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Special Communication  |   August 2008
Osteopathic Medicine and Community Health Fairs: Increasing Public Awareness While Improving Public Health
Author Notes
  • From the Ingham Regional Medical Center in East Lansing, Mich (Drs Stamat and Injety); Michigan State University College of Osteopathic Medicine in Lansing (Drs Liechty and Aguwa); and Edward R. Sparrow Hospital in Morrice, Mich (Dr Pohlod). 
  • Address correspondence to K. Regina Injety, DO, Ingham Regional Medical Center, 401 W Greenlawn Ave, Lansing, MI 48910-2819. E-mail: krinjety@yahoo.com 
Article Information
Preventive Medicine
Special Communication   |   August 2008
Osteopathic Medicine and Community Health Fairs: Increasing Public Awareness While Improving Public Health
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 397-403. doi:10.7556/jaoa.2008.108.8.397
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 397-403. doi:10.7556/jaoa.2008.108.8.397
Abstract

For members of the public, community health fairs are an opportunity to gather information and receive screening for a variety of common medical conditions. For the osteopathic medical community, they can be an opportunity to increase public awareness about osteopathic medicine. The authors conducted a survey at nine community-based health fairs in the Lansing, Mich, metropolitan area to determine public awareness of osteopathic medicine and to learn if event attendance later influenced attendees' decisions to seek medical care. Between November 2001 and February 2003, health fair attendees (N=202) completed questionnaires and had their blood pressure, glucose level, and cholesterol level measured and their body mass index calculated. Approximately half of study participants received telephone follow-up within 60 days. At that time, participants were asked the same survey questions as well as whether they had sought follow-up medical care in the past 30 days. Survey results suggest that higher levels of education (P<.001) and annual household income (P<.001) correlate with increased awareness of osteopathic physicians. Preference for osteopathic physicians over allopathic physicians correlates with lower age (P<.001) and higher levels of education (P=.004). One third of participants reported seeking medical care in the past 30 days, but 79% of these individuals said their decisions were not influenced by health fair attendance. Health fairs are useful for increasing public knowledge about osteopathic medicine. The authors suggest that similar locally based promotion efforts target middle-aged individuals who do not have college degrees and belong to lower socioeconomic groups.

Osteopathic physicians (DOs) represent approximately 6% of all physicians in the United States1 and more than 8% of all physicians serving in the US military.2 Each year, patients make about 60 million office visits to DOs.3 Yet, many Americans remain unaware that there are two types of licensed physicians in the United States—DOs and allopathic physicians (MDs). In 1998, to help increase public awareness of the osteopathic medical profession and promote its distinctiveness from the allopathic medical profession, the American Osteopathic Association (AOA) launched its Campaign for Osteopathic Unity. This ongoing campaign has included consumer advertisements, radio broadcasts, and Internet-based information.4 
Research concerning public knowledge about osteopathic medicine has been limited. In 2003, the results of the Second Osteopathic Survey of Health Care in America (OSTEOSURV-II), a national telephone survey conducted by John C. Licciardone, DO, MBA,5 suggested the need for expanded efforts to increase public awareness. Data from OSTEOSURV-II indicated that knowledge of DOs was directly associated with age (40-59 y), education (13-15 y), and residency in the Midwestern region of the United States.5 This data also showed that members of racial and ethnic minority groups were less likely than whites to be familiar with DOs.5 
We hypothesized that community health fairs provide a means to increase public awareness of the osteopathic medical profession and physician visits for individuals who are at risk of chronic medical conditions. According to Berwick,6,7 more than 2 million Americans participate in community health fairs annually. However, most published literature on community health fairs does not pertain to their effectiveness in public awareness campaigns. Instead, most available studies address the logistics of event planning.8-10 
In the present study, we sought to determine whether attendees at community health fairs were familiar with DOs and if they had a preference for a certain type of healthcare provider. Secondarily, in the follow-up phase of the study, we investigated whether health fair attendance influenced participants' decisions to seek medical care. 
Methods
Nine community health fairs were held in the Lansing, Mich, area between November 2001 and February 2003. These health fairs were organized and staffed by volunteer first- and second-year osteopathic medical students from the Michigan State University College of Osteopathic Medicine (MSUCOM) in East Lansing. A DO faculty member was present at each of these events to supervise student volunteers. 
All nine health fairs took place in public locations such as bus stations, churches, and schools. Each event was publicized through various means, including community bulletins and local newspapers. The University Committee on Research Involving Human Subjects at Michigan State University approved all aspects of the present study. 
The MSUCOM-organized health fairs occurred both as independent events and as components of much larger, cooperative health fairs held in that geographic area. Members of the public who participated in these events had the opportunity to gather diverse medical information and receive a variety of health screening services. Because the health fairs were staged at different locations, the setup and layout of each event was varied. However, it was standard practice at each health fair to use one or two tables for registration of study participants, and between two and five tables for health screening. 
In the present study, we sought to complete medical evaluations for at least 200 individuals. To participate in the study, potential subjects had to be aged 18 years or older, agree to participate in a medical research project, provide informed consent for that participation, and agree to respond to a follow-up telephone interview. Any potential subjects who did not meet these inclusion criteria were not eligible to participate in the present study. 
After written informed consent was obtained, subjects were asked to complete written surveys that included questions about basic demographic and socioeconomic information, personal health habits with regard to exercise and substance use (ie, alcohol, tobacco), medical history (personal and family), awareness of osteopathic medicine, and healthcare provider preference (ie, DO, MD, chiropractor, or nurse practitioner). The questions on general health history were based on the leading health indicators described in the Healthy People 2010 initiative, which was sponsored by the Office of Disease Prevention and Health Promotion in the US Department of Health and Human Services.11 The Healthy People 2010 indicators reflect public health concerns in the United States, including substance use, cardiovascular disease, diabetes mellitus, and hypertension.11 
Most survey questions that addressed personal and family medical history, such as those evaluating risk of diabetes mellitus, asked participants to provide “yes” or “no” responses. 
Alcohol consumption levels were measured using a 5-point scale ranging from 1 (no alcohol) to 5 (>1 drink per day). Participants were also asked about binge-drinking behaviors. Men were asked when they had last consumed more than 5 drinks in a single day; women, more than 4 drinks in that amount of time. Again, a 5-point scale was used to measure responses to this question, ranging from 0 (never) to 4 (within the past month). 
Tobacco use was assessed using the Fagerstrom Test for Nicotine Dependence.12 
Participants' physical activity levels were measured using a 4-point scale ranging from 1 (0 min most days of week) to 4 (>30 min most days of week). 
Finally, six questions were used to assess participant knowledge of osteopathic medicine and healthcare provider preferences. Participants answered “yes” or “no” to the questions “Have you heard of a DO before?” and “Have you seen or heard any advertisements (eg, magazines, television, radio) recently about DOs?” The questions “What do the initials DO stand for?” and “What is your preference for a healthcare professional?” had multiple-choice answers. In addition, participants were asked to use a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree) to reply to the following: 
  • Both DOs and MDs are licensed physicians by the state they practice in.
  • Is a DO the same as a Chiropractor?
Osteopathic medical student volunteers from MSUCOM interacted individually with study participants at the health screening stations. The students first verified participant-provided information on the questionnaires, assisting participants who needed clarification to complete their forms. The students then measured participant's height and weight to establish body mass index (BMI) and obtained blood pressure readings. Students also measured each participant's blood glucose and cholesterol levels using the “finger-stick” method of blood sampling. Participants' fingers were first cleaned with an alcohol swab. A lancet was used to stick the side of the fingertip until a drop of blood was obtained for the glucose test strip. A second drop of blood was obtained by squeezing the fingertip for the cholesterol test strip. Each test strip was placed into an analytical device to obtain a reading. If the total cholesterol reading was greater than 200 mg/dL, participants were asked if they would like to have their low-density lipoprotein and high-density lipoprotein cholesterol levels measured. Participants interested in obtaining this additional testing were informed that a second finger-stick blood sample would be required. 
To calculate a point-based risk assessment, student volunteers combined results of participants' basic health screenings with data available through their general health history questionnaires. High-, moderate-, and low-risk categories were ascertained for blood pressure, BMI, cholesterol, glucose, substance use, and level of physical activity. Risk for diabetes mellitus and cardiovascular disease were calculated based on answers given on the general health history questionnaire. 
Students discussed the results of this analysis with health fair participants. Suggestions for modifying certain risk factors and advice for making follow-up visits to physicians, when indicated, were provided by student volunteers. Participants were given carbon copies of their health assessments, including medical data from the health screening and copies of their completed forms and questionnaires. 
Participants were later contacted by the same student volunteer who worked with them at the fair. On follow-up, survey participants were queried once again regarding their awareness of osteopathic medicine and any preference they might have for their healthcare providers vis-à-vis educational background. Two new questions were added to the six basic questions used at the health fair: 
  • Have you visited your doctor within the last 30 days?
  • Did the information we gave you when you attended the health fair influence your decision to visit your physician?
At the conclusion of the follow-up interview, participants were given the opportunity to comment on how the health fairs might be improved. 
Statistical Analysis
All data were analyzed using SPSS statistical software (version 12.0; SPSS Inc, Chicago, Ill). Basic descriptive statistics were calculated for the demographic and general health history questions. 
To evaluate our hypotheses that community health fairs provide a means to increase public awareness of the osteopathic medical profession and physician visits, t tests were performed. Independent t tests were performed for participants' answers to questions on age, education level, annual household income, familiarity with DOs, and healthcare provider preference. Independent t tests were also used to ensure that the follow-up population was representative of the total study population. This step was necessary because the follow-up population was smaller than the total study population and not randomly selected. 
Results
Signed informed consent for study participation was obtained from 202 (78%) of the 259 individuals who were initially interviewed at the community health fairs. As previously noted, individuals who were not interested in participating in research, who did not sign the consent form, or who did not want a follow-up telephone call were excluded from further research. Participants were most likely to be white (144 [71%]) women (105 [57%]) aged 45 to 54 years (54 [30%]) with a minimum education level of high school diploma or general education development (GED) credential and an annual household income of more than $40,000 (Table 1). The demographics of the study participants somewhat reflected the demographics of the general population of Lansing, Mich: white, 65%; women, 52%; aged 45 to 54 years, 12%.13 However, study participants were likely to have achieved a higher level of education than the average Lansing resident.13 
Table 1
Baseline Demographic Characteristics of Health Fair Survey Participants Compared With Residents of Lansing, Mich

Characteristic

Participants, No. (%) (N=202)*

Residents, % (N=119,128)
Sex
□ Men 81 (43.5) 48.0
□ Women105 (56.5)52.0
Race/Ethnicity
□ African American14 (8.1)21.9
□ Asian 4 (2.3) 2.8
□ White123 (71.1)65.3
□ Hispanic 25 (14.5) 10.0
□ Native American4 (2.3)0.8
□ Other 3 (1.2) 0.1
Age, y
□ 18-24 11 (6.0) 8.8
□ 25-3425 (13.7)17.6
□ 35-44 28 (15.4) 15.2
□ 45-5454 (29.7)12.4
□ 55-64 29 (15.9) 6.9
□ ≥6535 (19.2)9.8
Education level
□ High school not completed3 (1.8)12.8§
□ High school diploma or GED 62 (35.9) 26.8
□ Associate degree18 (10.6)7.7
□ Bachelor degree 49 (28.8) 13.8
□ Master degree or higher39 (22.9)7.4
Annual household income
□ <$10,00025 (14.7)11.5
□ $10,000-$15,000 11 (6.5) 7.6
□ $16,000-$20,00015 (8.8)NA
□ $21,000-$30,000 15 (8.8) NA
□ $31,000-$40,00020 (11.8)NA
□ >$40,000 84 (49.4) NA
 Abbreviation: NA, not available.
 *Because some participants did not answer all survey questions, sample size varies for each characteristic. Missing responses were not calculated in the percentages reported. In addition, some percentages do not total 100 because of rounding.
 Data on the population of Lansing, Mich, are based on United States Census 2000.13 Some percentages do not total 100 because of rounding or because some categories do not include the entire city population.
 8.8% represents the population of Lansing, Mich, aged 20 to 24 years.
 §12.8% represents the population of Lansing, Mich, that did not complete high school or receive a general educational development (GED) credential.
 Household income levels reported in United States Census 200013 did not match categories listed in study questionnaire, so direct comparisons cannot be made between survey participants and residents of Lansing, Mich. However, 37.1% of city residents reported an annual income between $35,000 and $74,999.13
Table 1
Baseline Demographic Characteristics of Health Fair Survey Participants Compared With Residents of Lansing, Mich

Characteristic

Participants, No. (%) (N=202)*

Residents, % (N=119,128)
Sex
□ Men 81 (43.5) 48.0
□ Women105 (56.5)52.0
Race/Ethnicity
□ African American14 (8.1)21.9
□ Asian 4 (2.3) 2.8
□ White123 (71.1)65.3
□ Hispanic 25 (14.5) 10.0
□ Native American4 (2.3)0.8
□ Other 3 (1.2) 0.1
Age, y
□ 18-24 11 (6.0) 8.8
□ 25-3425 (13.7)17.6
□ 35-44 28 (15.4) 15.2
□ 45-5454 (29.7)12.4
□ 55-64 29 (15.9) 6.9
□ ≥6535 (19.2)9.8
Education level
□ High school not completed3 (1.8)12.8§
□ High school diploma or GED 62 (35.9) 26.8
□ Associate degree18 (10.6)7.7
□ Bachelor degree 49 (28.8) 13.8
□ Master degree or higher39 (22.9)7.4
Annual household income
□ <$10,00025 (14.7)11.5
□ $10,000-$15,000 11 (6.5) 7.6
□ $16,000-$20,00015 (8.8)NA
□ $21,000-$30,000 15 (8.8) NA
□ $31,000-$40,00020 (11.8)NA
□ >$40,000 84 (49.4) NA
 Abbreviation: NA, not available.
 *Because some participants did not answer all survey questions, sample size varies for each characteristic. Missing responses were not calculated in the percentages reported. In addition, some percentages do not total 100 because of rounding.
 Data on the population of Lansing, Mich, are based on United States Census 2000.13 Some percentages do not total 100 because of rounding or because some categories do not include the entire city population.
 8.8% represents the population of Lansing, Mich, aged 20 to 24 years.
 §12.8% represents the population of Lansing, Mich, that did not complete high school or receive a general educational development (GED) credential.
 Household income levels reported in United States Census 200013 did not match categories listed in study questionnaire, so direct comparisons cannot be made between survey participants and residents of Lansing, Mich. However, 37.1% of city residents reported an annual income between $35,000 and $74,999.13
×
According to the US Department of Health and Human Services14 National Vital Statistics Report, cardiovascular disease ranked first and diabetes mellitus ranked sixth among the leading causes of death in 2001. These statistics highlight the importance of evaluating blood pressure, cholesterol, and glucose measurements in our study population. Study participants had a median blood pressure reading of 128/80 mm Hg, a median total cholesterol measurement of 188.5 mg/dL, and a median random glucose level of 83.5 mg/dL (Table 2). Despite these generally healthy median values, 95 participants (48%) reported they had been told by physicians that they had high blood pressure, high cholesterol, or diabetes mellitus, and 138 participants (70%) reported a family history of at least one of these conditions (Table 3). 
Table 2
Median Results of Health Screenings for Health Fair Survey Participants (N=202)

Characteristic

Median Result (SD)
Systolic blood pressure, mm Hg128.0 (18.3)
Diastolic blood pressure, mm Hg 80.0 (11.1)
Body mass index27.0 (6.1)
Random glucose level, mg/dL 83.5 (31.1)
Total cholesterol level, mg/dL
188.5 (39.2)
Table 2
Median Results of Health Screenings for Health Fair Survey Participants (N=202)

Characteristic

Median Result (SD)
Systolic blood pressure, mm Hg128.0 (18.3)
Diastolic blood pressure, mm Hg 80.0 (11.1)
Body mass index27.0 (6.1)
Random glucose level, mg/dL 83.5 (31.1)
Total cholesterol level, mg/dL
188.5 (39.2)
×
Table 3
Results of Health History Questionnaire for Health Fair Survey Participants (N=202)

Characteristic

Participants, No. (%)*
▪ History of diabetes mellitus, hypertension, or high cholesterol
□ Personal 96 (47.5)
□ Family141 (69.7)
▪ Substance use
□ Smokes tobacco23 (11.4)
□ Consumes alcohol, ≥1 drink per mo 110 (54.5)
▪ Regular exercise
□ Physical activity, >30 min most days
82 (40.6)
 *Because some participants did not answer all survey questions, sample size varies for each characteristic. Missing responses were not calculated in the percentages reported.
Table 3
Results of Health History Questionnaire for Health Fair Survey Participants (N=202)

Characteristic

Participants, No. (%)*
▪ History of diabetes mellitus, hypertension, or high cholesterol
□ Personal 96 (47.5)
□ Family141 (69.7)
▪ Substance use
□ Smokes tobacco23 (11.4)
□ Consumes alcohol, ≥1 drink per mo 110 (54.5)
▪ Regular exercise
□ Physical activity, >30 min most days
82 (40.6)
 *Because some participants did not answer all survey questions, sample size varies for each characteristic. Missing responses were not calculated in the percentages reported.
×
Twenty-three study participants (11%) were current smokers (Table 3), compared with 23% of US adults who reported being current smokers in 1999-2001, according to the National Center for Health Statistics.15 One hundred nine study participants (55%) reported drinking at least one alcoholic beverage per month, while 78 participants (39%) reported no alcohol consumption. This rate of alcohol use was similar to that of the general US population in 1999-2001.15 The median BMI of study participants was 27 (Table 2), which is considered overweight (BMI 26-29).15 Approximately 35% of the US population was considered overweight in 1999-2001.15 
Awareness of Osteopathic Medicine
One hundred fifty-three study participants (80%) reported that they had heard of DOs, though 131 (74%) said they had not heard or seen recent advertisements about DOs. One hundred fifty-eight participants (90%) “strongly agreed” or “agreed” that DOs and MDs are both licensed physicians. One hundred forty-seven (84%) “disagreed” or “strongly disagreed” when asked if a DO is the same as a chiropractor. When asked about their preference for type of healthcare provider, 52 participants (29%) preferred an MD, 45 (25%) expressed no preference, and 41 (23%) preferred a DO. 
Education level correlated with awareness of osteopathic medicine (Table 4). Participants familiar with DOs were more likely to have attained some form of college degree; participants who had never heard of DOs were most likely to have a high school diploma or GED credential (P<.001). Annual household income also correlated with awareness of DOs. The average annual income of participants familiar with DOs ranged from $21,000 to $30,000, versus those who were not familiar with DOs, whose average annual earnings ranged from $16,000 to $20,000 (P<.001). 
Table 4
Independent t-Test Comparisons of Survey Participant Characteristics With Awareness of Osteopathic Medicine

Characteristic

Mean

P Value
Age*
□ Yes (n=140) 4.88 .59
□ No (n=33)5.03
Education level
□ Yes (n=132)2.58<.001
□ No (n=31) 1.48
Annual household income
□ Yes (n=131) 4.78 <.001
□ No (n=31)
3.42

 *Age mean value is based on the following scale: 1, 0-17 y; 2, 18-24 y; 3, 25-34 y; 4, 35-44 y; 5, 45-54 y; 6, 55-64 y; 7, ≥65 y.
 Education level mean value is based on the following scale: 0, did not complete high school; 1, high school diploma or general educational development (GED) credential; 2, associate degree; 3, bachelor degree; 4, master degree or higher.
 Annual household income mean value is based on the following scale: 1, <$10,000; 2, $10,000-$15,000; 3, $16,000-$20,000; 4, $21,000-$30,000; 5, $31,000-$40,000; 6, >$40,000.
Table 4
Independent t-Test Comparisons of Survey Participant Characteristics With Awareness of Osteopathic Medicine

Characteristic

Mean

P Value
Age*
□ Yes (n=140) 4.88 .59
□ No (n=33)5.03
Education level
□ Yes (n=132)2.58<.001
□ No (n=31) 1.48
Annual household income
□ Yes (n=131) 4.78 <.001
□ No (n=31)
3.42

 *Age mean value is based on the following scale: 1, 0-17 y; 2, 18-24 y; 3, 25-34 y; 4, 35-44 y; 5, 45-54 y; 6, 55-64 y; 7, ≥65 y.
 Education level mean value is based on the following scale: 0, did not complete high school; 1, high school diploma or general educational development (GED) credential; 2, associate degree; 3, bachelor degree; 4, master degree or higher.
 Annual household income mean value is based on the following scale: 1, <$10,000; 2, $10,000-$15,000; 3, $16,000-$20,000; 4, $21,000-$30,000; 5, $31,000-$40,000; 6, >$40,000.
×
Healthcare Provider Preference
Our results also showed a correlation between education level and healthcare provider preference. Participants who preferred a DO as their primary healthcare provider typically attained a college degree, compared with participants who preferred an MD, whose highest education level was typically a high school diploma or GED credential (P=.004) (Table 5). 
Table 5
Independent t-Test Comparisons of Survey Participant Characteristics With Whether Participants Preferred DOs or MDs as Healthcare Providers

Characteristic

Mean

P Value
Age*
□ DO (n=39) 4.10 <.001
□ MD (n=44)5.57
Education level
□ DO (n=37)2.76.004
□ MD (n=42) 1.95
Annual household income
□ DO (n=36) 4.81 .15
□ MD (n=41)4.20
 Abbreviations: DO, osteopathic physician; MD, allopathic physician.
 *Age mean value is based on the following scale: 1, 0-17 y; 2, 18-24 y; 3, 25-34 y; 4, 35-44 y; 5, 45-54 y; 6, 55-64 y; 7, ≥65 y.
 Education level mean value is based on the following scale: 0, did not complete high school; 1, high school diploma or general educational development (GED) credential; 2, associate degree; 3, bachelor degree; 4, master degree or higher.
 Annual household income mean value is based on the following scale: 1, <$10,000; 2, $10,000-$15,000; 3, $16,000-$20,000; 4, $21,000-$30,000; 5, $31,000-$40,000; 6, >$40,000.
Table 5
Independent t-Test Comparisons of Survey Participant Characteristics With Whether Participants Preferred DOs or MDs as Healthcare Providers

Characteristic

Mean

P Value
Age*
□ DO (n=39) 4.10 <.001
□ MD (n=44)5.57
Education level
□ DO (n=37)2.76.004
□ MD (n=42) 1.95
Annual household income
□ DO (n=36) 4.81 .15
□ MD (n=41)4.20
 Abbreviations: DO, osteopathic physician; MD, allopathic physician.
 *Age mean value is based on the following scale: 1, 0-17 y; 2, 18-24 y; 3, 25-34 y; 4, 35-44 y; 5, 45-54 y; 6, 55-64 y; 7, ≥65 y.
 Education level mean value is based on the following scale: 0, did not complete high school; 1, high school diploma or general educational development (GED) credential; 2, associate degree; 3, bachelor degree; 4, master degree or higher.
 Annual household income mean value is based on the following scale: 1, <$10,000; 2, $10,000-$15,000; 3, $16,000-$20,000; 4, $21,000-$30,000; 5, $31,000-$40,000; 6, >$40,000.
×
In addition, age proved to be statistically significant in terms of provider preference. Study participants aged between 35 and 44 years were more likely to prefer a DO as their healthcare provider, compared with participants aged between 45 and 54 years, who were more likely to prefer an MD (P<.001). 
We did not perform statistical analyses regarding participant preference for chiropractor or nurse practitioner because 3 participants selected a chiropractor for their healthcare provider and 1 participant selected a nurse practitioner. 
Follow-Up Telephone Survey
Student volunteers conducted follow-up telephone interviews 56 days on average (range 6-126 d) after participants received the community health fair screening. Students successfully contacted 100 (49%) of the original participants. Some participants could not be contacted—even after three attempts—because they did not provide correct contact information, or because their telephone numbers had been changed or disconnected. However, when age, sex, race or ethnicity, education level, and annual household income were examined, there were no statistically significant differences between the participants who were successfully contacted for follow-up and those who were not. 
Eighty-four of 100 follow-up participants reported that they had heard of DOs, though 80 said they had not recently heard or seen advertisements regarding DOs. These percentages were similar to the 80% and 74% reported, respectively, by health fair attendees. Ninety-three follow-up participants “strongly agreed” or “agreed” that DOs and MDs are both licensed physicians, a percentage that was similar to the 90% recorded at the health fairs. Eighty-six follow-up participants “disagreed” or “strongly disagreed” when asked if they believed a DO was the same as a chiropractor—similar to the 84% among original health fair participants. 
Twenty-nine of the 100 follow-up participants said they preferred to seek medical care from a DO, a rate that was up slightly from the 23% reported during health fair attendance. Twenty-five follow-up participants said they preferred an MD. Twenty-three follow-up participants thought the difference between a DO and MD was not important in selecting a healthcare provider. These rates compared with the 24% and 25%, respectively, found among participants' original responses during health fair attendance. 
On completion of the follow-up telephone interviews, 33 participants answered “yes” when asked if they had visited a physician within the previous 30 days. Twenty-six individuals who visited a physician (79%) reported that their decision to do so was not influenced by health fair attendance. 
Comment
A survey conducted by the AOA in 2003 concluded that 89% of Americans were not familiar with DOs—hence, researchers16 concluded there was a need to increase public awareness of osteopathic medicine. The results of the present study further clarify public awareness at the local level regarding osteopathic medicine. Our results correlate with the 2003 findings of OSTEOSURV-II.5 
The results of that nationwide study5 suggest that there is a great need to promote the osteopathic medical profession. According to Licciardone,5 public awareness of osteopathic medicine is directly associated with age (40-59 y), level of education (13-15 y), and geographic residence in the Midwestern region of the United States. The results of OSTEOSURV-II5 also indicate that members of racial and ethnic minority populations are less likely than whites to be aware of DOs. 
Our results also coincide with OSTEOSURV-II5 in associating public awareness of osteopathic medicine with level of education attained. Our findings differ slightly from those of Licciardone,5 however, with regard to age-dependent data. Our results showed no statistical difference among age groups when individuals were asked if they had heard of DOs. However, when study participants were asked about their preferences for healthcare providers, the age group between 35 and 44 years was statistically more likely to prefer DOs than the age group between 45 and 54 years, who typically preferred MDs (P<.05). 
The reasons for age-related statistical difference in provider preference are unclear. The difference may be the result of efforts by the AOA Campaign for Osteopathic Unity4 to target women aged 35 to 54 years. However, 74% of the participants surveyed during the health fairs denied seeing or hearing recent advertisements about DOs. 
Approximately 80% of the individuals surveyed during the health fairs reported that they had heard of DOs. When asked if they had any preferences by type of healthcare provider, 29% of participants said they preferred an MD, 25% had no preference, and 23% preferred a DO. Statistically, participants' preference for an MD vs a DO was related to their education level, with participants who were more educated (ie, with some form of college degree) being more likely to prefer a DO. This result may be related to Licciardone's5 finding that less educated individuals may be more likely to view osteopathic medicine as a form of complementary or alternative medicine. Barriers stemming from such a misconception may impede public acceptance of DOs in primary care, especially among individuals opposed to nontraditional treatments.5,17 However, the results of the present study indicate that the majority of participants who were surveyed were aware that DOs are licensed physicians, and that they are not the same as chiropractors. 
The results of the follow-up surveys conducted in the present study were similar to those of the initial questionnaires used at the health fairs, though approximately 50% of the original survey participants were successfully contacted during this phase of the study. Follow-up responses approximated initial responses regarding awareness of osteopathic medicine. When asked about preferences for type of healthcare provider, 29% of the individuals participating in the follow-up interviews said they preferred a DO, up slightly from the 23% who said they preferred DOs in the initial health fair survey—though this difference was not statistically significant. 
It is difficult to make any correlation for a possible increase in DO preference at follow-up without having data from a random sample. However, one possibility is that study participants at follow-up may have reported a preference for DOs to please telephone interviewers, who introduced themselves as calling from MSUCOM regarding the health fairs. Alternatively, study participants at follow-up may have been more familiar with DOs after learning about osteopathic medicine during the health fairs. Further examination of participants' reasons for preferring DOs or MDs was not pursued in the present study. 
The secondary aim of the present study was to determine if health fair attendance influenced participants' decisions to seek medical care. Our results show that physician visits were not influenced by health fair attendance. It should be noted that, according to Heath et al,18 laboratory testing services can provide health fair participants with a sense of control over their personal healthcare. Heath et al18 reported that 86% of their subjects (N=303) perceived “normal” test results as ensuring a “healthy” future for themselves. Likewise, the median laboratory values from the health screenings of participants in our study represent a fairly healthy population. Thus, study participants may have perceived their overall health status as “good,” perhaps accounting for the small number of subsequent physician visits. Those participants who visited physicians after the health fairs may have had other causes for concern, unrelated to health fair attendance. 
Study Limitations
Demographically, health fair attendees who participated in the present study represented the population of Lansing, Mich, fairly well, though only 16 participants (8.1%) identified themselves as African American, compared with a documented African-American population of 21.9% in the Lansing area.13 
The ability to use data from the present study to make generalizations for a wider population is difficult because health fairs, by their very nature, are more accessible to individuals who have the resources to attend (eg, access to transportation). Thus, health fairs do not provide a representative random sample of a local population. In addition, some demographic information was not available from one of the health fairs in the present study. This missing data and any other questions unanswered by health fair participants were coded as “unknown” during data analysis. 
Another study limitation was our inability to contact more of the original participants during the follow-up phase of the study. As noted, fewer than 50% of subjects were available or willing to take part in telephone follow-up interviews. At the beginning of the study, our goal was to contact all participants 30 days postattendance. However, due to time constraints for student volunteers, the average time to follow-up was 56 days postattendance. 
Additional limitations of the present study include the variability among health fair locations, which resulted in different demographic characteristics for participants at different study sites, and multiple student volunteers to conduct health screening activities. All student volunteers were trained in the appropriate techniques for measuring the objective variables recorded in participants' health screenings. Because students had varying levels of comfort with these techniques, however, there was a lack of standardization among blood pressure measurements and inconsistency in the ability to achieve appropriate finger-stick blood draws for the random glucose and total cholesterol measurements. 
Finally, a variety of social interactions between health fair participants and student volunteers may have affected participants' experiences at the health fairs, thereby altering their perceptions of osteopathic medicine. When participants who took part in the follow-up survey were asked if they had any comments about how to improve the health fairs, some reported that the student volunteers needed more training. As noted by Carter,10 having qualified screeners with properly calibrated equipment is one of the four criteria necessary for a health fair to be effective. 
Conclusion
The profession's efforts to enhance public awareness of osteopathic medicine should focus on individual communities. Health fairs can provide such an opportunity. Although the greater Lansing area is home to MSUCOM, 20% of study participants who attended health fairs in this geographic area reported that they had not heard of DOs. 
These results suggest that the population unfamiliar with osteopathic medicine is most likely to consist of middle-aged individuals who do not have college degrees and are from lower socioeconomic groups. The osteopathic medical profession should concentrate its efforts on this population to achieve greater public awareness of osteopathic medicine. The osteopathic medical profession also needs to explore why many individuals who are familiar with osteopathic medicine still prefer allopathic physicians as their primary healthcare providers. To promote the growth of the osteopathic medical profession, further research investigating these issues is warranted. 
 This study was supported by an Academic Administration Units in Primary Care Grant (2 D54 HP 00101-06) from the US Department of Health and Human Services—Health Resources and Services Administration.
 
We thank the Michigan State University College of Osteopathic Medicine in East Lansing; the Community Integrated Medicine Student Association; and all of the student volunteers, faculty advisors, and physicians who participated in the present study. 
Osteopathic medicine; 2003-2007. American Osteopathic Association Web site. Available at: http://www.osteopathic.org/index.cfm?PageID=ost_omed. Accessed July 21, 2008.
National DO day recognizes osteopathic physicians in military and uniform services [press release]. Chicago, Ill: American Osteopathic Association; April 9, 2003. Available at: http://www.osteopathic.org/index.cfm?PageID=mc_domilitarypr. Accessed July 21, 2008.
Cherry DK, Woodwell DA, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2005 Summary. Hyattsville, Md: National Center for Health Statistics; 2007. Advance Data from Vital and Health Statistics, No. 387.
Cook J. United for excellence. Forum. April 2006:19-23. Available at: http://www.osteopathic.org/pdf/mc_citeforumconvarticle0406.pdf. Accessed July 21, 2008.
Licciardone JC. Awareness and use of osteopathic physicians in the United States: results of the Second Osteopathic Survey of Health Care in America (OSTEOSURV-II). J Am Osteopath Assoc. 2003;103:281-289. Available at: http://www.jaoa.org/cgi/reprint/103/6/281. Accessed July 21, 2008.
Berwick DM. Screening in health fairs. A critical review of benefits, risks, and costs. JAMA. 1985;254:1492-1498.
Mess SE, Reese PP, Della Lana DF, Walley AY, Ives EP, Lee MC. Older, hypertensive, and hypercholesterolemic fairgoers visit more booths and differ in their health concerns at a community health fair. J Community Health. 2000;25:315-329.
Dillon DL, Sternas K. Designing a successful health fair to promote individual, family, and community health. J Community Health Nurs. 1997;14:1-14.
Germer P, Price JH. Organization and evaluation of health fairs. J Sch Health. 1981;51:86-90.
Carter KF. The health fair as an effective health promotion strategy [review]. AAOHN J. 1991;39:513-516.
Healthy People 2010 Web site. Available at: http://www.healthypeople.gov. Accessed July 21, 2008.
Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict. 1991;86:1119-1127.
United States Census 2000 page. US Census Bureau Web site. January 24, 2002. Available at: http://www.census.gov/main/www/cen2000.html. Accessed July 21, 2008.
Anderson RN, Smith BL. Deaths: leading causes for 2001. Natl Vital Stat Rep. 2003;52:1-85. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_09.pdf. Accessed July 21, 2008.
Schoenborn CA, Adams PF, Barnes PM, Vickerie JL, Schiller JS. Health behaviors of adults: United States, 1999-2001. Vital Health Stat 10. 2004;219:1-79 Available at: http://www.cdc.gov/nchs/data/series/sr_10/sr10_219.pdf. Accessed July 21, 2008.
Frequently asked questions—the campaign for osteopathic unity; 2003. American Osteopathic Association Web site. Available at: http://www.aoa-net.org/Executive/UnityCampaign/unityfaq.htm. Accessed March 21, 2004.
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Heath JM, Lucic KS, Hollifield D, Kues JR. The health beliefs of health fair participants. J Community Health. 1991;16:197-203.
Table 1
Baseline Demographic Characteristics of Health Fair Survey Participants Compared With Residents of Lansing, Mich

Characteristic

Participants, No. (%) (N=202)*

Residents, % (N=119,128)
Sex
□ Men 81 (43.5) 48.0
□ Women105 (56.5)52.0
Race/Ethnicity
□ African American14 (8.1)21.9
□ Asian 4 (2.3) 2.8
□ White123 (71.1)65.3
□ Hispanic 25 (14.5) 10.0
□ Native American4 (2.3)0.8
□ Other 3 (1.2) 0.1
Age, y
□ 18-24 11 (6.0) 8.8
□ 25-3425 (13.7)17.6
□ 35-44 28 (15.4) 15.2
□ 45-5454 (29.7)12.4
□ 55-64 29 (15.9) 6.9
□ ≥6535 (19.2)9.8
Education level
□ High school not completed3 (1.8)12.8§
□ High school diploma or GED 62 (35.9) 26.8
□ Associate degree18 (10.6)7.7
□ Bachelor degree 49 (28.8) 13.8
□ Master degree or higher39 (22.9)7.4
Annual household income
□ <$10,00025 (14.7)11.5
□ $10,000-$15,000 11 (6.5) 7.6
□ $16,000-$20,00015 (8.8)NA
□ $21,000-$30,000 15 (8.8) NA
□ $31,000-$40,00020 (11.8)NA
□ >$40,000 84 (49.4) NA
 Abbreviation: NA, not available.
 *Because some participants did not answer all survey questions, sample size varies for each characteristic. Missing responses were not calculated in the percentages reported. In addition, some percentages do not total 100 because of rounding.
 Data on the population of Lansing, Mich, are based on United States Census 2000.13 Some percentages do not total 100 because of rounding or because some categories do not include the entire city population.
 8.8% represents the population of Lansing, Mich, aged 20 to 24 years.
 §12.8% represents the population of Lansing, Mich, that did not complete high school or receive a general educational development (GED) credential.
 Household income levels reported in United States Census 200013 did not match categories listed in study questionnaire, so direct comparisons cannot be made between survey participants and residents of Lansing, Mich. However, 37.1% of city residents reported an annual income between $35,000 and $74,999.13
Table 1
Baseline Demographic Characteristics of Health Fair Survey Participants Compared With Residents of Lansing, Mich

Characteristic

Participants, No. (%) (N=202)*

Residents, % (N=119,128)
Sex
□ Men 81 (43.5) 48.0
□ Women105 (56.5)52.0
Race/Ethnicity
□ African American14 (8.1)21.9
□ Asian 4 (2.3) 2.8
□ White123 (71.1)65.3
□ Hispanic 25 (14.5) 10.0
□ Native American4 (2.3)0.8
□ Other 3 (1.2) 0.1
Age, y
□ 18-24 11 (6.0) 8.8
□ 25-3425 (13.7)17.6
□ 35-44 28 (15.4) 15.2
□ 45-5454 (29.7)12.4
□ 55-64 29 (15.9) 6.9
□ ≥6535 (19.2)9.8
Education level
□ High school not completed3 (1.8)12.8§
□ High school diploma or GED 62 (35.9) 26.8
□ Associate degree18 (10.6)7.7
□ Bachelor degree 49 (28.8) 13.8
□ Master degree or higher39 (22.9)7.4
Annual household income
□ <$10,00025 (14.7)11.5
□ $10,000-$15,000 11 (6.5) 7.6
□ $16,000-$20,00015 (8.8)NA
□ $21,000-$30,000 15 (8.8) NA
□ $31,000-$40,00020 (11.8)NA
□ >$40,000 84 (49.4) NA
 Abbreviation: NA, not available.
 *Because some participants did not answer all survey questions, sample size varies for each characteristic. Missing responses were not calculated in the percentages reported. In addition, some percentages do not total 100 because of rounding.
 Data on the population of Lansing, Mich, are based on United States Census 2000.13 Some percentages do not total 100 because of rounding or because some categories do not include the entire city population.
 8.8% represents the population of Lansing, Mich, aged 20 to 24 years.
 §12.8% represents the population of Lansing, Mich, that did not complete high school or receive a general educational development (GED) credential.
 Household income levels reported in United States Census 200013 did not match categories listed in study questionnaire, so direct comparisons cannot be made between survey participants and residents of Lansing, Mich. However, 37.1% of city residents reported an annual income between $35,000 and $74,999.13
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Table 2
Median Results of Health Screenings for Health Fair Survey Participants (N=202)

Characteristic

Median Result (SD)
Systolic blood pressure, mm Hg128.0 (18.3)
Diastolic blood pressure, mm Hg 80.0 (11.1)
Body mass index27.0 (6.1)
Random glucose level, mg/dL 83.5 (31.1)
Total cholesterol level, mg/dL
188.5 (39.2)
Table 2
Median Results of Health Screenings for Health Fair Survey Participants (N=202)

Characteristic

Median Result (SD)
Systolic blood pressure, mm Hg128.0 (18.3)
Diastolic blood pressure, mm Hg 80.0 (11.1)
Body mass index27.0 (6.1)
Random glucose level, mg/dL 83.5 (31.1)
Total cholesterol level, mg/dL
188.5 (39.2)
×
Table 3
Results of Health History Questionnaire for Health Fair Survey Participants (N=202)

Characteristic

Participants, No. (%)*
▪ History of diabetes mellitus, hypertension, or high cholesterol
□ Personal 96 (47.5)
□ Family141 (69.7)
▪ Substance use
□ Smokes tobacco23 (11.4)
□ Consumes alcohol, ≥1 drink per mo 110 (54.5)
▪ Regular exercise
□ Physical activity, >30 min most days
82 (40.6)
 *Because some participants did not answer all survey questions, sample size varies for each characteristic. Missing responses were not calculated in the percentages reported.
Table 3
Results of Health History Questionnaire for Health Fair Survey Participants (N=202)

Characteristic

Participants, No. (%)*
▪ History of diabetes mellitus, hypertension, or high cholesterol
□ Personal 96 (47.5)
□ Family141 (69.7)
▪ Substance use
□ Smokes tobacco23 (11.4)
□ Consumes alcohol, ≥1 drink per mo 110 (54.5)
▪ Regular exercise
□ Physical activity, >30 min most days
82 (40.6)
 *Because some participants did not answer all survey questions, sample size varies for each characteristic. Missing responses were not calculated in the percentages reported.
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Table 4
Independent t-Test Comparisons of Survey Participant Characteristics With Awareness of Osteopathic Medicine

Characteristic

Mean

P Value
Age*
□ Yes (n=140) 4.88 .59
□ No (n=33)5.03
Education level
□ Yes (n=132)2.58<.001
□ No (n=31) 1.48
Annual household income
□ Yes (n=131) 4.78 <.001
□ No (n=31)
3.42

 *Age mean value is based on the following scale: 1, 0-17 y; 2, 18-24 y; 3, 25-34 y; 4, 35-44 y; 5, 45-54 y; 6, 55-64 y; 7, ≥65 y.
 Education level mean value is based on the following scale: 0, did not complete high school; 1, high school diploma or general educational development (GED) credential; 2, associate degree; 3, bachelor degree; 4, master degree or higher.
 Annual household income mean value is based on the following scale: 1, <$10,000; 2, $10,000-$15,000; 3, $16,000-$20,000; 4, $21,000-$30,000; 5, $31,000-$40,000; 6, >$40,000.
Table 4
Independent t-Test Comparisons of Survey Participant Characteristics With Awareness of Osteopathic Medicine

Characteristic

Mean

P Value
Age*
□ Yes (n=140) 4.88 .59
□ No (n=33)5.03
Education level
□ Yes (n=132)2.58<.001
□ No (n=31) 1.48
Annual household income
□ Yes (n=131) 4.78 <.001
□ No (n=31)
3.42

 *Age mean value is based on the following scale: 1, 0-17 y; 2, 18-24 y; 3, 25-34 y; 4, 35-44 y; 5, 45-54 y; 6, 55-64 y; 7, ≥65 y.
 Education level mean value is based on the following scale: 0, did not complete high school; 1, high school diploma or general educational development (GED) credential; 2, associate degree; 3, bachelor degree; 4, master degree or higher.
 Annual household income mean value is based on the following scale: 1, <$10,000; 2, $10,000-$15,000; 3, $16,000-$20,000; 4, $21,000-$30,000; 5, $31,000-$40,000; 6, >$40,000.
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Table 5
Independent t-Test Comparisons of Survey Participant Characteristics With Whether Participants Preferred DOs or MDs as Healthcare Providers

Characteristic

Mean

P Value
Age*
□ DO (n=39) 4.10 <.001
□ MD (n=44)5.57
Education level
□ DO (n=37)2.76.004
□ MD (n=42) 1.95
Annual household income
□ DO (n=36) 4.81 .15
□ MD (n=41)4.20
 Abbreviations: DO, osteopathic physician; MD, allopathic physician.
 *Age mean value is based on the following scale: 1, 0-17 y; 2, 18-24 y; 3, 25-34 y; 4, 35-44 y; 5, 45-54 y; 6, 55-64 y; 7, ≥65 y.
 Education level mean value is based on the following scale: 0, did not complete high school; 1, high school diploma or general educational development (GED) credential; 2, associate degree; 3, bachelor degree; 4, master degree or higher.
 Annual household income mean value is based on the following scale: 1, <$10,000; 2, $10,000-$15,000; 3, $16,000-$20,000; 4, $21,000-$30,000; 5, $31,000-$40,000; 6, >$40,000.
Table 5
Independent t-Test Comparisons of Survey Participant Characteristics With Whether Participants Preferred DOs or MDs as Healthcare Providers

Characteristic

Mean

P Value
Age*
□ DO (n=39) 4.10 <.001
□ MD (n=44)5.57
Education level
□ DO (n=37)2.76.004
□ MD (n=42) 1.95
Annual household income
□ DO (n=36) 4.81 .15
□ MD (n=41)4.20
 Abbreviations: DO, osteopathic physician; MD, allopathic physician.
 *Age mean value is based on the following scale: 1, 0-17 y; 2, 18-24 y; 3, 25-34 y; 4, 35-44 y; 5, 45-54 y; 6, 55-64 y; 7, ≥65 y.
 Education level mean value is based on the following scale: 0, did not complete high school; 1, high school diploma or general educational development (GED) credential; 2, associate degree; 3, bachelor degree; 4, master degree or higher.
 Annual household income mean value is based on the following scale: 1, <$10,000; 2, $10,000-$15,000; 3, $16,000-$20,000; 4, $21,000-$30,000; 5, $31,000-$40,000; 6, >$40,000.
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