February 2007, Volume 11, Number 1

Guest Editorial
Health Promotion: Whose Responsibility Is It?

Suzanne M. Mahon, RN, DNSC, AOCN^®, APNG

Another new year is upon us. Human nature encourages people to strive to do better. Consequently, each new year, millions of people resolve to make changes in their lives. This year I will . . . stop smoking, eat better, walk more, get a mammogram, reduce stress, be a better parent, keep the house cleaner, get more organized, be more patient, get more sleep, schedule a colonoscopy, be a better nurse . . . the list goes on.

On the surface, few would argue that these things are bad. In fact, most of these resolutions have a positive domino effect. If I get more sleep, I may be less frustrated, more tolerant, and, ultimately, a better parent. If I get more organized, the house may be cleaner and I will be calmer, have less stress, and, yes, maybe even be a better parent.

If an individual gets a colonoscopy and has a polyp, it can be treated easily and toxic cancer therapies can be avoided, resulting in a less-stressed individual and family. If a woman has regular mammograms, any positive findings are likely to be caught early and treatment will be effective, resulting in minimal toxicity and a better quality of life. These are often major reasons cited for recommending cancer screening services. However, some look further and say that healthful behaviors are important because they save money. Although we cannot put a price on human life that is spared suffering, one can measure the healthcare dollars spent and productivity lost when a tumor is detected later and expensive therapies are required.

My nursing career has centered largely on the practice of prevention and early detection. To show how long, when I was taking extensive continuing education and training courses in prevention and early detection at the University of Texas M.D. Anderson Hospital in Houston in the late 1980s, it was estimated that for every dollar spent on cancer prevention and early detection, $9 in healthcare expenses and productivity losses were saved (University of Texas M.D. Cancer Center, 1988). If this inflation is similar to the price increases seen in gasoline and food costs, the savings today is likely to be substantial.

Financial savings are what ultimately attract many groups to educate about and make recommendations for cancer prevention—especially healthy lifestyle behaviors—and early-detection behaviors. The American Cancer Society (ACS) recently released revised recommendations for diet, exercise, and screening behaviors (Kushi et al., 2006). The organization estimated that about one-third of the 500,000 annual cancer deaths in the United States can be attributed to poor diet habits, obesity, and physical inactivity. Current ACS recommendations include 30 minutes or more of vigorous exercise at least five days per week, five or more servings of fresh fruits or vegetables daily, whole or refined grain consumption, desirable weight maintenance, and limited intake of alcoholic beverages. None of these recommendations is startling—many of them are resounded in New Year’s resolutions. Many agencies have similar guidelines. The federal government keeps an extensive list of guidelines at www.guidelines.gov. Clearly, keeping people healthy makes good fiscal sense, if not from an improvement in quality-of-life point of view.

Implementing these measures, however, is much more challenging. Most practicing oncology nurses have experienced frustration and disappointment in patients and families that do not implement obviously healthy behaviors. For many oncology nurses, patients who smoke and those who continue to do so after a cancer diagnosis are especially frustrating. What about patients with skin cancer who will not apply sunscreen? What about women who, despite extensive counseling and discussion, test positive for a BRCA mutation and neglect to get mammograms or consider other prevention measures?

As healthcare providers, oncology nurses often educate patients and encourage them to adopt a healthy lifestyle. Where does this responsibility begin and end? The answer may not be clear.

A new experiment in West Virginia’s Medicaid program is aimed at shifting some responsibility for personal health
to the patient (Solomon, 2006). The state’s Medicaid plan includes an enhanced benefit program for enrollees who sign a contract and agree to certain requirements. The program initially will reward enrollees who keep appointments, engage in recommended screening, take medications as directed, and follow recommendations for health improvement as directed by their healthcare provider. Patients who successfully meet these contractual agreements for health will be eligible for other health benefits not normally available under the plan. Those who fail to adhere to the contract run the risk of having their benefits reduced. Clearly, it is too early to determine whether the plan will improve personal health for the enrollees, what the costs will be, how many will fulfill the promises made in the contract, whether behaviors will be changed long term, and if quality of life is actually improved (Steinbrook, 2006).

What the West Virginia program addresses is the concept of compliance. When I was in my undergraduate program, students were taught that using the label “noncompliant” was wrong because of the term’s many negative connotations. If an individual chooses not to engage in a healthy lifestyle, he or she is maintaining autonomy.

Apparently, the pendulum is swinging. The West Virginia plan, although in its infancy, represents the opposite end of the spectrum. Patients control their destinies in the healthcare system to some extent through their compliance with the contract. Many extenuating issues beyond the control of patients could influence whether they can meet the commitments of the plan contract (Bishop & Brodkey, 2006). Is it the fault of children whose parents fail to get them to an appointment or fill a prescription? What if someone cannot arrive at an appointment because of transportation problems or an inability to leave work? Is it fair to penalize these individuals for circumstances beyond their personal control, especially if they are making other efforts to develop a healthy lifestyle? Ultimately, these social problems may limit services for some members.

The reality is that health promotion is probably the responsibility of patients and healthcare providers. Like many other relationships, the patient–provider relationship requires give and take, not an all-or-nothing approach. Patients need to be open to adopting health-promoting behaviors and make sincere and genuine efforts to incorporate those behaviors into their daily lives. Healthcare providers need to conscientiously introduce health-promoting behaviors, not just focus on fixing existing health problems.

Oncology nurses realize that recommending healthy behaviors to patients is one thing, but actually getting them to incorporate the behaviors into their daily lives is quite another. The West Virginia plan requires patients to sign a document that states they will read and follow the directions in health literature. Literacy rates are often lower for people living in poverty. Is simply providing literature and educational materials enough?

Other questions arise. Does health promotion have a place in practice? What about cancer survivors, who may not deal with malignancy again? Is ignoring other risks fair? Do healthcare providers really discuss health-promotion recommendations? Do patients get information on the rationale and scientific basis of such recommendations in understandable terms and in a way that might motivate them to choose the healthy behavior? Does the practice have a means to ensure that patients are informed about the importance of regularly scheduled checkups and screenings aimed at finding problems early? Dentists learned a long time ago that making appointments for next checkups before patients leave the office is best, even though the appointments are six months away. When patients schedule before leaving, they are making a commitment.

Most importantly, do we, as healthcare providers, take personal responsibility for our own health? Do we acknowledge to patients that this is sometimes hard to do, and do we share things that motivate us to engage in healthy behavior? Are you current in cancer screening tests such as mammography, gynecologic care, genitourinary care, skin cancer screening, and colonoscopy? Do you really protect your skin from ultraviolet light damage? Do you follow a healthy diet and try to maintain a reasonable weight? Do you walk or engage in exercise on a regular basis? Can your patients believe that you have a personal commitment to healthy behaviors, or do they look at you and think you probably do not do what you suggest they do? Are you a nurse who still smokes?

As you embark on another year filled with hopes and challenges, I hope you think about the resolutions that are easy to make and harder to keep. I hope you have incorporated at least one new healthy behavior into your life. I hope you take pride in any successes you have and that they have a domino effect, with one good behavior leading to another. I hope your efforts are obvious to your patients, inspiring them to make changes in their lives. I hope you develop at least one effective strategy to promote health in your patients outside of government mandates. May your new year be enriched by the challenges and, in the end, you look back and see all of the progress that you have made.

References

Bishop, G., & Brodkey, A.C. (2006). Personal responsibility and physician responsibility—West Virginia’s Medicaid plan. New England Journal of Medicine, 355, 756–758.

Kushi, L.H., Byers, T., Doyle, C., Bandera, E.V., McCullough, M., Gansler, T., et al. (2006). American Cancer Society guidelines on nutrition and physical activity for cancer prevention: Reducing the risk of cancer with healthy food choices and physical activity. CA: A Cancer Journal for Clinicians, 56, 254–281.

Solomon, J. (2006, May 31). West Virginia’s Medicaid changes unlikely to reduce state costs or improve health beneficiaries’ health. Center on Budget and Policy Priorities. Retrieved January 4, 2007, from http://cbpp.org/5-31-06health.htm

Steinbrook, R. (2006). Imposing personal responsibility for health. New England Journal of Medicine, 355, 753–756.

University of Texas M.D. Anderson Cancer Center. (1988). Cancer prevention and detection in the cancer screening center. Houston, TX: Author.

Suzanne M. Mahon, RN, DNSc, AOCN^®, APNG, is a clinical professor in the Division of Hematology and Oncology, Department of Internal Medicine, and in the Adult/Older Adult Nursing Program in the School of Nursing at Saint Louis University in Missouri.