increase that we yearly add to our hundred billion dollar health care bill apparently has only a marginal utility. The committee believes that a health education and promotion strategy offers hope, a hope manifested by shifting emphasis from curative medicine, currently the predominant and extraordinarily expensive modality, to prevention and health maintenance.

2. DEFINITION OF HEALTH EDUCATION

The Committee found that there was no single acceptable definition of health education. Several were offered, all contributing to an understanding of its potential application.

In view, then, of the frequent inconsistency in use of the terms "health education" and "consumer health education," the Committee felt it essential to develop what it has chosen to call a "mega-definition." The term "consumer health education and promotion" subsumes a set of activities which:

(1) inform people about health, illness, disability, and ways in which they can improve and protect their own health, including more efficient use of the delivery system;

(2) motivate people to want to change to more healthful practices;

(3) help them to learn the necessary skills to adopt and maintain healthful practices and lifestyles;

(4) help other health professionals to acquire these teaching skills:

(5) advocate changes in the environment that facilitate healthful conditions and healthful behavior; and

(6) add to knowledge via research and evaluation concerning the most effective ways of achieving the above objectives. In brief, consumer health education is a process that informs, motivates, and helps people to adopt and maintain healthy practices and lifestyles, advocates environmental changes as needed to facilitate this goal, and conducts professional training and research to the same end. For purposes of this Report, the definition agreed to by the Committee is as follows:

"Health education and promotion" is a process that favorably influences understandings, attitudes, and conduct, including cultural awareness and sensitivity, in regard to individual and community health. Specifically, it affects and influences individual and community health behavior and attitudes in order to moderate self-imposed risks, maintain and promote physical and mental health and efficiency, and reduce preventable illness, disability, and death.

3. HEALTH EDUCATION TARGET GROUPS AND PROGRAMS

A. Patient Education.-A consumer becomes a patient when he or she recognizes a health problem or a potential problem and turns to a physician, clinic, hospital, or some other component of the health care delivery system for assistance. This is an important distinction: Patients have recognized a problem and made a commitment of time. and frequently of money. They are, therefore, more receptive to medical intervention and health education efforts.

A large proportion of patient education is done on an informal oneto-one basis by physicians in their own offices, nurses, therapists, and other health professionals. They are usually under severe time constraints and cannot provide either in-depth coverage of the instructional material or follow up.

Hospital health education programs are scarce and inadequate. In those hospitals that do have formal programs, they commonly start in one of three types of activities: Classes for diabetics, cardiac patients, or others with serious chronic diseases or disability; classes for expectant parents; and pre-operative instruction. For each of these topics there is a large potential "student body" and the information and procedures are fairly well established. Instruction is usually provided upon referral by a doctor or nurse, on a group basis, and by a member of the professional staff. Good programs, however, go beyond teaching assorted courses. In some hospitals, the committee learned, there is a fulltime health education coordinator to identify problem areas, gather resources, and coordinate ongoing efforts as there is in the United Hospitals of St. Paul, Minnesota. Such hospitals also assume responsibility for teaching the teachers-nurses, and mid-level health practitioners.

Some health maintenance organizations and clinics are also operating formal health education programs. For many years, the Health Insurance Plan of Greater New York (HIP) operated a large-scale educational program under an experienced educator and several of the Kaiser-Permanente units operate health education activities-the Oakland program, with its large-scale audio-visual equipment, achieving particular fame.

A major theme in recent patient education efforts is that individuals. must take responsibility for their own health. Diabetes programs, for example, attempt to formalize a patient's responsibility for health maintenance. Consider the treatment. What are the respective roles for the doctor and the patient? Ideally the disease should be discovered early. The physician makes a diagnosis and prescribes therapy. The patient must inject himself with the correct dosage of insulin every day. interpret his own urine samples and decide when a change is sufficient to warrant calling his physician. The patient must be motivated to lose weight, recognize and report side effects, learn proper techniques for foot and toenail care to avoid the devastating complication of infection and gangrene, recognize early symptoms of complications, and visit his physician when scheduled. The physician's role is essential to effective treatment; so too is the patient's. No amount of resources devoted to physician or hospital care can substantially reduce the cost of diabetes if the patient has not been adequately trained and motivated to do his part. The Committee recognizes, however, that there are and will continue to be very significant problems with regard to the management of diabetes. Education alone will not resolve the problems attendant to this disease, but it is an important aspect that needs emphasis.

When patient education programs are well thought out they have proved to be very successful. In the Los Angeles County Medical Center diabetes education program, a telephone "hotline" was introduced for information, medical advice and for obtaining prescription refills. Patients were educated to use this service through an aggressive Campaign of pamphlets, posters and counseling sessions by physicians

and nurses. When the program was evaluated, it was found that the incidence of diabetic coma was reduced from 300 to 100, the number of emergency visits by the diabetic patients were reduced by half, and that 2,300 clinic visits were avoided. Over two years, total savings was estimated at more than $1.7 million.

A modification of present education programs is the "self-help preventive medicine" offered by Georgetown University's Community Health Plan at Reston, Virginia. This organization has crystallized a concept, employed by a small but growing number of physicians, into an organized course consisting of seventeen weekly evening sessions of two hours each. Patients are taught what behavior practices are healthful; how to use basic medical equipment such as stethoscopes, sphygmomanometers, and otoscopes; and what to do in emergencies. The goals of the program are to create "activated patients" with a positive sense of their ability to affect their health, and to reduce some of the unnecessary, time-consuming, burdens currently placed upon the physician.

There is also a recognition in industry of the potential value of health education. Several companies, for example, have entered the field with films, tapes, cassettes, slides, models, teaching texts, and other audio-visual and printed teaching aides.

B. School health education.-The long run success of consumer health education programs rests on the behavior and health habits of children and youth. The public school system has the potential to influence these children, but the potential has not been adequately developed and, in general, the record is not impressive.

It is difficult to determine which states have effective school health education programs. Many have enacted legislation or issued administrative directives mandating health education in public schools. Frequently, however, funds have not been appropriated to implement and enforce these regulations.

School health education programs are faced with three major constraints: A tradition of low visibility and priority, a narrow definition of the appropriate jurisdiction for health education efforts, and a shortage of adequately trained health educators. The Committee considered the problems of school health education and decided to focus their attention on inservice education, establishing a program of grants to local education agencies and institutions of higher education for education opportunities for elementary and secondary school teachers in a broad scope of health education areas.

c. Community Health Education. The goal of targeted community programs is to identify individuals who are at risk, make them aware of the risk and steps they can take to reduce that risk, and, if symptoms are brought to light, to direct them to the appropriate care setting. Targeted community programs frequently start with screening for hypertension, tuberculosis, breast cancer, and sickle cell anemia.

The value of multiphasic screening has been debated and recently preliminary results from a randomized controlled evaluation have become available. The results, from a study begun in 1964 by the Kaiser-Permanente Medical Care Program, for example, indicate that screening can reduce the number of "potentially postponable" deaths and reduce medical costs for older men by $800 a year.

A major problem in all screening programs is the difficulty of obtaining follow-up compliance.

The informational "hot line" is another approach to community education that has been successfully used in some communities. At Monmouth Medical Center in Long Branch, N.J., a VD hotline gave diagnostic and treatment information and directed callers away from the hospital emergency room to the less costly clinic. The Committee favors the development and implementation of a model toll-free telephone system.

A unique example of targeted community education is the Stanford Heart Disease Prevention Program. The objectives of this large fiveyear interdisciplinary study are to teach individuals between the ages of 35 and 69 about heart risk factors and to stimulate them to adopt more healthful behavior. The study compared risk factor decreases in three similar California communities exposed to different mixes of television spots, printed materials, and personal instruction. The conclusion was that educational campaigns directed at an entire community could produce striking increases in the level of knowledge about heart disease and risk factors and marked improvements in risk factor levels.

It is research of this type that the Committee believes most imperatively should be funded. Changing behavior is a very complex phenomena and requires a series of longitudinal studies to identify the most effective methods. Funding should be available to qualified researchers from private nonprofit and public agencies and institutions for these purposes.

D. Occupational Health Education.-Individuals are exposed to environmental hazards in their place of work that can have severe implications for their health. The Occupational Safety and Health Administration (OSHA) identifies two categories of risk: (1) Safety hazards or dangerous physical conditions such as inadequate guards on machines; and (2) health hazards or unsafe levels of toxic substances and harmful physical agents such a asbestos and carbon monoxide.

Over the years, great progress has been made in reducing occupational safety and health hazards affecting American workers. It has been pointed out that for every industrial accident death there are now 50 cardiovascular casualties. However, in a dynamic technological Society such as ours new hazards constantly arise and old ones reappear in new forms. In scattered instances, employers are still resistent to government- or union-inspired efforts to control toxic substances.

To detect and control new hazards and to inculcate in the employee better understanding of his own responsibilities and rights under the Federal occupational safety and health laws, OSHA has undertaken an extensive employee educational program. Employees can obviously affect the safety of their environment by following recognized safety practices such as wearing hard hats and ear plugs. However, in the inore subtle area of health hazards, which are often difficult to detect without sophisticated equipment, their only protection often is knowing and acting on their legal rights. They can also request OSHA inspections when they suspect a hazardous health condition exists (and have their names withheld from their employers), and can review their employers' records for monitoring and measuring hazardous materials.

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In fiscal years 1974 and 1975, OSHA allocated $6.6 million for fifteen grants related to health education projects that test models of occupational health education. The formats and curricula OSHA obtains from these projects can be adapted by employees and employee groups to their own particular needs. A substantial multiplier effect is anticipated.

The largest contract, for $3 million, was let to the National Safety Council, which has developed four short courses and implemented them through 39 participating local safety councils. The courses include orientation to rights and responsibilities under the Act and instructions on setting up safety and health programs within establishments. Over 100,000 individuals have already been reached by this massive, geographically dispersed, program.

Another contract demonstrates the feasibility of using community and junior colleges as part of the job safety and health education delivery system, while another entails the creation of thirty-minute television programs on selected job safety and health topics.

Training individuals to recognize health hazards is complex because the problems vary by occupations. OSHA has selected five "target industries" in which the disability and death rates are substantially above average including, longshoring, meat and meat products, roofing and sheet metal, lumber and wood products, and miscellaneous transportation equipment.

OSHA's work has been supplemented by that of a number of unions and companies that have initiated their own education programs in areas not related to occupational safety but using the workplace as a focus for more general health education. For example, the United Mine Workers Union, which administers its own prepaid health insurance plan, has hired full time health educators in several regions, and conducts programs in preventive care and specialized classes for diabetics and others.

The Connecticut Mutual Life Insurance Company in Hartford, Connecticut, and the Scoville Manufacturing Company in Waterbury, Connecticut, each have a program to help workers with alcohol or other drug problems. In addition, Connecticut Mutual offers employees periodic voluntary physical examinations, occasional videotape presentations during the lunch hour on topics such as heart disease or alcoholism, and frequent health articles in company publications. The programs of both companies direct their promotional efforts largely toward supervisory personnel in the hope that they will refer workers who appear to have problems. Scoville no longer considers their program a cost item, because of the savings resulting from increased worker output. In fact, savings in the Waterbury plant alone, which employs about 4,000 of their 24,000 workers nationwide, are estimated to be more than $200,000 for 1974.

Annual health examinations and counseling programs for executives, periodic screening of blue-collar employees, lunch-hour lectures on a variety of health topics for both blue-collar and white-collar workers: these and many other general health maintenance and educational activities are currently taking place throughout American business and industry. Such efforts, successful as they have proved to be in individual situations, have scarcely made a dent in the general health problems of American workers. The blame, however, cannot