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SECTION IV
THE CHALLENGE OF IDENTIFYING EFFECTIVE INTERVENTIONS



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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life SECTION IV THE CHALLENGE OF IDENTIFYING EFFECTIVE INTERVENTIONS

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life 17 Behavioral Health Interventions: What Works and Why? David M. Cutler Behavioral interventions are interventions designed to affect the actions that individuals take with regard to their health. The typical medical intervention is a clinical trial of a particular drug, surgery, or device. In the trial, doctors provide different services to different people, and then evaluate the outcomes. Variation in patient behavior is generally shunned; a strong emphasis is placed on making sure that patients do exactly what is expected from them. With behavioral interventions, in contrast, patient behavior is the key and the goal is to change it. In considering issues such as the high rate of preventable illness (McGinness and Foege, 1993) or racial disparities in health, behavioral interventions are key. This chapter reviews what is known about the success and failure of behavioral interventions and speculates about why some interventions are more successful than others. Behavioral interventions can be implemented at three levels.1 The first is the individual level. These interventions encourage people who are at high risk for a particular disease to do something about it. Examples are programs to encourage smokers to quit, hypertensives to take medications, or diabetics to exercise. These steps involve lifestyle changes (eating well and exercising) and medical changes (regular testing of blood pressure and cholesterol). In both cases, though, the actions taken are controlled by the individual. The most important individual intervention trial is the Multiple Risk Factor Intervention Trial (MRFIT) conducted in the 1970s. MRFIT enrolled more than 12,000 men at high risk for heart disease in a program to

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life lower their blood pressure and cholesterol and to stop smoking. The men received counseling and help with behavior modification. But the trial was only partly successful. Risk factors changed more in the treatment group than in the control group, but the impact was less than was hypothesized. Furthermore, mortality outcomes for the treatment group improved only slightly more than did outcomes for the control group. The relative failure of individual interventions was interpreted by many as evidence of the importance of environmental factors in health. Individuals are products of their environment, the theory went, and thus one cannot change the individual without changing the community in which he or she lives. This led to a second type of intervention—the community intervention, designed to change behaviors by modifying the environment that supports them. Several community-level interventions were implemented in the 1980s, again focusing on cardiovascular disease. These interventions used mass media, population screening, and community organizations to convey messages encouraging healthy behavior. The results of these trials were disappointing. Risk factors and health outcomes did not improve any more rapidly in the intervention sites than in the control sites. In contrast to the failure of community-level encouragement, public policies have been shown to have large effects on health behaviors. When governments tax cigarettes, smoking rates drop. Restrictions on where people are allowed to smoke also lower cigarette consumption. People respond to prices and regulations, even if they do not respond to reinforcing messages. The third level of health intervention is at the national level. The federal government or private groups often convey health information to people, with the goal of encouraging behavioral change. In at least some cases, these national interventions have a much more successful record than do community interventions. This chapter presents evidence that the campaign launched by the Surgeon General in 1964 to warn people of the harms of tobacco had a role in the reduction in smoking in the past four decades. Similarly, the movement against drunk driving pushed by Mothers Against Drunk Driving and the designated driver campaign have reduced the share of traffic fatalities involving drunk drivers. National information campaigns about the danger of high cholesterol have led to sustained reductions in consumption of red meat, eggs, and high-fat dairy products. Each of these behaviors is quite responsive to interventions. Determining why the national interventions had salient effects while individual- and community-level interventions had smaller effects is difficult. This chapter does not present a definitive answer, but several theories are discussed. The first is intensity. People would prefer not to change their behavior. Inertia is strong, and changing behaviors requires major changes in thinking and action. Health messages are easier to ignore when the

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life intervention is small; there is no pressing need to respond to each such impulse. But when information permeates widely, it is difficult to continue on the old path without contemplation. Doing nothing becomes a choice in itself that individuals must make. At such moments, people may be more willing to undertake large changes in behavior. The second theory is one of externalities. Many of the national interventions justified individual action by noting that people conducting the activities were hurting others in addition to themselves. Examples of these externalities include the movement against drunk driving (drunk driving kills children) and the argument against smoking (passive smoking has adverse health consequences). Highlighting these external consequences may induce more behavioral change than simply stressing the benefits of behavioral change to one’s self. The third theory is of peer effects. People may judge appropriate behavior on the basis of what others are doing, in addition to their own utility from the activity under question. Thus, changes in the share of people who engage in a certain behavior, for example smoking, may affect the decision of other people to quit. This chapter presents these theories, but does not offer direct evidence for or against them. Such evidence will need to be part of further research. Several other theories are highlighted that have been proposed but do not seem supported by the data. Some speculate that individual and community interventions do not have major effects because they are not implemented for a long enough period of time. But this chapter shows that many national interventions achieve large behavioral changes within a shorter period of time than typical individual- and community-level interventions. Similarly, the nature of the information provided does not seem to be so important. National intervention campaigns have succeeded when their message is positive (you should help yourself by quitting smoking) or negative (you are evil if you drive while drunk). Something more than the framing of the message is at issue. This chapter is structured as follows: The next section briefly outlines the nature of behavioral interventions. The following three sections consider evidence on the effectiveness of interventions at the individual, community, and national levels. The final section concludes by discussing the theories that are consistent and inconsistent with successful change. THE NATURE OF BEHAVIORAL INTERVENTIONS Health behavior encompasses many facets, and so behavioral interventions are broad as well. To introduce the subject, it is helpful to consider a particular example. Many of the interventions that have been attempted have focused on cardiovascular disease, and this chapter does the same.

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life To set the stage, information on cardiovascular disease health is presented. Figure 17-1 shows cardiovascular disease mortality over time for different racial and gender groups. Since 1950, cardiovascular disease mortality has declined across the board. Among white males, for example, mortality fell by 52 percent. For both men and women, the racial gradient in cardiovascular disease mortality has increased. The relative change was largest for men. Compared to the 52 percent decline in cardiovascular disease mortality among whites, mortality for blacks declined by only 36 percent. Among women, there was a 54 percent decline in mortality for whites and a 46 percent decline in mortality for blacks. The increased racial gradient in mortality suggests the importance of understanding how interventions affect particular racial and gender groups. FIGURE 17-1 Cardiovascular disease mortality by race. SOURCE: U.S. Department of Health and Human Services (2001).

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life The process of cardiovascular disease begins with risk factors—attributes of individuals that make them more likely to have a serious medical event. Some risk factors are exogenous to the individual, such as a family history of heart disease or genetic abnormalities. Other risk factors are (at least partly) under the control of the person. These factors include hypertension, high cholesterol, smoking, obesity, and diabetes. People with elevated risk factors are more likely to suffer a serious adverse event than people at lower risk, the most common of which are heart attacks and strokes. For those who survive the acute event, risk remains high for a subsequent time period. The classic medical intervention is in the treatment of people with a heart attack. There are a range of possible therapies, from medications to balloon angioplasty to coronary artery bypass surgery. The relative efficacy of these therapies has been evaluated in clinical trials. Similarly, clinical trials have examined which medications are most effective in managing hypertension, high levels of cholesterol, and diabetes. Behavioral interventions are targeted to the other factors. A “simple” intervention would be encouraging people to stop smoking (simple in the goals at least; smoking cessation is quite complex to achieve). A more complex intervention would target people with several risk factors and encourage a variety of behavioral changes: eliminating cigarette smoking, lowering consumption of fatty foods, reducing overall caloric intake, exercising more regularly, visiting physicians for hypertension and cholesterol screening, and adhering to medication guidelines. Behavioral changes are not independent of medical care; indeed, appropriate medical care requires behavioral changes. But the idea is to change the actions of people rather than to act on individuals passively. There are other interventions that bridge medical and behavioral factors. For example, physicians may not order the appropriate tests for measuring cholesterol, or may not prescribe the correct medications for reducing it. Some recent interventions have targeted physician behavior to correct these limitations. In the interest of considering widespread interventions, such programs are not considered in depth in this chapter. Individual behaviors might be modified in several ways. One possibility is to target particularly high-risk individuals and encourage behavioral changes among this group. This is the right strategy if individuals are autonomous actors and the greatest health damage is from people with very high risk. An alternative strategy, though, is to target the (usually) many more people with moderate risk. This would be more appropriate if many people with a small excess risk produce more adverse health outcomes than a few people with very substantial risk (Rose, 1992), or if there are peer effects that link the behaviors of particularly high-risk people to the average risk in the population. In considering the population strategy, one is natu-

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life rally led to community or national interventions. All individual, community, and national interventions can rely on changes in information or the environment. In the next sections of the chapter, I evaluate the efficacy of interventions at these three levels. INDIVIDUAL INTERVENTIONS The most important individual interventions in health behavior were conducted in the 1970s. Knowledge about cardiovascular disease risk factors solidified in the 1960s. Results from the Framingham Heart Study and other research efforts demonstrated the importance of several risk factors for cardiovascular disease: hypertension (or high blood pressure), high cholesterol, obesity, smoking, and diabetes. The natural policy goal was to intervene to change these risk factors. In the 1970s, experiments were designed to do just this. The most important of these interventions was the Multiple Risk Factor Intervention Trial (Gotto, 1997; Multiple Risk Factor Intervention Trial Research Group, 1982, 1990, 1996). The MRFIT was initiated in 1972. More than 350,000 men aged 35 to 57 were screened to produce a sample of 12,866 men at high risk for coronary heart disease. The screening focused on blood pressure, cholesterol, and smoking status. Individuals in the top 10 percent of the risk distribution were eligible for the trial and were enrolled if they agreed to the trial and randomization, and had no doubts about their ability to manage the heavily involved intervention. Eligible individuals were divided into two groups. Members of the control, or usual care, group were examined once a year for medical history, physical examination, and laboratory results. The results of the screening and lab exams were conveyed to their primary care physicians, but no other intervention was undertaken. Members of the treatment, or special intervention, group received several interventions. Smokers were counseled by physicians to quit smoking. All intervention members were invited to attend weekly discussion groups addressing control of risk factors. After an intensive initial phase, participants in the intervention group were seen every 4 months, when they received individual counseling from a team of behavioral scientists, nutritionists, nurses, physicians, and general health counselors. The intervention lasted 6 years, at a total cost of $180 million in 1980 (about $350 million today). The MRFIT investigators expected significant reductions in all three risk factors. It was hypothesized that cholesterol would decline by 10 percent for men with elevated levels (≥220 mg/dL), diastolic blood pressure would decline by 10 percent for those with high levels (≥95 mm Hg), and smoking would decline by 20 to 40 percent, depending on the initial level smoked (Sherwin, Kaelber, Kezdi, Kjelsberg, and Thomas, 1981). If

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life achieved, these changes would translate into a 27 percent reduced chance of coronary heart disease mortality. Table 17-1 shows the results the trial actually produced. For each of the three risk factors, there were improvements in risk factors for the intervention group. Blood pressure declined by 12 percent, smoking fell nearly in half, and cholesterol was lower by 5 percent.2 But there were also favorable changes in the three risk factors in the control group. Aside from smoking, where some reduction was expected in the control group, these risk factor changes in the control group were unexpected. As a result, the net change in risk factor control for the intervention group was below expectations. Cigarette smoking declined by more than the forecast amount, but the decline in blood pressure was only 75 percent of expected levels, and the decline in cholesterol was only half of expected levels. The behavioral intervention worked, but not to the extent forecast. Before moving on to the mortality outcomes, the racial homogeneity of the MRFIT results must be noted. Figure 17-2 shows the relative change in risk factors for whites and blacks in the intervention group compared to the treatment group (Connett and Stamler, 1984).3 For each risk factor—blood pressure, cholesterol, and smoking status—changes were similar for blacks and whites; if anything, changes were a bit larger for blacks than whites. Because blacks are more likely to be hypertensive than whites, this part of the intervention reduced racial disparities in health. TABLE 17-1 Effects of the MRFIT on Risk Factors and Mortality Measure Experimental Results Percentage of Hypothesized Effect Intervention Group Control Group Difference-in-Difference Diastolic blood pressure –12% –8% –4% 75% Smoking rate –46 –29 –17 145 Serum cholesterol –5 –3 –2 50 Coronary heart disease (CHD) mortality* 17.9 19.3 –7 26 Overall mortality* 41.2 40.4 2 — 10-year CHD mortality* 31.4 35.1 –11 — 10-year overall mortality* 77.2 83.4 –8 — 16-year CHD mortality* 57.6 64.7 –11 — 16-year overall mortality* 154.2 163.1 –6 — *Deaths are per 1,000 people. NOTE: Difference-in-difference is the percentage change for the intervention group less the percentage change for the control group. In the mortality rate rows, the difference-in-difference is the percentage reduction in mortality rate. Differential changes in blood pressure, cigarette smoking, and cholesterol were statistically significant; changes in mortality rate were not. SOURCE: Data are from Multiple Risk Factor Intervention Trial Research Group, 1982, 1990, 1996.

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life FIGURE 17-2 Decline in risk factors by race, MRFIT. SOURCE: Multiple Risk Factor Intervention Trial Research Group (1982). The ultimate end-point for the study was mortality. The mortality effects are also shown in Table 17-1. These effects are even smaller. Coronary heart disease mortality was only 7 percent lower in the treatment group than in the control group, and overall mortality was slightly higher. Neither estimate is statistically significant. The failure of the MRFIT trial to effect significant behavioral change does not imply that all individual intervention trials have had no impact. There have been a large number of individual intervention trials (many using much smaller samples of people), and some have shown positive behavioral effects (Orleans et al., 1999). But MRFIT is the largest behavioral change trial, and its failure casts a shadow over all of the results. Thus, it is worth considering that experiment in some detail. There are two disappointments in the MRFIT trial—the lower than expected effect of interventions on risk factors and the small translation between risk factor changes and mortality. The second issue has been investigated more extensively than the first. The leading hypothesis put forward is that risk factor reduction did not translate into large net mortality improvements because one of the antihypertensive medications used was actually harmful to some men. For men with electrocardiogram abnormalities at baseline, use of hydrochlorothiazide (a type of diuretic) was associated with increased mortality. On the basis of this evidence, in the fifth year of the intervention, a decision was made to replace use of hydrochlorothiazide with chlorthalidone (a different diuretic).

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life In a follow-up several years after the intervention was completed and 10 1/2 years after the trial began, the differences in mortality between the treatment and control groups were larger (11 percent for coronary heart disease mortality, 8 percent for total mortality), but still not statistically significant (one-tailed p = 0.12 and 0.10). This change was consistent with an adverse effect of the antihypertensive medication. The same conclusion was reached at a 16-year evaluation published late in the 1990s. Mortality was lower for the treatment group compared to the control group (11 percent for coronary heart disease mortality, 6 percent for total mortality), although again the results were not statistically significant. Perhaps more important for this chapter is the fact that the behavioral interventions had mixed effects. Smoking cessation was more successful than expected and hypertension control (largely through medication) was close to expectations, but cholesterol reduction (largely through weight reduction) was further away. The social component of the experiment was not a failure, but it was not a big victory. There are several possible explanations for this mixed record. A first explanation is that the 6-year trial was not long enough to effect significant behavioral changes. Without continuing the experiment longer, it is impossible to test this theory. The theory may be incorrect, however. If this theory were correct, the change in risk factors between the treatment and control groups should be increasing over time, as more treatment group members adopt healthier lifestyles. In fact, however, the risk factor change is relatively constant from year 1 to year 6 (Multiple Risk Factor Intervention Trial Research Group, 1982).4 A second theory is the effect of background changes. In the study design, it was assumed that there would be no major change in risk factors in the control group, other than a modest reduction in smoking. In fact, large changes occurred in all three of the risk factors. It is possible that even the modest intervention for the control group—annual risk factor measurement and referral to a doctor for care—led to changes in behavior for this group. A related possibility is that disappointment at not being in the intervention group led these men to change their behavior. However, a comparison of those in the control group with those at high risk but not in the trial suggests this is not the case (Luepker, Grimm, and Taylor, 1984). Rather, the control group improved because the population as a whole was improving. The treatment had some impact above that, but not an enormous amount. The reasons for these background changes are not hard to divine. Over this time period, a great deal of public attention was focused on the dangers of hypertension and smoking, and attention was also paid to cholesterol. The issue is not why behaviors in the control group improved, but why the intensive intervention was not even more successful.

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life adopted, and mobile vans were deployed to catch drunk drivers. In addition, courts were trained to screen for problem drinkers. The second theme was to encourage rehabilitation of problem drinkers. Identified problem drinkers were provided education and treatment programs to reduce continued drunk driving. ASAP programs were in place for 2 to 5 years, depending on the community. The project was expensive, costing $88 million between 1970 and 1977 (equivalent to about $275 million today). There is some debate about ASAP’s effectiveness, but most analysts believe the programs were not very successful. Some studies find positive effects, others find inconclusive effects, and still others find negative effects. Because the methodology is similar to the community-level cardiovascular disease interventions discussed earlier, details are not presented here. It is sufficient to note that the project was not an enormous success. As of the late 1970s, it was relatively easy for a researcher to conclude that drunk driving was a stubborn social problem, immune to public intervention. Beginning in the early 1980s, though, drunk driving began a dramatic decline. The initial spur for the decline was the formation of Mothers Against Drunk Driving (MADD) and similar grassroots programs. MADD was organized in 1980 by Candy Lightner, a mother in California whose 13-year-old daughter was killed by a drunk driver. The driver had been arrested a few days before for driving under the influence of alcohol (one of many such arrests for that driver), but had been released. MADD reached national prominence in 1982, when a TV special about the Lightner case was aired. By 1984, there were several hundred MADD chapters around the country. MADD focused on the passage and enforcement of more severe driving under the influence (DUI) laws. Legally acceptable blood-alcohol levels were lowered, and mandatory penalties for drunk driving were enacted. The legal age for alcohol purchase was increased. There are no national data on the share of people who drive with blood-alcohol levels above acceptable levels. Thus, it is impossible to know about trends in this area. But data on crash fatality victims are available since 1982. The beginning of the data in 1982 is unfortunate; one would like to measure the trend in drunk driving prior to the MADD experience. But it was only with the increased prominence given to drunk driving by MADD that accurate statistics began to be kept. The data on the share of fatalities to drunk drivers, presented in Figure 17-6,16 show a marked decline in the share of fatalities to people who were drunk in the years just after MADD was formed. The share was 30 percent in 1982 and declined to 25 percent by 1987. Although we do not know what the trend was prior to 1982, there does not seem to be a period before an effect is observed.

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life FIGURE 17-6 Share of drivers in fatal crashes with blood alcohol content (BAC) > = 0.10. SOURCE: U.S. Department of Transportation (2001). By 1987, drunk driving fatalities seemed to have plateaued. The share was falling only slightly compared to previous years. Around that time, a second campaign was launched, the designated driver campaign (DeJong and Winsten, 1998). The goal here was to have at least one nondrinker available to drive. This program seemed to have worked as well. Shortly after the program was launched, the share of deaths to drunk drivers began another 4-year decline. The share is now 17 percent. Ironically, the experience of the past two decades, for MADD in particular, violates a central tenet of many public health campaigns. It is frequently stressed in sociology writings that policies should avoid blaming people for their mistakes. The idea is that people respond poorly to being blamed for health problems. Since the early 1980s, however, drunk drivers have been stigmatized in exactly that way. Yet even with this blame, there have been large health improvements. The contrast between the ASAP programs and the MADD experience is also striking. Both actions focused largely on legal responses to drunk driving. Both targeted police and courts as natural enforcement agents. But one seems to be successful, while the other was not. It is not entirely clear what accounts for the difference. Certainly, the MADD experience drew far more media attention than the ASAP programs. The scale of the intervention may matter a great deal. The deterrent effect of the intervention may also be enhanced by the publicness of the intervention. Laws passed in response to drunk driving concerns were much more noticeable in this era

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life than were the changes brought about by ASAP. Whether these or other aspects account for the difference in response is not known. Dietary Change The final intervention to study is perhaps the most complex—changes in diet. Heart disease and many other conditions are affected by the overall amount of caloric intake and the type of calories consumed. Excessive caloric intake leads to obesity, diabetes, and hypertension, all leading risk factors for cardiovascular disease. Excessive fat intake, given the level of calories consumed, leads to high cholesterol and atherosclerosis. For some years, the message to American consumers has been twofold: reduce the overall level of calories and decrease the share of fat in the diet. The response to these messages has been mixed. Changes in the fat composition of the diet have been exemplary. This response is best seen since the early 1980s. Although it has been known for some time (since at least the 1950s) that high cholesterol leads to heart disease, clinical trials did not show the efficacy of cholesterol intervention programs until 1984. The critical trial, termed the Lipid Research Clinics Coronary Primary Prevention Trial (LRC-CPPT), showed conclusively that cholesterol control significantly reduced mortality risk. The LRC-CPPT was major news. It was covered in newspapers and magazines—often on the cover—and received attention on the evening news. Time series evidence suggests the message got through. Figure 17-7 shows food issues that are of most concern to consumers.17 Beginning in the early 1980s, concern about the fat and cholesterol content of food increased from about 10 percent of the population to nearly half. In the FIGURE 17-7 Nutritional issues that most concern consumers. SOURCE: U.S. Department of Agriculture (1999).

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life 1990s, public health officials stressed the importance of fat intake over cholesterol intake in explaining high cholesterol. Consumer concern mirrored this changing information. Food consumption data are shown in Figure 17-8. There are generally not sharp breaks in these series, but the trends are worth noting. The consumption of beef and eggs fell markedly over this period, as consumers shifted into lower fat foods such as chicken and salads (not shown in Figure 17-8). Within these categories, lower fat items were increasingly purchased instead of higher fat items. Coupled with these dietary changes were medical interventions such as increased cholesterol screening and use of anti-cholesterol medication. Figure 17-9 shows average levels of cholesterol over time. Accurate cholesterol levels require blood samples from a large share of the population, which standard population surveys do not measure. The only viable data are from the National Health and Nutrition Examination Surveys (NHANES). The data presented here are from the early 1970s (1971-1974) and the late 1980s and early 1990s (1988-1994). A more recent NHANES was conducted in the late 1990s, but these data have not yet been publicly released. Overall, the share of people with high cholesterol fell from 28 percent to 19 percent, a change of about 30 percent. Importantly, the change was common across racial groups. Indeed, high cholesterol rates for blacks declined by more than for whites, while starting from nearly the same base. FIGURE 17-8 Trends in food consumption. SOURCE: U.S. Department of Agriculture (1999).

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life FIGURE 17-9 Share of people with high cholesterol, 1971-1974 and 1988-1994. SOURCE: Author’s calculations form National Health and Nutrition Examination Surveys (NHANES). The change was also relatively similar by education groups. People with less than a high school education and those with a college degree had the largest declines. There was no substantial change in the socioeconomic status gradient of high cholesterol. At the same time as cholesterol has been falling, though, the overall level of caloric intake has increased. Food available for consumption in the United States increased by 500 calories per person per day between 1970 and 1994. Obesity increased as well, as Figure 17-10 shows.18 The share of people who are obese rose by over 10 percentage points between the early 1970s and the late 1980s. Other data show that obesity continued to increase throughout the 1990s. Blacks are more obese than whites. Somewhat surprisingly, though, obesity increased by more for whites than blacks. Increases were relatively similar by socioeconomic status. The more educated are less obese than the less educated, but the increase in obesity was relatively similar across education groups. In this case, the worsening of health status did not increase the racial or socioeconomic disparities in health. Summary of National Interventions Although the evidence is not crystal clear, many national health interventions seem to have had a large impact on health behaviors. With the exception of obesity, most health behaviors have improved over time, and public health interventions are a part of this improvement. In the case of

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life FIGURE 17-10 Obesity rate, 1971-1974 and 1988-1994. SOURCE: Author’s calculations form National Health and Nutrition Examination Surveys (NHANES). smoking cessation, the health improvement was greater for better educated people. That is not the case with the reduction in high cholesterol or the increase in obesity, however. A lot of changes either narrowed, or left unaffected, the racial, ethnic, and socioeconomic measures of health. IMPLICATIONS What makes for a successful behavioral intervention? Making sense of the various facts already presented is not straightforward. There may not be one theory that explains it all. In this section, some empirical regularities are proposed and one possible interpretation is suggested. Some basics seem to be true. Clearly, the message conveyed to people has to be simple. The harm in each of the national interventions is clear—drunk driving kills children; smoking causes lung cancer. The solution is also clear: don’t drive while drunk; stop smoking. People deal with simple messages far better than complex messages. Beyond that, the situation is murkier. Some theories can be rejected. One theory common in social psychology is that information provision is

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life not enough. People learn new information, the theory goes, but do not act on it readily. One has to change the environment as well. The evidence is not greatly supportive of this theory. Although new information does not always lead to behavioral change, it does sometimes. A good part of the decline in smoking, and certainly the initial decline, is a result of increased public knowledge about the damage from smoking. Changes in fat and cholesterol intake result to a significant extent from the same factors. Information by itself can change behavior. A second rejected theory is that the form of the message is very important. In particular, negative messages that blame people for their health problems will be less successful than messages that work with people in a positive way. But this theory too is incomplete. The campaign against drunk driving brings this out most prominently. The subtext of this intervention was telling drunk drivers that they were evil people who killed innocent children. They deserved punishment (or possibly reward if they had a nondrinking driver). People responded to this antagonistic message by limiting their drunk driving. A third theory is that behavioral experiments need to be carried out for a long time to have any effect. Clinical trials of interventions may simply not be long enough. But many of the behavioral experiments that have been conducted lasted for 5 to 7 years. That is a long period of time by the standards of many successful interventions. Within 6 years of the Surgeon General’s report on the harms of smoking, for example, cigarette consumption fell by nearly 10 percent. Drunk driving rates changed in that time frame as well, as did food purchasing habits. Behavior can change rapidly when the conditions are right. While some theories are clearly false, there are other theories that might explain these effects. The first is a theory of intensity. One reason why national information interventions may have greater impacts on behavior than community interventions may be the fact that national information permeates more widely and deeply in people’s minds. Behavioral change is hard; people always prefer to continue on their current path. In this theory, the key for interventions to succeed is that they force people to take some action. People can continue to do what they were doing, but if the information permeates widely enough, doing nothing becomes a choice that individuals have to rationalize. Once it becomes impossible to continue in the current path without making an explicit decision, people may be more likely to change to new paths. In this sense, information interventions may be similar to taxes or regulatory interventions. When taxes on cigarettes are raised, people cannot smoke to the extent they formerly could without giving up some other consumption. When smoking is banned in buildings, people have to walk outside to smoke. Similarly, when the information about smoking becomes

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life so clear as to obliterate any doubt about its harms, people cannot continue to smoke without consciously deciding to sacrifice their health. The national cholesterol intervention seems to fit the same pattern. It was impossible to miss the news about the harms from cholesterol. People had to act on it—for example, by cutting out foods high in fat or cholesterol or visiting the doctor—or consciously recognize that they were not going to do so. As a result, more people changed their behavior. The focus on the degree to which information permeates is not to deny that the message being conveyed is important. One of the features of all of the successful health information interventions is that their prescriptions are simple: one should not smoke; high cholesterol should be managed; drunk driving is bad. The simplicity of the message is clearly a key to its success.19 But the simplicity of the message is not enough. It has to impact so deeply that people cannot ignore it. A second theory has to do with externalities. One of the hallmarks of many interventions is that they stress the harm that people do to others, not just to themselves. Drunk driving was stigmatized because innocent people (frequently children) were killed by it. Cigarette smoking came in for additional scorn when studies linked secondhand smoke to poor health (a subject that is still controversial). People may respond more to the idea that they are hurting others than to the harm they cause themselves. External effects also allow people not engaging in the activity a safer route on which to base negative stigma on those who do. A third theory is of peer effects. People may decide what is appropriate behavior on the basis of what others are doing, in addition to their own utility from an activity. If more people engage in health-promoting practices, people who would not otherwise engage in those practices might decide to as well. This is often referred to as a “tipping point” phenomenon because it could be that small changes in the behavior of the average person could induce large changes in behavior even among those far away from the average. The tipping point model is similar to the theory of population epidemiology proposed by Rose (1992). It could help explain why national interventions seem to be more effective than community-level or individual interventions, because they result in more changes among the general population. These theories may or may not be right. Understanding why some health interventions succeed and others fail, though, is essential to making informed decisions about polities directed to health behaviors. ACKNOWLEDGMENTS This chapter was prepared for a National Academy of Sciences panel on Ethnic Disparities in Aging Health. I am grateful to Sharon Maccini for research assistance; to Angus Deaton, Sandy Jencks, Jim Smith, Leonard

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Critical Perspectives on Racial and Ethnic Differences in Health in Late Life Syme, and two anonymous reviewers for helpful comments; and the National Institute on Aging for research support. ENDNOTES 1.   Given the limits of this chapter, my discussion is necessarily brief. For a more complete discussion of many interventions, see Sorenson, Emmons, Hunt, and Johnston (1988); Emmons (1999); Syme (2003); and Powell (2001). 2.   Note that these are averages over the entire population of men enrolled in the trial, so they are not readily comparable to the goals for men at high risk on any particular dimension. 3.   Seven percent of the sample was black—more than 900 men. 4.   This is not a result of sample selection; the response rate was about 90 to 95 percent, and was relatively constant after some dropout during the first year. 5.   Some evidence shows that women whose husbands were in the MRFIT were more likely to change their risk factors than were women whose husbands were not enrolled (see Sexton et al., 1987). 6.   This chapter focuses on trials in the United States. Another trial in Finland was more successful. 7.   These results are for men. Changes for women are similar. 8.   The Stanford study found evidence of significant health changes using a cohort sample, but not a cross-section sample. Effects were also larger in the 2- to 4-year interval, but not the 6-year interval. 9.   Many authors have found that the advertising ban had a small impact on consumption, although others have not. Even the studies finding an effect estimate it to be relatively minor. 10.   Cigarette consumption data are tabulated by the Centers for Disease Control and Prevention. 11.   Ironically, the Surgeon General’s report was not very expensive for the government to produce or disseminate. 12.   The data in Figures 17-4 and 17-5 are from periodic years of the National Health Interview Survey, as tabulated by the Surgeon General, U.S. DHHS (2000). 13.   These rates are unadjusted for income. Adjusting for income, blacks smoke less than whites. 14.   Indeed, the 6 percent differential is probably larger than the difference a few years earlier; when incomes were lower, smoking rates were higher among higher income people than among lower income people. 15.   Because the programs were run separately in each community, they are interpreted as community-level interventions, in contrast to information provision for all or a national set of new legislation. 16.   The data are from the U.S. Department of Transportation, National Highway Traffic Safety Administration (2001). 17.   These data are from surveys conducted by the Food Marketing Institute. 18.   Medically, obesity is often defined as having a body mass index (BMI, or weight in kilograms divided by height in meters squared) of 30 or greater. 19.   Indeed, it is possible that the lack of a simple prescriptive message is the key to why we have not been able to reduce obesity. REFERENCES Carleton, R.A., Lasater, T.M., Assaf, A.R., et al. (1995). The Pawtucket Heart Health Program: Community changes in cardiovascular risk factors and projected disease risk. American Journal of Public Health, 85(6), 777-785.

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