4
Modifying Health Risk Behaviors1

Significant reductions in the burden of cancer are possible through changes in health behaviors. This chapter reviews current evidence of the effectiveness of interventions to promote three key behaviors in cancer prevention: nonsmoking, healthy diet, and physical activity. Although alcohol consumption was identified as a risk factor for cancer (Chapter 3), interventions to reduce alcohol consumption are not reviewed because of the cardiovascular health benefits associated with moderate consumption. The focus in this chapter is on changing individual behaviors through the provision of direct services (e.g., one-on-one counseling), contacts with health care providers or systems of care, and via community-based approaches such as worksite or school-based programs and public education media campaigns. Research on interventions to improve use of screening services is summarized in Chapter 6.

Interventions to modify behavioral risk factors can be implemented at several levels, for example, at the individual (e.g., group nutrition, exercise, or smoking cessation programs), interpersonal (e.g., advice and support from one’s physician for smoking cessation), organizational (e.g., worksite cafeteria menu changes, health care benefit policies, mass media programs),

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This chapter is based on three background papers: (1) Interventions to Promote Key Behaviors in Cancer Prevention and Early Detection, by Edwin B. Fisher, Ross C. Brownson, Amy A. Eyler, Debra L. Haire-Joshu, and Mario Schootman; (2) The Effectiveness of Interventions to Assist in Weight Loss, by Suzanne Phelan and Rena Wing; and (3) Provider, System and Policy Strategies to Enhance the Delivery of Cancer Prevention and Control Activities in Primary Care, by Judy Ockene, Jane Zapka, Lori Pebert, Suzanne Brodney, and Stephanie Leman (www.iom.edu/ncpb).



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Fulfilling the Potential of Cancer Prevention and Early Detection 4 Modifying Health Risk Behaviors1 Significant reductions in the burden of cancer are possible through changes in health behaviors. This chapter reviews current evidence of the effectiveness of interventions to promote three key behaviors in cancer prevention: nonsmoking, healthy diet, and physical activity. Although alcohol consumption was identified as a risk factor for cancer (Chapter 3), interventions to reduce alcohol consumption are not reviewed because of the cardiovascular health benefits associated with moderate consumption. The focus in this chapter is on changing individual behaviors through the provision of direct services (e.g., one-on-one counseling), contacts with health care providers or systems of care, and via community-based approaches such as worksite or school-based programs and public education media campaigns. Research on interventions to improve use of screening services is summarized in Chapter 6. Interventions to modify behavioral risk factors can be implemented at several levels, for example, at the individual (e.g., group nutrition, exercise, or smoking cessation programs), interpersonal (e.g., advice and support from one’s physician for smoking cessation), organizational (e.g., worksite cafeteria menu changes, health care benefit policies, mass media programs), 1   This chapter is based on three background papers: (1) Interventions to Promote Key Behaviors in Cancer Prevention and Early Detection, by Edwin B. Fisher, Ross C. Brownson, Amy A. Eyler, Debra L. Haire-Joshu, and Mario Schootman; (2) The Effectiveness of Interventions to Assist in Weight Loss, by Suzanne Phelan and Rena Wing; and (3) Provider, System and Policy Strategies to Enhance the Delivery of Cancer Prevention and Control Activities in Primary Care, by Judy Ockene, Jane Zapka, Lori Pebert, Suzanne Brodney, and Stephanie Leman (www.iom.edu/ncpb).

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Fulfilling the Potential of Cancer Prevention and Early Detection and societal level (e.g., tobacco control legislation, changes in standards for school nutrition programs) (Winett et al., 1989; McLeroy et al., 1988). These levels are not mutually exclusive, and reflect an evolution in prevention research from a primary focus on determinants of behavior within the individual to broader perspectives that encompass interpersonal, organizational, and community influences. This chapter begins with a description of the many opportunities to deliver behavioral interventions, from clinical settings to public health programs. An overview is then provided of conceptual frameworks and intervention paradigms that underlie much of the reviewed behavioral research. Next, treatment-outcome research is summarized for tobacco cessation and prevention, physical activity, and diet (weight loss interventions and modification of eating patterns). Lastly, the challenges faced by health care providers in delivering effective interventions are reviewed. THE DELIVERY OF BEHAVIORAL INTERVENTIONS The delivery of health behaviorial interventions can take place in the context of a clinical setting or be more broadly applied to public health practice (Lichtenstein and Glasgow, 1992). Clinical programs include group and individual counseling offered through a variety of channels, including private, non-profit agencies, commercial programs, community organizations such as schools, health care centers, churches or other religious institutions, and worksites. The target population for clinical interventions is usually individuals who are motivated (or who can be motivated) to actively seek treatment. Interventions may be delivered by medical or allied health professionals or by non-medical professionals with specialty training. Behavioral interventions are often intensive, involving multiple sessions. The target population for public health interventions is usually an unselected group of individuals or members of specific high-risk groups, regardless of their motivation to change their behavior. Interventions are delivered in natural settings, and the providers of interventions are not necessarily specialists. Public health interventions can include translating intensive behavioral programs into formats that can be delivered on a wide scale, such as self-help guides, computer-generated messages or reminders, and outreach telephone counseling. Advances in information technology have made it possible to create customized or tailored materials and to deliver them via the Internet. Also in the realm of public health interventions are large-scale efforts such as mass media programs (which can be paired with written self-help materials that are disseminated, for example, through community retail outlets) and legislative or regulatory approaches (e.g., excise taxes, school lunch policies). Related to the clinical-public health continuum of intervention is the construct of “program impact.” The impact of an intervention is a product

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Fulfilling the Potential of Cancer Prevention and Early Detection of its reach into the target population (i.e., the proportion of individuals who access the intervention) and the effectiveness (or rate of behavior change) associated with the interventions offered (Abrams et al., 1995). Because of their greater intensity and personal contact, clinical interventions have higher rates of individual change relative to public health interventions. However, intensive clinical programs may actually have less impact because of their lower reach in to the population. Modest changes in a large segment of the population can result in meaningful reductions in cancer incidence and mortality. Clearly, clinical and public health approaches are not mutually exclusive. The potential for cancer prevention through modification of health risk behaviors is optimized by a combination of the two approaches. In fact, strategies and interventions are needed on multiple levels to overcome barriers to the delivery of and access to cancer prevention and control interventions (Rimer et al., 2001). A general consensus has emerged that efforts to change social and behavioral risk factors are most successful if they link multiple levels of influence, for example, at the individual, interpersonal, institutional, community, and policy levels (Institute of Medicine, 2000b). CONCEPTUAL FRAMEWORKS GUIDING BEHAVIORAL RESEARCH Behavioral research is driven by theoretical models of the determinants of the target behavior. This section describes three models that guide assessments of behavioral interventions relating to tobacco use, diet, and physical activity: value expectancy theories, the social cognitive theory, and the transtheoretical or stages of change model. Value Expectancy Theories Value expectancy theories emphasize cognitive factors that are associated with motivation for behavior change. Motivation is viewed as a rational, decision-making process that results from an individual’s subjective value of an outcome and of the subjective probability or expectation that a particular behavior will attain the desired outcome. Two prominent value expectancy theories are the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). Health Belief Model First developed in the 1950s, the HBM has evolved into a psychosocial model that proposes three main determinants of motivation for health behavior change (Rosenstock, 1974):

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Fulfilling the Potential of Cancer Prevention and Early Detection perceived susceptibility to a disease or the subjective risks of contracting a serious illness; perceived seriousness of an illness, in terms of both medical and lifestyle consequences; and belief that particular behaviors will reduce the perceived threat, and that the associated benefits of those behaviors will outweigh the perceived costs and barriers. Perceived susceptibility and severity are based largely on an individual’s knowledge of a disease and its potential outcome. The HBM also recognizes the potential importance of “cues to action” in starting the process of behavior change. These cues can be internal (e.g., physical symptoms that suggest disease risk or vulnerability such as “smoker’s cough”) or external (e.g., strong advice from a physician to quit smoking). More recently, the concept of self-efficacy, the belief in one’s capability to organize and execute the courses of action required to manage prospective situations, was added to the HBM (Janz and Becker, 1984). Self-efficacy can affect initiation of behavior, motivation to change behavior, and maintenance of behavior changes. The addition of self-efficacy into the model acknowledges the importance of individuals needing to believe they have the skills and abilities to implement the change. Theory of Reasoned Action The Theory of Reasoned Action (TRA) is another value expectancy theory that provides a mathematical description of the relationship among beliefs, attitudes, intention, and behavior (Fishbein and Ajzen, 1975). According to this model, behavioral intentions are the best single predictor of behavior. Behavioral intentions are influenced by two factors: the individual’s attitude towards the behavior (i.e., whether the person has positive or negative feelings about engaging in the behavior), and subjective norms regarding the behavior (i.e., the individual’s perception of the social pressures to engage or not engage in the behavior and one’s motivation to comply with these normative influences). Although both the HBM and TRA focus on attitudes and beliefs, the TRA goes beyond the focus of the HBM on assessment of risk to also include assessment of the social normative context. The TRA has been expanded and renamed the Theory of Planned Behavior to incorporate the self-efficacy concept. There are potential limitations of exclusive use of value-expectancy models to guide intervention development and evaluation. First, these models assume a rational decision-making process, which is not always operative. Second, they focus primarily on health concerns as motivators. While necessary, health concerns may not be sufficient to motivate behavior

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Fulfilling the Potential of Cancer Prevention and Early Detection change. Finally, the emphasis of these models on cognitive factors needs to be augmented by models that take into account behavioral (e.g., skills) and environmental (e.g., situational determinants of behavior) components of the behavior change process. Social Cognitive Theory The cognitive-behavioral model on which most state-of-the art behavior change interventions are built has its conceptual roots in Social Cognitive Theory (SCT) (Bandura, 1989). This model extends the primarily cognitive focus of value expectancy theories and incorporates both behavioral and environmental components as equally important determinants of behavior. SCT highlights the influence of three factors: behavioral, cognitive, and environmental. Behavioral factors comprise an individual’s experiences with the target behavior (e.g., eating patterns, participation in preventive health care, prior attempts to quit smoking) and their general repertoire of behavioral skills (e.g., interpersonal skills, coping strategies, problem solving abilities). Cognitive factors include knowledge, attitudes and beliefs as outlined in the value-expectancy models plus more specific cognitive representations of situational factors relevant to the target behavior (e.g., the perception of high-fat meals as “comfort” food). Environmental factors refer to influences that are external to the person such as the actions of family members, physicians, and peer groups. Also included are more global environmental influences such as advertising and mass media, regulations and restrictions on behaviors (e.g., clean indoor air legislation), and availability of health-promoting alternatives (e.g., fruit and vegetable availability in supermarkets). Central to social cognitive theory is the concept of reciprocal determinism to indicate that cognitive, behavioral, and environmental factors are continually interacting in an open system. An intervention could, for example, start by teaching new skills in preparing lower-fat foods (behavioral) which leads to more positive attitudes towards dietary modification (cognitive), which then results in changes in food purchases and the availability of healthy food in the home (environmental). Social cognitive theory also introduced the concept of self-efficacy, described earlier. Transtheoretical Model The transtheoretical model is widely applied in studies of the determinants of behavioral risk factor modification as well as in randomized intervention trials in the areas of smoking cessation, dietary change, and physical activity (Velicer et al., 1999; Kristal et al., 2000a; Peterson and Aldana,

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Fulfilling the Potential of Cancer Prevention and Early Detection 1999). The model describes five stages of change along a continuum of intentions and actions to modify behaviors (Prochaska and DiClemente, 1982): precontemplation (not considering change in the near future); contemplation (planning to change in the near future, but not taking any immediate actions); preparation (taking early steps to change in the immediate future or having tried to change in the past); action (made the target behavior change within the past six months); and maintenance (maintained the target behavior change for more than six months). The transtheoretical model, in addition to laying out these stages of change, describes processes that are hypothesized to result in movement through the stages of change (e.g., stimulus control, reinforcement management, social liberation). The model also assumes that the decision-making process is rational, where individuals weigh the pros and cons associated with the target behavior (Janis and Mann, 1977). All of the models reviewed suggest that two fundamental processes must occur for successful adoption or modification of behaviors: individuals must be sufficiently motivated to attempt to change their behavior, and they must have the requisite skills and supports to initiate and maintain those changes. A counseling technique called motivational interviewing facilitates these processes by providing Feedback, enhancing personal Responsibility, giving Advice along with a Menu of options, and supporting self-Efficacy by using the success of others as encouragement in a non-confrontational and Supportive context (Miller and Rollnick, 1991). A FRAMES acronym summarizes these components. Brief motivational interviewing can be applied during routine medical encounters (Rollnick, Heather and Bell, 1992). Another strategy to bring about behavioral change is cognitive-behavioral skill-training. This approach is targeted to individuals who are actively working to change their behavior. Core components of skill-training interventions are listed in Box 4.1. The theoretic models and intervention strategies described are often applied in the context of assessments of efforts to promote behaviors to reduce the burden of cancer.

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Fulfilling the Potential of Cancer Prevention and Early Detection BOX 4.1 Core Components of Skill-Training Interventions Self-Monitoring • The systematic observation and recording of behavior. Stimulus Control • Eliminating or minimizing environmental cues for the behavior that are identified through self-monitoring. Cognitive Restructuring • The systematic identification and alteration of distorted thoughts and beliefs that may undermine behavior change efforts. Goal Setting • Setting specific, quantifiable, and reasonable goals. Focus is on setting both short-term (i.e., 1 to 2 weeks) and long-term (i.e., 6 months) goals. Problem Solving • Used to identify and cope with high-risk situations that may lead to relapse. The problem solving method for coping with high-risk situations involves: (a) specifying a situation; (b) generating several possible strategies for coping with it; (c) evaluating the possible coping strategies; (d) planning and implementing the best coping strategy(ies); (e) evaluating the effectiveness of the chosen strategy; and (f) reevaluating and selecting another solution if necessary. Social Support • Seeking support from others and informing others of the types of support desired. TOBACCO CESSATION INTERVENTIONS There is general agreement regarding the value of several approaches to smoking cessation (Task Force on Community Preventive Services, 2001; Hopkins et al., 2001a,b; US DHHS, 2000a; Fiore et al., 1996; US Preventive Services Task Force, 1996; http://www.cochrane.org/cochrane/revabstr/g160index.htm): individual treatment including behavioral change procedures and medication; advice to quit from physicians and other credible professionals; programs implemented through community channels such as worksites, churches, and health care settings; and broad, multicomponent, multichannel programs such as statewide programs to prevent smoking and encourage smoking cessation. Smoking cessation has the advantage of a well-defined, single outcome measure (abstinence from tobacco) that lends itself well to outcomes assessment. A central conclusion from the literature on smoking cessation is that the more comprehensive and varied the treatment and the longer it is sustained, the more likely cessation will be achieved.

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Fulfilling the Potential of Cancer Prevention and Early Detection SOURCE: Centers for Disease Control and Prevention. Christy Turlington. The 2000 Public Health Service Guideline presents the results of meta-analyses assessing the impact of various elements of treatments. As summarized in Table 4.1, increases in cessation rates and in the odds of quitting are parallel to increased amount of time and individualized personal contact. There is a similar trend when the data are disaggregated by the number of formats used. These analyses demonstrate an important feature of smoking cessation: the number of different formats used in cessation interventions may be more important than the nature of the formats used. There is no one “magic bullet” in smoking cessation. Similar trends for increased rates of cessation are found for duration of contacts, duration of programs, and intervention providers. Compared to no treatment, even contact as brief as three minutes improves the odds of quitting smoking by as much as 20%. The greatest benefit (OR = 2.4) occurs for contacts above 10 minutes. Interventions that are sustained beyond 8 weeks increase the odds of quitting nearly threefold (OR = 2.7) compared to those that last less than two weeks. Receiving interventions from either nonphysician (OR = 1.7) or physician providers (OR = 2.2) improves quit rates over no treatment. Quit rates also increase with the number of clinician types involved in treatment

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Fulfilling the Potential of Cancer Prevention and Early Detection TABLE 4.1 Summary of Treating Tobacco Uses and Dependence (TTUD) Meta-Analysis Assessing the Impact of Various Elements of Treatment Structure Structure variable Number of Study arms Estimated OR for abstinence (95% CI) Estimated abstinence rate (95% CI) Level of contact (43 studies) No contact 30 1.0 10.9 Minimal counseling (<3 min) 19 1.3 (1.01, 1.6) 13.4 (10.9–16.1) Low-intensity counseling (3–10 min) 16 1.6 (1.2, 2.0) 16.0 (12.8–19.2) Higher-intensity counseling (>10 min) 55 2.3 (2.0, 2.7) 22.1 (19.4–24.7) Total amount of contact time (35 studies) None 16 1.0 11.0 1–3 min 12 1.4 (1.1, 1.8) 14.4 (11.3, 17.5) 4–30 min 20 1.9 (1.5, 2.3) 18.8 (15.6, 22.0) 31–90 min 16 3.0 (2.3, 3.8) 26.5 (21.5, 31.4) 91–300 min 16 3.2 (2.3, 4.6) 28.4 (21.3, 35.5) >300 min 15 2.8 (2.0, 3.9) 25.5 (19.2, 31.7) Number of person-to-person sessions (45 studies) 0–1 session 43 1.0 12.4 2–3 sessions 17 1.4 (1.1, 1.7) 16.3 (13.7, 19.0) 4–8 sessions 23 1.9 (1.6, 2.2) 20.9 (18.1, 23.6) >8 sessions 51 2.3 (2.1, 3.0) 24.7 (21.0, 28.4) Type of clinician (29 studies) No clinician 16 1.0 10.2 Self-help 47 1.1 (0.9, 1.3) 10.9 (9.1, 12.7) Non-physician 39 1.7 (1.3, 2.1) 15.8 (12.8, 18.8) Physician 11 2.2 (1.5, 3.2) 19.9 (13.7, 26.2) Number of clinician types (37 studies) No clinician 30 1.0 10.8 One type 50 1.8 (1.5, 2.2) 18.3 (15.4, 21.1) Two types 16 2.5 (1.9, 3.4) 23.6 (18.4, 28.7) Three or more types 7 2.4 (2.1, 2.9) 23.0 (20.0, 25.9) Format (58 studies) No format 20 1.0 10.8 Self-help 93 1.2 (1.02, 1.3) 12.3 (10.9, 13.6) Proactive telephone counseling 26 1.2 (1.1, 1.4) 13.1 (11.4, 14.8) Group counseling 52 1.3 (1.1, 1.6) 13.9 (11.6, 16.1) Individual counseling 67 1.7 (1.4, 2.0) 16.8 (14.7, 19.1) Number of formats (54 studies) No format 20 1.0 10.8 One format 51 1.5 (1.2, 1.8) 15.1 (12.8, 17.4) Two formats 55 1.9 (1.6, 2.2) 18.5 (15.8, 21.1) Three or four formats 19 2.5 (2.1, 3.0) 23.2 (19.9, 26.6) OR, odds ratio; CI, confidence interval. Odds ratios and abstinence rates refer to long-term (>5-month) follow-up. SOURCE: Adapted from US DHHS (2000a), Tables 12–18. Reprinted from Piasecki and Baker (2001) (www.tandf.co.uk/journals).

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Fulfilling the Potential of Cancer Prevention and Early Detection delivery. The consistency in findings across different intervention characteristics reflects the importance of intensity and duration of interventions. The Effectiveness of Behavioral Interventions Cognitive-behavioral treatment components can be delivered in a variety of formats, ranging from minimal counseling and advice from medical providers to intensive, inpatient clinical programs. Self-Help Programs A variety of self-help pamphlets, books, videotapes, and resources on the World Wide Web are available commercially and through volunteer agencies, including the American Lung Association, the American Heart Association, and the American Cancer Society. In a review of 24 studies that used randomization in the research design, Curry (1993) found that self-help methods achieved long-term results comparable to those achieved by intensive interventions. She attributed this to the tendency of the success rates of the self-help interventions to increase over time. As opposed to a scheduled group program, self-help materials remain available for the smoker to use again as readiness to quit increases. Several studies have evaluated self-help programs that are tailored to individual characteristics, such as readiness to change, specific motives for quitting, or the reasons for a previous relapse. Preparation and dissemination of tailored materials may be automated to reach large numbers of smokers. Among the successful tailored approaches are individualized mailings based on participants’ answers to initial questionnaires about their smoking (Strecher et al., 1994; Prochaska et al., 1993, 2001), individualized mailings based on initial questionnaires and provided as supplements to use of over-the-counter (OTC) nicotine gum (Shiffman et al., 2000), and personalized feedback added to a self-help manual (Curry et al., 1991; Becona and Vazquez, 2001). Physician Advice A physician’s advice or brief counseling for smoking cessation often includes a presentation of the risks individualized by symptoms or family history, provision of accompanying cessation materials, and follow-up (Kottke et al., 1988; Ockene et al., 1991a; Rose and Hamilton, 1978; Russell et al., 1979). A recent meta-analysis (Silagy and Ketteridge, 1998) reviewed 31 studies of brief advice, defined as consisting of advice delivered in less than 20 minutes with the possibility of one follow-up contact. Smokers who received such advice were 1.7 times more likely to quit than were those who received usual care. On the basis of a review of such research, the

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Fulfilling the Potential of Cancer Prevention and Early Detection PHS Guidelines for Smoking Cessation (US DHHS, 2000a) emphasize the five A’s, “Ask, Advise, Assess, Assist, Arrange,” as a structure for organizing smoking cessation interventions. Adding a video on how to quit, counseling by a nurse, follow-up phone calls, referral to self-help materials, referral to group treatment, or giving patients a choice between self-help and group treatment all increased smoking cessation rates (Hollis et al., 1993; Whitlock et al., 1997a). The national Healthy People 2010 objectives set a goal of increasing to at least 85 percent the proportion of primary care providers who routinely identify their patients’ smoking status and offer smoking cessation advice, assistance, and follow-up for all their patients who smoke (US DHHS and Office of Disease Prevention and Health Promotion, 2000). Telephone Counseling Another channel for delivery of brief advice as well as repeated and more extended counseling and follow-up is the telephone. A review of this literature (Lichtenstein et al., 1996) found that reactive telephone services (those that users must call) are effective for those who do access them but are not used by many quitters. Proactive services provide outreach telephone counseling to smokers, usually in conjunction with written self-help materials. The 2000 PHS Clinical Practice Guidelines concluded that telephone counseling is an effective approach to smoking cessation counseling (US DHHS, 2000a, p. 63). Group Programs or Classes Group smoking cessation classes have long been offered by many hospitals and at many worksites as well as by volunteer agencies such as the American Lung Association. An analysis of 494 participants in 42 of the American Lung Association’s Freedom from Smoking clinics showed a long-term abstinence rate of 29 percent (Rosenbaum and O’Shea, 1992), relative to a benchmark of 20 percent suggested by a contemporary review of published studies (Glasgow and Lichtenstein, 1987). Group programs generally include multiple components. Study designs preclude assessment of the efficacy of individual components, but their aggregate impacts are appreciable (Compas et al., 1998; Stevens and Hollis, 1989). Overall, smoking cessation rates among groups across a wide array of multicomponent group programs are quite similar. Intensive Interventions for Individuals In 1992, Lichtenstein and Glasgow noted the popularity in the preceding decade of public health approaches to smoking that sought to dissemi-

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Fulfilling the Potential of Cancer Prevention and Early Detection et al., 1997; Havas et al., 1998). For example, Havas and colleagues (1998) worked with WIC participants and trained peer educators to deliver education sessions and food demonstrations to enhance fruit and vegetable consumption. Discussion groups and mailings were also included, resulting in a significant increase in the levels of fruit and vegetable consumption by the intervention participants (0.56 versus 0.13 daily servings). Cullen and colleagues (1997) recruited Girl Scout troops and used nutrition classes, self-help materials, tasting sessions, and parental information sheets to encourage home support. This resulted in significant increases in levels of fruit and vegetable consumption. Other studies targeting changes in levels of fruit and vegetable consumption have reached the community through communication systems. Marcus and colleagues (1998c) delivered telephone messages based on participants’ stage of change and offered follow-up mailings that resulted in improvements in the rates of adherence to the Five-a-Day program guidelines. Another intervention that included one call followed by two mailings to the home yielded significant improvements in the intervention group at the initial follow-up and at 4 weeks and 4 months of follow-up (Marcus et al., 1998a). Interventions designed to decrease levels of fat intake have also used multiple components. The Stanford Three-City Community Study used variations of intensive instruction on diet and other cardiovascular risk factors and an extensive media campaign (Farquhar et al., 1984, 1990; Fortmann et al., 1990). Results showed significant decreases in the levels of saturated fat intake between the intervention and the control groups. Several studies that have addressed fruit and vegetable consumption and fat intake combined have examined more intensive interventions, such as home visits with newsletters (Knutsen and Knutsen, 1991) and weekly classes or sessions (Fitzgibbon et al., 1996; Hartman et al., 1997), and minimal interventions such as computer-tailored letters (Brug et al., 1996, 1998, 1999) or telephone counseling (Pierce et al., 1997). Rodgers and colleagues (1994) altered supermarket environments to promote a significant positive dietary message. The North Karelia project used a range of interventions, from mass media educational campaigns to cooperation with agricultural and food merchandising groups, to improve the availability of healthy alternatives such as low-fat milk (Puska et al., 1985). The Minnesota Heart Health program and Project LEAN also used public-private partnerships to enhance the delivery of the dietary campaign message, further expanding on this collaborative concept (Heimendinger et al., 1996). Community-based behavioral interventions have been effective in promoting dietary change. These programs have targeted change across multiple levels. In addition, they are more frequently delivered by non-professional, lay, or peer educators, ensuring ongoing resources and the development of a community capacity for ongoing dietary change.

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Fulfilling the Potential of Cancer Prevention and Early Detection SOURCE: Agricultural Research Service, USDA. Photo by Scott Bauer. Programs to Reach Underserved and Minority Populations Among African Americans, diet may be an area of special vulnerability (World Cancer Research Fund and American Institute for Cancer Research, 1997). African Americans, particularly those living in rural communities, report poorer dietary intakes (Baranowski et al., 2000; Johnson et al., 1994; Lillie-Blanton et al., 1996; Schonfeld-Warden and Warden, 1997). Also, programs that promote healthy diets have not worked as well for African Americans as they have for other groups. The availability of fruits and vegetables is a substantial predictor of intake (Hearn et al., 1998), and the availability of fruits and vegetables is lower in rural communities than in other areas. Additionally, the low levels of educational attainment and the limited literacy skills often found among individuals in minority and rural communities may result in limited exposure and receptivity to health messages designed for better-educated, urban groups (Kirby et al., 1995). This association is not limited to the United States and has also been reported in England (Margetts et al., 1998).

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Fulfilling the Potential of Cancer Prevention and Early Detection Community-based organizations have tested interventions in several population groups. Fitzgibbon and colleagues (1996) recruited Hispanic families from literacy training programs and offered a culturally specific curriculum over 12 weeks designed to improve both fat intake and fruit and vegetable consumption (Fitzgibbon et al., 1996). Stolley and Fitzgibbon (1997) recruited low-income mothers and daughters from a tutoring program to receive a low-fat, multicomponent intervention. Significant reductions in total fat intake were noted for both mothers and daughters. Auslander and colleagues (Auslander et al., 2000; Haire-Joshu et al., 1999) used a stage-based, personalized intervention implemented by peers and offered to overweight, low-income African-American women through a local neighborhood agency. The results showed significant benefits in terms of increased skills in the interpretation of food labels and improved knowledge of nutrition and the fat contents of foods. Church-based approaches have also been effective in reaching ethnically diverse groups. A church program in Samoa used community-based organization approaches to program development and was successful in reducing waist circumference and eliminating weight gain in those at high risk for diabetes (Simmons-Morton et al., 1998). A combination of church- and community-based approaches had promising effects on helping African-American participants consume a healthy diet (Campbell et al., 1999a). In each county randomized to the intervention, the pastors of local churches appointed a three- to seven-member Nutrition Action Team that was “responsible for organizing and implementing many of the program activities” (Campbell et al., 1999a, p. 1391). The intervention itself “used an ecological framework, targeting activities at the individual, social network, and community levels” (p. 1391). It included tailored bulletins and other print materials; group activities such as gardening, educational sessions, and personal recipe tasting; and the serving of more fruits and vegetables at church functions. To reinforce healthy eating habits, the program also included lay health advisers, pastor support, and community-based coalitions (these coalitions were located within each county and were composed of church members, representatives of local agencies, farmers, and grocers) and distributed materials through local grocers. Reflecting the strong community focus of the program, individual churches were also encouraged to implement their own activities, in addition to the planned intervention. These included “5-a-Day Sundays,” gospelfests, and events for youth. The intervention lasted 20 months. It resulted in a significant difference (0.85 servings of fruits and vegetables per day) between the counties that received the intervention and the counties that received delayed treatment. Members of minority and low-income groups can be reached effectively at worksites, and individuals who are members of important social networks at worksites can be used to influence the dietary behaviors of their co-workers. For example, Buller and colleagues (1999) encouraged

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Fulfilling the Potential of Cancer Prevention and Early Detection the intake of five servings of fruits and vegetables per day via peers and managers at worksites with blue-collar workers. Informal social networks or cliques were used as a structure for the program. Workers from informal networks were trained to provide program interventions for their colleagues in those networks. The intervention included various print media and information sessions conducted by peer educators for large and small groups and included ethnically specific messages that encouraged the participants to increase their levels of fruit and vegetable consumption. In addition, the work environment was modified (through the use of cafeteria promotions). The intervention was found to have significant effects at 18 months (an increase of 0.77 servings) and 24 months (an increase of 0.41 servings) by use of dietary recall as the measurement method. However, use of food frequency methods showed a different effect at 18 months, but the effect remained significant (an increase of 0.46 servings); at 24 months there was no significant effect (an increase of 0.04 servings). THE HEALTH CARE SYSTEM AND BEHAVIOR RISK REDUCTION Health care organizations and settings and the providers who work in them have extraordinary opportunities to affect the health of a large percentage of people who are at risk for cancer. In 2000, 72 percent of U.S. adults reported going to a doctor’s office or clinic to get care in the past year (Agency for Healthcare Research and Quality, 2001b), with this contact providing opportunities to offer counseling and other interventions. In addition to the high rate of contact, providers who are credible sources of health-related information frequently provide care on a regular basis in primary care settings. All types of clinicians—physicians, nurses, nurse practitioners, dentists, psychologists, pharmacists, health educators, dietitians, and many others—can effectively deliver prevention messages and prevention counseling (Fiore et al., 1996, US DHHS, 2000a). Opportunities for the promotion and delivery of cancer prevention and control services can be found in a variety of locations where health care is delivered, including private physician office practices, integrated delivery systems or staff model health maintenance organizations (HMOs), and public health clinics. Health care providers in ambulatory health care settings have unique opportunities to promote the use of cancer prevention and early detection services; however, levels of access to such providers are not uniformly high. In 1998, the vast majority of individuals relied on doctors’ offices and HMOs (70 percent) and on clinics or health centers (16 percent) for their routine and preventive care (1998 National Health Interview Survey, special tabulations by National Cancer Policy Board staff). A significant segment of the adult population (11 percent) reported that they did not have a usual source of routine care, which points to the limits of

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Fulfilling the Potential of Cancer Prevention and Early Detection interventions aimed at health care professionals to improve access to cancer prevention and early detection services. As summarized in the previous sections, there is evidence of the effectiveness of interventions for smoking cessation, physical activity, and dietary modification delivered in health care settings. Unfortunately, there has been little integration of these interventions into routine health care delivery. According to surveys with patients and providers, behavior risk factors are not routinely addressed. With regard to tobacco use, only about one-half of patients who smoke report that they have received advice to quit (Doescher and Saver, 2000; Anda et al., 1987; CDC, 1993; Frank et al., 1991; Gilpin et al., 1993; Goldstein et al., 1997; Kottke et al., 1997; Pierce and Gilpin, 1994; Rogers et al., 1997; Thorndike et al., 1998) and far fewer report that they have received any smoking cessation assistance or follow-up (Goldstein et al., 1997; Rogers et al., 1997), as recommended by both the current clinical practice guidelines for tobacco treatment (US DHHS, 2000a) and the Healthy People 2010 objective (US DHHS and Office of Disease Prevention and Health Promotion, 2000). The type of visit affects the rate of smoking intervention, with more interventions occurring during well visits than during acute care visits and with more interventions occurring for smokers with chronic tobacco-related illnesses than for smokers with non-tobacco-related illnesses (Jaen, 1997; Jaen et al., 1997, 1998; Sesney et al., 1997; Stange et al., 1994; Thorndike et al., 1998; Frame, 1995). The general infrequency of well visits and patients not being ready to stop smoking may help explain the less than desirable rates of smoking cessation interventions by physicians. Recent clinical practice guidelines call for intervening with all smokers at all visits, whether or not the visit is for an illness caused or complicated by tobacco use (US DHHS, 2000a). Despite evidence of the effectiveness of physician-delivered smoking interventions, physicians may view them as ineffective because of their clinical experience, in which only about 5 percent of patients advised to quit will do so in the course of a given year (Warner, 1998). National data on the prevalence of provider provision of counseling to modify the diet as it relates to cancer prevention are lacking. Healthy People 2010 Objective 19-17 is to increase to 75 percent the proportion of physician office visits made by patients with a diagnosis of cardiovascular disease, diabetes, or hyperlipidemia that include counseling or education related to diet and nutrition (US DHHS and Office of Disease Prevention and Health Promotion, 2000). Although this objective does not relate specifically to provider counseling for cancer prevention, it is the only Healthy People 2010 objective that addresses provider counseling to modify the diet. It is difficult to gauge the prevalence of diet modification counseling specific to cancer prevention or even general nutrition counseling (e.g., to

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Fulfilling the Potential of Cancer Prevention and Early Detection decrease dietary fat intake, increase levels of consumption of fruits, vegetables, whole grains, and fiber, and limit red meat consumption) because available studies are based on provider practices in specific regions, organizations, or subpopulations and many of the studies suffer from low response rates. According to studies with acceptable response rates (above 60 percent) patients reporting that physicians offered dietary counseling ranged from 14 to 70 percent (Hunt et al., 1995; Kreuter et al., 1997; Taira et al., 1997). The rates of provision of diet modification counseling in selected studies that relied on physician self-report are somewhat higher, ranging from 66 to 79 percent (Glanz et al., 1995; Kushner, 1995; Ashford et al., 2000). On the basis of direct observation, the prevalence of counseling to modify the diet to reduce the risk of cancer ranged from 9 to 43 percent (Stange et al., 2000; Stange et al., 1998; Russell and Roter, 1993). Roughly one-third (34 percent) of individuals who had visited a physician in the past year were counseled by the physician to begin or to continue any type of exercise or physical activity, according to estimates from the 1995 National Health Interview Survey (Wee et al., 1999). Estimates of the prevalence of physical activity counseling by providers range from 13 to 36 percent according to studies in which providers in health care settings were directly observed as they provided care (Podl et al., 1999; Russell and Roter, 1993; Stange et al., 1998; Stange et al., 2000). There is a tendency for primary care providers to discuss secondary prevention rather than focus on primary prevention (Wee et al., 1999). Although the goal is to have primary care physicians conduct primary prevention counseling, patients who have disease are more likely to be counseled about physical activity (Podl et al., 1999; Rosen et al., 1984; Wee et al., 1999), and the more risk factors a patient has, the more likely it is that the patient will be counseled (Kreuter et al., 1997). The lack of a standard protocol has been identified as a barrier to carrying out physical activity counseling (Gemson and Elinson, 1986; Orleans et al., 1985). How a clinical practice is organized, its delivery capacity, and its manual and computerized administrative support systems can greatly affect a provider’s ability to deliver preventive health care in general and address behavioral risk factors specifically. Medical chart prompts, checklists, and reminders improve the physician’s ability to identify a patient’s needs and behavioral risk factor counseling rates (Chang et al., 1995; Cohen et al., 1989; Cummings et al., 1989a,b; Fiore, 1991; Fiore et al., 1995; McIlvain et al., 1992; Ockene et al., 1996; Robinson et al., 1995; Solberg et al., 1990; Strecher et al., 1991). Smoking status designated as a vital sign on the chart increases the rate at which physicians ask their patients about smoking, discuss or advise cessation, and arrange a follow-up appointment or referral to a stop smoking program (Ahluwalia et al., 1999; Robinson et al., 1995). Most studies of the effects of computerized systems demonstrate that physicians who use such systems counsel their patients about changes

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Fulfilling the Potential of Cancer Prevention and Early Detection in health behaviors at higher rates (McPhee et al., 1991; Ornstein et al., 1995). Computer-based reminder systems offer a quick and easy way to monitor patients (Frame and Werth, 1993), but such systems require considerable institutional commitment and resources. Health risk appraisals (HRAs) provide individualized estimates of health risks and can be used as part of behavioral counseling in primary care settings. The evidence that HRAs improve rates of provider counseling is conflicting, with some showing improvements (Geiger et al., 1993; Gemson and Sloan, 1995) and some not noting such improved rates (Smith et al., 1985). Periodic chart audits have been used as part of continuous quality improvement (CQI) initiatives as a way of assessing provider performance to provide feedback and improve compliance with clinical practice guidelines (Shortell et al., 1995). Trials of the effectiveness of CQI in improving prevention services have largely been negative (Solberg et al., 2000). The need for multiple strategies is embodied in the U.S. Public Health Service clinical practice guideline for the treatment of tobacco use and dependence (US DHHS, 2000a). It emphasizes that, without supportive systems, policies, and environmental prompts, it is unlikely that the individual clinician will routinely assess and treat tobacco use. These guidelines include six strategies for systems-level interventions, modified here to encompass multiple behavioral risk factors: implement a behavioral risk factor identification system in every clinic; provide education, resources, and feedback to promote provider delivery of an intervention; dedicate staff to provide treatment and include assessment of the delivery of this treatment in performance evaluations; promote policies within the organization that support and provide behavior change treatment services; include effective behavior change treatment as paid or covered services; and reimburse clinicians and specialists for delivery of effective behavior change treatments and include these treatments in the defined duties of clinicians. In addition to practice-specific factors, certain characteristics of the contemporary ambulatory care environment may not be conducive to preventive care practices (1998 National Ambulatory Medical Care Survey and 1998 National Hospital Ambulatory Medical Care Survey, special tabulations, NCPB staff): Prevention services are optimally provided in the context of routine health care visits or checkups, but such non-illness-related visits are rela-

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Fulfilling the Potential of Cancer Prevention and Early Detection tively unusual, making up 17 percent of the estimated 717.6 million ambulatory care visits made by adults in 1998. Prevention services are more likely to be provided when patients see their primary care physician, but less than half (44 percent) of ambulatory care visits made by adults in 1998 were to a patient’s primary care provider. Counseling about risk behaviors such as smoking cessation or describing the pros and cons of screening procedures can be time-consuming, yet most adult patients (63 percent) spend less than 15 minutes with the physician during their ambulatory care visits. During ambulatory care visits, adult patients generally spend time with physicians, but they also see other providers, although they see them less often. Patients see, for example, nurses, nurse practitioners, or physician’s assistants, but these encounters occur during roughly only 20 percent of ambulatory care visits. These nonphysician providers can be important sources of counseling services, even though they are not frequently encountered. One of the reasons most frequently cited by clinicians for not implementing prevention services is a real or perceived lack of time given the other demands of a primary care practice (Ashford et al., 2000; Battista and Mickalide, 1990; Burns et al., 2000; Cooper et al., 1998; Dunn et al., 2001; Jaen et al., 1994; Kottke et al., 1993; Kushner, 1995; Rafferty, 1998; Walsh et al., 1999). Responses to the patient’s presenting complaints and concerns often take precedence (Burns et al., 2000; McBride et al., 1997; Stange et al., 1994). The total amount of time needed by the physician to deliver effective preventive services may not be prohibitive. Physicians can, for example, initiate a smoking cessation intervention, and this can be followed by provision of most of the intervention and follow-up by another clinician (e.g., a nurse, a nurse practitioner, or a physician’s assistant). Physicians can deliver prevention services at high rates and still have a productive practice, as defined by relative value units, when formal systems for the delivery of prevention services are implemented (Kottke et al., 1993). Systems of care may reduce institutional or organizational barriers to the use of prevention services with strategies that facilitate a usual source of care or a “regular doctor,” the centralization of services, or the provision of an integrated structure (e.g., a centralized screening program [Thompson et al., 1995]), a requirement for minimal patient copayments for members, or reduction of clinicians’ financial disincentives (Gordon et al., 1998; Weinick and Beauregard, 1997). Financial incentives, management strategies, the physical plant, and normative influences of colleagues can all interact to facilitate or hinder the provision of preventive services (Malin et al., 2000). Organizational characteristics of HMOs might contribute to the relatively high rates of use of prevention services, for example, dedicated behav-

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Fulfilling the Potential of Cancer Prevention and Early Detection ioral health programs, innovative use of personnel including nurse practitioners and health educators (Mullen and Zapka, 1982; Palitz et al., 1997), consumer expectation (Jordan et al., 1995; Trnka and Henderson, 1997), and systems of accountability (Box 4.3.). Although the model program described in Box 4.3. focuses on tobacco, its key elements are readily generalizable to other health behaviors. The most prominent effort to define and measure plan performance has been the National Committee for Quality Assurance’s Health Plan Employer and Data Information Set (HEDIS®) (http://www.ncqa.org/programs/hedis/index.htm; Corrigan and Nielsen, 1993). This set of standardized performance measures helps purchasers and consumers reliably compare the performance of managed health care plans. In 2000, 273 organizations (health maintenance organizations, point-of-service plans, and other managed care plans) that collectively cover 63 million individuals voluntarily submitted performance data. In 2000, the median rate of advising smokers to quit reported by plans was 66 percent (National Committee for Quality Assurance, 2001). Expansion of measures to include obesity prevention and treatment and the promotion of physical activity could be considered. A disincentive for providers to provide preventive services is a lack of, or inadequate, reimbursement. The Medicare program, for example, does not provide reimbursement for smoking cessation services. Other barriers to the provision of prevention services are more subtle. The benefits of effective prevention interventions may be viewed by physicians and health care systems as abstract because the costs in terms of time and finances are incurred up front, but the benefits may not be seen for years or decades (Ockene and Ockene, 1992). SUMMARY AND CONCLUSIONS Interventions to modify tobacco use, diet, and physical activity have substantial similarities in terms of their effectiveness. Separate educational, psychological, and behavioral models for interventions for each behavior are not needed. Rather, behavioral change efforts need to focus on common models that emphasize the skills needed for behavioral change, diverse and sustained interventions, and social and other forms of support for the maintenance of behavioral changes. Two levels of intervention are generally found to be effective for all three preventive behaviors reviewed in this chapter. One level entails well-defined interventions delivered to individuals, such as counseling and prescription drugs for smoking cessation. The second level entails comprehensive, multicomponent, multichannel programs directed to large groups, for example, the statewide tobacco control programs that have emerged in the last decade. This finding is consistent with that of IOM’s Committee on Health and Behavior: Research, Practice and Policy. They concluded that “health and

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Fulfilling the Potential of Cancer Prevention and Early Detection BOX 4.3 A Model Tobacco Control Program in an HMO Group Health Cooperative (GHC) of Puget Sound is a large group model health maintenance organization established in 1947. The GHC program for smoking cessation targets interventions at three levels (Curry, 1998). On the practice setting level, interventions include self-help booklets, outreach telephone counseling, and group sessions. Several other interventions were prompted by the development and implementation of an evidence-based smoking cessation guideline. Training and ongoing consultation, patient questionnaires, education materials, chart stickers, vital sign stamps, patient flow sheets, and chart audit protocols are used. Staffing for guideline implementation includes full-time employee support for physicians, health educators, and an implementation coordinator who works in the primary care clinics to assess staff readiness to implement the guideline, arrange appropriate education and training and follow-up for staff, facilitate ownership for the guideline, and encourage progress in tracking through the use of chart audits and feedback reports. On the systems level, GHC tracks the percentage of audited charts with documentation of tobacco use status. GHC’s benefits committee in 1992 approved a tobacco services benefit that went into effect in 1993. The benefit included access to the Free and Clear behavioral program with a 50 percent copayment and with nicotine replacement therapy fully covered for smokers who participate in the Free and Clear program (there is no coverage for nonparticipants). Implementation of this benefit resulted in a 10-fold increase in program attendance. GHC experimented with benefit design and learned that even with full coverage and the use of multiple strategies to enhance use of the benefit, the annual rate of use of the benefit among smokers was about 11 percent (Curry, 1998). The following strategies to increase the reach of their tobacco cessation services are being implemented: provision of full coverage for tobacco use cessation services (elimination of copayments), a streamlined referral and registration process for participants in the Free and Clear program, use of automated clinical information systems to track patient tobacco use and provider practices, and ensured adherence to the practice guideline in specialty care. On the community and external environment levels, GHC has been involved in the formation of community coalitions, educational appearances on radio and television and in the print media, and community policy development (Thompson et al., 1995). Along with other health organizations, voluntary and state agencies, and tobacco control groups, GHC created the Washington Alliance for Tobacco and Children’s Health to conduct lobbying and media advocacy. These actions led to plans for a tobacco trust account in Washington State with Tobacco Master Settlement Agreement funds (McAfee, 2000). The GHC program has evolved over a period of about 15 years, demonstrating that development of multilevel programs takes considerable time, planning, and resources (Curry, 1998).

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Fulfilling the Potential of Cancer Prevention and Early Detection behavior are influenced by factors at multiple levels, including biological, psychological, and social. Interventions that involve only the person—for example, using self-control or willpower—are unlikely to change long-term behavior unless other factors, such as family relationships, work situation, or social norms, happen to be aligned to support a change” (IOM, 2001a). A striking finding is the recurrent demonstration of the importance of interventions that combine several different channels of information or types of influence, are sustained, and address self-management or behavioral skills for the identification and attainment of personal goals and for the avoidance of temptations that would undermine those efforts. A number of effective behavioral interventions exist, but no “magic bullet” or particular intervention is remarkably more effective than others. Additionally, different interventions may be effective in achieving similar goals. Thus, counseling as part of the delivery of primary heath care, mass media campaigns, and messages tailored to those not yet ready to change their behaviors may each be effective in reaching individuals and helping motivate change. Individual counseling, group programs, or self-help materials may each be effective in helping people plan their lifestyle changes and master behavioral self-management skills to avoid relapse. Follow-up from professionals, from trained volunteers, or through print or other media may help those who have changed their behavior maintain the healthy behavior. To be successful, behavioral health interventions delivered in health care settings must overcome the principle barriers that confront providers and health care systems. The greatest barriers to providers’ delivery of smoking cessation counseling are lack of education and training, limitations of time and practice setting systems, poor reimbursement levels, and a perceived lack of success with patients who smoke. For diet and physical activity, an additional critical barrier is the lack of clear guidelines regarding recommendations for cancer control. The potential for combinations of effects and the importance of the use of multiple approaches underscore the need for the use of comprehensive approaches. There are many different effective interventions, and their aggregate effects may not be captured by the evaluation of each one in isolation. Comprehensive programs that combine different intervention methods and channels have appreciable effects on all key behaviors for the prevention of cancer (CDC, 1999a; Rimer, 1997). Within such comprehensive programs, no single intervention method or channel is necessary or sufficient, but several different sets of strategies and methods may achieve comparable results. What is important is the overall strategy of combining multiple methods and channels.