Reflections on 25 Years of Health Promotion—Where Have We Been and Where Are We Going?

Michael O’Donnell asked me to reflect on the past 25 years as a member of the health promotion community and a member of his editorial board. Well, a lot has happened since 1986, when the American Journal of Health Promotion was first introduced, and most of it has been good—good for health promotion advocates and good for society as a whole. Michael gave us all a list of cues and issues to address, and I will comment on these later in this essay. But first, every so often, I stand back and reflect on what we, as health promotion practitioners, are trying to achieve. Why did we choose to work in the field of health promotion when we could have picked more lucrative careers as Wall Street bankers, social network Web site developers, major league sports celebrities, or used car salespeople? When we know, deep inside, that real money is made treating diseases, not preventing them? We do health promotion because we believe in the cause, and because it’s both challenging and fun. For decades, we’ve tried to figure out how to get people to change ingrained habits that are harmful to their physical and mental well-being—eat healthy, be physically active, don’t smoke, and watch your weight. As my nephew, who is headed off to medical school, once chided me, ‘‘You do that—that’s so lame.’’ So be it. All those behaviors I just listed above sound really easy to do, right? As we all know, not really. My kids, when they were younger, would ask me what I did for a living. I would describe to them, as best I could, that my work involved getting Americans to lead healthier lives—for example, to teach them how to eat right, be physically active, and not become obese. My children would stare at me, and, being appropriately blunt, would say, ‘‘Well, you’re not doing such a good job, are you?’’ Indeed, as a society, we are not doing such a good job addressing prevalent and significant health risks, such as obesity. On the other hand, we’ve made significant progress in other areas, such as smoking. During the past 50 years, we cut the rate of smoking among adults by more than half. We did so by invoking multiple policy interventions, such as increasing the price of cigarettes; putting no-smoking policies in place in public areas and workplaces; banning smoking in restaurants, in airplanes, and even on beaches; paying for pharmacological and other quit-smoking treatments (some available over the counter at drugstores); and changing a cultural norm so that smoking is no longer as ‘‘cool’’ as it used to be among teenagers. Nonetheless, one in five Americans still smokes today. Whereas progress has been made in smoking, obesity risk is going in the opposite direction, because two out of three Americans today are either overweight or obese. We need to address that problem the same way we dealt with smoking—through multiple intervention modalities that include individual, environmental, and policy changes. Now, let me respond to some of Michael’s specific queries. Do I believe that health promotion is being accepted as a viable strategy among clinicians, government officials, scientists, public health advocates, and the general population? Yes, I do believe there is greater acceptance today of health promotion as an effective public health strategy among these constituencies, but there are several qualifiers to that response. Clinicians still think about prevention within the context of a medical office setting, where they spend their day, and where they perform procedures for which they are reimbursed. So, prevention to clinicians most often means performing a colonoscopy or mammography and being reimbursed for a specific CPT-4 code. Seldom will a clinician take the time to counsel a patient on how to quit smoking, exercise more, or lose weight. They don’t have the training, and more importantly the time, to do that. Their job is to treat the illness once it occurs. That may be changing. Many care delivery and reimbursement models being tested today within the context of health care reform include interventions aimed at reducing health risks, coordinating care among a team of providers that may include health promotion practitioners, and borrowing principles first developed in the health promotion community, such as teaching self-management skills, applying stages of change theory, offering tailored communications, and conducting motivational interviewing. The federal government is also experimenting with various health promotion principles and practices with diverse populations, including Medicare and Medicaid beneficiaries. There are several health promotion demonstrations under way involving individuals insured under federal programs, and several health promotion provisions, such as an annual wellness visit for Medicare beneficiaries, are now in place Ron Z. Goetzel, PhD, Research Professor and Director, Institute for Health and Productivity Studies, Rollins School of Public Health, Emory University and Vice President, Consulting and Applied Research, Thomson Reuters. In 1986, he was Director, Data Analysis and Evaluation Services, Johnson and Johnson, Health Management Inc.