Health Promotion and Wellness: To Whom Does It Belong?

With the growing trend for some groups to take a proprietary view of a current bandwagon, the popularity of health promotion and wellness has become a vehicle for furthering self-interest agendas. It would seem that health promotion and wellness should first belong to patients - not political organizations, entrepreneurs, academic institutions or doctors using it as a marketing tool. When doctors of chiropractic are patient-centered, this growing trend in health care focuses first on the promotion of health and wellness in the patients we serve. When promoted solely as a practice management tool or denigrated as outside the scope of practice of chiropractors, the best interest of the patient is ignored.

Political organizations that primarily develop programs to garner members or to make a profit from postgraduate seminars also have taken a wrong turn. If political associations operate to ensure their own survival at the expense of patients' interests, they do not serve their members or the profession well. In addition, taking a narrow view of what constitutes health promotion and wellness to further a philosophical agenda sells the patient short. Considering a routine maintenance adjustment all the patient needs to promote health and wellness may shorten the journey and the patient's life. That is not to deny the health-giving benefits of regular spinal care, but adjustments alone cannot compensate for a polluted environment, unwholesome food and risky lifestyles. Equally shortsighted is a view of health promotion and wellness that equates it with disease prevention, abandoning the health-giving benefits on which chiropractic has been based. Denial of the health-promoting effects of adjusting the organ of posture minimizes the importance of a healthy spine to the overall health of the patient.

Entrepreneurs

Like technique peddlers, entrepreneurs who gouge for profit by disseminating educational material that should be included as part of their program are a pox on the chiropractic profession. Equally damaging are programs based on pseudoscience that purport to provide the latest evidence in support of health promotion and wellness, while making gargantuan leaps of faith, extrapolating well beyond given facts. The provision of resource material freely available from government and private agencies makes the promotion of healthy lifestyles cost-effective for both doctor and patient.

The rising cost of health care is one of the foremost issues facing a global economy. Promotion of health and wellness at a reasonable cost is a national imperative. Chiropractors can further this agenda by making it a pertinent part of their practice without sacrificing payment for services rendered. Billing third-party payers under established billing codes for health promotion and counseling can be facilitated by educating adjusters regarding the ability of doctors of chiropractic to promote healthy lifestyles.

Standardizing Health Promotion and Wellness

Moves by the Council on Chiropractic Education (CCE)¹ and the National Board of Chiropractic Examiners (NBCE)² to standardize health promotion and wellness undeniably can benefit patients, and also help doctors of chiropractic provide a valuable service. The adoption of health promotion and wellness competencies gives direction to teachers, students and clinicians to provide a program of health promotion and wellness based on recognized procedures. The goals of specific wellness competencies are designed to facilitate:

• patient understanding of factors that promote wellness;
• a proactive approach that encourages patients to take responsibility for their health;
• skills for counseling patients on healthy habits and lifestyle; and
• strategies for working with patients in a partnership for shared decision-making.

The CCE has taken a step forward that will promote standardization of material that can be included in practical fashion in daily practice, to the benefit of patients.

The NBCE included questions specific to health promotion and wellness in its Job Analysis of Chiropractic 2005. This summary of the practice of chiropractic in the United States analyzed the practice habits of those chiropractors surveyed. The analysis gives an indication of the percentage of doctors who offer counseling to promote healthy lifestyles. Not all patients seen by these doctors receive counseling, but responses indicate that more than 90 percent of doctors of chiropractic offer this service to over 50 percent of their patients. This includes counseling on physical fitness and exercise, nutritional recommendations, ergonomic and postural advice, changing risky and unhealthy behaviors, and self-care strategies, including advice on relaxation and stress reduction. Disease prevention and screening advice is provided to approximately 40 percent of patients.

Part I of the NBCE examination (public health section) also includes questions that focus on identifying risky behavior, taken from Healthy People 2010.³ Testing of health promotion and wellness competencies is imbedded in a number of sections, and the practical application of health promotion and wellness is tested appropriately in Part IV of the NBCE exam.

Chiropractic Undergraduate Courses That Promote Health and Wellness

A patient-centered partnership for promoting wellness is an important part of traditional chiropractic care. Chiropractic undergraduate training provides a basis for understanding the principles of nutrition. These include the biochemistry of proteins, enzymes, carbohydrates, lipids, vitamins and trace elements. Clinical nutrition courses discuss nutrient metabolism and nutritional needs throughout life. Nutritional management of common conditions encountered in chiropractic practice is emphasized. Pediatric, maternal and infant, and geriatric courses discuss the specific needs of these different age groups.⁴

Public health information is included for leading health indicators (tobacco use, substance abuse, responsible sex behavior, injury and violence, immunization, and access to health care). Screening and risk assessment, along with counseling for lifestyle modification and injury prevention, is included. The importance of a healthy spine receives emphasis mostly ignored by other health professions. Enhancement of function through physical activity and exercise is approached, considering individual variations and needs. Occupational health is considered in terms of work safety, environmental quality and ergonomics. Mental fitness that is dependent on sleep, rest and recreation, in addition to stress management, is part of a patient-centered approach to meeting individual patient needs.

Integration of Health Promotion and Wellness Into the Health Care System

Postgraduate programs have developed courses designed to integrate the practice of health promotion and wellness by doctors of chiropractic into the health care system.4 Medicine has achieved some diminution in the uncertainty associated with disease pathology by following a reductionist paradigm. The science of clinical medicine is based on precise observations and theories of causation, decision-making and evidence.⁵ Basing clinical care on a disease model has enabled the observation of a group of signs and symptoms into identifiable syndromes with somewhat predictable outcomes. This model is ideal for disease care, but has little relevance to health care or health promotion. The inadequacy of this model fails to encompass health promotion and wellness, which until recently has been left primarily to public health departments and health educators. Doctors of chiropractic who follow a traditional chiropractic model understand the need to emphasize to patients that their bodies have the capacity to heal, and that health comes more from within than from pills and potions.

A Chiropractic Consortium for Health Promotion and Wellness

It has been suggested that a consortium to promote health and wellness be formed, perhaps as a part of the ACC.⁶ Just as the Consortium for Chiropractic Research gave an impetus for more sophisticated research engaged in by a number of chiropractic colleges, a consortium to share pedagogical strategies and facilitate health promotion research is needed. It is important to establish dialectic between the science of health and the praxis. Health promotion research is needed to understand and act upon the interactions and relationships of individuals, not just a focus on the health of the public. Health promotion research needs to be dynamic, dealing with health as a process - one that changes health perceptions and lifestyles.

The science of health requires new assessment methods and thinking, far beyond the box that prescribes drug A for disease A. Outcome measures for health promotion are more difficult to measure, and disease prevention fits more easily within the still-dominant medical paradigm. There is a tendency to fall back upon disease prevention measures, rather than health promotion outcomes, a tendency that strengthens health education ideology. Health promotion is directed at people in all their variety, not at diseases or ideal patterns of health. Disease prevention may be, in part, a task of medicine, but health promotion is the challenge for doctors of chiropractic. Chiropractic principles can bring to health promotion more meaningful ways of describing and measuring health, including constitution and vitality, along with a rich source of ideas and a disciplined background for holistic studies.

The WHO initiatives to promote health should not be ignored by the chiropractic profession. The Ottawa Charter for Health Promotion (1986) defines health promotion as "the process which enables people to increase control over, and to improve their health to reach a state of well-being."⁷ It requires all health care professionals to contribute to the pursuit of health, and to reorient health services toward health promotion. The Ottawa Charter calls on authorities and individuals to advocate the promotion of health and to set up strategies and programs for health promotion.

Conclusion

Nothing is more powerful that an idea whose time has come. Health promotion and wellness are concepts that have grabbed the imagination of the public, and should be at the forefront of all health care professions. Public health policy should not be limited to disease prevention, nor should chiropractors be satisfied with treating back pain alone. Health promotion and wellness do not belong solely to health educators and public health departments.

So, who owns health promotion and wellness? The responsibility for promoting health and wellness lies with everyone. It is an active process that involves each and every one of us. It requires multidisciplinary integration without hierarchy. Let us take public recognition that our broken health care system can heal itself, at least in part, through health promotion and wellness, and then jump on this vehicle - in the best interest of the patient.

References

1. Gatterman MI, Brimhall JE. "CCE Adopts Health Promotion and Wellness Competencies." Dynamic Chiropractic, April 24, 2006. www.chiroweb.com/archives/24/09/02.html.
2. Christensen MG (Editor). Job Analysis of Chiropractic. A Project Report, Survey Analysis, and Summary of the Practice of Chiropractic Within the United States. Greeley, CO: National Board of Chiropractic Examiners, 2005.
3. Healthy People 2010. Understanding and Improving Health. U.S. Dept. Health and Human Services, November 2000.
4. Gatterman MI. Chiropractic, Health Promotion and Wellness. Boston; Jones & Bartlett, 2007: pp. 9-16.
5. Jamison J. Health Promotion for Chiropractic Practice. Gaithersburg, MD; Aspen Publishers, 1991: pp. 167-172.
6. Personal communication with Ron Rupert, Jan 31, 2007.
7. World Health Organization. Charter for Health Promotion. Ottawa: Canadian Public Health Association, 1986.