The National Prevention Strategy: Catching up with the Nation
With the nation about to renew its emphasis on wellness and prevention with the delivery of the National Prevention Strategy, it is fair to wonder if the long-established approaches to prevention and health promotion can truly upend their own paradigm and achieve the strategy’s goal of
“… Moving the nation from a focus on illness and disease to one based on wellness and prevention.”
That objective is a true clarion call and one that has great resonance for a large majority of the population who want of more investment in prevention (1).
Prevention is well understood within the national health policy and program establishment, which presents the first challenge to make such a dramatic change envisioned in the NPS.
For instance, Altarum’s George Miller noted in a February 2011 presentation of recent research into prevention spending: “National Health Expenditure Accounts do not identify spending for prevention … Previous estimates – on the order of 1-5 percent of U.S. health care expenditures – use inconsistent (and sometimes imprecise) language to describe what they measure.” And, he noted, those estimates rely on out-of-date research (2).
There is a real world disconnect between public preferences and solutions available from the prevention establishment. But it is not so difficult to understand why, after 30 years of effort, we don’t have better prevention data, a better understanding of prevention, or even agreement on the definition for the term. Instead, we contend with a health profile of our citizenry that is truly discouraging. One reason why: Prevention and health promotion have been executed from within the provinces of the health care enterprise and its surrounding public edifice, whose primary purpose is to create a great system to resolve illness, sickness, and injury. Wellness and prevention have never had a real place in that job description.
This is one reason why prevention programs and strategies can be a stew of unrelated issues, at least from a wellness perspective: blending with public safety issues, such as walkways to schools or using seatbelts, with matters of sheer biology like immunization.
Perhaps focusing on the term “wellness” will help. It presents a completely different challenge, in that apart from references to worksite wellness, it is hard to find defined in any broad coherent way. It really suggests more of an aspiration, probably centered on lifestyle choices, rather than an issue area, around which programs and funding regimes can be wrapped.
Yet if we choose to, we can look out onto a growing, expansive realm of wellness, one that is outside the traditional confines of prevention and health. That’s OK, since you can see new forms of wellness and prevention initiatives taking shape there.
Out here, we find that over the last 30 years, the nation has developed a massive, robust “national wellness infrastructure.” Most of its enterprises are not included when describing prevention and health promotion strategies. Yet each shares a common attribute that bears directly on wellness and prevention: the outcome of their work, stated directly or indirectly, is establishing a healthy base for civic life. Among them:
• Green building and systems
• Sustainability and environmental restoration
• The nutrition-centric wing of the health food industry
• Personal wellness, and fitness industries
• Complementary and integrative medicine
• Genomics, brain research, and personal biology
• Clean energy
• New professions, such as in employee behavior change and health coaching
• Technologies supporting personalization, prevention. and consumer health empowerment
This list is notable because in large part it represents the activities of the private and nonprofit sectors, innovations in local government and public-private partnership among them. These engines of real-world response to public demand have been all but absent in variations of the prevention strategy. They have also created a profusion of wellness-centric brushfires across the country:
• Spas providing evidence-based healing therapies (3).
• Green buildings and systems are establishing a healthier physical place, even as their primary objective is reducing operating costs (4).
• K-12 schools are suddenly test beds for completely revamped food programs, which in the process advance local farm-to-school initiatives.
• Innovative PE teachers have taken the research about the impact of exercise on cognition and have created “Learning Based Fitness” that will put “gym” with the leather football helmets (5).
• Green schools are instructing in the idea of stewardship by putting their students and curriculum into their green surroundings.
• Worksite wellness programs are expanding modality options to include health-bolstering integrative practices (6).
• Sustainability entrepreneurs have established market-based approaches to restoring natural systems such as streams (7).
The nation needs lots more initiatives like these. It also needs to understand better their health and wellness-creating attributes and outcomes. It needs to begin to take what has been learned in K-12 schools, for instance, and to accelerate its adoption in schools today, even though specific outcome evidence may be decades off in terms of the people (students) and their long-term health. This kind of institutionalization is happening in employer settings, although apparently without a lot in the way of health (not financial) outcome measures for the participating employees; that also takes time.
So, how does the nation actually get more of this, in the context of its new prevention strategy?
First, it is necessary to draw a distinction. Consider this: Wellness – let’s say optimal personal wellness – is a state of human health animated by its own unique, inherent values and potential. It stands apart from the corresponding values and potential of health care. Each merits serious personal and national focus, attention and commitment.
If we accept this distinction (and why wouldn’t we?), and we can thus elevate wellness and prevention as a distinct objective of national health, we can then imagine a realignment of assets already at hand that can be directed to accelerating the adoption of wellness ideas and practices like the brushfires described above. For instance:
1. Disentangle true wellness-creating activities from those historically included in prevention and health promotion programs, such as auto safety, work site safety, ensuring safe products, or requiring helmets for skiers.
2. Ensure that the health research enterprise creates a coherent approach to identifying and describing wellness-centric issues. That may even mean institutional distinctions to isolate research on the science of wellbeing from condition-centric research. A number of current and forthcoming changes in our health research already reflect the creeping influence of the “real world:”
a. The science of behavior change is being re-envisioned at the National Institutes of Health in order to match the market’s rapid adoption of worksite wellness and behavior-change-based incentive programs.
b. Comparative Effectiveness Research: the CER program created a Patient-Centered Outcomes Research Institute, which, along with independent initiatives in the patient community using social media, is bringing the patient closer to research design (8).
c. Nutrition science has revealed much about the relationship between food and brain health; the National Cancer Institute is studying the potential of diet to alter cancer effects (9).
d. The newly released strategic plan of the National Center for Complementary and Alternative Medicine at NIH reports that 50 percent of the use of integrative therapies – some $25 billion worth – are applied for personal health support, rather than to resolve a problem (10).
3. Recognize and stimulate initiatives in the commercial and nonprofit sectors and via existing public-private partnerships that are establishing not only healthier outcomes, but also a new appreciation for the importance of health and prevention, personally and in the community.
4. Establish a financial structure that will accelerate investments in, purchases of and adoption of wellness-inducing initiatives, enterprises and services.
In other words, we should pour some fuel on those brushfires.
The aggregation of the executive branch departments and agencies and the creation of an Advisory Group on Prevention created by the Affordable Care Act contain the seed for the kind of collaborative, paradigm-shifting actions that will be required to truly move to a focus on wellness and prevention. The challenge will be to move those actions out beyond the traditional confines of prevention and health promotion and ensure that “wellness and prevention” are given the discrete institutional and programmatic attention it will take to make a difference.
The best real outcome, and the only one that truly matters, is increasing the number of healthy, vital Americans in our population. The public, despite its contrary lifestyle behaviors, expects as much. In the last 15 years or so, we’ve learned enough about human biology and behavior to start the necessary realignment. And the actors in the marketplace have helped carve out real paths to follow.
(Adapted in part from the forthcoming paper, “The Integrative Healthspace: Organizing the Nation’s Wellness Infrastructure,” spring 2011. Integrative Health & Wellness Strategies; http://www.integrativestrategies.us)
1. Greenberg Quinlan Rosner Research and Public Opinion Strategies. (2009, November). American public supports investment in prevention as part of health care reform. Report for the Robert Wood Johnson Foundation.
2. Miller, G., Roehrig, C., Hughes-Cromwick, P., & Turner, A. (2011, February 19). What do we really spend on prevention in the U.S., and what is missing from our calculations? Presented at Preventive Medicine 2011, San Antonio.
3. Ellis, S. (2011, January 25). Let the spa research begin! (Guess what… it already has). Retrieved from http://blog.spafinder.com/spa-industry/spa-research-guess-whatit
4. Singh, A., Syal, M., Grady, S. C., & Korkmaz, S. (2010, September). Effects of green buildings on employee health and productivity. American Journal of Public Health, 100(9), 1665–1668.
5. Iskander, M. (2011, February 8). A physical education in Naperville. Retrieved from http://www.pbs.org/wnet/need-to-know/video/a-physical-education-in-naperville-ill/
6. Tu, H. T., Boukus, E. R., & Cohen, G. R. (2010, December 13). Workplace clinics: A sign of growing employer interest in wellness. Retrieved from http://www.rwjf.org/coverage/productpreview.jsp?id=71564&cid=XEM_910232
7. Harmon, R. (2010, November). How the market can keep streams flowing. Retrieved from
8. Walsh, T. (2010, November 23). Comparative Effectiveness Research (CER) in Oncology Summit. Retrieved from http://theintegratorblog.com/index.php?option=com_content&task=view&id=711&Itemid=93
9. Walsh, T. (2009, November). Back to the garden? NCI studying food and genetics. Retrieved from http://gettingto.wordpress.com/2009/12/28/back-to-the-garden-nci-studying-food-and-genetics/
10. National Center for Complementary and Alternative Medicine. (2011, February 4). Exploring the science of complementary and alternative medicine: Third strategic plan: 2011–2015. Retrieved from http://nccam.nih.gov/about/plans/2011/
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