper A New P e r s p e c t i v e on the H e a l t h of  C a n a d i a n s ( L a l o n d e , 1974). The D i r e c t o r a t e ' s p r i m a r y o b j e c t i v e i s to i n c r e a s e the c a p a c i t y of Canadians to m a i n t a i n and enhance t h e i r l e v e l of h e a l t h . The framework for t h i s paper i s based on the h e a l t h f i e l d concept which i d e n t i f i e s four p r i n c i p a l e lements tha t are r e s p o n s i b l e for d e t e r m i n i n g i n d i v i d u a l h e a l t h : human b i o l o g y , the env ironment , the o r g a n i z a t i o n of h e a l t h c a r e , and l i f e s t y l e . L a l o n d e , the f e d e r a l M i n i s t e r of H e a l t h from 1972 to 1977, a d d r e s s i n g the S o c i e t y of P r o s p e c t i v e M e d i c i n e at i t s ' 12th Annual Meet ing i n 1977, s t a t e d that "we b e l i e v e in Canada we are a l r e a d y d e r i v i n g maximum b e n e f i t s from our o r g a n i z e d h e a l t h care s e r v i c e s . C o n s e q u e n t l y , a t t e n t i o n i s be ing focussed on e n v i r o n m e n t a l and l i f e s t y l e f a c t o r s which 22 are a c c e s s i b l e to human i n f l u e n c e " ( L a l o n d e , 1977). S e v e r a l c o n s i d e r a t i o n s make the f e d e r a l government's p r i o r i t y on h e a l t h promot ion t i m e l y . H e a l t h promot ion s u p p o r t s the government's commitment to "help f i r s t those who need h e l p the most ." I t c o n t r i b u t e s to the achievement of two of the government's medium-term s o c i a l p o l i c y g o a l s : (1) the improvement of the q u a l i t y of l i f e , and , (2) the a l l e v i a t i o n of the e f f e c t s of p o v e r t y . The c o s t -e f f e c t i v e n e s s which proponents expect and which indeed seems l o g i c a l from d i s c o u r a g i n g b e h a v i o r s w i th a h i g h h e a l t h r i s k , encourag ing s e l f - h e l p , and s t i m u l a t i n g the development of p r e v e n t i v e s e r v i c e s i s c o n s i s t e n t w i th the government's l o n g - t e r m need for f i s c a l r e s t r a i n t . And , f i n a l l y , the c l i m a t e i s now s u p p o r t i v e because of p u b l i c awareness of • h e a l t h promot ion i s s u e s , i n t e r e s t i n s e l f - c a r e , and expres sed p r o v i n c i a l i n t e r e s t i n c o o p e r a t i n g w i t h the f e d e r a l government to make h e a l t h programs more p r e v e n t i v e . The government's p o s i t i o n on h e a l t h promot ion i s c l e a r l y s t a t e d : H e a l t h promot ion encompasses a c t i v i t i e s tha t a s s i s t communit ies and t h e i r c i t i z e n s to unders tand the h e a l t h consequences of p a r t i c u l a r l i f e s t y l e s and to engage i n the p r o t e c t i o n of h e a l t h and the p r e v e n t i o n of i l l n e s s . The aim of h e a l t h promot ion i s to in form and m o t i v a t e people to adopt and m a i n t a i n h e a l t h p r a c t i c e s . The d e s i r e d outcome i s a p o p u l a t i o n that p r o t e c t s i t s mental and p h y s i c a l h e a l t h by: (a) f o s t e r i n g w e l l n e s s ; (b) a v o i d i n g h e a l t h . r i s k s ; and (c) a t t a i n i n g self-management of d i s a b l i n g or c h r o n i c c o n d i t i o n s . 23 The o r g a n i z a t i o n a l r e s t r u c t u r i n g of H e a l t h and Wel fare Canada, which l e d to the c r e a t i o n of the H e a l t h Promotion D i r e c t o r a t e , r e p r e s e n t e d the b e g i n n i n g of a h e a l t h promot ion approach which focusses on the needs of the t o t a l i n d i v i d u a l . T h i s D i r e c t o r a t e i n c l u d e s the program components from n u t r i t i o n , f a m i l y p l a n n i n g and m a t e r n a l and c h i l d h e a l t h , h e a l t h e d u c a t i o n , s a f e t y p r a c t i c e s and s t r e s s , and the substance abuse areas of a l c o h o l , tobacco and drugs ( f o r m e r l y addressed by the N o n - M e d i c a l Use of D r u g s ) , and the H e a l t h R i s k Assessment U n i t (Hawkins, 1979). The purpose of the H e a l t h Promotion D i r e c t o r a t e ' s Program i s to i n c r e a s e b e h a v i o r s which c o n t r i b u t e to p e r s o n a l h e a l t h and w e l l - b e i n g , and to reduce b e h a v i o r s which expose i n d i v i d u a l s to r i s k of d i s e a s e or a c c i d e n t . -To a c h i e v e t h i s , the program i s d i r e c t e d toward the d e t e r m i n a n t s or causes of such b e h a v i o r s at the i n d i v i d u a l , s o c i a l , i n s t i t u t i o n a l and e n v i r o n m e n t a l l e v e l s , and employs the f o l l o w i n g four s t r a t e g i e s : 1. H e a l t h promot ion and e d u c a t i o n ; . 2. P o l i c y development and i n d u s t r i a l l i a i s o n ; 3. R i s k Assessment and s c r e e n i n g ; and , 4. I n t e r v e n t i o n . S i n c e t h i s e s t a b l i s h m e n t of an i n t e g r a t e d h e a l t h promot ion program w i t h i n one d i r e c t o r a t e , a t t e n t i o n has been g i v e n by the Department of H e a l t h and Wel fare to l o n g - r a n g e p l a n n i n g , o b j e c t i v e s e t t i n g and the c o n s o l i d a t i o n of 24 p r o j e c t s i n order to secure g r e a t e r impact . The Department has i n d i c a t e d tha t they are now ready for a new t h r u s t in h e a l t h p r o m o t i o n . The approach taken in the Report of the Ad Hoc  Committee on N a t i o n a l H e a l t h S t r a t e g i e s (1982) focuses on r e d u c i n g • C a n a d a ' s h e a l t h prob lems . Hence, the r e p o r t i s o r i e n t e d more towards the p r e v e n t i o n of problems that cause premature d e a t h , s i c k n e s s and d i s a b i l i t y , than to the r e s t r u c t u r i n g of the h e a l t h system. The r e p o r t p r o v i d e s an o p e r a t i o n a l framework tha t can be used to reduce h e a l t h r i s k s , improve h e a l t h s t a t u s and enhance q u a l i t y of l i f e through the c o o p e r a t i v e e f f o r t s of an a c t i v e F e d e r a l / P r o v i n c i a l / T e r r i t o r i a l Committee s t r u c t u r e i n the h e a l t h promot ion f i e l d (Roptman, 1982). G o a l s have been e s t a b l i s h e d f o r the p r i o r i t y h e a l t h problems a f f e c t i n g Canadians and as was expressed i n the r e p o r t : "Because the s e v e r i t y , magnitude and p r i o r i t y a t t a c h e d to each problem vary in d i f f e r e n t p a r t s of the c o u n t r y , the task of q u a n t i f y i n g the goa l s and e s t a b l i s h i n g t h e i r order of p r i o r i t y has been l e f t to p r o v i n c i a l and t e r r i t o r i a l j u r i s d i c t i o n s . " The s t r a t e g i e s proposed by the Ad Hoc Committee f a l l i n t o f i v e major a r e a s : 1. H e a l t h r i s k r e d u c t i o n 2. E a r l y d e t e c t i o n of h e a l t h problems 3. Treatment 25 4. R e h a b i l i t a t i o n 5. R e s e a r c h , e v a l u a t i o n and data c o l l e c t i o n . These s t r a t e g i e s complement the long term o b j e c t i v e s of the B . C . M i n i s t r y of H e a l t h (1979) which are to implement a p r o v i n c e - w i d e e d u c a t i o n program d i r e c t e d at the p u b l i c and d e a l i n g w i t h : (a) t h e i r f i n a n c i a l r e s p o n s i b i l i t y and u t i l i z a t i o n of s e r v i c e s ; (b) t h e i r l i f e s t y l e and a t t i t u d e s ; and (c) t h e i r p e r s o n a l , f a m i l y and community invo lvement . A c t i o n s p lanned by the M i n i s t r y for 1983/84 i n c l u d e a f u r t h e r emphasis on p r e v e n t i v e and h e a l t h promot ion programs w h i c h , i t i s a n t i c i p a t e d , w i l l be i n c o r p o r a t e d i n t o the l e g i s l a t i o n of a proposed new h e a l t h ac t f or B r i t i s h C o l u m b i a . However, the M i n i s t r y has not i n d i c a t e d that budget a l l o c a t i o n s for P r e v e n t i v e S e r v i c e s w i l l be i n c r e a s e d . A major means of i n i t i a t i n g these h e a l t h promot ion p o l i c y d i r e c t i o n s i s through c o o p e r a t i v e e f f o r t s between f e d e r a l , p r o v i n c i a l and l o c a l governments and w i t h p r o f e s s i o n a l and v o l u n t a r y a s s o c i a t i o n s , b u s i n e s s and l a b o u r . To t h i s end, t h i s t h e s i s i s d i r e c t e d toward the development of these c o o p e r a t i v e a c t i v i t i e s , p a r t i c u l a r l y at the p r o v i n c i a l and l o c a l l e v e l s , and w i l l addres s the f o l l o w i n g key assumptions in promot ing h e a l t h : 1. S i n c e , from both a s o c i e t a l and an i n d i v i d u a l p e r s p e c t i v e , i t i s l e g i t i m a t e and f e a s i b l e to promote h e a l t h and w e l l n e s s , e f f e c t i v e h e a l t h promot ion t o o l s 26 need to be des igned to reach i n d i v i d u a l s of d i f f e r e n t t a r g e t groups , and t h e i r use e v a l u a t e d . Chapter 2 reviews the s t a t e of the a r t of Canadian and American h e a l t h r i s k assessment s t r a t e g i e s and t h e i r r o l e in e f f e c t i v e h e a l t h promot ion e f f o r t s . A m a t r i x of s e l e c t e d c h a r a c t e r i s t i c s of a sample of r i s k assessment in s t ruments has been deve loped as a s u i t a b l e way to compare these c u r r e n t l y a v a i l a b l e approaches to l i f e s t y l e re form; 2. S ince i t i s l e g i t i m a t e and f e a s i b l e to d e s i g n h e a l t h promot ion t o o l s , a l l a v a i l a b l e pathways shou ld be used to reach i n d i v i d u a l s of d i f f e r e n t t a r g e t p o p u l a t i o n s . Chapter 3 addresses the need for a m a r k e t - o r i e n t e d approach to h e a l t h promot ion aimed at i n f l u e n c i n g a t t i t u d e s , knowledge and l i f e s t y l e b e h a v i o r s . A model for p l a n n i n g communication s t r a t e g i e s for h e a l t h promot ion i s p r e s e n t e d . T h i s p l a n d i s c u s s e s i n p a r t i c u l a r , the use of i n t e r a c t i v e e l e c t r o n i c t echno logy and mass communicat ions media s t r a t e g i e s for the promot ion of h e a l t h r i s k r e d u c t i o n . Chapter 4 a t tempts to marry the concept s of r i s k r e d u c t i o n and e f f e c t i v e communicat ions by p r o p o s i n g f i v e p o l i c y i n i t i a t i v e s for the i n t e g r a t i o n of assessment and communicat ion s t r a t e g i e s i n t o a h e a l t h promot ion p o l i c y for B r i t i s h C o l u m b i a . I t proposes a h e a l t h p a r t n e r s h i p of consumers , p u b l i c and p r i v a t e 27 s e c t o r p r o v i d e r s and the media, i n the p l a n n i n g of e f f e c t i v e r i s k r e d u c t i o n e f f o r t s . T h i s c h a p t e r a l s o d e v e l o p s the c r i t e r i a f o r d e s i g n i n g comprehensive h e a l t h assessment i n s t r u m e n t s f o r use w i t h d i f f e r e n t t a r g e t p o p u l a t i o n s i n v a r i o u s h e a l t h p r omotion s e t t i n g s . CHAPTER TWO H e a l t h Assessment S t r a t e g i e s For H e a l t h Promotion I l l n e s s i s more than a s t a t e of body. I t i n c o r p o r a t e s a l i f e s t y l e , a way of p e r c e i v i n g y o u r s e l f , and how you ask o t h e r s to see you and respond to y o u . ( J a f f e , 1980) 29 2.1 H e a l t h Hazard A p p r a i s a l / H e a l t h Risk Assessment: An  I n t r o d u c t i o n The u n d e r l y i n g p h i l o s o p h y of ( h e a l t h r i s k assessment) i s to encourage i n d i v i d u a l s to take s u c c e s s i v e l y more r e s p o n s i b i l i t y for t h e i r own h e a l t h . S u r e l y , no one can doubt t h a t , u l t i m a t e l y , t h i s w i l l be c r u c i a l l y important to the e v o l u t i o n of a t r u l y h e a l t h y s o c i e t y . (Mi l sum, 1981) The f i r s t h e a l t h r i s k assessment - H e a l t h Hazard A p p r a i s a l (HHA) - was p u b l i s h e d in 1970. The o r i g i n a l i n t e n t i o n s of Robbins and H a l l , c r e a t o r s of HHA, was to d e v e l o p ins truments tha t p h y s i c i a n s c o u l d put to p r a c t i c a l use i n c o u n s e l l i n g p a t i e n t s , and e s p e c i a l l y - in m o t i v a t i n g l i f e s t y l e change. Use among p h y s i c i a n s has r i s e n s l o w l y , whi l e at the same t ime , these ins truments have become w i d e l y adopted by h e a l t h e d u c a t o r s throughout Canada a n d ' t h e U n i t e d S t a t e s . Research i n d i c a t e s tha t h e a l t h r i s k assessment s t r a t e g i e s are u s e f u l i n h e l p i n g i n d i v i d u a l s i d e n t i f y t h e i r most l i k e l y causes of d i s e a s e and d e a t h . More i m p o r t a n t l y , t h e i r use can h e l p people e v a l u a t e t h e i r l i f e p a t t e r n s and show how, through t h e i r own a c t i o n s , they can improve t h e i r u s e f u l l i f e expec tancy . Swinehart (1979) p o i n t s out that "by p e r s o n a l i z i n g r i s k s , HHA undermines the common r e a c t i o n of d e n i a l ; by q u a n t i f y i n g p o t e n t i a l g a i n s i n l i f e expec tancy , i t p r o v i d e s 30 an unders tandab le reward and thus i n c r e a s e s m o t i v a t i o n ; and by i d e n t i f y i n g s p e c i f i c a c t i o n s tha t can be taken to reduce r i s k , i t a v o i d s the type of g e n e r a l e x h o r t a t i o n that i s t y p i c a l l y i n e f f e c t i v e . " B u i l t p r i m a r i l y on data from e p i d e m i o l o g i c a l s t u d i e s , t h i s h e a l t h promot ion t echn ique p r o v i d e s p r o b a b i l i t i e s , not d i a g n o s e s , through a "process of a s s e s s i n g the r i s k which i n d i v i d u a l s i n c u r for t h e i r major causes of d e a t h , be fore the presence of these p r e c u r s o r s have had a chance to be t r a n s l a t e d i n t o any p a t h o l o g y . The r i s k l e v e l of the p r e c u r s o r (eg. e l e v a t e d c h o l e s t e r o l l e v e l s ) i s a s se s sed n u m e r i c a l l y as a r i s k f a c t o r (eg. 1.6) which then must be a p p r o p r i a t e l y combined wi th o ther r i s k f a c t o r l e v e l s (eg . b l o o d p r e s s u r e ) i n a s s e s s i n g the t o t a l r i s k for each g i v e n cause of dea th (eg. h e a r t a t t a c k ) " (Mi l sum, 1983). By r e l a t i n g i n d i v i d u a l s ' h e a l t h - r e l a t e d b e h a v i o r s and p e r s o n a l c h a r a c t e r i s t i c s w i t h m o r t a l i t y s t a t i s t i c s , an i n d i v i d u a l ' s r i s k of d y i n g or a c q u i r i n g a s p e c i f i c d i s e a s e w i t h i n a d e f i n e d t ime p e r i o d ( u s u a l l y ten y e a r s ) i s e s t i m a t e d . S imply s t a t e d , the h e a l t h r i s k assessment proces s i d e n t i f i e s p r e v e n t a b l e and unpreventab le h e a l t h r i s k s for each i n d i v i d u a l p a r t i c i p a n t . These r i s k s demonstrate the b e n e f i c i a l e f f e c t s of r e d u c i n g p r e v e n t a b l e h e a l t h r i s k s , and t h e r e f o r e of h e a l t h , i n terms of l o n g e v i t y . Mi lsum (1983) e x p l a i n s that the reason on ly m o r t a l i t y s t a t i s t i c s for s p e c i f i c causes of death are used i s because the c u r r e n t 31 ep idemio logy i s a b l e to q u a n t i f y on ly these r i s k s reasonab ly a c c u r a t e l y . T h e r e f o r e , m o r b i d i t y , d i s a b i l i t y , c h r o n i c d i s e a s e , and w e l l n e s s are e x c l u d e d . However, i t shou ld be p o i n t e d out that the r a p i d p r o g r e s s of e p i d e m i o l o g i c and b i o m e d i c a l r e s e a r c h may w e l l have b e n e f i c i a l e f f e c t s on the-scope and v a l i d i t y of r i s k e s t i m a t i o n t e c h n i q u e s . Users of H e a l t h H a z a r d / H e a l t h R i s k A p p r a i s a l s have formed the "Soc i e ty of P r o s p e c t i v e M e d i c i n e " which i s ' " d e d i c a t e d to e x t e n d i n g u s e f u l l i f e expectancy by i d e n t i f y i n g a c t u a l and p o t e n t i a l h e a l t h h a z a r d s , and to r e d u c i n g these h e a l t h r i s k s by d e v e l o p i n g and implementing r i s k assessment t e c h n i q u e s and r i s k r e d u c t i o n programs ." The S o c i e t y h o l d s an annual meeting devoted to d i s c u s s i n g development , e x p e r i e n c e s and r e s e a r c h i n the f i e l d . T h i s mee t ing , now i n i t s n i n e t e e n t h y e a r , a t t r a c t s s e v e r a l hundred p a r t i c i p a n t s from the U n i t e d S t a t e s and Canada . The H e a l t h H a z a r d / H e a l t h Risk A p p r a i s a l p r o c e s s s t a r t s w i t h a q u e s t i o n n a i r e c o v e r i n g the areas of l i f e s t y l e , p e r s o n a l and f a m i l y m e d i c a l h i s t o r y , and a l i m i t e d number of c l i n i c a l measures . The format used at the U n i v e r s i t y of B r i t i s h C o l u m b i a , c u r r e n t l y c o n s i s t i n g of about 36 q u e s t i o n s , i s t y p i c a l and i s reproduced in Appendix A . The UBC format i s c o m p u t e r - s c o r e d , and upon e n t r y i n t o the computer , a p r i n t - o u t i s produced for c o u n s e l l o r and p a r t i c i p a n t . The p r i n t - o u t format v a r i e s w ide ly among d i f f e r e n t o r g a n i z a t i o n s , but the U n i v e r s i t y of B r i t i s h 32 C o l u m b i a ' s p r i n t - o u t shown i n Appendix B i s f a i r l y t y p i c a l . I t s h o u l d be noted t h a t HHA/HRA ins t ruments do not show a l l p o s s i b l e h e a l t h h a z a r d s , r a t h e r on ly those r i s k s tha t have been s u f f i c i e n t l y s t u d i e d and from which reasonab le p r e d i c t i o n s can be made are a n a l y z e d . F u r t h e r m o r e , emphasis i s on the h e a l t h r i s k s which are r e d u c i b l e by a c t i o n s taken by an i n d i v i d u a l . A s i d e from the major HHA/HRA i n s t r u m e n t s , there are three o ther g e n e r a l c l a s s e s of r i s k assessment i n s t r u m e n t s . The f i r s t c o n s i s t s of v a r i a t i o n s of the HHA/HRA i n s t r u m e n t s : for example, program p e r s o n n e l adapt the major ins trument to l o c a l needs by modi fy ing the q u e s t i o n s , an example b e i n g the YMCA des igned assessment t o o l , L I F E ( L i f e s t y l e I n v e n t o r y and F i t n e s s E v a l u a t i o n ) . The second c l a s s of i n s t r u m e n t s a l s o a s se s se s h e a l t h r i s k s but does not express these r i s k s i n p r o b a b i l i s t i c terms (eg . r i s k age, a p p r a i s e d l i f e expec tancy , chances of d y i n g of s p e c i f i c d i s e a s e , e t c . ) . However, these r i s k assessment i n s t r u m e n t s , used f r e q u e n t l y i n the media and in employee h e a l t h programs, a l s o p r o v i d e i n d i v i d u a l s w i t h feedback about t h e i r h e a l t h o u t l o o k . M a i n l y s e l f - s c o r e d , these t e s t s i n t e r p r e t a p e r s o n ' s score q u a l i t a t i v e l y a s , f or example, "average r i s k " , "moderate r i s k " or " r i s k at dangerous l e v e l " . The importance of these s e l f - s c o r e d t e c h n i q u e s i s tha t they o f t e n p r o v i d e the i n i t i a l exposure to the concept of some s e l f - r e s p o n s i b i l i t y towards h e a l t h . 33 An example of t h i s type of assessment ins trument i s the H e a l t h and Wel fare Canada s e l f - s c o r e d v e r s i o n of HHA, "Your L i f e s t y l e P r o f i l e " , which i s p r e s e n t e d in Appendix C . Born out of e f f o r t s to make the p u b l i c aware of i t s r i s k s for l a r g e l y p r e v e n t a b l e d i s e a s e s ( i n p a r t i c u l a r , c a n c e r s and d i s e a s e s of the h e a r t ) , a t h i r d c l a s s of h e a l t h r i s k assessment s t r a t e g i e s has been des igned to p r o v i d e p r e d i c t i o n s for many o ther h e a l t h prob lems . These measurements of r i s k and the p o t e n t i a l b e n e f i t s of b e h a v i o r a l change are p r e s e n t e d to i n d i v i d u a l s i n order to s t i m u l a t e t h e i r p a r t i c i p a t i o n in a c t i v i t i e s aimed at chang ing l i f e s t y l e and improv ing t h e i r h e a l t h (Wagner, B e e r y , Schoenbach and Graham, 1982). Examples i n c l u d e the U n i v e r s i t y of T u c s o n ' s "Well Aware About H e a l t h " p r o j e c t , and the " L i f e s t y l e Assessment Q u e s t i o n n a i r e " deve loped by the I n s t i t u t e for L i f e s t y l e Improvement at the U n i v e r s i t y of W i s c o n s i n , Stevens P o i n t . Whi le h e a l t h r i s k assessment ins truments are not p r e s e n t l y as comprehensive in t h e i r e s t i m a t i o n of r i s k s and s t i m u l a t i o n f o r b e h a v i o u r a l change as a l l would l i k e , they do , however, a c c o r d i n g to Milsum (1981) "seem to have the i n n a t e p o t e n t i a l to i n c l u d e w i t h i n t h e i r framework new knowledge as i t becomes a v a i l a b l e , and i n d e e d , to s t i m u l a t e the a c q u i s i t i o n of such new knowledge." Thus , H e a l t h R i s k A p p r a i s a l in s t ruments can c o n t r i b u t e to the knowledge base by becoming r e s e a r c h t o o l s themse lves . 34 In Canada and the U n i t e d S t a t e s , thousands of h e a l t h p r o f e s s i o n a l s have now been exposed to the concept of h e a l t h r i s k assessment , of whom a s u b s t a n t i a l p r o p o r t i o n have used i t i n p r a c t i c e . F u r t h e r , government agenc i e s i n both c o u n t r i e s have en tered i n t o a c o l l a b o r a t i v e agreement to r e s e a r c h , s t r e n g t h e n and e v a l u a t e t h i s p o t e n t i a l l y u s e f u l i n n o v a t i o n . 2.2 S t a t u s of H e a l t h R i s k Assessment in Canada C o n s i s t e n t wi th H e a l t h and Wel fare Canada's p o s i t i v e approach to h e a l t h promot ion (as o u t l i n e d in Chapter 1) are the p r i n c i p l e s of p r o s p e c t i v e m e d i c i n e : the development of a h e a l t h assessment and c o u n s e l l i n g system such as H e a l t h Hazard A p p r a i s a l for the b e n e f i c i a l r e d u c t i o n of i n d i v i d u a l h e a l t h r i s k s through h e a l t h f u l l i f e s t y l e change. In the Department of H e a l t h and W e l f a r e , the m i s s i o n of the H e a l t h Promot ion D i r e c t o r a t e ' s "Heal th R i s k Assessment U n i t " i s to e v a l u a t e and expand the development of t e c h n i q u e s needed to f i l l the gaps p r e s e n t e d by the more t r a d i t i o n a l Robbins & H a l l r i s k assessment d e v i c e s (Hawkins, 1979). S ince the e a r l y 1970s, the f e d e r a l government's c o m p u t e r - p r o c e s s e d v e r s i o n of H e a l t h Hazard A p p r a i s a l , now c a l l e d " E v a l u * L i f e / E v a l u * V i e " , has been p r o v i d e d by the H e a l t h R i s k Assessment U n i t to over 500 h e a l t h p r o f e s s i o n a l s a c r o s s Canada , and to at l e a s t 200 more by the two 35 u n i v e r s i t y p r o v i d e r s , the U n i v e r s i t y of B r i t i s h Columbia and D a l h o u s i e U n i v e r s i t y in Nova S c o t i a . These hundreds of users span a v a r i e t y of h e a l t h p r o f e s s i o n a l s and s e t t i n g s from f a m i l y p r a c t i c e to employee h e a l t h s e r v i c e s (Torrance and D ' A r c y , 1981). Whi le the number of users and volume of HHA use have been growing s t e a d i l y , even i n the absence of a g g r e s s i v e m a r k e t i n g , there i s o n l y a s m a l l number who c o u l d be c h a r a c t e r i z e d as s u s t a i n e d , r o u t i n e u s e r s . In a survey conducted by T o r r a n c e and D ' A r c y (1981), i t was found that 50 to 60 people out of over 500 on the H e a l t h and Wel fare m a i l i n g l i s t were r e g u l a r u s e r s . In terms of o v e r a l l volume, the e d u c a t i o n a l s e c t o r i s a heavy user of HHA, w i t h c o l l e g e and u n i v e r s i t y users a c c o u n t i n g for about 23% of a l l a p p r a i s a l s submit ted d u r i n g 1980. A s i d e from the core of s u s t a i n e d , committed u s e r s , i t was found tha t there i s a s i z e a b l e p o o l of more c a s u a l users who i n t e n d to use HHA o c c a s i o n a l l y in the f u t u r e , as and when the o p p o r t u n i t y a r i s e s . T o r r a n c e and D ' A r c y (1981) r e p o r t e d tha t t h e i r HHA sample appeared to be drawn from a subgroup of a l l p r a c t i t i o n e r s tha t i s h i g h l y committed to p r e v e n t i o n and h e a l t h p r o m o t i o n . "Your L i f e s t y l e P r o f i l e " , the p e r s o n a l use h a n d - s c o r e d v e r s i o n of H e a l t h Hazard A p p r a i s a l , has been d i r e c t l y d i s t r i b u t e d in pamphlet form to over 3.6 m i l l i o n f a m i l i e s i n Canada through the F a m i l y Al lowance and O l d Age Pens ion 36 "Cheque I n s e r t Program," and l e s s d i r e c t l y , by o ther means. In c o n j u n c t i o n wi th the M i n i s t r y of F i t n e s s and Amateur S p o r t s , i t has been r e c e n t l y programmed for use on microcomputers , and has been the c e n t e r of H e a l t h and Wel fare Canada e x h i b i t s at v a r i o u s n a t i o n a l e x h i b i t i o n s and f a i r s . Former s t a f f member of the H e a l t h R i s k Assessment U n i t , Lynne Hawkins (1979) acknowledges , "the p u b l i c ' s r e a c t i o n to t h i s k i n d of l i f e s t y l e awareness and i n t e r a c t i o n w i t h the computer has been very p o s i t i v e " . The Canadian H e a l t h Hazard A p p r a i s a l Users S u r v e y , conducted by T o r r a n c e and D ' A r c y in 1980 ( T o r r a n c e and D ' A r c y , 1981), c o n v i n c e d them tha t "there i s a committed community of h e a l t h and r e l a t e d p r o f e s s i o n a l s i n Canada eager to do something about l i f e s t y l e r i s k assessment and h e a l t h e d u c a t i o n " . With few p r o v i s o s , u sers see H e a l t h Hazard A p p r a i s a l as "performing a u s e f u l or even e s s e n t i a l r o l e as an a w a r e n e s s - s t i m u l a t i n g t o o l , as a t e a c h i n g a i d , and as an en tree to the t o p i c of l i f e s t y l e s and h e a l t h " ( T o r r a n c e and D ' A r c y , 1981). 2.3 The H e a l t h R i s k Assessment C o n t r o v e r s y : What r i s k  e s t i m a t i o n i s and what i t i s not Man's p h y s i c a l and mental s t a t e , in h e a l t h and d i s e a s e , i s a lways c o n d i t i o n e d by a l l the m u l t i p l e de terminant s of h i s n a t u r e . (Dubos, 1965) 37 I m p l i e d in t h i s method of a s s e s s i n g h e a l t h i s the comparison of the person whose r i s k i s be ing e s t i m a t e d wi th groups of persons i n the past who share the same set of r i s k i n d i c a t o r s . F u r t h e r i m p l i e d i s the assumption that the presence of the same set of r i s k i n d i c a t o r s then and now has the same h e a l t h consequences (Goetz , Duff and B e r n s t e i n , 1978). I t i s d i f f i c u l t to a s se s s the v a l i d i t y of these a s sumpt ions , and E l i a s (1982) warns that the s t a t e of the a r t i n e p i d e m i o l o g y , i n h i s o p i n i o n , has not reached a p o i n t which would r e l i a b l y permit p r e d i c t i o n of i n d i v i d u a l m o r b i d i t y or m o r t a l i t y r i s k from c u r r e n t e p i d e m i o l o g i c a l d a t a . R i s k e s t i m a t i o n i s not the p r e d i c t i o n of an i n d i v i d u a l ' s f u t u r e m e d i c a l h i s t o r y , Even i f two persons had an i d e n t i c a l se t of r i s k i n d i c a t o r s t h e i r f a t e may be v a s t l y d i f f e r e n t due to v a r i a b l e s as yet not c a p t u r e d in the r i s k i n d i c a t o r set> such as env ironmenta l exposures p r e s e n t l y not known to have consequences f o r r i s k , pa thogen ic proces se s underway, or d i f f e r e n c e s i n genotype (Goetz et a l , 1978). E s t i m a t e s of r i s k can o n l y g ive the odds or l i k e l i h o o d of an event (such as a m y o c a r d i a l i n f a r c t i o n ) o c c u r r i n g in a group of people w i t h or wi thout a c e r t a i n set of c h a r a c t e r i s t i c s (such as smoking, be ing of average we ight , or h a v i n g h i g h b l o o d p r e s s u r e ) . I t i s r e a s o n a b l e , t h e r e f o r e , to conc lude that the a c c u r a c y of r i s k p r e d i c t i o n s are l i m i t e d . However, wi th i n c r e a s i n g knowledge 38 about r i s k i n d i c a t o r s and f a c t o r s , the range of p o s s i b l e h e a l t h outcomes f o r an i n d i v i d u a l may w e l l be a s s e s s e d w i t h ever g r e a t e r p r e c i s i o n . S i m i l a r c o n c l u s i o n s were reached by W i l l i a m Beery and a s s o c i a t e s a t - t h e U n i v e r s i t y of N o r t h C a r o l i n a upon c o m p l e t i o n of an e x t e n s i v e D e s c r i p t i o n , A n a l y s i s and  Assessment of H e a l t h H a z a r d / H e a l t h R i s k A p p r a i s a l Programs (1981) i n the U n i t e d S t a t e s and Canada. Under c o n t r a c t w i th the Department of H e a l t h and Human S e r v i c e s , N a t i o n a l Center f o r H e a l t h S e r v i c e s R e s e a r c h , the p r o j e c t s t a f f i d e n t i f i e d 217 programs, of which 15 were s e l e c t e d for s i t e v i s i t . These s i t e s were s e l e c t e d by u s i n g a d e f i n e d set of c r i t e r i a i n an e f f o r t to i n c l u d e programs which had a d m i n i s t e r e d at l e a s t 300 HHA/HRAs in the p r e v i o u s y e a r , and , in the a g g r e g a t e , used a f u l l range of a v a i l a b l e HHA/HRA ins truments i n a v a r i e t y of s e t t i n g s , w i t h a broad range of a v a i l a b l e r i s k r e d u c t i o n s e r v i c e s . In a d d i t i o n , programs u s i n g i n n o v a t i v e approaches , c o n d u c t i n g major e v a l u a t i o n s or s e r v i n g m i n o r i t y or low-income c l i e n t s were g iven p r i o r i t y for s e l e c t i o n . S i t e v i s i t s were conducted over a one- to - two day p e r i o d u s i n g a s t r u c t u r e d p r o t o c o l . Both program s t a f f and managers i n the s p o n s o r i n g i n s t i t u t i o n ( s ) r e s p o n s i b l e for the program's c u r r e n t and f u t u r e p o s i t i o n w i t h i n the i n s t i t u t i o n were i n t e r v i e w e d . The review i n c l u d e d a c o n f e r e n c e i n v o l v i n g n a t i o n a l l y r e c o g n i z e d e x p e r t s i n the b e h a v i o r a l s c i e n c e s , e p i d e m i o l o g y , b i o s t a t i s t i c s and p o l i c y 39 s c i e n c e . The f i n a l r e p o r t c o n c l u d e d that "desp i te growing use of h e a l t h hazard a p p r a i s a l t e s t i n g , e f f e c t i v e n e s s of t e c h n i q u e des igned to encourage h e a l t h y b e h a v i o r i s s t i l l unknown" (Wagner, Beery et a l , 1982). That there are b a r r i e r s to the use of h e a l t h r i s k assessment ins truments i s i n d i s p u t a b l e . Upon e x t e n s i v e review of the l i t e r a t u r e , the major l i m i t a t i o n s of r i s k assessment have been c o m p i l e d and are p r e s e n t e d in T a b l e 2 . 1 . But a l t h o u g h h e a l t h r i s k a p p r a i s a l has many i n h e r e n t p r o b l e m s , compounded by some i n s t a n c e s of misuse , ( F i e l d i n g , 1982), concern w i t h these problems sh ou ld not l e a d us to o v e r l o o k the number of a c t u a l and p o t e n t i a l i n d i v i d u a l b e n e f i t s which i t can c o n f e r and the v a r i e t y of o ther uses to which i t can be p u t . These demonstrated b e n e f i t s are p r e s e n t e d i n T a b l e 2 . 2 . 40 T a b l e 2.1 B a r r i e r s To Us ing H e a l t h R i s k Assessment S t r a t e g i e s 1. Lack of economic i n c e n t i v e for h e a l t h p r o f e s s i o n a l s , p a r t i c u l a r l y n o n - b i l l a b l e t ime for p h y s i c i a n s 2. U n c e r t a i n t y about the r e l i a b i l i t y and v a l i d i t y of databases and r i s k e s t i m a t i o n a n a l y s i s 3. U n c e r t a i n t y about the measurement r e l i a b i l i t y and v a l i d i t y of independent v a r i a b l e s 4. U n c e r t a i n t y about the e f f e c t i v e n e s s in chang ing b e h a v i o r 5. Inaccuracy of s e l f - r e p o r t e d c l i e n t data 6. Problems in t r a n s l a t i n g p o p u l a t i o n - b a s e d a g e - s p e c i f i c data to i n d i v i d u a l s 7. Fundamental problems r e g a r d i n g d e f i n i t i o n , measurement and impact of e n v i r o n m e n t a l , p s y c h o l o g i c a l and s o c i o -economic f a c t o r s on h e a l t h and h e a l t h r e l a t e d b e h a v i o r s 8. May c o n s t i t u t e "blaming the v i c t i m " 9. H i g h l y q u a n t i t a t i v e p r e s e n t a t i o n g e n e r a l l y demands h i g h e r - t h a n - a v e r a g e e d u c a t i o n 10. N o n - a p p l i c a b i l i t y to persons wi th s p e c i a l r i s k s , i n c l . o c c u p a t i o n a l , r e c r e a t i o n a l , r a c i a l , e t h n i c , e t c . and p r e - e x i s t i n g pa tho logy 11. Promulga t ion of l i f e s t y l e s which may be i n c o n s i s t e n t w i t h v a l u e s and t r a d i t i o n s of s p e c i f i c p o p u l a t i o n 41 groups A d u l t - o r i e n t e d . P a u c i t y of ins truments a p p l i c a b l e to a d o l e s c e n t s and the e l d e r l y M o r t a l i t y - b a s e d Death postponement message r a t h e r than enhanced " w e l l n e s s'Vquality of l i f e Undue emphasis on formal e x e r c i s e and s p o r t s - l a c k of ' f u n c t i o n i n g s t a t u s ' e g . , e x e r c i s e s of d a i l y l i v i n g C l i e n t r e s i s t a n c e and concern over c o n f i d e n t i a l i t y of r e s u l t s P o s i t i v e re in forcement not n e c e s s a r i l y i n c l u d e d C o s t - e f f e c t i v e n e s s q u e s t i o n e d N u t r i t i o n , s t r e s s , s o c i a l s u p p o r t , s p i r i t u a l v a l u e s not addres sed Lack of c o - o r d i n a t e d c o n s u m e r - o r i e n t e d marke t ing mechan i sm S c e p t i c a l a t t i t u d e among p h y s i c i a n s T a b l e 2.2 Demonstrated B e n e f i t s From U s i n g H e a l t h R i s k Assessment S t r a t e g i e s 1. M o t i v a t i o n a l d e v i c e for s t i m u l a t i n g l i f e s t y l e behav ior change 2. Enhances c l i e n t knowledge of r e l a t i o n s h i p between 12. 13. 14. 15. 16. 17. 18. 19. 20. 21 . 4 2 h e a l t h r i s k s and p e r s o n a l b e h a v i o r 3. P r o v i d e s i n d i v i d u a l s w i t h i n f o r m a t i o n and r e i n f o r c e m e n t which w i l l a i d them in t h e i r d e c i s i o n - m a k i n g 4. Growing acceptance among h e a l t h e d u c a t o r s 5. P r o v i d e s a permanent document wi th p e r s o n a l i z e d i n f o r m a t i o n r e t a i n a b l e so as to t r a c k p r o g r e s s (or l a c k of i t ) in a m e l i o r a t i n g h e a l t h r i s k s 6. F a c i l i t a t e s h e a l t h p r o f e s s i o n a l s ' knowledge of p r i n c i p l e of p r e v e n t i v e medic ine 7. F a c i l i t a t e s the c o u n s e l l o r r o l e of h e a l t h c a r e p r o v i d e r 41bbbb 8. "Here and now" aspec t of i n d i v i d u a l ' s unique s i t u a t i o n i s a p r i n c i p a l s t r e n g t h 9. R a t i o n a l e u n d e r l y i n g the concept i s t i m e l y 10. A d a p t a b l e to m u l t i p l e h e a l t h promot ion programs in a v a r i e t y of s e t t i n g s 11. R e l a t i v e l y i n e x p e n s i v e 12. S e n s i t i v e i n d i c a t o r of l i f e s t y l e b e h a v i o r s in the community or work p l a c e 13. U s e f u l r e s e a r c h t o o l 14. A d a p t a b l e to i n t e r a c t i v e - m i c r o c o m p u t e r systems 15. M o t i v a t i o n a l component of mass media h e a l t h i n f o r m a t i o n programs 16. C o n s t a n t l y be ing updated , expanded, improved and made more b r o a d l y a p p l i c a b l e 17. S t i m u l a t e s a c q u i s i t i o n of new knowledge 43 The u l t i m a t e c r i t e r i o n for d e t e r m i n i n g h e a l t h r i s k assessment ' s va lue i s i t s impact on a t a r g e t p o p u l a t i o n ' s h e a l t h s t a t u s . The p e n u l t i m a t e c r i t e r i o n , and one more r e a d i l y measurable , i s i t s e f f e c t i v e n e s s in r e d u c i n g i d e n t i f i e d r i s k s by s t i m u l a t i n g b e h a v i o r change, or r e i n f o r c i n g the maintenance of h e a l t h f u l b e h a v i o r . To make use of the growing knowledge r e p o r t e d in the e p i d e m i o l o g i c a l and b i o m e d i c a l l i t e r a t u r e , and to o b t a i n b e t t e r p r e c i s i o n of r i s k e s t i m a t i o n , r i s k assessment ins truments must c o n t i n u a l l y up-date r i s k i n d i c a t o r s and r i s k f a c t o r s . 2.4 Component C h a r a c t e r i s t i c s of H e a l t h Risk Assessment  Ins truments A r e l i a b l e and v a l i d m u l t i p h a s i c h e a l t h t e s t i n g system c o u l d be a b a s e l i n e f o r the e v a l u a t i o n of h e a l t h s t a t u s and h e a l t h r i s k s . As w e l l , i t would complement the p r i m a r y o b j e c t i v e of our h e a l t h care system - the improved h e a l t h s t a t u s and q u a l i t y of l i f e f or i n d i v i d u a l s , and for the p o p u l a t i o n as a whole . Whi le people are l e a r n i n g h e a l t h i e r l i f e s t y l e s i n a v a r i e t y of s e t t i n g s ( p r i v a t e m e d i c a l p r a c t i c e s and community c l i n i c s , p u b l i c h e a l t h u n i t s , workplace h e a l t h s e r v i c e s , e d u c a t i o n a l s e t t i n g s and r e c r e a t i o n a l , community and f i t n e s s programs) there i s a c r i t i c a l need to i n t e g r a t e a h e a l t h 4 4 a p p r a i s a l system i n t o c o o r d i n a t e d h i g h - q u a l i t y r i s k r e d u c t i o n and h e a l t h enhancement programs. A m a t r i x of s e l e c t e d c h a r a c t e r i s t i c s of a sample of twenty c u r r e n t l y a v a i l a b l e Canadian and American h e a l t h r i s k a p p r a i s a l in s t ruments - c o m p u t e r - s c o r e d , i n t e r a c t i v e -computer and s e l f - s c o r e d - has been deve loped as a s u i t a b l e way to compare these d i f f e r e n t approaches to h e a l t h r i s k assessment . The f o l l o w i n g ins trument components were used to f a c i l i t a t e t h i s comparison ( r a t i n g s and a b b r e v i a t e d i d e n t i f i c a t i o n codes used in the m a t r i x are shown i n p a r a n t h e s e s ) . The m a t r i x i s p r e s e n t e d for the r e a d e r ' s i n f o r m a t i o n and i s shown i n T a b l e 2 . 3 . No c r i t i c a l a n a l y s i s of these a v a i l a b l e r i s k assessment ins truments w i l l be a t tempted h e r e . H e a l t h R i s k Assessment Instrument Components Format C o n s i d e r a t i o n s 1. What i s the in tended t a r g e t p o p u l a t i o n ? (TARGET POPUL) 2. Are sa feguards for p r i v a c y and c o n f i d e n t i a l i t y i n c l u d e d ? (CONFID SAFEGRD) 3. Are da ta p r o c e s s i n g q u a l i t y c o n t r o l mechanisms i n p l a c e to p r o t e c t a g a i n s t e r r o r s in e n t e r i n g i n f o r m a t i o n , p r i n t i n g out r e s u l t s , and d e l i v e r i n g h e a l t h p r o f i l e to 45 the c o r r e c t r e c i p i e n t ? (DATA PROC CONTROL) What are the sources of da ta and methodology used in c a l c u l a t i o n s of r i s k e s t i m a t i o n , i n c l u d i n g the review and update of these data bases? (DATA SOURCE) Des ign C o n s i d e r a t i o n s Length of q u e s t i o n n a i r e . (LENGTH) C l a r i t y of i n s t r u c t i o n s , q u e s t i o n s and feedback i n f o r m a t i o n for i n d i v i d u a l s of the i n t e n d e d a u d i e n c e , eg . w i t h a v a r i e t y of e d u c a t i o n a l background . (CLARITY) [ E x c e l l e n t , Good, A c c e p t a b l e , Poor] "User f r i e n d l y " in terms of des ign - c r e a t i v e , upbeat , use of g r a p h i c d e v i c e s . Des ign c o n s i s t e n t w i t h in tended a u d i e n c e , eg. , young p e o p l e , o l d p e o p l e . (USER FRIEND) [ E x c e l l e n t , Good, A c c e p t a b l e , Poor] 46 Feedback C o n s i d e r a t i o n s 1. Are recommendations made to improve i n d i v i d u a l r i s k score? Does feedback focus on a m e l i o r a b l e r i s k s ? (RISK RECOMM) 2. Does feedback c o n t a i n s u f f i c i e n t p o s i t i v e r e i n f o r c e m e n t for h e a l t h f u l b e h a v i o r s ? (POSITIVE FEED) 3. Is an e q u i v a l e n t age a n d / o r l i f e expectancy p r o j e c t e d ? (ESTIMATE AGE) 4. Are m e d i c a l r e f e r r a l s recommended? (MEDICAL REF) 5. Are a v a i l a b l e community and l i t e r a t u r e r e s o u r c e s recommended? (RESOURCE RECOMM) 6. Does the program o f f e r i n d i v i d u a l or group c o u n s e l l i n g ? (COUNSEL) 7. Does the program o f f e r f o l l o w - u p ? (FOLLOW-UP) Measurement C o n s i d e r a t i o n s 1. G e n e r a l p e r s o n a l h e a l t h h i s t o r y - past and c u r r e n t . (HEALTH HISTORY) 2. F a m i l y h e a l t h h i s t o r y . (FAMILY HISTORY) 3. P h y s i o l o g i c d a t a . (PHYSICAL DATA) [ s e l f - r e p o r t e d / m e a s u r e d ; not c o l l e c t e d ] 4. L a b o r a t o r y d a t a . (LAB DATA) [ s e l f - r e p o r t e d / m e a s u r e d ; 47 not c o l l e c t e d ] 5. Are h e a l t h a t t i t u d e s measured? (HEALTH ATTIT) 6. Is h e a l t h knowledge measured? (HEALTH KNOW) 7. Are o c c u p a t i o n a l / v o c a t i o n a l and r e c r e a t i o n r i s k s i d e n t i f i e d ? (OCCUPATION RECREAT) 8. Are g e o g r a p h i c a l and e n v i r o n m e n t a l v a r i a t i o n s ' taken i n t o account? (GEOGRAPHY ENVIRON) 9. Are c u l t u r a l , r a c i a l , e t h n i c v a r i a t i o n s c o n s i d e r e d ? (RACE OR ETHNIC) 10. Are h e a l t h - r e l a t e d sex d i f f e r e n c e s measured? (SEX DIFFER) 11. Is m e n t a l / e m o t i o n a l s t a t u s measured? (MENTAL EMOTION) 12. Are s o c i a l support systems measured? (SOCIAL SUPPORT) 13. Are s p i r i t u a l v a l u e s i d e n t i f i e d ? (SPIRITUAL) 14. Are s a f e t y and a c c i d e n t measures i n c l u d e d ? (SAFETY ACCIDENT) 15. Are abuse s u b s t a n c e s , eg . a l c o h o l , t o b a c c o , non-p r e s c r i b e d d r u g s , measured? (ABUSE SUBST) 16. Is s t r e s s - l i f e s t r e s s , work s t r e s s - i d e n t i f i e d ? (STRESS) 17. Is n u t r i t i o n measured? (NUTRITION) 18. Is f i t n e s s measured? (FITNESS) The twenty sample i n s t r u m e n t s d e s c r i b e d i n the m a t r i x a re Computer-Analyzed Q u e s t i o n n a i r e s (see T a b l e 2.3(a)) Canada: E v a l u * L i f e — H e a l t h & W e l f a r e Canada HHA -- U n i v e r s i t y of B r i t i s h Columbia Impco H e a l t h U n i t e d S t a t e s : MATRIX CODE HWC UBC IMPCO UW-SP L i f e s t y l e Assessment Q u e s t i o n n a i r e — U n i v e r s i t y of W i s c o n s i n , Stevens P o i n t W e l l Aware About H e a l t h -- U n i v e r s i t y of A r i z o n a UA H e a l t h R i s k A p p r a i s a l — CDC C e n t e r s f o r D i s e a s e C o n t r o l , G e o r g i a H e a l t h 80's -- M e d i c a l Datamation, Ohio MD P e r s o n a l H e a l t h P r o f i l e — GHC G e n e r a l H e a l t h Corp., D.C. Computer Interactive Questionnaires (see Table 2.3(b)) Canada: SPHERE — University of B r i t i s h Columbia Your L i f e s t y l e P r o f i l e --Health and Welfare Canada Fantastic L i f e s t y l e Assessment --McMaster University, Ontario United States: Healthwise --Computerized Health Appraisals, Ore. Millon Behavioral Health Inventory C l i n i c a l Assessment Systems, Inc. Health Risk Appraisal --University of Minnesota Self-Scored Questionnaires (see Table 2.3(c)) Canada: Your L i f e s t y l e P r o f i l e --Health and Welfare Canada Par-Q — B.C. Ministry of Health 50 Sunset Wel lnes s P r o j e c t - - VHD Vancouver H e a l t h Department I n d i v i d u a l S t r e s s Assessment - - WCHG Western Centre H e a l t h Group U n i t e d S t a t e s : H e a l t h S t y l e — Dept . of H e a l t h and Human S e r v i c e s P . L . U . S . - -Dept . of H e a l t h and Env ironment , Kansas See Appendix D for names and addresses of d i s t r i b u t o r s for the above i n s t r u m e n t s . HHS HEK 51 T a b l e 2 .3 (a) Instrument Component M a t r i x : Computer -Ana lyzed Q u e s t i o n n a i r e s . Format , d e s i g n and feedback c o n s i d e r a t i o n s C A N A D ; U N n CED ST/ VTES MEASURE HWC UBC IMPCO UW-SP UA CDC MD GHC TARGET 25-65 18-65 a d u l t 18 + a d u l t a d u l t a d u l t a d u l t POPUL work work CONFID yes yes yes yes yes yes yes yes SAFEGRD * DATA PROC D/U yes yes D/U D/U D/U D / U D/U CONTROL DATA R+H R+H Fram R+H R+H R+H D / U USM SOURCE CM CM SRRS Fram BSNI SSS LENGTH 2 5q 25q 80q 1 99q 1 80q 34q >300q 1 6p 30p 2-8p 48p CLARITY good good good good exc 1 good good e x c l USER good good good good e x c l good accp e x c l FRIEND RISK yes yes yes yes yes yes yes yes RECOMM POSITIVE no no yes no no no yes yes FEED ESTIMATE yes yes no yes yes no yes yes AGE MEDICAL yes yes P/R no no yes no D/U REF RESOURCE no no yes yes yes no yes yes RECOMM COUNSEL P/D P/D yes P/D yes P/D D / U I / D FOLLOW-UP P/D P/D yes P/D yes P/D D / U no LEGEND R+H - - Core Robbins and H a l l HHA CM Canadian M o r t a l i t y S t a t i s t i c s (1973-75) Fram - - Framingham h e a r t s tudy SRRS - - S o c i a l Readjustment R a t i n g S c a l e (Holmes & Rake) BSNI - - Berkman's S o c i a l Network Index sss -- S u b j e c t i v e S t r e s s S c a l e USM - - U n i t e d S t a t e s M o r t a l i t y S t a t i s t i c s P/D - - Program dependent D / U - - Data u n a v a i l a b l e I / D - I n c l u d e d in d e s i g n 52 Table 2.3(a) -- Continued Measurement Considerations CANAD; UNII ^ED ST/ ^TES MEASURE HWC UBC IMPCO UW-SP UA CDC MD GHC HEALTH yes yes yes yes yes yes yes yes HISTORY FAMILY yes yes yes yes yes yes yes yes HISTORY PHYSICAL S/R S/R M S/R S/R S/R S/R S/R DATA or M + M LAB S/R S/R M S/R S/R S/R S/R S/R DATA + M HEALTH no no yes yes yes no yes yes ATT IT HEALTH no no yes no yes no yes yes KNOW N/M N/M OCCUP no no yes yes yes no yes yes RECREAT GEOGRAPHY no no no no no no yes no ENVIRON RACE or no no no yes yes no yes yes ETHNIC SEX yes yes no yes yes .yes yes yes DIFFER MENTAL yes yes yes yes yes no yes yes EMOTION SOCIAL no no no yes yes no no yes SUPPORT SPIRITUAL no no no yes no no no no SAFETY yes yes yes yes yes yes yes yes ACCIDENT ABUSE yes yes yes yes yes yes yes yes SUBST STRESS no no yes yes yes no yes yes NUTRITION no no yes yes yes no yes yes FITNESS yes yes yes yes yes yes yes yes LEGEND M -- Measured N/M -- Not measured S/R — Self-reported 53 T a b l e 2 .3 (b) Instrument Component M a t r i x : Computer I n t e r a c t i v e Quest ionna i r e s . Format , Des ign and Feedback C o n s i d e r a t i o n s c; ^NADA UNITE! ) STATES MEASURE UBC HWC MCM CHA CAS UM TARGET 18-65 16 + 18+ a d u l t a d u l t 18 + POPUL CONFID yes yes D / U no yes yes SAFEGRD DATA PROC yes D / U D / U D/U D / U D / U CONTROL DATA R+H D / U D / U R+H MBHI R+H SOURCE CM B+B GWBI LENGTH 30q 3 5q 2 5q 1 50q 34q 1 2p CLARITY good good good good aver D/U USER good good good D/U D / U D / U FRIEND RISK yes yes yes yes no yes RECOMM POSITIVE yes yes yes no no no FEED ESTIMATE yes no no yes no no AGE MEDICAL yes no yes yes P / I D/U REF RESOURCE no no no P/D no no RECOMM COUNSEL P/D no no I / D P/D P/D FOLLOW-UP P/D no no P/D P/D P/D LEGEND R+H - - Core Robbins and H a l l HHA CM - - Canadian M o r t a l i t y S t a t i s t i c s (1973-75) B+B - - Bres low and Beloc l o n g e v i t y s tudy GWBI - - G e n e r a l W e i l - B e i n g Inventory MBHI - - M i l l o n B e h a v i o r a l H e a l t h Inventory P / I - - P h y s i c i a n / C l i n i c i a n I n i t i a t e d P/D - - Program dependent D / U - - Data u n a v a i l a b l e I / D - - Inc luded in d e s i g n 54 T a b l e 2 .3(b) — C o n t i n u e d Measurement C o n s i d e r a t i o n s C :ANADA UNITE ID STATES MEASURE UBC HWC MCM CHA CAS UM HEALTH yes no no yes no no HISTORY FAMILY yes no no yes no no HISTORY PHYSICAL S/R no S/R M no no DATA orM LAB S/R no N/C M no no DATA orM HEALTH no no no no yes no ATTIT HEALTH no no no no no no KNOW OCCUPATION no yes yes yes yes yes RECREAT GEOGRAPHY no no no no no no ENVIRON RACE or no no no no no no ETHNIC SEX yes yes no yes no yes DIFFER MENTAL yes yes yes yes yes yes EMOTION SOCIAL no no yes no yes no SUPPORT SPIRITUAL no no no no no no SAFETY yes yes yes yes no yes ACCIDENT ABUSE yes yes yes yes no yes SUBST STRESS no yes yes yes yes yes NUTRITION no yes yes yes no yes FITNESS yes yes yes yes no yes LEGEND M - - Measured N/M — Not measured S/R — S e l f - r e p o r t e d N/C - - Not c o l l e c t e d 55 T a b l e 2 .3 (c ) Instrument Component M a t r i x : S e l f - S c o r e d Q u e s t i o n n a i r e s , Format , Des ign and Feedback C o n s i d e r a t i o n s c ; WADA UNITED STATES MEASURE HWC BCH VHD WCHG HHS HEK TARGET 1 6 + a d u l t 65 + a d u l t 18 + a d u l t POPUL work work CONFID N/A N/A yes yes N/A N/A SAFEGRD DATA PROC D/U D / U N/A N/A D/U D / U CONTROL DATA D/U PARQ N/A OCRS D/U R+H SOURCE LCRS SRSS SEL SWC SR LENGTH 35q 7q 68q 1 83q 24q 1 04q 1 Op 36p CLARITY good good good good e x c l e x c l USER good aver i n t v good e x c l e x c l . FRIEND RISK yes yes • N/A yes yes yes RECOMM POSITIVE yes no yes yes yes yes FEED ESTIMATE no no no no no no AGE MEDICAL no yes no P/I no no REF RESOURCE no no no P/D no yes RECOMM COUNSEL N/A I / D P/D P/D N/A I / D FOLLOW-UP N/A N/A P/D P/D N/A I /D LEGEND P A R Q - - P h y s i c a l A c t i v i t y Readiness Q u e s t i o n n a i r e R+H - - C o r e Robbins and H a l l HHA O C R S - - O r g a n i z a t i o n Changes R a t i n g S c a l e (Naismi th) L C R S - - L i f e Changes R a t i n g S c a l e (Cochrane & Robertson) SEL — S t r e s s i n Everyday L i v i n g (Adams) SWC - - S t r e s s f u l Work C o n d i t i o n s (Adams) SR - - S t r e s s R e s i l i e n c e ( K i n d l e r ) S R S S - - S o c i a l Readjustment R a t i n g S c a l e (Holmes &.Rahe) I / D - - I n c l u d e d i n d e s i g n P/D - - Program dependent i n t v - - i n t e r v i e w format N/A - - Not a p p l i c a b l e P / l - - P h y s i c i a n / C l i n . I n i t i a t e d D / U - - Data u n a v a i l a b l e 5 6 T a b l e 2 . 3 ( c ) — C o n t i n u e d . Measurement C o n s i d e r a t i o n s CJ vNADA UNITED STATES MEASURE HWC BCH VHD WCHG HHS HEK HEALTH no yes yes yes no no HISTORY FAMILY no no no yes no no HISTORY PHYSICAL no yes M S/R no S/R DATA orM LAB no no M no no S/R DATA orM HEALTH no no no yes no yes ATTIT HEALTH no no no no no yes KNOW OCCUPATION yes no yes yes yes yes RECREAT GEOGRAPHY no no yes yes no no ENVIRON RACE or no no yes yes no no ETHNIC SEX yes no yes yes no yes DIFFER -MENTAL yes no yes yes yes yes EMOTION SOCIAL no no yes yes yes yes SUPPORT. SPIRITUAL no no yes yes yes no SAFETY yes no yes yes yes yes ACCIDENT ABUSE yes no yes yes yes yes SUBST . STRESS yes no yes yes yes yes NUTRITION yes no yes yes yes yes FITNESS yes no yes yes yes yes LEGEND M - - Measured S/R — S e l f - r e p o r t e d 57 Risk Reduct ion Resource Guides For f u r t h e r i n f o r m a t i o n on a v a i l a b l e h e a l t h r i s k r e d u c t i o n programs, the f o l l o w i n g r e s o u r c e s are h e l p f u l g u i d e s : 1. H e a l t h Risk A p p r a i s a l : An Inventory (1981) -p r e p a r e d for the U . S . Department of H e a l t h and Human S e r v i c e s and g i v e s i n f o r m a t i o n on a range of 29 h e a l t h ' r i s k a p p r a i s a l s c u r r e n t l y a v a i l a b l e to the American P u b l i c . No attempt to e v a l u a t e or compare the a p p r a i s a l s was made. Where a p p l i c a b l e , c o s t s and method of a n a l y s i s , are p r o v i d e d for each l i s t i n g a l o n g w i t h a g e n e r a l d e s c r i p t i o n . 2. D e s c r i p t i o n , A n a l y s i s , and Assessment o f . H e a l t h  H a z a r d / H e a l t h R i s k A p p r a i s a l Programs: A F i n a l Report (1981) - p r e p a r e d by Beery , Schoenbach., Wagner and Graham at the U n i v e r s i t y of Nor th C a r o l i n a , Chape l H i l l , under c o n t r a c t for the U . S . Department of H e a l t h and Human S e r v i c e s . T h i s v a l u a b l e f u l l - s c a l e review of c u r r e n t l y a v a i l a b l e r i s k r e d u c t i o n programs i n c l u d e s an a n n o t a t e d b i b l i o g r a p h y , an HHA/HRA program i n v e n t o r y , s i t e v i s i t r e p o r t s , and f u t u r e recommendat i o n s . 3. Proceed ings of the Annual Meet ings on P r o s p e c t i v e  M e d i c i n e and H e a l t h Hazard A p p r a i s a l - for c u r r e n t r e s e a r c h on a v a i l a b l e r i s k r e d u c t i o n programs and ins truments in Canada and the U n i t e d S t a t e s . See Appendix E for i n f o r m a t i o n on where to o b t a i n these r e s o u r c e s . 2.5 E v a l u a t i n g R i s k Reduct ion Programs There w i l l always be q u e s t i o n i n g of the numbers, but I have seen what a l i t t l e f a i t h can do i n d e v e l o p i n g a c r e d i b l e and e f f e c t i v e mechanism to h e l p people b e t t e r unders tand that they are the masters of t h e i r own f a t e - by c h o o s i n g to l i v e by c h o i c e and not by chance . (Hawkins, 1979) F i e l d i n g (1982) argues that wh i l e there may be debate about what h e a l t h r i s k a p p r a i s a l i s (or i s not) there i s l i t t l e doubt about the dramat i c growth i n use of these i n s t r u m e n t s . The q u e s t i o n tha t must be a s k e d : "How e f f e c t i v e i s t h i s s t r a t e g y i n promot ing h e a l t h y l i f e s t y l e s and s t i m u l a t i n g e n d u r i n g b e h a v i o r changes?" Wagner, B e e r y , Schoenbach and Graham (1982), i n t h e i r recent assessment of the s t a t e of the a r t , c o n c l u d e d t h a t w i d e l y - h e l d b e l i e f s i n the e f f i c a c y of H e a l t h Hazard A p p r a i s a l / H e a l t h R i s k A p p r a i s a l (HHA/HRA) for m o t i v a t i n g b e h a v i o r a l change cannot be s u b s t a n t i a t e d from a v a i l a b l e e v i d e n c e , nor can the assumed absence of adverse e f f e c t s . They argue tha t the "importance of t h i s p a r t i c u l a r h e a l t h promot ion t echn ique appears to have been e x a g g e r a t e d . " S i m i l a r concerns have been v o i c e d by Canadian r e s e a r c h e r s (Best and M i l s u m , 1977; Sacks , Krushat and 59 Newman, 1980; S p a s o f f , McDowel l , Wright and Dunkley , 1982). The r e s e a r c h f i n d i n g s g e n e r a l l y agree that a l t h o u g h h e a l t h r i s k assessment s t r a t e g i e s appear to be good m o t i v a t o r s , problems of r e l i a b i l i t y c l e a r l y e x i s t . B u t , as E l i a s and Dunton (1980) p o i n t o u t , the purpose for w h i c h ' r i s k a p p r a i s a l i s used w i l l determine the a c c e p t a b l e l e v e l of a c c u r a c y . They w r i t e " i f a g o a l i s h e a l t h e d u c a t i o n and a r i s k a p p r a i s a l i s used to e s t imate a g e n e r a l l e v e l of r i s k , such as h i g h or low, a great d e a l of a c c u r a c y i s not r e q u i r e d . I f , however, an o b j e c t i v e i s to p r o v i d e a comparat ive measure of the e f f e c t of b e h a v i o r change, and r i s k age i s be ing used as a measure, one ' s a c c u r a c y needs are g r e a t e r . " With r e s p e c t to the a c c u r a c y q u e s t i o n , the Spasof f team (1982) suspec t s tha t " in g e n e r a l the presen t approach o v e r -e s t i m a t e s r i s k . " They r e j e c t the p o s i t i o n argued by some tha t t h i s i s d e s i r a b l e s i n c e h i g h e r r i s k e s t i m a t e s may be more s u c c e s s f u l i n m o t i v a t i n g people to change, on the grounds tha t the p r e d i c t i o n s must r e f l e c t the s t a t e of the a r t a t a g iven t i m e . They argue that "us ing the aura of s c i e n c e without i t s . r i g o r l eads to a most u n d e s i r a b l e k i n d of pseudosc ience" ( S p a s o f f , et a l , 1982). Whi l e r i s k r e d u c t i o n programs have been p r o l i f e r a t i n g , s tandards for e v a l u a t i n g them have been l a c k i n g . In an attempt to meet t h i s need, the U n i v e r s i t y of A r i z o n a ' s "Well Aware About H e a l t h " program i s c o m p l e t i n g a f o u r - y e a r 60 e v a l u a t i o n p r o j e c t funded by the W.K. K e l l o g g F o u n d a t i o n . S p e c i f i c a l l y , the r e s e a r c h i s be ing conducted as a c o n t r o l l e d c l i n i c a l t r i a l to t e s t the e f f i c a c y of h e a l t h r i s k e s t i m a t i o n as an e d u c a t i o n t o o l and the r e l a t i v e e f f e c t i v e n e s s of v a r i o u s e d u c a t i o n a l i n t e r v e n t i o n approaches . Pr imary measurements w i l l be d e r i v e d from a n a l y s i s of change in p h y s i c a l c o n d i t i o n , l i f e s t y l e , h e a l t h c a r e r e s o u r c e use , c a p a c i t y f o r s e l f - c a r e r e s u l t i n g from enhanced h e a l t h knowledge, awareness and m o t i v a t i o n , and p r o v i d e r a t t i t u d e s and p r a c t i c e s w i th regard to p a t i e n t s e l f - r e s p o n s i b i l i t y . I t i s expected that the outcome of t h i s c o n t r o l l e d r e s e a r c h t r i a l w i l l make a major c o n t r i b u t i o n to the f i e l d of P r o s p e c t i v e M e d i c i n e by i n d i c a t i n g the i n f l u e n c e of H e a l t h Hazard A p p r a i s a l and e d u c a t i o n , used i n d e p e n d e n t l y or in c o m b i n a t i o n , i n m o t i v a t i n g i n d i v i d u a l s to change t h e i r n e g a t i v e h e a l t h b e h a v i o r s (Ramsay and Dunton, 1978). A l t h o u g h e v a l u a t i o n of h e a l t h r i s k assessment i s becoming more r i g o r o u s , a q u e s t i o n tha t has not been a d e q u a t e l y addressed i s one of g e n e r a l c l i e n t a c c e p t a n c e : How can an i n d i v i d u a l be encouraged to complete a h e a l t h r i s k assessment q u e s t i o n n a i r e in the f i r s t p l a c e ? The T o r r a n c e and D ' A r c y User Survey (1980) asked "How do c l i e n t s r e a c t i n i t i a l l y to the idea of h a v i n g an a p p r a i s a l ? " Most of the users (62%) s t a t e d tha t most c l i e n t s w i l l i n g l y accept the idea of hav ing an a p p r a i s a l . 61 Not s u r p r i s i n g l y , they r e p o r t e d that e d u c a t i o n a l users and p h y s i c i a n s f i n d t h e i r c l i e n t s / p a t i e n t s more w i l l i n g , whi l e p u b l i c h e a l t h users are more u n c e r t a i n . On the o ther hand, users were asked " O v e r a l l , how important a f a c t o r i s c l i e n t r e s i s t a n c e i n l i m i t i n g the extent to which you use HHA?" Nine % s a i d they see i t as "very i m p o r t a n t " , and 20% s a i d " f a i r l y i m p o r t a n t . " F u r t h e r , t h e i r added comments i n d i c a t e d that some c l i e n t s are r e l u c t a n t to complete an HHA because i t was "too p e r s o n a l " , "an i n v a s i o n of p r i v a c y " , or " f r i g h t e n i n g . " C l i e n t s were s k e p t i c a l about the c o n f i d e n t i a l i t y of the r e s u l t s , and p a r t i c u l a r l y r e l u c t a n t about p e r s o n a l data ending up in employer or government f i l e s (Torrance and D ' A r c y , 1981). P h y s i c i a n s share t h i s c o n c e r n . C e r t a i n l y , q u e s t i o n s i n a l l U . S . H H A ' s , and in the broader l i f e s t y l e assessment q u e s t i o n n a i r e s used by such programs as W e l l Aware About H e a l t h at T u c s o n , A r i z o n a and the L i f e s t y l e Assessment program at the U n i v e r s i t y of W i s c o n s i n , Stevens P o i n t , which ask about the c a r r y i n g of f i r e a r m s and c r i m i n a l r e c o r d s , o r , the onset of i n t e r c o u r s e as p r e s e n t l y asked in the HHA v e r s i o n s used in both the U . S . and Canada, are l i k e l y to arouse c l i e n t r e s i s t a n c e . I t i s i n t h i s area of concern t h a t de s ign to ensure c o n f i d e n t i a l i t y and e f f e c t i v e communication s t r a t e g i e s can make an impact on h a r d - t o - r e a c h i n d i v i d u a l s . The 1981 Canadian R i s k F a c t o r Review P r o j e c t , 62 undertaken by Spasof f and a s s o c i a t e s at the U n i v e r s i t y of Ottawa to improve the s c i e n t i f i c a c c u r a c y of the Canadian v e r s i o n s of H e a l t h Hazard A p p r a i s a l , proposed s e v e r a l s t r o n g recommendations, among which are the f o l l o w i n g : 1 . t h a t HHA be made more b r o a d l y a p p l i c a b l e by expanding the in tended "heal thy p o p u l a t i o n " b i a s to i n c l u d e persons at s p e c i a l r i s k , i n c l u d i n g o c c u p a t i o n a l , r e c r e a t i o n a l , r a c i a l and e t h n i c r i s k ; 2. that HHA be made more a p p l i c a b l e to persons wi th d i s e a s e s which do not s e r i o u s l y a f f e c t t h e i r a b i l i t y to f u l f i l t h e i r s o c i a l r o l e s ; 3. tha t r e g i o n a l v a r i a t i o n s be determined and i n c l u d e d ; 4. that p r e d i c t i o n s "for the young and the e l d e r l y be i n c o r p o r a t e d ; 5. t h a t b e f o r e any of t h e i r recommendations are implemented, the v a l i d i t y of t h e i r p r e d i c t i o n s be t e s t e d ; and f i n a l l y , 6. that Canadian s t u d i e s be undertaken to determine e f f e c t i v e n e s s of HHA and i t s component p a r t s . They argued tha t d e m o n s t r a t i o n of e f f e c t i v e n e s s would j u s t i f y the e f f o r t of the e p i d e m i o l o g i s t s and encourage h e a l t h p r o f e s s i o n a l s to use HHA. Hawkins (1979) in H e a l t h Hazard A p p r a i s a l i n Canada - P r o g r e s s and Problems suggests that what i s needed i s an approach to r i s k assessment which i s focussed on the major i n t e r v a l s d u r i n g a p e r s o n ' s l i f e c y c l e , such as p r e - and 63 p o s t - n a t a l , s choo l age, a d o l e s c e n c e , young a d u l t , middle and o l d age . T h i s a p p r o a c h , she p o i n t s o u t , "could make the most of the important ' t e a c h a b l e moments' d u r i n g our l i v e s . Assessment d e v i c e s c o u l d c o n c e i v a b l y be deve loped to address the s p e c i f i c needs of such g r o u p s . " Whi l e the North C a r o l i n a U n i v e r s i t y study conducted by Beery and a s s o c i a t e s (1981) r e v e a l e d a c o n t i n u i n g concern about the v a l i d i t y and r e l i a b i l i t y of h e a l t h r i s k assessment i n s t r u m e n t s and programs, the r e s e a r c h e r s a l s o made some p o s i t i v e comments. A f t e r c o n d u c t i n g s i t e v i s i t s , i n t e r v i e w s w i t h e x p e r t s , a l i t e r a t u r e rev i ew , and an a n a l y s i s of the d a t a , they agreed that "hea l th h a z a r d a p p r a i s a l t e s t s appear to be a u s e f u l a d j u n c t to h e a l t h e d u c a t i o n and b e h a v i o r a l c o u n s e l l i n g but a lone do not c o n s t i t u t e a h e a l t h p r o m o t i o n / d i s e a s e p r e v e n t i o n program." They recommended that h e a l t h h a z a r d a p p r a i s a l t e s t i n g be used i n s m a l l groups or c o u n s e l l i n g s e t t i n g s where i t s l i m i t a t i o n s as a r i s k p r e d i c t o r can be e x p l a i n e d to c l i e n t s . L e s t these e v a l u a t i o n s appear o v e r l y n e g a t i v e , i t shou ld be p o i n t e d out tha t a c c o r d i n g to a p r o f i l e of p u b l i s h e d e m p i r i c a l r e p o r t s on P a t i e n t E d u c a t i o n E v a l u a t i o n s  from 1974-78, reviewed by S q u y r e s , Green et a l (1980), most r e p o r t e d outcomes have t r a n s c e n d e d the knowledge-only c a t e g o r y and now i n c l u d e a t t i t u d i n a l , b e h a v i o r a l , b i o m e d i c a l and c o s t - e f f e c t i v e n e s s measures . They summarized t h e i r a n a l y s i s w i t h the b e l i e f that these r e p o r t s " c a r r y hopes 64 tha t informed people who have p o s i t i v e a t t i t u d e s about the e d u c a t i o n a l programs conducted on t h e i r b e h a l f go on to change t h e i r b e h a v i o r s . Adherence to m e d i c a l regimes u s u a l l y r e c e i v e pr imary a t t e n t i o n , w i t h some a t t e n t i o n g i v e n to changes i n l i f e s t y l e or p e r s o n a l h e a l t h b e h a v i o r s . " T h i s view i s supported by a growing body of t h e o r e t i c a l , d e s c r i p t i v e and c o r r e l a t i o n a l r e s e a r c h i n m e d i c a l s o c i o l o g y , h e a l t h 'educat ion and h e a l t h p s y c h o l o g y . T o g e t h e r , these v a r i o u s sources of data and theory p r o v i d e a s c i e n t i f i c base for the p l a n n i n g of r i s k r e d u c t i o n programs tha t shou ld enable h e a l t h promot ion p l a n n e r s to approach t h e i r task w i t h g r e a t e r c o n f i d e n c e and wi th more t e s t a b l e hypotheses than were p r e v i o u s l y j u s t i f i e d . That the r o l e and va lue of h e a l t h r i s k a p p r a i s a l have yet to be f u l l y e s t a b l i s h e d i s beyond d i s p u t e , but r e s u l t s of some s t u d i e s done thus f a r are p r o m i s i n g . Swinehart (1979) r e p o r t e d that 20% of p a r t i c i p a n t s or more, make some r i s k - r e d u c i n g b e h a v i o r change l a s t i n g a year or l o n g e r , and success appears to improve wi th p e r s o n a l c o u n s e l l i n g and the use of p r o b l e m - s p e c i f i c e d u c a t i o n a l m a t e r i a l s reques ted by p a r t i c i p a n t s . H e a l t h H a z a r d / H e a l t h R i s k A p p r a i s a l programs that are i n t e g r a t e d i n t o an ongoing h e a l t h or med ica l s e r v i c e , such as a m e d i c a l p r a c t i c e or an employee h e a l t h or a s s i s t a n c e s e r v i c e , seem to be the most s t a b l e and e f f i c i e n t . The Wagner et a l (1982) assessment of HHA/HRA programs c o n c l u d e d 65 that i t i s an a p p e a l i n g t echn ique that may have p o t e n t i a l as a t o o l in h e a l t h promotion e f f o r t s , but tha t i t "should be viewed wi th care and c i r c u m s p e c t i o n - care to ensure that assumptions are t e s t e d , and c i r c u m s p e c t i o n i n view of the p a u c i t y of c u r r e n t ev idence r e g a r d i n g i t s e f f e c t i v e n e s s . " F i e l d i n g (1982) agrees w i t h the data base and m e t h o d o l o g i c a l problems h i g h l i g h t e d i n the Wagner, Beery Schoenbach and Graham (1982) r e p o r t but argues tha t c o n s i d e r a b l e p r o g r e s s i s be ing made in c o d i f y i n g what i s known about major r i s k i n d i c a t o r s and improv ing methodolog ies for d e v e l o p i n g r i s k e q u a t i o n s . C u r r e n t r e s e a r c h and e v a l u a t i o n p r o j e c t s d i r e c t e d towards the development , r e f i n e m e n t , t e s t i n g , and market ing of h e a l t h r i s k assessment s t r a t e g i e s as a re source for h e a l t h e d u c a t i o n and promot ion i n c l u d e : 1. Under c o n t r a c t to H e a l t h and Wel fare Canada, D r . Robert Spasof f and a s s o c i a t e s at the U n i v e r s i t y of Ottawa deve loped a recommended procedure for u p d a t i n g and i n c r e a s i n g the p r e c i s i o n of E V A L U * L I F E , the Canadian government suppor ted h e a l t h h a z a r d a p p r a i s a l ( S p a s o f f , McDowel l , Wright and Dunkley , 1982). T h i s important c o n t r i b u t i o n to r i s k r e d u c t i o n r e s e a r c h i s born out of the c o l l a b o r a t i v e working r e l a t i o n s h i p e s t a b l i s h e d by H e a l t h and Wel f are Canada and the Bureau of H e a l t h E d u c a t i o n at the Center for D i s e a s e C o n t r o l (CDC) i n A t l a n t a , G e o r g i a . The hear t of t h i s 66 r e l a t i o n s h i p i s the mutual development of a r e s e a r c h p l a n which w i l l s y s t e m a t i c a l l y i n v e s t i g a t e the major h e a l t h r i s k assessment i s s u e s r e l a t e d to the m a t h e m a t i c a l , b e h a v i o r a l and e d u c a t i o n a l q u e s t i o n s that have been i d e n t i f i e d ( A l t h a f e r , 1980). In p a r t i c u l a r , t h i s c o n t r a c t has updated r i s k f a c t o r s on c a n c e r , motor v e h i c l e a c c i d e n t s , a c c i d e n t s o ther than motor v e h i c l e , s u i c i d e , c i r r h o s i s of the l i v e r , c h r o n i c o b s t r u c t i v e pulmonary d i s e a s e and pneumonia. In the U n i t e d S t a t e s , work has r e c e n t l y been completed on a companion c o n t r a c t to do s i m i l a r work for the o ther major causes of d e a t h . T h i s c o n t r a c t , l e t by the C e n t e r s for D i sease C o n t r o l (CDC) w i t h Breslow and A s s o c i a t e s at the U n i v e r s i t y of C a l i f o r n i a at Los Ange les (UCLA) , was to r e f i n e b i o s t a t i s t i c a l models for r i s k p r e d i c t i o n and to a p p l y f i n d i n g s to update r i s k e s t i m a t i o n for m o r t a l i t y and m o r b i d i t y due to c a r d i o v a s c u l a r d i s e a s e and trauma d e a t h s . The r e p o r t of t h i s p r o j e c t i n c l u d e s a procedure for u p d a t i n g r i s k e s t i m a t e s as new i n f o r m a t i o n becomes a v a i l a b l e (Risk F a c t o r Update P r o j e c t F i n a l R e p o r t , 1982). A c u r r e n t Canadian c o n t r a c t , i s s u e d i n J a n u a r y , 1983, has been e s t a b l i s h e d to take the r e s u l t s of the 1982 R i s k F a c t o r Update and to compi l e a set of s p e c i f i c a t i o n s f o r i n c o r p o r a t i o n of these r e s u l t s i n t o E V A L U * L I F E , the f e d e r a l government sponsored H e a l t h 67 Hazard A p p r a i s a l . The a c t u a l implementat ion of the r e s u l t s through r e v i s i o n of the h e a l t h h a z a r d a p p r a i s a l program i s open to another c o n t r a c t . F i e l d i n g (1982) p o i n t s out that these " c a r e f u l s c i e n t i f i c reviews of a v a i l a b l e data bases , i n t e n s i v e e f f o r t s to improve p r e d i c t i o n s , and i n c r e a s i n g a t t e n t i o n to d e l i n e a t e the l i m i t a t i o n s i n h e r e n t i n the q u a n t i t a t i v e i n f o r m a t i o n c o n t r i b u t e to more c r e d i b l e and s o p h i s t i c a t e d p r o d u c t s . " I t should a l s o be acknowledged tha t s p e c i f i c concerns and problems i d e n t i f i e d through r e s e a r c h and e v a l u a t i o n have a i d e d in the s t r e n g t h e n i n g and improvement of h e a l t h r i s k assessment t e c h n i q u e s , r a t h e r than in t h e i r abandonment. 2.6 The Role of H e a l t h Assessment S t r a t e g i e s i n H e a l t h  Promot ion In e s sence , we see H e a l t h H a z a r d / H e a l t h R i s k A p p r a i s a l as a p o t e n t i a l l y u s e f u l t o o l in the contex t of a l a r g e r h e a l t h e d u c a t i o n e f f o r t when used by t r a i n e d i n d i v i d u a l s , wi th c a r e f u l o r i e n t a t i o n , feedback and c o u n s e l l i n g p r o v i d e d . (Beery , 1981) For h e a l t h r i s k assessment to f u l f i l i t s promise as an e f f e c t i v e s t r a t e g y for i n t e g r a t i o n i n t o h i g h q u a l i t y r i s k r e d u c t i o n and h e a l t h enhancement programs, i t must  i n c o r p o r a t e the best a v a i l a b l e e p i d e m i o l o g i c i n f o r m a t i o n and  b i o s t a t i s t i c a l c o m p u t a t i o n a l r i g o r i n t o i t s i n s t r u m e n t s . In 68 t h e i r F i n a l Report (June, 1978) to H e a l t h and Wel f are Canada, the H e a l t h Hazard A p p r a i s a l Assessment Committee , c h a i r e d by D. T h o r n t o n , N . M . U . D . , expressed two major concerns about c u r r e n t h e a l t h r i s k assessment systems: 1. The p r o l i f e r a t i o n of c o m m e r c i a l l y m o t i v a t e d r i s k a p p r a i s a l t e c h n i q u e s , and the p e r c e i v e d r i s e i n the p u b l i c ' s acceptance and b e l i e f in these systems in s p i t e of an absence of w e l l documented ev idence of t h e i r v a l i d i t y and e f f e c t i v e n e s s ; and 2. The need for government to deve lop a c l e a r set of p o l i c y g u i d e l i n e s p e r t a i n i n g to the promot ion and l i m i t a t i o n s of h e a l t h r i s k assessment s t r a t e g i e s . The committee emphasized tha t " major a t t e n t i o n must be  g iven to p r o v i d i n g v a l i d and r e l i a b l e ins trument to the  p u b l i c . " S i m i l a r l y , in t h e i r H e a l t h Hazard User S u r v e y : F i n a l  Report for H e a l t h and W e l fare Canada, T o r r a n c e and D ' A r c y (1980) recommended that f o r H e a l t h Hazard A p p r a i s a l to become an e f f e c t i v e h e a l t h promot ion t o o l , over the l o n g -t erm, f u r t h e r work i s neces sary both to d e v e l o p more s e n s i t i v e ins t ruments des igned s p e c i f i c a l l y for d i f f e r e n t c l i e n t groups and c l i n i c a l / e d u c a t i o n a l s e t t i n g s , and to d e v e l o p i n t e g r a t e d model programs t a i l o r e d to these s e t t i n g s i n t o which h e a l t h r i s k assessment ins truments would f i t . The r e a l v a l u e of h e a l t h r i s k assessment l i e s i n i t s e f f e c t i v e n e s s as a m o t i v a t i o n a l ins trument for changing an 69 i n d i v i d u a l ' s a t t i t u d e s and b e h a v i o r s that impede p o s i t i v e h e a l t h a c t i o n s . In o ther words, h e a l t h r i s k assessments not on ly p o i n t out unhea l thy a c t i o n s to a v o i d , but make recommendations on what h e a l t h f u l a c t i o n s to t a k e . R e s u l t s of the T o r r a n c e and D ' A r c y (1981) survey showed tha t 70% of c u r r e n t Canadian users of H e a l t h Hazard A p p r a i s a l / E V A L U * L I F E b e l i e v e that t h e i r c l i e n t s are v e r y , or f a i r l y l i k e l y to change t h e i r b e h a v i o r . The great m a j o r i t y of respondents c o n s i d e r e d "HHA-based c o u n s e l l i n g much more,  or somewhat more, e f f e c t i v e than c o u n s e l l i n g in the absence  of HHA", and look upon HHA as a r e a s o n a b l y e f f e c t i v e way of  g a i n i n g e n t r e e to c o u n s e l l i n g and of i m p a r t i n g i n f o r m a t i o n  on r i s k f a c t o r s to c l i e n t s , i e . a " teachable moment." The r e p o r t c o n c l u d e s tha t in r e l a t i o n to a v a i l a b l e a l t e r n a t i v e s , "HHA i s c o n s i d e r e d a u s e f u l t o o l and has many e n t h u s i a s t i c  a d h e r e n t s . " I t i s t r o u b l i n g , however, that HHA/HRA must jump h u r d l e s which are h i g h e r than those p l a c e d i n the path of many w e l l - f u n d e d and accepted c u r a t i v e p r a c t i c e s ; sometimes there a r e n ' t even h u r d l e s to jump ( W e i n s t e i n , 1983) . F i e l d i n g (1982) r e p o r t s tha t there are s e v e r a l c l i n i c a l t r i a l s c u r r e n t l y under way in the U n i t e d S t a t e s to o b t a i n p r e l i m i n a r y assessment of the e f f e c t i v e n e s s of h e a l t h r i s k a p p r a i s a l s i n (a) i n c r e a s i n g knowledge; (b) i n c r e a s i n g m o t i v a t i o n and i n t e n t i o n to change; and (c) changing b e h a v i o r . However, he a r g u e s , that even were r e s u l t s of 70 these t r i a l s t o suggest t h a t h e a l t h r i s k a p p r a i s a l t e s t i n g a l o n e can p o s i t i v e l y a f f e c t a l l t h r e e outcomes under s p e c i f i e d c o n d i t i o n s , " i t would be i l l a d v i s e d t o c o n s i d e r  t h a t h e a l t h r i s k a p p r a i s a l a l o n e c o n s t i t u t e s a program." He s t r e s s e s t h a t the "method and q u a l i t y of feedback and l i n k a g e t o r i s k r e d u c t i o n programs and the i n h e r e n t e f f e c t i v e n e s s of the s e a c t i v i t i e s a r e l i k e l y t o be the im p o r t a n t d e t e r m i n a n t s i n the degree of change i n b e h a v i o r and the degree of p e r s i s t a n c e of whatever changes a re i n i t i a l l y seen." A d d i t i o n a l l y , l i t t l e i s known about the r e l a t i v e impact of d i f f e r e n t t y p e s of computer-generated r i s k i n f o r m a t i o n , and about how d e s i g n format and types and s t r e n g t h s of s u g g e s t i o n s made t o a l t e r p e r s o n a l h e a l t h h a b i t s may i n f l u e n c e i n i t i a l impact or l o n g e r term outcomes. With so l i t t l e known, F i e l d i n g b e l i e v e s " t h e r e i s  c o n s i d e r a b l e room f o r e x p e r i m e n t a t i o n i n a v a r i e t y of  s e t t i n g s and p o p u l a t i o n s , and as p a r t of d i v e r s e r i s k  r e d u c t i o n a c t i v i t i e s . " E l i a s (1982) s u g g e s t s t h a t t h e r e i s a need f o r a H e a l t h R i s k A p p r a i s a l t h a t goes beyond the l i m i t a t i o n s of the Robbins and H a l l model and recommends an i n s t r u m e n t which c o n t a i n s the best elements of the s t a n d a r d HHA/HRA, i e . r i s k and a c h i e v a b l e ages f o r those over 35, but then s i m p l y c o n c e n t r a t e s on g i v i n g i n d i v i d u a l s feedback on t h e i r h e a l t h h a b i t s and b e h a v i o r s by r a t i n g them a g a i n s t e i t h e r a m e d i c a l s t a n d a r d or one t h a t i s p o p u l a t i o n s p e c i f i c . He s t r e s s e s 71 the need for des ign of b e t t e r in s t ruments that reach more p e o p l e , tha t are more b r o a d l y a p p l i c a b l e and tha t are not so n e g a t i v e and a n x i e t y p r o d u c i n g . "The wave of the f u t u r e , " he b e l i e v e s , "is for i n t e r a c t i v e , s e l f s c o r i n g i n s t r u m e n t s . " He adds , "the a p p r a i s a l , the s i m p l e r the b e t t e r , shou ld be upbeat , f l a s h y , and g i v e people s t r o k e s for p o s i t i v e b e h a v i o r . " As the concept of m i n i m i z i n g h e a l t h r i s k s a s s o c i a t e d w i t h l i f e s t y l e becomes more w i d e l y a c c e p t e d , and as the bases for h e a l t h r i s k assessment and behav ior change methods become more f i r m l y deve loped and r e f i n e d , l o c i of  r e s p o n s i b i l i t y must be found to ensure that these p r e v e n t i v e  s e r v i c e s a c t u a l l y become a c c e s s i b l e to i n d i v i d u a l s and  communit ies (Bauer , 1980). T h i s view i s shared by M e l i a (1981) who, i n a p o s i t i o n paper for H e a l t h and W e l f a r e Canada, s u c c i n c t l y s t a t e s , "while r i s k r e d u c t i o n packages are a p o t e n t i a l l y v i a b l e h e a l t h promot ion r e s o u r c e for which c o n s i d e r a b l e demand has been e x p r e s s e d , market ing s t r a t e g i e s  and an i n t e g r a t i o n of t h e i r use i n t o h e a l t h promot ion p o l i c y  are r e q u i r e d . " A l t h o u g h i n d i v i d u a l l y t a i l o r e d h e a l t h e d u c a t i o n based on h e a l t h r i s k assessment i s , in one sense , the o p p o s i t e of mass media campaigns , there i s some ev idence tha t good segmentat ion of t a r g e t aud iences and p r e p a r a t i o n of s p e c i a l i z e d m a t e r i a l f or each c o n s t i t u t e an a p p r o x i m a t i o n of t h i s i n d i v i d u a l i z e d a p p r o a c h . T h u s , a c c o r d i n g to Swinehart 72 (1979) "mass media campaigns can markedly improve the chance of p r o d u c i n g a f a v o r a b l e impact." CHAPTER THREE Communication S t r a t e g i e s for H e a l t h Promotion Communications can c r e a t e awareness of an i d e a , they can s t i m u l a t e i n t e r e s t in i t , they can even generate a response to i t . ( P A R T I C I P a c t i o n ' s 10th A n n i v e r s a r y Report 1971-81: A Decade of A c t i o n ) 74 3.1 G u i d e l i n e s for P l a n n i n g Communication S t r a t e g i e s for  H e a l t h Promotion I d e n t i f y i n g h e a l t h r i s k s i s of l i t t l e va lue i f the o p p o r t u n i t y of exposure to r i s k r e d u c t i o n a l t e r n a t i v e s i s not made a v a i l a b l e . H e a l t h promot ion i n t e r v e n t i o n s , the aim of which are to i n f l u e n c e h e a l t h r i s k s r e l a t e d to l i f e s t y l e , shou ld be based on a sound marke t ing s t r a t e g y which i n c o r p o r a t e s the use of h e a l t h r i s k assessment t o o l s , c o u n s e l l i n g and m u l t i p l e communicat ion media . "Though some p e r s o n s , academic ians e s p e c i a l l y , may b r i d l e at the mention of the term ' m a r k e t i n g ' , " as N e l s o n , K e l l e r and Zubkoff (1981) p o i n t o u t , Runyon (1977) argues tha t " s u c c e s s f u l marke t ing i s and always has been based on the b e h a v i o r a l s c i e n c e s . " Modern market ing t e c h n i q u e s are grounded i n the d i s c i p l i n e s of s o c i o l o g y , p s y c h o l o g y , and s o c i a l p s y c h o l o g y , and r e l y on s c i e n t i f i c methods to conduct market r e s e a r c h ( N e l s o n , et a l , 1981). A m a r k e t i n g approach i s a l s o very c o n s i s t e n t w i t h the b a s i c e p i d e m i o l o g i c a l approach of p u b l i c h e a l t h ( W e i n s t e i n , 1983). The importance of the marke t ing concept - a "consumer-o r i e n t e d " s t r a t e g y b u i l t around the needs of the consumer (as opposed to s e l l i n g a p r o d u c t ) - i s u n d e r s c o r e d . . I t s b a s i c focus on "market segmentat ion" i s synonomous wi th the f i r s t s t e p i n the p l a n n i n g of a r i s k r e d u c t i o n program, tha t i s , i d e n t i f y i n g the c h a r a c t e r i s t i c s and needs of a t a r g e t p o p u l a t i o n through the use of h e a l t h r i s k assessment t o o l s 75 (see F i g u r e 3 . 1 ) . I d e n t i f y i n g the needs of a t a r g e t p o p u l a t i o n enables the t a i l o r i n g of a h e a l t h promot ion program to p i n - p o i n t a t - r i s k groups (thus making more e f f i c i e n t use of s c a r c e r e s o u r c e s ) , and u s i n g a p p r o p r i a t e communicat ion media e f f e c t i v e l y , these groups can be a l e r t e d to the h e a l t h r i s k s they face and the t h i n g s they can do to p r o t e c t themselves from those r i s k s . To a c h i e v e maximum and e f f e c t i v e exposure of the h e a l t h promot ion "message" at the lowest per c a p i t a c o s t s , American h e a l t h e d u c a t o r s and h e a l t h promot ion p l a n n e r s are t u r n i n g more and more to the mass media . Howe (1981) p o i n t s out t h a t as mass media use i n c r e a s e s , "the format and p r e s e n t a t i o n of the h e a l t h message become important areas f o r i n v e s t i g a t i o n . " At the 1981 " I n s t i t u t e of M e d i c i n e " c o n f e r e n c e , the f o l l o w i n g l i s t of q u e s t i o n s were formula ted for c o n s i d e r a t i o n when p l a n n i n g a mass media h e a l t h campaign: ( H e a l t h Promotion and the M e d i a , 1981) 1. What i s the message to be conveyed , and who shou ld d e v e l o p i t ? 2. Who i s the t a r g e t a u d i e n c e , and who s e l e c t s i t ? 3. What i s known about how the media can be most e f f e c t i v e i n r e a c h i n g the t a r g e t a u d i e n c e . 4. How can hea l th -damaging m a t e r i a l in en ter ta inment programming and a d v e r t i s i n g be c o u n t e r a c t e d ? 5. How can access to the media be a s sured f o r h e a l t h -76 promoting messages and programming? And, from S e i b e r t (1973), 6. How can b u s i n e s s , i n d u s t r y and l a b o r unions be encouraged to support and sponsor h e a l t h promot ion media campaigns? I t i s important tha t the message be c l e a r , cogent , and based upon s c i e n t i f i c ev idence i n order to a l l o w the aud ience to r e a l i z e that i t i s reasonable i n r e l a t i o n to t h e i r own exper ience ( E p s t e i n , Magrowski and M c P h a i l , 1975). Warner (1979) argues tha t the case for media-based h e a l t h promot ion e f f o r t s shou ld be s t rengthened by " r e c o g n i z i n g the p o t e n t i a l of u t i l i z i n g Madison Avenue e x p e r t i s e i n the d e s i g n and market ing of h e a l t h behav ior a d v e r t i s i n g . " Those who are concerned about h e a l t h and l i f e s t y l e must ask whether we can a c c o m p l i s h our goa l s and market our p r o d u c t by u t i l i z i n g our c u r r e n t h e a l t h c a r e system of h o s p i t a l s , med ica l c e n t e r s and p h y s i c i a n s ' o f f i c e s , or adapt and change to become e f f e c t i v e i n market ing h e a l t h and l i f e s t y l e ? I f there i s to be a focus on l i f e s t y l e and h e a l t h , r a t h e r than t r e a t m e n t , i t would a l l o w f o r the development of c o n s u m e r - o r i e n t e d s p e c i f i c , a c h i e v a b l e goa l s and o b j e c t i v e s for h e a l t h . M a r k e t i n g these g o a l s can then be "approached w i t h the e x p e r t i s e and s o p h i s t i c a t i o n they deserve" (Looney, 1978). "The p o t e n t i a l of the mass media to i n f o r m , educate and m o t i v a t e should not c o n t i n u e to be wasted and abused" argue 77 E p s t e i n et a l (1975), " r a t h e r i t shou ld be u t i l i z e d as an i n t e g r a l p a r t of a system des igned to d e l i v e r b e t t e r h e a l t h care to C a n a d i a n s . " A m a r k e t - o r i e n t e d h e a l t h promot ion campaign aimed at i n f l u e n c i n g s p e c i f i c a t t i t u d e s , knowledge and b e h a v i o r s i n v o l v e s a number of p r o c e s s e s . These are i l l u s t r a t e d in F i g u r e 3 . 1 , " G u i d e l i n e s f o r P l a n n i n g Communication S t r a t e g i e s f o r H e a l t h P r o m o t i o n . " 'While d i s c u s s i o n of t h i s p l a n throws l i g h t on the t e c h n o l o g i c a l subset of communicat ion s t r a t e g i e s - i n p a r t i c u l a r , the s t a t e of the a r t i n t e r a c t i v e e l e c t r o n i c t echno logy and the mass communicat ions media - the model can be g e n e r a l i z e d to i n c l u d e numerous o ther approaches to the promot ion of h e a l t h r i s k r e d u c t i o n . 78 F i g u r e 3 . 1 G u i d e l i n e s F o r P l a n n i n g C o m m u n i c a t i o n S t r a t e g i e s F o r H e a l t h P r o m o t i o n 4 ASSESS CHARACTERISTICS AND HEALTH NEEDS OF TARGET POPULATION fn STEP 1 DEVELOP HEALTH STATUS OBJECTIVES STEP II DEVELOP CONTENT OUTLINE ]/ STEP I I I SELECT HEALTH PROMOTION MESSAGE I STEP IV SELECT/PRODUCE APPROPRIATE COMMUNICATION MEDIA STEP V USE OF COMMUNICATION MEDIA STEP VI EVALUATE COMMUNICATION STRATEGIES STEP VII 79 STEP I Assess C h a r a c t e r i s t i c s and H e a l t h Needs of T a r g e t P o p u l a t i o n Before s e l e c t i o n of communication media can be made, i t i s e s s e n t i a l to unders tand the c h a r a c t e r i s t i c s and needs of p o p u l a t i o n be ing a d d r e s s e d . Research f i n d i n g s i n d i c a t e that h e a l t h e d u c a t i o n media that r e f l e c t the v a l u e s , b e l i e f s and a t t i t u d e s p e r c e i v e d r e l e v a n t to a p a r t i c u l a r t a r g e t group w i l l have a much g r e a t e r impact on the a t t i t u d e change, i n f o r m a t i o n ga in and b e h a v i o r of that group . B e a r i n g t h i s u n d e r s t a n d i n g i n mind, the f o l l o w i n g q u e s t i o n s must be answered be fore d e c i d i n g on s p e c i f i c s u b j e c t matter or methods of i n t e r v e n t i o n : 1. What are the s p e c i f i c needs of the t a r g e t p o p u l a t i o n ? 2. What i n f o r m a t i o n and s k i l l s must be communicated to answer those needs? 3. What s p e c i a l c h a r a c t e r i s t i c s of the t a r g e t p o p u l a t i o n need to be accommodated i n the s t r u c t u r e and approach of the program? At a minimum, the t a r g e t group should be d e s c r i b e d in the f o l l o w i n g demographic terms: age range , sex , e t h n i c i t y , c u l t u r a l v a l u e s , economic l e v e l , l o c a t i o n (urban versus r u r a l ) , and e d u c a t i o n a l l e v e l . As w e l l , p h y s i c a l 80 l i m i t a t i o n s that might a f f e c t r e a d i n g , v i e w i n g , l e a r n i n g , e t c . s h o u l d be d e s c r i b e d . A d d i t i o n a l l y , l e s s c o n c r e t e i n f o r m a t i o n can be h e l p f u l , such as an i n d i v i d u a l ' s r e a d i n e s s and m o t i v a t i o n to l e a r n ; p e r s o n a l e x p e r i e n c e s and l i f e s t y l e , i n c l u d i n g p r e v i o u s and recent i l l n e s s e s and , h e a l t h p r a c t i c e s i n c l u d i n g s t r e s s management. F i n a l l y , b e h a v i o r p a t t e r n s for d i e t , e x e r c i s e and s l e e p , and s o c i a l and work a c t i v i t i e s , c o n s t i t u t e l i f e s t y l e c h a r a c t e r i s t i c s h e l p f u l in u n d e r s t a n d i n g the needs of t a r g e t a u d i e n c e . Maccoby and Alexander (1980) s t r e s s tha t "acknowledgement of the audience as a f u l l p a r t n e r in the communicat ion proces s makes a deve lopmenta l approach to campaign p l a n n i n g neces sary to the s u c c e s s f u l p r e d i c t i o n of the s p e c i f i c f a c t o r s i n f l u e n c i n g the acceptance or r e j e c t i o n of campaign messages." S T E P I I Develop H e a l t h S t a t u s O b j e c t i v e s A c c o r d i n g to T a y l o r (1972), h e a l t h problem p r i o r i t y  s e t t i n g i s "the hear t of the p l a n n i n g p r o c e s s . " Once the h e a l t h needs of an i n d i v i d u a l , or of the s p e c i f i c t a r g e t p o p u l a t i o n have been d e t e r m i n e d , h e a l t h s t a t u s o b j e c t i v e s can be c l a r i f i e d and the d e s i g n of a s p e c i f i c h e a l t h 8 1 promot ion i n t e r v e n t i o n program can b e g i n . Communication media can be p a r t i c u l a r l y e f f e c t i v e in h e l p i n g people r e c o g n i z e the h e a l t h g o a l s they want to a c h i e v e , in m o t i v a t i n g them to work toward a c h i e v i n g the i d e n t i f i e d g o a l s , and in p r o v i d i n g o p p o r t u n i t i e s for the r e i n f o r c e m e n t of p o s i t i v e b e h a v i o r s . I t i s important when d e s i g n i n g a h e a l t h promotion i n t e r v e n t i o n to choose media tha t w i l l c o n t r i b u t e to the achievement of workable h e a l t h g o a l s and o b j e c t i v e s that have been i d e n t i f i e d in c o o p e r a t i o n w i t h the t a r g e t group , and which are c o n s i s t e n t w i t h t h e i r h e a l t h needs. S i n g l e or m u l t i p l e o b j e c t i v e s can be met w i th a v a r i e t y of media . For example, a p r i n t e d f a c t sheet on the i n c i d e n c e of b r e a s t cancer i s one type of medium that i s e f f e c t i v e f o r i n c r e a s i n g an i n d i v i d u a l ' s awareness of s u s c e p t i b i l i t y to a p a r t i c u l a r d i s e a s e . On the o ther hand, f i l m and v i d e o c a s s e t t e s are more a p p r o p r i a t e media i f the o b j e c t i v e i s to demonstrate a s k i l l such as breas t s e l f -e x a m i n a t i o n . STEP III Develop Content O u t l i n e The f i r s t s t ep in the d e s i g n p r o c e s s i n v o l v e s the development of a content . o u t l i n e which sh ou ld c o n t a i n the f o l l o w i n g f e a t u r e s : 1. De f ine the goa l s and o b j e c t i v e s of the s p e c i f i c h e a l t h 82 p r o m o t i o n / r i s k r e d u c t i o n program. 2. O u t l i n e the i n f o r m a t i o n to be i n c l u d e d , based on the s p e c i f i c h e a l t h s t a t u s o b j e c t i v e s a l r e a d y d e f i n e d . 3. D e s c r i b e the h e a l t h b e h a v i o r s to be a d d r e s s e d . 4. Review c u r r e n t knowledge. 5. L i s t b i b l i o g r a p h y and r e f e r e n c e m a t e r i a l s to be used as bac kground. The content of each media p r e s e n t a t i o n shou ld be l i m i t e d so as not to overwhelm the t a r g e t audience wi th too many c o n c e p t s . T h i s o u t l i n e sh ou ld be r e f e r r e d to when examining and s e l e c t i n g the media to be used in a program or campaign . STEP IV S e l e c t H e a l t h Promotion Message A decade ago, everyone was caught i n M a r s h a l l McLuhan's n o t i o n tha t "The Medium i s the Message." Today , b e l i e v e r s in p r e s s power t a l k of the importance of the p e r c e p t u a l env ironment . In t r u t h , the message i s the message, and the environment i s the env ironment . (Diamond, 1982) The key element in an e f f e c t i v e h e a l t h promotion  program i s the message. N o t h i n g i s more important than i t s 83 d e s i g n . I n n o v a t i v e use of communications media depends on a d e l i b e r a t e l y c o n c e i v e d message e lement , s i n c e in a h e a l t h promot ion campaign, there i s the d e l i b e r a t e e f f o r t to convey a p a r t i c u l a r message about w e l l n e s s and q u a l i t y of l i f e . To deve lop and c r e a t e messages and campaign des igns which not o n l y b r i n g h e a l t h - r e l a t e d i s s u e s to the p u b l i c ' s a t t e n t i o n , but a l s o change a t t i t u d e s and b e h a v i o r s , i t i s neces sary to draw upon r e s e a r c h f i n d i n g s in s e v e r a l areas r e l a t e d to the communication p r o c e s s . Taken as a whole, these f i n d i n g s , a c c o r d i n g to Maccoby and Alexander (1980), a l l o w the h e a l t h promot ion p l a n n e r "to d e a l w i t h a c o n f i g u r a t i o n of i n t e r a c t i n g f a c t o r s from which d i f f e r e n t -e f f e c t s on a t t i t u d e , i n f o r m a t i o n g a i n , and b e h a v i o r can be p r e d i c t e d . " A review of the communicat ions l i t e r a t u r e r a i s e d s e v e r a l r e l e v a n t v a r i a b l e s and q u e s t i o n s on message d e s i g n . The most p e r t i n e n t elements which must be addressed when s e l e c t i n g h e a l t h promot ion campaign messages i n c l u d e : 1. M e s s a g e / r e c i p i e n t i n t e r a c t i o n s : The b a s i c need i s f or more d e t a i l and d i f f e r e n t i a t i o n wi th r e g a r d to such t h i n g s as f e a r and other b a r r i e r s to a c t i o n , t a r g e t a u d i e n c e s , and types of m o t i v a t i o n a l a p p e a l s , which are o f t e n g l o b a l l y c o n c e p t u a l i z e d . For example, some people c o n t i n u e to ask whether c e r t a i n appea l s sh ou ld be used , but the more a p p r o p r i a t e q u e s t i o n , argues Swinehart (1976) i s "how much of what k i n d sh ou ld be used wi th which 84 aud iences under what c o n d i t i o n s . " Swinehart recommends that more s t u d i e s are needed which use as independent v a r i a b l e s , the s t a t e s t i m u l a t e d in a person by a message, r a t h e r than the c h a r a c t e r i s t i c s of the message i t s e l f or those of the r e c i p i e n t . " P a r t i c u l a r l y , " he adds , " in exper iments on very s e r i o u s d i s e a s e t o p i c s , the a p p r o p r i a t e a n a l y t i c v a r i a b l e i s not the amount of t h r e a t a p p l i e d but the amount of f ear p r o d u c e d , " and how that "state" impacts on changes in b e h a v i o r and h e a l t h s t a t u s . V e r t i n s k y (1978/79) s i m i l a r l y p o i n t s out t h a t " m a n i p u l a t i n g emotions through the proces s of b e h a v i o r a l m o d i f i c a t i o n i s a d e l i c a t e proces s and much harm can be done by overpowering or extreme f e a r - i n d u e i n g i n t e r v e n t i o n s . " She adds , " i t i s a p r o c e s s which may c r e a t e b a c k l a s h by p o p u l a t i o n s exposed to the message, even i f they were not the s p e c i f i c t a r g e t of the campaign" and suggests that " u n t i l more i s known about the c h a r a c t e r i s t i c s of r e c e i v i n g groups and message d e s i g n s t r a t e g i e s , i n t e r v e n t i o n p o l i c i e s s h o u l d p r o b a b l y remain c o n s e r v a t i v e , a iming at a slow i n c r e m e n t a l impac t ." 2. R i s k and u n c e r t a i n t y as p o s i t i v e v a l u e s : For many p e o p l e , i r o n i c a l l y , a warning of r i s k (such as the hazards of smoking) has reward p r o p e r t i e s ; the exc i tement of danger i s a source of g r a t i f i c a t i o n . In t h i s c i r c u m s t a n c e , Swinehart (1976) p o i n t s o u t , " e f f o r t s to m a i n t a i n u n c e r t a i n t y ( for example, by d e l a y i n g a checkup) 85 may be i n c r e a s e d r a t h e r than decreased by a message about h e a l t h r i s k s , thus p r o d u c i n g an e f f e c t o p p o s i t e to the one i n t e n d e d . " Mi l sum (1981) warns t h a t " i f we proceed to set up an a d v e r s a r y or c o m p e t i t i v e s i t u a t i o n in order to compel i n d i v i d u a l s to operate in a way c o n t r a r y to t h e i r normal h a b i t s , they may be s t i m u l a t e d , a lmost r e f l e x i v e l y , to outwi t the sys tem." He e x p l a i n s , " t h i s p e r v e r t s the i n d i v i d u a l ' s normal i n t e n t i o n away from promot ion of h i s or her own h e a l t h , and t a k i n g r e s p o n s i b i l i t y for i t , to that of e s s e n t i a l l y p u r s u i n g s e l f - d e s t r u c t i v e or u n n e c e s s a r i l y r i s k y b e h a v i o r . " N o r t h Vancouver p h y s i o t h e r a p i s t , M i c h a e l W h i t e , echoes , these c o n c e r n s and emphasized that h i s c l i e n t s f a l l more and more i n t o oppos ing p o i n t s of view about l i f e s t y l e : those who b e l i e v e i n l i v i n g a h e a l t h f u l l i f e s t y l e , and p r a c t i c e what they p r e a c h , and those who r a i l a g a i n s t p o s i t i v e l i f e s t y l e a d v i c e and e n t h u s i a s t i c a l l y take on d e s t r u c t i v e b e h a v i o r s l i k e smoking and o v e r - e a t i n g (White , 1983). P e r h a p s , as has been suggested by Kege les (1969), " m o t i v a t i o n to engage in h e a l t h behav ior may be o p e r a t i v e o n l y among those for whom h e a l t h i s s a l i e n t , or has h i g h p r i o r i t y ( i e . va lue ) v i s - a - v i s o ther a c t i v i t i e s i n l i f e . " T h i s p o i n t of view i s supported by r e s e a r c h conducted by B a r t h , V e r t i n s k y and Yang (1979) . They found t h a t the l i k e l i h o o d of p o s i t i v e b e h a v i o r change by people t r y i n g to 86 a v o i d p e r s o n a l i l l n e s s "is a f u n c t i o n of the i n d i v i d u a l ' s m o t i v a t i o n , the p e r c e i v e d va lue of i l l n e s s t h r e a t r e d u c t i o n , and the i n s t r u m e n t a l i t y of compl ian t behav ior i n r e d u c i n g the t h r e a t ( i e . , to p r e v e n t , d e l a y , or c u r e ) . " V e r t i n s k y et a l (1976), suggest tha t "Program p l a n n e r s must c o n t i n u e to i n v e s t i g a t e the gamut of reasons which m o t i v a t e or m i t i g a t e a g a i n s t p o s i t i v e h e a l t h behav ior so that measures can be chosen to promote g r e a t e r compl iance in v o l u n t a r y h e a l t h programs ." 3. Message content and format: In a communication which uses both t h r e a t and r e a s s u r a n c e , for example, shou ld the t h r e a t come f i r s t (because i t arouses concern and i n t e r e s t ) , or shou ld the r e a s s u r a n c e come f i r s t (because i t may make the person more r e c e p t i v e to the message)? Swinehart (1976) asks f u r t h e r , "What i s the. r e l a t i v e e f f e c t i v e n e s s of v a r i o u s appea l s i n a l t e r i n g the a n x i e t y va lue of d i s e a s e t o p i c s ? " In the case of c a n c e r , for example, "is i t e a s i e r to reduce a n x i e t y by emphas iz ing the v a l u e of e a r l y d e t e c t i o n , the e f f i c a c y of t r e a t m e n t , or o ther appea l s?" In c o n t r a s t to t h r e a t a p p e a l s , V e r t i n s k y , V e r t i n s k y and Zaltman (1972) suggest tha t "other emot iona l themes u s i n g sex, s t a t u s d r i v e s or v a n i t y may i n c r e a s e the s a l i e n c e of the message and a f f e c t , t e m p o r a r i l y at l e a s t , some of the p s y c h o l o g i c a l v a r i a b l e s which are r e l e v a n t to the p r o c e s s of response to the h e a l t h message." C a r e f u l r e s e a r c h as to the needs and 87 c h a r a c t e r i s t i c s of the t a r g e t p o p u l a t i o n , and p r e t e s t i n g of the message impact are c r u c i a l to p l a n n i n g an e f f e c t i v e h e a l t h campaign. Moreover , in o r d e r to ach ieve a r e a l h e a l t h r e v o l u t i o n , A l l e n (1980) argues , "we need to s w i t c h our a t t e n t i o n from an e x c l u s i v e focus on the i n d i v i d u a l to one that a l s o focusses on the h e a l t h c u l t u r e in which he or she l i v e s . " The h e a l t h promotion message can h e l p p o r t r a y what people need to l e a r n about what they shou ld and shou ld not do wi th r e g a r d to t h e i r own h e a l t h in r e l a t i o n to the c u l t u r a l norms of t h e i r s o c i a l env ironment . He recommends that an i n t e g r a t e d h e a l t h promot ion program which encourages p o s i t i v e l i f e s t y l e changes shou ld i n c o r p o r a t e the f o l l o w i n g g u i d e l i n e s i n t o the message d e s i g n : (a) emphasize the development of s u p p o r t i v e env ironments ; (b) deve lop a sound knowledge base; (c) use p o s i t i v e , n o n - b l a m e - p l a c i n g s o l u t i o n s ; and (d) emphasize w e l l n e s s . A l l e n argues tha t without an emphasis on " w e l l n e s s . . . i t i s u n l i k e l y t h a t a h e a l t h promot ion program w i l l work f o r the long t e r m . " M o t i v a t i o n for most p e o p l e , a c c o r d i n g to A l l e n , r e q u i r e s an emphasis on p o s i t i v e h e a l t h and w e l l n e s s . People have to f e e l tha t there i s something more than j u s t be ing "not s i c k . " Whi le the t h r e a t of i l l n e s s can m o t i v a t e for a shor t p e r i o d of t i m e , l o n g - r a n g e changes r e q u i r e "pleasure as a r e g u l a r r e i n f o r c i n g agent ." He 88 suggests that the h e a l t h promot ion message can emphasize the "joy of r u n n i n g , the joy of h e a l t h - g i v i n g food (not the d e n i a l of n o n - n u t r i t i o n a l f o o d s ) , and the joy and s a t i s f a c t i o n of s o c i a l and work r e l a t i o n s h i p s that c o n s t i t u t e a h e a l t h l i f e s t y l e and i n c r e a s e s the q u a l i t y of our l i v e s . " The impact on the Canadian p u b l i c made by P A R T I C I P a c t i o n , an independent , n o n - p r o f i t o r g a n i z a t i o n devoted to the promotion of p h y s i c a l a c t i v i t y and p h y s i c a l f i t n e s s in Canada, i s d i r e c t l y a t t r i b u t a b l e to the w e l l n e s s o r i e n t a t i o n of i t s v a r i o u s p r o m o t i o n a l campaigns . P A R T I C I P a c t i o n ' s 10th A n n i v e r s a r y R e p o r t , "1971-1981: A Decade of A c t i o n " d e t a i l s some important market ing s t r a t e g i e s for s u c c e s s f u l l i f e s t y l e behav ior change. I t c i t e s v a r i o u s methods of g e t t i n g people to change, namely: u s i n g scare t a c t i c s (an a p p r o a c h , the r e p o r t c o n t e n d s , which i s , u n f o r t u n a t e l y , popu lar w o r l d wide ) ; s imply g i v i n g people the o p p o r t u n i t y to change and hope they make i t ; d a n g l i n g a p r i z e to e n t i c e people i n t o c h a n g i n g ; or combining methods one and three in the time honored c a r r o t - a n d - s t i c k a p p r o a c h . " B u t , " the r e p o r t c o n t i n u e s , "where the behav ior to be changed i s l a r g e l y a matter of l i f e s t y l e , ideas loom l a r g e as agents for s o c i a l change, because ideas are the common c u r r e n c y u n d e r l y i n g a t t i t u d e s , v a l u e s and c h o i c e s . I n s o f a r as ideas are c r u c i a l , so are communicat ions - the e f f e c t i v e e x p r e s s i o n and exchange of i d e a s . " 89 PARTICI Pact ion has c o n s c i o u s l y adopted c e r t a i n market ing s t r a t e g i e s and t echn iques to serve the f i t n e s s i d e a , and they have reached the f o l l o w i n g c o n c l u s i o n s on "what the market ing of an idea r e a l l y means": (From: "Heart and M i n d , " in P A R T I C I P a c t i o n ' s 10th A n n i v e r s a r y R e p o r t , 1 981 ) I f people merely buy an idea and not use i t , i t i s  l o s t : An idea s tays a l i v e on ly when i t c r e a t e s l o n g - t e r m changes in the way people behave. In the long r u n , promot ing an idea means not j u s t s e l l i n g i t , but d e v e l o p i n g and n u r t u r i n g i t s v i t a l l i n k s w i t h i t s a u d i e n c e , i n t a k i n g people to the p o i n t where they w i l l put i t i n t o a c t i o n . "Should" ideas t u r n people o f f : A common mis take in s o c i a l market ing i s the assumption tha t an idea can have any l o n g - t e r m m o t i v a t i n g power without f i r s t s e c u r i n g p e o p l e ' s u n d e r s t a n d i n g of i t . J u s t because an idea i s good does not mean that people w i l l b e l i e v e i t or ac t upon i t . And j u s t because people sh ou ld do something does not mean that they w i l l . Communications campaigns based on t h i s f a l l a c y a l l share the same symptoms. They tend to d e a l i n f a l s e i m p e r a t i v e s . They g i v e people o r d e r s and t r y to manipu la te them. But people d o n ' t l i k e to take o r d e r s . And as soon as they f e e l that they are be ing m a n i p u l a t e d by an i d e a , they t u r n o f f . E f f e c t i v e s o c i a l market ing r e s p e c t s i t s a u d i e n c e . I t seeks to engage minds , not d i r e c t them. I t shows, r a t h e r than c l a i m s , that an idea i s good and how and why i t i s worth a c t i n g on . Nor does i t condescend. I t works from the a u d i e n c e ' s p o i n t of view to d e v e l o p an educated awareness of an idea and an informed w i l l i n g n e s s to change. Even the best ideas (and the best funded) are o n l y  as good as the way in which t h e y ' r e e x p r e s s e d : A p o o r l y expressed idea i s b a r e l y an idea at a l l . And any idea tha t i s r e p e a t e d l y expressed i n the same way w i l l e v e n t u a l l y not be heard at a l l . The s tock in t r a d e of a l l good communicat ions , t h e r e f o r e , i s c r e a t i v i t y , i n n o v a t i o n and a l i v e l y sense of s t y l e . Without t h e s e , there i s no way to make an i d e a , even the best - c o m p e l l i n g , or to 90 keep i t c o m p e l l i n g through a long campaign. We have found that n o t h i n g works so w e l l as a  p o s i t i v e message, humorously and c r e a t i v e l y  e x p r e s s e d . The market ing of an idea i s a l o n g - t e r m p r o j e c t in  which the most important s t ep i s always the next  one: I t ' s r e l a t i v e l y easy to r a i s e an i s s u e - and to grab p u b l i c a t t e n t i o n for a moment wi th a- few f l a s h y moves. The tough q u e s t i o n i s , what do you do with an i s sue once you 've brought i t b e f o r e the p u b l i c eye?" By b r i n g i n g an idea i n t o f o c u s , a t w o f o l d r e s p o n s i b i l i t y i s c r e a t e d : In the f i r s t p l a c e , to your a u d i e n c e . People need time to undergo any  r e a l change; they need to take a l l the s m a l l but  necessary s teps that l e a d to the u n d e r s t a n d i n g and  acceptance of an i d e a . Which i s why the most important s t ep i s always the next one. Communications e f f o r t s shou ld be des igned to h e l p people take i t . In the second p l a c e , you have a r e s p o n s i b i l i t y to your i d e a . I t should not be f o r g o t t e n amid the s h o r t - t e r m d e t a i l s . In one way or another you must s t a t e i t c l e a r l y in e v e r y t h i n g you do . And, as your idea grows, i t must be seen to grow. You h a v e , t o l e t people know, at every  s t a g e , t h a t they are not a lone i n t h e i r a c t i o n s . In that way the proper c l i m a t e for f u r t h e r growth i s a s s u r e d . PARTICIPac t ion has worked to a p p l y these p r i n c i p l e s to every phase of i t s communicat ions campaigns . In i t s f i r s t phase , the "awareness phase ," the p r o j e c t s t a f f worked for f i v e y e a r s to c r e a t e a broad a p p r e c i a t i o n of the importance of f i t n e s s to C a n a d i a n s . A l l t h e i r e a r l y communicat ions work was devoted to drawing p u b l i c a t t e n t i o n to the f i t n e s s problem in Canada and the need to do something about i t . T h e i r " W a l k - A - B l o c k " campaign focussed s o l e l y on g e t t i n g Canadians to take tha t f i r s t c r u c i a l s t e p . S u b s e q u e n t l y , 91 they implemented both a m o t i v a t i o n a l and an e d u c a t i o n a l phase which have o v e r l a p p e d in t h e i r e f f o r t s to encourage people to t r a n s l a t e t h e i r concern and i n t e r e s t i n t o a c t i o n . T h e i r c u r r e n t phase , " F i t n e s s Now and How" i s des igned to in form and guide a c t i o n . The r e p o r t c o n c l u d e d i t s remarks in the area of m o t i v a t i o n a l marke t ing wi th t h i s a d v i c e : What i t a l l comes down to i s l e a d e r s h i p , which i s a f t e r a l l , the a b i l i t y to competent ly take people s t ep by s t ep through a p r o c e s s wi thout l o s i n g s i g h t of your f i n a l o b j e c t i v e s . You must be w i l l i n g to s tand by an idea u n t i l i t becomes a r e a l i t y . You have to be committed to your l e a d e r s h i p r o l e i f you want to communicate at a l l , because e f f e c t i v e communicat ion i s in i t s e l f a k i n d of l e a d e r s h i p . ( P A R T I C I P a c t i o n ' s 10th A n n i v e r s a r y Report 1971-1981: A Decade of A c t i o n ) 4. Message impact T h i s i s an important v a r i a b l e when e v a l u a t i n g the impact of the message on changing behav ior and h e a l t h s t a t u s . The q u e s t i o n t h a t should be. asked i s , "How long a f t e r a message i s r e c e i v e d shou ld i t s e f f e c t s be measured?" As the i n t e r v a l i n c r e a s e s , the a b i l i t y to r e c a l l i n f o r m a t i o n l e a r n e d d e c l i n e s - but there i s a l s o g r e a t e r o p p o r t u n i t y for people to take a recommended a c t i o n . Swinehart (1976) s t r e s s e s t h a t "we need to know more about the frequency and t i m i n g of r e i n f o r c i n g messages i n order to produce both s u s t a i n e d knowledge g a i n and maximum a d a p t i v e a c t i o n s . " In an A u s t r a l i a n r e p o r t on h e a l t h p r o m o t i o n , Davidson 92 (1979) s t a t e s that "acceptance of the g e n e r a l p r i n c i p l e of the use of the media to promote h e a l t h i s o n l y a f i r s t s t e p . The type of use i s a l s o important as i s the c h a r a c t e r and p r e s e n t a t i o n of the message." He recommends the e s t a b l i s h m e n t of a "hea l th message t e s t i n g s e r v i c e " mode l l ed on an American s e r v i c e as d e s c r i b e d by Ward and Neva l (1977) . T h i s s e r v i c e , which i s based on t e c h n i q u e s d e r i v e d from market r e s e a r c h , p r e - t e s t s t e l e v i s i o n messages about h e a l t h for f a c t o r s i n c l u d i n g a t t e n t i o n , r e c a l l , p e r s o n a l r e l e v a n c e , b e l i e v a b i l i t y , e t c . The answers to these u n r e s o l v e d q u e s t i o n s r e g a r d i n g the s e l e c t i o n of the h e a l t h promot ion "message" sh ou ld p r o v i d e the o p p o r t u n i t y for h e a l t h communicat ions to become more c r e a t i v e and more e f f e c t i v e , p a r t i c u l a r l y i n the mass media (Swinehar t , 1976). STEP V S e l e c t / P r o d u c e A p p r o p r i a t e Communication Media There are no u n i v e r s a l de terminant s of s u c c e s s . There i s no formula for b e h a v i o r change that i s u n i v e r s a l l y a p p l i c a b l e for a l l p o p u l a t i o n s , s e t t i n g s , h e a l t h prob lems , or h e a l t h b e h a v i o r s . (Squyres and G r e e n , 1980) 93 V e r t i n s k y et a l (1972) suggest that f a r too l i t t l e i s known about the " c h a r a c t e r i s t i c s of a message which may be most e f f e c t i v e l y dep loyed by the h e a l t h e d u c a t o r . Even i f a message i s most p e r s u a s i v e , t h e r e i s no guarantee that the audience w i l l l i s t e n to i t , p e r c e i v e i t s t r u e i m p l i c a t i o n s , or r e t a i n the i n f o r m a t i o n r e l a t e d to i t . " Swinehart (1979) compares the chances of a h e a l t h promotion program s u c c e e d i n g to those of the American t e l e v i s i o n networks in p r e p a r i n g for a f a l l season: " T y p i c a l l y , each network buys about 150 s c r i p t s or t r e a t m e n t s ; of these on ly t h i r t y become p i l o t shows; on ly seven of these get on the f a l l s c h e d u l e , and perhaps none w i l l s u r v i v e the season ." The job of h e a l t h promot ion i s t o u g h e r , says Swinehar t , because everyone shou ld be r e a c h e d . As V e r t i n s k y (1978/79). e x p l a i n s , "The success of the communicator , who must compete for the a t t e n t i o n of h i s a u d i e n c e , w i l l depend upon h i s a b i l i t y to adapt h i s message so tha t i t has immediate meaning to the a u d i e n c e . " Be fore e f f e c t i v e l y s e l e c t i n g and p r o d u c i n g communicat ion media for h e a l t h promot ion programs, the p l a n n e r must a l s o d e c i d e on how to "promote the message", whether i t be through f a c e - t o - f a c e i n s t r u c t i o n or v i a mass communicat ions c h a n n e l s , or b o t h . I t shou ld be remembered, however, as d i s c u s s e d in Chapter 2, that the r o l e of c o u n s e l l i n g - c o n v e r t i n g i n f o r m a t i o n i n t o an a c t i o n s t r a t e g y to support an i n d i v i d u a l ' s h e a l t h s t a t u s o b j e c t i v e s - i s a 94 p a r t i c u l a r l y a p p r o p r i a t e a d j u n c t to h e a l t h r i s k r e d u c t i o n programs. Maccoby and Alexander (1980) b e l i e v e that "al though i t i s p o s s i b l e that i n the f u t u r e the e n t i r e ( h e a l t h promotion) e f f o r t might be accompl i shed v i a the media , our c u r r e n t view i s that the prudent c h o i c e of the ' b e s t ' s t r a t e g y for optimum e f f i c i e n c y of community-based r i s k r e d u c t i o n i s a matr ix p l a n which b lends a m i n i m a l , but focussed amount of f a c e - t o - f a c e i n s t r u c t i o n wi th an e x t e n s i v e media campaign that i s s t r o n g enough to c r e a t e the d e s i r e d outcome, in p a r t , by i t s e l f . " Such a s t r a t e g y does not use mass communications e x c l u s i v e l y ; however, use of the media i s c e n t r a l to the p l a n . Whi le the use of mass communicat ions media has l o n g been an a t t r a c t i v e method for promot ion of good h e a l t h p r a c t i c e s and the p r e v e n t i o n of v a r i o u s s o c i a l and h e a l t h prob lems , t h e r e i s s t i l l debate about i t s e f f e c t i v e n e s s i n changing a t t i t u d e s and b e h a v i o r s . F u r t h e r , one must r e c o g n i z e , there e x i s t s the p o s s i b i l i t y tha t mass media are not who l ly s u i t a b l e for communicating some of the s u b t l e t i e s i n v o l v e d i n d i s s e m i n a t i n g the h e a l t h promot ion message. For c e r t a i n d i m e n s i o n s , more complex mechanisms l i k e the use of h e a l t h assessment s t r a t e g i e s supplemented wi th i n t e r p e r s o n a l c o u n s e l l i n g might more p r o f i t a b l y be employed. Whi le some communications r e s e a r c h e r s s t i l l b e l i e v e * » that most mass media campaigns are i n e f f e c t i v e ; o t h e r s b e l i e v e t h a t , w i th c a r e f u l p l a n n i n g , a campaign can a c h i e v e 95 the d e s i r e d r e s u l t s (Solomon, 1982). The recent campaigns that have supplemented mass media wi th community o r g a n i z a t i o n and d i r e c t - c o n t a c t s t r a t e g i e s , r a t h e r than assuming that r e a c h i n g the g e n e r a l p o p u l a t i o n s o l e l y by means of the mass media i s s u f f i c i e n t (as has been done by some programs over the l a s t two decades) are examples of improved p l a n n i n g ( W a l l a c k , 1981). " I n t e r p e r s o n a l and media s o u r c e s , " suggests V e r t i n s k y et a l (1976), "play e s s e n t i a l but d i f f e r e n t r o l e s . " The media may w e l l be seen as an i n f o r m a t i v e r a t h e r than a m o t i v a t i o n a l s o u r c e . However, as V e r t i n s k y (1978/79) p o i n t s o u t , the range of s t r a t e g i e s a v a i l a b l e and the p o t e n t i a l i t y of the mass media for r e a c h i n g l a r g e and d i v e r s i f i e d aud iences p r o v i d e h e a l t h promot ion p l a n n e r s w i th the p o s s i b i l i t y of a d a p t i n g to v a r y i n g budgetary r e s t r a i n t s . There seems to be agreement that mass media does impact on b e h a v i o r , a l b e i t n e g a t i v e l y as w e l l as p o s i t i v e l y ( M a r s h a l l , 1981; V e r t i n s k y , 1978/79; Long , 1978; K e l l y , 1978). As Peter Newman, former e d i t o r of MacLean's Magaz ine , s u c c i n c t l y p o i n t s o u t : "The p r e s s does not have power, but has i n f l u e n c e - the media can change p e o p l e ' s minds" (Freeman, 1982). Wal lack (1981) c o n c l u d e s h i s e x t e n s i v e h i s t o r i c a l review of the impact of mass media campaigns on behav ior change wi th the argument that whi l e "we have been ab le to f i n d out reasonab ly w e l l what p lanned mass media campaigns cannot do , we know l i t t l e about what 96 they can d o . " He recommends that "unless broader t echn iques of i n q u i r y are i n c o r p o r a t e d i n t o e v a l u a t i o n s of such campaigns , we w i l l c o n t i n u e to over look v a l u a b l e sources of data and u s e f u l p r a c t i c a l i n f o r m a t i o n . " I t sh ou l d be r e c o g n i z e d , t h e r e f o r e , tha t s e r i o u s c o n s i d e r a t i o n must be g i v e n to u s i n g these powerfu l means of communicat ing i n f o r m a t i o n on w e l l n e s s and r i s k r e d u c t i o n to the p u b l i c in the most e f f e c t i v e ways p o s s i b l e . An example of a r i s k r e d u c t i o n campaign that made a s i g n i f i c a n t impact on the in tended t a r g e t p o p u l a t i o n u s i n g the media as the major i n t e r v e n t i o n mechanism i s the S t a n f o r d Three Community Heart D i sease Study in the U . S . ( F a r g u h a r , Maccoby, Wood, et a l , 1977). T h i s program, begun in 1970 by an i n t e r d i s c i p l i n a r y group of b i o m e d i c a l and b e h a v i o r a l r e s e a r c h e r s , e x p l o r e d the p o s s i b i l i t y that c a r d i o v a s c u l a r r i s k can be reduced by community e d u c a t i o n v i a the mass media . Two communit ies r e c e i v e d i n t e n s i v e mass media campaigns i n E n g l i s h and S p a n i s h . One of them a l s o had f a c e - t o - f a c e i n s t r u c t i o n for a s m a l l group of persons c o n s i d e r e d to be at h i g h r i s k . A t h i r d community s erved as a c o n t r o l . The media campaign c o n s i s t e d of a v a r i e t y of media ( e g . , TV s p o t s , bus c a r d s , e t c . ) tha t were r e l e a s e d to the t a r g e t audience through the most g e n e r a l l y a v a i l a b l e media c h a n n e l s . A broad range of m a t e r i a l s were p r o d u c e d : for example, about 50 t e l e v i s i o n s p o t s , three hours of 97 t e l e v i s i o n programming, over 100 r a d i o s p o t s , s e v e r a l hours of r a d i o programming, weekly newspaper columns, newspaper a d v e r t i s e m e n t s and s t o r i e s , b i l l b o a r d s , p r i n t e d m a t e r i a l sent v i a d i r e c t m a i l to p a r t i c i p a n t s , c a l e n d a r s , and o ther a s s o r t e d m a t e r i a l s . Before the campaign began, and a g a i n one and two years l a t e r , people from the communit ies were examined for c a r d i o v a s c u l a r prob lems . How much they knew about c a r d i o v a s c u l a r d i s e a s e and what, i f a n y t h i n g , they were d o i n g about i t were a l s o a s c e r t a i n e d . In a d d i t i o n , p h y s i o l o g i c a l measures such as b l o o d p r e s s u r e , we ight , and plasma c h o l e s t e r o l were t a k e n . The S t a n f o r d Heart D i sease P r e v e n t i o n P r o j e c t based t h e i r b e h a v i o r change s t r a t e g i e s on C a r t w r i g h t p o s t u l a t e s of mass p e r s u a s i o n . T h i s approach regards changes i n c o g n i t i v e , a f f e c t i v e and a c t i o n s t r u c t u r e s as neces sary p r e r e q u i s i t e s f o r behav ior change ( S t e r n , F a r g u h a r , Maccoby and R u s s e l , 1976). Wal lack (1981) s t a t e s "the S t a n f o r d p r o j e c t sought to teach s p e c i f i c s k i l l s (as w e l l as i n c r e a s e knowledge and change a t t i t u d e s ) through mass media" and adds , "with t h i s model , there i s a pr imary r a t h e r than secondary focus on b e h a v i o r . " The r e s u l t s of the Three Community P r o j e c t p r o v i d e ev idence that "behavior change for b e t t e r h e a l t h can be accompl i shed through s u s t a i n e d community-based e d u c a t i o n . " Maccoby and Alexander (1980) c o n c l u d e d that "It i s c l e a r 98 that the mass media can i n c r e a s e knowledge and change d i e t a r y b e h a v i o r . However," they add , "we b e l i e v e that the power of the media can be enhanced i f we can f i n d ways to  use them to s t i m u l a t e and c o o r d i n a t e programs of  i n t e r p e r s o n a l i n s t r u c t i o n in n a t u r a l community g r o u p s , and  to d e l i v e r some forms of s p e c i a l i z e d t r a i n i n g and  c o u n s e l l i n g . " The use of media f o r h e a l t h promot ion must be deve loped around sound e d u c a t i o n a l p r i n c i p l e s , but media a lone are not l i k e l y to a f f e c t b e h a v i o r change. Squyres (1980) s t r e s s e s t h a t " h e a l t h e d u c a t i o n t h e o r y and r e s e a r c h have warned t h a t no s i n g l e e d u c a t i o n a l input shou ld be expected to have s i g n i f i c a n t l a s t i n g impact on h e a l t h behav ior u n l e s s i t i s supported by other i n p u t s . " She adds , "The best combinat ion of e d u c a t i o n a l and c o u n s e l l i n g methods, media and message for some people i s not n e c e s s a r i l y the best combinat ion for o t h e r s . " The proces se s and i n t e r a c t i o n s d e s c r i b e d and i l l u s t r a t e d in F i g u r e 3.2 can be seen as a dynamic framework for s e l e c t i n g , p r o d u c i n g and e v a l u a t i n g communication media for h e a l t h p r o m o t i o n . i. F i g u r e 3.2 99 Framework For The S e l e c t i o n , P r o d u c t i o n And E v a l u a t i o n of Communication Media For H e a l t h Promotion PRELIMINARY PLANNING Assess target audience Identify goals and objectives Determine message, medium/media, setting, spokesperson, resources SELECT AND PRODUCE/ORDER SAMPLE MEDIA PRETEST AND EVALUATE SAMPLE MEDIA Pretest material with target audience Assess i f needs match Assess instructional/ motivational quality and effectiveness, technical quality, program resources Revise as necessary EVALUATE IN TERMS OF GOALS PRODUCE/ORDER AND OBJECTIVES IN A WAY THAT / PERMITS COMPARISON OF VARIOUS SELECTED MEDIA APPROACHES. 1 00 The p r e l i m i n a r y p l a n n i n g s teps for d e s c r i b i n g c h a r a c t e r i s t i c s and needs of the t a r g e t audience c o r r e l a t e w i th the p r e t e s t and e v a l u a t i o n s teps once sample media have been s e l e c t e d . P r i o r to f i n a l p r o d u c t i o n or o r d e r i n g of the s e l e c t e d media , i t i s c r i t i c a l to p r e t e s t a l l m a t e r i a l s to ensure tha t p r i n t a n d / o r a u d i o / v i d e o m a t e r i a l s r e p r e s e n t , or are a p p r o p r i a t e to the needs of the t a r g e t group; t h a t they a c c u r a t e l y present the i n f o r m a t i o n , and that they meet the i d e n t i f i e d campaign o b j e c t i v e s . Maccoby and A l e x a n d e r (1980) argue tha t "from the e x t e n s i v e body of r e s e a r c h tha t the e m p i r i c a l t r a d i t i o n in communication s t u d i e s has p r o d u c e d , the main c o n c l u s i o n the e x p e r i e n c e d p r a c t i t i o n e r must reach i s that the s t r a t e g y w i t h the h i g h e s t p r o b a b i l i t y of success" i s de termined by p r e t e s t i n g m u l t i p l e approaches . They e x p l a i n that the "primary method by which r e s e a r c h f i n d i n g s and e s t a b l i s h e d p s y c h o l o g i c a l p r i n c i p l e s are a p p l i e d to campaign d e s i g n i s an i t e r a t i v e p r o c e s s of audience a n a l y s i s , t r i a l r u n s , f o r m a t i v e e v a l u a t i o n for feedback, f i n a l l y u t i l i z i n g the e v a l u a t i o n r e s u l t s to reshape and r e s t r u c t u r e messages and campaign p l a n s . " Only through t h i s p r o c e s s , can the most p o s i t i v e approaches to p r e s e n t i n g the i n t e r v e n t i o n s t r a t e g y be l o c a t e d and r e f i n e d and some as surance p r o v i d e d that they w i l l be e f f e c t i v e wi th the in tended audience (Maccoby and A l e x a n d e r , 1980). 101 The c r i t e r i a by which the s e l e c t e d sample media shou ld be p r e t e s t e d and e v a l u a t e d are d e s c r i b e d w i t h i n the f o l l o w i n g four g e n e r a l c a t e g o r i e s : (For complete d i s c u s s i o n , see Source Book for H e a l t h E d u c a t i o n M a t e r i a l s and Community  R e s o u r c e s , 1982). 1 . How w e l l do the m a t e r i a l s match the needs of i n d i v i d u a l  or t a r g e t group as i d e n t i f i e d d u r i n g the i n i t i a l .assessment? The s e l e c t e d media sh ou ld be e v a l u a t e d a c c o r d i n g to the same c a t e g o r i e s o u t l i n e d in STEP I . Knowing the needs and c h a r a c t e r i s t i c s of the t a r g e t audience can h e l p d e c i d e on the a p p r o p r i a t e medium ( a u d i o / v i s u a l , p r i n t , e t c . ) f or the i n t e n d e d audience and p u r p o s e s . The s u b j e c t matter shou ld be e a s i l y u n d e r s t o o d , c u l t u r a l l y based , p e r s o n a l l y r e l e v a n t , c l e a r l y s t a t e d and must appea l or be a p p l i c a b l e to the o b j e c t i v e s of the t a r g e t group . The m a t e r i a l sh ou ld be a p p r o p r i a t e to the s e t t i n g i n which h e a l t h promot ion a c t i v i t y i s to be c a r r i e d o u t , and to the a u d i e n c e ' s a v a i l a b l e t ime , a t t e n t i o n span, and p o t e n t i a l use of the i n f o r m a t i o n . 2. What i s the m o t i v a t i o n a l / i n s t r u c t i o n a l q u a l i t y of the  m a t e r i a l s ? Which elements of formats of the program d e s i g n produce the most l e a r n i n g and which produce the most b e h a v i o r change? Swinehart (1976) p o i n t s out that f e a t u r e s which promote one sometimes undermine the 1 02 o t h e r , and those which maximize both need to be i d e n t i f i e d . The e f f e c t i v e n e s s and s u i t a b i l i t y of s p e c i f i c media for a t t a i n i n g s t a t e d h e a l t h promotion o b j e c t i v e s must be d e t e r m i n e d . Some media can impede l e a r n i n g among c e r t a i n a u d i e n c e s : f o r example, i f the message i s t a r g e t e d to an e l d e r l y group , a f i l m which i s e a s i l y seen and heard i s a b e t t e r media c h o i c e than a b ook le t w i th s m a l l p r i n t . Another recommendation that m e r i t s a t t e n t i o n i s that i m p r o p e r l y t r a n s l a t e d m a t e r i a l s are not g e n e r a l l y w e l l a c c e p t e d : for example, n o n - E n g l i s h m a t e r i a l s shou ld be w r i t t e n i n the n a t i v e language r a t h e r than be t r a n s l a t e d from E n g l i s h . I d e n t i f y i n g the t h r e s h o l d s at which i n f o r m a t i o n or m o t i v a t i o n a l appea l s produce behav ior s h o u l d , a c c o r d i n g to S w i n e h a r t , be a r e l a t i v e l y h i g h - p r i o r i t y r e s e a r c h t a s k . As p o i n t e d out i n STEP IV above, some people are prompted to a c t by low l e v e l s of i n f o r m a t i o n or m o t i v a t i o n , w h i l e o t h e r s r e s i s t even h i g h l e v e l s . He suggests that "greater knowledge of the nature and c o r r e l a t e s of these i n d i v i d u a l d i f f e r e n c e s s h o u l d make i t p o s s i b l e to de s i gn mass media programs which would be more e f f e c t i v e as w e l l as more e f f i c i e n t . " 3 . What i s the t e c h n i c a l q u a l i t y of the m a t e r i a l s ? Re ly on p r o f e s s i o n a l a d v i c e . Know where media can be produced p r o f e s s i o n a l l y and where produced media can 1 03 be l o c a t e d . I t i s c r i t i c a l to preview a l l m a t e r i a l s be fore u s i n g them. 4 . Do the m a t e r i a l s match program r e s o u r c e s and  l i m i t a t i o n s ? E v a l u a t e the p o t e n t i a l e f f e c t i v e n e s s of the -s p e c i f i c media be fore p r o d u c t i o n and use . To make the best use of l i m i t e d monies , i t i s important to c o n s i d e r the c o s t s v e r s u s q u a n t i t y and q u a l i t y of d i f f e r e n t types of communication media , and t h e i r advantages and d i s a d v a n t a g e s . In some c a s e s , i t may be b e t t e r to produce on ly a few expens ive but h i g h l y s p e c i a l i z e d m a t e r i a l s ; in o t h e r s i t may be more e f f e c t i v e to order l a r g e q u a n t i t i e s of i n e x p e n s i v e m a t e r i a l s . H e a l t h promot ion and r i s k r e d u c t i o n a c t i v i t i e s can be conducted through a v a r i e t y of i n t e r p e r s o n a l and mass media networks . Y e t , s e t t i n g s o f f e r both o p p o r t u n i t i e s and b a r r i e r s to the c r e a t i v e use of communication media . For example, r i s k r e d u c t i o n a c t i v i t i e s in a m e d i c a l o f f i c e are sometimes c o n s t r a i n e d by l i m i t e d space and p r o v i d e r t i m e . These c o n s t r a i n t s can be oversome by u s i n g such media as microcomputers and v i d e o c a s s e t t e systems. L a r g e r s e t t i n g s , such as h o s p i t a l s , o f t en have meet ing rooms a v a i l a b l e for group s e s s i o n s which can more e a s i l y accommodate screens for f i l m and overhead p r o j e c t o r s . Many media , e s p e c i a l l y p r i n t and microcomputer 1 04 m a t e r i a l s , f i t i n t o any s e t t i n g whether c l i n i c , c l a s s r o o m , or c a f e t e r i a . The American H o s p i t a l A s s o c i a t i o n ' s Media Handbook (1978) and the U . S . C e n t e r s for D i s e a s e C o n t r o l ' s Source  Book f o r H e a l t h E d u c a t i o n M a t e r i a l s and Community Resources (1982) have been used as re source gu ides for r e v i e w i n g c u r r e n t l y a v a i l a b l e communication media for h e a l t h promotion and r i s k r e d u c t i o n programs (see Appendix F for a d d r e s s e s ) . These c u r r e n t l y a v a i l a b l e media are summarized under 16 headings in T a b l e 3.1 "Communication Media S e l e c t i o n M a t r i x " and are d e s c r i b e d in some d e t a i l i n Appendix G . T h i s matr ix p r e s e n t s a h e l p f u l guide for d e t e r m i n i n g the e f f e c t i v e n e s s of these s e l e c t e d media based on c a t e g o r i e s of l e a r n i n g o b j e c t i v e s . A comprehensive l i s t of "Formats and D e f i n i t i o n s of Communication Media for H e a l t h Promot ion" i s p r e s e n t e d in Appendix H . 105 T a b l e 3.1 Communication Media S e l e c t i o n M a t r i x MEDIUM HEALTH PROMOTION LEARNING OBJECTIVE Learning Facts, Theori es Comprehending and Applying Facts, Principles, Concepts Influencing Attitudes, Opinions, Motivations Illustrations MEDIUM HIGH MEDIUM Photographic prints LOW MEDIUM LOW Chalkboard MEDIUM MEDIUM LOW Models LOW MEDIUM LOW Simulators (sound & visual) MEDIUM HIGH LOW Real objects LOW MEDIUM LOW Exhibits & displays MEDIUM MEDIUM MEDIUM Programmed material HIGH HIGH MEDIUM Printed media HIGH HIGH MEDIUM Audio recordings HIGH LOW MEDIUM 2" x 2" slides MEDIUM MEDIUM LOW Overhead projection MEDIUM MEDIUM LOW Filmstrips MEDIUM MEDIUM LOW Motion picture (silent) MEDIUM MEDIUM MEDIUM Motion picture (sound) MEDIUM HIGH HIGH Television MEDIUM HIGH HIGH Rating Scale: HIGH = very effective, MEDIUM = adequately effective, LOW = not effective. Adapted from: "Instructional Media/Learning Objective Matrix" American Hospital Association, Media Handbook, 1978. 1 06 STEP VI Use of Communication Media Whi le r e c o g n i z i n g the a v a i l a b i l i t y and p o t e n t i a l of a l l the above s e l e c t e d media , t h i s S tep in the p l a n n i n g p r o c e s s w i l l focus s p e c i f i c a l l y on the scope and advantages for h e a l t h promotion and r i s k r e d u c t i o n programs of u s i n g c u r r e n t l y a v a i l a b l e i n t e r a c t i v e i n f o r m a t i o n and t e l ecommunica t ion t e c h n o l o g i e s , namely, the microcomputer , v a r i o u s v i d e o t a p e / d i s c r e c o r d i n g and p layback u n i t s , c a b l e and s a t e l l i t e t e l e v i s i o n systems, and the mass media , p a r t i c u l a r l y the e l e c t r o n i c media . TECHNOLOGICAL STRATEGIES FOR HEALTH PROMOTION P r o b a b l y the next grea t l e a p in human e v o l u t i o n i s " i n f o r m a t i c s , " the c o n f l u e n c e of computers , i n f o r m a t i o n and t e l ecommunica t ion systems. We c a n ' t keep up w i t h a l l the t e c h n o l o g i c a l changes but we must know how to use t e c h n o l o g y . Those who know how to c r e a t e and manage the i n t e r f a c e between systems or p a r t s of system w i l l be g r e a t l y i n demand. ( H a r k i n s , 1982) The impact of t echno logy on the f u t u r e of h e a l t h promot ion cannot be i g n o r e d . "Technology r a i s e s the p r o d u c t i v i t y of i n f o r m a t i o n , p r o v i d e s c h o i c e s , f r e e s people 1 07 for r e s e a r c h and development" ( H a r k i n s , 1982). The advanced communication t e c h n o l o g i e s of the 1980's , as e x e m p l i f i e d by the microcomputer , v i d e o d i s c s and v i d e o t a p e s , data banks and networks , and i n t e r a c t i v e t e l ecommunica t ion systems, o f f e r important c h a l l e n g e s f o r i n n o v a t i v e and e f f e c t i v e h e a l t h promot ion s t r a t e g i e s . An overview of the growth of the m i c r o e l e c t r o n i c s i n d u s t r y and the use of the microcomputer i n medic ine and in h e a l t h r i s k assessment w i l l be p r o v i d e d i n the f o l l o w i n g sect i o n s . V i d e o d i s c s , expected to be p a r t of the new mode of communicat ion , can s t o r e l a r g e amounts of i n f o r m a t i o n e a s i l y . I t i s t e c h n i c a l l y p o s s i b l e , f or example, to s t o r e a 20 volume e n c y c l o p e d i a on j u s t two d i s c s . To be i n s t ep wi th the f u t u r e , some textbook p u b l i s h e r s are p r e s e n t l y p l a n n i n g e l e c t r o n i c p u b l i s h i n g d i v i s i o n s (Canadian Home Economics J o u r n a l , Summer, 1982). Over four m i l l i o n American homes a l r e a d y have v i d e o c a s s e t t e r e c o r d i n g / p layback equipment . S a l e s c o n t i n u e to f l o u r i s h i n the U . S . at a r a t e of around h a l f a m i l l i o n u n i t s a year (Diamond, 1982) . Another phenomenal growth i n d u s t r y i s the s a t e l l i t e to home/community e a r t h r e c e i v i n g s t a t i o n s (TVRO's or "dishes") be ing manufactured and s o l d throughout N o r t h A m e r i c a . A s s e m b l e - i t - y o u r s e l f k i t s are the l a t e s t development . Over 50,000 American homes, and an e s t i m a t e d 10,000 Canadian 108 homes, have s a t e l l i t e e a r t h s t a t i o n s capab le of r e c e i v i n g more than 50 p a y - t v and c a b l e program s e r v i c e s . E v e n t u a l l y c a b l e s u b s c r i b e r s w i l l have a c h o i c e of up to 100 c h a n n e l s , and two-way c a b l e opens up another set of programming o p t i o n s . As Canada has one of the h i g h e s t c a b l e p e n e t r a t i o n s i n the w o r l d , the p o t e n t i a l for h e a l t h - r e l a t e d programming and h e a l t h promot ion cannot be i g n o r e d . Two-way systems a l r e a d y in s e r v i c e in the U n i t e d S t a t e s i n c l u d e Warner Amex's QUBE c a b l e system o p e r a t i n g in Columbus, C i n c i n n a t i , P i t t s b u r g h , Houston and D a l l a s , which a l l o w s v i ewers to t e l l a computer what programs they l i k e , vote on i s s u e s , take c o l l e g e c o u r s e s and buy g r o c e r i e s ; and the' CBS and AT&T v i d e o t e x system which i s be ing t e s t e d in Ridgewood, N . J . T h i s system uses the te lephone network to l i n k a t e l e v i s i o n - l i k e t e r m i n a l in the home w i t h a c e n t r a l computer . By t y p i n g i n s t r u c t i o n s on a keyboard , people can c a l l up i n f o r m a t i o n from a computer , p l a y computer games, p l a c e o r d e r s w i t h s t o r e s and o b t a i n a wide v a r i e t y of news, weather, s p o r t s and a d v e r t i s i n g . Major t e s t - t r i a l s of TELIDON, Canada's p i o n e e r two-way v i d e o t e c h n o l o g y , are c u r r e n t l y be ing conducted throughout the c o u n t r y . The f i r s t commercia l a p p l i c a t i o n s of TELIDON i n v o l v e 250 Manitoba farmers w i r e d to " P r o j e c t G r a s s r o o t s , " which g i v e s them access to 3000 pages of i n f o r m a t i o n , and " T e l e g u i d e , " a t o u r i s t i n f o r m a t i o n p r o j e c t i n T o r o n t o , O n t a r i o . 109 I t shou ld be r e c o g n i z e d , that through the expans ion of these new t e c h n o l o g i e s , major s h i f t s w i l l occur in the l abour market b r i n g i n g wi th them profound changes i n how we l e a r n , work and p l a y . The l i f e s t y l e changes brought on by t h i s mushrooming " i n f o r m a t i o n s o c i e t y " a r e , in themse lves , of concern and need to be e v a l u a t e d i n terms of t h e i r impact on w e l l n e s s and q u a l i t y of l i f e . H e a l t h Promotion e x p e r t i s e can p l a y a major r o l e in a s s e s s i n g these s h i f t s , in d e t e r m i n i n g h e a l t h needs , and in d e s i g n i n g c r e a t i v e s t r a t e g i e s that w i l l impact p o s i t i v e l y on the h e a l t h s t a t u s of i n d i v i d u a l s and f a m i l i e s . H e a l t h promot ion s t r a t e g i e s must beg in to take advantage of these t e c h n o l o g i c a l deve lopments . The key o b j e c t i v e should be to deve lop q u a l i t y "user f r i e n d l y " programs on every aspec t of h e a l t h promot ion and h e a l t h r i s k assessment which have been adapted for use in v a r i o u s s e t t i n g s i n c l u d i n g the home, s c h o o l s , m e d i c a l o f f i c e s and p u b l i c h e a l t h u n i t s , and the w o r k p l a c e , and which can be p lugged i n t o a v a r i e t y of v i d e o c a s s e t t e s and microcomputers . S u c c e s s f u l d e s i g n of programs for these systems must i n c o r p o r a t e b a s i c communication and market ing s k i l l s which begin w i t h knowing how to present i n f o r m a t i o n capab le of m o t i v a t i n g people and p r o v i d i n g them wi th the knowledge and s k i l l s necessary to b r i n g about l a s t i n g changes in t h e i r l i f e s t y l e p a t t e r n s . And in order to a f f e c t a s i g n i f i c a n t 1 10 pe r c e n t a g e of the p o p u l a t i o n , t h e s e t e c h n o l o g i c a l t o o l s must a l s o be r e a s o n a b l y i n e x p e n s i v e so as t o p e r m i t w i d e s p r e a d i m p l e m e n t a t i o n of plann e d programs. These t e c h n o l o g i c a l developments w i l l b o th enable and f o r c e s p e c i a l i s t s i n h e a l t h promotion and p r o v i d e r s of h e a l t h r i s k assessment t o c o n c e n t r a t e on the u n d e r l y i n g need f o r a c h i e v i n g e f f e c t i v e communication w i t h i n d i v i d u a l s and the community a t l a r g e . The M i c r o c o m p u t e r : T e c h n o l o g i c a l R e v o l u t i o n i n the 80's (The computer) i s the source of new l i f e t h a t has been d e l i v e r e d t o us. ( S e r v a n - S c r e i b e r , 1983) The s i l i c o n c h i p has made p o s s i b l e the d r a s t i c r e d u c t i o n i n s i z e , b u l k , and p r i c e of the computer which now makes i t a c c e s s i b l e t o m i l l i o n s , and b r i n g s w i t h i t the promise of d r a m a t i c and f a r r e a c h i n g changes i n the way people l i v e and work. Recent r e p o r t s c o n f i r m t h a t almost f i v e m i l l i o n m icrocomputers have been s o l d i n the U n i t e d S t a t e s up t o and i n c l u d i n g 1982. E s t i m a t e s f o r number of p e r s o n a l computers i n use by the year 2000 r e a c h e i g h t y m i l l i o n . (One make a l o n e , the IBM P e r s o n a l Computer, i s r e p o r t e d t o be s e l l i n g 111 1000 u n i t s per d a y ) . Canadian s a l e s are e s t imated to be 10% of U . S . s a l e s , or 500,000, and B r i t i s h Columbian s a l e s are based on 12% of t o t a l Canadian s a l e s , or an e s t i m a t e d 60,000 microcomputers in B . C . as of the end of 1982 ( C a m p b e l l , 1 983) . I f s a l e s match U . S . e s t i m a t i o n s , a p o t e n t i a l of e i g h t m i l l i o n computers w i l l be i n use in Canadian o f f i c e s , homes, s c h o o l s , i n s t i t u t i o n s , e t c . by the year 2000; 960,000 of which w i l l be i n B r i t i s h C o l u m b i a , an overwhelming p o t e n t i a l f o r h e a l t h p r o m o t i o n . T h i s t e c h n o l o g i c a l r e v o l u t i o n has been i n the making for four decades . A Time Magazine correspondent (Machine of the Y e a r , 1983) w r i t e s that the " e s s e n t i a l element in the i n e v i t a b i l i t y of the c o m p u t e r i z a t i o n of A m e r i c a , (add, and Canada) i s the way in which the young take to computers as a game, a p l e a s u r e , a t o o l , and a system that f i t s n a t u r a l l y i n t o t h e i r l i v e s . North American c h i l d r e n have grown up w i t h TV s c r e e n s , and the computer i s a screen that responds to them the way they want i t t o . " S u p p o r t i n g t h i s a s s u m p t i o n , the Time Magazine a r t i c l e c i t e d a recent U . S . survey which r e p o r t e d tha t 68% of the people p o l l e d b e l i e v e d computers w i l l improve the q u a l i t y of t h e i r c h i l d r e n ' s e d u c a t i o n . The microcomputer has the p o t e n t i a l to be a powerfu l and u s e f u l e d u c a t i o n a l t o o l f or s choo l and home use . The next s t ep in microcomputer i n n o v a t i o n i s a machine 1 1 2 tha t responds to v o c a l commands. Hardware manufac turers i n the U . S . , Japan and Canada have a l r e a d y deve loped p r o t o t y p e s . The Vancouver Sun (January 17, 1983) r e p o r t e d tha t the Japanese are s t e p p i n g up investments for the development , by the 1990's , of a new g e n e r a t i o n of computers w i t h t e r m i n a l s that can be operated by people w i t h a b s o l u t e l y no knowledge of how a computer works, and in a lmost any language . With a microphone r e p l a c i n g the keyboard , the computer w i l l be a b l e to converse w i t h i t s u s e r . Above a l l , manufac turers throughout the wor ld are competing to produce microsystems that w i l l be cheap enough to be a f f o r d a b l e by almost every h o u s e h o l d . The microcomputer i s to the 80's consumer what the automobi le was to the consumer in the 1920's . Most i n t e r e s t i n g i s the awesome dimens ion of p a y - T V ' s f u t u r e : the marr iage of home computers w i th c a b l e systems, a l l o w i n g v iewers to access c e n t r a l data banks around the w o r l d . The m i c r o p r o c e s s o r s and keyboards for use w i th c a b l e systems have a l r e a d y been p i o n e e r e d by a Canadian f i r m , Nabu M a n u f a c t u r i n g C o r p . of Ottawa, O n t a r i o (Newman, 1983). And beyond the computer "hardware" e x p l o s i o n l i e s the v i r t u a l l y l i m i t l e s s market for "software" computer programs. A b r i e f look at computer systems for the s p e c i f i c area of h e a l t h c a r e f o l l o w s . 1 1 3 Microcomputers in Health Care: From High-tech Medicine to  High-tech Health Promotion We know advances are going on, but in the health care revolution they are being held at bay. (Picot, 1982) The use of the microcomputer in medicine has developed from keeping records and accounts to suggesting diagnoses, and the United States i s leading the way in medical data bases. The Telenet Network, a jo i n t venture between GTE Corp. of Stamford, Conn, and the American Medical Association, has put information of about 3,500 diseases and 1,500 drugs on a diagnostic data base. Plans c a l l for expansion of this system to dozens of c i t i e s , including larger Canadian centres (Immen, 1983). A system known as CADUCEUS i s programmed for some four thousand symptoms of more than five hundred diseases; MYCIN specializes in infectious diseases, and PUFF measures lung functions, and a l l can be plugged into a master network c a l l e d SUMEY-AIM whose headquarters are located in Stanford, C a l i f o r n i a and Rutgers, New York (Machine of the Year, 1983). Developments in Canada include government sponsored projects in Newfoundland, Ontario and B r i t i s h Columbia which link remote c l i n i c s and hospitals to urban hospitals and s p e c i a l i s t s . And closer to home, the University of B r i t i s h Columbia's Health Sciences Centre Hospital i s on i t s way to 1 1 4 becoming the most computer ized h o s p i t a l in Canada; a UBC F a c u l t y of M e d i c i n e Task Force i s c u r r e n t l y r e v i e w i n g mainframe to m i n i computers f o r t h e i r p o t e n t i a l a p p l i c a t i o n in computer a s s i s t e d l e a r n i n g ; UBC's B i o m e d i c a l Communications Department i s p l a n n i n g a microcomputer network l i n k between i t s s a t e l l i t e o p e r a t i o n s for a d m i n i s t r a t i v e and management i n f o r m a t i o n ; and , p l a n s are underway to l i n k up t e a c h i n g h o s p i t a l s throughout B r i t i s h Columbia for t e a c h i n g , c l i n i c a l rounds and t r a n s m i s s i o n of d i a g n o s t i c - r e l a t e d d a t a , to name j u s t a few. The microcomputer i s a l s o a c h i e v i n g dramat i c e f f e c t s on the a i l i n g body, f or example, c o n t r o l l i n g pacemakers implanted in p a t i e n t s wi th h e a r t d i s e a s e s ; pumping c a r e f u l l y measured q u a n t i t i e s - o f i n s u l i n i n t o d i a b e t i c s ; t e s t i n g b l o o d samples for hundreds of d i f f e r e n t a l l e r g i e s ; t r a n s l a t i n g sounds i n t o v i b r a t i o n s that the deaf can "hear ," and s t i m u l a t i n g denervated muscles w i t h e l e c t r i c impulses t h a t may e v e n t u a l l y enable p a r a l y z e d e x t r e m i t i e s to move. Evans (1982) r a i s e s the i s s u e that from a broad s o c i a l p e r s p e c t i v e , our s o c i e t a l i n t e r e s t s may c o n f l i c t w i t h the "economic i n t e r e s t s of three g r o u p s : the h e a l t h p r o v i d e r s , the t echno logy i n d u s t r y , and the p o t e n t i a l u sers of the i n n o v a t i o n . " On the o ther hand, he argues , " c o s t - r e d u c i n g t echno logy which s u b s t i t u t e s f o r the s e r v i c e s of h e a l t h c a r e workers serves the i n t e r e s t s of government and the g e n e r a l p u b l i c . " 1 1 5 However, on ly about two percent of Canadian p h y s i c i a n s have i n s t a l l e d t h e i r own computers . F a c t o r s h o l d i n g up m e d i c a l computer use and networking i n c l u d e c o s t s , p r o f e s s i o n a l w o r r i e s about d i l u t i n g the p h y s i c i a n ' s a u t h o r i t y , u n f a m i l i a r i t y w i t h the language and the hardware, and the problems of p a t i e n t c o n f i d e n t i a l i t y (Immen, 1983). Malco lm M c i n t o s h of the B . C . M e d i c a l A s s o c i a t i o n ' s "Medica l P r a c t i c e Computer Committee" r e p o r t s that some m u l t i -s p e c i a l i t y group p r a c t i c e s in B r i t i s h Columbia are u s i n g s o p h i s t i c a t e d minicomputers for t h e i r m e d i c a l r e c o r d s , p h y s i c i a n and p a t i e n t s c h e d u l i n g , b i l l i n g and r e s e a r c h . He added that a l t h o u g h there i s a g r e a t d e a l of i n t e r e s t in microsys tems shown by s i n g l e p r a c t i t i o n e r s , s u r p r i s i n g l y few are be ing used . He b e l i e v e s t h i s to be a " t h r e s h o l d s i t u a t i o n u n t i l c o s t - e f f e c t i v e m e d i c a l l y - o r i e n t e d sof tware programs are marke ted ." Computer r e q u i r e m e n t s , e s p e c i a l l y f o r the s i n g l e p r a c t i t i o n e r , must encompass more than b i l l i n g and med ica l r e c o r d c a p a b i l i t y . In f a c t , one of the most potent a t t r a c t i o n s at presen t i s the computer ' s p o t e n t i a l to lower overhead expenses by r e d u c i n g space and s t a f f r e q u i r e m e n t s . M c i n t o s h s a i d he was not aware of m i c r o - a p p l i c a t i o n s which have the added c a p a b i l i t y of r e s e a r c h and s torage of m e d i c a l r e c o r d s tha t are a v a i l a b l e for m i n i s y s t e m s . He suppor t s the use of m i c r o s for p a t i e n t -i n i t i a t e d h i s t o r y - t a k i n g , and t h e i r p o t e n t i a l for h e a l t h promot ion c o u n s e l l i n g u s i n g such software programs as 1 16 i n t e r a c t i v e h e a l t h r i s k assessment and l i f e s t y l e q u e s t i o n n a i r e s ( M c i n t o s h , 1983). S i n c e computers which s t o r e , t r a c k , and to an i n c r e a s i n g degree , a n a l y z e h e a l t h and m e d i c a l data are on t h e i r way to becoming s t a n d a r d , i f not i n d i s p e n s i b l e , equipment i n m e d i c a l o f f i c e s , the p o t e n t i a l for h e a l t h promot ion and we l lnes s must not be l o s t in the t e c h n o l o g i c a l s h u f f l e . H e a l t h promotion p l a n n i n g must not remain r u d d e r l e s s in the m i c r o c h i p r e v o l u t i o n . Indeed, as Evans (1982) s t a t e s , "Insofar as the ( t echnology) s u p p l i e r s respond to the New P e r s p e c t i v e , i t i s an argument for expanding the scope of the h e a l t h system i n t o new p r o d u c t s and s e r v i c e s . . . . for i n v a d i n g the l i f e s t y l e and e n v i r o n m e n t a l f i e l d s , not r e t r e a t i n g be fore them." W e l l - d e s i g n e d h e a l t h promot ion programs u s i n g these new communicat ion t e c h n o l o g i e s can e f f e c t i v e l y complement g e n e r a l p r a c t i t i o n e r s ' and m e d i c a l s p e c i a l i s t s ' s e r v i c e s , p u b l i c h e a l t h and s c h o o l programs, and employee w e l l n e s s programs . The p u b l i c has o b v i o u s l y accepted the "machine of the e i g h t i e s " . I t i s now up to h e a l t h c a r e p r o f e s s i o n a l s to use t h i s t i m e - s a v i n g , "user f r i e n d l y " t echno logy to h e l p m o t i v a t e t h i s same p u b l i c to improve i t s h e a l t h h a b i t s . 1 1 7 H e a l t h R i s k Assessment: Software Packages for H e a l t h  Prompt ion Newly deve loped communication t echno logy may w e l l power r e v o l u t i o n a r y development in h e a l t h r i s k a p p r a i s a l . . . (and) p r o v i d e many new o p p o r t u n i t i e s for h e a l t h p r o m o t i o n . B r o t h e r s , L a s z l o and Milsum (1982) R e g a r d l e s s of what e v a l u a t o r s d e c i d e h e a l t h r i s k i n s t r u m e n t s are e s p e c i a l l y good f o r , F i e l d i n g (1982) b e l i e v e s " i t i s d i f f i c u l t to see a n y t h i n g but growth in t h e i r use ." He adds , "most i n d i v i d u a l s - independent of background , income, or e d u c a t i o n - are f a s c i n a t e d by c o m p u t e r i z e d h e a l t h r i s k a p p r a i s a l which p e r s o n a l i z e s the importance of h e a l t h h a b i t s as d e t e r m i n a n t s of p r e v e n t a b l e h e a l t h prob lems , and g i v e s i n d i v i d u a l s a n o t i o n of how t h e i r o v e r a l l h e a l t h r i s k compares w i th tha t of a peer g r o u p . " The widespread a v a i l a b i l i t y , economy, and power of microcomputers make them a t t r a c t i v e t o o l s for implementing H e a l t h Hazard A p p r a i s a l and s i m i l a r c o u n s e l l i n g ins truments (SPHERE, 1983). The microcomputer p r o c e s s for h e a l t h r i s k assessment i n c l u d e s an a n a l y s i s o f , f o r example, an i n d i v i d u a l ' s , a f a m i l y ' s , or w o r k p l a c e ' s own unique s i t u a t i o n . T h i s a n a l y s i s i s p r o v i d e d q u i c k l y and a c c u r a t e l y , a long wi th i n f o r m a t i o n tha t w i l l a i d people in t h e i r l i f e s t y l e d e c i s i o n - m a k i n g . "The i n t e r a c t i v e nature of the microcomputer i n c r e a s e s the c a p a b i l i t y for e f f e c t i v e 1 18 s e l f - e d u c a t i o n by s p e c i a l i z a t i o n and s e l f - p a c i n g , and , by a l l o w i n g c l i e n t s to c a r r y out the more r o u t i n e a s p e c t s of h e a l t h a p p r a i s a l , more e f f e c t i v e use can be made of the c o u n s e l l o r ' s time" ( B r o t h e r s , L a s z l o and M i l s u m , 1982). S e v e r a l H e a l t h H a z a r d / H e a l t h Risk A p p r a i s a l programs p r e s e n t l y e x i s t on microcomputer . (These have been o u t l i n e d i n Chapter 2, T a b l e 2 . 3 . ) Examples i n c l u d e those c u r r e n t l y a v a i l a b l e in the U n i t e d S t a t e s and Canada: the one used by the H e a l t h Computer S c i e n c e s Center at the U n i v e r s i t y of M i n n e s o t a , i s the Center for D i sease C o n t r o l (CDC) HHA v e r s i o n put onto an Apple I I ; G e n e r a l H e a l t h I n c . i n Washington , D . C . has deve loped a microcomputer v e r s i o n ; Computer ized H e a l t h A p p r a i s a l s in Clackamas , Oregon s e l l a number of h e a l t h a p p r a i s a l programs c r e a t e d for use on the Radio Shack TRS; and , C o n t r o l Data C o r p o r a t i o n in M i n n e a p o l i s , M i n n . i s p u t t i n g t h e i r "Staywe l l" program onto the P l a t o h e a l t h e d u c a t i o n computer system ( E l i a s , 1982). And C l i n i c a l Assessment Systems, I n c . i n M i a m i , F l o r i d a have adapted t h e i r m u l t i d i m e n s i o n a l d i a g n o s t i c t o o l , the " M i l l o n B e h a v i o r a l H e a l t h Inventory" for use on any s m a l l computer . The Canadian f e d e r a l government's " L i f e s t y l e P r o f i l e " has been adapted to the Apple II System and i s be ing used at v a r i o u s n a t i o n a l f a i r s and e x h i b i t i o n s throughout the c o u n t r y . And, at the U n i v e r s i t y of B r i t i s h C o l u m b i a , Mi lsum and a s s o c i a t e s i n the D i v i s i o n of H e a l t h Systems are 119 c u r r e n t l y market ing a H e a l t h Hazard A p p r a i s a l microcomputer v e r s i o n e n t i t l e d SPHERE-HHA which i s now a v a i l a b l e for use on the Apple II and the IBM PC systems. SPHERE (System for P e r s o n a l H e a l t h R i s k E v a l u a t i o n ) i s to become a comprehensive system of microcomputer programs for h e a l t h c o u n s e l l i n g in the many a s p e c t s of o v e r a l l h e a l t h . Bes ides the HHA component, o ther r i s k r e d u c t i o n programs on such p e r t i n e n t t o p i c s as n u t r i t i o n and s t r e s s are to be deve loped by the D i v i s i o n . As an example of how the advantages of microcomputer t echno logy can be e x p l o i t e d , the f o l l o w i n g f e a t u r e s have been i n c o r p o r a t e d i n t o the UBC SPHERE-HHA software package: (SPHERE, 1983) 1. The c l i e n t f i l l s out the q u e s t i o n n a i r e i n d i r e c t i n t e r a c t i o n wi th the microcomputer so tha t any u n c e r t a i n t i e s may be c l e a r e d up immediate ly w i th the c o u n s e l l i n g s t a f f . Thus e r r o r s can be i d e n t i f i e d and c o r r e c t e d immedia te ly . 2. C l i e n t i n t e r e s t i s s t i m u l a t e d by t h i s i n t e r a c t i v e input mode, through a c t i v e p a r t i c i p a t i o n . F u r t h e r , the q u e s t i o n n a i r e i s custom t a i l o r e d to each i n d i v i d u a l by p r e s e n t i n g on ly those q u e s t i o n s which a p p l y to tha t i n d i v i d u a l (eg . "female on ly" q u e s t i o n s never appear f o r male c l i e n t s ) . 3. The r e s u l t s of the assessment can e i t h e r be d i s p l a y e d on the screen or p r i n t e d for immediate c o u n s e l l i n g , f or 1 20 r e f e r r a l , or for the c l i e n t ' s own use . A sample of SPHERE'S assessment i s p r e s e n t e d i n Appendix I . 4. The data for a l l c l i e n t s can be accumulated anonymously on d i s k to enable l a t e r computat ion of u s e f u l s t a t i s t i c a l i n f o r m a t i o n . With t h i s f e a t u r e , i n f o r m a t i o n can be o b t a i n e d r e g a r d i n g the c l i e n t e l e of i n d i v i d u a l p r a c t i c e s , p u b l i c h e a l t h u n i t s , and workplace h e a l t h programs. C r o s s - s e c t i o n a l and l o n g i t u d i n a l s t u d i e s or other r e s e a r c h are a l s o fac i 1 i t a t e d . 5. The p r o c e s s i n g c o s t per HHA i s much l e s s than wi th p r e v i o u s systems because of the v a s t l y reduced h a n d l i n g , c l e r i c a l and m a i l i n g c o s t s . (See Appendix J for i n f o r m a t i o n r e g a r d i n g the SPHERE system.) MASS MEDIA STRATEGIES FOR HEALTH PROMOTION On C T V ' s "Canada AM" (Oct . 22, 1982), P r o f e s s o r Anne White of the U n i v e r s i t y of T o r o n t o ' s F a c u l t y of E n v i r o n m e n t a l S t u d i e s c i t e d ev idence t h a t "most people get t h e i r h e a l t h i n f o r m a t i o n from the mass media , e s p e c i a l l y t e l e v i s i o n , and from u n i v e r s i t y s c i e n t i s t s v i a n e w s . r e p o r t s on t e l e v i s i o n and in newspapers." These f i n d i n g s are supported by v a r i o u s r e s e a r c h e r r e p o r t s i n c l u d i n g those 121 conducted by Z i b r i k , P e t e r s and K u h n l e i n (1981); Jones and Weimer ( 1977); and, the Trend Study (1977) by Response A n a l y s i s for Hoffman-LaRoche which c i t e d magazines , newspapers, t e l e v i s i o n and r a d i o as sources for i n f o r m a t i o n on n u t r i t i o n and food s a f e t y . Wade and Schramm (1969) observed that the p r i n t e d media are the main sources of h e a l t h i n f o r m a t i o n in the U n i t e d S t a t e s , except for non-white and persons wi thout h i g h s c h o o l e d u c a t i o n . The l a t t e r appear to pay more a t t e n t i o n to broadcas t h e a l t h communicat ions . Ev idence from more recent s t u d i e s suggests a r e l i a n c e on t e l e v i s i o n for h e a l t h i n f o r m a t i o n ( M a r t i n , 1980; Richman and Urban , 1978). In one s t u d y , "Te le 'v i s ion Programs" were named by 31 p e r c e n t of the respondents when asked to name two or three main sources of h e a l t h i n f o r m a t i o n ; o n l y p h y s i c i a n s and d e n t i s t s , at 45 p e r c e n t , were named more o f t e n (Genera l M i l l s Amer ican . F a m i l y R e p o r t , 1979). A r e c e n t l y completed nat ionwide ( U . S . ) survey found tha t more than t h r e e - f o u r t h s of the respondents b e l i e v e p u b l i c s e r v i c e announcements on t e l e v i s i o n and r a d i o were a r e l i a b l e source of h e a l t h i n f o r m a t i o n (Fremuth and M a r r o n , 1978). Another survey found t e l e v i s i o n an important source of h e a l t h i n f o r m a t i o n ( M i l l e r , et a l , 1974). T e l e v i s i o n p a r t i c u l a r l y appears to have an enormous p o t e n t i a l for i n f l u e n c i n g l a r g e segments of the p o p u l a t i o n by v i r t u e of e x t e n s i v e and repeated exposure which a c c e l e r a t e s awareness and f a m i l i a r i t y w i t h s p e c i f i c 1 22 i s sues ( T i c h e n o r , Donahue and O l i e n , 1970). Indeed, as i n d i c a t e d by Roper (1973), "American audiences have l o n g  regarded t e l e v i s i o n as the most d e s i r a b l e and c r e d i b l e of  mass m e d i a . " A c c o r d i n g to T i c h e n o r , et a l (1970), t e l e v i s i o n may prove to become a g e n e r a l knowledge l e v e l l e r , p r o v i d i n g i n f o r m a t i o n for the l e s s educated which they would u n l i k e l y r e c e i v e from any o ther source and V e r t i n s k y (1978/79) adds , " h e l p i n g to c l o s e the g e n e r a l knowledge gap between those wi th a h i g h e r soc io -economic s t a t u s and the lower s t a t u s segments." To a c h i e v e maximum p e n e t r a t i o n of a t a r g e t a u d i e n c e , a ba lanced media mix i s e s s e n t i a l to meeting the o b j e c t i v e s of a h e a l t h promot ion campaign. T a b l e 3.2 "Mass Media Communications S t r a t e g i e s for H e a l t h Promotion and H e a l t h Risk Assessment" l i s t s c u r r e n t l y a v a i l a b l e p r i n t and broadcas t media , and the message formats for these media . 123 T a b l e 3.2 Mas s - M e d i a C o m m u n i c a t i o n s S t r a t e g i e s F o r H e a l t h P r o m o t i o n And H e a l t h R i s k A s s e s s m e n t MEDIA M I X MESSAGE FQ R M A T PRINT MEDIA newspapers magazines journals books pamphlets posters billboards direct mail buscards editorials col limns articles features cartoons illustrations photographs advertisements public service promotion BROADCAST MEDIA public radio commercial radio public television commercial television educational television cable channel telecasting interactive telecommunications satellite communications pay-TV news reports public service announcements commercial spot announcements documentaries specials (drama, variety) series format educational format two-way format (via telephone, computer, or TV studio) An o v e r a l l c o m p a r i s o n o f t h e " M a r k e t S h a r e o f t h e L e a d i n g Forms o f Mass C o m m u n i c a t i o n s " i s i l l u s t r a t e d i n F i g u r e . 3.3: F i g u r e 3.3 M a r k e t S h a r e Of D a i l y Usage Times F o r The L e a d i n g Forms Mass C o m m u n i c a t i o n s Source: Radio Facts (Radio Advertising Bureau Research Department, New York) In: "Utilizing Mass Media for Health Messages" (Price and Allensworth, 1979) 125 P r i n t Media Newspapers and Magaz ines : As c i t e d above, newspapers and magazines are immensely p o p u l a r , and b e l i e v e d c r e d i b l e , sources of h e a l t h i n f o r m a t i o n . Indeed, r e s e a r c h on newspaper r e a d e r s h i p p a t t e r n s p r e s e n t e d by P r i c e and A l l e n s w o r t h (1979) i n d i c a t e s tha t among a d u l t s e i g h t e e n y e a r s of age and o v e r , a p p r o x i m a t e l y 3 out of 4 read a newspaper each weekday, and about one t h i r d of those read more than one d a i l y p a p e r . Weekend papers are read by about 2 out of 3 a d u l t s . I t was found that r e a d i n g of newspapers i n c r e a s e s w i th age, and more males read newspapers than females . The m a j o r i t y of people (73%) set a s i d e a s p e c i a l time of the day to read a newspaper, u s u a l l y a f t e r the e v e n i n g meal (see F i g u r e 3 . 3 ) . Men read the f o l l o w i n g segments of the newspaper in the f o l l o w i n g order of f r equency : s t r a i g h t news a r t i c l e s , e d i t o r i a l s and columns, and f e a t u r e s and e n t e r t a i n m e n t i t ems . In c o n t r a s t , women read e d i t o r i a l s and co lumns , e n t e r t a i n m e n t , and then s t r a i g h t - n e w s i t ems , in t h a t order (Weaver and Mauro, 1978). The v a r i e t y of magazines (genera l p o p u l a t i o n , t r a d e j o u r n a l s , r e c r e a t i o n a l magazines , e t c . ) r e f l e c t s the f a c t t h a t each type of magazine s erves a s p e c i f i c audience and can be used to reach that t a r g e t segment. The p r i n t media can be used e f f e c t i v e l y to reach the p u b l i c w i th p o s i t i v e h e a l t h b e h a v i o r i n f o r m a t i o n . H e a l t h 126 promot ion messages may be p u b l i s h e d in s p e c i a l f e a t u r e s , r e g u l a r s e r i e s a r t i c l e s , and a d v e r t i s e m e n t s . Recent examples of s e l e c t i v e , c r e a t i v e use of the p r i n t media for promot ing p o s i t i v e l i f e s t y l e b e h a v i o r s i n c l u d e : - s y n d i c a t e d c o l u m n i s t Ann Landers s t r e s s i n g the importance of s e a t b e l t s ; - a c t r e s s Brooke S h i e l d s and opera s i n g e r P l a c i d o Domingo p o r t r a y e d in a n t i - s m o k i n g p o s t e r s and a d v e r t i s e m e n t s for the American Lung A s s o c i a t i o n ; - a c t r e s s F a r r a h Fawcett in magazine a d v e r t i s e m e n t s promot ing b r e a s t s e l f - e x a m i n a t i o n on b e h a l f of the American Cancer S o c i e t y ; - an i n t e n s i v e "Attack Plaque" campaign i n B r i t i s h C o l u m b i a , p a i d f o r by B . C . d e n t i s t s , used newspapers and r a d i o . They a l s o r e c e i v e d some f r e e p u b l i c s e r v i c e t ime and space . Whi le no study was c o n d u c t e d , comments from the d e n t i s t s and the p u b l i c i n d i c a t e d tha t the program was u s e f u l ( E p s t e i n , et a l , 1975); - p u b l i c a t i o n of s e l f - s c o r e d h e a l t h r i s k assessment q u e s t i o n n a i r e s , such as the Canadian government's "Your L i f e s t y l e P r o f i l e " d i s t r i b u t e d i n the Canadian Automobi le A s s o c i a t i o n ' s magazines a c r o s s Canada, and "How Long W i l l You L i v e ? , " p r i n t e d i n a recent Time Magaz ine , are examples of how the p r i n t media can be e f f e c t i v e l y and i n n o v a t i v e l y used for h e a l t h r i s k r e d u c t i o n programs; 1 27 - B r i t i s h Columbia "Buckle-Up" program promot ing the use of s e a t b e l t s sponsored by the B r i t i s h Columbia M e d i c a l A s s o c i a t i o n (BCMA); - The Vancouver C i t y H e a l t h Department ' s "Cold Turkey" mass media campaigns of January 1982 and January 1983 were d e s i g n e d to i n c r e a s e the smoking c e s s a t i o n r a t e in the B . C . p o p u l a t i o n . J o i n t l y sponsored by The Vancouver Sun newspaper, the B . C . M e d i c a l A s s o c i a t i o n , the B . C . Heart F o u n d a t i o n , the B . C . Lung A s s o c i a t i o n and the Canadian Cancer S o c i e t y , the campaigns i n c l u d e d a s e r i e s of a r t i c l e s i n the Sun p r i o r to and f o l l o w i n g "Cold Turkey Day," a r e g i s t r a t i o n form to be completed wi th a photograph to The Sun, "Cold Turkey" but tons and s t i c k e r s , a pamphlet c o n t a i n i n g a d v i c e for those a t t e m p t i n g to s top smoking, and a "Cold Turkey C e l e b r a t i o n " at Robson Square . Radio Radio m e d i c a l b r o a d c a s t i n g may prove to be a u s e f u l p r e v e n t i v e and h e a l t h promot ion s t r a t e g y as w e l l as p r o v i d i n g p o p u l a r e n t e r t a i n m e n t . The use of p a i d and p u b l i c s e r v i c e announcements and programs, s e r i e s , i n t e r v i e w s , t e l ephone p a r t i c i p a t i o n programs a n d / o r news r e p o r t s on both p u b l i c , and commercia l r a d i o s t a t i o n s , shou ld be an i n t e g r a l p a r t of a mixed media approach to h e a l t h promot ion and h e a l t h r i s k assessment . 1 28 An i n e x p e n s i v e , f l e x i b l e medium, r a d i o i n v o l v e s a h i g h l e v e l of l i s t e n e r invo lvement , can be heard by automobi le as w e l l as home a u d i e n c e s , and has a long t r a d i t i o n of spoken programming. P r i c e and A l l e n s w o r t h (1979) p r e s e n t e d the f o l l o w i n g r a d i o audience r e s e a r c h : - at l e a s t one working r a d i o i s found in over 98% of a l l (North) American homes, and the average household has more than f ive s e t s ; - r a d i o i s l i s t e n e d to more d u r i n g weekdays than on weekends; - the l i k e l i h o o d of l i s t e n i n g to r a d i o i n c r e a s e s w i t h e d u c a t i o n ; - women spend more time l i s t e n i n g to r a d i o than men; - e i g h t y - e i g h t percent of the teenage p o p u l a t i o n i s reached by r a d i o on an average day and they l i s t e n t o , on a v e r a g e , three hours per day (see F i g u r e 3 . 3 ) . An example of an i n t e r a c t i v e program format i s p r e s e n t e d by M a r t i n (1980), an American p h y s i c i a n , who recommends u s i n g r a d i o as an i d e a l medium for r e a c h i n g the community by h e a l t h p r o f e s s i o n a l s , p a r t i c u l a r l y f a m i l y p h y s i c i a n s . M a r t i n , a l o n g wi th two other p h y s i c i a n s , broadcas t a weekly , l i v e , 45-minute program " C a l l Me In the M o r n i n g " . "The f a m i l y p h y s i c i a n , " he suggests "by v i r t u e of h i s or her b r e a d t h of t r a i n i n g and frequent r o l e as p a t i e n t a d v o c a t e , i s w e l l s u i t e d to a program d e a l i n g w i t h d i s e a s e 1 29 p r e v e n t i o n , h e a l t h p r o m o t i o n , s e l f - c a r e , and h e a l t h care consumerism." The i n t e r v i e w te lephone p a r t i c i p a t i o n format i s used p r i m a r i l y , and M a r t i n b e l i e v e s that " i t i s not on ly the l i s t e n i n g audience that b e n e f i t s from programs such as these ; there are s e v e r a l advantages for the p h y s i c i a n as w e l l . " S p e c i f i c a l l y , " p h y s i c i a n s ' awareness of community r e s o u r c e s i s expanded and t h e i r frame of r e f e r e n c e i s broadened by engaging i n a c t i v i t y o u t s i d e the t r a d i t i o n a l , i n s u l a r p r o f e s s i o n a l s e t t i n g " ( M a r t i n , 1980). T h i s view i s suppor ted by M i t c h e l l (1980) who encourages p h y s i c i a n s to be i n v o l v e d wi th the media , and p a r t i c u l a r l y w i t h r a d i o and t e l e v i s i o n , both as per formers and as c r i t i c s . Rogers (1980), another American p h y s i c i a n who s u p p o r t s involvement in mass communicat ions , wrote " O p e n - l i n e programmes i n v o l v i n g a g e n e r a l p r a c t i t i o n e r p r o v i d e a u s e f u l and e t h i c a l a d d i t i o n to o ther m e d i c a l s e r v i c e s " but c a u t i o n s tha t " f u r t h e r work s h o u l d be undertaken to e v a l u a t e the e f f e c t i v e n e s s of h e a l t h a d v i c e tha t may be g i v e n . " T e l e v i s i o n : The Medium of the E i g h t i e s How to communicate the 'keep w e l l ' message to make some impact on l i f e s t y l e , i s a c h a l l e n g e . I t must be by T V . ( B a y l e y , 1982) The 1979 Surgeon G e n e r a l ' s Report on H e a l t h Promotion 130 and D i s e a s e P r e v e n t i o n , "Healthy P e o p l e , " c o n c l u d e d that i l l n e s s , and c o n d i t i o n s in which p e r s o n a l r e s p o n s i b i l i t y and way of l i f e p l a y a key r o l e , account for about h a l f the m o r t a l i t y r a t e in the U n i t e d S t a t e s ( t h i s p r o b a b l y a p p l i e s e q u a l l y i n Canada) . The Report s t a t e d that the " c u r r e n t emphasis on maintenance of good h e a l t h and p r e v e n t i o n of i l l n e s s through b e h a v i o r p a t t e r n s and p r a c t i c e s suggests that t e l e v i s i o n wi th i t s p e r v a s i v e presence and g e n e r a l l e a r n i n g e f f e c t can e x e r t s i g n i f i c a n t impact on the p u b l i c ' s h e a l t h b e l i e f s and h e a l t h - r e l a t e d b e h a v i o r s . " In an update of the Surgeon G e n e r a l ' s Committee R e p o r t , a review of s c i e n t i f i c advances d u r i n g the 1970's began wi th a d i s c u s s i o n of t e l e v i s i o n ' s h e a l t h - p r o m o t i n g p o s s i b i l i t i e s ( T e l e v i s i o n and B e h a v i o r , Summary R e p o r t , 1982). T h i s Report noted that s e v e r a l campaigns have been conducted over the pas t few y e a r s . These t e l e v i s i o n campaigns c o v e r e d community mental h e a l t h , drug abuse , smoking, s e a t b e l t use , d e n t a l h e a l t h , c a n c e r , s e x u a l l y t r a n s m i t t e d d i s e a s e s and a l c o h o l i s m . Three t e l e v i s i o n campaigns t h a t have made an impact were s i n g l e d out and c i t e d : 1. F e e l i n g Good: An e d u c a t i o n a l t e l e v i s i o n s e r i e s on h e a l t h produced by the C h i l d r e n ' s T e l e v i s i o n Workshop (CTW) for the P u b l i c B r o a d c a s t i n g System (PBS) and broadcas t throughout 131 the U n i t e d S t a t e s (and Canada) ( M e i l i k e and S w i n e h a r t , 1976). The s e r i e s was supposed " t o a t t r a c t an a u d i e n c e , be f a i r and o b j e c t i v e , convey i n f o r m a t i o n and m o t i v a t e b e h a v i o r " ( S w i n e h a r t , 1976). Aimed at a d u l t s , i t c o n t a i n e d e l e v e n one-hour programs and t h i r t e e n h a l f - h o u r programs. While most s t u d i e s of mass communications i n d i c a t e t h a t they are f a r more l i k e l y t o r e i n f o r c e than t o change a t t i t u d e s , b e l i e f s or b e h a v i o r , Swinehart e x p l a i n e d , "we undertook t h i s program as an e x p e r i m e n t , i n p a r t , t o see whether t h i s r a t h e r c o n s i s t e n t f i n d i n g c o u l d be m o d i f i e d . " W ith t h i s f o c u s , e x p l i c i t b e h a v i o r a l g o a l s , and i n f o r m a t i o n t o convey i n support of those g o a l s , were d e v e l o p e d . The o v e r a l l e v a l u a t i o n of " F e e l i n g Good" i s p r o b a b l y , a c c o r d i n g t o K o bin (1976), "the most e x t e n s i v e ever c a r r i e d out on a t e l e v i s i o n s e r i e s i n h e a l t h e d u c a t i o n . " I t i n v o l v e d major s t u d i e s by the Response A n a l y s i s C o r p o r a t i o n , the N a t i o n a l O p i n i o n Research C e n t e r , the G a l l u p O r g a n i z a t i o n and the A.C. N i e l s e n Company. These n a t i o n a l and l o c a l s t u d i e s d e a l t w i t h the e f f e c t of programming on a t t i t u d e s , knowledge and b e h a v i o r ; the s i z e and c h a r a c t e r i s t i c s of the a u d i e n c e ; and the program a p p e a l . One major a s p e c t of the p r o j e c t was i t s i m p r e s s i v e o u t r e a c h a c t i v i t y . P r o j e c t s t a f f , over a two year p e r i o d , c o n t a c t e d over 1500 h e a l t h o r g a n i z a t i o n s t h r o u g h o u t the U n i t e d S t a t e s and a l e r t e d an e s t i m a t e d 3 1/2 m i l l i o n p e o p l e - m o s t l y i n poor and m i n o r i t y communities - w i t h f l y e r s , 1 32 n e w s l e t t e r s , r a d i o appearances , e t c . They a l s o o r g a n i z e d more than 75 s p e c i a l community p r o j e c t s -• such as h e a l t h f a i r s and s c r e e n i n g d r i v e s - in h o s p i t a l s , s c h o o l s , c l i n i c s , c o l l e g e s , and Ind ian r e s e r v a t i o n s . Kobin (1976) argues tha t " i f p r o j e c t s l i k e " F e e l i n g Good" are to be the most e f f e c t i v e , they must have e x t e n s i v e s u p p o r t . Without q u e s t i o n " he s t r e s s e s , "outreach and promot ion are  c r i t i c a l . " The T e l e v i s i o n and Behav ior Summary Report (1982) s t a t e s "there was s t r o n g ev idence of change in such b e h a v i o r s as e a t i n g more f r u i t , p e r f o r m i n g b r e a s t s e l f -e x a m i n a t i o n , hav ing an eye e x a m i n a t i o n , encourag ing someone to have a Pap t e s t , and sending for h e a l t h i n f o r m a t i o n o f f e r e d on t e l e v i s i o n . The main l e s s o n l e a r n e d from t h i s experiment i s that i t i s d i f f i c u l t but not i m p o s s i b l e for a  t e l e v i s i o n s e r i e s to have an impact on h e a l t h knowledge and  b e h a v i o r . " 2. The Nor th K a r e l i a P r o j e c t , F i n l a n d : T h i s s u c c e s s f u l campaign which emphasized smoking c e s s a t i o n and hear t d i s e a s e p r e v e n t i o n through b e t t e r l i f e s t y l e h a b i t s combined t e l e v i s i o n w i t h o ther e d u c a t i o n e f f o r t s , such as t r a i n i n g of p e r s o n n e l and making e n v i r o n m e n t a l changes (Puska, T v o m i l e h t o , Salonen et a l , 1979). The campaign was made up of seven t e l e v i s e d c o u n s e l l i n g s e s s i o n s w i t h ten smokers who were t r y i n g to q u i t . 133 P r e v e n t i n g r e l a p s e was emphasized. I t was e s t i m a t e d that about 100,000 a d u l t s p a r t i c i p a t e d , and about 10,000 stopped smoking for at l e a s t s i x months. The s i x - y e a r p r o j e c t produced a s i g n i f i c a n t change in c a r d i o v a s c u l a r r i s k f a c t o r s , a drop in hear t a t t a c k s , and cut the number of s t r o k e s n e a r l y in h a l f (Swinehart , 1979). A c c o r d i n g to the T e l e v i s i o n and Behav ior Summary Report (1982), " t h i s  campaign made good use of b e h a v i o r a l s c i e n c e theory by  p r o v i d i n g audience wi th a d u l t models and hav ing a s o c i a l  support system to encourage b e h a v i o r a l change ." 3. The S t a n f o r d Heart D i sease Three Community Study in the  U . S . ( F a r q u h a r , Maccoby, Wood, et a l , 1977): A f t e r one year of the mass media campaign (as p r e v i o u s l y d i s c u s s e d ) , the e s t i m a t e d r i s k of hear t a t t a c k and s t r o k e was reduced in the community r e c e i v i n g both the p e r s o n a l i n s t r u c t i o n and the t e l e v i s e d programs. But by the end of the second y e a r , the community r e c e i v i n g on ly the t e l e v i s i o n programs had reduced the r i s k by the same amount as the o ther community, i e . 15% to 20%. R i s k in the c o n t r o l community, however, had i n c r e a s e d . The T e l e v i s i o n and B e h a v i o r , Summary Report (1982) c o n c l u d e s t h a f ' t h e r e s u l t s c l e a r l y show t h a t mass  media campaigns can be e f f e c t i v e , but a d d i t i o n a l r e s e a r c h i s  needed on how to i n c r e a s e e f f e c t i v e n e s s even more so . T h i s  campaign used t e l e v i s i o n to t each s p e c i f i c b e h a v i o r a l  s k i l l s , and the ev idence i s that the program worked." 1 34 Other h e a l t h promot ion and r i s k r e d u c t i o n campaigns on t e l e v i s i o n tha t m e r i t ment ion , i n c l u d e : 4. P A R T I C I P a c t i o n : Canada ' s "movement for p e r s o n a l f i t n e s s " uses a m u l t i p l e media a p p r o a c h , i n c l u d i n g t e l e v i s i o n , and i s r e c o g n i z e d as one of the most important f o r c e s in c r e a t i n g a new p o s t i v i e we l lnes s environment in Canada. When PARTICIPac t ion s t a r t e d in 1971, f i t n e s s was a non-i s s u e wi th C a n a d i a n s , and v a r i o u s s t u d i e s i n d i c a t e d that l e s s than 5% of the a d u l t p o p u l a t i o n was r e g u l a r l y p h y s i c a l l y a c t i v e ( a v e r a g i n g a minimum of two or three a c t i v i t y s e s s i o n s each week). Over the i n t e r v e n i n g y e a r s , tha t percentage leve l ' has r i s e n c o n t i n u o u s l y to a present a l l - t i m e h i g h of 37% (Behavior and A t t i t u d e Toward P h y s i c a l A c t i v i t y Among C a n a d i a n s , 1982). The 1981 Canada "Fitness Survey conf i rmed t h i s i n c r e a s e d p a r t i c i p a t i o n l e v e l , c o n c l u d i n g tha t involvement i n s p o r t s i s up s i g n i f i c a n t l y from 1976. F u r t h e r , the survey found tha t compared to 1976, there are l a r g e i n c r e a s e s in the numbers of people wanting to beg in e x e r c i s e a c t i v i t i e s (Canada's F i t n e s s , 1981). 5. Coronary Risk F a c t o r T e s t : A dramat i c e x p r e s s i o n of n a t i o n a l concern about h e a r t a t t a c k s o c c u r r e d when A B C - T V ' s 20/20 program broadcas t a t e s t on c o r o n a r y r i s k f a c t o r s in F e b r u a r y , 1981. The. network, asked v iewers to r a t e 135 themselves and send in the r e s u l t s . Some 40,000 responses were expec ted ; i n s t e a d , the A r i z o n a Heart I n s t i t u t e which d e v i s e d the t e s t , was de luged wi th 260,000 s c o r e s , some w r i t t e n on paper p l a t e s and r e s t a u r a n t r e c e i p t s . Perhaps most h e a r t e n i n g , one c o u p l e s crawled t h e i r s c o r e s on an empty -hear t - shaped candy box, e x p l a i n i n g : "Because of your t e s t , we threw out the r e s t " (Coronary R i s k F a c t o r s , 1981). 6. N a t i o n a l D r i v i n g T e s t s : Produced by the Canadian T e l e v i s i o n Network ( C T V ) , two two-hour programs were t e l e c a s t on a l l CTV s t a t i o n s a c r o s s Canada: the f i r s t N a t i o n a l D r i v i n g Tes t was t e l e c a s t d u r i n g 1978, 1979 and 1980; the Second N a t i o n a l D r i v i n g Tes t i n 1980 and 1981. These i n n o v a t i v e p r o d u c t i o n s used a s e l f - s c o r e d t e s t , format as the focus for i m p a r t i n g i n f o r m a t i o n and i m p a c t i n g on d r i v i n g h a b i t s . Independent audience r e s e a r c h prepared by V i c k e r s and Benson L t d . for the program sponsor , the Insurance Bureau of Canada, p r o j e c t e d a t o t a l n a t i o n a l audience for the "Second S c r e e n i n g of Second N a t i o n a l D r i v i n g T e s t " (1981) in E n g l i s h Canada of over one m i l l i o n p e o p l e . The f i r s t showing, i t was no ted , r each almost two m i l l i o n p e o p l e . Almost 65% of the audience s a i d that they took p a r t i n the t e s t s which took p l a c e d u r i n g the show. In a d d i t i o n , the m a j o r i t y of the audience s a i d that they l e a r n e d something from the Second N a t i o n a l D r i v i n g T e s t . Most of 1 36 the audience s a i d tha t they l i k e d the show. On a s c a l e from 1 to 10, almost the e n t i r e audience gave the show a r a t i n g of between 8 and 10. The reasons why the audience l i k e d the show were as f o l l o w s : - the Second N a t i o n a l D r i v i n g Tes t was i n f o r m a t i v e and  educat i o n a l - i n p a r t i c u l a r , the audience l i k e d the i n d i v i d u a l t e s t s - the audience l i k e d the t o t a l r e a l i s m of the show P o s i t i v e feedback on the use of the s e l f - s c o r e d t e s t s i s suppor ted by r e s e a r c h conducted on the PBS s e r i e s , " F e e l i n g Good." Swinehart (1976) conf i rmed tha t " s e l f - t e s t s and o ther formats which d i r e c t l y i n v o l v e d the viewer r a t e d h i g h on both appea l and a b i l i t y to convey i n f o r m a t i o n e f f e c t i v e l y . " The C T V ' s N a t i o n a l D r i v i n g T e s t s , and the PBS s e r i e s " F e e l i n g Good," are examples of how t e l e v i s i o n can be c r e a t i v e l y and e f f e c t i v e l y used f o r r i s k r e d u c t i o n programs. I t i s suggested t h a t a t e l e v i s e d N a t i o n a l H e a l t h Tes t i n which the p u b l i c i s c h a l l e n g e d to answer f a c t u a l q u e s t i o n s r e g a r d i n g t h e i r own l i f e s t y l e and h e a l t h i s s u e s i s an a p p r o p r i a t e program format . T h i s sugges t ion s h o u l d be pursued w i t h the CTV, u s i n g as the t e s t i n g mechanism, a s e l f - s c o r e d h e a l t h r i s k a p p r a i s a l q u e s t i o n n a i r e v e r s i o n of H e a l t h Hazard A p p r a i s a l . The CTV Network has expressed i n t e r e s t in the i d e a . 1 37 7. C a b l e - T e l e v i s i o n : The r a p i d growth i n the number of c a b l e - t e l e v i s i o n s t a t i o n s s e r v i n g many p a r t s of the c o u n t r y and the p r o v i n c e g i v e s t e l e v i s i o n v i ewers a g r e a t e r s e l e c t i o n of programs and i s o f f e r s new a l t e r n a t i v e s to commercia l t e l e v i s i o n . G r e i s e n (1981) suggests tha t for " h o s p i t a l s i n t e r e s t e d in p r o v i d i n g h e a l t h i n f o r m a t i o n and e d u c a t i o n to t h e i r communi t ies , c a b l e - t v o f f e r s new c h a l l e n g e s and o p p o r t u n i t i e s . " H o s p i t a l s in the U . S . and Canada have begun to take advantage of these o p p o r t u n i t i e s . An example in B r i t i s h Columbia i s a s e r i e s of programmes f e a t u r i n g i n f o r m a t i o n c o n c e r n i n g h e a l t h care and h e a l t h e d u c a t i o n for the p u b l i c . T h i s s e r i e s i s be ing c o o r d i n a t e d by C a b l e West T e l e v i s i o n and L i o n s Gate H o s p i t a l and i s t e l e c a s t throughout N o r t h and West Vancouver on Nor th Shore Cable 10. 8. E d u c a t i o n a l T e l e v i s i o n : TV O n t a r i o produces and d i s t r i b u t e s v i d e o programming aimed d i r e c t l y at the h e a l t h p r o f e s s i o n a l as w e l l as f o r the h e a l t h community at l a r g e . T h e i r 14-program s e r i e s , f or age 14 and o v e r , "Outs ide I n : H e a l t h and the Environment" examines the r e l a t i o n s h i p between h e a l t h and the environment and pays p a r t i c u l a r a t t e n t i o n to the demands p l a c e d on the human body by modern t e c h n o l o g i c a l deve lopments . Areas of the environment i n which changes have o c c u r r e d - i n d u s t r y , c i t y l i f e , h e a l t h c a r e , p o l l u t i o n , energy , and n u t r i t i o n - are e x p l o r e d . 1 38 Other concerns and i s s u e s of i n t e r e s t to the h e a l t h community have been addressed i n TV O n t a r i o p r o d u c t i o n s . Examples i n c l u d e : "Head S t a r t " which examines the problems and o p p o r t u n i t i e s f a c i n g the growing p o p u l a t i o n of e l d e r l y people in Nor th A m e r i c a ; " D i f f e r e n t Unders tand ing" i n v e s t i g a t e s a wide v a r i e t y of h e a l t h r e l a t e d s u b j e c t s i n c l u d i n g a u t i s m , l e a r n i n g d i s a b i l i t i e s , mental r e t a r d a t i o n , e t c ; "The Body in Q u e s t i o n , " t h i r t e e n 55-minute c o l o u r programs, e x p l o r e s the systems of the body and such t o p i c s as the methods of h e a l i n g , r o l e of p a t i e n t , d i a g n o s t i c m e d i c i n e . "Bodyworks", a 10 minute /40 program c o l o u r s e r i e s for 6 to 14 year o l d s , promotes the l i f e l o n g h a b i t s of good n u t r i t i o n and r e g u l a r p h y s i c a l e x e r c i s e ; and another s h o r t program for ages 12 and under i s " C i t i z e n S e a t b e l t , " which g i v e s f a c t s of the importance of s e a t b e l t use . (See Appendix K for TV O n t a r i o C a t a l o g u e I n f o r m a t i o n . ) 9. H e a l t h E d u c a t i o n by S a t e l l i t e : B r i t i s h C o l u m b i a - The Knowledge Network e d u c a t i o n a l t e l e v i s i o n s e r v i c e i s a v a i l a b l e in homes throughout the p r o v i n c e v i a the Anik C S a t e l l i t e , l o c a l c a b l e systems and l o c a l r e b r o a d c a s t f a c i l i t i e s . The Network has a p o t e n t i a l of r e a c h i n g 85% of B r i t i s h Columbians in 135 communi t i e s . I t s r e s p o n s i b i l i t y i s to d e v e l o p i n n o v a t i v e ways of combining t e l e v i s i o n and l e a r n i n g to enable the p u b l i c to b e t t e r themselves through e d u c a t i o n and t r a i n i n g . Some of the t e c h n o l o g i c a l 1 39 i n n o v a t i o n s used i n c l u d e l i v e i n t e r a c t i v e t e l e v i s i o n ; m u l t i -c h a n n e l , c l o s e d - c i r c u i t c a b l e , and s a t e l l i t e s e r v i c e s ; t e l e c o n f e r e n c i n g ; and , computer a s s i s t e d l e a r n i n g for i n d i v i d u a l s at home or on the j o b . A l a s k a - Some of the most s o p h i s t i c a t e d s o c i a l and t e c h n i c a l exper iments ever at tempted i n e d u c a t i o n and h e a l t h c a r e d e l i v e r y have been made p o s s i b l e through aud io and v i d e o s a t e l l i t e communication to r u r a l s i t e s in A l a s k a ( F e i n e r , 1974; H a m i l t o n , 1975). F o c u s s i n g on s p e c i f i c h e a l t h needs of c h i l d r e n i n r u r a l A l a s k a , a h e a l t h e d u c a t i o n s e r i e s , c o n s i s t i n g of 64 h a l f -hour l e s s o n s , i s t e l e v i s e d twice each week d u r i n g the s c h o o l y e a r . A unique f e a t u r e of the t e l ecommunica t ions system in A l a s k a i s i t s i n t e r a c t i v e c a p a b i l i t y which i s e f f e c t i v e l y used d u r i n g the " i n t e r a c t i o n " p o r t i o n of the programs . Re l evant f o l l o w - u p a c t i v i t y , r e i n f o r c e m e n t and community support s t a f f supplement the program. E v a l u a t i o n , c u r r e n t l y b e i n g u n d e r t a k e n , i s an important p a r t of the o v e r a l l exper iment . 10. I n t e r a c t i v e T e l e v i s i o n : The American Cancer S o c i e t y b r o a d c a s t a l i v e t e l e v i s e d t r a n s m i s s i o n of an open forum over the U . S . ' s l a r g e s t i n t e r a c t i v e c a b l e TV network. The program "Women Need to Know: The N a t i o n a l B r e a s t Cancer T e a c h - I n " (Rimer, 1980) promoted c o n f i d e n c e i n d e t e c t i o n and m e d i c a l p r o c e d u r e s . The two-hour program reached 29 of the 1 40 n a t i o n ' s 30 most populous m e t r o p o l i t a n areas through 684 c a b l e TV s t a t i o n s s e r v i n g 1,481 communit ies and , supplemented by 33 p u b l i c TV s t a t i o n s , c o v e r e d a l l 50 s t a t e s and Puer to R i c o . Systems such as Home Box O f f i c e and Show Time agreed to c a r r y the program because of the h i g h p u b l i c i n t e r e s t i n the s u b j e c t . T o t a l c a l l s d u r i n g the program exceeded the most o p t i m i s t i c p r e d i c t i o n . V o l u n t e e r s screened over 575 c a l l s and c l o s e to 4,500 were backed up on the t e l ephone l i n e s . The l a r g e s t c l u s t e r of c a l l s came from Los Ange les and Miami where l o c a l c a b l e s t a t i o n s had mounted e x t e n s i v e advance p r o m o t i o n a l e f f o r t s . T o t a l e s t i m a t e d audience f o r the program was over three m i l l i o n (Rimer, 1980). Rimer a s s e r t s that " t h i s experiment has proved that i n t e r a c t i v e TV programs can s i g n i f i c a n t l y s t r e n g t h e n p o p u l a r u n d e r s t a n d i n g of c u r r e n t i s s u e s , c o s t - e f f e c t i v e l y . And tha t p r e s e n t i n g the f u l l s c o p e . o f i n f o r m a t i o n on a s u b j e c t , and u s i n g a u t h o r i t i e s who can i n t e r a c t e f f e c t i v e l y w i t h the p u b l i c , can win for an o r g a n i z a t i o n g r e a t e r p u b l i c c o n f i d e n c e and r e s p e c t . " The p o t e n t i a l of the broadcas t media , and t e l e v i s i o n i n p a r t i c u l a r , to promote d e s i r e d h e a l t h b e h a v i o r s , a c c o r d i n g t o Warner (1979.), i s d e r i v e d from: - the mass exposure i t a c h i e v e s : For example, 97% of a l l Canadian households have t e l e v i s i o n , and 99% of the 141 p o t e n t i a l v iewers in these households watch at l e a s t 15 minutes of t e l e v i s i o n per week. T h i s ev idence i s suppor ted by r e s e a r c h conducted by Comstock (1977) . A breakdown of the average weekly t e l e v i s i o n v i e w i n g by Canadians i n t o t a l h o u r s , shows tha t women, age 18+ watch 23.51 hours (the h i g h e s t ) ; men, age 18+, 20.43 h o u r s ; t e e n a g e r s , ages 12-17 watch 19.22 h o u r s , and c h i l d r e n , ages 2-11, 18.22 hours (1981/82 r e s e a r c h from TV B a s i c s , T e l e v i s i o n B u r e a u , T o r o n t o , O n t . ) ; - the a p p a r e n t l y s i g n i f i c a n t i n f l u e n c e on a t t i t u d e s and  b e h a v i o r (as p r e v i o u s l y d i s c u s s e d ) "It appears there i s a v i e w i n g audience that has c o n f i d e n c e in t e l e v i s i o n . " (Richman and Urban , 1978); - the f a c t t h a t , to be c o s t - e f f e c t i v e , the approach  r e q u i r e s on ly a s m a l l r a t e of re sponse . (For example, a s m a l l percentage of smokers r e d u c i n g or q u i t t i n g smoking can have a s u b s t a n t i a l impact on h e a l t h and h e a l t h c o s t s in terms of a b s o l u t e magni tude . ) Madison Avenue has used t h i s approach w i t h great success for a c o u p l e of decades , and p r a c t i t i o n e r s of the a r t of t e l e v i s i o n a d v e r t i s i n g have suggested tha t i t c o u l d be extended to the realm of h e a l t h behav ior (Warner, 1979) . D e s p i t e the h i g h u n i t cos t of commercia l t ime on broadcas t media , p a r t i c u l a r l y t e l e v i s i o n , and the l i m i t e d r e s o u r c e s of both government and v o l u n t a r y a g e n c i e s , Warner 1 42 (1979) argues that "the a b i l i t y of t e l e v i s i o n to reach and a p p a r e n t l y i n f l u e n c e l a r g e numbers of people r e p r e s e n t s an o p p o r t u n i t y d e s e r v i n g s e r i o u s e x p l o r a t i o n . " M a r s h a l l (1981) endorses t h i s v i e w p o i n t even more s t r o n g l y : I f h e a l t h e d u c a t i o n i s ever to have a major i n f l u e n c e on the h e a l t h s t a t u s of the (American) p o p u l a t i o n , i t must use t e l e v i s i o n , p a r t i c u l a r l y i f i t i s to reach (and i n f l u e n c e ) those people who have the most to g a i n from a d d i t i o n a l knowledge of b e n e f i c i a l h e a l t h b e h a v i o r . The T e l e v i s i o n Audience of the 1980's N o r t h American v iewers have become more demanding and more a c t i v e in t h e i r t e l e v i s i o n w a t c h i n g . Gone i s the view p o s i t e d by M a r s h a l l McLuhan i n the S i x t i e s t h a t t e l e v i s i o n was a p a s s i v e , "coo l" medium. In f a c t , argues Diamond (1982), "watching h a b i t s have changed fundamenta l ly whi l e the c r i t i c s and e x p e r t s were l o o k i n g the o ther way." He adds that "some i n t e l l e c t u a l s may s t i l l put down t e l e v i s i o n as the 'boob tube or the i d i o t box' and , t ex tbooks and communicat ions courses may s t i l l t a l k about "the p a s s i v i t y of the t e l e v i s i o n v i e w e r , the homogeneity of t e l e v i s i o n f a r e d i c t a t e d by the b i g three American networks - CBS, NBC, and ABC, and the dominance of a u d i e n c e - f l o w t h e o r y , i e . the n o t i o n tha t v iewers are s i t t i n g i n e r t l y i n f r o n t of t h e i r t e l e v i s i o n s e t s a l l even ing as one network show succeeds 1 43 another l i k e so much e l e c t r o n i c w a l l p a p e r . " A c t u a l l y , Diamond argues , "the t h e o r i s t s ' image of the t y p i c a l t e l e f i x e d f a m i l y was always an e x a g g e r a t i o n . " He adds , " i t  i s now c l e a r that the p a s s i v e audience i s be ing d i s p l a c e d by  v i ewers who i n t e r a c t c o n s c i o u s l y w i t h t h e i r t e l e v i s i o n  s e t s . " The most obv ious v e h i c l e s of the v i e w e r ' s new i n t e r a c t i o n wi th t e l e v i s i o n are the c a b l e - t e l e v i s i o n systems and the v a r i o u s v i d e o d i s c and v i d e o c a s s e t t e r e c o r d i n g machines ( V C R ' s ) . A recent m a r k e t i n g study c i t e d by Diamond, conc luded t h a t by the m i d - 1 9 8 0 ' s , one in every ten American households w i l l have a VCR u n i t . The new t e c h n o l o g i e s of v i d e o d i s c s , V C R ' s and c a b l e - t e l e v i s i o n means m o r e . c h o i c e , i n c r e a s e d v i ewing f l e x i b i l i t y , and a c c o r d i n g to Diamond, "the c a b l e / V C R f a m i l y i s go ing to take a c l o s e r , more a c t i v e i n t e r e s t i n t e l e v i s i o n f a r e than i t d i d b e f o r e . " One s u c c e s s f u l example of f i t n e s s promot ion i s the growing home market for v i d e o e x e r c i s e programs such as the "Jane Fonda Workout" which i s a v a i l a b l e on v i d e o t a p e and v i d e o d i s c . To conc lude t h i s s e c t i o n on the use of t e l e v i s i o n for h e a l t h promot ion and r i s k r e d u c t i o n programs, the f o l l o w i n g i s quoted from T e l e v i s i o n and B e h a v i o r , Summary Report (1982) : There seems to be g e n e r a l agreement t h a t , i f the campaigns are c a r e f u l l y p lanned and e v a l u a t e d , t a k i n g i n t o account what i s known from the 1 4 4 b e h a v i o r a l s c i e n c e s , t e l e v i s i o n has a grea t  untapped p o t e n t i a l for encourag ing v o l u n t a r y  changes in behav ior to promote b e t t e r h e a l t h in  the p o p u l a t i o n at l a r g e . I t a l s o seems l i k e l y tha t the mass audience can be reached wi th h i g h e f f e c t i v e n e s s and r e l a t i v e l y low c o s t s . What i s needed i s a b e t t e r u n d e r s t a n d i n g of how t e l e v i s i o n i s now used and how t e l e v i s i o n might be m o d i f i e d to i n c r e a s e i t s p o s i t i v e e f f e c t s . 145 STEP V I I E v a l u a t e C o m m u n i c a t i o n S t r a t e g i e s To r e v i e w t h e p r o c e s s of p l a n n i n g h e a l t h p r o m o t i o n c a m p a i g n s , t h e "Model o f Campaign P r o c e s s " ( S w i n e h a r t , 1979), i s p r e s e n t e d i n F i g u r e 3 .4 . T h i s model p r o v i d e s a u s e f u l g u i d e l i n e t o d e v e l o p i n g a s t r o n g e v a l u a t i o n component f o r a s s e s s i n g c o m m u n i c a t i o n s t r a t e g i e s f o r h e a l t h p r o m o t i o n and r i s k r e d u c t i o n p r o g r a m s . F i g u r e 3.4 Model o f Campaign P r o c e s s Identify Need for Campaign Research Steps: Operational Steps: Establish Objectives and Iden-t i fy Target| Audiences Develop Preliminary Evaluation Strategy Initial Campaign Planning Campaign Design and Production Operate Campaign Post Campaign Assessment Conduct Pretest Finalize Monitor Conduct Market Materials Evaluation Commun- Final Research Strategy/ ications Program Collect Activity Evaluation Baseline (1) (2) Data (3) (4) Management Feedback Points (#1) What is in the minds of the target audience and how do we communicate with them? (#2) Do the campaign materials actually communicate as intended or do they require revision? (#3) Is the campaign actually reaching the target audience? (#4) Was the campaign effective in achieving its objectives? (Swinehart, 1979) 1 46 A w e l l - p l a n n e d h e a l t h promot ion program, or campaign, must e s t a b l i s h sound communication s t r a t e g i e s and e v a l u a t i o n p r o c e d u r e s . Before c o m p l e t i n g the s e l e c t i o n , and implementat ion of these p r o d u c t i o n communication s t r a t e g i e s , i t i s important to p r e t e s t the message and s e l e c t e d media to determine s t r e n g t h s and weaknesses. (Review F i g u r e s 3.2 and 3 . 4 . ) Based on r e s u l t s of the p r e t e s t , the message can be m o d i f i e d and s t rengthened as n e c e s s a r y , and the f i n a l media mix can be c o n f i r m e d . F o l l o w i n g implementat ion of the program, the e v a l u a t i o n component i s implemented. The o b j e c t i v e s of a h e a l t h promot ion campaign or program are c l o s e l y r e l a t e d to the r e s e a r c h d e s i g n and data c o l l e c t i o n procedures to be used , as w e l l as to campaign methods and s t r a t e g y . "Consequent ly ," s t r e s s e s Swinehart (1979) , " i t i s v i t a l to p l a n the e v a l u a t i o n at the time d e c i s i o n s are f i r s t be ing made about the content and form of the campaign. The answers c o n c e r n i n g program o b j e c t i v e s w i l l shape the k inds of e v a l u a t i o n measures to be used , the p o p u l a t i o n s to be sampled, the t i m i n g of data c o l l e c t i o n , and the c r i t e r i a to be used in j u d g i n g whether any g iven campaign shou ld be repeated in the same form, extended to o ther t a r g e t groups , m o d i f i e d i n c e r t a i n ways, or scrapped e n t i r e l y . " He argues that "the answers are not merely i m p o r t a n t ; they are c r u c i a l : a r e s u l t which takes s i x months to d e v e l o p w i l l be missed i f the e v a l u a t i o n i s done three months a f t e r a campaign; i f an assessment i n c l u d e s on ly 147 changes in a t t i t u d e s or awareness , n o t h i n g can be s a i d about the p o s s i b l e achievement of b e h a v i o r a l o b j e c t i v e s ; and measurements taken in the wrong k i n d of sample may c o m p l e t e l y miss d e s i r a b l e r e s u l t s t h a t occur in the t a r g e t p o p u l a t i o n . " The g o a l of e v a l u a t i o n s t u d i e s shou ld be to maximize the q u a l i t y , q u a n t i t y and r e l e v a n c e of i n f o r m a t i o n about a p a r t i c u l a r h e a l t h promot ion program, or an o v e r a l l h e a l t h promot ion campaign. Wal lack (1981) recommends t h a t "program p l a n n e r s and e v a l u a t o r s broaden t h e i r avenues of i n q u i r y by l o o k i n g for campaign e f f e c t s on s e v e r a l l e v e l s r a t h e r than j u s t one ." M a r s h a l l (1981) s u p p o r t s t h i s p o s i t i o n and adds tha t "to cope wi th the g o a l of h e a l t h p r o m o t i o n , i . e . , m o t i v a t i n g the p u b l i c to change t h e i r l i f e s t y l e s and g ive up i n g r a i n e d h a b i t s to reduce r i s k s and perhaps f o r e s t a l l or prevent events that might not occur at some f u t u r e t i m e , we need to experiment wi th a number of approaches and e v a l u a t e them f o r m a t i v e l y as w e l l as summat ive ly ." In p l a n n i n g the e v a l u a t i o n component of l i f e s t y l e change programs, the d i f f i c u l t i e s of measurement must be a d d r e s s e d . To h e l p overcome t h i s prob lem, Nage lberg (1981) recommends that " i d e a l l y , o v e r t , p h y s i o l o g i c a l , and c o g n i t i v e components of b e h a v i o r would a l l be a s s e s s e d . " A d d i t i o n a l l y , the "success" of a program must be measured i n terms of how w e l l the needs of the t a r g e t p o p u l a t i o n are a s s e s s e d and u n d e r s t o o d . We need to ask, for example: What 1 48 i s the p r o p o r t i o n of change in h e a l t h a t t r i b u t a b l e to a p a r t i c u l a r program, or p a r t of a program? When are i n d i v i d u a l s and f a m i l i e s more v u l n e r a b l e to c r i s i s , more s e n s i t i v e to change? What are the i n f l u e n c e s of e d u c a t i o n and p u b l i c i t y programs r e g a r d i n g l i f e s t y l e s and h e a l t h r i s k s ? Who a c c e p t s , uses or i s a f f e c t e d but i s not a p a r t i c i p a n t w i t h i n a program under s tudy? What are the s h o r t and l o n g - t e r m c o s t - b e n e f i t f a c t o r s for both the i n d i v i d u a l and the p u b l i c ? And f i n a l l y , i t s h o u l d be p o i n t e d out that " s u c c e s s f u l " program e v a l u a t i o n i s not on ly determined by " p o s i t i v e " r e s u l t s ( i . e . , support of the h y p o t h e s i s under s tudy) but a l s o by the recommendations for improvement which f o l l o w from such r e s e a r c h ( N a g e l b e r g , 1981). Recent e v a l u a t i o n s of p a t i e n t e d u c a t i o n reviewed by G r e e n , S q u y r e s , A l t r o y and Hebert (1980) i n d i c a t e t h a t we have t u r n e d the c o r n e r from most ly a r t , i d e o l o g y , and i n t u i t i o n to a road that a l l o w s us to d e v e l o p the next g e n e r a t i o n of programs and e v a l u a t i o n s w i th a g r e a t e r sense of c o n t i n u i t y w i t h s c i e n t i f i c ev idence and e d u c a t i o n a l t h e o r y . (Green et a l , 1980) 1 49 3.2 Summary The f o l l o w i n g program p l a n n i n g g u i d e l i n e s are p r e s e n t e d to summarize t h i s c h a p t e r , and to r e i n f o r c e the concepts of "Communication S t r a t e g i e s for H e a l t h Promotion and H e a l t h R i s k Assessment:" (Adapted from Swinehar t , 1976) 1. Program o b j e c t i v e s shou ld be s p e c i f i e d i n d e t a i l , so t h a t e f f .or t s can be kept on t r a c k and r e s u l t s e v a l u a t e d c l e a r l y ; 2. Program p lans ( c h o i c e s of media , themes or a p p e a l s , spokepersons , e t c . ) shou ld be based on c u r r e n t l y a c c u r a t e knowledge of p e o p l e ' s b e l i e f s and a t t i t u d e s r e g a r d i n g the b e h a v i o r be ing promoted; 3. C o o p e r a t i o n , c o o r d i n a t i o n and support mechanisms among government h e a l t h promot ion a g e n c i e s , s c h o o l systems, v o l u n t a r y and p u b l i c h e a l t h a g e n c i e s , b u s i n e s s , i n d u s t r y and l a b o u r , and o ther i n v o l v e d groups shou ld be encouraged and d e v e l o p e d ; 4. H e a l t h care p r o f e s s i o n a l s , i n c l u d i n g p h y s i c i a n s , d e n t i s t s and c l i n i c i a n s , sh ou ld be t r a i n e d and encouraged to take a more a c t i v e r o l e i n the h e a l t h e d u c a t i o n of t h e i r p a t i e n t s and c l i e n t s u s i n g h e a l t h r i s k assessment s t r a t e g i e s , and of the p u b l i c at l a r g e u s i n g the mass media; 5. M u l t i p l e appea l s shou l d be used , i n c l u d i n g s o c i a l , c u l t u r a l and p e r s o n a l themes not d i r e c t l y r e l a t e d to p h y s i c a l h e a l t h ; 1 50 More emphasis shou l d be p l a c e d on m o t i v a t i o n r a t h e r than e d u c a t i o n ; t h a t i s , to reduce the gap between b e l i e f s and b e h a v i o r r a t h e r than s imply to i n c r e a s e p e o p l e ' s knowledge about h e a l t h problems; New m a t e r i a l s s h o u l d be p r e t e s t e d w i t h a p p l i c a b l e t a r g e t a u d i e n c e s , and r e v i s e d as n e c e s s a r y ; "Perhaps most important in the long r u n , programs s h o u l d be e v a l u a t e d i n a way t h a t p e r m i t s comparison of v a r i o u s approaches so that our knowledge of what works and what doesn ' t can become c u m u l a t i v e " (Swinehar t , 1976). 151 CHAPTER FOUR Towards P o l i c y - M a k i n q For H e a l t h Promotion . . . t h e r e i s a s u b s t a n t i a l community of people in p r i m a r y h e a l t h care d e l i v e r y , e d u c a t i o n , s o c i a l s e r v i c e s , and the f i t n e s s f i e l d s i n Canada eager to do something about h e a l t h promot ion and l i f e s t y l e e d u c a t i o n and c o u n s e l l i n g . ( T o r r a n c e & D ' A r c y , 1981) 1 52 4.1 Framework for the I n t e g r a t i o n of Assessment and Communication S t r a t e g i e s i n t o a H e a l t h Promotion P o l i c y  f o r B r i t i s h Columbia There are s e l e c t e d , s i g n i f i c a n t o p p o r t u n i t i e s in p r e v e n t i o n to reduce the c o s t s of i l l n e s s , both d i r e c t and i n d i r e c t , p e c u n i a r y and n o n p e c u n i a r y . The problem i s to i d e n t i f y and unders tand these o p p o r t u n i t i e s , to determine how to e x p l o i t them e f f e c t i v e l y , to m o b i l i z e the r e q u i s i t e r e s o u r c e s , and to mount a s u c c e s s f u l e f f o r t . (Warner, 1979) H e a l t h p r o m o t i o n , as d e f i n e d in Chapter 1, i s a c o m b i n a t i o n of m o t i v a t i o n a l , o r g a n i z a t i o n a l , p o l i t i c a l a n d / o r economic support s des igned to promote behav ior changes that are conduc ive to h e a l t h " (Source Book for H e a l t h E d u c a t i o n M a t e r i a l s , 1982). The purpose of t h i s Chapter i s t o : (a) e x p l o r e p o l i c y - m a k i n g s p e c i f i c a l l y d i r e c t e d towards the p o t e n t i a l of l i f e s t y l e re form through a j o i n t - a c t i o n h e a l t h promotion e f f o r t to be undertaken by r e p r e s e n t a t i v e s from the p u b l i c and p r i v a t e s e c t o r s , from v o l u n t a r y h e a l t h o r g a n i z a t i o n s and from the consumer p u b l i c , (b) p r o v i d e a framework for the i n t e g r a t i o n of assessment and communication s t r a t e g i e s i n t o a h e a l t h promot ion p o l i c y des igned to meet the h e a l t h needs of i n d i v i d u a l s and of the community at l a r g e , and (c) address the r e l e v a n t c r i t e r i a for d e s i g n i n g a 1 53 comprehensive h e a l t h assessment ins trument for use w i th d i f f e r e n t t a r g e t p o p u l a t i o n s in v a r i o u s h e a l t h promot ion s e t t i n g s . S i n c e h e a l t h i s c o n s t i t u t i o n a l l y a p r o v i n c i a l r e s p o n s i b i l i t y , much of the d i s c u s s i o n w i l l focus at the p r o v i n c i a l l e v e l . P r e v e n t i v e and c u r a t i v e medic ine have come to be regarded as be ing in c o m p e t i t i o n w i t h each other as demands from both are made upon the same tax d o l l a r s , a l t h o u g h most p h y s i c i a n s would d i s a g r e e . In p o l i t i c a l terms, the making of p o l i c y d e c i s i o n s which s h i f t some of these f i n i t e r e s o u r c e s from i l l n e s s s e r v i c e s to h e a l t h p r o m o t i o n , the e f f e c t of which may s t r e t c h f a r beyond a s i n g l e government 's l i f e t i m e , c a r r i e s w i t h i t obv ious p o l i t i c a l d i s a d v a n t a g e s . However, such a paradigm s h i f t o c c u r r e d d u r i n g the 1970's wi th the f e d e r a l government's p o s i t i o n paper New P e r s p e c t i v e  on the H e a l t h of Canadians ( L a l o n d e , 1974). "With s o a r i n g c o s t s i n h e a l t h and s o c i a l s e r v i c e s " w r i t e s Ferguson (1980) , " L a l o n d e ' s 'New P e r s p e c t i v e ' gave b i r t h to a d i s t i n c t l y new way of t h i n k i n g about h e a l t h and h e a l t h c a r e d e l i v e r y i n C a n a d a . " T h i s was f o l l o w e d in 1979 by the B . C . M i n i s t r y of H e a l t h ' s c l e a r l y s t a t e d l o n g - t e r m o b j e c t i v e s : to promote programs of a p r e v e n t i v e nature as w e l l as other a l t e r n a t i v e s in order to c o n t a i n r i s i n g c o s t s of h e a l t h c a r e and p r o v i d e an optimum s t a t e of h e a l t h ; and to implement a p r o v i n c e - w i d e p u b l i c e d u c a t i o n program d i r e c t e d at the 1 54 p u b l i c ' s (a) f i n a n c i a l r e s p o n s i b i l i t y and u t i l i z a t i o n of s e r v i c e s , (b) l i f e s t y l e s and a t t i t u d e s , and (c) p e r s o n a l , f a m i l y and community invo lvement . Indeed, these s h i f t s i n d i c a t e tha t the p r e s e n t c o s t - c o n t a i n m e n t c r i s i s i n Canadian h e a l t h care may w e l l p r o p e l l i f e s t y l e re form to a c e n t r a l p l a c e i n h e a l t h p l a n n i n g ( W i x l e r , 1978). Whi le r e s p o n s i b i l i t y for the n a t i o n ' s h e a l t h i s l a r g e l y a l l o c a t e d to the p u b l i c s e c t o r , i t shou ld be r e c o g n i z e d that major a c t i v i t i e s and o p p o r t u n i t i e s for l i f e s t y l e re form a l s o e x i s t i n the p r i v a t e s e c t o r and, as h e a l t h and l i f e s t y l e are u l t i m a t e l y a p e r s o n a l r e s p o n s i b i l i t y , h e a l t h promot ion p o l i c y - m a k i n g must take i n t o account a l l l e v e l s of r e s p o n s i b i l i t y . Inherent in the p l a n n i n g of such p o l i c y , "is the n e c e s s i t y of m a r s h a l l i n g a wide enough 'range of approaches from r e l e v a n t p u b l i c and p r i v a t e sources to ensure the d e s i r e d r e s u l t s " . (Davidson et a l , 1979). A p o l i c y can be s u c c e s s f u l l y implemented when an i s sue has a t t a i n e d a h i g h degree of l e g i t i m a c y among the p o p u l a c e , and when f e a s i b l e new s t r u c t u r e s are deve loped to permit i m p l e m e n t a t i o n . The t ime i s r i p e f o r new i n i t i a t i v e s c o n c e r n i n g the impact of l i f e s t y l e on the h e a l t h and q u a l i t y of l i f e of B r i t i s h C o l u m b i a n s . The f i v e p o l i c y i n i t i a t i v e s set out below may be the best r e s u l t of the c u r r e n t a t t e n t i o n to the r o l e of l i f e s t y l e i n m a i n t a i n i n g and enhancing h e a l t h : 1. Development of a h e a l t h promot ion c o - o r d i n a t i n g agency. 1 55 2. H e a l t h promotion fund ing mechanisms. 3. H e a l t h r i s k assessment: A s t r a t e g y that deserves a t t e n t i o n . 4. M a r k e t i n g l i f e s t y l e r e f o r m . 5. E v a l u a t i o n s tandards for h e a l t h p r o m o t i o n . The implementat ion of these i n i t i a t i v e s "would serve two g o a l s over which there cannot be s e r i o u s d i s p u t e : e n a b l i n g people to be as h e a l t h y as they want to be , g i v e n the c o s t s i n v o l v e d ; and r e d u c i n g o v e r a l l m e d i c a l need so as to make room i n the h e a l t h c a r e system for a l l who s t i l l r e q u i r e c a r e " ( W i x l e r , 1978). These p o l i c y i n i t i a t i v e s attempt to address the f o l l o w i n g o b j e c t i v e s : 1. to d e v e l o p a c o o r d i n a t e d p u b l i c / p r i v a t e s e c t o r e f f o r t f o r l i f e s t y l e re form which p l a c e s a major emphasis on the p r e v e n t i o n a s p e c t s of c h r o n i c d i s e a s e s , a c c i d e n t s and premature d e a t h s , and on the enhancement of the q u a l i t y of l i f e of the whole p o p u l a t i o n by improv ing i t s h e a l t h ; 2. to d e s i g n a package of comprehensive h e a l t h r i s k assessment ins truments for use w i th d i f f e r e n t t a r g e t p o p u l a t i o n s ; and 3. to deve lop a sound marke t ing s t r a t e g y which uses these in s t ruments in v a r i o u s h e a l t h promotion s e t t i n g s . Dav idson et a l , (1979) have found that h e a l t h promotion works best when the t o t a l community i s i n v o l v e d and commit ted . The e f f e c t i v e implementat ion of the proposed 156 h e a l t h promot ion i n i t i a t i v e s w i l l r e q u i r e a committed c o l l a b o r a t i o n between h e a l t h c a r e p o l i c y - m a k e r s , p l a n n e r s and p r o v i d e r s , and the t a r g e t p o p u l a t i o n s be ing s e r v i c e d . To make any ga i ns in h e a l t h w i l l r e q u i r e i n n o v a t i v e l e a d e r s h i p , a commitment to s t r o n g h e a l t h promot ion p o l i c i e s , and s u f f i c i e n t f i n a n c i a l support from the p u b l i c and p r i v a t e s e c t o r s i n the community. In o r d e r to implement p o l i c y , e f f e c t i v e a d m i n i s t r a t i v e mechanisms are r e q u i r e d . Problems i n c o - o r d i n a t i o n between m u l t i p l e j u r i s d i c t i o n s can be a n t i c i p a t e d ; t h e r e f o r e , l i n k a g e s at s e v e r a l l e v e l s i n the system w i l l be n e c e s s a r y . These l i n k a g e s are i l l u s t r a t e d in F i g u r e 4 . 1 , "Framework for the I n t e g r a t i o n of Assessment and Communication S t r a t e g i e s i n t o H e a l t h Promotion P o l i c y . " 157 F i g u r e 4.1 Framework for the I n t e g r a t i o n of Assessment and Communication S t r a t e g i e s i n t o H e a l t h Promotion P o l i c y ADVISORY COMMITTEE B.C. Ministry of Health Health & Welfare Canada Vancouver Health Department Universities and Colleges Private Health Care Providers Public Health Care Providers Business and Industry Labour Unions Voluntary Organizations Consumers Mass Media (2 ) FUNDING AND COMMITMENT FROM Governments Private Sector Voluntary Agencies Foundations (1) COORDINATING AGENCY (Division of Health Systems, Coordinator's Office, Health Sciences Centre, UBC) (3) ASSESSMENT > STRATEGIES (5) COMMUNICATION STRATEGIES (5) EVALUATION OF STRATEGIES ON RE-DUCING RISKS AND IMPROVING HEALTH STATUS 1 58 P o l i c y I n i t i a t i v e (1 ) : Development of a H e a l t h Promotion C o - o r d i n a t i n g Agency The a d m i n i s t r a t i v e mechanism that w i l l p r o v i d e l i n k a g e s to government, to the p r i v a t e s e c t o r and to the p o p u l a t i o n at l a r g e i s the c r e a t i o n of an A d v i s o r y Committee r e p r e s e n t i n g h e a l t h and e n v i r o n m e n t a l i n t e r e s t s from a l l l e v e l s of government, u n i v e r s i t i e s , p r i v a t e and p u b l i c h e a l t h c a r e p r o v i d e r s , v o l u n t a r y h e a l t h c a r e o r g a n i z a t i o n s , l abour u n i o n s , bus ines s and i n d u s t r y , c i t i z e n s and consumer g r o u p s , and the media . T h i s p a r t n e r s h i p , which w i l l e x p l o r e the p r o t e c t i o n and enhancement of the p u b l i c ' s h e a l t h , c o u l d enable the i n i t i a t i o n of a p r o c e s s that would l e a d to s p e c i f i c recommendations for c o n s t r u c t i v e p o l i c y - m a k i n g , but perhaps more i m p o r t a n t l y , i t c o u l d p l a y a c r i t i c a l r o l e i n chang ing the c o n s c i o u s n e s s of the p u b l i c , and of p u b l i c and p r i v a t e i n t e r e s t groups , by b u i l d i n g support for h e a l t h promot ion and l i f e s t y l e r e f o r m . T h i s view i s supported by Blum (1983) who p o i n t s out tha t p r o f e s s i o n a l s and academics are s t i l l i n the best p o s i t i o n to p r o v i d e l e a d e r s h i p f o r i m p a r t i a l examinat ion of the n a t i o n ' s major prob lems , w i t h a view to what i s l i k e l y to be best for the g e n e r a l w e l f a r e as w e l l as f o r the i n d i v i d u a l . He recommends tha t "high on t h e i r l i s t of t h i n g s to do sh ou ld be c a r e f u l examinat ion of the m i c r o , macro and j o i n t s t r a t e g i e s for r i s k m i n i m i z a t i o n ( i . e . , s u i t a b l e i n d i v i d u a l and c o l l e c t i v e i n t e r v e n t i o n s for our worst w e l l - b e i n g p r o b l e m s ) . " 159 T h i s proposed p a r t n e r s h i p w i l l : - ac t as an a d v i s o r y committee and l i a i s o n wi th p r o v i d e r s of h e a l t h promot ion and w e l l n e s s programs, and w i t h the g e n e r a l p u b l i c ; - h e l p determine i n f o r m a t i o n and e d u c a t i o n a l needs of the p u b l i c and the p r o v i d e r s , and support p l a n s to meet these needs; - f a c i l i t a t e g r e a t e r communicat ion and promote an exchange of i n f o r m a t i o n and ideas between p r o v i d e r s ; - promote the e s t a b l i s h m e n t of more and improved h e a l t h promot ion and w e l l n e s s programs which i n c o r p o r a t e assessment and communicat ion s t r a t e g i e s i n t o t h e i r f o r m a t s . In the B . C . scene , one p o s s i b l e f e a s i b l e s t r u c t u r e for c o - o r d i n a t i n g and n u r t u r i n g t h i s p a r t n e r s h i p i s a l r e a d y i n p l a c e : the D i v i s i o n of H e a l t h Systems, i n . t h e C o - o r d i n a t o r ' s O f f i c e * , H e a l t h S c i e n c e s C e n t r e , at the U n i v e r s i t y of B r i t i s h Columbia has been o p e r a t i n g for e i g h t years do ing r e s e a r c h on and development of t o o l s for h e a l t h promot ion and e v a l u a t i o n . Indeed, the H e a l t h S c i e n c e s at UBC are becoming i n c r e a s i n g l y committed to the a r e a of h e a l t h promot ion as e v i d e n c e d , i n p a r t i c u l a r , by the recent * The C o - o r d i n a t o r ' s O f f i c e i s charged w i t h the r e s p o n s i b i l i t y of p u r s u i n g h e a l t h o b j e c t i v e s which are broader than those of any one f a c u l t y or s c h o o l . 1 60 f o r m a t i o n of the D i v i s i o n of P r e v e n t i v e M e d i c i n e and H e a l t h Promotion in the Department of H e a l t h Care and E p i d e m i o l o g y of the F a c u l t y of M e d i c i n e . F u r t h e r , the Department of F a m i l y P r a c t i c e i s working to e s t a b l i s h a D i v i s i o n of B e h a v i o r a l M e d i c i n e and the Schoo l of P h y s i c a l E d u c a t i o n to e s t a b l i s h a Mas ters program i n L i f e s t y l e Management. The D i v i s i o n of H e a l t h Systems and , i n d e e d , the new D i v i s i o n of P r e v e n t i v e M e d i c i n e and H e a l t h Promotion are committed to t h r e e b a s i c themes: r e s e a r c h - to e s t a b l i s h how h e a l t h may be best promoted; e v a l u a t i o n - to e s t a b l i s h how w e l l programs ach ieve t h e i r o b j e c t i v e s , and h e a l t h promot ion - to persuade consumers to accept p r e v e n t i v e measures and to take p e r s o n a l r e s p o n s i b i l i t y for t h e i r h e a l t h and l i f e s t y l e s . The D i v i s i o n of H e a l t h Systems c o u l d take a key l e a d e r s h i p r o l e in c o - o r d i n a t i n g t h i s e f f o r t . C o n s i d e r a t i o n of the a l t e r n a t i v e s : To l e g i t i m i z e the h e a l t h o b j e c t i v e s of B r i t i s h C o l u m b i a n s , s e v e r a l a l t e r n a t i v e h e a l t h promotion c o -o r d i n a t i n g s t r u c t u r e s were c o n s i d e r e d by t h i s w r i t e r : 1) The s e t t i n g up of a p r o v i n c i a l government h e a l t h promot ion c o - o r d i n a t i n g agency was r e j e c t e d because t h i s type of c e n t r a l i z a t i o n has a p o t e n t i a l danger of b e i n g c o n s i d e r e d "big b r o t h e r , " and because such a government a p p o i n t e d agency might w e l l be impotent in i m p a c t i n g on a h e a l t h care system that c u t s a c r o s s so many government j u r i s d i c t i o n s , i . e . , h o s p i t a l and m e d i c a l s e r v i c e s , 161 community h e a l t h , human r e s o u r c e s , h o u s i n g , l a b o u r , f a c u l t i e s and s c h o o l s of h e a l t h c a r e , e t c . , or i n g a i n i n g s u f f i c i e n t support and funding from the p r i v a t e s e c t o r . 2) U s i n g the v e h i c l e of Community H e a l t h S e r v i c e s ( p r o v i n c i a l l y f i n a n c e d p u b l i c h e a l t h s e r v i c e s such as the Vancouver H e a l t h Department and o ther p r o v i n c i a l h e a l t h u n i t s ) was the second a l t e r n a t i v e that was c o n s i d e r e d and r e j e c t e d on the same b a s i s . A l t h o u g h community h e a l t h promot ion e f f o r t s c o u l d b e n e f i t from the i n t e g r a t i o n of assessment and communication s t r a t e g i e s i n t o t h e i r h e a l t h e d u c a t i o n programs, the m a j o r i t y of the community's l i f e s t y l e - r e l a t e d h e a l t h problems cannot be addres sed s o l e l y through the Community H e a l t h S e r v i c e s framework because of the l i m i t a t i o n s of t h e i r j u r i s d i c t i o n . 3) A p o t e n t i a l l y v i a b l e t h i r d a l t e r n a t i v e i s the c r e a t i o n of an independent c o - o r d i n a t i n g agency . T h i s a l t e r n a t i v e was a l s o r e j e c t e d because there i s no l e g i t i m a t e a d m i n i s t r a t i v e s t r u c t u r e c u r r e n t l y in p l a c e in the community tha t c o u l d i n i t i a t e a l e a d e r s h i p r o l e and garner the neces sary support and f u n d i n g . UBC's D i v i s i o n of H e a l t h Systems, l i k e o ther advocates of p r o s p e c t i v e m e d i c i n e , r e s p e c t s c o n v e n t i o n a l medic ine and seeks to e s t a b l i s h a working p a r t n e r s h i p w i t h i t , hoping tha t over t i m e , h e a l t h c a r e e n e r g i e s and e x p e n d i t u r e s w i l l s h i f t from treatment of d i s e a s e to i t s p r e v e n t i o n (Wel l Aware, 1978). A l though academia may be viewed by some as 162 too "academic" for such a v e n t u r e , i t i s in f a c t e s s e n t i a l l y n e u t r a l and thus has the p o t e n t i a l . o f g a i n i n g support and input from h e a l t h care p r o f e s s i o n a l s and academics , from b u r e a u c r a t s and governments at a l l l e v e l s , from the c o r p o r a t e boardrooms and labour o r g a n i z a t i o n s throughout the p r o v i n c e , and from the g e n e r a l p u b l i c . The mandate for the c r e a t i o n of a j o i n t - a c t i o n A d v i s o r y Committee i s the l i n k i n g of p u b l i c h e a l t h needs wi th p u b l i c and p r i v a t e r e s o u r c e s a c r o s s a m u l t i p l i c i t y of h e a l t h problem s o l v i n g e f f o r t s . The g e n e r a l r e s p o n s i b i l i t i e s of t h i s p o l i c y - m a k i n g and p l a n n i n g committee shou ld i n c l u d e g i v i n g p r i o r i t y to the most p r e s s i n g of the community's w e l l - b e i n g prob lems , g i v i n g h e a r i n g to the p u b l i c at l a r g e and s p e c i a l a t - r i s k g r o u p s , p r e s s i n g for r e l e v a n t e x p l a n a t i o n s and encourag ing the s e a r c h for s o l u t i o n s (Blum, 1983). Indeed, t h i s p a r t n e r s h i p of committed p r o f e s s i o n a l s c o u l d p r o v i d e the impetus for p l a n n i n g and implementing a c o - o r d i n a t e d p r o v i n c i a l l i f e s t y l e re form e f f o r t . 1 63 P o l i c y I n i t i a t i v e ( 2 ) : H e a l t h Promotion Funding Mechanisms I t must be underscored tha t the implementat ion of such a h e a l t h promot ion c o - o r d i n a t i n g s t r u c t u r e must be backed by s u f f i c i e n t funding to ensure i t s s u c c e s s . The p o t e n t i a l impact on w e l l n e s s and q u a l i t y of l i f e which i s the expected outcome "of p r e v e n t i v e med ic ine and h e a l t h promot ion i s d r a s t i c a l l y u n d e r - e x p l o i t e d . The a b i l i t y of h e a l t h promot ion to f u n c t i o n as an i n t e g r a l and neces sary p a r t of the h e a l t h c a r e system can be s t rengthened by a s h i f t i n p e r s p e c t i v e from the c u r r e n t expens ive med ica l model to one that o f f e r s a ba lance of p r e v e n t i v e and c r i s i s s e r v i c e s wherein the whole person i s c o n s i d e r e d , not the " i l l n e s s , " and where the focus i s not on "blaming the v i c t i m s " for t h e i r d e s t r u c t i v e b e h a v i o r s , but on the s t r e s s e s of l i f e and on the impact of o c c u p a t i o n a l , e n v i r o n m e n t a l , s o c i a l , c u l t u r a l and economic i n f l u e n c e s on h e a l t h and q u a l i t y of l i f e . The debate over whether e x p e n d i t u r e s in h e a l t h promot ion are c o s t - e f f e c t i v e , or s i m p l y r e p r e s e n t i n c r e a s e d h e a l t h care c o s t s , d e t r a c t s from the r e a l h e a l t h needs of the community. What must be addressed i s the need to make an impact on the epidemic p r o p o r t i o n s of c h r o n i c d i s e a s e s tha t s t r i k e in midd le -age and on the a c c i d e n t r a t e s and premature deaths among younger C a n a d i a n s . H e a l t h p l a n n i n g might best c o n t r i b u t e to lowered h e a l t h care c o s t s and r a i s e d h e a l t h s t a t u s by a d o p t i n g a c u l t u r a l l y and 1 64 e n v i r o n m e n t a l l y based comprehensive we l lnes s s t r a t e g y which focusses on l i f e s t y l e v a l u e s . T h i s w i l l r e q u i r e a new approach to h e a l t h and h e a l t h promot ion p l a n n i n g , to a s s e s s i n g t e c h n o l o g i c a l and communication c a p a b i l i t i e s , to f o r e c a s t i n g re source r e q u i r e m e n t , and to d e v e l o p i n g c r i t e r i a for the e v a l u a t i o n of these s t r a t e g i e s . Indeed, h e a l t h promot ion p l a n n i n g must "th ink i n the f u t u r e tense" by s t a y i n g in touch wi th s o c i e t a l t r e n d s , e n v i r o n m e n t a l i s s u e s and t e c h n o l o g i c a l deve lopments . A s t r o n g c o - o r d i n a t e d p l a n n i n g e f f o r t funded through the a c t i v i t i e s of the bus ines s s e c t o r and supported by bod ies such as the Vancouver F o u n d a t i o n , the Woodward F o u n d a t i o n , union a s s o c i a t i o n s , v o l u n t a r y o r g a n i z a t i o n s l i k e the U n i t e d A p p e a l , and through government b l o c k f u n d i n g , e i t h e r by d i r e c t g r a n t s or v i a p r o v i n c i a l l o t t e r y funds , c o u l d become a dynamic f o r c e in a new era of p u b l i c / p r i v a t e j o i n t - a c t i o n , the r e s u l t of which c o u l d make a major impact on improv ing h e a l t h s t a t u s . T h i s c o - o r d i n a t i n g body c o u l d a l s o r e c e i v e a n d / o r d i s b u r s e r e s e a r c h g r a n t s , from for example, the H e a l t h Promotion D i r e c t o r a t e (HW/C), Community H e a l t h S e r v i c e s , the B . C . M e d i c a l A s s o c i a t i o n , CARS, the Cancer C o n t r o l Agency, e t c . , f or the d e s i g n , implementat ion and e v a l u a t i o n of assessment and communication s t r a t e g i e s for h e a l t h p r o m o t i o n . 1 65 P o l i c y I n i t i a t i v e (3) H e a l t h R i s k Assessment: A S t r a t e g y that Deserves A t t e n t i o n . . . there i s a need and demand for s t a n d a r d i z e d r i s k a s s e s s m e n t / c o u n s e l l i n g t o o l s a l o n g the l i n e s of H e a l t h Hazard A p p r a i s a l . (Torrance and D ' A r c y , 1981) Based p a r t l y on the r e s u l t of t h e i r 1981 survey of Canadian users of H e a l t h Hazard A p p r a i s a l (HHA) and p a r t l y on the c o n j u n c t i o n of developments in Canadian h e a l t h c a r e p o l i c y , T o r r a n c e and D ' A r c y (1981) determined tha t "there i s a need and a demand for h e a l t h r i s k assessment s t r a t e g i e s . " Indeed, h e a l t h r i s k assessment i s a h e a l t h promot ion t e c h n i q u e tha t i s consonant w i th c u r r e n t t h i n k i n g and p u b l i c i t y about the r o l e of l i f e s t y l e in d i s e a s e e t i o l o g y and i t "prov ides a core element f o r d e v e l o p i n g a system of p r e v e n t i v e medic ine and h e a l t h promot ion" (Mi l sum, 1981). I t r e l i e s on s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e s , s imple p h y s i o l o g i c measurements, and c o m p u t e r - a s s i s t e d c a l c u l a t i o n s , making i t s a p p l i c a t i o n to i n d i v i d u a l s and to l a r g e g r o u p s , f e a s i b l e , e f f i c i e n t , and r e l a t i v e l y i n e x p e n s i v e (Beery et a l , 1981). T h i s p o s i t i o n i s r e i n f o r c e d by s e v e r a l recent a u t h o r i t a t i v e s t u d i e s and l e g i s l a t i v e deve lopments . Among these are the Canadian Task Force on The P e r i o d i c H e a l t h E x a m i n a t i o n (1979); Breslow and Somer's L i f e t i m e H e a l t h M o n i t o r i n g Program (1977), and the proposed new h e a l t h 166 P r o t e c t i o n Act in O n t a r i o , a l l of which support an i n c r e a s e d r o l e f o r p r e v e n t i v e c a s e - f i n d i n g , c o u n s e l l i n g and h e a l t h e d u c a t i o n . T o r r a n c e and D ' A r c y (1981) suggest tha t as these p r o p o s a l s are implemented, and as new graduates of h e a l t h and a l l i e d p r o f e s s i o n s who have been exposed to p r e v e n t i v e concept s in t h e i r p r o f e s s i o n a l t r a i n i n g enter the f i e l d , t h e r e w i l l be a " r i s i n g demand f o r t o o l s l i k e HHA based on a c c u m u l a t i n g e p i d e m i o l o g i c a l data and the s t a t e of the a r t i n i n t e r a c t i v e e l e c t r o n i c t e c h n o l o g y . " Mi l sum and a s s o c i a t e s at the U n i v e r s i t y of B r i t i s h C o l u m b i a ' s D i v i s i o n of H e a l t h Systems have found tha t h e a l t h r i s k assessment ins truments e i t h e r p r o v i d e or encourage the concomitant development of the f o l l o w i n g h e a l t h p r o m o t i o n a l fundamenta l s : 1. B a s i c c l i e n t / c o u n s e l l o r / h e a l t h r i s k assessment p r o c e s s . 2. E d u c a t i o n a l programs for h e a l t h p r o f e s s i o n a l s and the p u b l i c . 3. I n t e g r a t i o n wi th community r e s o u r c e s for l i f e s t y l e change. 4. S t a t i s t i c a l and e p i d e m i o l o g i c a l a n a l y s e s based on a c u m u l a t i v e , anonymous data bank. 5. E v a l u a t i o n s t u d i e s on h e a l t h r i s k assessment , p o t e n t i a l l y l e a d i n g to changes in government p o l i c i e s . 6. C o n t i n u a l u p d a t i n g of r i s k f a c t o r s and r i s k assessment f o r m a t s . Other major advantages p o s i t e d by T o r r a n c e and D ' A r c y 1 67 i n c l u d e : 7. P e r s o n a l i z e d entree to l i f e s t y l e c o u n s e l l i n g , a " teachable moment." 8. S c r e e n i n g d e v i c e for i d e n t i f i c a t i o n of a t - r i s k i n d i v i d u a l s . 9. E d u c a t i o n a l and m o t i v a t i n g s t r a t e g y for recommending l i f e s t y l e change, a s s e s s i n g compl iance and p r o v i d i n g r e i n f o r c e m e n t . 10. A u t h o r i t a t i v e b a c k - u p , or "second o p i n i o n . " 11. Impact made by q u a n t i t a t i v e , c o m p u t e r i z e d format . And f i n a l l y , 12. The data g a t h e r i n g d e v i c e s , computer so f tware , and the o ther a s p e c t s l i s t e d above, can be marketed as a package f o r use i n a wide v a r i e t y of p u b l i c and p r i v a t e h e a l t h promot ion s e t t i n g s . The emphasis on l i f e s t y l e re form as p r e s e n t e d in The  New P e r s p e c t i v e on the H e a l t h of Canadians ( L a l o n d e , 1974) has s t r u c k a r e s p o n s i v e c h o r d among those in the f r o n t l i n e s of h e a l t h c a r e as w e l l as among p l a n n e r s and academics , and many want to put t h i s approach i n t o p r a c t i c e ( T o r r a n c e and D ' A r c y ) . To t h i s end, t h e r e f o r e , i t i s recommended tha t a p r i m a r y u n d e r t a k i n g of the C o - o r d i n a t i n g Agency sh ou ld be to support r e s e a r c h i n t o the expans ion of h e a l t h r i s k assessment programs i n t o a l l segments of the community; and to c o - o r d i n a t e the d i s s e m i n a t i o n of new l i f e s t y l e re form s t r a t e g i e s as they are d e v e l o p e d , e v a l u a t e d and judged ready 1 68 for g e n e r a l a p p l i c a t i o n . The D i v i s i o n of H e a l t h Systems at the U n i v e r s i t y of B r i t i s h C o l u m b i a , which i s committed to the r e s e a r c h and improvement of r i s k r e d u c t i o n programs, c o u l d work i n t e g r a l l y w i th the C o - o r d i n a t i n g Agency i n these endeavours . The D i v i s i o n , which i s c u r r e n t l y d e v e l o p i n g a package of comprehensive c o m p u t e r - p r o c e s s e d , s e l f - s c o r e d , and i n t e r a c t i v e microcomputer ins truments for use in v a r i o u s p r o v i n c i a l p u b l i c and p r i v a t e h e a l t h promot ion s e t t i n g s , c o u l d serve as the c l e a r i n g - h o u s e for h e a l t h r i s k assessment r e s e a r c h , i n f o r m a t i o n and programs throughout the p r o v i n c e . P o l i c y I n i t i a t i v e (4 ) : M a r k e t i n g L i f e s t y l e Reform I b e l i e v e people w i l l make changes i n t h e i r h e a l t h h a b i t s i f they b e l i e v e they w i l l f e e l b e t t e r and have something to ga in on a day to day b a s i s . The idea of l i v i n g longer h a s n ' t s topped people from smoking. (HHA User in T o r r a n c e and D ' A r c y , 1980) The focus of t h i s p o l i c y i n i t i a t i v e i s to encourage the development of a m a r k e t - o r i e n t e d approach to h e a l t h p r o m o t i o n , an approach which takes advantage of the s t a t e of the a r t i n t e r a c t i v e - c o m p u t e r and mass communication t e c h n o l o g i e s of the 1980's for the d i s s e m i n a t i o n of r i s k r e d u c t i o n programs and w e l l n e s s i n f o r m a t i o n , the aim of 1 69 which i s to i n f l u e n c e h e a l t h r i s k s r e l a t e d to l i f e s t y l e . These newly deve loped and d e v e l o p i n g communication t e c h n o l o g i e s ( o u t l i n e d i n Chapter 3) "may w e l l power r e v o l u t i o n a r y development in h e a l t h r i s k a p p r a i s a l " ( B r o t h e r s , L a s z l o and M i l s u m , 1982). As r e s e a r c h e r s of h e a l t h r i s k assessment s t r a t e g i e s have s t r e s s e d , i t i s u n r e a l i s t i c to expect these t o o l s a l o n e , in the absence of c o u n s e l l i n g and f o l l o w - u p , to "produce e n d u r i n g b e h a v i o r change on the p a r t of c l i e n t s ( T o r r a n c e and D ' A r c y , 1981). The " o n e - t i m e - t h r o u g h s c h o o l " of h e a l t h e d u c a t i o n needs r e i n f o r c e m e n t w i th subsequent exposure , and the use of the mass media , i n p a r t i c u l a r the e l e c t r o n i c media , r e p r e s e n t an a t t r a c t i v e h e a l t h p r o m o t i o n a l a l t e r n a t i v e (Rushmer, 1975). The major b a r r i e r s that impede the s u c c e s s f u l a p p l i c a t i o n of marke t ing p r i n c i p l e s to p r e v e n t i v e i n t e r v e n t i o n s , a c c o r d i n g to Que lch (1980), i n c l u d e : - the w idespread , inadequate u n d e r s t a n d i n g among h e a l t h c a r e p r o f e s s i o n a l s of marke t ing s t r a t e g y and the d es ign of e f f e c t i v e communications programs; - inadequate a t t e n t i o n to consumer r e s e a r c h ; - l i m i t a t i o n s on the r a p i d d i f f u s i o n of p r e v e n t i o n -o r i e n t e d behav ior among the p o p u l a t i o n ; - the l a c k of g e n e r a l l y accepted s tandards of measurement; - and the a t t i t u d e s of p o l i c y makers and h e a l t h c a r e 170 p r o f e s s i o n a l s toward p r e v e n t i v e h e a l t h c a r e i n g e n e r a l and the r o l e of m a r k e t i n g i n p a r t i c u l a r . Former f e d e r a l h e a l t h m i n i s t e r Marc La londe (1977) s t r e s s e d t h a t "the h i g h l y complex task of ' s e l l i n g ' the p u b l i c on the need for h e a l t h y l i f e s t y l e s w i l l c e r t a i n l y r e q u i r e the a s s i s t a n c e of everyone concerned - government, the p r i v a t e s e c t o r and v o l u n t a r y agenc ies" i f any ga in s i n h e a l t h are to be made. And Warner (1979) e x p l a i n s that "future p r e v e n t i o n o p p o r t u n i t i e s may l i e in n o n - t r a d i t i o n a l a c t i v i t i e s which v i o l a t e / r u l e s ' of e f f e c t i v e h e a l t h c a r e d e l i v e r y or communication of p r e v e n t i o n i n f o r m a t i o n . " The p r i v a t e s e c t o r has had many y e a r s of e x p e r i e n c e i n s u c c e s s f u l l y impac t ing on p u b l i c a t t i t u d e s and m o t i v a t i o n through mass media m a r k e t i n g . Dav idson et al_, (1979) w r i t e ; "It i s a x i o m a t i c that those promot ing h e a l t h would wish to i n f l u e n c e the l a r g e s t number of i n d i v i d u a l s p o s s i b l e . O b v i o u s l y , t h e r e f o r e , t e l e v i s i o n , r a d i o , magazines and newspapers - the mass media - are important channe l s of communication for h e a l t h promot ive a c t i v i t i e s . " Indeed, they add , "By d e f i n i t i o n , these mass media reach the whole or a s u b s t a n t i a l m a j o r i t y of the p o p u l a t i o n and in r e g a r d to commercia l a d v e r t i s i n g at l e a s t , t h e r e i s good ev idence that they succeed i n shaping p u b l i c o p i n i o n and b e h a v i o r . " Governments, and u n i v e r s i t i e s , o f t e n seem l o a t h to borrow these m a r k e t - o r i e n t e d approaches , p e r h a p s , as L a l o n d e e x p r e s s e d , "because of an i n g r a i n e d d i s t a s t e to appear s e l f -171 i n t e r e s t e d . " "But ," he a r g u e s , "modesty i s not a v i r t u e when i t comes to the d i s s e m i n a t i o n of h e a l t h i n f o r m a t i o n , " and he goes on to say tha t the "same communicat ion and marke t ing s k i l l s tha t s e l l p r o d u c t s and dangerous , or at b e s t , adverse l i f e s t y l e s shou ld be a p p l i c a b l e to s e l l i n g a sane l i f e s t y l e . " Davidson et a l , (1979) argue that "without u s i n g the mass media there would appear to be l i t t l e chance of i n f l u e n c i n g h e a l t h behav ior in groups o ther than those who are c u r r e n t l y m o t i v a t e d and a c t i v e l y i n t e r e s t e d in h e a l t h promot ion a l r e a d y . " "Because of t h i s " , they c o n t i n u e , " i t i s of c o n s i d e r a b l e importance to deve lop s t r a t e g i e s for use of the mass media that are as p r o d u c t i v e as p o s s i b l e . " Mi l sum (1983) c o u n t e r s t h i s argument w i t h the concern tha t a " p o t e n t i a l problem and danger e x i s t s w i t h t a k i n g on mass media t e c h n i q u e s w i th t h e i r v a r i o u s background p s y c h o l o g i c a l and market ing e x p e r t i s e . Namely, tha t i f h e a l t h i s a c c e p t e d to be a m u l t i - d i m e n s i o n a l r e p r e s e n t a t i o n of a p e r s o n ' s c o n d i t i o n s at a l l the v a r i o u s p h y s i o l o g i c a l , m e n t a l , s o c i a l and s p i r i t u a l l e v e l s , then h e a l t h promotion u n a v o i d a b l y c a r r i e s w i th i t a c e r t a i n h igher e t h i c a l p u r p o s e . " "In c o n t r a s t , " he a r g u e s , "there i s no such aspec t c l a i m e d for market ing the 'un- sane ' l i f e s t y l e , such as i n s e l l i n g c i g a r e t t e s and a l c o h o l . " Mi l sum p o i n t s out tha t "There i s , t h e r e f o r e , a s u b t l e danger i n t a k i n g on t e c h n i q u e s which have proven s u c c e s s f u l in s e l l i n g non-sane 172 l i f e s t y l e s that may i n v o l v e some of the u n d e r l y i n g l a c k of ) a t t e n t i o n to e t h i c a l p r i n c i p l e s . " He summarizes tha t "It would seem e s s e n t i a l to p l a c e j u s t as much e t h i c a l concern upon the t echn iques of i n d u c i n g l i f e s t y l e change as upon the nature of the l i f e s t y l e changes to be i n d u c e d . " B e a r i n g t h i s concern in mind , t h i s r e s e a r c h e r i s of the o p i n i o n that i t i s the i n f o r m a t i o n , the "message," that u l t i m a t e l y c o u n t s , and that the everyday means of communicat ions -r a d i o , t e l e v i s i o n , newspapers and magazines - are o n l y c o n d u i t s , channe l s for d i s s e m i n a t i n g t h i s message. So too are books , a l t h o u g h that may w e l l be an a l i e n a t t i t u d e for those s t i l l e n t r a n c e d by the p r i n t e d word. The mass media r e p r e s e n t an important f o r c e which i n f l u e n c e s l i f e s t y l e s and r e i n f o r c e s p a t t e r n s of thought and l i v i n g in c o u n t l e s s ways. T h e r e f o r e , i t a l s o has an important r o l e to p l a y i n d i s c o u r a g i n g s e l f - i n d u c e d i n c r e a s e in hazard or r i s k through i n d i v i d u a l v o l i t i o n or i n d u l g e n c e , and i n r e d u c i n g the impact of such s e l f - i n f l i c t e d hazards as o v e r e a t i n g , c a r e l e s s d r i v i n g , l a c k of e x e r c i s e , e t c . (Rushmer, 1975). N e l s o n , K e l l a r and Zubkoff (1981) b e l i e v e that "peop le ' s h a b i t s and v a l u e s do change in response to i n f l u e n c i n g f a c t o r s in the s o c i a l m i l i e u . " As d i s c u s s e d p r e v i o u s l y , a p o s i t i v e example of mass media i n f l u e n c e i s Canada' s P A R T I C I P a c t i o n campaign which has he lped make p o p u l a r an i n t e r e s t i n p h y s i c a l f i t n e s s and w e l l n e s s (see Chapter 3 ) . The e s s e n t i a l message t h e n , in t h i s c a s e , i s the p r o c e s s of 1 73 u n d e r t a k i n g l i f e s t y l e change, and on ly as a r e s u l t of i t , can the e f f e c t s of t h i s change be r e a l i z e d i n terms of an end p r o d u c t , namely in improved h e a l t h s t a t u s and q u a l i t y of l i f e . Indeed, i f the end r e s u l t i s p o s i t i v e , there shou ld be no e t h i c a l di lemma. C a r e f u l l y c o n c e i v e d programs on h e a l t h and h e a l t h improvement and q u a l i t y of l i f e , produced w i t h s u f f i c i e n t s k i l l to a t t r a c t p u b l i c i n t e r e s t can be deve loped and shou ld be used as much as p o s s i b l e (Rushmer, 1975) and l i k e a l l f u t u r e h e a l t h promot ion programs, mass media i n i t i a t i v e s shou l d be e v a l u a t e d (Davidson et a l , 1979). To t h i s end, our n a t i o n a l and r e g i o n a l mass communicat ions networks shou l d be e x p l o r e d to determine what u s e f u l r o l e they might p l a y in d i s p e n s i n g l i f e s t y l e - r e l a t e d h e a l t h i n f o r m a t i o n to the p u b l i c . tf P o l i c y I n i t i a t i v e (5 ) : E v a l u a t i o n Standards for H e a l t h Promotion H e a l t h i n s t i t u t i o n s in Canada f i n d themselves under i n c r e a s i n g p r e s s u r e to demonstrate that they are c a r e f u l l y managing the r e s o u r c e s a v a i l a b l e to them for the d i s c h a r g e of t h e i r o b l i g a t i o n s i n the h e a l t h care sys tem. In the face of i n c r e a s i n g cos t c o n s t r a i n t s in governments g e n e r a l l y , and w i t h i n the m i n i s t r i e s of h e a l t h s p e c i f i c a l l y , the time i s 1 7 4 r i g h t for h e a l t h promot ion s p e c i a l i s t s to take a more a c t i v e r o l e in the measurement of the e f f e c t i v e n e s s of the s e r v i c e s they p r o v i d e . . E v a l u a t i o n of h e a l t h promot ion and h e a l t h r i s k assessment s t r a t e g i e s shou ld be of major concern to p o l i c y -makers . La londe (1974) w i s e l y emphasized the need for the " s c i e n t i f i c community to r e s o l v e the debates on h e a l t h -r e l a t e d q u e s t i o n s of environment and l i f e s t y l e . " I t should be a s k e d , for example: What i s the p r o p o r t i o n of change in h e a l t h a t t r i b u t a b l e to a p a r t i c u l a r program, or p a r t of a program? When are i n d i v i d u a l s and f a m i l i e s more v u l n e r a b l e to c r i s i s , more s e n s i t i v e to change? What are the i n f l u e n c e s of e d u c a t i o n and p u b l i c i t y programs r e g a r d i n g l i f e s t y l e s - a n d h e a l t h r i s k s ? Who a c c e p t s , uses or i s a f f e c t e d but i s not a p a r t i c i p a n t w i t h i n a program under s tudy? What are the s h o r t and l o n g - t e r m c o s t - b e n e f i t f a c t o r s for both the i n d i v i d u a l and the s o c i e t y . These f i n d i n g s shou l d be complemented wi th r e s e a r c h that e v a l u a t e s e f f i c i e n c y w i t h which r e s o u r c e s and p e r s o n n e l are used , i . e . , o p e r a t i o n s r e s e a r c h ; tha t determines the t r u e c o s t s of i l l n e s s , v i z , not on ly the d o l l a r c o s t s borne by government i n s u r a n c e p l a n s , but a l s o the c o s t s borne by a f a m i l y or an i n d i v i d u a l ; tha t c l a r i f i e s the s o c i a l c o s t s of i l l - h e a l t h ; and t h a t h e l p s to deve lop more s o p h i s t i c a t e d methods of measuring the e f f e c t i v e n e s s and b e n e f i t s of s i c k n e s s care (Ge l lman , 1974). 1 75 The C o - o r d i n a t i n g Agency, by t a k i n g advantage of i t s p o t e n t i a l j o i n t p u b l i c / p r i v a t e s e c t o r d e l i b e r a t i o n s , can i n i t i a t e the e v a l u a t i o n of s tandards for and q u a l i t y of h e a l t h promot ion programming to ensure the employment of the most e f f e c t i v e assessment and communication s t r a t e g i e s that w i l l impact on r i s k r e d u c t i o n and u l t i m a t e l y on the improved h e a l t h s t a t u s of the community. T h i s p o l i c y i n i t i a t i v e i s r e i n f o r c e d by a statement p o s i t e d i n The P e r i o d i c H e a l t h Examinat ion (1979): " D i s s e m i n a t i o n of p u b l i c i n f o r m a t i o n must be s u s t a i n e d . Programs must be i n t r o d u c e d to improve compl iance wi th e f f i c a c i o u s p r e v e n t i o n and t r e a t m e n t , and the r e l a t e d e v a l u a t i o n procedures must be kept in f o r c e . At the same t i m e , we must r e c o g n i z e t h a t s u b s t a n t i a l s o c i a l adjustments take time and that o b t a i n i n g the ev idence for e f f e c t i v e n e s s for a l l approaches r e q u i r e s l e n g t h y and complex r e s e a r c h . " 4.2 On D e s i g n i n g a Comprehensive H e a l t h Assessment Q u e s t i o n n a i r e for Use w i t h D i f f e r e n t T a r g e t P o p u l a t i o n s E f f e c t i v e l y h e l p i n g people a c h i e v e t h e i r normal l i f e expectancy as h e a l t h y , m o t i v a t e d and p r o d u c t i v e c i t i z e n s i s r e a l l y the bottom l i n e . ( M e d i c a l D i r e c t o r , K i m b e r l y - C l a r k in B e r r y , 1981) The p r o s p e c t i v e approach to h e a l t h enhancement, which 1 76 is directed to a n t i c i p a t i n g and solving problems before they become c r i s e s , must take into account the relationship between the s o c i a l , environmental, c u l t u r a l and s p i r i t u a l , as well as bio-physical and psychological c h a r a c t e r i s t i c s , and health and quality of l i f e . This comprehensive view recognizes that an individual's q u a l i t y of l i f e must ultimately depend upon a l e v e l of t o t a l well-being and supports the World Health Organization's conclusion that health is "a state of complete physical, mental and s o c i a l well-being, and not merely the absence of disease of i n f i r m i t y . " Research has established that i t i s c l e a r l y not enough to simply t e l l people what their risk factors are, and what forms of disease, accident and death are l i k e l y to occur unless those risk factors are eliminated or substantially reduced (Well Aware, 1978). The key elements in planning health promotion programs concerned with l i f e s t y l e reform include: (a) the design and content of the "message," i . e . , information and s k i l l s which must meet the i d e n t i f i e d health p r i o r i t i e s of s p e c i f i c target groups; (b) the appropriate communication channels through which th i s message i s disseminated to reach these populations; and (c) "the education, the motivation, the encouragement, and the support which program participants must be given in their attempts to carry out risk-reducing recommendations" (Well Aware, 1978). 177 As has been d i s c u s s e d in some d e t a i l above, there i s c o n s i d e r a b l e ev idence which i n d i c a t e s that a comprehensive h e a l t h assessment q u e s t i o n n a i r e can be an e f f e c t i v e e d u c a t i o n a l and m o t i v a t i o n a l i n t e r v e n t i o n mechanism for h e a l t h promot ion programs which focus on a l i f e s t y l e approach to o p t i m a l w e l l - b e i n g . T h i s s t r a t e g y , f or which there i s a growing commitment, enab le s the "process of f o s t e r i n g awareness , i n f l u e n c i n g a t t i t u d e s , and i d e n t i f y i n g a l t e r n a t i v e s " so that i n d i v i d u a l s can make informed c h o i c e s about changing t h e i r b e h a v i o r s i n order that they may a c h i e v e t h e i r "optimum l e v e l of p h y s i c a l and mental w e l l -b e i n g , and improve t h e i r p h y s i c a l and s o c i a l environments" (Longe and Tedesco , 19.82). Whi l e there may be some i n h e r e n t l i m i t a t i o n s in the h e a l t h r i s k assessment formats as they c u r r e n t l y e x i s t which h i n d e r t h e i r e f f e c t i v e n e s s as t o o l s for s t i m u l a t i n g b e h a v i o r change, n e v e r t h e l e s s , i t i s g e n e r a l l y agreed tha t "improved  i n s t r u m e n t s based on the same p r i n c i p l e s can and shou ld be  deve loped" (Torrance and D ' A r c y , 1981). E l i a s (1982) s u p p o r t s t h i s p o s i t i o n but adds "that there i s a d e f i n i t e  need f o r a h e a l t h r i s k a p p r a i s a l t h a t goes beyond the  l i m i t a t i o n s of the o l d Robbins and H a l l model" ( i n i t i a l l y deve loped i n the e a r l y 1960's as a t o o l for p h y s i c i a n s ) . E l i a s goes on to say tha t he b e l i e v e s that "the s t a t e of the a r t i n ep idemio logy has not yet reached the p o i n t at which p r e d i c t i o n of i n d i v i d u a l m o r b i d i t y or m o r t a l i t y r i s k s i s 1 78 p e r m i t t e d from e p i d e m i o l o g i c a l d a t a . T h e r e f o r e , " he recommends as a l r e a d y n o t e d , "the compromise shou ld be an ins trument which c o n t a i n s the best elements of the s t a n d a r d h e a l t h h a z a r d a p p r a i s a l , i . e . , r i s k and a c h i e v a b l e ages f o r those over t h i r t y - f i v e , but then s imply c o n c e n t r a t e s on g i v i n g i n d i v i d u a l s feedback on t h e i r h e a l t h h a b i t s and b e h a v i o r s by r a t i n g them a g a i n s t e i t h e r a m e d i c a l s t a n d a r d or one tha t i s p o p u l a t i o n s p e c i f i c . " He suggests tha t the a p p r a i s a l shou l d be "upbeat, f l a s h y , and g ive people s t r o k e s for p o s i t i v e b e h a v i o r s . " A f u r t h e r concern tha t deserves c o r r o b o r a t i o n i s one p o s i t e d by K a p l a n , Bush & B e r r y (1976) . They b e l i e v e tha t the d i f f e r e n c e between the " w e l l - y e a r s " and "expected y e a r s of l i f e " are the years of " d i m i n i s h e d q u a l i t y of l i f e . " It . i s to t h i s gap, they s t r e s s , tha t " h e a l t h p l a n n i n g , improvements i n h e a l t h c a r e d e l i v e r y , m e d i c a l r e s e a r c h , p r e v e n t i v e m e d i c i n e , and programs to produce changes i n l i f e s t y l e s h o u l d be addressed perhaps as much as to e x t e n s i o n s of the l i f e expectancy i t s e l f . " The move to modify the b a s i c Robbins and H a l l model i n t o a more b r o a d l y - b a s e d p r e d i c t i v e and m o t i v a t i o n a l i n s t r u m e n t , the o b j e c t i v e of which i s to mot iva te b e h a v i o r change, must address not o n l y the non-debatab le "hard data" or m o r t a l i t y s t a t i s t i c s , but a l s o the e q u a l l y n o n - d e b a t a b l e data on p e r s o n a l h a b i t s which are the p r e c u r s o r s , i n a c t u a l i t y , the de terminant s of a c c i d e n t s , d i s e a s e s and 1 79 premature deaths w i t h which those h a b i t s are d i r e c t l y l i n k e d (Wel l Aware, 1978). The development of such a s t a n d a r d i z e d comprehensive l i f e s t y l e assessment instrument must take i n t o account the i n t e r p l a y between the p h y s i c a l , e m o t i o n a l / a f f e c t i v e , s o c i a l , c u l t u r a l , o c c u p a t i o n a l , e n v i r o n m e n t a l , s p i r i t u a l and economic a spec t s of i n d i v i d u a l s ; i t must c o n s i d e r the i n d i v i d u a l s ' own p e r c e p t i o n s of t h e i r h e a l t h and q u a l i t y of t h e i r l i v e s ; i t must e v a l u a t e the v a r i o u s demographic d i f f e r e n c e s that i n f l u e n c e t h e i r h e a l t h and h e a l t h h a b i t s such as age, sex, o c c u p a t i o n , f a m i l y h i s t o r y , e d u c a t i o n a l background , r a c e , e t h n i c i t y , e t c ; and c l e a r l y , i t must be a b l e to p r o v i d e r e l i a b l e , u s e f u l i n f o r m a t i o n to these i n d i v i d u a l s and to h e a l t h c a r e p r a c t i t i o n e r s , c o u n s e l l o r s , r e s e a r c h e r s and p l a n n e r s . And i t shou ld be re -emphas ized tha t the p u b l i c must be i n v o l v e d i n a p p r o p r i a t e ways to i s o l a t e h e a l t h problems and d e v e l o p s o l u t i o n s . T h i s r e s e a r c h e r acknowledges that c r e a t i n g a h e a l t h r i s k assessment ins trument tha t w i l l answer the many l e g i t i m a t e p r a c t i c a l and t h e o r e t i c a l q u e s t i o n s that can be r a i s e d i s an i n h e r e n t l y complex t a s k , however, as K a p l a n , Bush & Berry (1976) a r g u e , such an i n s t r u m e n t , which can o n l y r e s u l t from r i g o r o u s r e s e a r c h , "need not be d i f f i c u l t to comprehend or a p p l y . " As d i s c u s s e d p r e v i o u s l y , r e s e a r c h e f f o r t s are c u r r e n t l y underway in the U n i t e d S t a t e s and in Canada tha t are examining the more b r o a d l y a p p l i c a b l e c h a r a c t e r i s t i c s of 180 "hea l th" which can be a p p r o p r i a t e l y measured and a n a l y z e d , and f o r which i n t e r v e n t i o n s are e f f i c a c i o u s . The f o l l o w i n g i s a review of the ins trument components used to a n a l y z e the sample h e a l t h r i s k assessment q u e s t i o n n a i r e s d e s c r i b e d in Chapter 2, as w e l l as o ther content and des ign c r i t e r i a which t h i s r e s e a r c h e r deems important to the c o n s t r u c t i o n of s t a n d a r d i z e d , comprehensive h e a l t h assessment in s t ruments tha t are g e n e r a l l y a p p l i c a b l e to d i f f e r e n t t a r g e t p o p u l a t i o n s i n v a r i o u s h e a l t h promot ion s e t t i n g s . H e a l t h R i s k Assessment Instrument Component C r i t e r i a Des ign The d e s i g n of a q u e s t i o n n a i r e may a f f e c t response r a t e and a c c u r a c y of r e sponse . I t has been shown tha t formats that are easy to f o l l o w and p l e a s i n g to the eye encourage p a r t i c i p a t i o n and c o m p l e t i o n . Q u e s t i o n n a i r e s s h o u l d be a t t r a c t i v e ( c a r e f u l l y chosen p a p e r , t y p e f a c e , v i s u a l d i s p l a y , e t c . ) , g r a p h i c a l l y w e l l -d e s i g n e d and "f lashy" i n order to c a p t u r e a t t e n t i o n and encourage invo lvement . Typefaces used shou ld be e a s i l y l e g i b l e ( d i f f e r e n t type s i z e s and shades of t y p e ) , and for emphas is , u n d e r l i n e or e n c l o s e i n a box format the most s a l i e n t p a r t s . Use of i l l u s t r a t i o n s , g r a p h i c s and c o l o r 181 a m p l i f y a p r e s e n t a t i o n and can h e l p to s i m p l i f y i n s t r u c t i o n s and d i r e c t p a r t i c i p a n t s to a p p r o p r i a t e i t ems . V i s u a l s shou ld be a p p l i c a b l e to the p r e s e n t a t i o n and the t a r g e t a u d i e n c e . The q u e s t i o n n a i r e shou ld be des igned so that i t i s easy to i d e n t i f y , code and s t o r e . S t y l e The q u e s t i o n n a i r e shou ld c o n t a i n s i m p l e , c l e a r , "user f r i e n d l y " i n s t r u c t i o n s and q u e s t i o n s t a i l o r e d , p r e - t e s t e d  and r e f i n e d w i t h t a r g e t audience in mind. The q u e s t i o n n a i r e shou ld be p r e f a c e d w i t h a g e n e r a l purpose statement and a statement a s s u r i n g p a r t i c i p a n t s c o n f i d e n t i a l i t y and anonymity . S t y l e Recommendations: - keep i n s t r u c t i o n s and q u e s t i o n s as c l e a r and as s p e c i f i c as p o s s i b l e ; - c o n s u l t S t a t i s t i c s Canada' s S o c i a l Concepts D i r e c t o r y  f or S t a t i s t i c a l Surveys f o r wording of commonly asked q u e s t i o n s ( m a r i t a l s t a t u s , income, age, e t c . ) i f these items are to be compared wi th data from S t a t i s t i c s Canada such as m o r t a l i t y and m o r b i d i t y s t a t i s t i c s ; - d o n ' t assume too much knowledge or use complex l eng thy 182 i n s t r u c t i o n s and q u e s t i o n s ; - respondents can be asked to omit i n a p p l i c a b l e q u e s t i o n s by use of a s k i p p a t t e r n , f or example, "If answer i s No, go on to next q u e s t i o n ; " - a v o i d - fore ign phrases or s l a n g e x p r e s s i o n s ; - a v o i d the use of e m o t i o n a l l y charged words which may c r e a t e a b i a s ; - mention a l l a l t e r n a t i v e answers or none, s i n c e ment ion ing on ly some a l t e r n a t i v e s can c r e a t e a b i a s ; - i f p o s s i b l e , a v o i d p e r s o n a l q u e s t i o n s which convey n e g a t i v e or i n c r i m i n a t i n g i m p l i c a t i o n s ( f o r example, the q u e s t i o n c o n c e r n i n g c r i m i n a l r e c o r d as asked on American h e a l t h r i s k a p p r a i s a l s ) u n l e s s the c o r r e s p o n d i n g h e a l t h r i s k i s v a l i d a t e d . I f o b j e c t i o n a b l e q u e s t i o n s must be a sked , they shou ld be p l a c e d near the end of the q u e s t i o n n a i r e , and the response asked i n a contex t which so f t ens the impact; - add a touch of humour to the format . T h i s w i l l h e l p h o l d the a u d i e n c e ' s i n t e r e s t i n the m a t e r i a l , even in the most t e c h n i c a l i n f o r m a t i o n ; - use an "upbeat" s t y l e and a p o s i t i v e w e l l n e s s o r i e n t a t i o n , e s p e c i a l l y when making r i s k - r e d u c i n g recommendations f o r l i f e s t y l e change, and g i v e people s t r o k e s for p o s i t i v e b e h a v i o r s . S t y l e c r i t e r i a s p e c i f i c to i n t e r a c t i v e - c o m p u t e r programs: 183 I n t e r a c t i v e - c o m p u t e r programs sh ou ld meet the b a s i c requ irements for v i s u a l a c c e p t a n c e . The minimal c r i t e r i a for an a c c e p t a b l e v i s u a l d i s p l a y i n c l u d e : (The H a r v a r d M e d i c a l Schoo l H e a l t h L e t t e r , A p r i l 1983) 1. the image shou ld not f l i c k e r ; 2. the e n t i r e d i s p l a y shou ld be i n sharp focus (no b l u r r e d edges ) ; 3. the c o n t r a s t between l i g h t and dark areas sh ou ld be at l e a s t 8 to 1; 4. the c h a r a c t e r s s h o u l d be formed i n a 5x7 matr ix of dots at the very l e a s t ; 5. a l l V D T ' s should have b r i g h t n e s s and c o n t r a s t c o n t r o l s tha t the o p e r a t o r can f i n d and a d j u s t ; and 6. d a r k e r c h a r a c t e r s on a l i g h t e r background may be somewhat e a s i e r to read than a n e g a t i v e image. Other recommendations i n c l u d e : - tha t t h o u g h t f u l room l i g h t i n g and c o m f o r t a b l e f u r n i t u r e be i n c o r p o r a t e d i n t o the assessment area wherever p o s s i b l e ; - t h a t i n t e r a c t i v e - c o m p u t e r programs be geared i n speed to the r e a d i n g a b i l i t y and comprehension of the t a r g e t p o p u l a t i o n , and have i n h e r e n t in t h e i r d e s ign a way of s t o p p i n g and s t a r t i n g the program, and the a b i l i t y to repeat a q u e s t i o n or i n s t r u c t i o n t h a t i s not c l e a r l y u n d e r s t o o d . The responder sh ou ld never be rushed nor the program t e c h n i c a l l y complex; and 184 - that i n t e r a c t i v e - c o m p u t e r programs be "user f r i e n d l y " in d e s i g n and s t y l e so that they are accepted as an e n j o y a b l e and n o n - t h r e a t e n i n g e x p e r i e n c e by the p a r t i c i p a n t s . For f u r t h e r a s s i s t a n c e , r e f e r to the Guide to  Q u e s t i o n n a i r e C o n s t r u c t i o n and Q u e s t i o n W r i t i n g (1980) p u b l i s h e d by the Canadian P u b l i c H e a l t h A s s o c i a t i o n . (See Appendix L f o r i n f o r m a t i o n . ) Content 1. R e l i a b i l i t y and v a l i d i t y of measurement data s o u r c e s : In o r d e r to be u s e f u l , a h e a l t h r i s k assessment ins trument must s a t i s f y c e r t a i n p r a c t i c a l r e q u i r e m e n t s . As d e f i n e d by Berg (1976): "It shou ld be s imple i n c o n s t r u c t i o n , use and a p p l i c a t i o n . I t shou ld be a c c e p t a b l e to respondents and to u s e r s . I t sh ou ld be e c o n o m i c a l , and make use of a v a i l a b l e data or data t h a t are r e a d i l y g a t h e r e d . " S o l i d r e s u l t s r e q u i r e competent m e t h o d o l o g i c a l procedures which are based on r e l i a b l e measures tha t can be a d e q u a t e l y v a l i d a t e d . R e l i a b i l i t y , as o u t l i n e d by Woodward and Chambers (1980), i s u s u a l l y determined by such t a c t i c s as (a) examining the i n t e r n a l , c o n s i s t e n c y of re sponses , and (b) 185 repeated a d m i n i s t r a t i o n of the q u e s t i o n n a i r e on two or more o c c a s i o n s . The q u e s t i o n of the v a l i d i t y of the s c i e n t i f i c b a s i s for the assessment of i n d i v i d u a l r i s k s and of b e n e f i t s from a p p r o p r i a t e b e h a v i o r a l changes i s c l e a r l y a more d i f f i c u l t one to answer. K a p l a n , Bush & B e r r y (1976) conc lude that as no s i n g l e d i r e c t l y o b s e r v a b l e measure of w e l l - b e i n g e x i s t s , t e s t i n g for c r i t e r i o n v a l i d i t y (the agreement of a new measure w i t h a w e l l - e s t a b l i s h e d or more t r u s t e d measure) "is i n a p p r o p r i a t e ; " content v a l i d i t y (the c a r e f u l review of the component p a r t s of an ins trument to be sure that they a d e q u a t e l y measure the areas of concern) can be demonstrated by " i n c l u d i n g a l l p o s s i b l e l e v e l s of f u n c t i o n and symptom/problem complexes and a c l e a r r e l a t i o n to the death s t a t e , as w e l l as consumer r a t i n g s of the r e l a t i v e importance of the s t a t e s ; " and data for c o n s t r u c t v a l i d i t y (where no s i n g l e c r i t e r i o n i s a v a i l a b l e for v a l i d a t i o n and where d i f f e r e n t a s p e c t s or domains of a c o n s t r u c t are compared and r e l a t e d to each o t h e r ) can be p r o v i d e d , for example, from a m e t r o p o l i t a n 4household i n t e r v i e w survey which can p r o v i d e convergent ev idence by d e m o n s t r a t i n g an expected p o s i t i v e c o r r e l a t i o n of the index w i t h s e l f - r e l a t e d w e l l - b e i n g and expected n e g a t i v e c o r r e l a t i o n s w i t h age, number of c h r o n i c m e d i c a l c o n d i t i o n s , number of r e p o r t e d symptoms or problems , number of p h y s i c i a n c o n t a c t s , and d y s f u n c t i o n a l s t a t u s . " 186 D e t e r m i n a t i o n of h e a l t h , in the broadest sense , and of the b e n e f i t s of r i s k r e d u c t i o n need to be c a l c u l a t e d on the b a s i s of the most c u r r e n t e p i d e m o l o g i c a l knowledge, knowledge which i s c o n s t a n t l y re -examined and u p - d a t e d , wh i l e b e a r i n g in mind, a c c o r d i n g to Beery et a l (1981), " a r i t h m e t i c p r e c i s i o n i s n e i t h e r necessary nor r e l e v a n t to the o b j e c t i v e of h e a l t h r i s k assessment in g e n e r a l . More important c o n s i d e r a t i o n s , " they d e t e r m i n e d , "are the s c i e n t i f i c v a l i d i t y , c r e d i b i l i t y , and va lue of the message  r e c e i v e d by the c l i e n t . " Of p a r t i c u l a r concern in the c o n s t r u c t i o n of a comprehensive q u e s t i o n n a i r e , are the e x t r a p o l a t i o n s of v a r i o u s k inds from data s o u r c e s , such as the Framingham study and Robbins and H a l l , to determine r i s k f a c t o r v a l u e s , e s p e c i a l l y when making p r e d i c t i o n s for t e e n a g e r s , the e l d e r l y , N a t i v e Ind ians and o ther d i s s i m i l a r g r o u p s . For example, as c h r o n i c d i s e a s e s g e n e r a l l y do not appear u n t i l a f t e r age f o r t y , the Robbins and H a l l method p r o v i d e s l i t t l e i n c e n t i v e for young people to modify t h e i r l i f e s t y l e h a b i t s which a f f e c t the r i s k of these d i s e a s e s . What a comprehensive h e a l t h r i s k assessment shou ld communicate i s the ex tent to which i n d i v i d u a l h e a l t h r i s k s can be reduced through a change of l i f e s t y l e h a b i t s . T h i s can be e f f e c t i v e l y i l l u s t r a t e d to an i n d i v i d u a l v i a an " a p p r a i s e d age" which compares h i s a p p r a i s e d r i s k to h i s own a c h i e v a b l e r i s k , r a t h e r than by comparing i t to "average" r i s k 187 ( B r o t h e r s , 1980). T h i s approach can be used for a l l age groups whether the measure of h e a l t h r i s k i s based on m o r t a l i t y or m o r b i d i t y s t a t i s t i c s , and can be used as w e l l f or any measure of h e a l t h r i s k tha t i n c r e a s e s or decreases s t e a d i l y w i th age. Another method of communicat ing r i s k i s a s i m p l i f i e d c o m p u t a t i o n a l approach which p r o v i d e s feedback in the form of a " r i s k s c o r e . " T h i s method can f r e e a h e a l t h r i s k assessment format from the c o n t r a i n t s i n v o l v e d i n the m o r t a l i t y p r e d i c t i o n framework. I t deserves emphasis , however, that any q u a n t i t a t i v e index i s on ly as good as the data tha t are used in the computat ion (Chen, 1976). 2. Measurement of H e a l t h and L i f e s t y l e C h a r a c t e r i s t i c s T a r g e t P o p u l a t i o n : The d e t e r m i n a t i o n of h e a l t h c h a r a c t e r i s t i c s , p r i o r i t i e s and c a l c u l a t i o n of p e r s o n a l r i s k s shou ld be based on answers to q u e s t i o n s c o n s t r u c t e d for the f o l l o w i n g s p e c i f i c var i a b l e s : Demographic v a r i a t i o n s Age Sex M a r i t a l S t a t u s Number of c h i l d r e n by age group Race or e t h n i c group E d u c a t i o n a l l e v e l 188 C u l t u r a l background Occupat ion c a t e g o r y / p o s i t i o n Employment s t a t u s Income s tatus /number of people supported R e l i g i o u s a f f i l i a t i o n E n v i r o n m e n t a l - g e o g r a p h i c a l d i f f e r e n c e s S p e c i a l a t - r i s k d i f f e r e n c e s (handicapped , e t c . ) P h y s i o l o g i c a l and B i o c h e m i c a l Measurements Height Weight B lood P r e s s u r e C h o l e s t e r o l B lood A n a l y s i s About H e a l t h in G e n e r a l H e a l t h knowledge H e a l t h a t t i t u d e s ( i n c l u d i n g s e l f - c a r e ; s e l f - m e d i c a t i o n ) H e a l t h S t a t e H e a l t h h i s t o r y P e r c e p t i o n s of (sex s p e c i f i c ) present h e a l t h ( i n c l u d i n g m e d i c a t i o n s ) and q u a l i t y of l i f e 189 p h y s i c a l c h a r a c t e r i s t i c s e m o t i o n a l / m e n t a l (Type "A" p e r s o n a l i t y ; d e p r e s s i o n , e t c . ) s o c i a l and s o c i a l support networks F a m i l y h e a l t h h i s t o r y L i f e s t y l e L i f e s t y l e s ( o r , s e l f - c r e a t e d r i s k s ) may be d i v i d e d i n t o the f o l l o w i n g e lements : Consumption P a t t e r n s : N u t r i t i o n ( r e g u l a r mea l s , o b e s i t y , c h o l e s t e r o l , abundant g l u c o s e , c a l c i u m , e t c . ) Abuse substances ( smoking/second-hand smoke, a l c o h o l and d r u g s , i n c l u d i n g s e l f - m e d i c a t i o n ) S a f e t y P a t t e r n s : On the road ( s e a t b e l t s , s p e e d i n g , d r i n k i n g and d r i v i n g ) In the home In the workplace ( s a f e t y s t an d ard s ) In the r e c r e a t i o n a l environment O c c u p a t i o n a l and E d u c a t i o n a l R i s k s : S t r e s s e s , a n x i e t i e s and t e n s i o n s 190 T r a v e l Sh i ftwork E n v i r o n m e n t a l hazards F i n a n c i a l concerns L e i s u r e A c t i v i t i e s : S t r e s s management ( r e l a x a t i o n and r e l a x a t i o n t e c h n i q u e s , e t c . ) R e c r e a t i o n a l a c t i v i t i e s (games, h o b b i e s , mus ic , T V , r e a d i n g , e t c . ) E x e r c i s e and f i t n e s s S l eep h a b i t s S o c i a l a c t i v i t i e s ( s o c i a l ne tworks , f r i e n d s , f a m i l y , groups) R e l i g i o u s a c t i v i t i e s , m e d i t a t i o n L i f e Sat i s f a c t i o n s / P o s i t ive P r a c t i c e s P e r s o n a l l i f e s t a g e s / l i f e changes ( e s p e c i a l l y l o s s e s ) F a m i l y r e l a t i o n s h i p s ( m a r r i a g e , p a r e n t i n g ) S o c i a l r e l a t i o n s h i p s S o c i a l support W o r k / l i f e s a t i s f a c t i o n s P e r s o n a l growth, i n t e r e s t s ( o r g a n i z a t i o n a l a c t i v i t i e s , s p i r i t u a l v a l u e s , m e d i t a t i o n , c o n t i n u i n g e d u c a t i o n , workshops, time o u t , time a l o n e , 1 9 1 g o a l s e t t i n g , problem s o l v i n g , j o u r n a l keeping) P o s i t i v e h a b i t s ( l a u g h t e r , hugg ing , t o u c h i n g , l o v i n g , i n t i m a c y ) A n a l y s i s and Feedback A h e l p f u l h e a l t h f u l and e d u c a t i o n a l review of p e r s o n a l r i s k s , needs and support r i s k s , which i n c l u d e s : R i s k score or a c h i e v a b l e age c a l c u l a t i o n s R i s k r e d u c t i o n recommendations P o s i t i v e feedback for h e a l t h h a b i t s and p r a c t i c e s N o n - t h r e a t e n i n g / n o n - b l a m i n g feedback s t y l e M e d i c a l r e f e r r a l i f needed Community r e s o u r c e l i s t - where to go for h e l p and support Other r e s o u r c e s - books , t a p e s , v i d e o , e t c . Program dependent c o u n s e l l i n g and f o l l o w - u p 1 92 4.3 Assessment and Communication S t r a t e g i e s for V a r i o u s  H e a l t h Promotion S e t t i n g s As has been expressed in the p o l i c y i n i t i a t i v e s for p l a n n i n g community-based l i f e s t y l e reform programs, there i s a c r i t i c a l need for a c o o r d i n a t e d e f f o r t i n order to implement the r e s e a r c h and development of a comprehensive assessment s t r a t e g y which takes i n t o account the v a r i a b l e s d e s c r i b e d above, and to market i t s use in a broad range of p u b l i c and p r i v a t e h e a l t h enhancement programs. T h i s h e a l t h r i s k - r e d u c t i o n s t r a t e g y , the success of which can on ly be de termined by r e s e a r c h , c a r e f u l p l a n n i n g and a p p r o p r i a t e use of i n t e r p e r s o n a l and mass media communication o p t i o n s , can be d e s i g n e d for use i n the f o l l o w i n g s p e c i f i c s e t t i n g s : 1. P r i v a t e m e d i c a l p r a c t i c e s and community c l i n i c s -i n t e r p e r s o n a l c o u n s e l l i n g supported by computer-p r o c e s s e d s e l f - a d m i n i s t e r e d formats a n d / o r sof tware programs for microcomputers , and supplemented wi th v i d e o c a s s e t t e r i s k r e d u c t i o n programs. 2. P u b l i c h e a l t h u n i t s and i n s t i t u t i o n a l s e t t i n g s -sof tware programs for microcomputers , computer-p r o c e s s e d s e l f - a d m i n i s t e r e d formats , community-based i n t e r a c t i v e t e l ecommunica t ion systems such as T e l i d o n , and s e l f - s c o r e d ins truments supplemented by i n d i v i d u a l or group c o u n s e l l i n g and v i d e o c a s s e t t e r i s k r e d u c t i o n programs. 3. Workplace h e a l t h s e r v i c e s - i n the p u b l i c and p r i v a t e 1 93 s e c t o r s , same s t r a t e g i e s as those for p u b l i c h e a l t h u n i t s . E d u c a t i o n a l s e t t i n g s - same s t r a t e g i e s as those for p u b l i c h e a l t h and workplace s e t t i n g s , p l u s s eminars , l e c t u r e s and use of i n t e r a c t i v e e d u c a t i o n a l t e l e v i s i o n (eg. Knowledge Network) . H e a l t h r i s k assessment s t r a t e g i e s as a focus for t e a c h i n g p r e v e n t i v e medic ine and h e a l t h promot ion to h e a l t h care p r a c t i t i o n e r s , p r o f e s s i o n a l s i n v o l v e d wi th l i f e s t y l e management and e d u c a t o r s can open the door to g a i n i n g a c o n c e p t u a l approach to the m u l t i p l e i n f l u e n c e s in c h r o n i c d i s e a s e and premature d e a t h , the r a t i o n a l e for r i s k d e t e c t i o n and r e d u c t i o n , the use of p o p u l a t i o n - b a s e d d a t a , and an u n d e r s t a n d i n g of e p i d e m i o l o g i c p r i n c i p l e s . R e c r e a t i o n a l , community and f i t n e s s programs - same s t r a t e g i e s as for p u b l i c h e a l t h and workplace s e t t i n g s . Home - s e l f - s c o r e d formats for mass p r i n t and e l e c t r o n i c media d i s t r i b u t i o n , i n c l u d i n g e d u c a t i o n a l and c a b l e - t e l e v i s i o n b r o a d c a s t i n g ; software programs for home computers and i n t e r a c t i v e t e l ecommunica t ion systems; and , v i d e o c a s s e t t e r i s k r e d u c t i o n programs d e s i g n e d for the g e n e r a l p u b l i c and for s p e c i f i c h i g h -r i s k t a r g e t p o p u l a t i o n s . P u b l i c p l a c e s - g r e a t untapped p o t e n t i a l f o r "wel lness" v i d e o games, microcomputer and v i d e o c a s s e t t e d i s p l a y s , 1 94 and i n t e r a c t i v e t e l ecommunica t ion systems l i k e T e l i d o n in shopping m a l l s , conference h a l l s , a i r p o r t s , bus s t a t i o n s , h o s p i t a l and h o t e l l o b b i e s , c o n v e n t i o n l o c a t i o n s , h e a l t h f a i r s , marke t s , and o ther p u b l i c meet ing p l a c e s . D e s i g n i n g e f f e c t i v e h e a l t h r i s k r e d u c t i o n programs i s , a c c o r d i n g to Blum (1980), "noth ing more than competent problem a n a l y s i s d i r e c t e d to i d e n t i f y i n g and then a t t a c k i n g p r e c u r s o r s to prob lems , eg . r i s k s . " He s t r e s s e s that " t h i s problem s o l v i n g approach must i n c l u d e a s u i t a b l e s e a r c h for problem p r e c u r s o r s among the env ironment , p e r s o n a l b e h a v i o r s , m e d i c a l c a r e and g e n e t i c s " but c a u t i o n s : "keeping r i s k r e d u c t i o n in a l e g i t i m a t e and u s e f u l i n d i v i d u a l and c o l l e c t i v e focus i s not go ing to be easy ." The l o n g - t e r m task of g i v i n g people more c h o i c e about how they w i l l l i v e t h e i r l i v e s r e q u i r e s c o l l a b o r a t i o n not o n l y a c r o s s s c i e n t i f i c and p r o f e s s i o n a l d i s c i p l i n e s , but a c r o s s governmental and e d u c a t i o n a l s e c t o r s and w i t h b u s i n e s s , i n d u s t r y , l abour and the consumer p u b l i c . Grea t t h i n g s can flow from t h i s c o l l a b o r a t i o n , not the l e a s t be ing an improved h e a l t h s t a t u s and q u a l i t y of l i f e f or the p u b l i c at l a r g e . The t e c h n o l o g i c a l s c e n a r i o tha t has been p r e s e n t e d i n t h i s s t u d y , a s c e n a r i o roo ted i n c o - o p e r a t i v e e f f o r t , o f f e r s the p o s s i b i l i t y for r a d i c a l change in the e n t i r e proces s of p r e v e n t i n g d i s e a s e and d i s a b i l i t y , and of promot ing w e l l n e s , 195 wi th r e s u l t a n t c o s t b e n e f i t s to i n d i v i d u a l s , and to s o c i e t y as a whole . But when a l l i s s a i d and done, the bottom l i n e for d e v e l o p i n g a h e a l t h r i s k r e d u c t i o n p o l i c y i s an approach s u c c i n c t l y expressed-by M a r i l y n Ferguson i n the A q u a r i a n C o n s p i r a c y (1980): "If we want to h e l p people change, i t ' s important tha t we d o n ' t push them or p u l l them, j u s t walk t o g e t h e r . " Or as in the words of K r u p i n s k i (1980), i n c o n c l u d i n g h i s f i n d i n g s from an e x t e n s i v e study on H e a l t h and Q u a l i t y of L i f e in A u s t r a l i a : I t i s suggested that we s h o u l d not aim in h e a l t h e d u c a t i o n programmes at imposing our va lues on the p o p u l a t i o n at l a r g e but r a t h e r s h ou l d t r y to h e l p i n d i v i d u a l s to determine and to f u l f i l t h e i r d e s i r e s in a c t u a l l i f e . People need to be educated to d i s c o v e r what i s important for them and how to shape t h e i r l i v e s in terms of t h i s knowledge. 196 REFERENCES A l c o l a y , R. The need of s o c i a l support for h e a l t h . I n : The P r o c e e d i n g s of the 16th Annual Meet ing of the S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1980. Bethesda , M a r y l a n d : The S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1981, 80-87. A l l e n , R . F . The c o r p o r a t e h e a l t h - b u y i n g s p r e e : boon or boondoggle? Advanced Management J o u r n a l , 1980. A l t h a f e r , C . The e v a l u a t i o n of h e a l t h r i s k a p p r a i s a l / l i f e s t y l e programs at the Center for Disease  C o n t r o l . I n : The P r o c e e d i n g s of the 16th Annual Meet ing of the S o c i e t y for P r o s p e c t i v e M e d i c i n e , 1980. Be thesda , M a r y l a n d : The S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1981, 30-32. Antonovsky , A . H e a l t h , s t r e s s , and c o p i n g . San F r a n c i s c o , C a l i f o r n i a : J o s s e y - B a s s , I n c . , 1979. A s s i s t a n t S e c r e t a r y for h e a l t h , U . S . H e a l t h E d u c a t i o n and W e l f a r e , 1977. In M c C o n n e l l , H . , M e d i c a l P o s t , September 11, 1979. B a r t h , R . T . , V e r t i n s k y , P . & Yang, C . Some s o c i o b e h a v i o r a l and o ther de terminants of c o m p l i a n c e : A v o l u n t a r y h e a l t h s e r v i c e c o m p a r i s o n . Human R e l a t i o n s , 1979, 32  ( 9 ) , 781-792. Bauer , K . G . Improving the chances for h e a l t h : L i f e s t y l e  change and h e a l t h e v a l u a t i o n . San F r a n c i s c o , C a l i f o r n i a : N a t i o n a l Centre for H e a l t h E d u c a t i o n , 1980. B a y l e y , C M . P e r s o n a l communicat ion , September 18, 1982. B e e r y , W . , Schoenbach, V . J . , Wagner, E . H . , Graham, R . M . , K a r o n , J . M . , & P e z z u l l o , S. D e s c r i p t i o n , a n a l y s i s and  assessment of H e a l t h H a z a r d / H e a l t h R i s k A p p r a i s a l  Programs. E x e c u t i v e summary. F i n a l r e p o r t . Chapel H i l l , Nor th C a r o l i n a : H e a l t h S e r v i c e s Research C e n t e r , U n i v . of Nor th C a r o l i n a , 1981. 1 97 B e g i n , M. In H e a l t h & W e l f a r e Canada January 25, 1983 pres s r e l e a s e . Vancouver Sun, January 26, 1983. Behav ior and a t t i t u d e toward p h y s i c a l a c t i v i t y among C a n a d i a n s : R e s u l t s of a n a t i o n a l s u r v e y , March 1982. , T o r o n t o , Canada: P A R T I C I P a c t i o n , 1982. B e r g , R . L . Annotated guide to p a p e r s . H e a l t h S e r v i c e s  R e s e a r c h , 1976, 11 (4 ) , 335-348. B e r r y , C . A . An approach to good h e a l t h for employees and  reduced h e a l t h c a r e c o s t s for i n d u s t r y . H e a l t h Insurance A s s o c i a t i o n of A m e r i c a , H e a l t h Insurance I n s t i t u t e , 1981. B e r t o n , P . Why we ac t l i k e Canadians. T o r o n t o , Canada: M c L e l l a n d S tewart , 1982. B e s t , J . A . Mass media , self-management and smoking m o d i f i c a t i o n . In P . O . Davidson & S . M . Dav idson ( E d s . ) B e h a v i o r a l m e d i c i n e : Changing h e a l t h l i f e s t y l e s . New York": B r u n n e r / M a z e l , I n c . , 1980. B e s t , J . A . , M i l s u m , J . H . HHA and the e v a l u a t i o n on l i f e s t y l e change programs: M e t h o d o l o g i c a l i s s u e s . I n : P r o c e e d i n g s of the 13th Annual Meet ing of the S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1977. Bethesda , M a r y l a n d : H e a l t h and E d u c a t i o n R e s o u r c e s , 1978, 95-97. B i h n s , C . UBC D i v i s i o n of P r e v e n t i v e M e d i c i n e and H e a l t h Promotion Seminar, January 20, 1983. B l o m q v i s t , A . The h e a l t h c a r e b u s i n e s s : I n t e r n a t i o n a l ev idence on p r i v a t e v e r s u s p u b l i c h e a l t h c a r e systems. Canada: M a c m i l l a n , 1979. Blum, H . L . S o c i a l p e r s p e c t i v e on r i s k r e d u c t i o n . F a m i l y  and Community H e a l t h , 1980, 3 (1 ) , 41-61. B r e s l o w , L . & Somers, A . R . The l i f e t i m e h e a l t h - m o n i t o r i n g program. A p r a c t i c a l approach to p r e v e n t i v e m e d i c i n e . New E n g l a n d J o u r n a l of M e d i c i n e , 1977, 296(11) , 601-608. B r o t h e r s , K . M . Some a l t e r n a t i v e s to the Robbins and H a l l method of H e a l t h Hazard A p p r a i s a l . I n : Proceed ings of the 16th Annual Meet ing of the S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1980. Be thesda , M a r y l a n d : The S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1981, 142-144. 198 B r o t h e r s , K . M . , L a s z l o , C . A . & M i l s u m , J . H . Communication  t echno logy and HHA. I n : Proceed ings of the 18th Annual Meet ing of the S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1982. Be thesda , M a r y l a n d : H e a l t h and E d u c a t i o n R e s o u r c e s , 1 983 ( i n p r i n t ) . C a m p b e l l , W . J . P e r s o n a l Communicat ion. J a n u a r y , 1983. Canada's f i t n e s s : P r e l i m i n a r y f i n d i n g of the 1981 s u r v e y . Ottawa: Government of Canada, F i t n e s s and Amateur S p o r t , 1982. C a p r a , F . The t u r n i n g p o i n t : S c i e n c e , s o c i e t y and the  r i s i n g c u l t u r e . New Y o r k : Simon & S c h u s t e r , 1982. Chen, M . K . The K index: A proxy measure of h e a l t h c a r e q u a l i t y . H e a l t h S e r v i c e s R e s e a r c h , 1976, 11(4) , 452-463. Comstock, G . A . The impact of t e l e v i s i o n on american i n s t i t u t i o n s . J o u r n a l of Consumer R e s e a r c h , 1977, 4, 12-28. Coronary r i s k f a c t o r s : A r i z o n a Heart I n s t i t u t e Tes t as broadcas t on A B C - T V ' s "20/20," F e b . , 1981. T ime , June 1, 1981 . C r i c h t o n , A . E q u a l i t y : A Concept i n Canadian h e a l t h c a r e from i n t e n t i o n to r e a l i t y of p r o v i s i o n . S o c i a l S c i e n c e  and M e d i c i n e , 1980, 14(C) , 243-257. D a v i d s o n , L . , Chapman, S . , & H u l l , C . H e a l t h promot ion in  A u s t r a l i a 1978-79. A R e p o r t . C a n b e r r a : Commonwealth Department of H e a l t h , A u s t r a l i a n Government P u b l i s h i n g S e r v i c e , 1979. D e s c r i p t i o n , a n a l y s i s and assessment of H e a l t h H a z a r d / H e a l t h  R i s k A p p r a i s a l Programs: [appendices A-G] (PB81-239071) . H e a l t h S e r v i c e s Research C e n t e r , N o r t h C a r o l i n a U n i v e r s i t y at Chapel H i l l . H y a t t s v i l l e , M . D . : N a t i o n a l Center for H e a l t h S e r v i c e s R e s e a r c h , 1981. Dever , G . E . A . The p u r s u i t of h e a l t h . S o c i a l I n d i c a t o r s  R e s e a r c h , 1977, 4, 475-497. Dever , G . E . A . An e p i d e m i o l o g i c a l model for h e a l t h p o l i c y a n a l y s i s . S o c i a l I n d i c a t o r s R e s e a r c h , 1976, 2, 453-466. 199 Diamond, E . S ign o f f : The l a s t days of t e l e v i s i o n . Cambridge , Mass: The MIT P r e s s , 1982. E l i a s , W.S . & Dunton, S . D . E f f e c t of r e l i a b i l i t y on r i s k  f a c t o r e s t i m a t i o n by a H e a l t h Hazard A p p r a i s a l . I n : Proceed ings of the 16th Annual Meet ing of the S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1980. Be thesda , M a r y l a n d : The S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1981, 1-4. E l i a s , W.S . P e r s o n a l Communicat ion. F e b r u a r y 25 and May 12, 1982. Emery, J . C . An e l e c t r o n i c marketp lace of i d e a s . J o u r n a l of  Communicat ion, 1978, 28, 77-80. E p s t e i n , J . B . , Magrowski , W.D. & M c P h a i l , C . W . B . The r o l e of r a d i o and TV spot announcements i n p u b l i c h e a l t h e d u c a t i o n . Canadian J o u r n a l of P u b l i c H e a l t h , 1975, 66 , 396-398. E k s t r a n d , W.D. The economics of h e a l t h c a r e in A l b e r t a : R e l a t i o n s h i p to p l a n n i n g . I n : D . E . L a r s o n & E . J . Love ( E d s . ) H e a l t h Care R e s e a r c h , A l b e r t a : U n i v e r s i t y of C a l g a r y O f f s e t P r i n t i n g , 1974. E v a n s , R. A r e t r o s p e c t i v e on the "New P e r s p e c t i v e . " J o u r n a l of H e a l t h P o l i t i c s , P o l i c y and Law, 1982, 7 ( 2 ) , 325-345. E v a n s , R. P e r s o n a l communicat ion . F e b r u a r y , 1983. F a b e r , M . M . A survey of r i s k r e d u c t i o n programs. F a m i l y  and Community H e a l t h , 1980, 3 ( 1 ) , 97-105. F a r q u h a r , J . W . , Maccoby, N . , Wood, P . , A l e x a n d e r , J . , B r i e t r o s e , H . , Brown, B . , H a s k a l l , W . , M c A l i s t e r , A . , Meyer , A . , Nash, J . & S t e r n , P. Community e d u c a t i o n for c a r d i o v a s c u l a r h e a l t h . The L a n c e t , 1977, 1(8023), 1192-1195. F e i v e r , A . H e a l t h c a r e and e d u c a t i o n : On the t h r e s h o l d of space . S c i e n c e , 1974, 186, 1178-1186. F e r g u s o n , M. The a q u a r i a n c o n s p i r a c y : P e r s o n a l and s o c i a l  t r a n s f o r m a t i o n i n the 1980's . Los A n g e l e s , U . S . A . : J . R . T r a c h e r I n c . , 1980. 200 F i e l d i n g , J . E . A p p r a i s i n g the h e a l t h of h e a l t h r i s k a p p r a i s a l . American J o u r n a l of P u b l i c H e a l t h , 1982, 72 (4 ) , 337-339. Freeman, N . V . Student of power. C i t y Woman, F a l l , 1982, 58. Fremuth , U . S . & M a r r o n , T . The p u b l i c ' s use of h e a l t h i n f o r m a t i o n . H e a l t h E d u c a t i o n , 1978, 9, 18-20. F u c h s , V . R . Who s h a l l l i v e ? New Y o r k : B a s i c Books, I n c . , 1 974. G e l l m a n , D. Commenting on E k s t r a n d . In D . E . L a r s o n & E . J . Love ( E d s . ) H e a l t h Care R e s e a r c h . A l b e r t a : U n i v e r s i t y of C a l g a r y O f f s e t P r i n t i n g , 1974. G o e t z , A . A . , D u f f , J . F . & B e r s t e i n , J . E . H e a l t h R i s k A p p r a i s a l : The e s t i m a t i o n of r i s k . Washington , D . C : G e n e r a l H e a l t h , 1978, 1-13. Grantham, P . P e r s o n a l Communicat ion . June , 1983. G r e e n , L . W . , S q u y r e s , W . D . , D ' A l t r o y , L . H . & H e b e r t , B . What do recent e v a l u a t i o n s of p a t i e n t e d u c a t i o n t e l l us? In W. Squyres ( E d . ) P a t i e n t e d u c a t i o n : An i n q u i r y  i n t o the s t a t e of the a r t . New Y o r k : S p r i n g e r Pub. C o . , 1980, 11-32. G r e i s e n , D. O p p o r t u n i t y knocks . Suburban h o s p i t a l answers by p r o d u c i n g h e a l t h e d u c a t i o n s e r i e s for C a b l e - T V . Promot ing H e a l t h , 1981, 2(3) , 1-3. H a m i l t o n , N . K . H e a l t h e d u c a t i o n by s a t e l l i t e . H e a l t h  E d u c a t i o n Monographs, 1975, 3 ( 1 ) , 56-61. H a r k i n s , A . The impact of t e c h n o l o g y on the f u t u r e of h e a l t h c a r e . Paper p r e s e n t e d to the American H o s p i t a l A s s o c i a t i o n Conference for the S o c i e t y of Management E n g i n e e r s , San D i e g o , C a l i f . , F e b r u a r y , 1982. Hawkins, L . H e a l t h Hazard A p p r a i s a l in Canada - p r o g r e s s  and p r o b l e m s . I n : P r o c e e d i n g s of the 15th Annual Meet ing on P r o s p e c t i v e M e d i c i n e and H e a l t h Hazard A p p r a i s a l , 1979. H e a l t h and E d u c a t i o n Resources , 1980, 19-22. 201 H e a l t h Hazard A p p r a i s a l Assessment Committee F i n a l R e p o r t . Ottawa: H e a l t h and Wel fare Canada, 1978. H e a l t h promot ion and the media . Conference Summary. Washington , D . C : I n s t i t u t e of M e d i c i n e , N a t i o n a l Academy P r e s s , 1981. H e a l t h y p e o p l e : The Surgeon G e n e r a l ' s r e p o r t on h e a l t h promot ion and d i s e a s e p r e v e n t i o n . Washington: U . S . Department of H e a l t h , E d u c a t i o n and W e l f a r e , U . S . Government P r i n t i n g O f f i c e , 1979. Hochbaum, G . M . M o t i v a t i n g people for b e t t e r h e a l t h . Background paper , H e a l t h E d u c a t i o n Seminar . New Y o r k : Blue C r o s s / B l u e S h i e l d , 1974. Howe, H . L . Enhanc ing the e f f e c t i v e n e s s of media messages promot ing r e g u l a r b r e a s t s e l f - e x a m i n a t i o n . P u b l i c  H e a l t h R e p o r t s , 1981, 96(2) , 134-142. Immen, W. P r o f e s s i o n a l s slow to adapt to computer r e s e a r c h . The Globe and M a i l , F e b r u a r y 28, 1983, R6. J o n e s , J . L . & Weimer, J . P . Food S a f e t y : Homemakers' a t t i t u d e s and p r a c t i c e s . A g r i c u l t u r e Economic R e p o r t , 1977, 360, 26. J o n e s , S. A p e r s p e c t i v e on e d u c a t i n g p h y s i c i a n s for p r e v e n t i o n . P r e v e n t i o n and M e d i c a l E d u c a t i o n , 1 9 8 2 , 9 7 ( 3 ) , 1 9 9 - 2 0 4 . K a p l a n , R . M . , Bush, J . W . & B e r r y , C C H e a l t h S t a t u s : Types of v a l i d i t y and the index of w e l l - b e i n g . H e a l t h  S e r v i c e s R e s e a r c h , 1 9 7 6 , 1 1 ( 4 ) , 4 7 8 - 5 0 7 . K e g e l e s , S. A f i e l d e x p e r i m e n t a l attempt to change b e l i e f s and b e h a v i o r of women i n an urban g h e t t o . J o u r n a l of  H e a l t h and S o c i a l B e h a v i o r , 1 9 6 9 , J _ 0 , 1 1 5 - 1 2 4 . K e l l y , N . M . H e a l t h e d u c a t i o n through e n t e r t a i n m e n t : A m u l t i m e d i a campaign. J o u r n a l of American C o l l e g e  H e a l t h A s s o c i a t i o n , 1 9 7 8 , 2 6 , 2 4 8 - 2 5 2 . Kelman, S. The s o c i a l nature of the d e f i n i t i o n problem in h e a l t h . I n t e r n a t i o n a l J o u r n a l of H e a l t h S e r v i c e s , 1 9 7 5 , 5 ( 4 ) , 6 2 5 - 6 4 2 . 202 K e r r , A . A t o e h o l d for p r o f i t - m a k i n g h o s p i t a l s . M a c L e a n ' s . F e b . 21, 1983, p 42. K n o b e l , R . J . H e a l t h promot ion and d i s e a s e p r e v e n t i o n : improv ing h e a l t h whi l e c o n s e r v i n g r e s o u r c e s . F a m i l y &  Community H e a l t h , February 1983, 16-27. K o b i n , W. F e e l i n g good: The anatomy of a program. P u b l i c  Te lecommunicat ions Review, 1976, 32-37. K r u p i n s k i , J . H e a l t h and q u a l i t y of l i f e . S o c i a l Sc i ence  and M e d i c i n e , 1980, 14(A) , 203-211. L a l o n d e , M. A new p e r s p e c t i v e on the h e a l t h of Canadians: A  working document. Ottawa: H e a l t h & Wel fare Canada, 1 974. L a l o n d e , M. O p e r a t i o n L i f e s t y l e . I n : Proceed ings of the 12th Annual Meet ing of the S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1976. H e a l t h and E d u c a t i o n Resources , 1977, 16-19. L o n g , M . C . T e l e v i s i o n : H e l p or h i n d r a n c e to h e a l t h e d u c a t i o n . H e a l t h E d u c a t i o n , May/June 1978, 32-34. Longe , M. & Ted'esco, J . A . L e t t e r to C o l l e a g u e s . C h i c a g o , 1 1 1 . : American H o s p i t a l A s s o c i a t i o n , June , 1982. Looney , M . A . S e l l i n g O p t i m a l H e a l t h . I n : P r o c e e d i n g s of the 13th Annual Meet ing of the S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1977. Be thesda , M a r y l a n d : H e a l t h and E d u c a t i o n R e s o u r c e s , 1978, 58-61 . M c C o n n e l l , H . M e d i c a l P o s t , September 11, 1979. M c i n t o s h , M. P e r s o n a l Communicat ion. J a n u a r y , 1983. McKeown, T . The r o l e of m e d i c i n e : dream, mirage or nemesis . B l a c k w e l l s , 1979. Maccoby, N . & A l e x a n d e r , J . Use of media in l i f e s t y l e programs. In P . O . Davidson & S . M . Davidson ( E d s . ) , B e h a v i o r a l m e d i c i n e : Changing h e a l t h l i f e s t y l e s . New Y o r k : B r u n n e r / M a z e l , I n c . , 1980. M a r s h a l l , C . L . Toward an educated h e a l t h consumer: Mass  communication and q u a l i t y in m e d i c a l c a r e (PHEW Pub. No. (NIH) 7 7-881 ) ) . A r e p o r t of conferences sponsored by the John E . F o g a r t y I n t e r n a t i o n a l Center for Advance Study in H e a l t h S c i e n c e s . Bethesda , M a r y l a n d : N a t i o n a l I n s t i t u t e s of H e a l t h , U . S . Department of H e a l t h , E d u c a t i o n and W e l f a r e , 1977. 203 Machine of the Y e a r : The computer moves in T ime , January 3, 1983, 121(1) , 8-27. M a r t i n , M. F a m i l y p h y s i c i a n s and r a d i o b r o a d c a s t i n g . J o u r n a l of Fami ly P r a c t i c e , 1980, 11(4) , 665-666. Media Handbook: A guide to s e l e c t i n g , p r o d u c i n g and u s i n g  media for p a t i e n t e d u c a t i o n programs. C h i c a g o , 1 1 1 . : American H o s p i t a l A s s o c i a t i o n , 1978. Me 1 i a , P . Canadian h e a l t h r i s k assessment r e s e a r c h a c t i v i t i e s . I n : Proceed ings of the 16th Annual Meet ing of the S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1980. Be thesda , M a r y l a n d : The S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1981, 35-38. M i e l k e , K.W. & Swinehart , J . W . E v a l u a t i o n of the F e e l i n g  Good t e l e v i s i o n s e r i e s . New Y o r k : C h i l d r e n ' - s T e l e v i s i o n Workshop, 1976. M i l l e r , P . V . , M o r r i s o n , A . J . , & K l i n e , F . G . Approaches to  c h a r a c t e r i z i n g i n f o r m a t i o n env ironments . Paper p r e s e n t e d at the meeting of I n t e r n a t i o n a l Communication A s s o c i a t i o n , New O r l e a n s , 1974. M i l s u m , J . H . H e a l t h hazard a p p r a i s a l and the h e a l t h c a r e system. In L . K . Y . Ng and D . L . Dav i s ( E d s . ) , S t r a t e g i e s for p u b l i c h e a l t h : Promoting h e a l t h and  p r e v e n t i n g d i s e a s e . New Y o r k : Van Nos trand R e i n h o l d , 1 981 . M i l s u m , J . P e r s o n a l Communicat ion . A p r i l , 1983. M i t c h e l l , D. The doc tor and the media . J o u r n a l of the  I r i s h M e d i c a l A s s o c i a t i o n , 1980, 73(8) , 289-291. N a g e l b e r g , D . B . E v a l u a t i n g a h e a l t h r i s k r e d u c t i o n program. C o l l e g e H e a l t h , 1981, 29, 269-271. N e l s o n , E . C . K e l l e r , A . M . & Z u b k o f f , M. I n c e n t i v e s for h e a l t h p r o m o t i o n : The government's r o l e . In L . K . Y . Ng and D . L . D a v i s ( E d s . ) , S t r a t e g i e s for p u b l i c h e a l t h :  Promot ing h e a l t h and p r e v e n t i n g d i s e a s e . New Y o r k : Van N o s t r a n d R e i n h o l d , 1981. Newman, P . C . The p o t e n t i a l of p a y - T V . M a c L e a n ' s , January 31, 1983, 37. 204 PARTI CI Pact i o n s ' 10th A n n i v e r s a r y Report 1971-1981: A Decade  of A c t i o n . T o r o n t o , O n t a r i o : P A R T I C I P a c t i o n , 1982. P i c o t , J . In W. Immen, P r o f e s s i o n a l s seen to adapt to computer r e s e a r c h . The Globe and M a i l , F e b r u a r y 28, 1983, R6. P r e t e s t i n g i n Cancer Communicat ions . (DHEW Pub. No. (NIH) W, 1493) . Bethesda , M a r y l a n d : U . S . Department of Health . , E d u c a t i o n and W e l f a r e , 1978, 1-11. P r i c e , J . H . & A l l e n s w o r t h , D . D . U t i l i z i n g mass media for h e a l t h messages. H e a l t h E d u c a t i o n , J u l y / A u g u s t , 1979, 17-19. Puska , P. T v o m i l e h t o , J . S a l o n e n , J . , N e i t t a a n e a l , J . , M a k i , J . , V i r t u m o , J . , N i s s i n e n , A . , K o s k e l a , K . & T a k a l o , T . Changes in c o r o n a r y r i s k f a c t o r s due to a comprehensive f i v e - y e a r community program to c o n t r o l c a r d i o v a s c u l a r d i s e a s e s (North K a r e l i a P r o j e c t ) . B r i t i s h M e d i c a l J o u r n a l , 1979, 1173-1178. Q u e l c h , J . A . M a r k e t i n g p r i n c i p l e s and the f u t u r e of p r e v e n t i v e h e a l t h c a r e . M i l l b a n k Memoria l Fund Q u a r t e r l y / H e a l t h and S o c i e t y , 58 (2 ) , 1980, 310-347. Ramsey, D . K . & Dunton, S . M . P r o s p e c t i v e h e a l t h : Focus on  w e l l n e s s . I n : Proceed ings of the 14th Annual Meet ing on P r o s p e c t i v e M e d i c i n e and H e a l t h Hazard A p p r a i s a l , 1977. H e a l t h and E d u c a t i o n Resources , 1978, 58-60. Randt , G . G a i n i n g p h y s i c i a n s u p p o r t : The problem and some p r a c t i c a l s o l u t i o n s . Promot ing H e a l t h , 1983, 4 ( 3 ) , 1 & 3. R e i z e n s t e i n , R . C . & Barnaby, D . J . An a n a l y s i s of s e l e c t e d  consumer energy environment t r a d e - o f f segments. 1976 E d u c a t o r s P r o c e e d i n g s , S e r i e s No. 39 of the American M a r k e t i n g A s s o c i a t i o n , 1976, 522-526. Report of the ad hoc committee on n a t i o n a l h e a l t h s t r a t e g i e s . Ottawa: H e a l t h & Wel fare Canada, May, 1 982. Report of The A d v i s o r y Committee on H e a l t h I n s u r a n c e . (The Heagerty Report ) Ottawa, Canada: 1943. 205 Richman, L . A . & U r b a n , D. H e a l t h e d u c a t i o n through t e l e v i s i o n : some t h e o r e t i c a l a p p l i c a t i o n s . I n t e r n a t i o n a l J o u r n a l of H e a l t h E d u c a t i o n , 1978, 21, 46-52. Rimer , I . C a b l e - T V as a t e a c h - i n t o o l . P u b l i c R e l a t i o n s  J o u r n a l , 1980, 36 (9 ) , 24-26. R o b b i n s , L . C . & H a l l , J . H . How to p r a c t i c e p r o s p e c t i v e medic i n e . I n d i a n a p o l i s : M e t h o d i s t H o s p i t a l of I n d i a n a , 1970. R o g e r s , A . Radio m e d i c i n e : Doctor on the a i r . J o u r n a l of  Roya l C o l l e g e of G e n e r a l P r a c t i t i o n e r s , 1980, 30(219) , 629-631. Rombout, M . K . H o s p i t a l s and the e l d e r l y : Present and f u t u r e t r e n d s . I n : Canada's O l d e r P o p u l a t i o n . S t a f f Papers : Long Range H e a l t h P l a n n i n g . Ottawa: H e a l t h and Wel fare Canada, 1975. Rootman, I . P e r s o n a l Communicat ion . Ottawa. A p r i l 29, 1982. Roper , B.W. What people t h i n k of t e l e v i s i o n and other. media: 1959-1972. ERIC R e p o r t s , No. ED. 079-944, 1973. Runyon, K. Consumer b e h a v i o r and the p r a c t i c e of m a r k e t i n g . O h i o : C h a r l e s E . M e r r i l l , 1977. Rushamer, R . F . Humanizing h e a l t h c a r e : A l t e r n a t i v e f u t u r e s  f or m e d i c i n e . Cambridge , Mass: MIT P r e s s , 1975. S a c k s , J . , K r u s h a t , W. & Newman, J . R e l i a b i l i t y of the H e a l t h Hazard A p p r a i s a l . American J o u r n a l of P u b l i c  H e a l t h , 1980, 70(7) , 730-732. Second S c r e e n i n g of Second N a t i o n a l D r i v i n g T e s t T o r o n t o , O n t a r i o : Insurance Bureau of Canada, V i c k e r s and Benson, L t d . , A p r i l 13, 1981. S e i b e r t , W.A. H e a l t h e d u c a t i o n and t e l e v i s i o n communication - 1973. I n : H e a l t h E d u c a t i o n Monographs, Proceed ings  of the W i l l Rogers Conference on H e a l t h E d u c a t i o n . New Y o r k : Saranac L a k e , June 22-23, 1973, 84-87 . 206 S e r v a n - S c r e i b e r , J . J . In Machine of the y e a r : The computer  moves i n . U . S . A . : Time, January 3, 1983, 121(1) , 8-16. Source book for h e a l t h e d u c a t i o n m a t e r i a l s and community r e s o u r c e s . U . S . Dept . of H e a l t h and Human S e r v i c e s , C e n t e r s for D i sease C o n t r o l , Center for H e a l t h Promot ion and E d u c a t i o n , 1982. S p a s o f f , R . A . McDowel l , I , W . , W r i g h t , P . A . & Dunkley , G . C . The Canadian r i s k f a c t o r review p r o j e c t . I n : P r o c e e d i n g s of the 17th Annual Meet ing of the S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1981. H e a l t h and E d u c a t i o n R e s o u r c e s , 1982, 36-44. Solomon, D . S . H e a l t h Campaigns. In D. P e a r l , L . B o u t h i l e t and J . L a z a r ( E d s . ) , T e l e v i s i o n and  B e h a v i o r : Ten Years of S c i e n t i f i c p r o g r e s s and  i m p l i c a t i o n s for the e i g h t i e s . Washington: U . S . Government P r i n t i n g O f f i c e , 1982. SPHERE: System for p e r s o n a l h e a l t h r i s k e v a l u a t i o n . SPHERE/HHA. H e a l t h Hazard A p p r a i s a l Module , D i v i s i o n of H e a l t h Systems, U n i v e r s i t y of B r i t i s h C o l u m b i a , 1983. S q u y r e s , W. ( E d i t o r ) . P a t i e n t E d u c a t i o n : An e n q u i r y i n t o  the s t a t e of the a r t . New Y o r k : S p r i n g e r Pub. C o . I n c . , 1980. S t e r n , M . P . , F a r q u h a r , J . W . , Maccoby, N . & R u s s e l l , S . H . R e s u l t s of a two-year h e a l t h e d u c a t i o n campaign on d i e t a r y b e h a v i o r . C i r c u l a t i o n , 1976, 54, 826-833. S w i n e h a r t , J . W . R i s k a p p r a i s a l , l i f e s t y l e s and behav ior  change . Paper p r e s e n t e d at M i s s o u r i - I o w a - N e b r a s k a -Kansas Conference on H e a l t h E d u c a t i o n , Kansas C i t y , M i s s o u r i , September 19, 1979. S w i n e h a r t , J . W . E v a l u a t i n g P u b l i c R e l a t i o n s . P u b l i c  R e l a t i o n s J o u r n a l , J u l y , 1979, 13-16. S w i n e h a r t , J . W . C r e a t i v e Use of Mass Media to A f f e c t H e a l t h B e h a v i o r . In J . W . C u l l e n , B . H . Fox & R . N . Isom ( E d s . ) , C a n c e r : The b e h a v i o r a l d i m e n s i o n s . New Y o r k : Raven P r e s s , 1976, 231-238. 207 Swinehar t , J . W . Some l e s sons from the F e e l i n g Good t e l e v i s i o n s e r i e s . In I . M . Newman ( E d . ) , symposium p r o c e e d i n g s Consumer behav ior in the h e a l t h  m a r k e t p l a c e . Nebraska: Center for H e a l t h E d u c a t i o n , U n i v e r s i t y of Nebraska , 1976, 45-54. T a y l o r , C . E . Stages of P l a n n i n g P r o c e s s . In W. Reinke & K. W i l l i a m s ( E d s . ) , H e a l t h P l a n n i n g : Q u a l i t a t i v e  Aspec t s and Q u a n t i t a t i v e Techniques (3rd E d i t i o n ) , B a l t i m o r e : John Hopkins P r e s s , 1972, 20-29. T e l e v i s i o n and b e h a v i o r : Ten years of s c i e n t i f i c p r o g r e s s  and i m p l i c a t i o n s for the e i g h t i e s . Summary Report ( V o l . 1) . Washington, D . C . : U . S . Department of H e a l t h and Human S e r v i c e s , 1982. The G e n e r a l M i l l s American f a m i l y r e p o r t 1978-79: F a m i l y h e a l t h in an era of s t r e s s . M i n n e a p o l i s : G e n e r a l M i l l s I n c . , 1979. The p e r i o d i c h e a l t h e x a m i n a t i o n . Canadian task f o r c e on p e r i o d i c h e a l t h e x a m i n a t i o n : Task f o r c e r e p o r t . Canadian M e d i c a l A s s o c i a t i o n J o u r n a l , 1979, 121, 1193-1254. (Monograph) T i c h e n o r , P . J . Donahue, G . A . , O l i e n , C . N . & Bowere, J . K . Environment and p u b l i c o p i n i o n . The J o u r n a l of  E n v i r o n m e n t a l E d u c a t i o n , 1970, 2, 38-42. T i c h e n o r , P . J . Donahue, G . A . & O l i e n , C . N . Mass media flow and d i f f e r e n t i a l growth i n knowledge. P u b l i c  O p i n i o n Q u a r t e r l y , 1970, 3_4, 158-170. T o r r a n c e , G . M . & D ' A r c y , C . R e s u l t s of the Canadian H e a l t h  Hazard Users Survey . I n : P r o c e e d i n g s of the 17th Annual Meet ing of the S o c i e t y of P r o s p e c t i v e M e d i c i n e , 1981. H e a l t h and E d u c a t i o n Resources , 1982, 76-78. T o r r a n c e , G . M . & D ' A r c y , C . H e a l t h Hazard A p p r a i s a l Users  Survey F i n a l R e p o r t . Ottawa: H e a l t h Promot ion D i r e c t o r a t e , H e a l t h and W el fare Canada, June , 1981. Trend Study What consumers say about n u t r i t i o n , v i t a m i n s , and v i t a m i n - f o r t i f i e d food p r o d u c t s . Response A n a l y s i s C o r p o r a t i o n , Hoffman-LaRoche, 1977, 37. 208 V e r t i n s k y , P . The use of mass communication s t r a t e g i e s to promote l i f e s t y l e change: The case of energy c o n s e r v a t i o n in Canada. J o u r n a l of Bus ines s  A d m i n i s t r a t i o n , 1978/79, 10Q&2) , 383-420. V e r t i n s k y , P . A . , Yang, C , MacLeod, P . M . & Hardwick , D . F . A study of compl iance f a c t o r s in v o l u n t a r y h e a l t h b e h a v i o r . I n t e r n a t i o n a l J o u r n a l of H e a l t h E d u c a t i o n , 1976, r e p r i n t of XIX ( 1 ) 1 - 1 5 . V e r t i n s k y , P . , V e r t i n s k y , I . & Zal tman, G . H e a l t h i n f o r m a t i o n d i f f u s i o n . I n t e r n a t i o n a l J o u r n a l of H e a l t h  E d u c a t i o n , 1972, Supp. to X V ( 1 ) , 1-22. Wade, S. & S c h r a n e n i , W. The mass media as sources of p u b l i c a f f a i r s , s c i e n c e and h e a l t h knowledge. P u b l i c  O p i n i o n Q u a r t e r l y , 1969, 33 (2 ) , Wagner, E . H . , Beery , W . L . , Schoenbach, V . J . & Graham, R . M . An assessment of h e a l t h h a z a r d / h e a l t h r i s k a p p r a i s a l . American J o u r n a l of P u b l i c H e a l t h , 1982, 72 (4 ) , 347-351 . W a l l a c k , L . Mass media campaigns: The odds a g a i n s t f i n d i n g behav ior change. H e a l t h E d u c a t i o n Q u a r t e r l y , 1981, 8 ( 3 ) , 209-260. Ward, G.W. + Van N e v a l , J . P . T e s t i n g t e l e v i s i o n messages about h e a l t h . P u b l i c H e a l t h R e p o r t s , 1977, 92 (4 ) , 392. Warner, K . E . The economic i m p l i c a t i o n s of p r e v e n t i v e h e a l t h c a r e . S o c i a l S c i e n c e and M e d i c i n e , 1979, 13C, 227-237. Weaver, D . H . & Mauro, J . B . Newspaper r e a d e r s h i p p a t t e r n s . J o u r n a l i s m Q u a r t e r l y , 1978, 55, 84-91; 134. W e i n s t e i n , M . S . P e r s o n a l Communicat ion . J u l y 1983. W e l l Aware What i s w e l l aware about h e a l t h ? A r i z o n a : Board of Regents , W e l l Aware About H e a l t h , U n i v e r s i t y of A r i z o n a , 1978. W h i t e , A . In terv i ewed on C T V ' s "Canada A M , " October 21 & 22, 1982. W h i t e , M. P e r s o n a l Communicat ion . F e b r u a r y , 1983. 2 0 9 W i l s o n , J . Home Computers - the l a t e s t e x t e n s i o n e d u c a t i o n t o o l . Canadian Home Economics J o u r n a l , 1981 31 (3 ) , 140-144. W i x l e r , D . I . P e r s u a s i o n and c o e r c i o n for h e a l t h : E t h i c a l i s s u e s i n government e f f o r t s to change l i f e s t y l e s . H e a l t h and S o c i e t y , 1978, 56(3) , 303-339. Woodward, C . A . & Chambers, B . A . Guide to Q u e s t i o n n a i r e  C o n s t r u c t i o n and Ques t ion W r i t i n g . Ottawa: The Canadian P u b l i c H e a l t h A s s o c i a t i o n , 1980. World H e a l t h O r g a n i z a t i o n . Text of The C o n s t i t u t i o n of The World H e a l t h O r g a n i z a t i o n . O f f i c i a l R e c o r d , World  H e a l t h O r g a n i z a t i o n , 1948, 2 (100) . Z i b r i k , D . A . , P e t e r s , H . F . and K u h n l e i n , H . V . Knowledge and a t t i t u d e s of Vancouver r e s i d e n t s towards food a d d i t i v e s . Canadian J o u r n a l of P u b l i c H e a l t h , 1981, 72 (1 ) , 49-54. 210 APPENDIX A HHA/UBC QUESTIONNAIRE 211 HEALTH HAZARD APPRAISAL Processed By: Division of Health Systems 4th Floor, IRC Building Health Sciences Centre University of British Columbia Vancouver, B.C. V6T 1Z6 Phone: (604) 228-2258 S U R N A M E J_l, GIVEN N A M E INIT. SOCIAL INSURANCE NUMBER OCCUPATION COUNSELLOR ORGANIZATION STREET CITY POSTAL CODE PROVINCE TELEPHONE ENTER A L L N U M B E R S C O R R E S P O N D I N G TO C O R R E C T R E S P O N S E S IN THESE C O L U M N S 1. Have you ever completed a HEALTH HAZARD APPRAISAL questionnaire? [ i j yes |2) no 2. LANGUAGE ( 1 ] english | 2 | french 3. SEX | 1 | male | 2 | female 4. AGE 5. MARITAL STATUS | 1 | single | 2 1 married 1 3 1 separated | 4 | widowed | 5 I divorced | 6 I other 6. HEIGHT (without shoes) feet and inches OR centimeters 7. WEIGHT (naked) pounds OR kilograms 8. SMOKING a) | 1 | smoker | 2 | ex-smoker (stopped) | 3 | non-smoker (never smoked) b) Enter average amount smoked per day in the last five years OR in the last five years before quitting Average number of cigarettes per day Average number of pipes / cigars inhaled per day Auesage number of pipes /cigars not inhaled per day c ) Enter number of years stopped smoking (Note, enter 1 for less than one year) 9. ALCOHOL a) | 1 | does drink | 2 | ex-drinker (stopped) | 3 | non-drinker (never drank) B | If you drink alcohol, enter the average number of drinks per week bottles of beer (12oz) glasses of wine (4oz) shots of spirits (1-1 % oz) 10. DISABLING DEPRESSION | 1 | often | 2 | seldom or never 11. DISTANCE per year as driver of a motor vehicle and/or passenger of an automobile miles OR kilometers 12 SEAT BELT USE (% of time used) I L I L l _L I I I ;,0 0, 0! ; 76 b ' o NHW 676(10-781 P L E A S E T U R N OVER E N T E R A l l N U M B E R S C O R R E S P O N D I N G T O C O R R E C T R E S P O N S E S IN T H E S E C O L U M N S 13. Have you taken the CANADIAN HOME FITNESS TEST? LlJ yes LLl "o If YES, indicate level achieved If NO. indicate activity level | 1 | undesirable personal fitness level LlJ l i t , l e o r n 0 Physical activity | a | minimum personal fitness level LU occasional physical activity 1 3 1 recommended personal fitness level LU regular physical activity at least 3 times — per week NOTE: Physical Activity includes work and leisure activities that are sustained physical exertion such as walking briskly, running, lifting and carrying. 14. Did your parents die of a HEART ATTACK before the age of 60? 1 , 1 ves-L U both of them LLl one" of them LLl "° 15. Do you have a family history of SUICIDE? Imother, father, sister, brother! LlJ yes [ 2 j n o 16. Do you have a family history of DIABETES? Imother, father, sister, brother, child) 1 1 1 yes L 2 j n o 177 Do £Ou have DIABETES? 1 1 l v e s " L U n o t controlled LU controlled LU"° 18. Do you have a history of RECTAL DISORDERS? Growth (other than hemorrhoids) ' ' . Bleeding LU ves 11 I yes LLh° LUn0 i19. Has your physician ever said you have CHRONIC BRONCHITIS and / or EMPHYSEMA? I 1 | yes I 2 | no 20. BLOOD PRESSURE to be measured - otherwise leave blank SYSTOLIC mm mercury DIASTOLIC mm mercury ; 2 ' -i FASTING CHOLESTEROL LEVEL to be measured • otherwise leave blank CHOLESTEROL mg / dl F E M A L E S O N L Y 22. CERVICAL CANCER RISK If you have had a hysterectomy (cervix removed), please leave blank PAP SMEAR | 1 | Have never had a pap smear | 2 | Have had 1 pap smear - more than 1 year ago • but less than five years ago | 3 | Have had 1 pap smear within the past year • negative | 4 | Have had 3 or more pap smears within the past 5 years - all negative - negative 23. REGULAR SEXUAL INTERCOURSE began LlJ yean?" LUM-^ j , rat age 26+ L r - l o r never 24. BREAST CANCER RISK Did your mother or sister have BREAST CANCER? | ^  | y e s | 2 | no 25. MONTHLY BREAST SELF EXAMINATION L±J yes LU N 0 213 A P P E N D I X B S E D E N D I V I S I O N O F H E A L T H S Y S T E M S - U N I V E R S I T Y O F B R I T I S H C O L U M B I A > > > H E A L T H H A Z A R D A P P R A I S A L < < < > > > A P P R A I S A L T A B L E < < < P A G E 1 O F M A R 2 7 , 1 9 8 0 R T H E T O P T W E L V E A C A U S E S O F D E A T H I N N C A N A D A ( 1 9 7 1 ) F O R K M A L E S O F A G E 5 0 1 H E A R T A T T A C K C H A N C E S O F D Y I N G P E R 1 0 0 , O O O W I T H I N T E N Y E A R S A V - I A P - I A C H I E V -E R A G E j P R A I S E D A B L E 4 4 5 6 1 8 4 3 3 8 2 2 9 T O T A L A N D P A R T I A L R I S K S F O R E A C H C A U S E O F D E A T H D U E T O Y O U R C O N D I T I O N / L I F E S T Y L E R E L A T E D T O T H O S E O F A N A V E R A G E C A N A D I A N O F Y O U R S E X A N D A G E ( 1 . 0 O ) C O N D I T I O N W E I G H T S M O K I N G S Y S T O L I C B P D I A S T O L I C B P C H O L E S T E R O L P H Y S . A C T V T Y F H H E A R T D I A B E T E S A P P R A I S E D P A R T T O T A L 4 . 1 4 A C H I E V A B L E P A R T T O T A L 1 . 8 5 3 0 C I G A R E T T E S / D A Y 1 6 0 M M M E R C U R Y 9 6 M M M E R C U R Y 2 8 0 M G / D L L I T T L E O R N O N E Y E S - O N E P A R E N T < 6 0 N O 0 9 9 7 3 K I L O G R A M S 0 8 8 1 4 5 S T O P P E D S M O K I N G 0 7 5 1 3 0 R E C H E C K - S E E Y O U R D R . 1 3 0 1 4 5 R E C H E C K - S E E Y O U R D R . 1 4 5 1 5 0 2 8 0 M G / D L 1 5 0 2 2 5 R E G U L A R - 3 X P E R W E E K 0 6 0 1 2 0 Y E S - O N E P A R E N T < 6 0 1 2 0 1 0 0 N O 1 0 0 u u N G C A N C E R S G o i 3 S 5 1 1 ) 6 i 1 . 5 4 1 . 2 3 S M O K I N G 3 0 C I G A R E T T E S / D A Y 1 . 5 4 S T O P P E D S M O K I N G 1 . 2 3 3 S T R O K E 5 3 5 1 3 1 1 1 2 0 4 2 . 4 5 2 . 2 5 S M O K I N G S Y S T O L I C B P D I A S T O L I C B P C H O L E S T E R O L D I A B E T E S 3 0 C I G A R E T T E S / D A Y 1 . 2 0 1 6 0 M M M E R C U R Y 1 . 3 0 9 6 M M M E R C U R Y 1 . 4 5 2 8 0 M G / D L 1 . 5 0 N O 1 . 0 0 S T O P P E D S M O K I N G 1 . O O R E C H E C K - S E E Y O U R D R . 1 . 3 0 R E C H E C K - S E E Y O U R D R . 1 . 4 5 2 8 0 M G / D L 1 . 5 0 N O 1 O O 4 C I R R H O S I S O F L I V E R 3 6 2 1 0 5 8 3 6 2 A L C O H O L 1 6 D R I N K S P E R W E E K 2 9 2 1 . 0 0 2 9 2 3 - 6 D R I N K S P E R W E E K 1 . O O 2 . 5 0 2 . 5 0 5 I N T E S T I N A L C A N C E R I N C L U D I N G R E C T U M 3 4 2 8 5 5 8 5 5 R E C T L D I S O R D R E C T L D I S O R D R E C T A L G R O W T H N O R E C T A L B L E E D I N G 2 . 5 0 1 . 0 0 R E C T A L G R O W T H 2 . 5 0 N O R E C T A L B L E E D I N G 1 . 0 0 6 M O T O R V E H I C L E A C C I D E N T S 3 2 7 7 9 1 3 6 0 2 . 4 2 1 . 1 0 A L C O H O L 1 6 D R I N K S P E R W E E K D R I V E / Y E A R 1 3 , O O O M I L E S S E A T B E L T B U C K L E D 1 7 % O F T I M E 2 . 0 9 3 - 6 D R I N K S P E R W E E K 1 . O O 1 - 3 0 1 3 , O O O M I L E S 1 . 3 0 1 . 0 3 B U C K L E D 1 0 0 % O F T I M E 0 . 8 0 7 S U I C I D E 3 1 6 3 1 6 3 1 6 1 . 0 0 1 . 0 0 D E P R E S S I O N F H S U I C I D E S E L D O M O R N E V E R N O 1 . 0 0 1 . 0 0 S E L D O M O R N E V E R 1 . 0 0 N O 1 . O O 8 C H R O N I C B R O N C H I T I S A N D E M P H Y S E M A 2 6 3 4 0 5 2 8 4 S M O K I N G 3 0 C I G A R E T T E S / D A Y 1 5 4 1 . 0 8 1 - 5 4 S T O P P E D S M O K I N G 1 . 0 8 1 . 0 0 9 S T O M A C H C A N C E R 2 2 7 2 2 7 2 2 7 1 . O O SEDEN DIVISION OF HEALTH SYSTEMS - UNIVERSITY OF BRITISH COLUMBIA > » HEALTH HAZARD APPRAISAL < « >>> APPRAISAL TABLE <<< PAGE 2 OF 1 MAR 27. 19BO R THE TOP TWELVE A CAUSES OF DEATH IN N CANADA (1971) FOR K MALES OF AGE 50 CHANCES OF DYING PER 1O0.0O0 WITHIN TEN YEARS AV- I AP- I ACHIEV-ERAGE PRAISED ABLE TOTAL AND PARTIAL RISKS FOR EACH CAUSE OF DEATH DUE TO YOUR CONDITION/LIFESTYLE RELATED TO THOSE OF AN AVERAGE CANADIAN OF YOUR SEX AND AGE (1.00) CONDITION APPRAISEO PART TOTAL 1 .00 ACHIEVABLE PART TOTAL 1 .00 2.2S 10 CANCER OF PANCREAS 183 183 183 11 DISEASES OF ARTERIAL SYSTEM 177 434 398 2.45 SMOKING SYSTOLIC BP DIASTOLIC BP CHOLESTEROL DIABETES 30 CIGARETTES/ DAY 1.20 160 MM MERCURY 1.30 96 MM MERCURY 1.45 280 MG/DL 1.50 NO 1 .00 STOPPED SMOKING 1.00 RECHECK-SEE YOUR DR. 1.30 RECHECK-SEE YOUR OR. 1.45 280 MG/DL 1.50 NO 1.00 12 TUMOUR-LYMPH. BLOOD 1 EXCEPT LEUKEMIA | 167 167 II 1 OO 1 00 ALL OTHER CAUSES | 3021 3021 3021 || 1 00 1 .00 ALL CAUSES OF DEATHJ 1 1281 28596 16722 || 2 53 1 .48 ACTUAL AGE 50 APPRAISED AGE 62 ACHIEVABLE AGE 55 >>> PRESCRIPTION TABLE <<< YOUR ACHIEVABLE AGE IS BASEO ON THE FOLLOWING MODIFICATIONS OF YOUR CONDITION/LIFESTYLE: ALCOHOL FROM 16 DRINKS PER WEEK TO 3-6 DRINKS PER WEEK SYSTOLIC BP FROM 160 MM MERCURY TO RECHECK-SEE YOUR DR. DIASTOLIC BP FROM 96 MM MERCURY TO RECHECK-SEE YOUR DR. SEAT BELT FROM BUCKLED 17% OF TIME TO BUCKLED 100% OF TIME SMOKING FROM 30 CIGARETTES/ DAY TO STOPPED SMOKING WEIGHT FROM 82 KILOGRAMS TO 73 KILOGRAMS PHYS. ACTVTY FROM LITTLE OR NONE TO REGULAR -3X PER WEEK i-H SEDEN DIVISION OF HEALTH SYSTEMS - UNIVERSITY OF BRITISH COLUMBIA » > HEALTH HAZARD APPRAISAL < « » > PRESCRIPTION TABLE <<< PAGE 3 OF 1 MAR 27, 1980 ACTUAL AGE 50 APPRAISED AGE 62 ACHIEVABLE AGE 55 YOUR ACHIEVABLE AGE IS BASED ON THE FOLLOWING MODIFICATIONS OF YOUR CONDITION/LIFESTYLE: CONDITION/LIFE STYLE P R E S E N T R E C O M M E N D A T I O N PHYSICAL ACTIVITY SMOKING ALCOHOL SEATBELT USE WEIGHT BLOOD PRESSURE LITTLE OR NONE 30 CIGARETTES/ DAY 16 DRINKS PER WEEK BUCKLED 17% OF TIME 82 KILOGRAMS 160/ 96 GRADUALLY AND PROGRESSIVELY INCREASE REGULAR PHYSICAL ACTIVITY STOP - BEST TO QUIT - TRY TO CUT DOWN AND SWITCH TO LOWER TAR MODERATE - REDUCE TO 3-6 DRINKS PER WEEK BUCKLE UP ALWAYS - 100% OF TIME REDUCE TO APPROXIMATELY 73 KILOGRAMS RECHECK- IF STILL ELEVATED CONSULT YOUR PHYSICIAN 5 E 0 E N D I V I S I O N O F H E A L T H S Y S T E M S - U N I V E R S I T Y O F B R I T I S H C O L U M B I A > > > H E A L T H H A Z A R D A P P R A I S A L < < < > > > A P P R A I S A L C H A R T < < < P A G E 4 O F 1 M A R 2 7 , 1 9 S O T H E N U M B E R O F R O W S S H O W S T H E R E L A T I V E M A G N I T U D E O F T H E A V E R A G E C A N A D I A N R I S K F O R E A C H C A U S E O F D E A T H . T H E L E N G T H O F E A C H R O W S H O W S Y O U R R I S K R E L A T I V E T O T H E C A N A D I A N A V E R A G E ( 1 ) . T H E R E D U C I B L E P A R T O F Y O U R R I S K I S I N D I C A T E D B Y L E T T E R S ( L E G E N D A T B O T T O M R I G H T ) . 1 H E A R T A T T A C K 2 L U N G C A N C E R 3 S T R O K E 4 C I R R H O S I S O F L I V E R 5 I N T E S T I N A L C A N C E R I N C L U D I N G R E C T U M 6 M O T O R V E H I C L E A C C I D E N T S 7 S U I C I D E 8 C H R O N I C B R O N C H I T I S A N D E M P H y S E M A 9 S T O M A C H C A N C E R 1 0 C A N C E R O F P A N C R E A S 1 1 D I S E A S E S O F A R T E R I A L S Y S T E M 1 2 T U M O U R - L Y M P H , B L O O D E X C E P T L E U K E M I A 2 3 4 ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y = W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y = W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y • W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y " W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y V Y Y Y Y Y Y Y ' W W S S S S S S S S S S S S S Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y • S S S S S S ' S S S S S S ' S S S S S S ' S S S S S S = = = = " = = S S S S : * = = = * = = S S S S ========ssss = A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A ' A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A = A A A A A A A A A A A A A A A A A A A A A A C C C C = A A A A A A A A A A A A A A A A A A A A A A C C C C ' S S S S S S S S S = S S S S « . . . . A C H I E V A B L E R I S K A A L C O H O L B S Y S T O L I C B P B D I A S T O L I C B P C S E A T B E L T S S M O K I N G W W E I G H T Y P H Y S . A C T V T Y 218 APPENDIX C 2 1 9 HEALTH & WELFARE CANADA; YOUR L I F E S T Y L E PROFILE Your Lifestyle Profile Attributed by permission oT Canadian Government by Bureau of Health Education Department of Health and Environment Forbes Building 321 Topeka. Kansas 66620 To encourage people to take better care of themselves, the Department of National Heatth and Welfare in-cludes health information with monthly old-age security and family allowance checks. About 11 million copies of the Lifestyle Profile reached some 17 million Canadians. Circle or check the coloured signs that apply to you (+ indicates more than; — indicates less than). Exercise Personal Health Amount of physical effort expended during the work- Do you experience periods of depression? day: mostly Heav^kasical, walkin^^Musework Desk work Occasionally ,tly Participation in physical activities—(skiing, golf, swimming, etc.) (lawn mowing, gardening, etc.)? • Participation in a vigorous exercise program? 3 tii^^eekly Weekly Average miles walked or jogged per day? Flights of stairs climbed per day? A —10 Nutrition Are you overweight? ^ 5 to 19 lbs. 2 0 @ ' 1 Do you eat a wide variety of foods—something from each of the following five food groups: (1) meat, fish, poultry, dried legumes, eggs or nuts; (2) milk or milk Do you wear a seatbelt? products; ( 3 ) bread or cereals; (4) fruits; ( 5 ) vegetables? ~ £<I^ ^^ V 3 times weekly Alcohol Average no. of bottles (12 oz.) of beer per week? Average no. hard liquor ( lVi oz.) drinks per week? 8 '" 1 5 Average no. of glasses (5 oz.) of wine or cider per week? 8 u 15 ^ Total no. of drinks per week, including beer, liquor, ^y drugs? and wine? U 8 to 15 {|p Drugs Do you take drugs illegally? Does anxiety interfere with your daily activities? £ Occasionally F ^ ' ' y Do you get enough satisfying sleep? Are you aware of the causes and dangers of VD? Breast self-examination? (If not applicable, do not score.) l ^ ^ b Occasionally Road and Water Safety Mileage per year as driver or passenger? —^^pO 10,000+ Do you often exceed the speed limit? ^ by 10 mph+ by ^ p h + J^^JS Occasionally Do you drive a motorcycle, moped or snowmobile? If yes to the above, do you always wear a regulation safety helmet? Do you ever drive under the influence of alcohol? Do you ever drive when your ability may be affected _ Occ^lly Are you aware of water safety rules? ^ f c No Do you consume alcoholic beverages together with certain drugs (tranquilizers, barbiturates, antihista-mines or illegal drugs)? Do you use pain-killers improperly or excessively? Tobacco Cigarettes smoked per day? Cigars smoked per day? Pipe tobacco pouches per week? •A If you participate in water sports or boating, do you wear a life jacket? (If not applicable, do not score.) General Average time watching T V per day (in hours)? Are you familiar with first-aid procedures? Do you ever smoke in bed? Occasionally Do you always make use of clothing and equipment provided for your safety at work? (If not applicable, do not score.) Occasionally gS£>) Scoring: 1 point per 3 per ; 5 per | g | 3 4 - 4 5 Excellent. 4 6 - 5 5 Good. 5 6 - 6 5 Risky. 6 6 - Hazardous. 220 APPENDIX D 221 SAMPLE OF CURRENTLY AVAILABLE HEALTH ASSESSMENT INSTRUMENTS Computer -Ana lyzed Q u e s t i o n n a i r e s : Canada E V A L U * L I F E / E V A L U * V I E H e a l t h and Wel fare Canada H e a l t h Promotion D i r e c t o r a t e 4th F l o o r , Jeanne Manee B u i l d i n g Tunney ' s P a s t u r e Ottawa, O n t a r i o K1A 1B4 HEALTH HAZARD APPRAISAL (HHA) D i v i s i o n of HEALTH Systems H e a l t h S c i e n c e s Centre U n i v e r s i t y of B r i t i s h Columbia Vancouver , B . C . V6T 1Z6 IMPCO HEALTH P r e v e n t i v e H e a l t h and F i t n e s s Programs for Bus ines s and I n d u s t r y Impco H e a l t h S e r v i c e s #261-900 West G e o r g i a S t r e e t Vancouver , B . C . V6C 1P9 U n i t e d S t a t e s : LIFESTYLE ASSESSMENT QUESTIONNAIRE I n s t i t u t e for L i f e s t y l e Improvement UW-SP Foundat ion U n i v e r s i t y of W i s c o n s i n Stevens P o i n t , WI 54481 WELL AWARE ABOUT HEALTH U n i v e r s i t y of A r i z o n a H e a l t h S c i e n c e s Center P . O . Box 43338 T u c s o n , A r i z o n a 85733 HEALTH RISK APPRAISAL D i r e c t o r , S p e c i a l P r o j e c t s Center for H e a l t h Promotion and E d u c a t i o n C e n t e r s for D i sease C o n t r o l A t l a n t a , G e o r g i a 30333 HEALTH 80's M e d i a l Datamation I n c . Southwest and H a r r i s o n B e l l e v u e , OH 4481 1 PERSONAL HEALTH PROFILE G e n e r a l H e a l t h C o r p . 1046 Potomac S t r e e t , N.W. Washington , DC 20007 INTERACTIVE-COMPUTER QUESTIONNAIRES  Canada: SPHERE D i v i s i o n of H e a l t h Systems H e a l t h S c i e n c e s Centre U n i v e r s i t y of B r i t i s h Columbia Vancouver , B . C . V6T 1-Z6 YOUR LIFESTYLE PROFILE H e a l t h and Wel fare Canada H e a l t h Promotion D i r e c t o r a t e 4th F l o o r , Jeanne Manee B u i l d i n g Tunney ' s Pas ture Ottawa, O n t a r i o K1A 1B4 FANTASTIC LIFESTYLE ASSESSMENT (1982) Department of F a m i l y M e d i c i n e McMaster U n i v e r s i t y H a m i l t o n , O n t a r i o L8N 3Z5 U n i t e d S t a t e s : HEALTHWISE Computer ized H e a l t h A p p r a i s a l s 13705 S . E . 142nd Clackamas , OR 97105 MILLON BEHAVIORAL HEALTH INVENTORY C l i n i c a l Assessment Systems, I n c . P . O . Box 570175 M i a m i , FL 331 57 STAYWELL HEALTH RISK APPRAISAL H e a l t h Computer S c i e n c e s Center Schoo l of P u b l i c H e a l t h U n i v e r s i t y of Minneso ta 611 Beacon S t r e e t M i n n e a p o l i s , MN 55455 SELF-SCORED QUESTIONNAIRES  Canada: YOUR LIFESTYLE PROFILE H e a l t h and Wel fare Canada H e a l t h Promotion D i r e c t o r a t e Ottawa, O n t a r i o K1A 1B4 PAR-Q H e a l t h Promotion M i n i s t r y of H e a l t h Government of B r i t i s h Columbia 1515 B l a n s h a r d S t r e e t V i c t o r i a , , B . C . V8V 1X4 SUNSET WELLNESS PROJECT HEALTH SURVEY Vancouver H e a l t h Department 1060 West 8th Avenue Vancouver , B . C . V6H 1C4 INDIVIDUAL STRESS ASSESSMENT Western Centre H e a l t h Group S u i t e 455 717 Denman S t r e e t V a n c o u v e r , B . C . V6G L6 U n i t e d S t a t e s : HEALTHSTYLE Department of H e a l t h and Human S e r v i c e s N a t i o n a l H e a l t h I n f o r m a t i o n Clear inghou . P . O . Box 1133 Washington , D . C . 2001 3 P . L . U . S . Bureau of H e a l t h E d u c a t i o n Kansas Department of H e a l t h and Environment B u i l d i n g 321 Forbes F i e l d Topeka , KS 66620 225 APPENDIX E 226 HEALTH RISK ASSESSMENT RESOURCES H e a l t h R i s k A p p r a i s a l : An Inventory(1981) DHHS(PHS) Pub. No. 81-50163 Department of H e a l t h and Human S e r v i c e s P u b l i c H e a l t h S e r v i c e O f f i c e of D i sease P r e v e n t i o n and H e a l t h Promotion O f f i c e of H e a l t h I n f o r m a t i o n , H e a l t h Promot ion and P h y s i c a l F i t n e s s and S p o r t s M e d i c i n e P r e p a r e d by: N a t i o n a l H e a l t h I n f o r m a t i o n C l e a r i n g h o u s e P . O . Box 1133 Washington , D . C . 2001 3 D e s c r i p t i o n , A n a l y s i s , and Assessment of H e a l t h H a z a r d /  H e a l t h R i s k A p p r a i s a l Programs: A F i n a l R e p o r t . PB81-239071 P r e p a r e d under c o n t r a c t No. 233-79-3008 f o r the N a t i o n a l Centre for H e a l t h S e r v i c e s R e s e a r c h ; O f f i c e of H e a l t h P o l i c y , Research and S t a t i s t i c s ; U . S . Department of H e a l t h and Human S e r v i c e s . F o r i n f o r m a t i o n w r i t e t o : N a t i o n a l Centre f o r H e a l t h S e r v i c e s Research C e n t e r B u i l d i n g , Room 8-30 3700 East -West Highway H y a t t s v i l l e , MD 20782 P r o c e e d i n g s of the Annual Meet ings on P r o s p e c t i v e  Medic ine and H e a l t h Hazard A p p r a i s a l P u b l i s h e d by H e a l t h and E d u c a t i o n Resources S u i t e 735, 4733 Bethesda Avenue B e t h e s d a , MD 2001 4 227 APPENDIX F RESOURCE GUIDES FOR COMMUNICATION MEDIA Media Handbook(1978) A guide to s e l e c t i n g , p r o d u c i n g and u s i n g media for p a t i e n t e d u c a t i o n programs. Copies may be purchased from: American H o s p i t a l A s s o c i a t i o n 840 North Lake Shore D r i v e C h i c a g o , I l l i n o i s 6061 1 Source Book for H e a l t h E d u c a t i o n M a t e r i a l s  and Community Resources (1982) U . S . Department of H e a l t h and Human S e r v i c e s P u b l i c H e a l t h S e r v i c e C e n t e r s f or D i s e a s e C o n t r o l Center for H e a l t h Promot ion and E d u c a t i o n Cop ie s may be purchased from: Super in tendent of Documents U . S . Government P r i n t i n g O f f i c e Washington, D . C . 20402 (Stock No. 017-023-00144-2) 229 APPENDIX G 230 CURRENTLY AVAILABLE COMMUNICATION MEDIA  I l l u s t r a t i o n s and Photographs: Used most o f t en to r e i n f o r c e and supplement v e r b a l p r e s e n t a t i o n s - ( p r i n t e d , r e c o r d e d , or spoken) , i l l u s t r a t i o n s and photographs can have a powerfu l impact on in tended a u d i e n c e . They can be used u n a l t e r e d as p a r t of a d i s p l a y or e x h i b i t , or c o n v e r t e d to another medium such as s l i d e s , overhead t r a n s p a r e n c i e s or as p a r t of a p r i n t e d handout or p r o m o t i o n a l a d v e r t i s e m e n t . C h a l k b o a r d : Found i n v i r t u a l l y every e d u c a t i o n a l env ironment , the c h a l k b o a r d i s p r o b a b l y the most used medium in t e a c h i n g . Can be e f f e c t i v e i f p a r t of a p lanned t e a c h i n g event and used by e x p e r i e n c e d p r e s e n t e r . M o d e l s , S i m u l a t o r s and R e a l O b j e c t s : These common t e a c h i n g d e v i c e s can be i n t e g r a t e d i n t o a t o t a l t e a c h i n g program for i n d i v i d u a l or s m a l l - g r o u p i n s t r u c t i o n . They can be used e f f e c t i v e l y , f or example, i n programs on n u t r i t i o n , c a r d i o - p u l m o n a r y r e s u s c i t a t i o n (CPR) , and lung and b r e a s t c a n c e r , e t c . E x h i b i t s and D i s p l a y s : The e x h i b i t or d i s p l a y i s an e f f e c t i v e method for combining 231 drawings , photographs and models i n t o a comprehensive d e s i g n , u s u a l l y deve loped and assembled for one theme or s u b j e c t a r e a . They can be" as s imple as photographs , drawing and c a p t i o n s a r r a n g e d on a b u l l e t i n board or as complex as a w a l k - t h r o u g h environment complete w i t h mechan ica l models and f i l m l o o p s . E x h i b i t s and d i s p l a y s can c r e a t i v e l y and e f f e c t i v e l y i n c o r p o r a t e a u d i o / v i s u a l m a t e r i a l s , i n c l u d i n g i n t e r a c t i v e microcomputer systems. Programmed M a t e r i a l : Programmed m a t e r i a l s y s t e m a t i c a l l y o r g a n i z e s s u b j e c t matter i n t o a l o g i c a l sequence and then breaks i t down i n t o s m a l l d i s c r e t e s t e p s , each of which b u i l d s upon the p r e c e d i n g s t e p . The p a r t i c i p a n t s proceed at t h e i r own pace depending on past knowledge and a b i l i t y to l e a r n . There are two b a s i c program p a t t e r n s : (a) the l i n e a r program takes the p a r t i c i p a n t a long a s i n g l e l e a r n i n g p a t h , each q u e s t i o n b u i l d i n g upon the p r e v i o u s q u e s t i o n s ; and (b) the b r a n c h i n g program which takes p a r t i c i p a n t s a long paths d i c t a t e d by t h e i r responses to m u l t i p l e - c h o i c e q u e s t i o n s . These responses then d i r e c t the program to a p p r o p r i a t e background i n f o r m a t i o n , r e s o u r c e s , a l t e r n a t i v e s . Programmed m a t e r i a l may be as s imple as a p r i n t e d t e x t w i th answers or as complex as a v i d e o d i s p l a y t e r m i n a l opera ted i n c o n j u n c t i o n w i t h a computer . L e a r n i n g can take p l a c e at any conven ien t 232 t ime , and the m a t e r i a l can be repea ted or r e s t u d i e d as needed. Programmed m a t e r i a l r e q u i r e s the p a r t i c i p a n t s ' a c t i v e involvement i n the l e a r n i n g proces s and can be used e f f e c t i v e l y i n a l l h e a l t h promot ion s e t t i n g s . As o u t l i n e d in Chapter 2, a broad range of h e a l t h assessment formats are c u r r e n t l y be ing t r a n s l a t e d for use on v a r i o u s microcomputer systems. P r i n t e d M e d i a : A wide range of p r i n t e d m a t e r i a l s are a v a i l a b l e f o r h e a l t h promot ion - pamphle ts ; t ex tbooks ; workbooks; j o u r n a l s , newspaper and magazine a r t i c l e s and p r o m o t i o n a l a d v e r t i s e m e n t s ; r e s e a r c h r e p o r t s ; handouts ; b r o c h u r e s , and m i c r o f o r m s . The i n f o r m a t i o n may be p r e s e n t e d i n words, i l l u s t r a t i o n s , c a r t o o n s , c h a r t s , , g r a p h s , or p h o t o g r a p h s . P r i n t e d media can be used to p r o v i d e supplementa l or b a s i c i n f o r m a t i o n for i n d i v i d u a l or l a r g e group s i t u a t i o n s ; and can be used as a s e l f - i n s t r u c t i o n a l medium or to reach mass media r e a d e r s . As p r i n t e d m a t e r i a l i s a one-way medium, c a r e f u l s e l e c t i o n i s very i m p o r t a n t . However, i n n o v a t i v e and c r e a t i v e content and d es ign can complement a w e l l - p l a n n e d r i s k r e d u c t i o n campaign. Audio R e c o r d i n g s : Tapes and r e c o r d s s t o r e i n f o r m a t i o n for p l a y b a c k , and can be 233 d u p l i c a t e d for broad d i s t r i b u t i o n to d i f f e r e n t l e a r n i n g e n v i r o n m e n t s , i n c l u d i n g the p u b l i c and p r i v a t e r a d i o b r o a d c a s t i n g systems. S m a l l , p o r t a b l e , and r e u s a b l e , they can be p l a y e d i n d e f i n i t e l y wi thout l o s i n g q u a l i t y . Audio r e c o r d i n g s can be an e f f e c t i v e , i n e x p e n s i v e medium for h e a l t h promot ion and h e a l t h e d u c a t i o n . They are e s p e c i a l l y e f f e c t i v e for people w i th low r e a d i n g s k i l l s . T h i s medium can be used i n c o n j u n c t i o n wi th v i s u a l m a t e r i a l s and can be i n t e g r a t e d i n t o a s e l f - i n s t r u c t i o n a l program for independent s t u d y . P h o t o g r a p h i c S l i d e s and Overhead T r a n s p a r e n c i e s : These are f l e x i b l e , i n e x p e n s i v e to p r o d u c e , and s imple to use v i s u a l m e d i a . S l i d e s are p r o j e c t e d on two types of p r o j e c t o r s in g e n e r a l use - a manual p r o j e c t o r which r e q u i r e s i n s e r t i n g each new s l i d e by hand; and a c a r t r i d g e , or c a r o u s e l , p r o j e c t e r which has a l l the s l i d e s a r r a n g e d i n sequence and which may be o p e r a t e d by remote c o n t r o l . S l i d e p r e s e n t a t i o n s can be adapted for i n d i v i d u a l or group s e t t i n g s and can be combined wi th taped a u d i o n a r r a t i o n or w r i t t e n t e x t to form a s e l f - i n s t r u c t i o n a l program. S l i d e / t a p e audio v i s u a l s f or h e a l t h r i s k assessment programs have been e f f e c t i v e l y used by the U n i v e r s i t y of A r i z o n a ' s "Well Aware About H e a l t h P r o j e c t " as p a r t of a modular e d u c a t i o n a l and s e l f - h e l p o r i e n t a t i o n package for p a r t i c i p a n t s i n H e a l t h Hazard A p p r a i s a l (HHA). N a r r a t i o n , 234 m u s i c , c a r t o o n s , and photography were used in the des ign to make the i n f o r m a t i o n i n t e r e s t i n g and unders tandab le to anyone be ing i n t r o d u c e d to the ideas of P r o s p e c t i v e M e d i c i n e (Ramsey and Dunton, 1977). T r a n s p a r e n c i e s are to be shown on an overhead p r o j e c t o r which enab le s the p r o j e c t i o n not o n l y of t r a n s p a r e n t images on c l e a r a c e t a t e but a l s o s i l h o u e t t e s on t r a n s p a r e n t or t r a n s l u c e n t o b j e c t s . The p r e s e n t e r can w r i t e or draw on the t r a n s p a r e n c y and can a l s o c o n t r o l the time and r a t e of the p r e s e n t a t i o n . Overhead t r a n s p a r e n c i e s can be used for l a r g e or s m a l l group i n s t r u c t i o n , and have been e f f e c t i v e l y used i n p r e s e n t i n g the concept of h e a l t h r i s k assessment ( H e a l t h Hazard A p p r a i s a l ) to groups in v a r i o u s s e t t i n g s such as u n i v e r s i t i e s , h o s p i t a l s , s c h o o l s , and p u b l i c h e a l t h u n i t s , e t c . F i l m s t r i p s and S i l e n t F i l m s : A r e l a t i v e l y inexpens ive v i s u a l approach most o f t e n used for i n d i v i d u a l study or i n s m a l l group i n s t r u c t i o n a l s e t t i n g s , and which can be used as p a r t of a h e a l t h promot ion e x h i b i t or d i s p l a y . A l b e i t somewhat i n f l e x i b l e , t h i s t e c h n i q u e can be augmented wi th a r e c o r d , a u d i o t a p e or w r i t t e n s c r i p t . T e l e v i s i o n , F i l m s , V i d e o t a p e s , V i d e o d i s c s , V i d e o C a s s e t t e s ' ) A u d i o / v i s u a l media have become a f a m i l i a r p a r t of the p u b l i c ' s s o c i a l and l e a r n i n g environments in i n s t r u c t i o n a l 235 s e t t i n g s , v i d e o c a s s e t t e systems for home, o f f i c e and e d u c a t i o n a l use , and through c l o s e d c i r c u i t systems, s a t e l l i t e to home t r a n s m i s s i o n s , c a b l e - t e l e v i s i o n d i s t r i b u t i o n , and the e x t e n s i v e exposure of p u b l i c and p r i v a t e b r o a d c a s t i n g systems. T h i s f a m i l i a r a c t i v i t y o f f e r s an a n x i e t y - f r e e means of l e a r n i n g tha t does not r e q u i r e a h i g h degree of v e r b a l a b i l i t y . The emot iona l impact of a u d i o / v i s u a l media o f t e n serves as a s p r i n g b o a r d for d i s c u s s i o n and a t t i t u d e / b e h a v i o r change. "Video c a s s e t t e s , " a c c o r d i n g to Beery (1981) "are a p a r t i c u l a r l y e f f e c t i v e way to p r e s e n t r i s k f a c t o r i n f o r m a t i o n to an i n d i v i d u a l or a d i s c u s s i o n g r o u p . " T h i s approach may be combined w i t h a f o l l o w - u p b o o k l e t . Beery goes on to say tha t the N a t i o n a l Foundat ion f o r the P r e v e n t i o n of D i sease has as "one of i t s g o a l s , development of s e t s of such c a s s e t t e s for both a d u l t s and c h i l d r e n . " A l t h o u g h the a u d i o / v i s u a l approach i s r e l a t i v e l y expens ive because of r e q u i r e d p layback equipment such as p r o j e c t o r s f o r f i l m s and t e l e v i s i o n moni tors for v i d e o c a s s e t t e sys tems, i t shou l d be noted that there are many s m a l l , e a s y - t o - o p e r a t e and moderate ly p r i c e d r e c o r d / p l a y b a c k systems a r e now a v a i l a b l e . The s m a l l screen s i z e of t e l e v i s i o n m o n i t o r s cause d i f f i c u l t y for l a r g e - g r o u p s e t t i n g s , however, l a r g e p layback moni tors now e x i s t f o r use in these env ironments . F i l m s are not e a s i l y adapted or changed, however, 236 v i d e o t a p e s are t e c h n i c a l l y f l e x i b l e , can be e a s i l y e d i t e d and a l low for i n s t a n t r e p l a y . Simple v i d e o t a p e r e c o r d i n g equipment makes i t p o s s i b l e to produce in -house h e a l t h promot ion and r i s k r e d u c t i o n programs i n e x p e n s i v e l y . A l t e r n a t i v e l y , programs can be p r o f e s s i o n a l l y produced to meet a broad range of i n s t r u c t i o n a l and mass media a u d i e n c e s . A comprehensive l i s t of Formats and D e f i n i t i o n s of Communication Media for H e a l t h Promotion i s p r e s e n t e d in Appendix H . 237 APPENDIX H 238 FORMATS AND DEFINITIONS OF COMMUNICATION MEDIA FOR HEALTH PROMOTION Audiocassette: A permanently encased plastic tape which is coated with magnetic particles on one surface in order to record and reproduce sound. The cassette winds and re-winds from reel to reel. Book: Nonperiodical printed publication of at least 49 pages, exclusive of cover pages. Brochure: A short printed work of a few leaves, merely stitched together, and not otherwise bound, usually less than 80 pages in length (also booklet). Catalog: A list of books, maps, or other items arranged in some definite order. Coloring Book: A noncolored, illustrated brochure designed for public or patient education. Comic Book: A publication in pamphlet format containing a group of cartoons or drawings arranged in a narrative se-quence usually designed for public or patient education. Chart: An opaque sheet exhibiting information in graphic or tabular form or by the use of contours, shapes, or figures. Directory: A list of persons or organizations, systematically arranged, usually in alphabetic or classed order, giving address, affiliations, etc., for individuals, and address, offi-cers, functions, and similar data for organizations. Exhibit and Display: Combinations of visual media usually developed and assembled around one theme or subject area. Fact Sheet: A list or brief information summary on a speci-fic subject. Filmstrip: A strip of 16-mm or 35-mm film varying in length up to about 50 frames and bearing pictures, text, or cap-tions used as a visual aid to teaching. Game: An amusement, pastime, or competition. Graph: A diagram using bars, dots, or lines to represent the interrelationships of two or more things. Graphics: Nonverbal material, e.g., diagrams, drawings, photographs, graphs. Handbook: A treatise on a special subject; often a simple but all-embracing treatment containing concise information and small enough to be held in the hand. Also called a "Manual." Information Package: A collection of materials that are subject-related and intended for use as a unit. Instructional Package: A collection of materials in one or more than one medium that are subject-related and in-tended for educational use. Instructional Television: An electronic device for transmit-ting the sights and sounds of instruction. Leaflet: A small printed sheet of paper folded once to make two to four pages following in the same sequence as a book, but not stitched or bound. Microrepresentation: A reproduction produced photographically or by other means on either transparent or opaque materials in a size too small to be read by the unaided eye. Also called "microform." It includes micro-cards, microfiche, and microfilm. Models and Mockups: Three-dimensional representations of objects that differ from the real object in size, material, and/or function. Mockups are differentiated from models by their usually larger size and by their moving and operating parts, for example, a replica of the circulatory system in which a red liquid is pumped through clear plastic tubing is a mockup. Motion Picture: A series of still pictures on film, with or without sound, designed to be projected in rapid succes-sion to produce the optical effect of motion. Newsletter: A report or bulletin issued at regular intervals intended to keep recipients informed of recent news. Pamphlet: A nonperiodical publication of a least 5 but not more than 48 pages, exclusive of the cover pages. Phonorecord: A registration of sound vibrations recorded in a continuous groove in the revolving surface of a disc. Photograph: An image produced on a sensitized surface by the action of light. Picture: A representation made on opaque material by drawing, painting, photography, or other techniques of graphic arts. Poster: A large, single sheet of paper, usually printed but sometimes written, with an announcement or advertise-ment on one side for display on a wall or notice board. Also called a "Placard." Program: Material that describes the continuing, organized activities of a group involved in education, detection, reha-bilitation, etc. Programmed Material: Systematically organized subject matter in a logical sequence and broken down into small discrete steps, each of which builds upon the preceding step. Quiz: An informal test or examination. Real Object: A device used as a teaching tool. Reel-to-Reel Audiotape: A registration of sound vibrations on a plastic tape so that sound may be reproduced. Script: A written document of an oral presentation. Used for written text of stage play, screen play, TV or radio broadcast, or taped message. Simulator: An apparatus used in the teaching of a skill or procedure. Slide: A positive image on transparent material, usually film, mounted in rigid format designed for projection. This term is tending to be superseded by the term "trans-parency." Slide-Tape Presentation: A program composed of slides and a sound track on an accompanying audiocassette. Videocassette: A permanently encased plastic tape which is coated with magnetic particles on one surface in order to record and reproduce television pictures and sound. Videotape: A magnetic tape upon which audio and or video signals are recorded for playback through a television re-ceiver. 239 APPENDIX I 2 4 0 SPHERE PARTICIPANT ASSESSMENT D i v i s i o n o f H e a l t h Systems U n i v e r s i t y o f B r i t i s h C o lumbia SYSTEM FOR PERSONAL HEALTH RISK EVALUATION HEALTH HAZARD APPRAISAL (c) 1983 Kent M . B r o t h e r s CLIENTNAME PERSONAL DATA 21 Jun 1983 Sex: Female H e i g h t : 70 i n Age: 50 We i g h t : 190 l b B l o o d P r e s s u r e : 160/96 C h o l e s t e r o l : 280 mg/dl E x e r c i s e : L i t t l e or none Smoking H a b i t s : Smoker Type: C i g a r e t t e s Amount: 2+ packs per day A l c o h o l Consumption: 7 - 2 4 d r i n k s per week S e a t b e I t Use: 20% M i l e a g e : 13,000 mi D i a b e t e s : No F a m i l y H i s t o r y o f D i a b e t e s : No F a m i l y H i s t o r y o f I s c h a e m i c H e a r t D i s e a s e : One p a r e n t d i e d o f a h e a r t a t t a c k b e f o r e age 60 Emphysema: No s i g n s o r symptoms B a c t e r i a l Pneumonia: Have n o t had D e p r e s s i o n : Seldom o r n e v e r F a m i l y H i s t o r y o f S u i c i d e : No R e c t a l Growth: Have had R e c t a l B l e e d i n g : Have not had Age R e g u l a r I n t e r c o u r s e Began: under 20 Pap Smear: 1 or more t e s t s w i t h i n 5 y e a r s , but not w i t h i n 1 y e a r — most r e c e n t t e s t n e g a t i v e F a m i l y H i s t o r y o f B r e a s t C a n c e r : No Mon t h l y B r e a s t S e l f E x a m i n a t i o n : No 241 CLIENTNAME RISK AGES 21 Jun 1983 A c t u a l : 50 A p p r a i s e d : 58.2 A c h i e v a b l e : 52.4 ACHIEVABLE REDUCTIONS IN YOUR TEN-YEAR RISK OF DEATH PER 100,000 P r e s e n t a p p r a i s e d r i s k 9344 A c h i e v a b l e r e d u c t i o n s B l o o d P r e s s u r e -1090 30% Smoking H a b i t s -1068 30% A l c o h o l Consumption -658 18% M o n t h l y B r e a s t S e l f E x a m i n a t i o n -310 9% E x e r c i s e -298 8% P e r c e n t Overweight -142 4% S e a t b e l t Use -50 1% A c h i e v a b l e r i s k 5728 RECOMMENDATIONS Your a c h i e v a b l e r i s k i s based on the a d o p t i o n o f the f o l l o w i n g recommendations: Weight: Reduce t o about 167 l b . B l o o d P r e s s u r e : Recheck — i f s t i l l e l e v a t e d , c o n s u l t y o u r p h y s i c i a n about r e d u c i n g t o at most 140/90. C h o l e s t e r o l : Your h i g h c h o l e s t e r o l l e v e l p l a c e s you a t e l e v a t e d r i s k . C o n s u l t your p h y s i c i a n about d e s i r a b l e l i f e s t y l e changes t o r e d u c e t h i s l e v e l . Recheck i n 6 months. Smoking H a b i t s : Best t o q u i t ! A t l e a s t t r y t o c u t down, and d o n ' t i n h a l e . E x e r c i s e : G r a d u a l l y and p r o g r e s s i v e l y i n c r e a s e p h y s i c a l a c t i v i t y t o v i g o r o u s l e v e l i n c o n s u l t a t i o n w i t h y o u r p h y s i c i a n o r h e a l t h c o u n s e l l o r . A l c o h o l Consumption: Your l e v e l o f a l c o h o l consumption p l a c e s you a t e l e v a t e d r i s k o f c i r r h o s i s , pneumonia, and a c c i d e n t s . However, r e c e n t r e s e a r c h s u g g e s t s t h a t moderate a l c o h o l consumption r e d u c e s r i s k o f h e a r t d i s e a s e . T h e r e f o r e , moderate your consumption t o 3-6 d r i n k s per week. S e a t b e l t Use: B u c k l e - u p a l w a y s ! Pap Smear: Have as o f t e n as your p h y s i c i a n a d v i s e s , i f not a l r e a d y d o i n g so. M o n t h l y B r e a s t S e l f E x a m i n a t i o n : Conduct a s e l f - e x a m i n a t i o n — i f u n c e r t a i n o f t h e t e c h n i q u e , c o n s u l t y o u r p h y s i c i a n o r a h e a l t h n u r s e . 242 CLIENTNAME TEN-YEAR RISKS OF DEATH 21 Jun 1983 MOST IMPORTANT DESEASES AND INFLUENTIAL FACTORS R i s k F a c t o r s Death Rates per 100,000 - App Ach Avg App Ach I s c h a e m i c H e a r t D i s e a s e 3.9 1.7 744 2902 1264 P e r c e n t Overweight 1.1 1.0 B l o o d P r e s s u r e 1.8 1.0 C h o l e s t e r o l 1.4 1.4 Smoking H a b i t s 2.0 1.1 E x e r c i s e 1.4 1.0 Di abetes 1.0 1.0 F a m i l y H i s t o r y o f IHD 1.2 1.2 C e r e b r o v a s c u l a r D i s e a s e ( S t r o k e ) 2.7 1.4 336 908 470 B l o o d P r e s s u r e 1.8 1.0 C h o l e s t e r o l 1.4 1.4 Smoking H a b i t s 1.5 1.0 D i a b e t e s 1.0 1.0 Cancer: I n t e s t i n e s , Rectum 2.5 2.5 266 664 664 R e c t a l Growth 2.5 2.5 R e c t a l B l e e d i n g 1.0 1.0 Cancer: Lung 3.0 2.4 216 648 518 Smoking H a b i t s 3.0 2.4 Cancer: B r e a s t 1.0 0.5 618 618 308 F a m i l y H i s t o r y o f B r e a s t Cancer 1.0 1.0 M o n t h l y B r e a s t S e l f E x a m i n a t i o n 1.0 0.5 C i r r h o s i s o f the L i v e r 2.0 0.2 184 368 36 A l c o h o l Consumption 2.0 0.2 Other Forms o f He a r t D i s e a s e 1.9 1.0 186 354 186 P e r c e n t Overweight 1.1 1.0 B l o o d P r e s s u r e 1.8 1.0 A c c i d e n t : Motor V e h i c l e 2.3 0.6 142 326 86 A l c o h o l Consumption 2.0 0.5 S e a t b e l t Use 1.0 0.6 M i l e a g e 1.3 1.3 D i s e a s e s o f the A r t e r i e s 2.7 1.4 92 248 128 B l o o d P r e s s u r e 1.8 1.0 C h o l e s t e r o l 1.4 1.4 Smoking H a b i t s 1.5 1.0 Di abetes 1.0 1.0 Other 2032 2308 2068 ALL CAUSES 4812 9344 5728 243 CLIENTNAME RISK CHART 21 Jun 1983 Fo r each cause o f d e a t h , t he h e i g h t o f the b l o c k i s p r o p o r t i o n a l to t h e ave r a g e r i s k o f d y i n g o f t h a t c a u s e . The w i d t h o f t h e b l o c k i n d i c a t e s y o u r r i s k r e l a t i v e t o t h e a v e r a g e . The a r e a o f the b l o c k t h e r e f o r e r e p r e s e n t s y o u r t o t a l r i s k f r o m t h a t c a u s e . Composite P e r s o n a l R i s k F a c t o r 0 1 2 3 -Isc h a e m i c H e a r t D i s e a s e C e r e b r o v a s c u l a r D i s e a s e ( S t r o k e ) C a n c e r : I n t e s t i n e s , Rectum C a n c e r : Lung C a n c e r : B r e a s t C i r r h o s i s o f t h e L i v e r Other Forms o f H e a r t D i s e a s e A c c i d e n t : Motor V e h i c l e D i s e a s e s o f the A r t e r i e s ::::::::::::::::::WBBBBBBBBBSSSSSSSSSSEEEE ::::::::::::::::::WBBBBBBBBBSSSSSSSSSSEEEE ::::::::::::::::::WBBBBBBBBBSSSSSSSSSSEEEE ::::::::::::::::::WBBBBBBBBBSSSSSSSSSSEEEE ::::::::::::::::::WBBBBBBBBBSSSSSSSSSSEEEE ::::::::::::::::: WBBBBBBBBBSSSSSSSSSSEEEE ::::::::::::::::::WBBBBBBBBBSSSSSSSSSSEEEE :::::::::::::::::WBBBBBBBBBSSSSSSSSSSEEEE :::::::::::::::::WBBBBBBBBBSSSSSSSSSSEEEE I ::::::::::::::BBBBBBBBBSSSSSS ::::::::::::::BBBBBBBBBSSSSSS ::::::::::::::BBBBBBBBBSSSSSS ::::::::::::::BBBBBBBBBSSSSSS I I ::::::::::::::::::::::::::SSSSSSS ::::::::::::::::::::::::::SSSSSSS ::::::::::::::::::::::::::SSSSSSS I ::::MMMMMM ::::MMMMMM ::::MMMMMM ::::MMMMMM ::::MMMMMM ::::MMMMMM ::::MMMMMM ::::MMMMMM I AAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAA I ::::::::::WBBBBBBBBB ::::::::::WBBBBBBBBB I :::::AAAAAAAAAAAAAAAALLLL :::::AAAAAAAAAAAAAAAALLLL I ::::::::::::::BBBBBBBBBSSSSSS B...Blood P r e s s u r e S...Smoking M. . . B r e a s t S e l f Exam E . . . E x e r c i s e I S e a t b e l t A . . . A l c o h o l W...Weight 244 APPENDIX J 246 A P P E N D I X K 247 TV ONTARIO CATALOGUE TV O n t a r i o 2180 Yonge S t r e e t T o r o n t o , O n t a r i o M a i 1 i n g Address f or i n f o r m a t i o n and c a t a l o g u e s : TV O n t a r i o M a r k e t i n g Box 200 S t a t i o n Q T o r o n t o , O n t a r i o Canada M4T 2T1 248 APPENDI-X L 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0095811/manifest

Comment

Related Items