Promoting Health Intervention Strategies from Social and Behavioral Research (2000) / Chapter Skim
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Paper Contribution F: Behavioral and Social Science Contributions to the Health of Adults in the United States
Paper Contribution F: Behavioral and Social Science Contributions to the Health of Adults in the United States
Pages 254-321
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From page 254... ...
The purpose of this paper is to briefly review the major causes of morbidity and mortality during adulthood and to provide a selected review of the literature that addresses efforts to reduce the prevalence of preventable disease among adults in the United States. Substantial progress has been made in reducing risk factor prevalence among adults.
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From page 255... ...
Second, more research is needed in how to effectively target multiple risk factors for chronic disease and to take advantage of naturally occurring relationships between health behaviors. Third, behavioral scientists need to anticipate the impact that advances in computer technology may have on intervention development and delivery, and to be prepared to take advantage of the resources that this technology has to offer.
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Death rates due to heart disease are twice as high in black men as in white men, and slightly higher for Native American men than white men. Unintentional injury is the third leading cause of death in this age range (USDHHS, 1999~.
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Heart disease is the leading cause of diabetes-related deaths. Type 2 diabetes, which accounts for more than 90% of all diagnosed diabetes, is associated with modifiable risk factors (e.g., obesity, physical inactivity)
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Modifiable risk factors for chronic disease morbidity and mortality include individual and environmental-level exposures. Strong relationships exist between health behaviors and risk for all of the leading causes of morbidity and mortality during adulthood.
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cancer mortality by approximately 60% (Colditz et al., 1996, Willett et al., 1996~. Given the encouraging estimates of the additional health gains that could be achieved from population-level adoption of recommended health behaviors, and the fact that many gains have been made, it is still disheartening that more than 50 years after the Framingham Heart Study demonstrated that behavioral risk factors greatly increase the risk of developing coronary heart disease, the prevalence of risk factors for this and many other diseases remains high.
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Unfortunately, the higher-than-ideal prevalence of modifiable risk factors is not limited to disease-free groups. There is an astonishingly low rate of action taken to control disease among those who have already been diagnosed with a chronic disease.
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For example, health behavior interventions often address intrapersonal and interpersonal levels, while occupational health and injury prevention interventions typically address policy and regulatory levels. Examples of interventions at each of the levels in the social ecological model are provided in Box 2.
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Self-help materials are another strategy for reaching large numbers of people. With most health behaviors, self-help interventions are more effective than
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However, as noted earlier, small changes at the population level can lead to large effects on disease risk. In evaluating health promotion interventions, the level of intervention impact must be judged as a function of the intervention's efficacy in terms of producing individual change, as well as its reach or penetration within the population (Abrams et al., 1996, Glasgow et al., 1999, Sorensen et al., in press)
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From page 265... ...
COMMUNITY-BASED TRIALS Community-based health promotion interventions were first studied in the late 1970s and early 1980s, as a result of the increased recognition that coronary heart disease prevention requires efforts beyond the individual level (Farquhar, 1978, Farquhar et al., 1977, 1985, Kottke et al., 1985, Puska et al., 1983, Rose, 1982~. The behavioral sciences made key contributions to the development and evaluation of these trials and to the movement of chronic disease prevention and management out of the medical model.
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Work Site Interventions There is a relatively large body of work site health promotion research, work sites are now considered key channels for disease prevention among adults (Abrams, 1991, Abrams et al., 1994a, Fielding, 1984, Heimendinger et al., 1990~. Work site interventions have the advantage of being able to reach across intervention levels and include interventions targeting individuals, the organization, and the environment.
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From page 267... ...
(1997~. Although few work site health promotion interventions effectively include multiple levels of intervention over a sustained period of time, those that do have improved outcomes and have shown effects for more difficult-to-reach subgroups (Sorensen et al., 1998c, Willemsen et al., 1998~.
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Several national and clinical care guidelines recommend that physicians routinely advise their patients regarding behavioral risk factors for chronic disease (American Cancer Society, 1980, National Cancer Institute, 1987, USDHHS, 1991) and screen for mental health problems such as depression (Elkin et al., 1989, U.S.
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. Such office system interventions have been found to significantly increase the rate of several health promotion or prevention interventions among community physicians (Dietrich et al., 1992, Harvey et al., 1999~.
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Becker and colleagues have conducted a number of church-based interventions as part of a model partnership program between the Johns Hopkins Academic Health Center and the East Baltimore community, within which organizations such as Clergy United for Renewal of East Baltimore and other community organizations play key leadership roles (Becker et al., 1999, Levine et al., 1994, Voorhees et al., 1996~. Much of this work has utilized spiritually based"environmental" interventions (e.g., pastoral sermons on smoking, testimony during church services, training of volunteers as lay smoking cessation counselors)
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From page 271... ...
Regulatory Channels There have been some examples of regulatory action to promote preventive health behaviors, although the potential of regulatory interventions has not nearly been realized. For example, legislative and policy efforts that create a safe physical environment and incentives for increased activity have been virtually untested in the United States (Bauman et al., in press, King et al., 1995~.
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This is a wonderful example of what can be done if resources are available and coordinated. This section of the paper focuses on a discussion of factors that have an impact on the success of health behavior change interventions, including the need to link multiple levels of intervention, development of effective strategies for targeting multiple risk factors, anticipation of the impact that advanced computer technology may have on intervention design and delivery, a focus on sustainability and dissemination, and consideration of the social context of health behaviors.
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In the health promotion area, there have been efforts to link access and policy-level interventions with individual-level interventions, although this is rarely
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There is growing evidence that full-spectrum interventions (McKinley, 1995) show substantial promise for improving the effectiveness of behavior change interventions related to health promotion topics, although few interventions targeting adults have provided a substantial intervention dose across all levels of the social ecological model.
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Strong interventions across all levels are needed in order to consistently outperform secular trends (Bauman et al., 1999, Glasgow et al., 1995, Sorensen et al., 1998a, Winkleby et al., 1997~. In their "report card" on progress in population health promotion, Orleans and colleagues (Orleans et al., in press)
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Community-placed research is not usually the result of an interest to exclude the community from the research planning process, but more likely a function of researchers finding themselves in the situation of having an idea for a study or a funding opportunity with a very tight time line and then approaching community organizations or members with the agenda well formulated. A1though many trials have been conducted under these circumstances, such an approach often ignores the agenda and context of the community and thus is likely to lead to difficulties in implementation and/or suboptimal outcomes.
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First, the clustering of risk factors and the interrelationships in cognitive mediators across health behaviors suggest that there may be some efficiency in targeting more than one risk factor at a time. Second, prevalence of multiple risk factors is high.
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Efforts to develop and evaluate strategies for reducing multiple risk factors simultaneously are an important part of efforts to improve the outcome of health promotion interventions. Use of Computer Technology for Intervention Development and Delivery Computer technology offers several new options for intervention development and delivery.
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Many tailored interventions have been found to increase short- and longterm behavior change rates (Bastani et al., 1999, Brug et al., 1998, 1996, Curry et al., 1995, King et al., 1994, Koffman et al., 1998, Rakowski et al., 1998, Rimer and Glassman, 1997, Rimer et al., 1994, Strecher et al., 1994) , although other studies have not yielded significant results across all (Bull et al., 1999, Crane et al., 1998, Kreuter and Strecher, 1996, Lutz et al., 1999, Rimer et al.,
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with tailored interventions to promote smoking cessation among low-income African Americans who were patients in a community health center (Lipkus et al., in press)
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(1998d) found that 2 years following completion of a work site intervention, the infrastructure for continuing the program was in place (e.g., committees existed that had responsibility for health promotion planning, specific individuals had job responsibilities that included health promotion planning)
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This model illustrates the importance of factors at all levels of the social ecological model on health and well being. Figure 3 illustrates a conceptual model of the ecology of urban violence in low-income minority communities that addresses the impact that exposure to violence may have on health promotion behaviors (Sanders-Phillips, 1996~.
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284 / Health care system / / ·Factors related to effectiveness ·Cultural sensitivity ·Culturally specific programs 1~ ~ ·Factors related to effectiveness ·Cultural sensitivity ·Culturally specific programs \\ \ it' >I \ Lifestyle ·Factors related to effectiveness ·Cultural sensitivity ·Culturally specific programs PROMOTING HEALTH v\ \ ) (/vironment I \ / / i I' '/~ FIGURE 2.
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, that help to reduce the burden of heavy caring responsibilities, and that improve participants' social material circumstances may be a step toward lifting the barriers that prevent low-income individuals from focusing on health behaviors. An example of work focused on addressing social contextual factors is Fisher et al.'s (1993)
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From page 286... ...
Careful and thoughtful collaboration between social epidemiologists who are examining the relationship between social factors and health behaviors, and behavioral scientists who are developing interventions will increase the likelihood that health promotion interventions more systematically address these contextual factors. Contamination increasingly, community-based trials have utilized communities or organizations as the unit of analysis and have utilized the intention-to-treat principle to guide outcome analysis.
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From page 287... ...
Societal and policy-level changes are likely to be slow in the making, and thus exclusion of behavior change efforts at the individual level is likely to lead to generations of children being exposed to even higher prevalence of poor health behaviors in the future. Further, it is likely that there will always be population groups that need additional, individual assistance with health behavior change, and it would be unfortunate indeed if this likelihood was not considered in the development of disease prevention paradigms for entire populations.
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From page 288... ...
Further study is needed of the impact of combined interventions, across levels, including policy interventions, on the initiation and maintenance of behavior change. It is critical that the next generation of health promotion research begin to address the need to develop truly integrated, multilevel interventions that provide continuity of intervention, so that societal influences reinforce healthy behaviors and serve to shift population norms in a healthful direction.
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Research must address mechanistic questions such as how best to operationalize theoretical variables within tailored communications, whether tailoring is more effective for some behaviors than others or more effective in certain settings than others, what optimal types and number of variables should be included in tailored communications, and how to use advanced computer technologies to enhance the effectiveness of tailoring (Dijkstra et al., 1998, Kreuter et al., 1999~. Other technologies that deserve further exploration include computer-based risk assessment and behavior change programs that can be incorporated into primary care practice (Emmons et al., in press)
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are least effective (Berg et al., 1998, Freemantle et al., 1999~. Following completion of the Working Well Trial, intervention materials were disseminated to the 42 control work sites, no increase in the number of tobacco control activities offered was observed by the 2-year follow-up (Sorensen et al., 1998d)
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From page 291... ...
A System for Disseminating Office Systems Interventions to Health Care Providers Is Essential Particular consideration should be given to building an infrastructure for institutionalization and dissemination of effective programs in the health care setting. Health care providers are effective at providing prevention interventions, and office systems greatly increase the likelihood that providers will address health behaviors.
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From page 292... ...
NCQA and other oversight bodies provide incentives for providers in some health care environments to implement office systems, although incentives for prevention are limited in many settings. One way to increase provider interest in adopting office systems for prevention might be to incorporate multiple risk factors and screening, so that the systems can be utilized with all patients, and to also incorporate strategies for addressing adherence to treatment recommendations.
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From page 293... ...
Intervention research must begin to address the role of social factors in health behaviors, to expand our theoretical models to incorporate social factors, and to develop innovative intervention designs that will help to elucidate the most effective strategies for intervening within this context. Intervention research that represents a collaboration with existing community groups, social service agencies, and health care providers, and utilizes existing social networks and relationships to creatively design interventions that address social contextual factors, is critical if we are to make a significant impact on health risk factors in the United States.
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Theory is needed that is grounded in social experience and thus creates more effective practice (Altman, 1995, Israel et al., 1998, Schensul, 1985~. Cultural influences on both mediating mechanisms and health behaviors are also important to consider.
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healthcare providers, teachers, community leaders, preachers, camp counselors) · Provide key community leaders with materials and resources for extending their intervention efforts · In target organizational settings, review policies that can impact on norms for health behaviors (e.g., choice of foods for vending machines, smoking policies, youth access to cigarettes)
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296 to a' o cd so ¢ Ad; au o a can a .
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In order to continue to build on these contributions, innovations are needed that draw upon insights from social epidemiology, policy, and regulatory approaches, and interventions are needed that integrate strategies for dealing with social factors with those developed for individual-level change. Health behavior research also needs to stretch beyond the individual and interpersonal levels and continue to explore ways to work together with communities to systemically integrate social, governmental, and policy-level factors into behavior change interventions.
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, Health Behavior and Health Education, 2nd ea., pp.
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Preventative Medicine, 29~5)
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(1997~. Can dietary interventions change diet and cardiovascular risk factors?
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(1997~. Linking Research and Public Health Practice: A Review of CDC's Program of Centers for Research and Demonstration of Health Promotion and Disease Prevention.
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American Journal of Health Promotion, 4~5)
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. A prospective analysis of change in multiple risk factors for cancer.
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(1985~. Leisure time physical activity and its relationship to coronary risk factors in a population-based sample.
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(1994~. Physician advice to reduce chronic disease risk factors.
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(1998~. Prevalence of multiple cardiovascular disease risk factors among women in the United States, 1992 and 1995: The Behavioral Risk Factor Surveillance System.
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(1997~. Community action for health promotion: A review of methods and outcomes 1990-1995.
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(1989~. Evaluating community level health promotion and disease prevention interventions.
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American Journal of Health Promotion, 13~2)
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(1988~. Disease prevention and health promotion practices of primary care physicians in the United States.
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(1994~. Community education for cardiovascular disease prevention: Risk factor changes in the Minnesota Heart Health Program.
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(1988~. An ecological perspective on health promotion programs.
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American Journal of Preventative Medicine, Iltsupp)
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(1983~. Change in risk factors for coronary heart disease during 10 years of a community intervention programme (North Karelia project)
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American Journal of Health Promotion, 11~2)
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(1989~. Epidemiology and interaction of risk factors in cardiovascular disease.
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(1995~. A model for worksite cancer prevention: Integration of health protection and health promotion in the Wellworks Project.
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(1992~. Risk factors for coronary heart disease: A study in inner London.
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(1996~. Stages of change of smoking cessation: Relationships with other health behaviors.AmericanJournalofPreventative Medicine, 12, 134-138.
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American Journal of Health Promotion, 9~4)
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. A comprehensive review of the effects of worksite health promotion on health-related outcomes.
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