I am very pleased to be here to contribute some ideas which are evolving in the innovation diffusion and planned change areas. These ideas have important implications for anyone concerned with introducing new information or diffusing new behaviors among some particular target group.

So, post-purchase satisfaction is important because it shapes the patient's subsequent behavior. But, there are also several reasons why post-purchase satisfaction is important to health care management. These are summarized in Figure I.

Leon Robertson talked about some of the problems with using education as a means of trying to influence people to do things we all know we are supposed to do. Most of the time, as he noted, results are rather discouraging. People do not pay much attention, or if they do pay attention and learn, they still do not do what they say they know they should do.

Education is one means of getting people to do things. Technology and legislation are two other means of making things happen. Our program did not deal with either the passage of new legislation or the enforcement of existing legislation is such areas as the use of fluoridation or seat belts. We were not involved with technology. Technological solutions to some problems are obviously going to lessen the necessity for public education. Even with technological advances, however, there will still be need for people to know about health problems and what they can do about them.

To provide a context for discussing our series, let us focus first on health education in general (Figure I). Pamphlets, radio, television, films, newspaper columns, and a variety of other things are used in health education. Television alone can be split into commercial and non -commercial.

High blood pressure is a direct consequence of the heart having to force blood through excessively constricted blood vessels. Therefore, the heart is overtaxed and can fail; furthermore, blood vessels are exposed to high pressure and therefore have the potential for sttoke, or the bursting of a blood vessel in the brain. In addition, the presence of high blood pressure accelerates the process of atherosclerosis or hardening of the arteries.

Despite these clear dangers and their growing prevalence, it was not until 1967 and 1970 when it was conclusively demonstrated that the treatment of both severe and even mildly elevated blood pressure had any effect on the reduction of the various morbidities mentioned above.1.2 Now that the benefits of treatment have been documented, other problems have become apparent and demand answers from the various scientific disciplines involved in research in this field. One of these problems is the fact that the disease generally has no symptoms until end organ damage has resulted some ten or more years after the onset of even a mild form of the disease. The only way that a person knows that he/she has high blood pressure is to have the blood pressure read by use of a sphygmomanometer (a blood pressure cuff). The procedure takes approximately 30 seconds, is simple to do and painless; but in only 66 percent of physician visits was this procedure performed. 3 Once high blood pressure is documented through a series of three or four blood pressure readings, the treatment of the vast majority of cases of high blood pressure is rather simple. The patient is put on an appropriate medication which he/she will probably have to take for the rest of his/her life. While that may sound simple enough, one of the most significance problems in blood pressure control is helping the patient toward self motivation to maintain him/herself on therapy. The maintenance of such therapy is problematic because the patient is asymptomatic and occasional undesirable side effects may accompany therapy thus militating against pill taking. Some of the research to be reported on here involves this issue of patient facilitation in maintaining clinical regimens.

It has been suggested that techniques used to market products and services can be used to help individuals fulfill their needs in both prevention and amelioration of illness as well as in the alleviation of other social problems. In this paper I shall review some principles that have emerged from studies of health and illness behavior with special attention to their implications for the notion of health consumers in a health marketplace. The marketplace concept requires a focus on suppliers as well as consumers; therefore I shall attempt to explicate some important aspects of the roles of both consumers and suppliers in the health marketplace. The roles of behavioral scientists, educators and marketing specialists in this marketplace will also be considered along with some historical lessons.

We have started to define epidemiology and we have started to define preventive medicine. Before we go any further, I want to tell you what these things really are in a way you will remember. I want you to imagine there are three kinds of people who come upon a scene where there are folks floating down a river, drowning. There is one kind of guy that comes on this scene, rips off his coat and pants, swims out and saves somebody, struggles back to shore, goes back out, saves somebody else, keeps that up until he is exhausted. There is another guy who comes on this scene and says, "Boy, is he wasting his time." He goes back in the woods and maybe an occasional fellows goes by in the meantime, but he gets big logs and throws them in, so he saves several people at a time. Then there is the third sort of individual who goes up river to see who is throwing people in the water. That is an epidemiologist and what he does, if he's bigger than the guy throwing them in, is called preventive medicine. I learned this when I became a preventive medicine officer in the army, but when I came to the University of Missouri, I discovered that there was another person that the Army did not know about. There is a fourth individual who comes upon the scene and goes into the woods and immediately starts doing research on how to grow a bigger tree!

The gradual rise in age-adjusted cardiovascular disease mortality in industrialized countries has considerably diminished what would otherwise be seen as striking gains in health in the last 75 years. These gains, due primarily to increased and improved practices in modern medicine, have occurred mainly in the prevention of infant and early childhood mortality and in the improvement in crisis intervention techniques after the onset of disease symptoms. Unfortunately, much cardiovascular disease is apparently unresponsive to anything but pre-crisis preventive intervention. The U.S. male who has survived to age 45 now has only a slightly greater life expectancy than did his forebear in 1900. Table I shows comparative rates of coronary heart disease, treating the U.S. rate as base 100. That is not the actual figure but shows, by comparison, for example, that Japan and Greece and Yugoslavia have considerably lower rates and that only Finland is worse off than we are.

Let me start by developing a little historical perspective. All of the great teachers of ancient history were teachers of adults, not teachers of children. In ancient times, Confucius and Lao-tse were teachers of adults, the Hebrew prophets and Jesus were teachers of adults; the ancient Greek educators Socrates, Aristotle and Plato were teachers of adults. The great Roman teachers Cicero and Quintillian were teachers of adults. The Institute of Alexandria where Euclid worked was an adult institution which did not admit persons under 18. It is interesting, therefore, that the writings about learning, the theorizing about learning in the ancient literature, were based upon experience of teachers with adults. And what they had to say about assumptions concerning learning were actually assumptions that we are now beginning to discover are true with adults.

These terms have become quite popular in recent years because the presumed success of Madison Avenue and the methods and gimmicks of commercial sales promotion easily tempt health professionals to adopt these same methods and gimmicks in the cause of health education.

I feel uncomfortable with these terms and with what they seem to suggest for health education because I believe that they threaten to lead the health professions into ineffective and even self-defeating approaches.

There are many critical differences between selling commercial goods and services to consumers on the one hand and selling people on using health services and healthful living habits on the other. I would like to point out just a few of the most glaring differences.

Health care policy makers, planners, administrators, and medical care consumers themselves are increasingly voicing their concern that access to the medical care system should be improved. A plethora of programs has been launched during the past decade with the expressed objective of achieving equity of access to medical care in the United States.

Some of these programs are directed at increasing the buying power or medical knowledge of the health care consumer-e.g., Medicaid, Medicare, national health insurance, and health education and nutrition programs. Others seek to improve the availability or organization of medical manpower and facilities-e.g., development of family practice as a specialty, paramedical training programs, and HMOs.

All these programs are intended in some way to provide equal access to the medical care system to various groups in the population. Just what the concept of "access" means, however, much less how it might be measured and what methods should be used to evaluate it, is ill-defined. Thus far, access has been primarily a political concept. It has for some time been an expressed or, at least, implicit goal of health policy, but few attempts have been made to provide systematic conceptual or empirical definitions of access that would permit policy makers and consumers actually to monitor the effectiveness of various programs in providing equal access to the medical system.