02. Wellness and Health Promotion

Wellness and Health Promotion


After you have successfully completed this chapter, you should be able to:

Define health

Identify the nurse’s role in promoting wellness

Identify factors that affect health

Identify normal sleep patterns for various age groups

Identify factors that can affect normal sleep patterns

Identify normal exercise patterns for various age groups

Identify factors that can affect normal exercise patterns

Identify stressors for various age groups

Identify risks for injury for various age groups


aerobic exercise   Activity in which oxygen is metabolized to produce energy.

anaerobic exercise   Activity in which the energy required is provided without using inspired oxygen.

biology   Genetic background, gender, race and ethnicity, family history, and problems occurring throughout life.

health promotion   Behavior motivated by the desire to increase well-being and actualize human potential.

Healthy People 2010   A report by the United States Department of Health and Human Services, focusing on health promotion of individuals, families, and communities.

leading health indicators   Factors that impact individual and community health and wellness.

physical environment   Consists of all the things that are experienced through the individual’s senses and some harmful elements such as radiation, ozone, and radon.

primary prevention   Implies health and a high level of wellness for the individual.

secondary prevention   Focus on early diagnosis of health problems, and prompt treatment with the restoration of health.

social environment   Interactions between individuals and others as well as the institutions in an individual’s community, including churches, schools, transportation systems, and protective services.

tertiary prevention   Activity aimed to restore the individual to the highest possible level of health and functioning.

wellness   A state of life that is balanced, personally satisfying, and characterized by the ability to adapt and to participate in activities that enhance quality of life.



  • Healthcare has changed from an illness focus to concern with health promotion and wellness.

  • Wellness is a state of life that is balanced, personally satisfying, and characterized by health-enhancing behaviors.

  • Dunn defined wellness as an integrated method of functioning, oriented toward maximizing the potential of the individual.

  • Dunn’s theory of wellness uses two intersecting axes: health and environment.

  • Leavell and Clark described wellness in terms of primary, secondary, and tertiary levels of prevention.

  • Travis used a continuum to describe the state of health.

Health promotion

  • Health promotion refers to actions to increase health and well-being of individuals, families, and communities.

  • Individual health promotion includes identifying biological, lifestyle, and environmental risks that influence wellness and promoting efforts to reduce risks.

  • Models for health promotion include the health belief model, the theory of reasoned action/planned behavior, and the health promotion model.

  • Health promotion models guide interventions.

Healthy People 2010

  • Physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization, and access to healthcare are leading health indicators related to significant public health concerns in the United States.

  • Individual biology and behaviors, environmental factors, health policies, and access to care impact individual and community health and wellness.

  • Health insurance is the most significant factor in access to healthcare.

  • Cultural differences influence physical and social behaviors that impact wellness.

Health promotion and the nursing process

  • Comprehensive health assessment is essential to health promotion.

  • The professional nurse takes on a variety of roles when implementing plans for health promotion.

  • Evaluation of goals for health promotion is an ongoing process that may result in new priorities or strategies to meet health-related goals.



Health is a broad concept that is difficult to define. Older definitions viewed health as the absence of disease. But today health is seen as a goal, a dynamic process that involves the self and self-care ability; optimal functioning of body, mind, and spirit; the ability to adapt; feelings of well-being and wholeness; and growing and becoming.

People also have their own definitions of health, which are affected by gender, sociocultural factors, previous experience, age, and personal goals. These personal definitions influence their health promotion goals.

The three basic levels of prevention are primary, secondary, and tertiary.Primary prevention is essential to maintaining a state of wellness. At this level, the assessment process should include screening procedures, immunizations, and especially,prevention education.



How do you teach people to stay well? Follow these steps:

Set an example with a healthy lifestyle.

Motivate them to change unhealthy behaviors.

Propose strategies for behavior change.

Show them how to care for themselves more effectively.

Build on their strengths.

Help them find and use available resources.

Provide support through telephone, individual, and group counseling and continuing education.


Healthy People 2010 has identified leading health indicators that are used to measure the health of our nation over the next 10 years. These indicators were selected based upon the ability to motivate change, data availability to evaluate progress, and importance as public health issues (Healthy People 2010). The indicators are not disease specific, but rather, many are behavior specific. It is the unhealthy behaviors that increase the risk for disease, such as smoking increases the risk for lung disease (chronic obstructive pulmonary disease [COPD]) and lung cancer. As healthcare providers, you are in prime position to promote wellness.

The leading health indicators are:

Physical activity.

Overweight and obesity.

Tobacco use.

Substance abuse.

Responsible sexual behaviors.

Mental health.

Injury and violence.

Environmental quality.


Access to healthcare.


These leading health indicators are addressed throughout this text. This chapter focuses on assessing four key areas fundamental to maintaining wellness—rest and sleep,exercise,stress management,and injury prevention—and suggests questions to ask at each developmental stage.


Factors Affecting Health Behaviors

Many factors influence a person’s choice to maintain healthy behaviors. Some of these factors include support systems, psychological state of mind, access to healthcare, and motivational level. Some of these factors may be beyond your patient’s control, and your influence on these factors could lead to a positive outcome. Referrals may be needed to facilitate healthy behaviors, and providing support for your patient can be crucial to his or her wellness.

Support Systems

The encouragement of friends and family can mean the difference between achieving personal health goals and falling short of them. Ask the person about her or his support systems, and then use these systems in the assessment process when needed. Other types of supports include organized religious groups, nurses and other caregiving professionals, and self-help groups such as Weight Watchers.

Psychological State

A person’s psychological state affects his or her physical state. For example, if a person knows that he or she needs to stop smoking, start eating more healthfully, and start exercising more, then why doesn’t he or she do it? Part of the assessment process is determining these reasons and working with people to change harmful behavior.

Access to Healthcare

People may be motivated to maintain or improve their state of wellness but be prevented from doing so because they lack access to healthcare. Causes include lack of finances or insurance coverage; rural location; lack of transportation; crowding at available healthcare resources; age, gender, ethnicity, and/or religion (possibly because of prejudice);and healthcare rationing based on these factors.

Motivational Level

Because people tend to resist change, convincing them to trade unhealthy behaviors for healthy ones can be difficult. Teaching them the importance of primary prevention does not ensure that they will practice what you preach. For example, people know that smoking, obesity, and lack of exercise are dangerous to their health, but they still have trouble changing long-standing behaviors unless they are truly motivated.

The wellness assessment entails asking the person and/or caregiver first general questions about health promotion behaviors and then specific questions about sleep and rest, exercise, stress management, and injury prevention. Health promotion behaviors and needs differ according to the person’s developmental stage.

Factors Affecting Health Status

This chapter examines some of the factors affecting health status that are driving health care spending among the Medicare population. The workshop presentations covered three such factors, which research shows are important to consider in projecting future Medicare costs:

1.     health and health care cost consequences of obesity among the Medicare population;

2.     the role of socioeconomic status and health-related behavior in driving medical care spending; and

3.     the role of chronic diseases and disability in health care costs.


Justin Trogdon (RTI International) described the current costs of obesity in terms of health outcomes and spending among the Medicare population, presenting cross-sectional, lifetime, and recent trend estimates. He also reviewed different types of strategies that modelers have used to estimate costs and forecast the future, both for the prevalence and health consequences of obesity and how obesity impacts projections of Medicare spending.

Health Consequences of Obesity

Obesity has the attention of researchers and policy makers. It is associated with increased risk for many chronic conditions, such as hypertension, high cholesterol, cardiovascular disease, and cancer, among others. Obesity impacts nearly every major system in the body. It is, in itself, an outcome of several different behavioral and policy decisions; it is also an input into chronic disease.

Improved treatment for many of the conditions associated with obesity means that, in some sense, an obese person in 2010 is “healthier” than an obese person in 1950 or probably even 1980. That is good from a morbidity and health status point of view, but such improvements have been achieved often at increased health care cost. Statins to reduce cholesterol and other drugs to lower blood pressure, for example, are not cheap. Also, improved treatment may or may not lead to major changes in health outcomes such as mortality.

Years of Life Lost

Does obesity shorten life expectancy? Trogdon summarized research he and colleagues conducted in which they calculated years of life lost associated with obesity using life tables by weight categories and smoking status. They found that overweight and moderate obesity (obese I) will not shorten a person’s life. Severe obesity (obese II and III) will take years off one’s life. At age 65, a typical age at which people enter the Medicare program, being an obese II person (about 40 pounds overweight) is associated with 3 years of life lost for whites, while being an obese III person (a little over 100 pounds overweight) is associated with 4 to 6 years of life lost across gender and race These findings indicate that although rates of chronic conditions, such as diabetes and hypertension, are higher among obese people, they do not necessarily translate into a shorter life span.

Health Care Costs of Obesity

How much does obesity increase health care costs at a given point in time? To answer this question, Trogdon reported on the findings from a recently published update of national estimates of annual medical spending attributable to obesity . Comparing a Medicare beneficiary who is obese to one who is not obese and controlling for other differences between those two groups, Trogdon and colleagues estimated that obesity increases per capita Medicare expenditures by about $1,723 per year. Those dollars, for the most part, go to treating all of the chronic diseases that obesity is associated with and not just direct treatment for obesity. This estimate means that the annual medical burden of obesity is nearly 8.5 percent of total annual Medicare expenditures. If the 8.5 percent estimate, generated using data from the Medical Expenditure Panel Survey (MEPS), is applied to all of the national health expenditure accounts, assuming the institutionalized population has a similar share of medical spending going toward obesity, the Medicare costs associated with obesity could be as high as $85 billion per year in 2008 dollars.

Another way to look at the cost of obesity is to ask the question: How do medical care costs associated with obesity vary over a lifetime? This question points to the importance of preventing obesity for the Medicare population. Using the life tables described above along with MEPS data, Trogdon and colleagues estimated survival-adjusted lifetime obesity cost estimates One of the major conclusions as a result of that work is that, compared with the private insurance market, Medicare has potentially a greater incentive to prevent obesity because costs attributable to it are near their peak around the age of entry into the Medicare program (ages 60 to 65). What that means for the private insurance market is that, often, the major costs of obesity are not likely to be its problem. The likelihood that a potential cohort of employees would still be on the company’s health insurance rolls after 5 years might be relatively low.

Thorpe and colleagues (2004) examined recent trends in the health care costs of obesity. To answer the question of how much of the increase in medical care spending over the last 10 to 20 years is due to obesity, they estimated medical costs and obesity-attributable health care costs in 1987 and 2001. They found that obesity-attributable costs increased per capita medical care spending by about $300, accounting for about 27 percent of the increase in per capita medical care spending between 1987 and 2001. This percentage has been relatively stable over the past 5 or 6 years.

Forecasting the Future of Obesity Prevalence

Currently, obesity is important to the Medicare program from a cost perspective, both on an annual basis and as each cohort of Medicare beneficiaries ages through the system. Obesity has contributed greatly to increases in health care costs.

The current prevalence of obesity in the adult population is about 30 percent. What is going to happen to the prevalence of obesity moving forward in time? This is a much trickier question. Unlike predictions of health care spending, obesity prevalence has a natural limit—100 percent. Models that merely project recent trends into the future will predict that everyone will be obese, and it is just a matter of when. That does not seem to be the most likely occurrence, but one has to think about when and how those trends would turn around.

Several recent attempts have been made to project obesity prevalence, but none is specific to Medicare. For example, in California, obesity rates are projected to increase from 24 to 35 percent of the adult population between 2010 and 2020 At the national level, there are other estimates that have been published over the last 2 to 3 years. The predicted prevalence of obesity in 2020 is estimated at around 42 percent and 44 or 45 percent. That amounts to about a 10 to 15 percentage point increase in obesity prevalence, which is an additional 50 percent increase over the current level.

Thorpe, in a recently released report (2009), also projected the estimated prevalence of obesity for the period 2008 to 2018. His midpoint estimates of the prevalence rates for the 10-year period are also around 42 to 44 percent of the adult population. Projecting the obesity-attributable costs over a 10-year time horizon using extrapolation, he found that obesity-attributable health care spending could range from $864 per capita in Colorado to $1,906 in Oklahoma. It should be noted that these are total and not Medicare-specific costs. Total obesity-attributable health care spending in the United States was projected to increase from $79 billion in 2008 to $344 billion in 2018. If one is willing to extrapolate past trends forward, these estimates suggest that the United States may be in for a much higher obesity prevalence and increased costs in the future.

Factors Influencing Future Obesity Rates

Most forecasts of obesity, both for prevalence and costs, are extrapolation of past trends. Even when a microsimulation model is used, there is still an assumption of past trends continuing on. Whether that is a reasonable assumption will depend on policy and technological changes in the food supply and medical care systems or both, all of which will influence the future of obesity over the next several years.

Food system changes include policies on food prices, taxes, subsidizing certain products, labeling requirements, and nutrient rules such as transfat bans. The question is: If there are structural changes in some of these underlying policies, how would that impact obesity prevalence rates? A simple extrapolation is not going to answer that question.

Changes to the medical care system could change the prevalence rates of obesity. However, such changes are not necessarily going to slow the growth in obesity prevalence—some changes might actually accelerate them. Some examples are technologies to treat obesity with surgery and lap bands, several prescription drugs specifically for weight control that are being tested for federal approval, and even some of the technological advances that would treat obesity comorbidities. These could have behavioral impacts on incentives for people to control their weight. For example, if it is relatively cheap for a person to be treated for hypertension and cholesterol by just taking a pill, there is less of an incentive to be concerned about weight and diet. These behavioral impacts will have implications, especially for Medicare, when all of the obesity-attributable costs start coming in.

Trogdon concluded his presentation by stating that, based on current knowledge, it is likely that there will be continued increases in obesity over the next 10 or 20 years.


Eileen Crimmins (University of Southern California) opened her presentation by observing that socioeconomic status (SES) is a fundamental cause of health differences in the population. The United States is a society of haves and have-nots. Large differences exist between these two groups, and the SES distribution of the population relates to people’s health status. Socioeconomic differences in health exist all over the world; they tend to be larger in the United States than in other countries. They are omnipresent over geography, and they also have been present over time.

Some differentials by SES in health outcomes have been relatively stable over time. People with lower SES—low education or low income or low occupation—have worse health by almost all health indicators. They have more diseases, physiological risk indicators, disability, and physical and cognitive functioning problems. Socioeconomic status in and of itself is a fundamental cause of health problems that works through many mechanisms to affect health. It can affect health outcomes through health-related behaviors, knowledge and skills obtained through education, and the ability to use income and wealth to purchase things that affect health. People with higher incomes are more likely to have access to care, a regular provider of medical care, and health insurance coverage. Social-psychological differences, differences in depression and stress, and health care access affect health. Thus, health outcomes differ by SES, and these differences affect differences in health care costs.

In models of use of health care services, the inclusion of such health indicators as disability and diseases tends to eliminate, or greatly reduce, the effect of SES variables. Cost is yet another issue because costs are affected by geographic location and the characteristics of the environment in which a person lives, not just the characteristics of the individual. To a large extent, most of the differences in costs for people with different SES come from either observed health differences or the different places they get care.

Incorporating SES in Projection Models

Is there some way to consider SES in order to make better cost projections? For example, are changing education levels in the population, or a changing set of differentials within the population, something that needs to be incorporated in models in order to make better projections?

Crimmins presented research findings to show the significance of SES differences in health outcomes. Using data from the Health and Retirement Study (HRS), Banks and colleagues (2006) looked at the prevalence of a set of diseases by three levels of education—low, medium, and high—among non-Hispanic whites ages 55–64. For heart problems, hypertension, stroke, diabetes, chronic lung disease, heart attack, and all of these conditions combined, lower education status was associated with higher prevalence.

This association holds for all kinds of measured risks. Using data from the National Health and Nutrition Examination Survey (NHANES) for the period 2001–2006, Karlamangla and colleagues (no date) looked at SES differences in metabolic syndrome and 10-year global chronic heart disease risk and found a much higher prevalence of poor scores among low SES people. In terms of risk factors, the data from HRS on the percentage of people ages 50 and older who were obese, current smokers, and heavy drinkers by education level showed that those at the highest education level had the lowest number of risk factors and those at the lowest education level had the highest number.

SES Differences in Health Outcomes and Age

There is no question that higher rates of ill health are found among people with low SES; however, these differences vary by age. The age at onset of the deterioration in health varies by SES; problems arise earlier among those with low SES. The maximal point of difference is at older working ages; at very old ages, they disappear or are reduced, at least partly because of mortality.

One of the more important points that comes out of RAND’s Future Elderly Model (FEM) is that people who survive to old age are different from those who do not survive. People with relatively high SES survive longer and people in better health survive longer; people with low SES and those with poor health do not survive as long. That is the key to thinking about how one needs to incorporate changes over time in a model that projects health care costs. For purposes of modeling, one has to think about the timing aspect and a life-cycle effect aspect, rather than just looking at prevalence and modeling it forward.

Health events are age related; for most health problems, at the age of Medicare eligibility, low SES people are going to have more health problems but a shorter expected length of life. Crimmins observed that life expectancy at age 60 for people with low, medium, and high SES shows a difference of about 5 years. In order to understand health differentials and their ability to change overall costs, one has to figure out how long people in different SES groups live, how many years of that life are spent unhealthy by a variety of definitions, and the cost of an unhealthy year. Costs need to be determined to understand how technology and policies will change the age at onset of health conditions, the length of survival with conditions, and the overall length of life.

SES and Healthy Life Expectancy

Data from various sources show that social and economic differences in health and mortality result in more years of ill health, fewer years of healthy life, and lower life expectancy overall, for people with low SES status. These differences arise from a process of earlier onset of health problems and higher mortality. The effect of this process of health deterioration on differential population health depends on where in the process of health deterioration the change occurs. Increasing the average length of life can have relatively little change on the distribution of population health. If healthy and unhealthy life are both increased at the same time, population health may not change much at all. At the same time, the length of an individual’s healthy life may increase.

Crimmins explained that changes in population health characteristics and the life-cycle characteristics of individuals can be different, and they tend to get mixed up when people think about improving population health. For example, reducing deaths from heart disease may increase the prevalence of heart disease in the population, as well as its costs. The prevalence of disease in the population can increase because of success in lengthening the life span of people with disease.

To improve the health of the population, what needs to be done is to delay the age of onset of conditions and reduce the time with health problems. This has not happened much yet; instead, the time with health conditions has been increased. That is one of the reasons it is important to think about years with conditions and years in good health.

Trends in Health

Both the incidence and the prevalence of disease in the population have increased. In most cases, the prevalence of disease has increased because of the decline in mortality, with little or no change in the incidence or rate of disease onset. Diabetes may be a different case because the rate of onset has increased. Changes in every disease need to be looked at differently. The prevalence of diagnosed risk factors, such as hypertension and high cholesterol, has increased. Yet disability has declined in the older population; physical and cognitive functioning and ability to work have improved. Although for some people who have disease, the progression to either becoming disabled or dying has been delayed, the underlying diseases have not been eliminated.

Rising education has been a major force for improvement in health over time, primarily in the area of disability. A number of recent papers have essentially attributed at least 50 percent of the decline in disability to change in the education composition of the population. This means that health processes have not changed in the population, but that the composition of the population has changed, with more people in the better educated group. Over the long run, that has been an important factor in increasing life expectancy. It is not clear, however, that this factor will continue to operate in the same way into the future, because in recent years the increase in education at older ages (60–69) is starting to slow down in the younger population (ages 50–59).

Crimmins and a colleague found that in the 10-year period, 1997–2007, the number of people unable to work and those limited in their ability to work at age 60 have declined. Rising education has been a force for improvement in disability. In general, SES differences have not changed much over long periods of time, but over time the more educated population comprises a greater percentage of the total population. There is also some evidence of widening of SES differentials in mortality in recent years, which could be a short run or long run trend. That is one reason why it is important to understand changes in how SES is linked to health outcomes, because there is now a wide difference between the lowest and the highest SES groups. If the lowest group were to change to be like the highest group, there would be a substantial increase in the number of people who would need to be covered by Medicare, increasing the health care costs for the total population.

In summary, Crimmins emphasized that an important national aim is to reduce health differentials. Reducing mortality differentials and reducing differentials in age at onset could have different effects for population health. A lot more detail on the processes of health change is needed to better understand what is underlying the observed differences in the population prevalence of health problems.

Microsimulation can be used to address these processes. That does not mean one has to incorporate a simulation of changes in health status into major national projection models. Yet to understand the role of a given factor for health status, microsimulation of all of the processes involved is needed, and the more detailed the simulations, the more one can understand the processes.

Finally, Crimmins observed that some things are known about cohort change in SES, but this research relies on cross-sectional, time-related data rather than cohort data. Clearly, there is need for more information on lifetime health circumstances to understand changes in health outcomes. Today many diseases have a life span of 20, 30, or 40 years, with long spans of treatment. The onset of risk factors and treatment can start very early in life. For example, the implications of being treated for hypertension or high cholesterol for 30 or 40 years, in terms of mortality and cardiac events, are not understood. In order to better understand the future implications of cohort characteristics and experiences, it is necessary to have more lifetime models of health rather than models that are based only on recent cross-sectional data.


Jay Bhattacharya (Stanford University) opened his presentation with two general observations. The first purpose of forecasting models of health care expenditures is to alert Congress and other policy makers about problems in the outlying years. A second and related purpose is to answer counterfactual questions about what will happen if various events (such as the development of new medical technologies) should occur. Both purposes, but especially the second, require that the forecasting apparatus adopt an underlying theoretical idea about the primary drivers of health care spending. In his presentation, Bhattacharya proposed the development of chronic disease and the competing risks phenomenon as the theoretical ideas driving health care expenditures. A forecasting apparatus centered on these ideas is well positioned to answer counterfactual questions about the effect of changes in health status on future health expenditures.

Bhattacharya mentioned a working paper by White (2006, later published in 2008) that noted a slowdown in the growth of Medicare expenditures between 1997 and 2005 relative to previous years. The paper attributed this slowdown to a new prospective payment system for hospitals and postacute care providers and to limits on the growth of payments to physicians. If these reforms could be maintained and extended, then the future financing of Medicare would not be so bleak. However, Medicare expenditures grew at more than 8 percent, compared with 4.4 percent growth in overall health care expenditures nationwide, despite the continuation of payment reforms. When looking forward into the future, it is therefore important to understand the underlying processes that drive health care expenditures.

Ken Manton and his colleagues at Duke University, in a series of papers, have shown that disability rates among the elderly have been declining since the 1980s and that disability is an important driver of health care costs. In their analysis of data from the National Long-Term Care Survey, Manton, XiLiang, and Lamb (2006) found that, in 1982, 5.7 percent of the elderly population was unable to perform instrumental activities of daily living (IADLs), whereas in 2004, this proportion was only 2.4 percent. With the exception of the prevalence of severe disability (inability to perform 3+ activities of daily living, ADLs), a similar and even more dramatic decline was observed for ADLs . These findings show a reversal of the trends of the 1970s, during which disability prevalence was increasing, and the decline accelerated in the 1980s and 1990s. Combined with increasing life expectancy, these declines yield a compression of morbidity. If these trends toward declining disability among the elderly continue, then Medicare expenditures could be substantially lower than is currently expected. But will these trends continue?

Bhattacharya argued that there is good reason to believe that the trend toward decreasing disability will not continue. He and his colleagues have found that disability is increasing in the under-65 population. Their analysis of data from the National Health Interview Survey (NHIS) on disability prevalence for 1982 to 1996 replicated the findings of Manton and colleagues of declines in disability among the elderly. At the same time, they found that younger populations, ages 50–59, 40–49, and 30–39, were experiencing substantial increases in disability.

What caused the change in disability prevalence among older people? Was it chronic disease prevention? Or was it better management of chronic disease, such as the availability of breakthrough technologies and assistive devices? Or was it more educated people? Which of these factors was more important?

He explained that chronic disease is directly relevant to policy. The chronically ill are more likely to become disabled. The policy choice for focusing resources is between reducing the prevalence of chronic illness or, once people are chronically ill, preventing them from developing disabilities. Understanding which of these approaches has played an important role in past improvements of disability trends may therefore inform what could be expected in the future.

A lifetime perspective is essential to understand the implications for medical care expenditures. For example, a decline in the prevalence of chronic disease would reduce the prevalence of disability and lead to declines in associated medical expenditures per year. But longer life may lead to greater expenditures. The costs are higher for prevention, which is more expensive in part because one does not know who is going to get a disease. Chronic disease management, in contrast, leads to a decline in disability prevalence among the chronically ill, but incurs higher expenditures on assistive technologies.

Disability, Survival, and Medical Expenditures

Bhattacharya next described the relationship between disability, survival, and medical care expenditures. He and his colleagues analyzed data collected annually from 1992 to 2003 in the Medicare Current Beneficiary Survey for people ages 65 and older with and without disabilities. They linked these data to Medicare administrative records for comprehensive measures of all medical care expenditures except prescription drugs. They found that survival of a person with disabilities is affected by the age (65, 75, or 85) at onset of disability. Medical care expenditures of elderly people with a disability are considerably more than those without disabilities, thus raising lifetime Medicare expenditures. Yet the disabled elderly have higher mortality rates, which would lower lifetime Medicare expenditures. The timing of disability onset therefore has a major effect on survival as well as Medicare expenditures.

Disability and Chronic Disease

Disability prevalence can be decomposed into two parts: one part attributable to the chronically ill population and a second part attributable to the nonchronically ill population. Changes in disability prevalence among the chronically ill can be decomposed further into two parts: changes in disability prevalence among the chronically ill and changes in the prevalence of chronic disease . Bhattacharya cautioned, however, that disease-by-disease decomposition may double count people with multiple chronic conditions, leading to an overestimate of the importance of chronic conditions in explaining disability trends. He argued that his research team’s estimates adjust for this double counting for the most common chronic diseases.

In their analysis of data from NHIS, Aronovich and colleagues considered the most common chronic conditions afflicting elderly populations: arthritis, chronic obstructed pulmonary disease, diabetes, hypertension, heart disease, stroke, and obesity. They found that based on data from NHIS, except for overweight and obesity (which increased sharply), chronic disease prevalence rates stayed mostly about the same or improved between 1982 and 1996 and hence did not contribute substantially to the decline in elderly disability over that period. For example, in 1999 there were fewer people with arthritis per 10,000 elderly individuals than there were in 1982. Similarly, prevalence rates for hypertension and heart disease were lower in 1999 than in 1982. By contrast, the rise in obesity prevalence over that period, if not countered by some other factor, would have led to a rise in disability in the elderly population.

Unlike overall chronic disease prevalence, disability prevalence among the chronically ill elderly improved substantially between 1982 and 1999. This decline more than countered the increase in disability due to increases in obesity prevalence and led to the overall decline in disability observed in the elderly population. Advances in medical technology played an important role in managing and reducing disability among the elderly. For example, new pharmaceutical products that control the progress of arthritis, better pain relievers, and joint replacement surgery helped reduce disability. Likewise, more intensive medical and surgical management of heart disease, reduced smoking rates, newer portable supplemental oxygen tanks, and specialized pulmonary rehabilitation centers may have contributed to declines in disability.

How much of the overall disability trends is attributable to the prevalence of chronic disease and how much is attributable to disability prevalence conditional on chronic disease? The analysis of Bhattacharya and colleagues suggests that disability declines among the elderly are mostly not due to improvements in primary prevention of chronic disease, but rather to preventing disability among the chronically ill. Much of the decline in disability among the chronically ill involves IADLs. Such declines, which often involve the purchase of expensive assistive devices, can result in higher Medicare expenditures.

Disability and Chronic Disease in Younger Populations

Younger populations tell a different story. Bhattacharya and colleagues used the same methods they used for the elderly for decomposition of disability trends among the younger population. They found that, between 1984 and 1996, disability prevalence among people under age 65 had increased, in sharp contrast to the decline in disability prevalence among the elderly over this period. About half of this increase in disability was attributable to prevalence of chronic diseases, much of which was in turn attributable to obesity. The remainder was attributable to an increasing rate of disability among the chronically ill, including people with hypertension or chronic obstructive pulmonary disease. Among the nonchronically ill, disability rates actually fell. The main implication of this work is that younger populations are not becoming healthier. Disability prevention efforts, if they are to be successful, should focus on reductions in obesity prevalence and limiting disability among chronically ill populations.

Predicting Future Medicare Expenditure

What will be the health care status of the population 30 years from now, and how is medical technology going to affect it? What effect is that going to have on medical care expenditures?

Bhattacharya turned to projections from RAND FEM, commenting that the model is ideally suited to answer questions like this. FEM is theoretically oriented toward chronic disease and health care costs and has been used to look at three prevention interventions in this context—smoking cessation, obesity control, and diabetes prevention—to project cost savings to Medicare. It also includes information on disability. The researchers found that disability declined sharply among the elderly between 1982 and 1999, similar to the findings noted above. Prevention of disability among the chronically ill played an important role in the decline; primary prevention of chronic disease was less important.

Among the younger population, disability increased over the same period. Higher prevalence of obesity and higher rates of disability among the chronically ill contributed to the increase. Consequently, future Medicare expenditures may not decline by much, even if future disability rates decline.

Bhattacharya concluded that disability is a major driver of health care costs, but eliminating it is not necessarily a major way to improve future health care expenditures for the Medicare population. Also, primary disease prevention is not a major cost saver in future health care expenditure projections. Preventing disability may nonetheless be the right thing to do, as it will allow people to live in a nondisabled state for a longer time and improve their quality of life.


Several participants expressed their views on the various issues flowing from the presentations. Most of the discussion was broadly on measuring socioeconomic status in modeling, projecting costs of medical treatment, and data for improved health care cost estimates.

Measuring Socioeconomic Status in Modeling

Referring to the discussion by Crimmins about socioeconomic status, which focused mainly on education and her statement that it did not matter much whether one measured SES by education, income, or occupation, Joseph Newhouse (Harvard University) interpreted that to suggest that the measures were treated as causal. He had a two-part question: First, what is known about causality? Second, from the point of view of modeling the future, and assuming that there will be changes in the distribution of the population by education as well as by income and occupation, would it matter which of those measures are causal, or are they all causal?

Crimmins responded that she views education as a fundamental cause that determines income. Income is a lot more complex as a variable because the causal relationship is much more likely to be a two-way street. As one gets sick and leaves the labor force, or one does not work as long, one’s pension will be reduced. Particularly at older ages, there is a lot of reverse causation in the income and health relationship. There certainly is some reverse causation using education in terms of people who become ill before the period when educational attainment ends, which tends to be in the twenties. These people have less educational attainment, but the effects on health tend to be small and not to lead to the diseases and conditions of old age.

The differences among population groups are always there, but they look slightly different depending on the SES measure used. Current occupation is a pretty useless measure for older people because most of them do not have one, and a lot of women never had one, although that is changing. The relationship with health is easier to understand if SES is indexed by education. Certainly going forward with a time path, one knows the educational attainment of the older population for the next 50 years, so it is a reasonably stable variable; in contrast, one does not know about income and how that is going to change over time.

Richard Suzman (National Institute on Aging) observed that not enough attention has been given in the presentations or discussions to people’s work patterns. Given the trend of being healthier and living longer, people are going to have to work longer. He therefore thought that combining Medicare projections with retirement modeling in both the United States and cross-nationally might be useful.

He mentioned that there was a lot of talk at the workshop about the short-term and long-term advantages of prevention coupled with costs. Essentially, longer life is not free; it has to be financed in some way, but there are relatively few data sets that look at the downstream impact of prevention or major medical investments over the rest of the life course. That is an important area to consider.

Bhattacharya commented that issues relating to work are important, especially in the context of disability and changes in disability trends in the younger population because disability has effects both on health care expenditures and on financing. So if a larger share of the younger population is disabled and therefore less able to work and retires earlier, the financing models are going to be off in addition to the expenditure models.

Projecting Cost Estimates of Medical Treatment

Referring to Bhattacharya’s discussion of predicting future medical expenditures, Michael Chernew (Harvard University) wanted to know, when forecasting medical spending and looking at cost effects, if the cost estimate of, say, treating a hypertensive patient or a disabled patient in 2020 is like a life table, using the cost of treating that hypertensive patient today, or if there is some growth rate beyond regular inflation to get to that point. If so, how does one inflate the cost of treating a current hypertensive to treat the hypertensive in 2020? To project the number of people with disabilities for a short time period, say 20 years, one can use the number with disabilities who are age 20 now and project out. But for longer term time periods, how does one project out the number of people with disabilities in 2050 or 2070?

Bhattacharya responded that in FEM the researchers assume that there is existing technology for everything. So they do not change anything other than the probability of transiting into obesity, for example.

In response to Chernew’s second comment, Bhattacharya explained that the method used in FEM is to look at the whole population—the transitional probabilities from age X to age X + 1 are fixed—and then age people forward. So if there are higher rates of disability among 30-year-olds today, that means there are going to be higher rates of disability for the entering cohorts at age 65, 35 years from now. But the transition probabilities from age 30 to 31, 30 to 32, etc., are just as in a life table based on today’s estimates.

Data for Improved Health Care Cost Estimates

Dana Goldman (University of Southern California) observed that the work of Crimmins and other research suggest that early determinants matter for future morbidity and mortality. That highlights the need for longitudinal panels. In addition, better cost estimates are needed, because trying to get self-reported cost information is almost impossible and leads to the need for linked data. HRS has linkage with Medicare records, but it is difficult to get those data. Although the Medicare Beneficiary Survey is available, it does not ask any of the SES questions that go back in years. It is very hard to link the household component of MEPS, and it does not include the institutionalized population. So the question is, What is needed in terms of data to improve these health care cost forecasts?

Liming Cai (National Center for Health Statistics) responded that the National Center for Health Statistics (NCHS) has provided several unique data sets that can be used for forecasting purposes. NCHS has linked data in the national surveys, NHIS, and NHANES, to the National Death Index (NDI), Social Security, Medicare, and Medicaid down to the end of this year. So one has the health measures, the socioeconomic and demographic measures, and all of the other survey measures available in a particular panel, and these panels are linked down the road through the mortality records, the claims records of the Centers for Medicare & Medicaid Services (CMS), the Social Security earnings record, and the Medicaid claims records. The impact of trends in health, by demographic and socioeconomic factors for the entire set of entitlement programs, can thus be estimated.

These useful data sets are currently available at NCHS, but the user has to submit a research request to an NCHS research data center to use them. There are research data centers across the United States; the user does not have to go to NCHS in Hyattsville, Maryland, to do the research.

Crimmins countered that she has used the NHANES extensively, but many of the important variables are not there. Neither cognition nor depression are measured in NHANES. Early life is not measured at all. NCHS has relatively poor measures of lifetime experiences. So there is intensive information from the National Death Index and Medicare, but the independent variables are lacking. The answer to Goldman’s question is therefore a composite of data sets, because no existing data set is perfect. Lifetime information is needed, but several early life measures are missing from current data sets.

Cai responded that there are certainly some topics missing from the surveys. At the same time, for some important research topics, such as obesity, no matter what disability status a person has, lifetime health care spending is probably the same .Cai and his colleagues looked at obesity status at around age 45, using the first NHANES follow-up survey linked to Medicare and the NDI, and obtained their lifetime Medicare expenditures. While more obese 45-year-olds will die before reaching age 65, their lifetime spending from age 65 on for Medicare is still significantly higher than normal-weight 45-year-olds who survive to age 65 and beyond.

Crimmins remarked that some of the emphasis on obesity makes her nervous. The link between obesity and socioeconomic status was extraordinarily strong in the past, and so some of what is being interpreted as an effect of obesity could be an effect of low SES. Without a comprehensive model that includes both obesity and SES, there is a risk of misallocating the effect.

Cai further pointed out that measures of SES, such as education, are not available in census population projections from 2002 to 2050. So although education is important to understand the relationship, when projecting out 50 years, that variable is not available for a projected population.

Bhattacharya noted that a theoretical idea is key to forecasting. If the idea is an extrapolation, then one can make do with expenditure cross-sections. If the idea is changes in disability, in obesity, in educational status, then one needs some sort of longer panel. There is a fundamental trade-off in that the longer the panel, the less representative it is of the population as a whole. So ideally one would want a long panel refreshed routinely to make it look more like the population at large.

Todd Caldis (Centers for Medicare & Medicaid Services Office of the Actuary) pointed out that the long-term models of both the Office of the Actuary and the Congressional Budget Office already include crude adjustments for the level of population health risks. In principle, it would be feasible to incorporate into those models more sophisticated measures.


General Questions to Ask at Each Developmental Stage

Tailor your assessment questions to the person’s developmental level—infant, toddler/preschool/school age, adolescent, young adult, middle age, or older adult. Include younger children in the interview as maturational level permits, and definitely include them by late school age. For young children, also assess health promotion behaviors for the family and the ability of the family to meet the child’s needs.


Ask the parent(s) or caregiver(s): Has your child’s blood pressure been checked? Does the child brush her or his own teeth? How often? Are her or his immunizations (polio,diphtheria-tetanus-pertussis,measles-mumps-rubella, Haemophilus influenzae type B, hepatitis A and B, chickenpox, pneumococcal disease) up to date? Has she or he had a vision and hearing assessment? If so,when? If the assessment was abnormal, what follow-up has occurred? What are your child’s nutritional habits?  Has she or he been tested for anemia or tuberculosis? What are your child care arrangements? Have you ever harmed your child or wanted to? Do you know what community resources are available related to child abuse?


Individualize your patient’s health promotion plan—it increases the chance of success.

Do not assume that people know how to stay well. We may be bombarded with health information in the media and on the Internet, but what seems simple and obvious to the healthcare professional may still seem complex to the layperson.

Assessing People’s Strengths

Knowing your patient’s strengths and weaknesses will help both of you set realistic goals and help you plan appropriate interventions. Ask some or all of the following questions:

What abilities do you possess to take care of your health?

What activities help you to maintain or improve your health?

What changes have you made in your lifestyle in the past 2 years to improve your health?

What goals have you set to improve your health? Do you have a plan for reaching them?

What changes in your life do you see in the future?

What people currently give you the most support?

What current activities make you feel happy?

When you were younger, what activities gave you strength, comfort, and support?

What helps you cope in a crisis?

What gives you direction in your life?

How do you spend a typical day?

What do you feel motivated to do in terms of a lifestyle change?

What barriers do you think will inhibit your lifestyle change?

What health problems have you successfully dealt with in the past?


Health Promotion Plan of Action

Identify the person’s healthcare goals.

Identify behavioral or health outcomes.

Develop a behavior change plan.

Reiterate benefits of change.

Address environmental and interpersonal facilitators and barriers to change.

Determine a time frame for implementation.

Ask the person to make a commitment to healthcare goals.


School-Age Children

Adapt the questions in the previous paragraph and also ask the following: Has your child been part of home, school, or community education programs related to alcohol,drugs, sexuality, acquired immunodeficiency disease syndrome (AIDS), birth control, or sexually transmitted diseases (STDs)? Does the child brush his or her teeth and practice other health promotion behaviors without being reminded? How is he or she doing in school?


Ask the adolescent the same questions as you asked about the school-age child, and also ask the following:

Who are your community role models?

All Adults

Ask adults of any age: What is your or your family’s definition of health? Do you believe you are healthy? Do other family members believe they are healthy? What health practices are included in your and your family’s lifestyle?

How is the family affected when someone is ill? Do you and your family have access to healthcare? Do you all have health insurance? Do you all receive regular physical and dental examinations? What religious or cultural beliefs do you all have that guide your purpose in life and your health practices?

Young Adults

Primary physical growth is completed during the 20s,and body systems usually reach peak functioning.

Although most young adults are healthy, some major threats include accidental injury, cancer, heart disease, suicide, AIDS, and homicide. Men are more likely to die than women, especially as a result of homicide involving handguns. Ask the following questions: Are your immunizations up to date? Do you visit a family doctor? Do you perform self-screening (e.g., breast or testicular selfexamination)?

How often? What do you eat in a 24-hour period? Are there behaviors affecting your health that you would like to change?

Middle-Aged Adults

At this stage, people are likely to be knowledgeable and assertive about their health and healthcare. However, they may not know what specific screening tests they should have.Middle-aged men are less likely to seek routine preventive care than women,which may be one reason why the life expectancy for women is approximately7 years longer than that of men.Ask the following questions:How do you care for your teeth? What screening tests have you had and when (e.g., mammograms and prostate-specific antigen blood tests)? What were the results? Do you keep a written record of your physician visits,immunizations,and screenings? Do you get a yearly flu shot? How about pneumonia vaccinations, tetanusdiphtheria, and hepatitis B injections?

Older Adults

Many older people begin to develop health problems,but they need to know that it is never too late to begin living more healthfully. Social support is the key in maintaining wellness in the later years. Research shows that older people who regularly attend religious services are less likely to require hospitalization, and when they do, have shorter hospital stays.Ask the same questions you asked the middle-aged person, but stress the importance of getting immunized, limiting medication use, eating nutritious foods, drinking enough fluids, interacting with family and friends, and keeping active in the church or community.


Assessing Areas of Wellness

The following four areas are critical to maintaining wellness: rest and sleep, exercise, stress management, and injury prevention.

Rest and Sleep

Sleep restores, rejuvenates, and sometimes, heals the body. Lack of sleep causes fatigue, stress, depression, and a decrease in lymphatic system functioning, which increases the risk of infection and disease. The following factors can directly affect how well and how long we sleep:

Circadian rhythms: Also called the biological clock, these rhythms help regulate the sleep/wake cycle, body temperature, and hormonal levels within a 24-hour period. Disruption affects muscle strength and coordination, attention, memory, and concentration.

Age: Infants sleep 16 to 20 hours a day; preschoolers, 10 to 12 hours a day;school-age children, 9 to 10 hours a day; adolescents 71⁄2 hours a day; and adults and older adults, 6 to 8 hours a day. Babies spend more time in rapid eye movement (REM) sleep than adults. Young children may experience sleep problems such as nocturnal enuresis (bedwetting), nightmares (bad dreams), night terrors (nightmare from which child awakens screaming), and somnambulism (sleepwalking).  Older adults may take more time to fall asleep (sleep latency), may have a fragmented sleep pattern with less  deep sleep, and may awaken early.

Exercise: Moderate exercise has little or no effect on sleep; however, vigorous exercise before retiring may inhibit sleep.

Nicotine, caffeine, alcohol: Smoking increases the time needed to fall asleep and causes lighter sleeping and more frequent awakening. Caffeine near bedtime can increase sleep latency and reduce total sleep time, especially in older adults. Alcohol affects REM sleep, causing a fragmented sleep pattern, and also exacerbates sleep apnea.

Diet and weight: Sleep apnea is more common in obese people. High-protein foods increase alertness; carbohydrates promote relaxation. People who are gaining weight usually sleep more; those who are losing weight sleep less.

Medical problems: COPD, congestive heart failure (CHF), and pain can affect sleep patterns.

Stress: Stress often increases arousal and inhibits sleep.

Medications: Some prescription and over-the-counter (OTC) drugs can affect the number of hours a person sleeps as well as the sleep process.


Questions to Ask at Each Developmental Stage


Ask the parent(s) or caregiver(s):Where does the infant sleep? In what position do you place her or him? Does the infant sleep through the night? Does she or he go to sleep with a bottle? If so,do you remove it once she or he is asleep? (Having a nipple drip milk into the mouth once the child is asleep can cause tooth decay and ear infections, in addition to being a choking hazard.)

Toddlers/Preschoolers/School-Age Children

Ask the parent(s) or caregiver(s): Where does the child sleep? How many hours does he or she sleep? Does the child take naps? Does he or she sleep through the night?If not, how do you console the child when he or she awakens? What bedtime rituals do you practice? Does the child act tired during the day?


Ask the adolescent:How many hours do you sleep? Are you tired during the day? Do you have trouble paying attention at school or at work because of fatigue? Do you have a regular time you go to bed, and do you stick to it? Do you usually sleep through the night? If not, what causes you to wake up? How do you get back to sleep?

Young Adults

Ask the young adult: How many hours of sleep do you need to feel rested? How many hours of uninterrupted sleep do you get each night? Do you usually sleep through the night? If not, what causes you to wake up? How do you promote sleep or get back to sleep? Do you have a bedtime routine? Do you take medications that interrupt a normal sleep cycle? Do you take medications to help you sleep? Do you maintain a physical fitness program? Do you have problems concentrating because of fatigue? What are your usual work hours?

Middle-Aged Adults

Ask the same questions as you asked the young adult, as well as the following:How would you describe your quality of sleep? What time do you usually go to bed? How long does it take you to go to sleep? What time do you usually wake up and get up? What do you do for relaxation and how often do you do it?

Older Adults

Adapt the questions you asked the young and middleaged adults, and add the following:What activities do you engage in during late afternoon or early evening? If you have trouble falling asleep, have you tried a light, warm snack at bedtime?



Today, with so many people working at sedentary jobs,exercise needs to be planned for. Research shows that women are less active than men; people with lower incomes and less education are less active than those with higher incomes and education; people with disabilities are less active than people without disabilities; African Americans and Hispanics are less physically active than Caucasians; and many children and youth are overweight and exercising less, except for those active in organized sports. Major barriers to increasing physical activity are lack of time, access to convenient facilities,and safe environments in which to be active.


Questions to Ask at Each Developmental Stage


Keep in mind what gross and fine motor skills are normal at this age.Ask the parent(s) or caregiver(s):Does the infant play with her or his hands and feet and make noises? What kinds of toys do you give her or him? Which toys does the infant prefer? How often do you change her or his toys and play environment? Do you check toys regularly for loose parts and other safety hazards?


Keep in mind what gross and fine motor skills are normalat this age. Ask the parents(s) or caregiver(s): Does the child have any physical limitations? Does he or she tire easily? What activities does he or she like? Does the child have a safe environment to explore and play? Whom does he or she play with? How many hours does your child watch TV or participate in other sedentary activities? What do you do to encourage physical activity during bad weather?

School-Age Children

Ask the same questions as you asked about the toddler/preschool child, as well as the following:

To the child: Do you play organized sports? What precautions do you take, and what protective equipment do you wear?

To the parent(s) or caregiver(s): Do you encourage physical activity? Do you engage in physical activities with your children?


Ask the adolescent: What competitive sports or other physical activities do you like? Do you schedule exercise during your week? How often and for how long? Do you exercise with friends? Do you have any physical limitations? Have you ever been injured during exercise? Does your school encourage participation in physical activities? What precautions do you take and what protective equipment do you wear? Do you gain satisfaction from exercising?

Young Adults

Ask the young adult: What physical activities do you include during an average week? How often and for how long? Do you have any physical limitations? Do you have any health conditions that should be evaluated before beginning an exercise program? Where do you exercise?Do you participate in activities that raise your heart rate? Do you include a warm-up and cool-down period? Do you participate in organized sports? What precautions do you take and what protective equipment do you wear?Have you had any exercise-related injuries? With whom do you exercise? Do you engage in physical activities as a family? Do you enjoy your exercise program?

Middle-Aged Adults

Ask the middle-aged adult:What kinds of exercise do you do? How often and for how long? Where do you exercise? With whom do you exercise? Do you warm up before and cool down after each exercise period? Have you had any unusual or uncomfortable feelings before,during, or after exercising? (If so, refer back to the person’s cardiovascular, respiratory, and musculoskeletal history data.)

Older Adults

Ask the same questions as you asked the middle-aged patient, but emphasize that the older adult should check with her or his doctor before starting a new exercise program.


Stress Management

Multiple stressors can occur at any age, even infancy,although different age groups are subject to different stressors.

Over time, stress can cause hypertension, cardiac arrhythmias, cardiovascular disease, gastrointestinal problems, headaches, and decreased immunological functioning, which can contribute to cancer and other diseases.


Questions to Ask at Each Developmental Stage


Keep in mind what social developmental milestones are normal for this age. Ask the parent(s) or caregiver(s) the following: What emotions have you seen the infant express? How does the infant calm himself or herself when crying? How do you calm the infant when he or she is unable to become calm? How would you describe his or her temperament? Does the infant entertain himself or herself when alone? How do you set limits for him or her? Does your home environment provide cognitive, physical, and psychosocial stimulation for the infant?

Who provides child care when needed? Does the caregiver stick to the infant’s usual routines?


Adapt the preceding questions, and also ask the following:How does your child calm herself or himself after an emotional outburst? Children tend to regress when ill, so what do you do to support the child’s developmental level when she or he is ill? How do you show affection to your child, and how does she or he respond? How well does your child play with other children? What kinds of conflicts occur with other children? How do you set disciplinary guidelines for your child? How do you encourage her or his development of autonomy and initiative? How does she or he interact with siblings? How does she or he express positive (love,affection,happiness,joy) and negative emotions (hate, jealousy, anger, fear)? Do you actively model healthy expression of emotions in the home? Does your child enjoy child care experiences?

School-Age Children

To the child:Do you usually feel happy and contented?Do you like yourself? What do you do when you feel bored or sick? Do you like to compete with others in organized or informal activities? Do you enjoy learning new things? Do you feel confident as you begin new projects?Do you enjoy the challenge of solving new problems? Do you feel like your parents or caregivers support your activities and enjoy your successes? Do they support you even when you do not meet their expectations?Do you think of the consequences of your behavior before acting? Who are your friends? Do you feel included in most peer-group activities? If you have conflicts with friends,what is the source of the conflict, and how do you resolve it? Do you receive an allowance or have an opportunity to earn money? How do you manage your money? Do you feel good about your progress at school? What do you like most and least about school?How often do you miss school or other activities because you do not feel well? What types of physical activities do you do? How often and for how long?

To the parent(s) or caregiver(s): Do you give your child an allowance and provide general guidelines for money management? How do you display your interest in your child’s school work/progress? How do you support your child when he or she does not feel well? How would you describe your child’s friends? What stressmanagement techniques do you model or actively teach your child? How does your child act when he or she is tired or stressed out? How does he or she cope with emotional stress? What types of changes have affected your family and the child during the last year?


Adapt the questions for the school-age child, and also ask the following: Do you feel comfortable with the physical changes accompanying puberty? What accomplishmentsare most important to you? What stressors do you experience weekly? How do you reduce stress or the effects of stress? Are you able to be assertive when you need to be?

Can you give an example? What risks have you taken in the last year? Do you use tobacco, alcohol, or street drugs? What about OTC and prescription drugs? If so,what kinds,how often,and how much? How would you describe your peer group and your relationship with the group? How would you describe your relationships with the same sex, the opposite sex, and adults? How do you usually make decisions? What plans do you have once you leave or complete high school? Who are your role models for stress management? How do your parents support your efforts to be an independent person? What are the most common sources of conflict with your family and your peers? How do you resolve conflicts when they occur? Whom do you go to for support when you have a problem? What steps would you take if you were depressed or had thoughts of suicide or if you saw these characteristics in a friend? Have you ever been the victim of violence? Have you ever abused an animal or another person?

Young Adults

What stressors do you experience weekly? How do you reduce stress or the effects of stress? What risks have you taken in the last year? How do you make decisions? How would you describe your relationships with the same sex and the opposite sex? What are the most common sources of conflict with your family, friends, and coworkers? How do you resolve conflicts when they occur? Do you use tobacco, alcohol, or street drugs? What about OTC and prescription drugs? If so,what kinds,how often, and how much? Have you ever been the victim of violence? Have you ever wanted to hurt or abuse another person? Are you satisfied with your career choice? If not, what are your plans for a change? Do you have problems with time management?If you have children, what parenting rewards and challenges do you encounter? Do you feel confident and satisfied with your parenting skills?

Middle-Aged Adults

Ask the same questions that you asked the young adult.

Older Adults

Adapt the questions you asked the young adult and middleaged adult,and also ask the following:When do you plan to retire from a full-time position? Are your financial resources adequate? Do you plan to work part-time after retirement? What activities are you interested in (e.g., travel, hobbies,volunteer work in the community)?


Injury Prevention

Injuries can occur at any age, and most people have a significant injury at some time in their lives. Although most accidents are predictable and preventable, accidental injuries are the leading cause of death in the 1- to 34-year old age group. Additional millions are incapacitated by accidental injuries.


Questions to Ask at Each Developmental Stage


Ask the parent(s) or caregiver(s):What have you done tomake your home safe for the infant? Do you use an infant car seat? Is the infant regularly exposed to tobacco smoke? Has she or he been injured as a result of an accident in the home, in another’s home, or while riding in a motor vehicle? How often do you check equipment and toys for possible hazards? Are there guns in your home or in your caretaker’s home? If so, are they securely stored?

Toddlers/Preschoolers/School-Age Children

Adapt the preceding questions, and also ask the parent(s) or caregiver(s) the following: Have you taught your child personal safety guidelines? Does he or she use protective equipment when participating in physical activities like skating or bicycling? Who supervises your child when he or she is playing? Can he or she swim and does he or she know water safety guidelines?


Case Study Analysis and Plan


Ask the adolescent: Do you like to take risks? Have you completed a driver education course? What safe-driving behaviors do you practice? Do you talk on a cell phone while driving? Do you consider yourself well informed regarding the transmission, signs, symptoms, and treatment of STDs? Are you sexually active, and if so, do you practice safe sex? Do you know where to get confidential medical attention if you believe you have an STD or may be pregnant? Do you use alcohol, tobacco, or street drugs? What about OTC and prescription drugs? If so, what kinds, how often, and how much? Do you ever drive while under the influence of alcohol or drugs? Do you have guns in your home, and if so, are they securely stored? Have you ever been injured as a result of participation in physical activities? What protective measures do you take? Would you recognize signs and symptoms of depression in yourself or a peer? What would you do if you or a peer were depressed or had thoughts of suicide?

Young Adults

Adapt the preceding questions, and also ask: Have you evaluated your occupational health risks? What resources are available to you at work related to health maintenance or injury prevention? Do you have smoke and carbon monoxide detectors in your home,and do you check them frequently?

Middle-Aged Adults

Adapt the preceding questions, and also ask: Are you aware of environmental hazards in the home (e.g., loose rugs, electrical cords, stairways, steps)?

Older Adults

Adapt the questions for young and middle-aged adults,but focus on the prevention of falls.Ask:Can you describe any hazards in your home, especially in the bathroom,kitchen, or outside steps and sidewalks? Do you use an assistive device,such as a cane,walker,or wheelchair? Do you keep them in good repair? Have you made any modifications to your home, such as a wheelchair ramp or grab bars in the tub and by the toilet?

Definition of Health Promotion

Health Promotion is the provision of information and/or education to individuals, families, and communities that-encourage family unity, community commitment, and traditional spirituality, that make positive contributions to their health status. Health Promotion is also the promotion of healthy ideas and concepts to motivate individuals to adopt healthy behaviors.

According to the World Health Organization, Health promotion is the process of enabling people to increase control over, and to improve their health.

Health promotion represents a comprehensive social and political process, it not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual health.

Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. Participation is essential to sustain health promotion action.

The Ottawa Charter identifies three basic strategies for health promotion. These are advocacy for health to create the essential conditions for health indicated above; enabling all people to achieve their full health potential; and mediating between the different interests in society in the pursuit of health.

These strategies are supported by five priority action areas as outlined in the Ottawa Charter for health promotion:

Build healthy public policy

Create supportive environments for health

Strengthen community action for health

Develop personal skills, and

Re-orient health services

The Jakarta Declaration on Leading Health Promotion into the 21st Century from July 1997 confirmed that these strategies and action areas are relevant for all countries. Furthermore, there is clear evidence that:

Comprehensive approaches to health development are the most effective. Those that use combinations of the five strategies are more effective than single-track approaches;

Settings for health offer practical opportunities for the implementation of comprehensive strategies;

Participation is essential to sustain efforts. People have to be at the center of health promotion action and decision-making processes for them to be effective;

Health literacy/ health learning fosters participation. Access to education and information is essential to achieving effective participation and the empowerment of people and communities.

For health promotion in the 21st century the Jakarta Declaration identifies five priorities:

Promote social responsibility for health

Increase investments for health development

Expand partnerships for health promotion

Increase community capacity and empower the individual

Secure an infrastructure for health promotion

Each of these priorities is further defined in the glossary. Increasing community capacity is addressed in the definition of community action for health. Empowerment for health is included as a definition.

The most well known definition of health promotion is that of the World Health Organization’sOttawa Charter


Health promotion is the process of enabling people to increase control over, and to improve their health (the full definition is provided in the WHO website).

This definition was slightly modified in 2005, in WHO’s Bangkok Charter for Health Promotion in a Globalised World to:

Health promotion is the process of enabling people to increase control over their health and its determinants, and thereby improve their health.

WHO has produced seven consensus documents on health promotion, the latest in 2009 in Nairobi. For more information on these, go to Milestones in health promotion and the7thGlobal Conference on Health Promotion.

Models of health promotion

While the definition of health promotion has been universally adopted, there have been a number of different approaches to promoting health. Over the past 30 years, three key models of health have influenced health promotion. 

The biomedical model of health (pre-1970s):

§  focuses on risk behaviours and healthy lifestyles

§  emphasises health education – changing knowledge, attitudes and skills

§  focuses on individual responsibility

§  treats people in isolation of their environments

 The social model of health (from 1970s onwards):

§  addresses the broader determinants of health

§  involves inter-sectoral collaboration

§  acts to reduce social inequities

§  empowers individuals and communities

§  acts to enable access to health care

 The ecological model of health (from late 1970s onwards):

§  acknowledges the reciprocal relationship between health-related behaviours and the environments in which people live, work and play (behaviour does not occur in a vacuum)

§  considers the environment is made up of different subsystems – micro, meso, exo and macro

§  emphasises the relationships and dependencies between these subsystems

§  is comprehensive and multi-faceted, using a shared framework for change at individual and environmental levels

The World Health Organisation defines as - "the process of enabling people to increase control over, and to improve, their health..."

To reach a state of physical, mental and social wellbeing an individual or group must be able to identify and to realise aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore seen as a resource for life, not the objective of living. Health is a positive concept emphasising social and personal resources, as well as physical capacities. Therefore health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to wellbeing" (Ottawa Charter for Health Promotion, 1986).

Health promotion represents a comprehensive social and political process. It not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual health. Health promotion is therefore the process of enabling people to take control over the determinants of their health and thereby improve their health (Nutbeam, 1998)

Health Promotion is about making a difference to people’s health and the conditions that support their health. It is a way of thinking and doing. The basic principles and values that characterise health promotion and assess whether you are working in a health promoting way include;

§  Adopting a holistic view of health (physical, social, spiritual and mental health)

§  Focusing on equity and the addressing of inequities (guided my social justice)

§  Focusing on the determinants of health, the social, behavioural, economic and environmental conditions that are the root cause of health and illness

§  Emphasising active consumer and community participation (including all concerns and needs at all stages work)

§  Building on existing strengths and assets, not just addressing health problems and deficits

§  Using multiple strategies to promote health at the individual and community/population level (policy development, organisational change, community development, advocacy, education, communication and legislation)

§  Basing work on best available evidence and having a commitment to planning and evaluation

§  Working in partnership with key stakeholders (both inside and especially outside the health care setting)

§  Considering the differences in gender and cultures


There is no uniform definition of health as it applies to individuals, families, and communities. Yet, a definition forms the foundation for personal perceptions and is crucial in determining individual health promotion behaviors.

Some factors that affect health behaviors are the person’s motivation, support system, psychological state, and access to healthcare.

The key to assessing wellness is to identify the person’s perspective of health and any factors that affect health behaviors, and then work with him or her to develop a plan that promotes healthy living.