These and other encouraging trends and developments have occurred amidst an apparent shortage of prevention counseling from health providers. For example

• Although cardiovascular disease remains the leading cause of death in the United States, the majority of doctors are not counseling their patients about behavior changes that can cut their risk of heart disease.
• Many physicians are missing opportunities to help their patients quit smoking. One study showed that doctors counseled smokers to quit at only 21 percent of office visits.
• Obesity, like smoking, is a risk factor for many diseases, including diabetes, stroke, heart disease, and cancer. Today, nearly one-third of American adults are over-weight, and the number is growing. Yet a recent study revealed that physicians counseled patients about exercise during only 19 percent of office visits, diet during 23 percent of office visits, and weight reduction during 10 percent of office visits. All three—diet, exercise, and weight reduction—are steps that individuals can take to reduce their risk of disease and death.

Findings like these are all the more significant given the potential influence of physicians and other health providers on personal health. Numerous studies have demonstrated the positive effect health providers can have on the health behavior of their patients, such as improving their dietary habits, increasing their physical activity, and helping them stop smoking. Clinical counseling pro-grams have been shown to lower blood pressure, reduce the risk of certain forms of cancer, reduce pain and disability from arthritis, reduce the incidence of low birth weight babies, and improve blood glucose levels in people with diabetes.

As we approach the next century, it is becoming increasingly clear that improved health among Americans will be the result of teamwork between members of the clinical community and health consumers. At the beginning of the 20th century, the average American had a life expectancy of 45 years. Today the average lifespan has increased to 75 years. According to at least one study, 25 years of this 30-year gain in life expectancy can be attributed to public health measures, only 5 years to curative medicine.

Experts agree that additional gains in life expectancy and in the quality of those added years are still possible. Some 50 percent or more of all premature deaths are traceable to individual behaviors, such as poor dietary habits, lack of exercise, and smoking. Continued improvements in the health of all Americans will depend on cooperation between individuals and health providers.

Focus on Quality
Currently, over half of all privately insured Americans are covered by some form of managed are. Cost pressures brought on by the increased enrollment in managed care has raised concerns about quality of care and whether there is a trade-off between restraining costs and access to needed services. This concern has fueled the development of quality measures as a means to ensure the continued provision of high-quality services in this new health care environment. One example of such indicators are the HEDIS measures (Health Plan Employer Data and Information Set) created by the National Committee for Quality Assurance. The HEDIS measures include several measures that reflect the delivery of preventive services. The HEDIS 1999 proposed measures include: childhood immunization status, adolescent immunization status, advising smokers to quit, breast and cervical cancer screening, and yearly dental visits. Such indicators have increased awareness of prevention and its role as an integral component of quality.

Despite a trend toward improving preventive care, significant barriers remain. Among patients, barriers include:

• Lack of knowledge or motivation
• Anxiety about procedures and possible results
• Costs
• Inconvenience
• Unrealistic expectations (leading to the overuse of some preventive services)
• Among clinicians, barriers include:
• Lack of training in preventive services
• Lack of "self-efficacy," or confidence that prevention interventions work
• Lack of time in the face of competing demands
• Confusion over conflicting recommendations
• Lack of knowledge about new tests
• Inadequate reimbursement for preventive services
• Liability concerns
• Patient demands and expectations

In clinics and other health care settings, barriers include

• Lack of knowledge, motivation, readiness for change, or support among office staff members
• Clinical emphasis on curing illness and injury rather than prevention
• Inadequate systems for tracking, monitoring, and following up on the delivery of preventive services

To overcome these barriers, the Office of Disease Prevention and Health Promotion (ODPHP) created Put Prevention Into Practice (PPIP). Launched in 1994, PPIP is a research-based program designed to expand the use of clinical preventive services such as screening, immunizations, and counseling. Earlier, the U.S. Preventive Services Task Force found solid evidence that a variety of clinical preventive services can delay or avoid many of the leading causes of death and disability.

After completing the 1997-98 revision of materials, PPIP recently was transferred from ODPHP to the Agency for Health Care Policy and Research, where it is now part of the agency’s integrated program of clinical preventive services.

Comprehensive Preventive Services
Today, PPIP is the only national campaign that promotes a comprehensive noncategorical approach to preventive services, covering every stage of life and addressing the major health risks of the U.S. population. PPIP materials are aimed at three audiences—clinicians, medical office staff members, and health consumers.

The centerpiece of the program is the Clinician’s Handbook of Preventive Services. This practical guide contains comprehensive information on the delivery of clinical preventive services. The Handbook is divided into separate sections for children and adolescents and for adults and older adults. Chapters in each section contain information on screening tests, immunizations, and counseling.

Each chapter also includes a description of the target condition, risk factors for the condition, the effectiveness of the preventive service, instructions for performing the services, and listings of patient and provider resources.

The Handbook is the only resource available that provides a comprehensive listing of clinical guidelines from major authorities. Information is included only if recommended for routine use in the care of asymptomatic persons by a major U.S. authority such as the U.S. Preventive Services Task Force or other non-Federal expert panel, a Federal health agency, a national professional organization, or a national voluntary health organization. The recommendations and guidelines in the Handbook represent the consensus of these and other major authorities. Important clinical differences in the recommendations are included as well. The Handbook also identifies references, resources for patient education and provider materials, and Internet sites for locating additional information.

Additional PPIP Materials
In addition to the Handbook, PPIP materials include items for use by members of the office or clinic staff. For example:

• Patient chart flow sheets (adult/child/childhood immunization)—to prompt and track preventive services
• Patient reminder postcards (child/adult)—to remind patients to come in for preventive services
• Waiting room poster—to remind patients to come in for preventive services and to encourage patients to ask about preventive services
• Prevention care timeline posters (child/adult)—to remind clinicians, office staff members, and patients when preventive care is recommended

Other PPIP materials are designed for health care consumers. Included are two easy-to-read pocket-sized booklets—Personal Health Guide and Child Health Guide. Aimed at adults, Personal Health Guide contains brief topical information on clinical preventive services. Child Health Guide contains information to help parents get their children off to a healthy start in life. Topics include tests and exams, immunizations, nutrition, vision and hearing, oral health, physical activity, growth and development, and safety. Each booklet features charts to prompt or record preventive services.

Looking to the 21st Century
As the 20th century draws to a close, health care planners and policymakers are already preparing for Healthy People 2010, the evolution of Healthy People 2000, the Nation’s prevention agenda. Early drafts of 2010 materials indicate that the need for clinical preventive services and the quality of those services remain key issues. Only through teamwork among individuals, their clinicians, and the health care community will the full benefits of prevention be realized.

For more information about PPIP, contact Lynn Soban at the Agency for Health Care Policy and Research at (301) 594-1364, ext. 1379, or e-mail lsoban@ahcpr.gov. Organizations wishing to reprint PPIP materials can contact Judy Wilcox at (301) 594-1364, ext. 1389, to obtain computer disks and photographic negatives. Information also is available on the World Wide Web at www.ahcpr.gov/ppip/.