Abstract
A time-honored principle in education is that changes in knowledge, attitudes, and beliefs are precursors to changes in actions or behaviors. Nevertheless, health promotion professionals occasionally hear the bromide that “people know what they’re supposed to do, they just don’t do it!” What does it mean to know something really well? And when is knowledge influential enough that it affects our very way of being? This editorial introduces a new section for the American Journal of Health Promotion called “Knowing Well, Being Well: Well-being born of understanding” (KWBW). Premiering in this issue of the journal, KWBW will be led by coeditors Drs Sara Johnson and David Katz, two of the most recognized and respected leaders in health promotion. Although today’s health promotion practitioners seem intent on moving “from wellness to well-being,” our discipline is in the nascent stages of reconciling theories of behavior change and pathways to well-being. “Knowing Well, Being Well” will chart a course to explore how knowledge, supportive environments, and purposeful living contribute to health, happiness, and life satisfaction.
What does it mean to know something truly well? What’s the difference between knowledge that informs the way you think compared to knowledge that changes how you live or your life itself? How should we parse between emerging facts and salient truths? To be even more evocative, does knowing something well actually change who you are and whom you are becoming? What’s more, does understanding something deeply affect your well-being and your life satisfaction? Does a deep understanding of something edify your life’s ultimate purpose? Awaiting answers to questions no less challenging than these, I am delighted to introduce a new section for the American Journal of Health Promotion (AJHP) called “Knowing Well, Being Well: Well-being born of understanding” (KWBW). Premiering in this issue of the journal, KWBW will be led by coeditors Drs Sara Johnson and David Katz, two of the most recognized and respected leaders in the health promotion discipline. The KWBW replaces “The Art of Health Promotion” (TAHP) section of this journal. Where TAHP sought to translate research into useful guidance for health promotion practitioners, KWBW carries forward that goal with an emphasis on the interface between emerging evidence and consensus building and between personal health and individual and collective well-being.
The coronavirus is proving to be a teacher of historic consequence, and given how little we know about COVID-19, the stakes behind knowing well and being well grow larger each day. Education scholars consider gains in knowledge to be the impetus for changes in attitudes, then beliefs, then behaviors. How do epidemiological forecasts of death rates differ from real-time data about death rates when it comes to decisions about marching toward herd immunity versus laying low? Given so few studies about the effectiveness of using face coverings, why do some experts recommend wearing do it yourself (DIY) masks and others argue against DIY masks based on the same data? 1 How much does adherence to Centers for Disease Control and Prevention’s recommendation to wear masks erode when leaders reveal their attitudes by not walking the talk? When is sharing information about risks and benefits better guided by humility than by confidence? When is it better to say “I don’t know” than to offer guidance based on an educated guess?
While KWBW is a newly minted venue for sorting through the kinds of epistemological questions posed above, we are not presuming here to recycle Greek philosophies about the nature of truth, differences between doubt and ignorance, or the role of logic in resolving such. After all, for over 3 decades, AJHP has been contributing evidence-based ideas to inform health promotion research and practice and we navigate regularly between facts and truth. Albeit, the role of science in revealing truths has become increasingly uneasy. 2 Nor are we rehashing smartly trodden Aristotelian notions about the meaning of life or harkening back to the forefather of wellness, Halbert Dunn, per how mind/body/spirit interactions arouse well-being. 3,4 Rather, KWBW is aiming at 3 no less lofty aspirations. First, to bring insights, definitions, and clarity that can guide the direction of our profession’s movement from wellness to well-being. Clarity hails from empiricism but some have asked, without hubris, whether truth is dead. So our second aim is to offer a platform for leaders who bring integrity and veracity to the discord sown by our illiberal new media.
More troubling, still, than the threats of a post-fact era, are concerns about whether civility is eroding and polarity is growing in science as it has been in politics and in the civic commons. Hence, a third aim is to use KWBW as a platform for building consensus, good will, and esprit de corps within the health and well-being professional community. Related to this, I am pleased to note that this section of the journal will remain open access as a service to our professional health promotion community and those who are not yet subscribers to this journal. We have every confidence that readers who find their way to AJHP via this new KWBW section will become enthusiastic candidates as future subscribers of AJHP.
The only thing that surpasses the grand ambitions of KWBW is the scholarly prolificacy of our coeditors for this new section, Dr David Katz and Dr Sara Johnson. Our readers already know Johnson as the coeditor, alongside the inimitable Dr Jessica Grossmeier, of the TAHP section now being retired. Johnson trained in clinical psychology from the University of Rhode Island where she now serves as an adjunct faculty member. Johnson is copresident and CEO of Pro-Change Behavior Systems, Inc, and has been principal investigator on over $6 million in National Institutes of Health grants. In her explorations of a wide range of topics for TAHP, Johnson has routinely recruited top national authorities as contributors. I’m ever grateful to Johnson and Grossmeier for their consummate leadership for our profession.
For David Katz, the one thing he has amassed more of than degrees (MD, MPH, FACPM, FACP, FACLM) is the millions of readers who follow his steadfast and eloquent prose on main stream and social media. When he is not indulging his passion as a health journalist, Katz is CEO of DietID, president of the True Health Initiative, and was founding director of the Yale-Griffin Prevention Research Center where he secured and managed over $40 million in research funding from agencies such as CDC and NIH. Katz is past-president of the American College of Lifestyle Medicine, holds multiple U.S. patents, and has published over 200 scientific articles and textbook chapters and has just released his 18th book. Katz’s writings return often to the genesis of knowledge in our discipline and the foibles of our over reliance on select research methods, in particular, what he refers to as the “tyranny of the RCT.” Twenty years ago, Katz and his Yale team invented “evidence mapping,” a 9-step process for “specifying the boundaries” of a subject in systematic literature reviews. 5 And recently, Katz has argued that our field’s evidence base should derive from a “systematically weighted approach” that he has coined “HEALM”: (Hierarchies of Evidence Applied to Lifestyle Medicine). 6
We are thrilled to have Dr Katz join our editorial team at the AJHP. Although health promotion is a relatively young profession when compared to Katz’s other loves of medicine and nutrition science, ours has the same potential to become a field similarly fraught with misinformation and confusion promulgated by trolls and deniers. I expect KWBW to be a potent antidote to such cynicism as I’ve experienced the healthy doses of hopefulness and brightness that Johnson and Katz so kindly offer through their inexhaustible writing and teaching.
Connecting Knowledge, Attitudes, and Beliefs
If you have worked for a while in health promotion, you will not have escaped this inane but inevitable quip: “people know what they’re supposed to do, they just don’t do it!” I’ve experienced a number of subtexts when this bromide comes up. Sometimes it’s frustration. That is, why would tobacco quit rates only reach 30% after such a thorough educational experience? Sometimes it seems intended to trivialize the role of education. Such as, no amount of individual coaching is going to work in weight management until we fundamentally change our culture. Other times I hear it as an expression of resignation. As in, matters of free will, intrinsic motivation, or phenomenology will assuredly override the best laid plans in behavior change programs. But as much as I find this quip to be a misappropriation of the health promotion discipline, it’s a common comment that may simply reveal how much ballast comes with the democratization of information. In today’s information echo chambers, knowing something well may be as much about our ability to undo fraudulence as it is about celebrating truths.
Basic tenets of health promotion are rooted in the same religious and political history that led to universal systems of education in Europe and United States. David Labaree, a leading scholar in the history of schooling notes that “theories differ in the degree to which they see schools as a shared social construction or an imposition by one group over another.” 7 In health promotion, how is learning affected when information and attitudes emanate from experts versus peers? And when is it best to tap the wisdom of the crowd? Views also differ about educational form versus function. Per Labaree, “some stress that the primary effects of schools arise from the substance of what they teach, but others stress that the impact of schooling arises less from the substance of learning than from the form of schooling.” Similarly, knowing something well in health promotion is sometimes about understanding precepts of nutrition or addiction where other times knowing well is about internalizing skills needed to sustain behavior change. Sometimes we do well to give someone a fish to eat, more often it’s best to teach them to fish. 8
According to Labaree, the history of education reveals longstanding conflicts about whether meritocracy (people getting what they deserved) or functionalism (society gets what it needs) was best suited to build a knowledge economy. Still, consensus grew for the idea to “bring people together” and “induct in them a sense of citizenship and a common set of useful skills and lead them from the old world of patriarchal obligation to the modern world of individual achievement by freestanding citizens.” 7 So also has the health promotion profession argued over competing theories about how best to support and sustain healthy behavior change. The field’s movement from wellness to well-being in recent years suggests a paradigm shift from individual risk reduction to personal and community self-actualization.
The logic model extolling the value of health promotion once focused on the relatedness of lifestyle medicine to disease management and cost containment. Practitioners today are more apt to chart a course from supportive environments and purposeful living to the knowledge most apt to create health, happiness, and life satisfaction. In a past editorial, I reflected on how many art historians had offered their deep, heart felt analysis of “Van Gogh’s Chair.” To my lay person’s eye, it simply looks like a common 4-legged chair, but to a passionate artist’s eye, it’s represented everything from utilitarianism to sexual angst.
I reflected on the scholarly analysis of the chair in the context of my colleague Jessica Grossmeier’s use of a 4-legged stool metaphor when she describes the foundation needed to advance employee health and performance. 9 She notes that investments in leadership, culture, policies, and program offerings are all needed in relatively equal measure to provide the foundational support for employees to thrive. I anticipate contributors to KWBW will balance reviews of the foundational knowledge needed for a field to incrementally advance. But I’ll also be awaiting the artist’s eyes of our contributors as they argue for profundities that can transform our current best practices into an ever more effective future state.
Having been an avid reader of Johnson and Katz over the years, I’m excited that KWBW can offer them a long, wide runway for ideas ready to soar. They are both firmly grounded in health promotion theories and constructs and are champions for advancing best practices that should be more uniformly and universally deployed. As tenured leaders in our field, they are also positioned well as trend spotters who can bring emerging evidence-based ideas to our readers. And per the grand aspirations for KWBW, our readers should watch for trend-setting concepts on these pages as well. “Well-being born of understanding” is the Dunn-esque sub-heading for this new section: “The spirit of man stems largely from within him,” wrote Dunn, “consequently, we must find ways of making him more aware of his inner world through which he conceptualizes and interprets his perceptions of the outer world.” 4 I am confident that Aristotle and Dunn would be pleased to see that their torch will be taken up so ably by Johnson and Katz. Here’s to our new editors for “Knowing Well, Being Well” and to knowing they will make KWBW a welcome home for those who share their passion for seeking and speaking truth.