Public Opinion About Public Health—California and the United States, 1996 FREE

MMWR. 1998;47:69-73

DESPITE widespread belief that public support is critical to the success of public health programs and agencies, systematic efforts to measure public opinion about public health have been limited. This report summarizes surveys conducted by two organizations—one a public policy center in California, the other a national opinion polling firm—to measure support for public health activities. The findings indicate widespread support for community-oriented disease-prevention and health-promotion activities.

From September 30 through November 5, 1996, the Field Institute of San Francisco (with consultation by Louis Harris and Associates, Inc.) conducted a random-digit-dialed telephone survey of California residents aged ≥18 years; the survey was commissioned by the nonprofit California Center for Health Improvement and was funded by The California Wellness Foundation.¹ A representative sample of 4803 persons was interviewed. The standard error associated with the results of this survey was ±2% at the 95% confidence level.

The percentage of respondents who reported that selected public health services were "top priority" ranged from 29% (for collecting community health data) to 84% (for ensuring safe drinking water). The percentage who reported delivery of these services as "very effective" ranged from 18% (for providing community education and counseling services about improving health) to 37% (for minimizing the spread of disease carried by insects or animals). Selected local and state fees or tax increases were supported by substantial proportions of respondents if funds were needed to pay for what the survey instrument termed as "adequate programs." Most respondents preferred that funds for public health services be raised at the state level instead of at the local level. The sources of revenue for those services that were most supported by respondents were increases in state taxes on alcoholic beverages and tobacco. Most respondents opposed state surtaxes on health insurance premiums (72%), local residential property taxes (64%), and local sales taxes (57%). Respondents supported the existing state requirements that nonprofit health-care providers fund community health programs (84%) and that nonprofit health-care providers that convert to for-profit status be required to dedicate funds to promote health (82%). In addition, most respondents indicated support for a statewide initiative for a 63 cents per pack increase in cigarette tax (i.e., 72% strongly or somewhat favored the increase).

During December 12-16, 1996, Louis Harris and Associates, Inc., conducted a national random-digit–dialed telephone survey of 1004 U.S. residents aged ≥18 years.² This survey was conducted for the Harris Poll column, which is syndicated to the media but is not commissioned by any one client. The standard error associated with the survey was ±3% at the 95% confidence level. The response rate was 62%.

Respondents were asked to rank the importance of eight services "to improve the health of the public" on a five-point scale (i.e., very important, somewhat important, not very important, not at all important, or did not know). The percentage of respondents who rated specific public health services as very important ranged from 56% (for helping persons cope with stress) to 93% (for preventing the spread of infectious diseases).

Respondents also were asked "Who do you think should be mainly responsible for the performance of prevention rather than the treatment of disease." Most (57%) respondents indicated that government should be responsible for this service; and 40%, that "someone else" should be responsible. Of those persons who responded that government should provide this service, 53% stated that the federal government should do so; 32%, the state government; and 13%, city and local governments.

When asked the open-ended question, "What do the words ‘public health' mean to you?," <4% of respondents gave answers corresponding to what the Harris Poll considered "generally . . . regarded as referring to public health" (i.e., health education/healthier lifestyles, prevention of infectious diseases, immunization, and medical research).² Eighty-three percent of respondents identified one or more of the following: general physical health, mental health, and well-being of the public; the health-care system; welfare programs; universal health care; health assurance; health insurance; and Medicaid and Medicare.

K Bodenhorn, MPH, California Center for Health Improvement, Woodland Hills, California. H Taylor, Louis Harris and Associates, Inc., New York. Office of the Director, Public Health Practice Program Office, CDC.

Opinion polling is used extensively as an adjunct to or in assessing contemporary public policy. Polling can help to clarify the perceived importance of issues and the impact of advocacy campaigns and other factors on public support for, or opposition to, policies. The survey conducted in California identified (1) substantial support for public health services and (2) substantial support for taxes, if necessary, to achieve more effective public health programs and services. Although findings from the national survey were consistent with findings from the California survey about support for public health services, the national survey did not address financial concerns.

The findings in this report are subject to several limitations. First, the results of the two surveys were not directly comparable because the samples were drawn from different populations, the questions differed, and the results were reported in different formats. Second, each survey gauged public opinion at a specific point in time; therefore, the reported opinions could not be linked to contextual, secular events. Other limitations associated with survey methodology (e.g., refusals to be interviewed, wording and order of questions, and interviewer bias) also apply to the results of these two surveys. (See Table 1, Table 2, and Table 3.)

Interest in marketing public health has been stimulated by perceived low public support for public health activities, limited financial resources, and the impact of extensive restructuring in the health-care sector. The findings in this report indicate substantial public support for public health services and suggest the need to determine the extent to which this support is consistent across jurisdictions and whether it can be translated into policy. Finally, these findings suggest the need for strengthened methods to improve the polling of opinion about public health, including clarifications of the distinction between clinical care and community- or population-oriented disease and injury prevention, and the practical meanings of "public health," "community health," and other key terms.

MMWR. 1998;47:73-77

2 tables omitted

LACK OF health-care–insurance coverage has been associated with decreased use of preventive health services, delay in seeking medical care, and poor health status.^1- 2 In 1995, an estimated 30.5 million persons aged 18-64 years in the United States did not have health insurance.³ To determine state-specific estimates of the prevalence of persons aged 18-64 who reported either short-term (i.e., <12 months) or long-term (i.e., ≥12 months) lapses in health-care coverage, CDC analyzed data from the 1995 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis and indicates that among adults who reported having no health insurance in 1995, most were without insurance for ≥1 year and that long-term lapses were more prevalent among men than women.

The BRFSS is a state-based, random-digit–dialed telephone survey of the U.S. noninstitutionalized population aged ≥18 years. Data were obtained from all 50 states participating in the 1995 BRFSS. A total of 90,691 persons responded. Analyses were restricted to persons aged 18-64 years. Sample estimates were statistically weighted by sex, age, and race to reflect the noninstitutionalized civilian population of each state. Respondents were asked, "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?" Persons who reported having no health-care coverage at the time of the interview were considered to be uninsured. Persons who were uninsured were asked "How long has it been since you had health care coverage?" Persons who reported having had coverage during the preceding year were classified as having short-term lapse, and those reporting not having had coverage for ≥1 year were classified as having long-term lapse.

During 1995, the prevalence of persons who reported having health-care–insurance coverage ranged from 76.5% (Louisiana) to 93.3% (Hawaii) (median: 87%). The prevalence of reported lapses in health-care–insurance coverage of <1 year ranged from 1.8% (New Jersey) to 9.4% (California) (median: 4.2%); lapses of ≥1 year ranged from 2.9% (Hawaii) to 17.1% (California) (median: 9.3%).

Among men, the percentage reporting having health-care–insurance coverage ranged from 75.5% (California) to 91.5% (Hawaii) (median: 84.7%). The percentage of men reporting lapses in health-care–insurance coverage of <1 year ranged from 2.0% (South Dakota) to 10.3% (California) (median: 4.2%), and the percentage reporting lapses of ≥1 year ranged from 3.8% (Hawaii) to 17.1% (Texas) (median: 10.6%). Among women, the percentage reporting having health-care–insurance coverage ranged from 74.6% (Louisiana) to 95.1% (Hawaii) (median: 88%). The percentage of women reporting lapses of <1 year in health-care–insurance coverage ranged from 1.6% (New Jersey) to 8.5% (California) (median: 4.1%), and the percentage reporting lapses of ≥1 year ranged from 2.0% (Wisconsin) to 17.9% (Louisiana) (median: 8.6%).

During 1995, having health-care–insurance coverage was reported more commonly by white respondents (median: 88%) than by respondents of other races/ethnicities (median: 80%), and more commonly by respondents who were employed for wages (median: 89%) than by those who were self-employed (median: 76%), homemakers (median: 82%), or unemployed (median: 61%).

J Cook, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; D McTague, MS, Florida; E Pledger, MPA, Georgia; A Onaka, PhD, Hawaii; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; N Costello, MPA, Indiana; A Wineski, Iowa; M Perry, Kansas; K Asher, Kentucky; R Meriwether, MD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; P Arbuthnot, Mississippi; T Murayi, PhD, Missouri; P Smith, Montana; S Huffman, Nebraska; E DeJan, MPH, Nevada; K Zaso, MPH, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; T Melnik, DrPH, New York; K Passaro, PhD, North Carolina; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; Y Gladman, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; L Redman, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; E Cautley, MS, Wisconsin; M Futa, MA, Wyoming. Behavioral Surveillance Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

This report documents substantial variation in the state-specific prevalence of self-reported short-term or long-term lapses in health-care–insurance coverage. State-specific variations may reflect differences in population composition (e.g., age, race/ethnicity, and sex), socioeconomic factors (e.g., per capita income, median number of years of education, and unemployment level), and other factors. Variation in health-care–insurance coverage between male and female respondents may reflect differences in coverage from public sources (e.g., Medicaid). Women are more likely than men to be covered by Medicaid through the Aid to Families with Dependent Children program because they are more likely to be caring for children.⁴ Race-specific differences in health-care–insurance coverage may be related to the relative income and employment status of the two groups.⁵ Persons employed for wages are more likely to obtain insurance through their employer, who pays all or part of the cost of coverage. In comparison, persons who are either self-employed or unemployed must pay the total cost of coverage.

BRFSS estimates can differ from those of other surveys because of differences in methodology or wording of questions. For example, BRFSS estimates of the percentage of uninsured adults aged 18-64 years were lower than those reported from the March 1996 Current Population Survey.³ Unlike the Current Population Survey, BRFSS data are based on questions about insurance status at the time of the interview, rather than during the previous calendar year. In addition, BRFSS findings may underestimate persons without health-care–insurance coverage because BRFSS excludes households without telephones; persons without a telephone are more likely to be less educated, have a lower income, or be unemployed.⁶

Based on the findings of previous studies, being uninsured may be associated with declines in health status⁷; in addition, compared with insured patients, those who are hospitalized while without health-care–insurance coverage may receive fewer inpatient services and may be at increased risk for dying while hospitalized.^8- 9 The risks associated with lack of insurance coverage may result in substantial increases in the number of persons with chronic conditions and the cost of providing care for these persons.

Although providing health-care–insurance coverage to persons with short-term lapses is important, targeting efforts toward the long-term uninsured may be more effective because of the larger number of persons in this category and because of their potentially increased health risks. The methods and findings in this report can assist state planners in evaluating the progress of efforts to improve health-care and public health and in prioritizing programs to close insurance gaps.

MMWR. 1998;47:105-108

During November 7-December 9, 1997, three previously healthy collegiate wrestlers in different states died while each was engaged in a program of rapid weight loss to qualify for competition. In the hours preceding the official weigh-in, all three wrestlers engaged in a similar rapid weight-loss regimen that promoted dehydration through perspiration and resulted in hyperthermia. The wrestlers restricted food and fluid intake and attempted to maximize sweat losses by wearing vapor-impermeable suits under cotton warm-up suits and exercising vigorously in hot environments. This report summarizes the investigation of these three cases.

During November 6-7, over a 12-hour period, a 19-year-old man in North Carolina attempted to lose 15 lbs to compete in the 195-lb weight class of a wrestling tournament scheduled for November 8. His preseason weight on August 27 was 233 lbs, and during the next 10 weeks he lost 23 lbs. On November 6, from 3 p.m. to 11:30 p.m., using the weight-loss regimen described above, he lost an additional 9 lbs. After a 2-hour rest, he resumed his weight-loss regimen on November 7 at 1:45 a.m. At approximately 2:45 a.m., he stopped exercising but began to experience extreme fatigue and became incommunicative; an hour later, he developed cardiorespiratory arrest. Resuscitation was unsuccessful. Chemistry findings in vitreous humor obtained 7 hours after death were sodium, 152 mmol/L (normal postmortem: 135-151 mmol/L); urea nitrogen, 40 mg/dL (normal postmortem: ≤40 mg/dL); and urine myoglobin, <20 ng/mL (normal antemortem: 0-40 ng/mL); creatinine results were unavailable. Anatomic findings from the autopsy were insufficient to determine the cause of death.

On November 21, over a 4-hour period, a 22-year-old man in Wisconsin attempted to lose 4 lbs to compete in the 153-lb weight class of a wrestling tournament scheduled for November 22. His preseason weight on September 6 was 178 lbs. During the next 10 weeks he lost 21 lbs, of which 8 lbs were lost during November 17-20. On November 21 at 5:30 a.m., he initiated the same weight-loss regimen as in case 1. An hour later, he complained of shortness of breath but continued exercising. By 8:50 a.m., he had lost 3.5 lbs. He drank approximately 8 oz of water, rested for 30 minutes, and resumed exercise. At 9:30 a.m., he stopped exercising and indicated he was not feeling well. Efforts were made to cool him, and his clothing was removed. He became unresponsive and developed cardiorespiratory arrest; resuscitation was unsuccessful. Chemistry findings in antemortem blood were serum sodium, 161 mmol/L (normal: 136-145 mmol/L); urea nitrogen, 34 mg/dL (normal: 7-18 mg/dL); and creatinine, 5.0 mg/dL (normal: 0.8-1.3 mg/dL). Serum myoglobin was >5000 ng/mL (normal: 0-110 ng/mL). Rectal temperature was 108 F (42 C) at the time of death. The autopsy report cited the cause of death as hyperthermia.

On December 9, over a 3-hour period, a 21-year-old man in Michigan attempted to lose 6 lbs to compete in the 153-lb weight class of a wrestling meet scheduled for December 10. His preseason weight on September 4 was 180 lbs. During the next 13 weeks he lost 21 lbs, of which 11 lbs were lost during December 6-8. On December 9, from 3:30 p.m. to 5 p.m., he lost 2.3 lbs and weighed 156.7 lbs. After wrestling practice, he initiated the same weight-loss regimen as in case 1; after 75 minutes, he had lost an additional 2 lbs. After a 15-minute rest, he resumed exercise. Approximately 1 hour later, he stopped exercising to weigh himself and demonstrated fatigue. A few minutes later, his legs became unsteady, he became incommunicative, and he had difficulty breathing. Attempts to administer fluid orally were unsuccessful, and he developed cardiorespiratory arrest. Resuscitation was unsuccessful. Chemistry findings in vitreous humor obtained 4 hours after death were sodium, 159 mmol/L (normal: 136-146 mmol/L); urea nitrogen, 31 mg/dL (normal: 8-20 mg/dL); and creatinine, 0.7 mg/dL (normal: 0.9-1.3 mg/dL). Urine myoglobin was 4280 ng/mL (normal: 0-45 ng/mL). The autopsy report cited the cause of death as rhabdomyolysis.

D Remick, MD, Univ of Michigan, Ann Arbor, Michigan. K Chancellor, MD, North Carolina Dept of Health and Human Svcs. J Pederson, MD, Franciscan Skemp Healthcare, LaCrosse, Wisconsin. EJ Zambraski, PhD, Rutgers Univ, Piscataway, New Jersey. MN Sawka, PhD, CB Wenger, MD, US Army Research Institute of Environmental Medicine, Natick, Massachusetts. Office of Regulatory Affairs; Center for Food Safety and Applied Nutrition, U.S. Food and Drug Administration. Div of Environmental Hazards and Health Effects, National Center for Environmental Health; Div of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, CDC.

This report describes the first identified deaths in collegiate wrestling and the first deaths associated with intentional rapid weight loss in interscholastic or collegiate wrestling since national record keeping began in 1982.¹ Many coaches and wrestlers believe that wrestlers should compete at a weight category lower than their preseason weight to maximize their competitive advantage.^2- 3 To reach their competition weight, many wrestlers achieve rapid weight loss by dehydration through such practices as vigorous exercise, fluid restriction, wearing vapor-impermeable suits, and using hot environments (e.g., saunas, hot rooms, and steam rooms). More extreme but less common measures include consuming diuretics, emetics, and laxatives and self-induced vomiting.^2- 3 A combination of these practices are often used during the days that precede each competition.⁴ Alone or in combination, these practices can adversely affect cardiovascular function, electrical activity, thermal regulation, renal function, electrolyte balance, body composition, and muscular endurance and strength.^3,5- 6

Vigorous exercise and dehydration increase body temperature, which is further increased by use of vapor-impermeable suits that decrease evaporative and convective heat loss. In the three cases presented in this report, all three wrestlers used vapor-impermeable suits and exercised vigorously in hot environments. These conditions promoted dehydration and heat-related illness^3,5- 6 In all three cases, elevated sodium and urea in antemortem blood or postmortem vitreous fluid indicated clear evidence of dehydration. The exercise regimen, the elevated rectal temperature in case 2, and the rhabdomyolysis and myoglobinuria in case 3 indicate that hyperthermia may have contributed to these deaths.^6- 7

Among the three wrestlers, the difference between their preseason weight and their goal weight for competition was 30 lbs (range: 25-37 lbs), or approximately 15% of total body weight. Among collegiate wrestlers, the difference between their preseason and competitive weights averages approximately 16 lbs,⁵ or approximately 10% of total body weight.⁴ These cases highlight the extreme extent of absolute and relative weight loss. Under such conditions, particularly when dehydration is involved, there are no established limits for safe weight loss.

To ensure fair and safe competition, wrestlers compete within defined weight categories. At the time of these deaths, existing National Collegiate Athletic Association (NCAA) guidelines recommended that the rapid weight-loss behaviors associated with these deaths be prohibited.⁸ Using practices contrary to the guidelines, all three wrestlers, while under the supervision of athletic staff, attempted to lose unsafe amounts of weight in a short period of time. The findings in the three cases suggest that failure to follow these guidelines may have contributed to these deaths. The weight-loss behaviors reported in these three cases are common among wrestlers; however, deaths associated with weight loss in collegiate wrestling have not been reported previously.¹ No information is available to indicate whether the amount or rate of intentional weight loss or other conditioning practices may have changed recently among collegiate wrestlers.

As a result of these deaths, the NCAA revised the guidelines governing weight-loss practices and weigh-in procedures and added penalties for noncompliance.⁹ The NCAA now prohibits the use of laxatives, emetics, diuretics, excessive food and fluid restriction, self-induced vomiting, hot rooms >79 F (>26 C), hot boxes, saunas, steam rooms, vapor-impermeable suits, and artificial rehydration techniques (e.g., intravenous hydration between weigh-in and competition). In addition, for this season the NCAA has added a 7-lb weight allowance to each weight class, required all wrestlers to compete only in the weight class that they were in as of January 7, and stipulated that all weigh-ins be held no more than 2 hours before the beginning of competition. The NCAA plans to reassess its wrestling policies this spring. The effectiveness of these changes should be monitored and evaluated.

The sudden deterioration and resulting deaths of previously healthy, young, well-trained athletes underscores the need to eliminate weight-control practices that emphasize extreme or rapid weight loss. To ensure safe weight-control practices, a health-care professional should identify an appropriate competition weight and specify rates and limits of allowable weight loss for each wrestler. In addition, coaches and athletes should be trained in proper weight-control strategies and work collaboratively with a health-care professional to develop and monitor a weight-control regimen. Use of intentional dehydration to lose weight should be prohibited. To monitor compliance, a practical test to assess hydration status should be explored and employed. In addition, existing surveillance systems should be strengthened to evaluate effectiveness in preventing athletic injuries, illnesses (e.g., hyperthermia and dehydration), and deaths among the 400,000 wrestlers who participate annually in the United States.¹⁰ Because wrestlers have traditionally used dehydration as a means to lose weight, vigorous efforts will be necessary to ensure compliance with rules and guidelines designed to reduce health risks and the potential for death.

MMWR. 1998;47:95

NEW AND Reemerging Infectious Diseases: A Clinical Course will be held June 13-15, 1998, in Atlanta. Cosponsors are CDC, Emory University School of Medicine, and the National Foundation for Infectious Diseases (NFID). This course focuses on the epidemiology, recognition, treatment, and management of new and reemerging infectious diseases. Infectious disease clinicians and epidemiologists will present pertinent information about emerging problems, as well as the latest information about prospective therapeutic agents.

Additional information is available from Kip Kantelo, NFID, 4733 Bethesda Avenue, Suite 750, Bethesda, MD 20814-5228; telephone (301) 656-0003; fax (301) 907-0878; World-Wide Web site: http://www.nfid.org/nfid; or by e-mail: kkantelo@aol.com.