Week Two Discussion: The History of Health Program Planning and Evaluation (CLO 2; PLO 1)
Utilizing Chapter 1 of the course textbook, briefly describe the history of health program planning and evaluation in the U.S. What one event stands out as a significant catalyst in this process and why?
Please make sure to reference your course textbook using APA 6th Edition Format.
Planning, Implementing,
and Evaluating Health
Promotion Programs
A Primer
SeVenth edition
James F. McKenzie, Ph.d., M.P.h., M.C.h.e.S.
Ball State University
Brad L. neiger, Ph.d., M.C.h.e.S.
Brigham Young University
Rosemary thackeray, Ph.d., M.P.h.
Brigham Young University
Senior Acquisitions Editor: Michelle Cadden
Project Manager: Lauren Beebe
Program Manager: Susan Malloy
Editorial Assistant: Heidi Arndt
Program Management Team Lead: Mike Early
Project Management Team Lead: Nancy Tabor
Production Management: Charles Fisher, Integra
Compositor: Integra
Design Manager: Marilyn Perry
Cover Designer: Yvo Riezebos, Tandem Creative, Inc.
Rights & Permissions Project Manager: William Opaluch
Rights & Permissions Management: Rachel Youdelman
Senior Procurement Specialist: Stacey J. Weinberger
Executive Product Marketing Manager: Neena Bali
Senior Field Marketing Manager: Mary Salzman
Cover Photo Credit: Edhar Shvets / Shutterstock
Copyright ©2017, 2013, 2009 Pearson Education, Inc. All Rights Reserved. Printed in the United States of America.
This publication is protected by copyright, and permission should be obtained from the publisher prior to any
prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise. For information regarding permissions, request forms and
the appropriate contacts within the Pearson Education Global Rights & Permissions department, please visit www
.pearsoned.com/permissions/.
Unless otherwise indicated herein, any third-party trademarks that may appear in this work are the property
of their respective owners and any references to third-party trademarks, logos or other trade dress are for
demonstrative or descriptive purposes only. Such references are not intended to imply any sponsorship,
endorsement, authorization, or promotion of Pearson’s products by the owners of such marks, or any
relationship between the owner and Pearson Education, Inc. or its affiliates, authors, licensees or distributors.
Library of Congress Cataloging-in-Publication Data
McKenzie, James F.
Planning, implementing, and evaluating health promotion programs: a primer/
James F. McKenzie, Brad L. Neiger, Rosemary Thackeray.—7th ed.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-13-421992-9—ISBN 0-13-421992-9
I. Neiger, Brad L. II. Thackeray, Rosemary. III. Title.
[DNLM: 1. Health Promotion—United States. 2. Health Education—United States.
3. Health Planning—United States. 4. Program Evaluation—United States. WA 590]
613.0973—dc23
2015044450
ISBN-10: 0-13-421992-9
ISBN-13: 978-0-13-421992-9
1 2 3 4 5 6 7 8 9 10—V355—20 19 18 17 16
www.pearsonhighered.com
Acknowledgments of third party content appear on pages 477–478, which constitutes an extension of this
copyright page.
http://www.pearsonhighered.com
www.pearsoned.com/permissions/
This book is dedicated to seven special people—
Bonnie, Anne, Greg, Mitchell, Julia, Sherry,
and Callie Rose
and to our teachers and mentors—
Marshall H. Becker (deceased), Mary K. Beyer, Noreen Clark (deceased),
Enrico A. Leopardi, Brad L. Neiger, Lynne Nilson, Terry W. Parsons,
Glenn E. Richardson, Irwin M. Rosenstock (deceased),
Yuzuru Takeshita, and Doug Vilnius
This page intentionally left blank
Preface xiii
Acknowledgments xvii
Chapter 1 health education, health Promotion, health education
Specialists, and Program Planning 1
Health Education and Health Promotion 4
Health Education Specialists 4
Assumptions of Health Promotion 9
Program Planning 10
Summary 13
Review Questions 13
Activities 13
Weblinks 14
PART I Planning a HealtH Promotion Program 15
Chapter 2 Starting the Planning Process 17
The Need for Creating a Rationale to Gain the Support
of Decision Makers 18
Steps in Creating a Program Rationale 20
Step 1: identify Appropriate Background information 20
Step 2: title the Rationale 26
Step 3: Writing the Content of the Rationale 26
Step 4: Listing the References Used to Create the Rationale 30
Planning Committee 33
Parameters for Planning 36
Summary 37
Review Questions 37
Activities 37
Weblinks 38
Chapter 3 Program Planning Models in health Promotion 41
Evidence-Based Planning Framework for Public Health 43
Mobilizing for Action Through Planning and Partnerships (MAPP) 45
Contents
v
vi Contents
MAP-IT 46
PRECEDE-PROCEED 48
the eight Phases of PReCede-PRoCeed 48
Intervention Mapping 50
Healthy Communities 51
SMART 53
the Phases of SMARt 55
Other Planning Models 57
An Application of the Generalized Model 58
Final Thoughts on Choosing a Planning Model 62
Summary 63
Review Questions 63
Activities 64
Weblinks 64
Chapter 4 Assessing needs 67
What to Expect from a Needs Assessment 70
Acquiring Needs Assessment Data 71
Sources of Primary data 71
Sources of Secondary data 82
Steps for Conducting a Literature Search 87
Using technology to Map needs Assessment data 88
Conducting a Needs Assessment 90
Step 1: determining the Purpose and Scope of the needs
Assessment 91
Step 2: Gathering data 91
Step 3: Analyzing the data 93
Step 4: identifying the Risk Factors Linked to the health Problem 96
Step 5: identifying the Program Focus 97
Step 6: Validating the Prioritized needs 98
Application of the Six-Step needs Assessment Process 98
Special Types of Health Assessments 100
health impact Assessment 100
organizational health Assessment 101
Summary 102
Review Questions 102
Activities 103
Weblinks 103
Chapter 5 Measurement, Measures, Measurement instruments,
and Sampling 105
Measurement 106
the importance of Measurement in Program Planning and evaluation 107
Levels of Measurement 108
types of Measures 111
Contents vii
Desirable Characteristics of Data 111
Reliability 112
Validity 114
Bias Free 117
Measurement Instruments 117
Using an existing Measurement instrument 117
Creating a Measurement instrument 118
Sampling 121
Probability Sample 123
nonprobability Sample 126
Sample Size 127
Pilot Testing 127
Ethical Issues Associated with Measurement 129
Summary 130
Review Questions 130
Activities 131
Weblinks 131
Chapter 6 Mission Statement, Goals, and objectives 133
Mission Statement 134
Program Goals 135
Objectives 136
different Levels of objectives 136
Consideration of the time needed to Reach the outcome
of an objective 138
developing objectives 139
Questions to be Answered When developing objectives 139
elements of an objective 139
Goals and Objectives for the Nation 142
Summary 148
Review Questions 149
Activities 149
Weblinks 150
Chapter 7 theories and Models Commonly Used for health
Promotion interventions 151
Types of Theories and Models 154
Behavior Change Theories 154
intrapersonal Level theories 157
interpersonal Level theories 176
Community Level theories 182
Cognitive-Behavioral Model of the Relapse Process 186
Limitations of Theory 187
Summary 188
viii Contents
Review Questions 188
Activities 189
Weblinks 190
Chapter 8 interventions 191
Types of Intervention Strategies 193
health Communication Strategies 194
health education Strategies 203
health Policy/enforcement Strategies 206
environmental Change Strategies 210
health-Related Community Service Strategies 211
Community Mobilization Strategies 212
other Strategies 215
Creating Health Promotion Interventions 225
intervention Planning 225
Adopting a health Promotion intervention 226
Adapting a health Promotion intervention 226
designing a new health Promotion intervention 228
Limtations of Interventions 233
Summary 234
Review Questions 234
Activities 235
Weblinks 236
Chapter 9 Community organizing and Community Building 237
Community Organizing Background and Assumptions 238
The Processes of Community Organizing and Community Building 241
Recognizing the issue 244
Gaining entry into the Community 244
organizing the People 245
Assessing the Community 248
determining Priorities and Setting Goals 252
Arriving at a Solution and Selecting intervention Strategies 254
Final Steps in the Community organizing and Building Processes 254
Summary 255
Review Questions 255
Activities 255
Weblinks 256
PART II imPlementing a HealtH Promotion Program 259
Chapter 10 identification and Allocation of Resources 261
Personnel 264
internal Personnel 264
Contents ix
external Personnel 265
Combination of internal and external Personnel 266
items Related to Personnel 267
Curricula and Other Instructional Resources 272
Space 275
Equipment and Supplies 276
Financial Resources 276
Participant Fee 277
third-Party Support 277
Cost Sharing 278
Cooperative Agreements 278
organization/Agency Sponsorship 278
Grants and Gifts 279
Combining Sources 282
Preparing and Monitoring a Budget 282
Summary 287
Review Questions 287
Activities 287
Weblinks 288
Chapter 11 Marketing: developing Programs that Respond
to the Wants and needs of the Priority Population 291
Marketing and Social Marketing 291
The Marketing Process and Health Promotion Programs 293
exchange 293
Consumer orientation 294
Segmentation 296
Marketing Mix 301
Pretesting 310
Continuous Monitoring 312
Summary 314
Review Questions 314
Activities 315
Weblinks 316
Chapter 12 implementation: Strategies and Associated Concerns 319
Logic Models 321
Defining Implementation 322
Phases of Program Implementation 322
Phase 1: Adoption of the Program 323
Phase 2: identifying and Prioritizing the tasks to Be Completed 323
Phase 3: establishing a System of Management 326
Phase 4: Putting the Plans into Action 331
Phase 5: ending or Sustaining a Program 335
Implementation of Evidence-Based Interventions 335
x Contents
Concerns Associated with Implementation 336
Safety and Medical Concerns 336
ethical issues 338
Legal Concerns 340
Program Registration and Fee Collection 341
Procedures for Record Keeping 341
Procedural Manual and/or Participants’ Manual 341
Program Participants with disabilities 342
training for Facilitators 342
dealing with Problems 345
documenting and Reporting 345
Summary 346
Review Questions 346
Activities 347
Weblinks 348
PART III evaluating a HealtH Promotion Program 349
Chapter 13 evaluation: An overview 351
Basic Terminology 352
Purpose of Evaluation 354
Framework for Program Evaluation 356
Practical Problems or Barriers in Conducting an Evaluation 358
Evaluation in the Program Planning Stages 360
Ethical Considerations 360
Who Will Conduct the Evaluation? 361
Evaluation Results 362
Summary 362
Review Questions 363
Activities 363
Weblinks 363
Chapter 14 evaluation Approaches and designs 365
Formative Evaluation 366
Pretesting 373
Pilot testing 373
Summative Evaluation 374
Selecting an Evaluation Design 375
Experimental, Control, and Comparison Groups 376
Evaluation Designs 378
Internal Validity 381
External Validity 382
Contents xi
Summary 383
Review Questions 383
Activities 384
Weblinks 384
Chapter 15 data Analysis and Reporting 387
Data Management 388
Data Analysis 389
Univariate data Analyses 390
Bivariate data Analyses 391
Multivariate data Analyses 392
Applications of data Analyses 393
Interpreting the Data 394
Evaluation Reporting 396
designing the Written Report 397
Presenting data 397
how and When to Present the Report 398
Increasing Utilization of the Results 399
Summary 400
Review Questions 400
Activities 400
Weblinks 401
Appendix A Code of ethics for the health education Profession 403
Appendix B health education Specialist Practice Analysis (heSPA 2015)–
Responsibilities, Competencies and Sub-competencies 409
Glossary 419
References 433
Name Index 459
Subject Index 465
Text Credits 477
This page intentionally left blank
this book is written for students who are enrolled in a professional course in health
promotion program planning. It is designed to help them understand and develop the skills
necessary to carry out program planning regardless of the setting. The book is unique among
the health promotion planning textbooks on the market in that it provides readers with both
theoretical and practical information. A straightforward, step-by-step format is used to make
concepts clear and the full process of health promotion planning understandable. This book
provides, under a single cover, material on all three areas of program development: planning,
implementing, and evaluating.
Learning Aids
Each chapter includes chapter objectives, a list of key terms, presentation of content,
chapter summary, review questions, activities, and Weblinks. In addition, many of the
key concepts are further explained with information presented in boxes, figures, and
tables. There are also two appendixes: Code of Ethics for the Health Education Profession
and Health Education Specialist Practice Analysis 2015—Responsibilities, Competencies, and
Sub-competencies; an extensive list of references; and a Glossary.
Chapter Objectives
The chapter objectives identify the content and skills that should be mastered after read-
ing the chapter, answering the review questions, completing the activities, and using
the Weblinks. Most of the objectives are written using the cognitive and psychomotor
(behavior) educational domains. For most effective use of the objectives, we suggest that
they be reviewed before reading the chapter. This will help readers focus on the major
points in each chapter and facilitate answering the questions and completing the activi-
ties at the end.
Key Terms
Key terms are introduced in each chapter and are important to the understanding of the
content. The terms are presented in a list at the beginning of each chapter and are printed
in boldface at the appropriate points within the chapter. In addition, all the key terms are
presented in the Glossary. Again, as with the chapter objectives, we suggest that readers skim
PrefaCe
xiii
xiv Preface
the key terms list before reading the chapter. Then, as the chapter is read, particular attention
should be paid to the definition of each term.
Presentation of Content
Although each chapter could be expanded—in some cases, entire books have been written
on topics we have covered in a chapter or less—we believe that each chapter contains the
necessary information to help students understand and develop many of the skills required
to be successful health promotion planners, implementers, and evaluators.
Responsibilities and Competencies Boxes
Within the first few pages of all except the first chapter, readers will find a box that contains
the responsibilities and competencies for health education specialists that are applicable to
the content of the chapter. The responsibilities and competencies presented in each chapter
are the result of the most recent practice analysis—the Health Education Specialist Practice
Analysis 2015 (HESPA 2015), which is published in A Competency-Based Framework for Health
Education Specialists—2015 (NCHEC & SOPHE, 2015). These boxes will help readers under-
stand how the chapter content applies to the responsibilities and competencies required of
health education specialists. In addition, these boxes should help guide candidates as they
prepare to take either the Certified Health Education Specialist (CHES) or Master Certified
Health Education Specialist (MCHES) exam. A complete listing of the Responsibilities,
Competencies, and Sub-competencies are presented in Appendix B.
Chapter Summary
At the end of each chapter, readers will find a one- or two-paragraph review of the major con-
cepts covered in the chapter.
Review Questions
The questions at the end of each chapter provide readers with some feedback regarding their
mastery of the content. These questions also reinforce the objectives and key terms presented
in each chapter.
Activities
Each chapter includes several activities that allow students to use their new knowledge and
skills. The activities are presented in several different formats for the sake of variety and to ap-
peal to the different learning styles of students. It should be noted that, depending on the ones
selected for completion, the activities in one chapter can build on those in a previous chapter
and lead to the final product of a completely developed health promotion program plan.
Weblinks
The final portion of each chapter consists of a list of updated links on the World Wide Web.
These links encourage students to explore a number of different Websites that are available
to support planning, implementing, and evaluating programs.
Preface xv
new to this edition
In revising this textbook, we incorporated as many suggestions from reviewers, colleagues, and
former students as possible. In addition to updating material throughout the text, the follow-
ing points reflect the major changes in this new edition:
⦁ Chapter 1 has been updated to include information about the revised areas of
responsibility, competencies, and subcompetencies based on the Health Education
Specialist Practice Analysis (HESPA 2015) (NCHEC & SOPHE, 2015), and the implications
of HESPA 2015 for the Health Education Profession.
⦁ Chapter 2 has been expanded to include additional information on sources of evidence
to support a program rationale, additional information on determining the financial
burden of ill health, a new example of a written program rationale, and information on
the importance of partnering with others when creating a program.
⦁ Chapter 3 has been restructured to place more emphasis on the prominent planning
models used in health promotion. The chapter also now includes the Evidence-
Based Planning Framework in Public Health, the CHANGE tool used to plan healthy
community initiatives, and more evidence-based examples of how planning models are
used in practice.
⦁ Chapter 4 has new information on the importance of needs assessment in the accredita-
tion of health departments and the IRS requirement for not-for-profit hospitals, new
information on using technology while conducting a needs assessment, and a new
section on organizational health assessments.
⦁ Chapter 5 includes new information on wording questions for different levels of
measurement, how to present data in charts and graphs, how to write questions and
response items for data collection instruments, and guidelines for the layout and visual
presentation of data collection instruments.
⦁ Chapter 6 now includes a new section on short-term, intermediate, and long-term
objectives, and a new SMART objective checklist.
⦁ Chapter 7 includes additional information on the expansion of the socio-ecological
approach, additional information on the constructs of the social cognitive theory,
the inclusion of the diffusion of innovations theory which was previously found in
Chapter 11, and a new section on the limitations of theory.
⦁ Chapter 8 features new information on motivational interviewing, new content on
the built environment, new content on behavioral economics, information on the
Affordable Care Act and its impact on incentives, and new content on the limitations
of interventions.
⦁ Chapter 9 includes new information on the renaming of community organizing
strategies and updated figures on community organizing and community building
typology and on mapping community capacity.
⦁ Chapter 10 now includes expanded information on using volunteers as a program
resource, and program funding by governmental agencies.
⦁ Chapter 11 has been reworked and now has several new boxes and tables that include a
social marketing planning sheet, factors to consider when selecting pre-testing methods,
a 4Ps marketing mix example, types of questions to ask for formative research, and
examples of segmentation.
xvi Preface
⦁ Chapter 12 content includes expanded information on logic models, new content on
professional development including a template for a professional development plan, new
content on monitoring implementation, and new content on the implementation of an
evidence-based intervention.
⦁ Chapter 13 now includes updated information on CDC’s Framework for Program
Evaluation and new information on CDC’s characteristics of a good evaluator. In
addition, new information has been added to support the importance of evaluation and
the use of evaluation standards.
⦁ Chapter 14 includes updated terminology and context for internal and external validity,
and updated context for experimental, quasi-experimental, and non-experimental
evaluation designs.
⦁ Chapter 15 includes updated information for data management, data cleaning, and
the transition to data analysis. In addition, new information is presented to show
the relationship between levels of measurement and the selection of statistical tests
including parametric and non-parametric tests.
⦁ All chapters include more practical planning examples and, where appropriate, new
application boxes have been added to chapters.
⦁ A new appendix has been added that contains all of the Responsibilities, Competencies,
and Sub-competencies that resulted from the Health Education Specialist Practice
Analysis 2015.
⦁ To assist students, the Companion Website (https://media.pearsoncmg.com/bc/bc_
mckenzie_health_7) has been updated and includes chapter objectives, practice quizzes,
Responsibilities and Competencies boxes, Weblinks, a new example program plan, the
Glossary, and flashcards.
⦁ To assist instructors, all of the teaching resources have been updated by Michelle LaClair,
Pennsylvania State College of Medicine. These resources are available for download on
the Pearson Instructor Resource Center. Go to http://www.pearsonhighered.com and
search for the title to access and download the PowerPoint® presentations, electronic
Instructor Manual and Test Bank, and TestGen Computerized Test Bank.
Students will find this book easy to understand and use. We are confident that if the
chapters are carefully read and an honest effort is put into completing the activities and
visiting the Weblinks, students will gain the essential knowledge and skills for program
planning, implementation, and evaluation.
https://media.pearsoncmg.com/bc/bc_mckenzie_health_7
https://media.pearsoncmg.com/bc/bc_mckenzie_health_7
http://www.pearsonhighered.com
A project of this nature could not have been completed without the assistance and
understanding of many individuals. First, we thank all our past and present students, who
have had to put up with our working drafts of the manuscript.
Second, we are grateful to those professionals who took the time and effort to review
and comment on various editions of this book. For the first edition, they included Vicki
Keanz, Eastern Kentucky University; Susan Cross Lipnickey, Miami University; Fred Pearson,
Ricks College; Kerry Redican, Virginia Tech; John Sciacca, Northern Arizona University;
and William K. Spath, Montana Tech. For the second edition, reviewers included Gordon
James, Weber State; John Sciacca, Northern Arizona University; and Mark Wilson, University
of Georgia. For the third edition, reviewers included Joanna Hayden, William Paterson
University; Raffy Luquis, Southern Connecticut State University; Teresa Shattuck, University
of Maryland; Thomas Syre, James Madison University; and Esther Weekes, Texas Women’s
University. For the fourth edition, reviewers included Robert G. LaChausse, California
State University, San Bernardino; Julie Shepard, Director of Health Promotion, Adams
County Health Department; Sherm Sowby, California State University, Fresno; and William
Kane, University of New Mexico. For the fifth edition, the reviewers included Sally Black,
St. Joseph’s University; Denise Colaianni, Western Connecticut State University; Sue Forster-
Cox, New Mexico State University; Julie Gast, Utah State University; Ray Manes, York
College CUNY; and Lois Ritter, California State University East Bay. For the sixth edi-
tion, reviewers included Jacquie Rainey, University of Central Arkansas; Bridget Melton,
Georgia Southern University; Marylen Rimando, University of Iowa; Beth Orsega-Smith,
University of Delaware; Aimee Richardson, American University; Heather Diaz, California
State University, Sacramento; Steve McKenzie, Purdue University; Aly Williams, Indiana
Wesleyan University; Jennifer Banas, Northeastern Illinois University; and Heidi Fowler,
Georgia College and State University. For this edition, reviewers included Kimberly A. Parker,
Texas Woman’s University; Steven A. Branstetter, Pennsylvania State University; Jennifer
Marshall, University of South Florida; Jordana Harshman, George Mason University; Tara
Tietjen-Smith, Texas A & M University, Commerce; Amy L. Versnik Nowak, University of
Minnesota, Duluth; Amanda Tanner, University of North Carolina, Greensboro; Deric R.
Kenne, Kent State University; and Deborah J. Gibson, University of Tennessee, Martin.
Third, we thank our friends for providing valuable feedback on various editions of
this book: Robert J. Yonker, Ph.D., Professor Emeritus in the Department of Educational
Foundations and Inquiry, Bowling Green State University; Lawrence W. Green, Dr. P. H.,
Professor, Department of Epidemiology and Biostatistics, School of Medicine, University
aCknowledgments
xvii
xviii Acknowledgments
of California, San Francisco (UCSF); Bruce G. Simons-Morton, Ed.D., M.P.H., Senior
Investigator, Eunice Kennedy Shriver National Institute of Child Health and Human
Development, National Institutes of Health; and Jerome E. Kotecki, H.S.D., Professor,
Department of Physiology and Health Science, Ball State University. We would also like to
thank Jan L. Smeltzer, Ph.D., coauthor, for her contributions to the first four editions of
the book.
Fourth, we appreciate the work of the Pearson employees Michelle Cadden, Senior
Acquisitions Editor for Health, Kinesiology, and Nutrition who has been very supportive
of our work, and Susan Malloy, Program Manager, whose hard work and encouragement
ensured we created a quality product. We also appreciate the careful work of Allison
Campbell and Charles Fisher from Integra–Chicago.
Finally, we express our deepest appreciation to our families for their support, encourage-
ment, and understanding of the time that writing takes away from our family activities.
J. F. M.
B. L. N.
R. T.
1
1
Chapter Health Education, Health Promotion,
Health Education Specialists, and
Program Planning
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁⦁ Explain the relationship among good health
behavior, health education, and health promotion.
⦁⦁ Explain the difference between health education
and health promotion.
⦁⦁ Write your own definition of health education.
⦁⦁ Explain the role of the health educator as
defined by the Role Delineation Project.
⦁⦁ Explain how a person becomes a Certified
Health Education Specialist or a Master
Certified Health Education Specialist.
⦁⦁ Explain what the Competencies Update
Project (CUP), Health Educators Job Analysis
(HEJA-2010), and Health Education Specialists
Practice Analysis (HESPA-2015) have in common.
⦁⦁ Explain how the Competency-Based Framework
for Health Education Specialist is used by colleges
and universities, the National Commission for
Health Education Credentialing, Inc. (NCHEC),
Council for the Accreditation of Educator
Preparation (CAEP), and the Council on
Education for Public Health (CEPH)
⦁⦁ Identify the assumptions upon which health
education is based.
⦁⦁ Define the term pre-planning.
Key Terms
Advanced level
1-health education
specialist
Advanced level-2
health education
specialist
community
decision makers
entry-level health
education
specialist
Framework
health behavior
health education
health education
specialist
health promotion
Healthy People
pre-planning
primary prevention
priority population
Role Delineation
Project
secondary
prevention
stakeholders
tertiary prevention
2 Chapter 1
History has shown that much progress was made in the health and life expectancy
of Americans since 1900. During these 116+ years, we have seen a sharp drop in infant
mortality (NCHS, 2015); the eradication of smallpox; the elimination of poliomyelitis in
the Americas; the control of measles, rubella, tetanus, diphtheria, Haemophilus influenzae
type b, and other infectious diseases; better family planning (CDC, 2001); and an increase
of 31.5 years in the average life span of a person in the United States (CDC, 2015e). Over
this same time, we have witnessed disease prevention change “from focusing on reducing
environmental exposures over which the individual had little control, such as providing
potable water, to emphasizing behaviors such as avoiding use of tobacco, fatty foods, and
a sedentary lifestyle” (Breslow, 1999, p. 1030). Yet, even with this change in focus we, as a
society, have done little to encourage health community design, and as individuals, most
Americans have not changed their lifestyle enough to reduce their risk of illness, disability,
and premature death. As a result, unhealthy lifestyle characteristics have lead to the United
States ranking 94th (out of 225 countries) in crude death rate; 42nd (out of 224 countries) in
life expectancy at birth; and 1st in health care spending (CIA, 2015).
Today in the United …
