|
PUBLIC HEALTH MATTERS
<br /> r
<br /> r
<br /> agree to be tested) are critical pieces of pro- According to this view, an intervention While many health education programs are
<br /> gram planning and evaluation and may be whose goal is to improve access to care very effective at transmitting information that
<br /> crucial to achieving health improvement, the among hard-to-reach populations has an ex- recipients learn and understand, programs
<br /> fundamental goal of decreased morbidity tremely relevant public health goal, assuming, generally are less successful at inducing be-
<br /> and mortality is the outcome by which the of course, the program is effective in improv- havior change. 17�18 Thus, while a rather nar-
<br /> program or series of programs ultimately ing access. Other examples of interventions row evaluation may demonstrate success (in
<br /> must be assessed. This is not to say that designed to reduce social inequalities will be terms of participants' understanding the mes-
<br /> each individual program or research study discussed further in step 5. sage), a program ultimately cannot claim suem
<br /> must achieve this end. Epidemiologic studies Also relevant when we consider public cess if behavior is unaffected and morbidity
<br /> may provide descriptive data that lead s& health goals and benefits is to whom the and mortality rates remain unchanged.
<br /> enlists years later to develop an intervention benefit will accrue. Public health interven- This is not to suggest that each program
<br /> that will result in a reduction in morbidity lions often are targeted to one set of individ- must reduce morbidity by itself. Individual
<br /> or mortality; a health education program uals to protect other citizens' health. Partner health education or screening programs, for
<br /> may be one of multiple and varied interven- notification programs and directly observed example, might be pieces of larger initiatives
<br /> tions that together reduce risks and ill therapy for tuberculosis are designed prima- to reduce cardiac morbidity and mortality.
<br /> health. The argument put forth here, how- rily to protect citizens from the health Data may show that multiple education cam-
<br /> ever, is that public health programs, inter- threats posed by others. In some contexts, paigns in different formats and with different
<br /> ventions, or studies must be designed with public health programs are designed prima- messages are required to induce widespread
<br /> an awareness of the relationship between rily to protect individuals from themselves, behavior change. Multidimensional efforts are
<br /> this program and an ultimate reduction in revealing that much of public health is inner- appropriate and useful, if data show that the
<br /> morbidity or mortality. ently and unabashedly paternalistic. Health combination is likely to evoke the desired rem
<br /> Of course, other types of benefits, gener- education campaigns, blood pressure screen- sult Again, however, if the multiple ap-
<br /> ally social benefits, can accrue from public ing, seat belt laws, and 55-mile-per-hour proaches are simply hypothesized or assumed
<br /> health programs as well. Public health pro- speed limits, while motivated in part by so- to reduce illness events, then further research
<br /> grams can result in greater employment, for cial concerns about costs, are, I suggest, mom must be done; a public health program is not
<br /> example, as well as less tangible benefits, tivated primarily to further individuals' abil- yet justified.
<br /> such as coalition building or the strengthen- ity to protect their own health. Restricting This step of examining existing data to
<br /> ing of communities. These benefits are ex- someone's liberty to protect him- or herself challenge our assumptions and implement
<br /> tremely important and should be given and restricting liberty to protect another per- only data-based policies or programs is often
<br /> strong consideration. They are, however, the son pose different ethical burdens, discussed neglected in public health. One can assume
<br /> incidental or intermediary outcomes of pub- further in step 3 . that this is not because professionals are indi&
<br /> lie health programs, rather than the pro- ferent to whether their methods relate to
<br /> grams' final goal. If a program has as its goal 2. How effective is the program in their outcomes, but because we simply as-
<br /> to increase employment as an end in itself achieving its stated goals? sume that they do, and we neglect to find
<br /> (rather than, for example, to increase employ- Proposed interventions or programs are data that prove us right or wrong. Thus, we
<br /> ment as a means to lower psychological mor- based on certain assumptions that lead us to introduce a program based on the assumption
<br /> bidity or as a means to improve socioeco- believe the programs will achieve their stated that some number of people who learn that
<br /> nomic, status and therefore lead to improved goals. Step 2 asks us to examine what those cigarettes cause asthma and lung cancer will
<br /> health) or to strengthen communities (rather assumptions are and what data exist to sub- quit smoking, or we call for HIV screening
<br /> than to strengthen communities as a means stantiate each of them. A cardiac risk reduc- because we assume that individuals who
<br /> to decrease interpersonal violence or as a tion program has as its ultimate goal the re- learn they are infected will begin to use con-
<br /> means to help watch out for the well-being of duction of fatal and nonfatal cardiac events. doms in sexual relationships. It is when our
<br /> the young or old persons in the community), The assumptions of this education program assumptions seem most intuitively obvious
<br /> then the program is primarily a social pro- (or the larger effort of which it is a piece) are that we are at greatest risk of neglecting to
<br /> gram, not a public health program. that the program will reach individuals at risk determine to what extent they are supported
<br /> As described further below, a reduction in for cardiac events; those individuals will learn by real evidence.
<br /> morbidity and mortality need not and could the risk reduction messages; individuals will While all programs must be based on
<br /> not be the goal of every individual public change their behavior (e.g., stop smoking, sound data rather than informed speculation,
<br /> health intervention or program; however, in- change diets, increase exercise) in ways sug- the quality and volume of existing data will
<br /> dividual public health programs should not be gested by the program; these changes would vary. The question for policy and ethics anal-
<br /> undertaken that are not part of a larger pack- not have occurred without the program; and ysis, then, is what quantity of data is enough
<br /> age of programs whose combined goal is the the behavior change in itself will result in to justify a program's implementation? As a
<br /> reduction of morbidity and mortality. fewer cardiac events. rule of thumb, the greater the burdens posed
<br /> 1778 1 Public Health Matters I Peer Reviewed Kass American Journal of Public Health November 2001 , Vol 91 , No . 11
<br />
|