Conclusions: Failure is a common and consequential aspect of health behavior change; a deeper understanding of failure should inform chronic disease interventions. Abstract Background: Half of all Americans have a chronic disease. Gov't Research Support, U. When one or more of the following steps are ignored, the intervention might lack focus and effectiveness and therefore be more likely to fail:.
Interventions that fail often spend too much time dwelling on the past instead of discussing solutions for the future. Drew W. Edwards states the importance of focusing on the solution, saying that in an intervention, the friends and family should emphasize the immediate next steps towards the solution. Another flaw in unsuccessful interventions involves giving the person too many choices for how and when to receive treatment. Otherwise, the person may continue to think that her problem is not severe, and that she can receive help at some distant date in the future.
This chapter presents evidence that the campaign launched by the Surgeon General in 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 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. 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. To set the stage, information on cardiovascular disease health is presented.
Figure shows cardiovascular disease mortality over time for different racial and gender groups. Since , 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.
Cardiovascular disease mortality by race. Department of Health and Human Services 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 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, , 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 naturally 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.
The most important individual interventions in health behavior were conducted in the s. Knowledge about cardiovascular disease risk factors solidified in the s. 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 s, experiments were designed to do just this. More than , men aged 35 to 57 were screened to produce a sample of 12, 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.
If achieved, these changes would translate into a 27 percent reduced chance of coronary heart disease mortality. Table 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.
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 shows the relative change in risk factors for whites and blacks in the intervention group compared to the treatment group Connett and Stamler, Because blacks are more likely to be hypertensive than whites, this part of the intervention reduced racial disparities in health.
The ultimate end-point for the study was mortality. The mortality effects are also shown in Table 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.
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. This change was consistent with an adverse effect of the antihypertensive medication.
The same conclusion was reached at a year evaluation published late in the s. 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, 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, 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. One possibility is that the background knowledge dissemination was close to mimicking what the treatment group received.
Thus, there might have been little additional information from the intervention. The intervention had little effect because only a small push was needed to get the trial participants to do better. This explanation is not very satisfying, though. Just telling people to quit smoking or exercise more, it was assumed, would not be sufficient to induce smoking cessation or greater physical activity. A second explanation is that the trial was unsuccessful because the behavioral intervention was poorly designed.
There are two possible reasons for this. In this theory, one needs more positive messages than negative ones. A second issue is that the intervention focused on individual change, but ignored the environment in which the person lived. Eating better is difficult if one's family and friends do not change their eating patterns. Smoking cessation is harder when a person's coworkers and family continue to smoke. In this theory, the focus should be on community-level interventions rather than individual-level interventions.
This latter argument was convincing to many. The failure of the MRFIT to achieve risk reduction on the scale hypothesized led to a series of community-level interventions to reduce cardiovascular disease risk. These community-level interventions are described in the next section. The community-level interventions were not very successful either, however, so this interpretation is probably not right.
From today's perspective, it is not clear why the MRFIT trial failed to have the impact on behavior that was hypothesized. The final section of this chapter suggests that it may have to do with the degree to which the MRFIT information forced the men to reevaluate their lives or to consider the external effects of their actions. But that is just speculation. The successor to individual-level interventions was community-level interventions, designed to change the environment as a whole.
These interventions are discussed in two strands. The first strand discusses community-level experiments designed to encourage better health behaviors. The second strand includes public policy interventions such as taxation and regulation that affect what people are allowed to do or the price they pay for doing things.
The implication some people drew from the MRFIT trial was that individual interventions are not enough. People's actions cannot be separated from the environment in which they live. Changing individual behaviors thus requires changing the environment as a whole. The logical implication of this finding is that trials need to be undertaken at the community level, rather than at the individual level. This conclusion was acted on in the s.
Several community interventions were sponsored in that decade. Again, most had the goal of reducing cardiovascular disease risk. Table describes these trials and the individual results. Each trial had one or more treatment cities matched with an equal number of control cities two treatment and two control cities in the Stanford Five City Project; three treatment and three control cities in the Minnesota Heart Health Program; and one treatment and one control city in the Pawtucket Heart Health Program.
The interventions began in the early s and lasted for 5 to 7 years. Data collection began before the intervention and continued for a short time. Although the goals of the experiments were similar—to reduce coronary heart disease risk—the interventions differed somewhat across sites.
Phonics and related skills can be addressed in all tiers of instruction within an RTI framework. Thank you for your comments. I believe systemic change is required to make RtI work. Without this paradigm shift in education, where evidence-based instructional practices are the norm in every classroom, the model will not serve the children who need it the most. Ideally, this model should help struggling students in the early grades get supplemental, targeted help based on need. Unfortunately, this is not the case.
I agree with you that it is an instructional issue; but until we can get schools up to speed with best practices, the concept has no chance of working. Your email address will not be published.
Post Comment. Research-driven approaches are not being utilized. Louisa Moats, National Literacy Expert.
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