Interview #1:

'Confronting the Barriers to Physical Activity'

Nico Pronk, PhD, is senior director for the Center for Health Promotion at HealthPartners, a Minneapolis, MN, managed care organization. Over the past 15 years he has conducted research on the physiological and psychological impacts of exercise, and he has helped develop numerous behavioral interventions to promote physical activity.

Q: Why is physical activity so important?

A: In addition to the previously known role of exercise in reducing the risk of obesity, hypertension, heart disease, stroke, and diabetes, newer studies suggest it also may be linked with reductions in breast, colon, and other cancers. We also know that physical activity can be a health- and performance-enhancing behavior, improving your mood and how you feel about yourself, as well as how you perform at work or interact with your family. So the importance is not only in preventing disease, but also in optimizing health and functional capability for people.

Q: How big a problem is physical inactivity?

A: Two-thirds of the population isn't doing enough exercise or physical activity. Guidelines from the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) recommend that people accumulate at least 30 minutes of moderate physical activity a day on five or more days a week.[20] The guidelines expand physical activity beyond the realm of exercise and account for all the activities a person might do during the day. Your 30 minutes of activity a day might include 10 minutes walking up and down stairs to and from your office, a 10-minute walk at lunch, and 10 minutes raking leaves when you get home.

Q: Previous guidelines from ACSM recommended 20 minutes or more of vigorous exercise on three or more days a week. Why the change?

A: Those guidelines remain valid, but they were designed to help people reach a particular level of cardiovascular fitness. The newer guidelines are more focused on behavior -- getting people off the couch and starting to do something. The evidence is very clear that there is a health benefit to physical activity that does not meet those cardiovascular fitness guidelines. So when someone goes from being pretty sedentary to active, the decrease in disease risk is dramatic. They may still benefit from more vigorous activity, but the greatest benefit comes from simply becoming physically active.

Q: Most people have difficulty remaining physically active. Why?

A: Many people say they have a lack of time or are not able to build it into their daily routine. Others say it is too expensive to join a health club or purchase home exercise equipment. In the end, a lot of these barriers can be overcome with adequate support from friends or family members. For example, if a coworker is interested in taking a 15-minute walk at lunch, I’m more likely to stick with it. Or if my family makes it a routine to walk after dinner or go to the YWCA, it is much easier for me to stick with that.

But there are other barriers to physical activity that I think may be more important than the time and money issues. These are more related to the communities where people live -- for example, not having sidewalks or paths to walk on or not being respected on the road while bicycling. Then there are social issues, such as neighborhood violence, that make it unsafe to walk to the corner grocery. We may not immediately think of these things when we consider ways to promote physical activity, but they need to be part of the agenda.

Q: What is the role of physicians and other health-care providers in promoting physical activity?

A: Many clinicians and health care systems are struggling with that question. Physicians typically have a strong relationship with their patients and can play a powerful role as motivators. They should ask patients about their physical activity and advise them on why it is important to remain active. But many physicians have neither the time nor the training to counsel patients adequately on how to increase their activity or maintain it. Instead, after they advise patients on the need to remain active, they should be able to direct them to sources that can provide them with guidance on starting and maintaining an active lifestyle -- either available in the community or through their health plan.

Q: How can health plans help people be more physically active?

A: The first step is an assessment to find out where people are in terms of physical activity and their readiness to make changes. The second step is to identify their needs, whether it is advice on how to adopt a physical activity program or how to prevent relapse. And the third step is to provide the interventions and then assess the needs again.

Interventions can be done through phone-based counseling where health educators counsel people on how they can build physical activity into their day. One of our newest interventions is our "10,000 Steps" program. Everyone who enrolls gets a pedometer and is encouraged to build 10,000 steps into a daily routine, which is equivalent to walking three to five miles. Participants receive weekly reminder cards emphasizing the reasons to stay active, and at the end of eight weeks, they turn in their daily log and are eligible for a prize. Our preliminary findings show that people double their steps by the end of the program, from about 4,000 steps a day to 8,500. We plan to follow them for a year to see how they do over time. Added to all this should be a partnership approach with community organizations to leverage each other’s strengths and tap into policy efforts and other social means for creating change.

Q: Most health plans are organized to provide medical care. What is the incentive for them to promote physical activity?

A: In every health plan, the people with chronic illness have higher health care costs, and they are more likely to stay with the plan than are other patients. If you recognize that, then it starts making sense to invest in activities that might actually lower the cost of treatment. And it also makes sense to keep all of your plan members healthy. We looked at the benefits of promoting physical activity among our members during an 18-month period.[23] For every additional day per week that patients were physically active, their treatment costs decreased by 4.7 percent. That works out to about $200 a year per patient, which may not sound like much until you consider that you have a million members in your plan and 75 percent of them are not active enough.

Interview #2:

'Tailoring the Advice to the Patient'

Bess H. Marcus, PhD, is professor of psychiatry and human behavior at the Brown University Center for Behavioral and Preventive Medicine, in Providence, RI. Dr. Marcus has conducted numerous studies of interventions designed to increase exercise and physical activity within physician office, work site, and community settings.

Q: Much of your research has explored ways to increase participation in exercise and physical activity by tailoring intervention programs to people’s readiness to make changes in their lives. How does this approach work?

A: People who have not yet considered an exercise program tend to focus more on the barriers to being active -- "I don’t have money to join a gym" or "I can’t do this every day, so why bother" -- than on the benefits, like having more energy, sleeping better, or weight control. So, we try to tip the balance on what they see, by suggesting ways to overcome the barriers and making the benefits more personal and immediate for them.

At the next level, someone thinking about starting a routine of physical activity may need education about how to stretch and walk appropriately or how teaming up with a friend or co-worker will help her keep active.

For the person already doing occasional activity, say on the weekend or certain seasons of the year, the job is helping him figure out how to re-work his schedule around the desire to be active.

The goal for the people who already are active is to get the activity to become a habit. We encourage them to do different activities to relieve boredom and to keep track of their activity in some kind of log so they can mark their success.

Finally, to maintain the physical activity habit for life, we might concentrate on ways to stay active on vacation or how to keep active after a major life change, such as having a baby.

Q: You’ve compared this tailored approach to standard self-help materials. What did you find?

A: In one study, we followed 194 sedentary adults who were randomly assigned to receive a series of standard self-help booklets developed by the American Heart Association or to receive a series of booklets tailored to each person’s readiness to adopt physical activity plus individually tailored reports.[17] At six months, both groups had increased their physical activity, but the increase was significantly greater for those who received the individually tailored materials compared with those who received the standard materials -- 150 minutes each week vs. 98 minutes, respectively. More than 40 percent of the individually tailored group was able to accumulate the recommended 30 minutes or more of moderate activity compared with 18 percent of those who received the standard materials.

Q: Many businesses have programs to promote physical activity among their workers. How effective are they?

A: There is a lot of optimism for doing interventions in the workplace. But just having an aerobics class or building a gym at the workplace is not going to be the solution. Research shows that when new facilities are put on site, it is mainly the people who were already exercising at other clubs in the community who take advantage of the facilities.[11] On the other hand, we've done some very low-cost, low-intensity worksite interventions offering people materials that are tailored to their levels of motivation.[18] Again, we found that when you give people information that addresses their time barriers or need for social support or other concerns, it helps them take up physical activity quicker and do more than when they just get standard educational material with facts about walking, swimming, or cycling.

Q: You’ve looked at public education campaigns to promote physical activity.[19] How can they be made more effective?

A: I’ll give you an example. Locally there was a large cardiovascular disease prevention trial called the Pawtucket Heart Health program. The part of the program focused on exercise was called "Get Fit." Not surprisingly, most of the people who took part in the Get Fit program were already active. We then developed a program to supplement Get Fit called "Imagine Action."[16] It had great success getting people who were inactive to imagine being more active and to slowly take up some activity. So the media messages have to match the goal -- both for getting people interested in change and in achieving actual behavior change. In England, there currently is a big public education campaign called "Active for Life" that targets a different part of the population each year. Last year it was 18- to 25-year-old women, and the year before it was middle-aged and older adults. There are media messages built around the idea of 30 minutes a day of activity -- it’s just half an hour, fit it in however you like. So media messages can be very effective in raising people's awareness. But you also need to have local programs in communities and at worksites so that people have safe and convenient places to go to follow up on the media messages.

Q: Can you give an example of an effective local program?

A: In Rhode Island we’ve adopted a program called "Paths to Health," which was started in Ireland and is going on in a variety of European countries. The goal is to get people to walk in areas where they live and work. Traditional bike paths or walking paths are fine, but they are often in places where people have to travel in order to use them. In downtown Providence we set up walking paths that people can use on their lunch hour. We’re hopeful that providing the paths and letting people know how they can work physical activity in throughout their day will help them achieve a more active lifestyle.

Physician Advice Can Spur Activity:

Brief advice from a doctor may be all it takes to get people to increase their physical activity. Research shows, however, that physicians are more likely to counsel patients about smoking and other health practices than physical activity. If they do talk about physical activity, they are more likely to do so with patients with chronic conditions, such as hypertension or diabetes, than they are with other healthy patients who might benefit from increased activity as well.[22]

A number of investigators have developed protocols to train physicians to counsel patients about physical activity effectively. One of the better known programs is PACE (Physician-based Assessment and Counseling for Exercise).[4] Developed by researchers at San Diego State University, the program is designed to overcome barriers that physicians say prevent them from doing more counseling about physical activity, including lack of training and time.

Under the PACE program, patients first complete a questionnaire designed to assess their readiness to adopt physical activity into their lives. The physician then delivers three to five minutes of advice tailored to the patient’s readiness to change. With people who are contemplating getting more active, for example, the physician might help the patient to set goals and address issues -- such as time pressures -- that prevent them from being active. For patients who are already active, the physician might discuss ways to avoid becoming inactive, such as involving friends or family members in their activity. Physicians receive training from PACE personnel, and a manual helps guide them in performing the assessment and counseling.

In a controlled trial of the PACE program, researchers led by Karen J. Calfas, PhD, compared activity levels among 98 patients who received activity counseling with a control group of 114 patients who did not. All of the patients were sedentary but were contemplating getting more active. Patients who received counseling also received a 10-minute "booster" phone call after their visit to answer questions and discuss progress.

Physician counseling had significant effects on patient activity, the investigators found. Four to six weeks following their initial physician visit, 52 percent of patients who received counseling were active on a regular basis compared with 12 percent of the control patients. And patients who received counseling increased their walking by 37 minutes each week compared with a seven-minute increase among control patients.

Some type of follow-up after the initial physician counseling is essential, says Bess H. Marcus, PhD, who participated in a field trial of the PACE program and has been involved in several other studies of physician activity counseling.

"Studies [in the medical literature] have shown that we can find short-term benefit from having physicians address [the need for physical activity], but the increase is not always long-lasting," says Marcus, of Brown University.

In her own studies, Marcus is exploring ways to prolong the benefits of physician activity counseling, including scheduling patients for brief follow-up visits to discuss progress, sending them newsletters or other print materials that reinforce the physician’s message, and using the telephone as a way of extending the reach of the office staff.

Trails, Parks, and Facilities Promote Activity:

A range of environmental factors can influence the amount of physical activity people receive, researchers have found. For example, people are more likely to want to walk in their neighborhoods if there are places to shop nearby. They are more active in parks with tree-lined walking paths than in those with empty open spaces.[8] And they exercise more frequently if more exercise facilities (both free and pay) are located near their homes.[25]

Many communities have built walking trails to offer people safe places to be active. That was the approach taken by community coalitions in rural, southeastern Missouri, an area with few sidewalks, shopping malls, or other places to walk. Ross C. Brownson, PhD, of the Saint Louis University School of Public Health found that 55 percent of those who used the trails said they had increased their walking since starting to use the trails.[3] Women and people with a high school education or less were twice as likely as others were to increase walking since beginning to use the trails.

Another strategy is to get people to incorporate activity where opportunities present themselves in daily life. In one study for example, Ross E. Andersen, PhD, of Johns Hopkins University School of Medicine and colleagues placed signs touting the benefits of stair-walking near stairs that were adjacent to escalators in a suburban shopping center.[2] Stair use increased from 4.8 percent to 6.9 percent among people who saw signs highlighting the general benefits of stair walking and to 7.2 percent among people who saw signs promoting its weight-control benefits.

Finally, some communities have attempted comprehensive programs to stimulate physical activity. Physical fitness improved significantly on a naval air station after bicycling trails were constructed, running paths were marked, new equipment was installed in gyms, and walking and cycling clubs were organized, according to researchers at the University of North Carolina, Chapel Hill.[15] After one year, improvements in overall fitness -- as measured by running times, percentage of body fat, and numbers of sit-ups and pull-ups performed -- were significantly greater among 1,600 personnel on the naval air station than among two other comparison groups of Navy personnel.

Elders Benefit from Active Lives:

By age 75, one in three men and one in two women engage in no physical activity.[7]

Fear of losing their balance and falling down is one reason frequently cited by older Americans for not being active, says Connie Davis, RN, a geriatric nurse practitioner with Group Health Cooperative and associate director of clinical improvement for Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation.

To counter that fear, Davis encourages seniors to twist and turn "so their bodies can remember what it is like to be slightly off kilter." Stretching and flexibility exercises help restore range of motion and agility. Teaching people to crumple in a ball instead of extending their arms if they fall can prevent broken wrists and other injuries. Weight or resistance training can help forestall the loss in muscle mass that frequently accompanies aging.

Guidelines for seniors are the same for middle-aged and young adults -- accumulate 30 minutes or more of moderate-intensity activity on most days. Seniors may need to make some adaptations in order to exercise safely, especially if they have a chronic health condition, Davis says. A woman with osteoporosis might avoid certain twisting motions that put pressure on the spine. People with high blood pressure should avoid activities like weight lifting that can involve straining, until they learn to breathe appropriately while doing them.

Safety can be another concern, she says. In one exercise program for seniors, the most frequent injury was falls caused by tripping on uneven sidewalks and pavement. That’s one reason many seniors are attracted to walking clubs at local shopping malls, where the surface is smooth, security guards are present, and a hospital sponsor may provide a nurse on site in case of emergencies.

In a study Davis participated in that incorporated these principles, physicians referred 200 elders to a senior-center health-promotion program.[14] Half met with a geriatric nurse practitioner who counseled them on techniques to manage their chronic health conditions better and encouraged them to select from a menu of physical activities available at the center that included walking; swimming; dancing; tai chi; and a supervised strength, endurance, and flexibility training program. A control group received a tour of the center and had access to the same programs.

One year later, those who received counseling and support from the nurse practitioner were 12 percent more active than the control group. They also had a 38 percent decrease in hospitalizations, compared with a 69 percent increase among the controls.

Helping Kids Increase Activity throughout the Day:

"Physical education should be physical and it should be educational, but that is not the way most children experience it in this country," says James F. Sallis, PhD, of San Diego State University.

In the typical PE class you might see a line of 30 kids standing around while one child dribbles a basketball to the hoop. "You wouldn’t teach reading that way, with one book being passed around the class," he says.

Sallis and his colleagues have been working to improve the quantity and quality of physical education and activity that children and teens get within and outside of school. Interest in this area has increased as researchers have documented rising numbers of overweight children[28] along with increasing numbers of children with type II diabetes, particularly among blacks and Hispanics.[9]

In studies with elementary and middle school students, the investigators have developed a series of strategies to maximize children’s activity in PE class and to ensure that they learn skills they can use after school.[26] For example:

• When playing team games, teachers divide groups of children into smaller sides so everyone is involved and feels engaged.
• Some activities have been modified to limit standing around. In "all-run softball" when one person hits, the whole team runs around the bases; fielders must throw the ball to every person on the team before tagging a player out.
• When new activities are introduced, children are led through learning a progression of skills. In volleyball, children practice serving, hitting, or jumping for the ball before they ever play a game.
• Teaching kids activities they can do outside of PE class is emphasized. "A Frisbee(R), for example, is something just about any kid can afford and learn to throw and create games with," Sallis says.

Schools can also foster physical activity outside PE classes. Many children arrive early and, if minimum supervision and equipment are provided, they are happy to play handball or soccer before the first bell. The same strategy can be used during lunch. Despite school policies frequently encouraging children to leave at the end of the school day, making the grounds available for an aerobics club, intramural sports teams, or informal games provides a needed outlet for many kids.

In a recently completed study of 24 middle schools, children who got the revised PE classes and were encouraged to be active at lunch and before and after school were 20 percent more active than children who received conventional PE and no additional encouragement.

Sallis says families can also play a role in helping children to be more active. A number of studies have looked at boosting parents’ activity levels as a way of encouraging kids to do more, but some studies show active parents have active kids and some studies do not. Getting parents to encourage kids to be more active does not reliably increase activity.[12] It can be effective when parents go and play with their children, but most parents don’t do it often enough.

"The one thing that does work -- and suburban parents will identify with this -- is transporting kids somewhere to be more active, whether it is to play in a park, take dance lessons, or participate in an organized sport," Sallis says.[24]

"For safety, a lot of parents don’t want the kids playing around in the street or don’t have a big enough yard," Sallis says. "So if the kids are going to be active they have to be somewhere else and the parents have to take them."

Steps to Collaborative Reduction of Health Behavior Risks:

Successfully reducing health behavior risks such as smoking, physical inactivity, obesity, and alcohol and substance abuse is a process that may be best achieved through the collaborative engagement of providers and patients. These simple steps, drawn from research on the collaborative management of chronic illness, provide one framework for providers and patients to work together to help patients improve their chances of staying healthy.

1. Ask: Providers provide a context for helping patients reduce health risks by asking patients about their lives and the regular activities in which they engage. Asking about health-threatening and health-promoting behaviors helps providers and patients establish a common starting point in addressing potential health risks.
2. Advise: Based on the information patients share with them, providers can help patients recognize how and why specific behaviors may threaten their health and advise them about steps that can be taken to change health-threatening behaviors.
3. Arrange: Armed with knowledge about programs and services that are appropriate to patients’ needs, priorities, and preferences, providers can play a key role in helping patients reduce health risks through referrals to appropriate sources of supplementary health behavior change intervention and support.
4. Assist: Providers can help catalyze successful behavior change by targeting their assistance and interventions to patients’ specific circumstances. Arranging regular telephone contacts by office staff, for example, may help one patient’s efforts to change a lifelong habit, while another patient may do best with face-to-face visits with a provider that occur at less frequent intervals.
5. Anticipate: Successfully reducing health behavior risks involves a lifelong process of behavior change and monitoring. A critical step in this process is anticipating points at which re-evaluation of behavior change efforts and subsequent course corrections may be necessary. Planned follow-up by providers is one way to help ensure that needed course corrections take place.

The Research:

1. American College of Sports Medicine Position Stand. (1990). The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Medicine and Science in Sports and Exercise, 22(2):265-74.
   
   
2. Andersen RE, Franckowiak SC, et al. (1998). Can inexpensive signs encourage the use of stairs? Results from a community intervention. Annals of Internal Medicine, 129(5):363-69.
   
   
3. Brownson RC, Housemann RA, et al. (2000). Promoting physical activity in rural communities. Walking trail access, use, and effects. American Journal of Preventive Medicine, 18(3):235-41.
   
   
4. Calfas KJ, Long BJ, et al. (1996). A controlled trial of physician activity counseling to promote the adoption of physical activity. Preventive Medicine, 25:225-33.
   
   
5. Calfas KJ, Sallis JF, et al. (1997). Mediators of change in physical activity following an intervention in primary care: PACE. Preventive Medicine, 26:297-304.
   
   
6. Centers for Disease Control and Prevention. (1999). Neighborhood safety and the prevalence of physical inactivity: Selected states. Morbidity and Mortality Weekly Report, 48(7):143-6.
   
   
7. Centers for Disease Control and Prevention, National Center for Chronic Disease. (1996). Prevention and Health Promotion, President’s Council on Physical Fitness and Sports. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA. http://www.cdc.gov/nccdphp/sgr/sgr.htm.
   
   
8. Corti B, Donovan RJ, et al. (1996). Factors influencing the use of physical activity facilities: Results from qualitative research. Health Promotion Journal of Australia, 6(1):16-21.
   
   
9. Dabelea D, Pettitt DJ, et al. (1999). Type 2 diabetes mellitus in minority children and adolescents. An emerging problem. Endocrinology and Metabolism Clinics of North America, 28(4):709-29.
   
   
10. Damush TM, Stewart AL, et al. (1999). Prevalence and correlates of physician recommendations to exercise among older adults. Journals of Gerontology. Series A. Biological Sciences and Medical Sciences, 54(8):M423-7.
    
    
11. Dishman RK, Oldenburg B, et al. (1998). Worksite physical activity interventions. American Journal of Preventive Medicine, 15:344-61.
    
    
12. Elder JP, Broyles SL, et al. (1998). Direct home observations of the prompting of physical activity in sedentary and active Mexican and Anglo-American children. Journal of Developmental and Behavioral Pediatrics, 19(1):26-30.
    
    
13. Jones DA, Ainsworth BE, et al. (1998). Moderate leisure-time physical activity: Who is meeting the public health recommendations? A national cross-sectional study. Archives of Family Medicine, 7(3):285-9.
    
    
14. Leveille SG, Wagner EH, et al. (1998). Preventing disability and managing chronic illness in frail older adults: A randomized trial of a community-based partnership with primary care. Journal of the American Geriatrics Society, 46(10):1191-8.
    
    
15. Linenger JM, Chesson CV 2d, & Nice DS. (1991). Physical fitness gains following simple environmental change. American Journal of Preventive Medicine, 7(5):298-310.
    
    
16. Marcus BH, Banspach SW, et al. (1992). Using the stages of change model to increase the adoption of physical activity among community participants. American Journal of Health Promotion, 6(6):424-9.
    
    
17. Marcus BH, Bock BC, et al. (1998). Efficacy of an individualized, motivationally tailored physical activity intervention. Annals of Behavioral Medicine, 20(3):174-80.
    
    
18. Marcus BH, Emmons KM, et al. (1998). Evaluation of motivationally tailored vs. standard self-help physical activity interventions at the workplace. American Journal of Health Promotion, 12(4):246-53.
    
    
19. Marcus BH, Owen N, et al. (1998). Physical activity interventions using mass media, print media, and information technology. American Journal of Preventive Medicine, 15(4):362-78.
    
    
20. Pate RR, Pratt M, et al. (1995). Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. Journal of the American Medical Association, 273(5):402-7.
    
    
21. Peterson TR & Aldana SG. (1999). Improving exercise behavior: An application of the stages of change model in a worksite setting. American Journal of Health Promotion, 13(4):229-32.
    
    
22. Pinto BM, Goldstein MG, & Marcus BH. (1998). Activity counseling by primary care physicians. Preventive Medicine, 27(4):506-13.
    
    
23. Pronk NP, Goodman MJ, et al. (1999). Relationship between modifiable health risks and short-term health care charges. Journal of the American Medical Association, 282(23):2235-9.
    
    
24. Sallis JF, Alcaraz JE, et al. (1999). Predictors of change in children’s physical activity over 20 months. Variations by gender and level of adiposity. American Journal of Preventive Medicine, 16(3):222-9.
    
    
25. Sallis JF, Hovell MF, et al. (1990). Distance between homes and exercise facilities related to the frequency of exercise among San Diego residents. Public Health Reports, 105(2):179-85.
    
    
26. Sallis JF, McKenzie TL, et al. (1997). The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Sports, play and active recreation for kids. American Journal of Public Health, 87(8):1328-34.
    
    
27. Sallis JF, Prochaska JJ, et al. (1999). Correlates of physical activity in a national sample of girls and boys in grades 4 through 12. Health Psychology, 18(4):410-5.
    
    
28. Troiano RP, Flegal KM, et al. (1995). Overweight prevalence and trends for children and adolescents. The National Health and Nutrition Examination Surveys, 1963 to 1991. Archives of Pediatrics and Adolescent Medicine, 149(10):1085-91.

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American Academy of Nursing
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychosomatic Society
American Society of Psychiatric Oncology
American Sociological Association
Association for Applied Psychophysiology and Biofeedback
College on Problems of Drug Dependence
Institute for the Advancement of Social Work Research
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education
Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health, a nonprofit organization, promotes the science underlying the relationship between mental and physical states that influence health and illness, and works to turn that knowledge into practical health care solutions. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For more information contact:
Petrina Chong Director of Communications
phone: 202.387.2829
To e-mail Petrina Chong