If we want more evidence-based practice, we need more practice-based evidence.*

Chapter 21
Personal Health Care Services and Resources

Table of Contents




The task of community and population health in relation to personal health services is distinguished from that of medicine by the emphasis on distribution and equity of services for all rather than the highest possible quality of care for those who are able to pay. It also emphasizes the preventive medicine, rather than curative, aspects of clinical care. The objective of this chapter is to leave you with the challenge of contributing to the capacity of individuals and communities to take greater control of the resources and factors influencing their health.


Chapter 21 acquaints the reader with the range of consumer and personal health agencies that exist to protect and serve the public interest. These services fall into three major categories: consumer protection, personal health resources, including available personnel and facilities, and personal health care systems. Consumer protection is discussed in the context of medical quackery and health fraud. Types of health fraud, special services designed to benefit the consumer and agencies responsible for the control of fraudulent health services are reviewed. The discussion of personal health resources focuses on the medical, dental and hospital needs of the population, professional personnel, and hospital and nursing home facilities. Chapter 21 concludes with a review of health care systems in Sweden, Canada and the United States. Health care reform proposals for the United States are reviewed.


Table of Contents

Recent Headlines 

Milestones of U.S. National Health Insurance before Social Security Act

Milestones in Developing Access to Health Care between World War II and the Medicare-Medicaid Act

Canadian Milestones in Health Insurance and Health Services

Milestones in U.S. Managed Care


Recent Headlines

Medicaid costs increased 10% per year from 2000-2003, resulting mainly from downturn in economy. Health Affairs, Jan 2005.

DHHS Secretary nominee Leavitt testifies on possibility of Medicaid cuts at Senate Finance Committee. Jan 21, 2005. 

Care of Undocumented Immigrants Straining Hospitals in Southwestern U.S.  Apr. 15, 2003.

Bacteria Winning the Fight Against Drugs.  (Atlanta Journal Constitution, March 8, 2003) - According to a recent survey, antimicrobial resistance is increasing among the bacteria that cause meningitis, pneumonia, bloodstream infections, sinusitis, and otitis media.  Researchers say that 40% of all such infections will be resistant to at least penicillin and erythromycin by mid 2004.   McGeer, A & Low, DE.  (2003).  Is Resistance Futile?  Nature Medicine, 9(4):  390-392.

Herbal Remedies: Natural Does Not Mean Safe.  (New York Times, March , 2003) - The use of herbal remedies is on the rise, however, herbal remedies are do not meet standards of the Federal food, drug, and Cosmetic Act.

Medical Errors Come Home.  (Washington Post, February 18, 2003) -  A recent study published in the Annals of Internal Medicine suggests that  the number of medical errors that do not become apparent until the patient returns home are greater, but less deadly, than errors identified prior to release from the hospital.  Many of these errors are the result of wrong drug, dose, or treatmentSee: Forster, A.J. et al.  The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the HospitalAnnals of Internal Medicine, 138(3):  161-167.

Pharmacy Consultations Cut Death, Hospitalization Rates Jan. 21, 2003

Organization of Health Care Facility Linked to Successful Patient-Physician Relationship.  January 12, 2002

Nursing Deficit Linked to Hospital Deaths.  The Atlanta Journal-Constitution (August 8, 2002).   A report issued by the Joint Commission on Accreditation of Healthcare Organizations has linked the shortage of nurses to ill health.  However, many healthcare facilities deny that the shortage is having any impact on the health of patients.

Doctors Scale Back Medicare Business.  The Atlanta Journal-Constitution (June 9, 2002).  With the amount of reimbursements dropping and a heavy paperwork load, may physicians are limiting the number of Medicare patients being accepted or opting out of the program altogether.

The AMA Adopted a Policy on June 23, 1999 That Doctors Should Not Sell Health-Related Products For Profit. Likening the practice to "snake oil" peddling of the 1800s. Associated Press report on policy against product sales: http://www.inno-vet.com/articles/1999/58.htm. 

Drug-Related Hospitalizations Cost Florida Over $300 Million. (CSTAT by FAX, June 9, 1999, Vol.4, Issue 2). Nearly 40,000 hospitalizations in Florida were related to illicit substance abuse, and they increased the State's hospital costs by $304 million in 1997. See the full report at: http://www.cesar.umd.edu/cesar/csatfax/vol4/csat4-3.PDF .

Kaiser Members Sue HMO Over Ads. SAN FRANCISCO (AP, Mar. 17, 1999) - Members of one of the nation's largest HMOs have sued the organization, claiming they were duped by ads that said its doctors weren't influenced by financial concerns. The lawsuit contends Kaiser Permanente and its parent, The Permanente Federation, compromised care with their policies. "Kaiser has gone beyond the pale with its statements here that doctors make decisions based on medical need and there's no fiscal interference," said Jamie Court of the nonprofit Foundation for Taxpayer and Consumer Rights, which filed the proposed class-action lawsuit in Superior Court on Tuesday. The lawsuit contends that Kaiser withheld up to 30% of doctors' salaries and tied physician bonus pay and other compensation to reaching certain profit goals.
Kaiser called the allegations "patently false."

Clinton Pushes Medicare, Social Security Rescue ( Feb. 25, 1999) President Bill Clinton, on the road to build support for his administration's plan to shore up Social Security and Medicare, said Monday, that the nation will be glad 10 to 20 years from now that it made the hard decisions now needed to save the two programs. For related stories: http://cnn.com:80/ALLPOLITICS/stories/1999/02/25/clinton.arizona/

Medicare Makes Strides Vs. Waste. WASHINGTON (AP, Feb. 10, 1999) - Medicare is losing significantly less money to waste, fraud and mistakes, government auditors say. "It appears we have turned a corner and are headed in the right direction," said Nancy-Ann DeParle, administrator of the health insurance program for the elderly and disabled. An audit released Tuesday by the Health and Human Services Department's inspector general estimates that Medicare paid out $12.6 billion it shouldn't have in the government's fiscal year 1998, which ended Sept. 30. That's about 7 cents out of every dollar that was spent by Medicare in direct payments to health care providers, including doctors and hospitals.

President Offers Plan To Curb Medicare Fraud By Providers. (Associated Press January 25, 1998). Clinton clamps down on fraud and anticipates a savings of $2 billion.

Patients ' Bill Of Rights Stalled. (New York Times March 9, 1998).
A presidential commission is stalled on the important questions of how to enforce the Patients' Bill of rights.

Budget May Have Bigger Medicare Premium Increase. (Washington Post May 17, 1997). Medicare premiums for 37 million seniors have doubled in two weeks while budget is debated.

Drive-Through Mastectomies The Next Target. (USA Today November 19, 1996). Some medical plans are making mastectomies an outpatient service.

The Options For Medicare (Globe and Mail November 21, 1996). Fee for service or what? This article looks at the choices Canadians face in deciding what sort of medical insurance scheme they would like and can afford.

For related news stories, please click here.

Historic Dates in U.S. Health Insurance before the Social Security Act


1789  The Reverend Edward Wigglesworth assessed the health of Americans and produced the first American mortality tables.

1798  U.S. Marine Hospital Service established by U.S. Congress. Compulsory deductions for hospital service were made from seamen's wages.

1847  The first insurer to issue sickness insurance was organized: The Massachusetts Health Insurance Company of Boston.

1849  New York State passed the first general insurance law.

1850s The first insurance supervisory boards were created in New Hampshire, Massachusetts, Rhode Island, and Vermont.

1850  Individual accident insurance became available in the United States with the chartering of the Franklin Health Assurance Company in Massachusetts.

1851  One of the earliest voluntary mutual protection associations, La Societe Francaise de Bienfaisance Mutuelle, was organized in San Francisco. It is noteworthy for having established a hospital in 1852 to provide care for its members.

1855  The first separate insurance department, independent of any established agency, was created in Massachusetts.

1859  The first full-time insurance commissioner was appointed in New York.

1863  The Travelers Insurance Company of Hartford, Connecticut, offered accident insurance for railway mishaps, then all forms of accident protection. It was the first company to issue insurance on a basis resembling its present form.

1875  A number of mutual benefit associations, called ``establishment funds,'' were formed for employees of a single employer. The benefits provided usually included small payments for death and disability.

1890  Policies providing benefits for disability from specified diseases were first offered.

1890s This period brought the promotion of many fraternal associations, assessment mutuals, and industrial insurers. Because many of these companies and associations were inadequately financed and poorly managed, many states passed legislation against them.

1900  Shortly after the turn of the century, disability benefits became available for substantially all diseases.

1910  Montgomery Ward & Co., Inc, replaced its ``employee establishment fund'' with an insured contract. This plan is generally regarded as the first group health insurance policy.

1912  The Standard Provisions Law drafted by the National Convention of Insurance Commissioners (now the NAIC) was enacted by most states. This model law sought to provide uniformity and fairness in the ``operating conditions'' of the health insurance contract.

1916  First noncancellable disability income contract was offered.

1917  Group accidental death and dismemberment insurance was first written.

1920s Early in this decade individual hospitals began offering hospital expense benefits on an individual prepaid basis.

1920s First partial disability benefits for sickness and accidents became available.

1929  The first health maintenance organization, the Ross-Loos Clinic, was established in Los Angeles, California.

1929  A group of school teachers arranged for Baylor Hospital in Dallas, Texas, to provide room and board and specified ancillary services at a predetermined monthly cost. This plan is considered the forerunner of what later became known as the Blue Cross plans.

1929  With the depression, many companies entered a period of retrenchment in their disability income product line, particularly in the area of maintaining reasonable indemnity limits in order to avoid overinsurance.

1930s The depression stimulated the expansion of insurance coverages through both public demand and hospitals' encouragement.

1932  First citywide Blue Cross plan was tried out with a group of hospitals in Sacramento, California.

1935  The Social Security Act (P.L. 74-241) provided for the first time federal grant-in-aid to states for such public health activities as maternal and child care, aid to crippled children, blind persons, the aged, and other health-impaired persons.


Milestones in Developing Access to Health Care between World War II and the Medicare-Medicaid Act

1948  The National Labor Relations Board ruled, in a dispute between the United Steel-workers' Union and the Inland Steel Company, that the term ``wages'' be construed to include pension and insurance benefits. The U.S. Supreme Court upheld this ruling in a 1949 decision.

1949  Major medical expense benefits were introduced by Liberty Mutual Insurance Company to supplement basic medical care expenses.

1954  Congress introduced the disability ``freeze'' that stated that the quarters during which a worker is disabled are not counted in determining the number of quarters needed to be fully or currently insured under Old Age and Survivors Insurance (OASI).

1956  Disability insurance was added to the Social Security System, providing monthly cash benefits for insured persons who are totally disabled.

1957  Vision care expense benefits were introduced by private insurers, followed in 1959 by extended care facility expense benefits.

1959  Continental Casualty Company issued the first comprehensive group dental insurance plan written by an insurance company.

1960s Eligibility for disability benefits under Social Security was expanded.

1961  First state enrollment plan was made available by Connecticut to persons 65 and over on a state basis and under special enabling legislation allowing the pooling of risks by a group of insurance companies (Associated Connecticut Health Insurance Companies).

1963  The Health Professions Educational Assistance Act (P.L. 88-129) aided training of physicians, dentists, and public health personnel.

1964  Prescription drug expense benefits were introduced.

1964  The Nurse Training Act (P.L. 88-581) provided special Federal effort for training professional nursing personnel.

1965  Social Security Amendments of 1965 (P.L. 88-97) established a Social Security hospital insurance program for the aged and voluntary supplementary medical insurance program (Medicare) and grants to states for medical assistance programs (Medicaid).

1966  Program of governmental health insurance, Medicare, for people aged 65 and over, effective July 1.

1967  The Age Discrimination in Employment Act (ADEA) guaranteed employees between the ages of 40 and 65 the same benefits under employee benefit plans as younger employees.


Canadian Milestones in Health Insurance and Health Services


1919    National Health Plan first proposed


1947        First universal Hospital Insurance Plan introduced in Saskatchewan.


1957        Federal Hospital Insurance and Diagnostic Services Act (50/50 cost sharing between federal and provincial governments)


1961        Universal Hospital Plans in all provinces.


1962        First Universal Medial (physician) Care Plan in Saskatchewan.


1968        Federal Medical Care Act (50/50 cost sharing with provinces).


1972        Medical Plans in all provinces and the two territories.


1974    Minister of Health, Marc Lalonde, issues report, A New Perspective on the Health of Canadians, in which the three determinants of health other than medical care (lifestyle, genetics and environment) are given greater importance.


1977        Established Programs Financing (EPF) replaces 50/50 cost sharing to put the federal transfers to provinces and territories on a per capita basis.


1979    Hall Commission reports that extra-billing by doctors, requiring their patients to supplement what the provincial plan paid the doctor for specific services, threatened to create a two-tiered system.


1984        Canada Health Act passed, establishing the 5 principles for universality, accessibility, comprehensiveness, public administration, and portability of health care coverage across provinces.


1986    Minister of Health, Jake Epp, issues report on Achieving Health for All, simultaneously with the international Ottawa Charter for Health Promotion, giving renewed attention to determinants and strategies for health other than medical care.


1996    Federal government contributions to provincial health and social programs consolidated into a new single block transfer payment, the Canada Health and Social Transfer.


1997        National Health Care Forum issues report concluding that ďThe answer to the genuine need and desirability of health care reform will not be found in increased spending on health care. At the same time, emerging knowledge about non-medical interventions demands action at all levels of society.Ē


Milestones in Managed Care


1789        The Reverend Edward Wigglesworth assessed the health of Americans and produced the first American mortality tables.


1851    An early voluntary mutual protection association organized in San Francisco and established a hospital to provide care for its members.


1910        First example of an HMO, known then as a ďprepaid group practice,Ē at the Western Clinic in Tacoma, Washington, for lumber mill owners and employees.


1929        First rural farmersí cooperative health plan created by a doctor in Elk City, Oklahoma. Baylor Hospital in Houston, Texas, also provided prepaid care to 1,500 teachers. Ross-Loos Clinic established in Los Angeles as a forerunner of HMOs.


1932        The AMA adopts a strong opposition to prepaid group practices, endorsing instead indemnity-type insurance.


1937        In southern California, Kaiser Foundation Health Plan begins financing medical care for workers building an aqueduct in the desert. By 1990s, this plan covered 16 states and 7.3 million members.


1944        New York City employees get the Health Insurance Plan (HIP) of Greater New York as an early HMO for government workers. It now covers 1.1 million members.


1960        Kerr-Mills Act passed as forerunner of Medicare and Medicaid.


1965        Lyndon Johnson signs Medicare-Medicaid amendments to the Social Security Act (PL 88-97).


1967     Initial enrollment in Medicare for people aged 65+  was 19.5 million. In 1996 it was 8.1 million.


1973        Congress passes HMO Act to ensure access to employer-based insurance markets and and authorizes start-up funding.


1977        Carter administration reduces barriers to HMO creation; enrollment jumps from 6.3 million in 1977 to 67 million in 1997.


1978        First preferred provider organization (PPO) created when a benefits consulting firm in Denver negotiated discounts with physicians not in the contracted network of an HMO.


1994        HMO and PPO enrollment both reach 51 million, each accounting for 25% of the health plan market.


1997        Acquistions, alliances and mergers produce conglomerates of hospitals, insurance payers, and practitioners as managed care systems designed to provide comprehensive care.


Sources: Editorial: managing managed care, Washington Post Dec 25, 1997; Fisher I: HMO premiums rising sharply, stoking debate on managed care, NY Times Jan 11, 1998; Meyers E: The evolution of managed care, Academic Nurse 14(2):13, 1997. Health Headlines, daily from NY Times.



EP Publishing


Humorous medical anecdotes and bloopers submitted by physicians, nurses, transcriptionists, and therapists all over the world. All in the format of a day-to-day calendar. Truth is funnier than fiction!

Health Care Finance Administration
Office of Medicaid Management
Room 281, East High Rise Bldg.
PO Box 26678
Baltimore, MD 21207-0278 


Ask for the manual on Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.

National Council on Patient Infor. & Education
666 11th Street, NW, Suite 810
Washington, DC 20001
Phone: (202) 347-6711

Conducts professional meetings and occasional public information campaigns, such as "Speak up for Children: Talk About Prescriptions."

American Medical Association
AMA Book and Pamphlet Products
PO Box 10946, Chicago, IL 60610-0946
Phone: (800) 621-8335

Free catalog lists professional and patient education materials on a variety of topics. Volume discounts.

National Center for Health Services
5600 Fishers Lane
Rockville, MD 20857
Phone: (301) 443-5650

Conducts and supports research, demonstrations, and evaluations of problem in the organization, delivery, and financing of health care services; coordinates health services; disseminates the findings of health services research

Food and Drug Administration
Department of Health and Human Services
5600 Fishers Lane
Rockville, MD 20857

Insures that foods are safe, pure and whole-some; that drugs, medical devices and bio-logical products are safe and effective; that cosmetics are harmless; that all of the above are honestly and informatively packaged.

Consumer Product Safety Commission
1111 Eighteenth Street, NW
Washington, DC 20207
Phone: (202) 634-7740

Protects the public against unreasonable risks of injury from consumer products; assists consumers in evaluating the comparative safety of consumer products; promote research & investigation into the causes & prevention of product-related deaths and injuries.

Federal Trade Commission
Health Care Fraud Bureau of Consumer Protection
Pennsylvania Avenue at 6th Street, NW
Washington, DC 20580
Phone: (202) 523-3711

Prevents the dissemination of false or deceptive advertisements of consumer products in general, food, drug, cosmetics and therapeutic devices in particular, as well as other unfair or deceptive practices.

National Second Surgical Opinion Program Hotline
Washington, DC
Phone: (800) 638-6833; (800) 492-6603 MD only

The Second Surgical Opinion Hotline is open 24 hours a day, 7 days a week. It helps consumers find a specialist near them for a second opinion in non-emergency surgery. Callers to the National number will be referred to a local referral center for information on physicians in their area.

Pan American Health Organization
Regional Office of the World Health Organization
525 Twenty-third Street, N.W.
Washington, DC 20037

The program aims to enhance the preparedness of health institutions through contingency planning, training, public education and coordination with other sectors.

Community-Based, Problem-Focused,Health Services W.K. Kellogg Foundation
400 North Avenue
Battle Creek, MI 49017-3398
Phone: (616) 968-1611

The W.K. Kellogg Foundation has distributed more than $1 billion in support of programs in agriculture, education and health. Areas of emphasis within those broad fields include adult continuing education; community-based, problem-focused health services; a wholesome food supply; and broadening leadership capacity of individuals.

U.S. Department of Health and Human Services Public Health Service
Agency for Health Care Policy and Research
Suite 501, Executive Office Center
2101 East Jefferson Street
Rockville, MD 20852

Brochure on health insurance, Checkup on Health Insurance Choices.

American College of Preventive Medicine
1015 Fifteenth Street, N.W.
Suite 403
Washington, DC 20005
Phone: (202) 789-0004

The mission of the National Council for the Education of Health Professionals in Health Promotion is to assure that all health professionals are adequately prepared to make health promotion and disease prevention a part of their routine practice.



Consumer health including information on the latest fad drugs, diets, and quackery.

Managed Care Organizations and in Medicare http://www.ucpa.org/ucp_generaldoc.cfm/45/42/8/11399-11408/2384

For an example of a brochure describing patient rights 

More Websites on Personal Health Care Services and Resources


Woman's Guide to Health Care



Amery, W.K. (1999). Coming Full Circle In Pharmacovigilance: Communicating Safety Information To Patients Through Patient Packageinserts. PHARMACOEPIDEMIOLOGY AND DRUG SAFETY 8 (2): 121-129.
    ABSTRACT: Optimal drug therapy requires that the patient should be informed adequately, unequivocally and in timely fashion. Patient package inserts (PPIs) have an important facilitating role to play in this respect. Patients' confidence in the benefit of a drug treatment and their fear of its side effects are strong determinants of their adherence to that treatment. The patient should be informed of the expected benefit of a drug treatment, its likelihood and the expected time course of the effect, and not only of side effects and interactions, which constitutes the present focus. Moreover, prescribers need to be informed about the content of the PPIs for the medicines they prescribe.

Brown, R., Butow, P.N., Boyer, M.J., & Tattersall, M.H.N. (1999). Promoting Patient Participation In The Cancer Consultation: Evaluation Of A Prompt Sheet And Coaching In Question Asking. BRITISH JOURNAL OF CANCER 80 (1-2): 242-248.
    ABSTRACT: Active participation in the medical consultation has been demonstrated to benefit aspects of patients' subsequent psychological well-being. We investigated two interventions promoting patient question-asking behavior. The first was a question prompt sheet provided before the consultation, which was endorsed and worked through by the clinician. The second was a face to face coaching session exploring the benefits of, and barriers to, question-asking, followed by coaching in question-asking behavior employing rehearsal techniques. We conclude that a question prompt sheet addressed by the doctor is a simple, inexpensive and effective means of promoting patient question asking in the cancer consultation.

Buchanan, D. R. (2000). An ethic for health promotion: Rethinking the sources of human well-being. New York: Oxford University Press.

Desnick, L., Taplin, S., Taylor, V., Coole, D., & Urban, N. (1999). Clinical Breast Examination In Primary Care: Perceptions And Predictors Among Three Specialties. JOURNAL OF WOMENS HEALTH 8 (3): 389-397.
    ABSTRACT: To assess predictors of reported performance of screening clinical breast examination (CBE) by internists, family physicians, and obstetrician/gynecologists, we surveyed members of these specialties in four counties of Washington State. Fifty-one percent of physicians reported that they perform regular CBE on greater than or equal to 90% of their patients, although the proportion varied across specialty type. In a multivariate model, male gender, family practice specialty, and the perception of patient embarrassment were all associated with lower reported rates of performing regular CBE (p <0.05). Work to increase the performance of CBE should consider the role of male physician embarrassment and family physician training.

Freund, D., Lave, J., Clancy, C., Hawker, G., Hasselblad, V., Keller, R., Schneiter, E., & Wright, J. (1999). Patient Outcomes Research Teams: Contribution to Outcomes and Effectiveness Research. ANNUAL REVIEW OF PUBLIC HEALTH 20: 337-360.

Hulscher, M.E.J.L., Wensing, M., Grol, R.P.T.M., van der Weijden, T., & van Weel, C. (1999). Interventions To Improve The Delivery Of Preventive Services In Primary Care. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 737-746.
    ABSTRACT: Objectives. This review was conducted to determine the effectiveness of different interventions to improve the delivery of preventive services in primary care. Results. The 58 studies included comprised 86 comparisons between intervention and control groups. Postintervention differences between intervention and control groups varied widely within and across categories of interventions. Most interventions were found to be effective in some studies, but not effective in other studies. Conclusions. Effective interventions to increase preventive activities in primary care are available. Detailed studies are needed to identify factors that influence the effectiveness of different interventions.

Krieger, J., Collier, C., Song, L., & Martin, D. (1999). Linking Community-Based Blood Pressure Measurement To Clinical Care: A Randomized Controlled Trial Of Outreach And Tracking By Community Health Workers. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 856-86.
    The Journalís Home Page is at: http://www.ajph.org/.
    ABSTRACT: Objectives. This study assessed the effectiveness of enhanced tracking and follow-up services provided by community health workers in promoting medical follow-up of persons whose elevated blood pressures were detected during blood pressure measurement at urban community sites. Results. The enhanced intervention increased follow-up by 39.4% relative to usual can. Follow-up visits were completed by 65.1% of participants in the intervention group, compared with 46.7% of those in the usual-care group. The number needed to treat was 5 clients per additional follow-up visit realized. Conclusions. Enhanced tracking and outreach increased the proportion of persons with elevated blood pressure-detected during community measurement who followed up with medical care.

Lipton, H. L., Kreling, D. H.; Collins, T., & Hertz, K. C. (1999). Pharmacy Benefit Management Companies: Dimensions of Performance. ANNUAL REVIEW OF PUBLIC HEALTH 20: 361-402.

Mainous, A. G. III, Hueston, W. J., Love, M. M., & Griffith, C. H. III. (1999). Access To Care For The Uninsured: Is Access To A Physician Enough? AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 910-912.
    The Journalís Home Page is at: http://www.ajph.org/.
    ABSTRACT: Objectives. This study examined a private-sector, statewide program (Kentucky Physicians Care) of care for uninsured indigent persons regarding provision of preventive services. Results. The Kentucky Physicians Care group had significantly lower rates of receipt of preventive services. Of the individuals in this group, 52% cited cost as the primary reason fur not receiving mammography, and 38% had not filled prescribed medicines in the previous year. Conclusions. Providing free access to physicians fills important needs but is not sufficient for many uninsured patients to receive necessary preventive services.

Nawaz, H., Adams, M.L., & Katz, D.L. (1999). Weight Loss Counseling By Health Care Providers. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 764-767.
    ABSTRACT: Objectives. This study explores the pattern of weight loss counseling by health care providers in Connecticut and the associated weight loss efforts by patients. Methods. Data from the 1994 Connecticut Behavioral Risk Factor Surveillance system survey were analyzed to determine (1) the frequency of weight management counseling by health care providers of overweight adults with and without additional cardiovascular risk factors and (2) the current weight loss practices of overweight subjects. Results. Only 29% of all overweight respondents, and fewer than half with additional cardiovascular risk factors, reported that they had been counseled to lose weight. Conclusions. the findings suggest need for more counseling of overweight persons, especially those with cardiovascular disease risk factors.

Nichol, M. B., Venturini, F., & Sung, J. C. Y. (1999). A Critical Evaluation Of The Methodology Of The Literature On Medication Compliance. ANNALS OF PHARMACOTHERAPY 33 (5): 531-540.
    ABSTRACT: OBJECTIVE: To develop a simple evaluation tool to assess methodological rigor of the literature on patient compliance with medications, and to apply the tool to a sample of the literature. CONCLUSIONS: The quality of the compliance research was generally poor. These low scores reflect very important shortcomings in the methodology, such oversights make it difficult for the reader to critically assess the validity of the conclusions.

Powell-Griner, E., Bolen, J., & Bland, S. (1999). Health Care Coverage And Use Of Preventive Services Among The Near Elderly In The United States. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (6): 882-886.
    The Journalís Home Page is at: http://www.ajph.org/.
    ABSTRACT: Objectives. It has been proposed that individuals aged 55 to 64 years be allowed to buy into Medicare. This group is more likely than younger adults to have marginal health status, to be separating from the workforce, to face high premiums, and to risk financial hardship from major medical illness. The present study examined prevalence of health insurance coverage by demographic characteristics and examined how lack of insurance may affect use of preventive health services. Methods. Results. Many near-elderly adults least likely to have health care coverage were Black or Hispanic, had less than a high school education and incomes less than $15 000 per year, and were unemployed or self-employed. Health insurance coverage was associated with increased use of clinical preventive services even when sex, race/ethnicity, marital status, and educational level were controlled. Conclusions. Many near-elderly individuals without insurance will probably not be able to participate in a Medicare buy-in unless it is subsidized in some way.

Other References

Alternative Medicine And Behavioral Medicine. On Nov 11, 1998 the Journal of the American Medical Association (JAMA) published an "Alternative Medicine Theme Issue," (v.260, no.18) and in late October Congress voted to elevate the NIH's Office of Alternative Medicine to a new National Center on Complementary and Alternative Medicine (NCCAM), with a $50 million budget increase.

But what IS alternative medicine? The NCCAM defines it functionally, as interventions which are not taught widely in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance companies." NCCAM elaborates further, listing six fields of alternative medicine: diet-nutrition-lifestyle changes, mind-body interventions, bioelectromagnetic applications, alternative systems of medical practice, manual healing, pharmacological and biological treatments, and herbal medicine. Based on a similar definition, researcher David Eisenberg MD, Director of the Center for Alternative Medicine and Research at the Beth Israel Deaconess Hospital, found that 40 percent of the American population used some form of alternative medicine therapy in 1997.

American Medical Association / Medicare RBRVS: The Physicians' Guide. 1999. Chicago: American Medical Association, 1999, $64.95. ISBN: 0899709672.

Presents new and revised Medicare payment regulations & relative values issued by the Health Care Financing Administration. Easy-to-use guide providing an overview of the current American health care nonsystem and how it operates.

Joint Commission for the Accreditation of Healthcare Organizations. The Complete Guide to the 1999 Hospital Survey Process. Chicago: Joint Commission for the Accreditation of Healthcare Organizations, 1999, $55.00. ISBN: 0866886109.

Manual designed to help hospitals prepare for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey process. Updates the previous 1998 edition.

National Center for Health Statistics (1999). Decreasing Hospital Use for HIV. NCHS Health E-Stats, No. 1.

The reduction in hospitalization for AIDS patients from 1995 to 1997 is consistent with the dramatic 62 percent decline in the AIDS death rate during the same period. The use of intensive antiretroviral therapies and continued AIDS prevention efforts were credited with the drop in the death rate and appear to have had a major impact on the need for hospital care for the treatment of HIV. "Decreasing Hospital Use for HIV, NCHS Health E-Stats, No. 1" is available on the NCHS Home Page at http://www.cdc.gov/nchs/products/pubs/pubd/hestats/hosphiv.htm.

 Studies using parts of the Precede Model (see Chapter 4) in understanding the determinants of physicians' practices in preventive care, :

Battista, R. N., Williams, J. L., & MacFarlane, L. A. (1986). Determinants of primary medical practice in adult cancer prevention. Medical Care 24: 216-24.

Burglehaus, M. J., Smith, L. A., Sheps, S. B., & Green, L. W. (1997). Physicians and breastfeeding: Beliefs, knowledge, self-efficacy and counselling practices.  Canadian Journal of Public Health, 88: 383-387.

Cheng, T. L., DeWitt, T. G., Savageau, J. A., & OíConnor, K. G.  (1999).  Determinants of counseling in primary care pediatric practice. Archives of Pediatrics & Adolescent Medicine 153: 629-635.


Costanza, M. E. (1992).  Physician compliance with mammography guidelines: Barriers and enhancers. Journal of the American Board of Family Practice 5(2): x1-x10.


Desnick, L., Taplin, S., Taylor, V., Coole, D., & Urban, N.  (1999). Clinical breast examination in primary care: Perceptions and predictors among three specialties. Journal of Womenís Health 8: 389-397.


Donovan, C. L. (1991). Factors predisposing, enabling and reinforcing routine screening of patients for preventing fetal alcohol syndrome: A survey of New Jersey physicians. Journal of Drug Education 21: 35-42.


Green, L. W. (1999b). What can we generalize from research on patient education and clinical health promotion to physician counseling on diet?  European Journal of Clinical Nutrition 53 (Suppl. 2): S9-S18.


Heywood, A., Firman, D., Sanson-Fisher, R., & Mudge, P. (1996).  Correlates of physician counseling associated with obesity and smoking.  Preventive Medicine 25: 268-276.


Hiddink, G. J., Hautvast, J. G. A. J., van Woerkum, C. M. J., Fieren, C. J., vanít Hof, M. A. (1995). Nutrition guidance by primary-care physicians: perceived barriers and low involvement. European Journal of Clinical Nutrition 49:842-851, 1995.


Hiddink G. J., Hautvast, J. G. A. J., van Woerkum, C. M. J., & Fieren, C. J. (1997a). Consumers' expectations about nutrition guidance: the importance of primary care physicians. American Journal of Clinical Nutrition, 65(suppl):1974S-1995S.


Hiddink, G. J., Hautvast, J. G. A. J., van Woerkum, C. M. J., Fieren, C. J., & vanít Hof, M. A.  (1997b).  Driving forces for and barriers to nutrition guidance practices of Dutch primary care physicians.  Journal of Nutrition Education, 29 (1), 36-41.


Hiddink G, J. , Hautvast, J. G. A. J., van Woerkum, C. M. J., Fieren, C. J., & van't Hof, M. A. (1997c). Information sources and strategies of nutrition guidance used by primary care physicians. American Journal of Clinical Nutrition, 65 (suppl):1996S-2003S.


Hiddink, G. J., Hautvast, J. G. A. J., van Woerkum, C. E. J., Fieren, C. J. & vanít Hof, M. A. (1997d). Nutrition guidance by primary-care physicians: LISREL analysis improves understanding.  Preventive Medicine, 26: 29-36.


Hiddink, G. J., Hautvast, J. G. A. J., van Woerkum, C. M. J., vanít Hof, M. A., & Fieren, C. J. (1999).  Cross-sectional and longitudinal analyses of nutrition guidance by primary care physicians. European Journal of Clinical Nutrition 53 (Suppl. 2): S35-S43.


Laitakari. J, Miilunpalo, S., & Vuori, I. (1997). The process and methods of health counseling by primary health care personnel in Finland: a national survey.  Patient Education and Counseling 30: 61-70.


Langille, D. B., Mann, K. V., Gailiunas, P. N. (1997). Primary care physiciansí perceptions of adolescent pregnancy and STD prevention practices in a Nova Scotia county.  American Journal of Preventive Medicine 13: 324-30.


Mann, K.V., & Putnam, R.W. (1989). Physicians' perceptions of their role in cardiovascular risk reduction. Preventive Medicine 18: 45-58.


Mann, K. V., & Putnam, R. W. (1990).  Barriers to prevention: physician perceptions of ideal versus actual practices in reducing cardiovascular risk. Canadian Family Physician 36: 665-670.


Mirand, A. L., Beehler, G. P., Kuo, C. L., and Mahoney, M. C.  (2002).  Physician perceptions of primary prevention:  qualitative base for the conceptual shaping of a practice intervention tool.  BioMed Central Public Health, 2(1): 16.


Walsh, J. M. E. & McPhee, S. J. (1992). A systems model of clinical preventive care: An analysis of factors influencing patient and physician. Health Education Quarterly 19:157-175.



Guidelines for physician action in preventive health care practices based on PRECEDE model (see chapter 4):


Clearie, A. F., Blair, S. N., & Ward, W. B. (1982).  The role of the physician in health promotion: Findings from a community telephone survey.  The Journal of the South Carolina Medical Association 78: 503-505.


Cooke, B. E. M. (1995).  Health promotion, health protection, and preventive services.  Primary Care  22: 555-564.


Downey, A. M., Cresanta, J. L., & Berenson, G. S. (1989). Cardiovascular health promotion in 'Heart Smart' and the changing role of physicians.  American Journal of Preventive Medicine 5: 279-95.


Green, L. W. (1987a). How physicians can improve patients' participation and maintenance in self-care. Western Journal of Medicine 147: 346-9.


Green, L. W.,  Eriksen, M. P., &  Schor, E. L.(1988). Preventive practices by physicians: Behavioral determinants and potential interventions. American Journal of Preventive Medicine 4 (suppl. 4, 1988): 101-7, reprinted in R. N. Battista and R. S. Lawrence, (Eds.), Implementing Preventive Services. New York: Oxford University Press, 1988; pp. 101-7. 


Green, L.W., Cargo, M., and Ottoson, J. M. (1994). The role of physicians in supporting lifestyle changes. Medicine, Exercise, Nutrition and Health 3: 119-130.   Also in Proceedings of the Twenty-ninth Annual Meeting of the Society of Prospective Medicine, St. Louis, Missouri, April 15-17, 1993.  Indianapolis, IN: Society of Prospective Medicine, Publishers, 1993, pp. 89-129.


Haber, D. (1994). Medical screenings and health assessments.  In D. Haber (Ed.), Health Promotion and Aging (pp.41-76).  New York, NY: Springer Publishing Company.

Herbert, C. P. (1999).  Editorial.  Should physicians assess lifestyle risk factors routinely? Canadian Medical Association Journal 160: 1849-1850.


Levine, D. M., Fedder, D. O., Green, L. W., McClellan, W., Roccella, E. J., Saunders, E., Simonds, S. K., Weiss, S., and Winston, M. (National High Blood Pressure Education Program Working Group on Health Education in High Blood Pressure Control).  (1987). The physician's guide:  Improving adherence among hypertensive patients.  Bethesda:  National Heart, Lung, and Blood Institute, National Institutes of Health.


Levine, D. M., Green, L. W., Russell, R. P., Morisky, D., Chwalow, A. J., and Benson, P. (1979). Compliance in hypertension management: what the physician can do. Practical Cardiology 5:151-160.

Li, V. C., Coates, T. J., Spielberg, L. A., et al. (1984). Smoking cessation with young women in public family planning clinics: The impact of physician messages and waiting room media. Preventive Medicine 13: 477-89.


Maiburg, H. J. S., Hiddink, G. J., vanít Hof, M. A., Rethans, J. J., & van Ree, J. W.  (1999).  The NECTAR-Study: development of nutrition modules for general practice vocational training; determinants of nutrition guidance practices of GP-trainees. European Journal of Clinical Nutrition 53 (Suppl. 2): S83-S88.


Makrides, L., Veinot, P. L., Richard, J., Allen, M. J. (1997). Primary care physicians and coronary heart disease prevention: a practice model. Patient Education & Counseling 32: 207-217.

Continuing medical education, dissemination and translation of research to practice in clinical settings, using the Precede Model (see chapter 4):

Bertram, D. A., & Brooks-Bertram, P. A. (1977). The evaluation of continuing medical education: A literature review. Health Education Monographs 5: 330-62.

Davis, D. A., Thomson, M. A., Oxman, A. D., & Haynes, R. B.. (1995).  Changing physician performance: A systematic review of the effect of continuing medical education strategies. Journal of the American Medical Association 274: 700-705.


Lomas, J. (1993). Diffusion, dissemination, and implementation: Who should do what? In K. S. Warren & F. Mosteller (Eds.). Doing more good than harm: The evaluation of health care interventions (pp. 226-237). New York: Annals of the New York Academy of Sciences, Vol. 703. Also in: Lomas, J. (1993). Diffusion, dissemination, and implementation: who should do what? Annals New York Academy of Sciences 703:  226-237.


Mann, K.V. (1994). Educating medical students: lessons from research in continuing education. Academic Medicine 69: 41-47.

Mann, K. V., Lindsay, E. A., Putnam, R. W., & Davis, D. A. (1996). Increasing physician involvement in cholesterol-lowering practices. Journal of Continuing Education in the Health Professions 16: 225-240.

Mann, K. V., Putman, R. W., Lindsay, E. A. & Davis, D. A. (1990). Cholesterol: Decreasing the Risk.  An educational program for physicians.  Journal of Continuing Education in the Health Professions, 10: 211-222.


Wang, V. L., Terry, P., & Flynn, B. S., et al. (1979). Multiple indicators of continuing medical education priorities for chronic lung diseases in Appalachia, Journal of Medical Education 54, 803-811.


Applications of the PRECEDE Model (see Chapter 4) in development of curriculum for nursesí education and standards, and assessment of primary care practices for purposes of planning continuing education and training for nurses and allied health personnel:


Berland, A., Whyte, N. B., & Maxwell, L. (1995). Hospital nurses and health promotion. Canadian Journal of Nursing Research 27: 13-31.


Canadian Council of Cardiovascular Nurses (1993). Standards for cardiovascular health education. Ottawa: Heart and Stroke Foundation of Canada.


Cretain, G. K. (1989). Motivational factors in breast self-examination: implications for nurses. Cancer Nursing 12: 250-256.


DeJoy, D. M., Murphy, L. R., & Gershon, R. M. (1995).  The influence of employee, job/task, and organizational factors on adherence to universal precautions among nurses. International Journal of Industrial Ergonomics 16: 43-55.


Macrina, D., Macrina, N., Horvath, C., Gallaspy, J., & Fine, P. R. (1996). An educational intervention to increase use of the Glasgow Coma Scale by emergency department personnel.  International Journal of Trauma Nursing 2: 7-12.


Mahloch, J., Taylor, V., Taplin, S., & Urban, N. (1993). A breast cancer screening educational intervention targeting medical office staff. Health Education Research 8: 567-579.


Mann, K. V., Viscount, P. W., Cogdon, A., Davidson, K., Languille, D. B., & Maccara, M. E.  (1996). Multidisciplinary learning in continuing professional education: the heart health Nova Scotia experience.  Journal of Continuing Education in the Health Professions 16: 50-60.


Miilunpalo, S., Jukka, L., & Ilkka, V. (1995). Strengths and weaknesses in health counseling in Finnish primary health care. Patient Education and Counseling 25: 317-328.


Morrison, C. (1996). Using PRECEDE to predict breast self-examination in older, lower-income women. American Journal of Health Behavior 20(2): 3-14.


Shamian, J., & Edgar, L. (1987). Nurses as agents for change in teaching breast self-examination. Public Health Nursing 4: 29-34.


Shine, M. S., Silva, M. C., & Weed, F. S. (1983).  Integrating health education into baccalaureate nursing education. Journal of Nursing Education 22: 22-7.


Simpson, G. W., & Pruitt, B. E. (1989). The development of health promotion teams as related to wellness programs in Texas schools. Health Education 20: 26-8.


Smith, P. H., Danis, M., & Helmick, L. C. (1998) Changing the health care response to battered women: A health education approach. Family & Community Health 20: 1-18.


Whyte, N., & Berland, A. (1993). The role of hospital nurses in health promotion: A collaborative survey of British Columbia hospital nurses. Vancouver: Registered Nurses Assn. of British Columbia and Vancouver General Hosp., Pub.28. [See summary: Health promotion in acute care settings: Redefining a nursing tradition. Nursing BC March-April, 1994, pp. 21-22.]



Applications of the PRECEDE Model (see Chapter 4) with pharmacists and pharmacy interventions:

Fedder, D. O. (1982). Managing medication and compliance: Physician-pharmacist-patient interactions. Journal American Geriatric Society 11 (Suppl.): 113-7.


Fedder, D. and Beardsley, R. (1979). Preparing pharmacy patient educators. American Journal of Pharmacy Education 43: 127-9.


Hill, J. (1990). Patient education--What to teach patients with rheumatic disease. Journal of the Royal Society of Health 110: 204-207.


Mann, K. V., Viscount, P. W., Cogdon, A., Davidson, K., Languille, D. B., & Maccara, M. E.  (1996). Multidisciplinary learning in continuing professional education: the heart health Nova Scotia experience.  Journal of Continuing Education in the Health Professions 16: 50-60.


Opdycke, R. A. C., Ascione, F. J., Shimp, L. A., & Rosen, R. I. (1992).  A systematic approach to educating elderly patients about their medications.  Patient Education and Counseling 19: 43-60.


Paluck, E. C. M. (1998). Pharmacist-client communication: A study of quality and client satisfaction.  Unpublished doctoral dissertation, University of British Columbia, Vancouver, Canada.

Paluck, E. C., Green, L.W., Frankish, C.J., Fielding, D.W., & Haverkamp, B. (2003). Assessment of communication barriers in community pharmacies. Evaluation and the Health Professions. In press for Dec 2003 issue.


Paluck, E.C., Haverkamp, B., Frankish, C.J., Fielding, D.W., Green, L.W. (2004). Pharmacist-client communication: An investigation into the relationship between client and expert ratings. Submitted.

Wallenius, S. H. (1995). Self-initiated modification of hypertension treatment in response to perceived problems.  The Annals of Pharmacotherapy.  29: 1213-1217.



1. Hospice care. Increasingly, medical and allied health personnel find it mutually beneficial to work together and with the lay public. The hospice provides an example of a setting in which such collaboration occurs. Visit a local hospice to determine how many, if any, teams of professional personnel (physician, nurse, social workers) exist to serve special patient needs. Also, to determine what kinds of volunteer or lay services support the hospice. What types of patients do they help? What types of special programs does the hospice offer as an adjunct to strict medical care (health education, support groups, nutrition counseling)? Is there any role for health promotion in a hospice setting?

2. Containing personal health service costs. The rising cost of health care in the United States is of grave concern to policy makers, public health professionals and the general public. Blame for spiraling costs is attributed to such factors as physician salaries, unnecessary hospitalizations, advances in technology, use of services by patients with preventable conditions, and the unwillingness of government to reform our massive health care system. How do current policies alleviate the strain of rising personal health service costs? At what level (community, state or federal) should health care reform policies be implemented? How can the effectiveness of these policies be evaluated?

3. Diagnosis related groupings (DRGs) and prospective payment. Diagnosis Related Groupings are an innovation whose impact has yet to be fully understood. Hospital stays, elective surgery and medicare expenditures declined. However, there are other factors to consider when evaluating the effect of DRGs on American hospitals. In particular, how will university teaching hospitals be affected? Will the learning experience of medical students and nursing students suffer or improve? How is size of the hospital and severity of illness among the hospital's patient population related to the impact of DRGs? Will patients be used as pawns in the stakes for financial survival? Pursue a more probing evaluation of DRGs, based on these and other questions in the DRG debate.

4. Hospitals. Ascertain the number of hospitals in your region. For each hospital, determine: bed size, average length of stay, type of facility (primary, secondary, tertiary), funding status (public, private, nonprofit) and annual budget for the current fiscal year. What types of acute and preventive services are provided in the hospitals? In your opinion, how well do these hospitals meet the needs of the community?

5. Health fraud. Review your local newspaper or monitor TV advertisements for two weeks. Compile examples of quackery and health fraud. What types of fraud do these advertisements represent? What claims are made or implied by the advertisement?

6. Comparative health systems. The text notes that over 50 nations have national medical service programs. Select a national medical program; do not use those discussed in the text. Describe the program's history, organization, financing, access to the public and degree of public participation.

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