Adult health builds on the disease prevention and health promotion successes and failures achieved in maternal, infant, child, and adolescent health. The previous chapters have outlined principles and strategies for a community and population approach to health that apply similarly to an approach to adult health. One philosophical principle that increases in importance as we progress through the life span is the principle of participation. With infants and children, paternal guidance and discipline is unavoidable and essential but with adolescents, it begins to backfire as teenagers rebel against authority. With adults, the will of others tends to be ignored unless it is clearly understood to correspond with the self-interests and needs of the adults themselves. Besides the technical objectives outlined for this chapter, we attempt to illustrate approaches that apply principles of adult education and democratic decision-making to community self-determination in matters of health.

Most of the risk factors for adult health involve the pleasures of life and will be indulged by the public regardless of the admonitions of health professionals. The risk factors for heart disease, stroke, cancer, and lung disease are reviewed epidemiologically and behaviorally to illustrate this point, which will be developed further in Chapter 12.

A Lifetime of Poking Pays off. YELLOW SPRINGS (AP, Mar. 10, 1999). Over the past 32 years, Suzanne Bosl has been pierced with large-bore needles, held her breath in an underwater tank, spit into test tubes and even endured ice-cold cakes of glycerin on her skin. But Bosl says any discomfort was worth being part of the "Fels family," a group of test subjects for perhaps the largest and longest-running study of human growth, body composition and risk factors or heart disease. The Fels Longitudinal Study began in 1929 in this southwest Ohio village. The study was initially funded by Samuel Fels of the Fels soap company in Philadelphia at the request of his friend Arthur Morgan, then president of Antioch College in Yellow Springs.

Test May Cut Colon Cancer Deaths. WASHINGTON (AP, Mar. 3, 1999) The death rate from colon cancer, the second leading cancer killer in the United States, could be reduced by up to a third if more people over 50 started using a simple screening test that detects bleeding in the bowel, researchers say. In a study published Wednesday, Minnesota researchers say a study of the long-term health of 46,000 volunteers shows that people who take an annual fecal occult blood test have 33% fewer deaths from colon cancer than do people who do not take the test. Among those who are tested every other year, the death rate is reduced by 21%, the study found. The study is published Wednesday in the Journal of the National Cancer Institute.

PAP Screening Result May Lead to New Guidelines. WASHINGTON (AP, Feb. 5, 1999)  A large study of Canadian women says very few cases of mild cervical abnormalities detected by Pap smears progress to cervical cancer, a finding that may affect how women with the condition are treated. Some 50 million women in the United States get a Pap smear every year, a simple test that can detect precancerous cell changes before they turn into cervical cancer. Paps detect mild abnormalities, called "mild dysplasia," as well as severe lesions that are poised to become cancerous imminently. Regardless of the degree of dysplasia, women often are referred for more in-depth testing called colposcopy, or even a biopsy. But doctors have questioned how necessary the extra - and expensive - care is for women whose dysplasia is mild.

Two books on women caring for men's health. NY Times book reviews. July 20, 2004.

Prevalence of Diabetes and Impaired Fasting Glucose in Adults --- United States, 1999--2000. (2003). MMWR Weekly Report, 52, No. 35, Sept 4, 2003. 

Public Health Dispatch: Multistate Outbreak of Hepatitis A Among Young Adult Concert Attendees --- United States, 2003. (2003). MMWR Weekly Report, 52, No. 35, Sept 4, 2003.
   http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5235a5.htm

Public Health Dispatch: Multistate Outbreak of Hepatitis A Among Young Adult Concert Attendees --- United States, 2003. (2003). MMWR Weekly Report, 52, No. 35, Sept 4, 2003.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5235a5.htm

Cocco, P., Heineman, E.F., & Dosemeci, M. (1999). Occupational Risk Factors For Cancer Of The Central Nervous System (CNS) Among US Women. AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 36 (1): 70-74.
    ABSTRACT: Background: In a recent report, we found an elevated risk of cancer of the central nervous system (CNS) in several occupations and industries, and-a modest association with exposure to solvents and to contact with the public. Results: Overall, CNS cancer risk showed a 20-30% increase among women exposed to electromagnetic fields methylene chloride, insecticides and fungicides, and contact with the public. Risk for meningioma was elevated among women exposed to lead (OR = 1.9; 95% CI 1.0,3.9). CNS cancer did not show a clear pattern of risk increase by probability and intensity of exposure to any of the explored risk factors, Cross-classification by probability and intensity of exposure did not reveal any significant trend Cases were too few to explore trends of meningioma by probability and intensity of exposure to lead. Conclusions: We did not find evidence of a strong contribution of 11 occupational hazards to the etiology of CNS cancer. However; limitations of the occupational information might have reduced our ability to detect clear patterns of risk.

De Grasse, C. E., O'Connor, A. M., Boulet, J., Edwards, N., Bryant, H., Breithaupt, K. (1999). Changes In Canadian Women's Mammography Rates Since The Implementation Of Mass Screening Programs. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 927-929.
    The Journal’s Home Page is: http://www.ajph.org/.
    ABSTRACT: Objectives. This study reports on Canadian mammography rates between 1990, when mass screening programs were launched, and 1994/95. Methods. Mammography rates from 2 national surveys were compared according to the presence of a provincial screening program. Results. Mammography rates among women aged 50 to 69 years (the targeted group) increased significantly, by 16%; increases were twice as high in provinces with screening programs, Among women in their 40s (nontargeted group), the changes were insignificant and independent of screening program status. Conclusions. Screening programs appear to have influenced the mammography rates of targeted women aged 50 to 69 years.

Glasgow, R.E., Fisher, E.B., Anderson, B.J., LaGreca, A., Marrero, D., Johnson, S.B., Rubin, R.R., Cox, D.J. (1999). Behavioral Science In Diabetes - Contributions And Opportunities.  DIABETES CARE 22 (5): 832-843.
    ABSTRACT: Objective - To summarize the current status of behavioral research and practice in diabetes and to identify promising future directions. Conclusions - Changes are required on the part of behavioral scientists in how they organize and present their research and on the part of potential users of this knowledge, including other health professions, organizations, and funding agencies. Integrating behavioral science advances with other promising genetic, medical, nutritional, technology health care, and policy opportunities promises not only to broaden our understanding of diabetes but also to improve patient care, quality of life, and public health for persons with diabetes.

Jeffery, R.W., & French, S.A. (1999). Preventing Weight Gain In Adults: The Pound Of Prevention Study. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 747-751.
    ABSTRACT: Objectives. This study examined whether weight gain with age could be prevented through the use of a low-intensity intervention. Results. Individuals in intervention groups reported favorable changes over time in frequency of weighing and healthy dieting practices relative to those in the control group. These behavior changes were in turn related to a reduced rate of weight gain over time. However, weight gain over 3 years did not differ significantly by treatment group. Conclusions. This low-intensity educational approach to weight gain prevention sustained interest over a lengthy time period and was associated positively with behavior change, but it was not strong enough to significantly reduce weight gain with age.

McHorney, C. A. (1999). Health Status Assessment Methods for Adults: Past Accomplishments and Future Challenges. ANNUAL REVIEW OF PUBLIC HEALTH 20: 309-336.
    ABSTRACT/Full-Text: Abstract.

McNeil, C. (1999). Can Guidelines Be Integrated Into Everyday Practice? The NCCN in Year 4. JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 753-755.
    ABSTRACT: http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;91/9/753.

Michaud, D.S. et al (1999). Fluid intake and the risk of bladder cancer in men. THE NEW ENGLAND JOURNAL OF MEDICINE 340 (18): 1390-1397. 
    ABSTRACT: http://content.nejm.org/cgi/content/short/340/18/1390. A study that followed nearly 48,000 men over a 10-year period, showed that those drinking over 6 cups (1440 ml) of water per day had up to a 50% lower rate of bladder cancer than those who drank less than 1 cup (240 ml) per day.

Mosca, L., McGillen, C., Rubenfire, M. (1998).  Gender Differences in Barriers to Lifestyle Change for Cardiovascular Disease Prevention. JOURNAL OF WOMEN'S HEALTH 7 (6): 711-716.

Nelson, N. J. (1999). Purple Carrots, Margarine Laced With Wood Pulp? Nutraceuticals Move Into the Supermarket.   JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 755-757.
    ABSTRACT: http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;91/9/755.

Pollan, M., & Gustavsson, P. (1999). High-risk occupations for breast cancer in the Swedish female working population. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 875-881.
    ABSTRACT: The purpose of this study was to estimate, for the period 1971 through 1989, occupation-specific risks of breast cancer among Swedish women employed in 1970. For the complete abstract, go to: http://www.ajph.org/cgi/content/abstract/89/6/875.
    The Journal’s Home Page is at: http://ajph.org/.

Ramirez, A.G., Villarreal, R., McAlister, A., Gallion, K.J., Suarez, L., & Gomez, P. (1999). Advancing The Role Of Participatory Communication In The Diffusion Of Cancer Screening Among Hispanics. JOURNAL OF HEALTH COMMUNICATION 4 (1): 31-36.
    ABSTRACT: Based on previously demonstrated methods, a cancer prevention program combining media and interpersonal communication was conducted in a Texas border city (Brownnsville) in 1995-1996. To evaluate the program a quasi-experimental panel design study followed 107 women in a program site and 105 women in a comparison site from 1994 to 1996. Women in the program site reported an increase in levels of Pap screening adherence.

Reynolds, T. (1999). Declining Breast Cancer Mortality: What's Behind It? JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 750-753.
    ABSTRACT: http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;91/9/750.

Schwartz, M.D., Rimer, B.K., Daly, M., Sands, C., & Lerman, C. (1999). A randomized trial of breast cancer risk counseling: The impact on self-reported mammography use. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 924-926.
    The Journal’s Home Page is: http://www.ajph.org/.
    ABSTRACT: Objectives. We evaluated the impact of individualized breast cancer risk counseling on mammography use among women at risk for breast cancer. Methods. Participants (n = 508) were randomized to the breast cancer risk counseling intervention or a general health education control intervention, and 85% completed follow-up. Results. in multivariate modeling, a significant group-by-education interaction demonstrated that among less-educated participants, standardized breast cancer risk counseling led to reduced mammography use. There was no intervention effect among the more-educated participants. Conclusions. These results suggest that standard breast cancer risk counseling could have an adverse impact on the health behaviors of less-educated women.

Toobert, D.J., Strycker, L.A., Glasgow, R.E.  (1998). Lifestyle Change in Women with Coronary Heart Disease: What Do We Know?  JOURNAL OF WOMEN'S HEALTH 7 (6): 685-700.

Wannamethee, S.G., & Shaper, A.G. (1999). Type Of Alcoholic Drink And Risk Of Major Coronary Heart Disease Events And All-Cause Mortality. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 685-690.
    ABSTRACT: Objectives. This study examined the effects of beer, spirits, and wine drinking on coronary heart disease (CHD) events (fatal and nonfatal) and all-cause mortality. Results. Regular drinkers showed a significantly lower relative risk of CHD, but not all-cause mortality, than occasional drinkers, even after adjustment for potential confounders. The benefit for CHD of regular drinking was seen within both beer drinkers and spirit drinkers but not among men who reported wine dl inking. However, all men who reported wine drinking (both occasional and regular) shelved significantly lower age-adjusted risks of CHD and all-cause mortality than men drinking beer or spirits; beer and spirit drinkers showed similar risks. Conclusions. The findings suggest that regular intake of all alcoholic drinks is associated with a lower risk of CHD, but not all-cause mortality, than occasional drinking. A large part, but not all, of the greater benefit seen in wine drinkers relative to other drinkers can be attributed to advantageous lifestyle characteristics (e.g., low rates of smoking and obesity).

Prevalence of Diabetes --- U.S. Virgin Islands, 1999-2001.  Morbidity and Mortality Weekly Report, 52(27), July 10, 2003.

Update:  Cardiac and Other Adverse Events Following Civilian Smallpox Vaccination --- United States, 2003.

Colorectal Cancer Test Use Among Persons Aged greater than or equal to 50 Years --- United States, 2001.  Morbidity and Mortality Weekly Report, 52(10), March 14, 2003.    

At Home HCV Test Gains FDA Approval. JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 908, 1999. The first over-the-counter test of its kind, called "Hepatitis C Check," has been approved by the U.S. Food and Drug Administration. It is made by the Home Access Health Company of Hoffman Estates, Ill., and will be sold nationwide at pharmacies in the United States. Abstract:
http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;91/11/908

Stat Bite: Melanoma Incidence in U.S. Whites. JOURNAL OF THE NATIONAL CANCER INSTITUTE 91: 912, 1999. Abstract:
http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;91/11/912

Stat Bite: Breast Cancer Mortality Rates: U.K., Canada, and U.S., 1950-1994. Journal of the National Cancer Institute 91: 752, 1999. http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;91/9/752

2. Mass media. Campaigns and public service announcements are used to inform the public about the health consequences of alcohol, smoking, hypertension and diet. What would you include in a report which addresses the effectiveness of mass media campaigns. Can such reports be used successfully to change behavior?

3. Community resources. Voluntary, government, and private agencies and organizations play varying roles in offering assistance to those seeking to change life-style related behaviors. Pick a health-related behavior, such as smoking, over or under eating, alcohol abuse, and explore the various community resources available to assist in lifestyle change. Gather materials from these agencies and compare them by message, cost, feasibility, and appropriateness for different segments of the adult population. What recommendations would you make as community workers to various segments of the population regarding these different resources?

4. Family health history. Develop a family health history that explores as far back as you can go and with as extended a view as possible, the following questions: How long did people live? From what did they die? What current health problems/strengths to adults (over age 21 years) have? Pull this information together in a "family tree" chart. How does your family compare with national or local statistics with regard to longevity? Mortality? Morbidity? What implications are there for your own health-related behaviors?

5. Social determinants of health. Explore the broader social contexts within which lifestyle behaviors exist. Either pick a lifestyle behavior, such as smoking or drug use, or a disease, such as cancer or heart disease, and explore the statistics of these through the lenses of gender, socioeconomic status, and ethnicity. For example, how are women who present with heart attack symptoms treated in comparison with men? How is it that those in lower socioeconomic strata are more likely to be obese? What contributes to different smoking rates among ethnic groups?

6. Making changes. Changing lifestyle behaviors is difficult. Interview an adult who has either been successful or unsuccessful in making a lifestyle change such as quitting smoking or loosing or gaining weight. Explore with the person the history of this behavior, the factors that contributed to it, and the factors that facilitated or hindered them in making changes. Explore these influences on behavior using the PRECEDE model introduced in Chapter 4, with particular focus on the educational diagnosis. Categorize influences on behavior (facilitators or barriers) using the predisposing, enabling, and reinforcing factors. Such diagnosis often reveals that people trying to make lifestyle changes have sufficient knowledge, but lack other kinds of support necessary for sustained change.

Consider issues of confidentiality and ethics in conducting research, such as interviews. What do you need to learn about interviewing in order to ask the right questions? How will you treat the data with confidentiality? Consider using participatory research in which you would take your data analysis of the predisposing, enabling, and reinforcing factors back to the person interviewed for comment and input.