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Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences
Clinical trials such as the Multiple Risk Factor Intervention Trial (MRFIT Research Group, 1982), the Lipid Research Clinics Coronary Primary Prevention Trials (Lipid Research Clinics Program, 1984a,b), and the Lifestyle Heart Trial (Ornish et al., 1990) have provided important contributions to the development of successful interventions and to the current understanding of risk factors for disease. Education and counseling can promote primary prevention measures reducing smoking and choosing a healthy diet. Interventions aimed at secondary prevention behaviors can influence early detection of illness. For instance, willingness to self-examine and participate in screening procedures is important for detection and treatment of cancer. Psychosocial interventions can improve people’s coping skills and provide emotional support, thereby improving quality of life and medical outcomes among the chronically ill. The role of behavioral interventions for improving adherence to treatment is discussed below. Interventions addressing behavioral and psychosocial risk factors are also briefly reviewed.
Adherence, the match between a patient’s behavior and health care advice (Haynes et al., 1979), mediates the effectiveness of treatment recommendations, the scientific evaluation of treatment protocols, and even public health. For example, when treating bacterial infections, some patients stop taking antibiotics when symptoms stop, but before all the targeted bacteria are eradicated, resulting in relapse for the patient and the development of resistant bacteriological strains. Failure to follow medical recommendations for treatment is a common problem that is not without controversy. The term “adherence” has been increasingly used to replace the previous label of “compliance” to convey the patient’s active participation in following a treatment regimen, rather than the patient’s submission to a provider’s directive (Roter et al., 1998). Between 30% and 70% of patients do not adhere effectively to treatment recommendations. Nonadherence to difficult behavioral recommendations, such as smoking cessation or following a restrictive diet, occurs in more than 80% of patients (National Heart, Lung, and Blood Institute [NHLBI], 1998). The reasons are varied: Providers sometimes fail to describe the treatment regimen clearly, resulting in confusion on the part of the patient. Patients may also not fully appreciate the consequences of nonadherence. Some regimens