Professional Documents
Culture Documents
Minimising The Costs of Healthy Behaviour
Minimising The Costs of Healthy Behaviour
Minimising The Costs of Healthy Behaviour
The environment in which we live can either facilitate or inhibit our level of
engagement in health-related behaviour. Poor street lighting, busy roads and high
levels of pollution may inhibit some inner-city dwellers from taking exercise
such as jogging or cycling; shops that sell healthy foods but that are a long way
from housing estates may result in more use of local shops that sell less healthy
foodstuffs, and so on. Making the environment safe and sup-portive of healthy
activity presents a challenge to town planners and govern-ments. Such an
environment should promote safety, provide opportunities for social integration
and give the population control over key aspects of their lives.
A number of projects, under the rubric of the 'Healthy Cities movement'
(World Health Organization 1988), have attempted to design city environ-ments
in ways that promote the mental and physical health of their inhab-itants. The
movement initially involved cities in industrialised countries, but is now
expanding to include cities in industrialising countries such as Bangladesh,
Tanzania, Nicaragua and Pakistan. To be a member of the movement, cities have
to develop a city health profile and involve citizen and community groups.
Priorities for action include attempts to reduce health inequalities as a result of
socio-economic factors (see Chapter 2), traffic con-trol, tobacco control, and
care of the elderly and those with mental health problems (Kickbusch 2003).
Unfortunately, this rather broad set of strategies has proved difficult to translate
into measurable and concrete action. Indeed, as recently as 2006, O'Neill and
Simard (2006) were still writing discussion papers on how to evaluate the
effectiveness of the, by then, twenty-year-old programme. Nevertheless, where
appropriate measures have been used and the principles of the healthy cities
movement enacted, this does seem to influence health behaviour. Sharpe et al.
(2004), for example, found that levels of moderate or vigorous exercise were
greater in the general popula-tion when there was good street lighting, safe areas
for jogging or walking,
ENVIRONMENTALINFLUENC ESONHEALTHBEHAVIOUR 199
Making unhealthy behaviour difficult in some way (often through pricing) can
act as a barrier to unhealthy behaviour and a facilitator of healthy behaviour.
Economic measures related to public health have been largely confined to
taxation on tobacco and alcohol. The price of alcohol impacts on levels of
consumption, particularly for wines and spirits: beer consumption may be less
sensitive to price (Godfrey 1990). These effects may hold not just
CHAPTER 7 • POPULATIONAPPROACHEST OPUBLICHEALTH
for 'sensible' drinkers but also for those who have alcohol-related problems
(Sales et al. 1989). Increases in tobacco taxation may also be the most effec-tive
measure in reducing levels of cigarette smoking, with an estimated 4 per cent
reduction in consumption for every 10 per cent price rise (Brownson et al. 1995).
Hu et al. (1995) modelled the relative effectiveness of taxation and media
campaigns on tobacco consumption in California. They estimated that a 25 per
cent tax increase would result in a reduction in sales of 819 mil-lion cigarette
packs, compared with 232 million packs as a result of media influences. Taxation
seems to be a particularly effective deterrent among young people, who are three
times more likely to be affected by price rises than older adults (Lewit et al.
1981). However, these findings must now be interpreted against attempts to
avoid these costs. In the UK, for example, increasing levels of smuggled tobacco
and alcohol from the continent (where tax levels are much lower) compete
against higher prices in formal outlets.
While prohibition may be seen as a necessary barrier by some, others have
called for more modest barriers to availability. Godfrey (1990), for example, has
suggested restricting the number of outlets for drugs such as alcohol. This would
result in increasing transaction 'costs' as people have to travel further and make
more effort to purchase their alcohol, and in reduced cues to con-sumption from
advertising in shop windows and other signs. By contrast, increasing availability
– as has occurred relatively recently in Sweden through the Saturday opening of
alcohol retail shops – may result in an increase in consumption (Norström and
Skog 2005).
A more direct form of control over smoking has been the introduction of
smoke-free work and social areas. These clearly reduce smoking in public places
– and may impact on smoking elsewhere. Heloma and Jaakalo (2003) found that
secondary smoke inhalation levels fell among non-smokers, while smoking
prevalence rates at work fell from 30 per cent to 25 per cent fol-lowing a national
smoke-free workplace law. Following a ban on smoking in Norwegian bars and
restaurants, Braverman et al. (2007) reported significant reductions in the
prevalence of daily smoking, daily smoking at work by bar workers, number of
cigarettes smoked by continuing smokers, and the number of cigarettes smoked
at work by continuing smokers. Restaurants and bars have expressed some
concern that smoking bans will reduce their profits. Countering this claim, the
US Centers for Disease Control and Prevention (2004) reported the outcome of
a ban on smoking in all public work and social outlets, including restaurants and
bars, in El Paso, Texas. Breaking the ban would result in a $ 5,000 fine. There
was no reported fall in profits or consumption in any bar or restaurant. Even
more encouraging are emerging data suggesting that such bans can positively
impact on health. Although they do not provide absolute proof of an association
between reduced smoking and reduced disease, a number of studies have now
shown reductions in the number of admissions to hospital with myocardial
infarc-tion both in the USA (eg Juster et al. 2007) and Europe (Barone-Adesi et
al. 2006) since the ban was implemented.
HEALTHPROMOTIONPROGRA MMES 201
IN THE SPOTLIGHT
Some of the first health promotion programmes targeted at whole towns aimed
to reduce the prevalence of key risk factors for CHD – smoking, low levels of
exercise, high fat consumption and high blood pressure – across the entire adult
population. The first of these, known as the Stanford Three Towns project
(Farquhar et al. 1977), provided three towns in California with three levels of
intervention.
The first town received no intervention. The second received a year-long
media campaign targeting CHD-related behaviour. Although the media pro-
gramme preceded the stages of change model (Prochaska and di Clemente 1984;
see Chapter 6) by some years, it followed a programme very similar to that
suggested by that model. It started by alerting people to the need to
CHAPTER 7 • POPULATIONAPPROACHEST OPUBLICHEALTH
Plate 7.2 For some, environmental interventions may be far from complex. Simply
providing clean water may prevent exposure to a variety of pathogens in dirty water.
Source: © Comic Relief UK, reproduced courtesy of Comic Relief UK
change their behaviour (itself a relatively novel message in the early 1970s). This
was followed by a series of programmes modelling behaviour change – for
example by broadcasting film of people attending a smoking cessation group or
showing cooking skills. These were based on social learning theory (Bandura
1977; see Chapters 5 and 6) and were aimed at teaching skills and increasing
recipients' confidence in their ability to change and maintain change of their own
behaviour. This phase was followed by further slots reminding people to
maintain any behavioural changes they had made, and showing images of people
enjoying the benefits of behavioural change such as a family enjoying a healthy
picnic (potentially impacting on attitudes and perceived social norms). In the
third town, a group of individuals at par-ticularly high levels of risk for CHD and
their partners received one-to-one education on risk behaviour change and were
asked to disseminate their knowledge through their social networks. This
strategy was used to provide another channel for disseminating information –
through the use of people given the role of opinion leaders – and increasing
motivation in both high-risk people and the general public.
Table 7.1 The three levels of intervention in the Stanford Three Towns project
Expected
Approach What it involved effect
restaurants, smoke-free areas in public and work areas, and increased phys-ical
recreation facilities. Despite this complex and sophisticated approach, the
programme had surprisingly little impact on health and health behaviour. Levels
of smoking in the intervention areas, for example, differed little from those in
the control areas, while the average adult weight in both control and intervention
areas rose over the course of the study by seven pounds. Similar findings were
found for another intervention known as the Community Intervention Trial for
Smoking Cessation (COMMIT Research Group 1995), which did not change
heavy smokers' behaviour and had only a marginal effect on light smokers.
At first glance, these data appear disappointing. Indeed, they provide little
encouragement to suggest that the approaches they used should be con-tinued.
However, before they are dismissed, it is important to contextualise their
findings. First, apart from the original Stanford study, they occurred at a time
when there were significant changes in health behaviour and disease throughout
the countries in which the studies were conducted. Rates of CHD fell by 20 per
cent over the time they were running (Lefkowitz and Willerson 2001), and there
was a general increase in health-promoting behaviour and a concomitant fall in
health-damaging behaviour such as smoking. Why did these changes occur, and
what implications do they have for interpretation of the results of the large-scale
programmes considered above?
Perhaps the experiences of the five-year Heartbeat Wales programme (Tudor-
Smith et al. 1998) sum up those of all the programmes so far considered. This
programme combined health education via the media with health screening and
environmental changes designed to promote behavioural change. These included
some of the first food labelling (low fat, low sugar, etc.) in the UK, establishing
exercise trails in local parks, no-smoking areas in restaurants, the promotion of
low-alcohol beers in bars, and so on. It also used doctors and nurses as opinion
leaders within their own communities to argue the case for adopting healthy
lifestyles. Remember that the interven-tions in each programme were compared
with 'control' areas – areas that did not receive the intervention. However, these
were not true 'control' areas in the sense that they received no intervention at all.
They received whatever local health education programmes were being
conducted at the time. In addition, any innovations conducted by these major
research programmes could not be guaranteed to remain only in the intervention
area. In the case of Heartbeat Wales, for example, its 'control' area was in the
northeast of England, which itself was subject to large-scale heart health
programmes conducted in England at the same time as Heartbeat Wales. It was
certainly not a 'no intervention' control. In addition, innovations such as food
labelling, originally conducted just in Wales, spread through to England via
supermarkets such as Tesco over the course of the programme. It is perhaps not
surprising, therefore, that although levels of risk factors for CHD fell in Wales
over the five-year period of Heartbeat Wales, they did not fall any further than
levels in the control area. The research programme essentially compared the
effectiveness of two fairly similar interventions. In addition, the majority of
health promotion affecting the population with regard to CHD is now probably
provided by the mass media as part of its general reporting – through reporting
and discussion of healthy diets, issues such as men's health, and so on. It is
therefore increasingly difficult for any health
HEALTHPROMOTIONPROGRA MMES 205
prevention – working with specific groups of people rather than trying to impose
change from without. This may have been a crucial factor. Janz et al. (1996), for
example, conducted a process evaluation of thirty-seven AIDS prevention
programmes and concluded that the use of trained community peers whose life
circumstances closely resembled those of the target popula-tion was one of the
most important factors influencing acceptance of health messages. Similarly,
Kelly et al. (1993) suggested that the use of peers and role models was an
important means of delivering health messages. Merzel and D'Afflitti speculated
that a second reason for these differences may lie in the natural history of the
diseases that each programme was trying to influence. Coronary heart disease
develops over time, and there is no marked increase in risk as a result of
particular behaviour – 'One bar of chocolate won't do me any harm'. It is
therefore relatively easy to minimise risk and put off behaviour change. By
contrast, the risks associated with unsafe sex are highly salient. It can take
relatively few unsafe sexual encounters to contract HIV, and the consequences
can be catastrophic – so the imperatives of change are much more salient than in
CHD.
While the above studies allow comparison of interventions within the same
culture, it should not be forgotten that AIDS is a global issue. Given the
devastating impact of HIV/AIDS in Africa, interventions here and in other parts
of the developing world are of paramount importance. Galavotti et al. (2001)
described a model known as the Modeling and Reinforcement to Combat HIV
(MARCH), which has been developed for use in developing countries. The
intervention model has two main components:
use of the media
local influences of change.
It uses the media to provide role models in 'entertainment that educates'.
Interventions include testimonials from people living with HIV/AIDS and peer
education similar to that used, for example, in the USA and UK. These provide
information on how to change, and model steps to change in sexual behaviour.
Serial dramas on television are also used to educate, because they involve the
viewer emotionally with the action on the screen, increase its salience and
encourage viewing. Interpersonal support involves the creation of small media
materials such as flyers depicting role models progressing through stages of
behaviour change for key risk behaviour, mobilisation of members of the
affected community to distribute media materials and rein-force prevention
messages, and the increased availability of condoms and bleacher kits for
injecting drug users. In one study of effectiveness of the media elements of this
approach (Vaughan et al. 2000), Radio Tanzania aired a radio soap opera called
Twende N a W akati ('Let's go with the times'). This soap played twice weekly
for two years with the intention of promoting reproductive health and family
planning, and preventing HIV infection. In comparison with an area of Tanzania
that did not receive national radio at the time of the study, people who lived in
areas where the radio programme was received reported greater commitment to
family planning and higher uptake of safer sex practices. In addition, attendance
at family planning clinics increased more in the intervention than control area.
HEALTHPROMOTIONPROGRA MMES 207
RESEARCH FOCUS
Amirkhanian, YA, Kelly, JA, Kabakchieva, E. et al. (2005). A randomized social network HIV pre-vention
trial with young men who have sex with men in Russia and Bulgaria. AIDS, 19: 1897–905.
This study describes the outcomes of a social network HIV prevention intervention carried out
among young gay men in Russia and Bulgaria. HIV prevention is particularly important in these
countries as the prevalence of known HIV cases is increasing dramatically, and the criminalisation
of homosexual behaviour in the Soviet era has meant that until recently many gay men remained
hidden and received little HIV prevention information.
Method
The study involved a number of stages:
Identification of social groups of gay men in bars and nightclubs by ethnographers. Groups
were monitored and their leaders identified, approached and invited to take part in the study.
Fifty per cent of those approached agreed to participate in the study.
Group leaders were asked to identify nine group members – people they most liked to spend
time with. These individuals were approached by the research team, and 93 per cent agreed to
participate in the study. A total of 52 networks with 276 network members took part in the
study. Their mean age was 22.5 years, and 92 per cent of respondents were unmarried, 49 per
cent of participants were students, and 52 per cent were employed. Groups were randomly
assigned to receive either the social intervention or no intervention.
Among those receiving the intervention, all group members completed questionnaires to
identify the most influential individuals within each social group. The network member with
the highest social status score in each group was invited to attend an educational pro-gramme
designed to help them teach other members of their group about HIV prevention.
Measures
Measures included the following:
Psychosocial scales: included measures of five AIDS-related issues: knowledge and miscon-
ceptions about AIDS, risk behaviour and risk reduction steps, safer-sex peer norms, atti-tudes
towards condom use and safer sex, strength of risk reduction behavioural intentions, and
perceived risk reduction self-efficacy.
L ifetime, past year, and past 3 months sexual risk behaviour: Participants reported how many
times they had intercourse, and how many of these acts were condom-protected.
Communication with friends about AIDS-related topics in the past 3 months.
Social network leader training intervention
Each social network leader attended a group training programme in which they learned how to
communicate HIV prevention messages and personal risk reduction advice to their network
members. The intervention involved five weekly group sessions, with four booster sessions over
the next 3 months. They were asked to incorporate HIV prevention messages into natu-rally
occurring conversations and to tailor messages to the particular risk issues of each friend.
Results
Network leaders attended an average of eight of the nine group sessions. Talk about AIDS with
friends nearly doubled (from a mean of 3.5 times at baseline to 6.1 times at follow-up) among
experimental network members but fell among control group members.
continued
CHAPTER 7 • POPULATIONAPPROACHEST OPUBLICHEALTH
Baseline to 3 -month follow-up outcomes: the intervention group evidenced significant increases dalam
pengetahuan AIDS risiko, norma rekan seks yang lebih aman, dan niat pengurangan risiko. Secara
keseluruhan, mem-bers jaringan eksperimental kurang mungkin untuk terlibat dalam hubungan seks tanpa
kondom dengan wanita, bukan pria. Lebih semangat, pria dengan pasangan berganda dalam kondisi
intervensi melaporkan tingkat yang lebih rendah dari hubungan seksual tanpa pelindung dan tingkat yang
lebih tinggi dari penggunaan kondom.
Dasar untuk 1 2 -month hasilpemeliharaan:Perbedaan antara kondisi menjadi atten-uated pada titik waktu
ini. Namun demikian, peserta dalam kondisi intervensi kurang mungkin untuk terlibat dalam hubungan
seks tanpa kondom, meskipun perbedaannya tidak begitu besar seperti pada 3 bulan follow-up. Efek
intervensi terkuat yang ditemukan di antara peserta yang memiliki beberapa mitra di tiga bulan
sebelumnya. Mereka pada kelompok intervensi melaporkan episode kurang dari hubungan seks tanpa
kondom daripada di kondisi kontrol.
Diskusi
Makalah ini adalah yang pertama dari Eropa Timur untuk menggambarkan hasil dari intervensi jaringan
sosial yang bertujuan untuk pengurangan perilaku seksual berisiko. Data menunjukkan bahwa pemimpin
kelompok bersedia dan mampu memberikan informasi pencegahan terkait AIDS dan saran. Satu tahun
pada dari intervensi, ada bukti mengurangi perilaku berisiko, particu-larly antara peserta yang memiliki
banyak pasangan seksual. Hal ini memberikan dorongan untuk lebih menggunakan jenis intervensi -
mungkin dengan biaya-manfaat, ekonomi, analisis untuk menghalangi-tambang apakah itu tidak hanya
efektif, tetapi juga biaya yang efektif. Satu peringatan metodologis penulis dicatat adalah bahwa seperti
banyak penelitian perilaku seksual, penelitian ini mengandalkan laporan diri peserta dari perilaku mereka,
berpotensi rentan untuk mengingat kesalahan dan presentasi diri Bias. Perubahan dalam jaringan kelompok
kontrol pada akhir follow-up menunjukkan kemungkinan bahwa rinci dan berulang-ulang penilaian risiko
perilaku mungkin telah menghasilkan efek reaktif dan perilaku juga dipengaruhi.