fea Nae Preventing health problems g ~] rH] = “J = a] rs = = ~ 4 oy = e = = Se > c Ss i = a ry ryOBJECTIVES By the end of the chapter you should have an understanding of the effectiveness of the following approaches to changing health damaging behaviours: - Individually based interventions including risk factor screening programmes, motivational interview-based interventions, and problem- focused approaches - Using the mass media, including information framing, population targeting and the use of fear - environmental interventions, including increasing cues to action, minimising the costs of healthy behaviour and increasing the costs of unhealthy behaviour - Public health programmes focusing on reducing risk for coronary heart disease and increasing safer sex - Worksite public health - School-based interventions - Using new technologiesCONTENTS 1. Working with individuals 2. Mass persuasion through the media 3. Environmental interventions 4. Public health programmes 5. Using technologyWorking with individuals Providing health information Simplest way to motivate and facilitate behaviour change = informing people of their risk of disease — knowledge will evoke behaviour e.g screening for coronary heart disease (CHD) following high cholesterol levels.Working with individuals Risk factor screening programmes - Early screening programmes = very general, 1994 OXCHECK developed a programme which offered all adults participating in primary care a ‘health check’ which identified risk behaviours and were required to be followed up with advice to change. Small changes were seen but not enough and on a too small scale. - Now more specific ones are used e.g. direct advice from your doctor to stop smoking. TTWorking with individuals Motivational interviewing - More sophisticated approach to triggering behaviour change particularly for those with low motivation. - Initially used for substance abuse. - Now used more generally - fruit and veg consumption etc - Increasing effectiveness of motivational interviewing = integrate it within more complex programmes of change.Working with individuals Problem focused approaches - More effective than simply providing information. - More complex intervention addressing behaviour through: motivational interviewing + problem focused counselling + taken through real life examples = most effective.Working with individuals Problem focused approaches — Studies have found that anxiety is a prominent predictor as to why people don't go and get screened. - The only way to combat this is educating on anxiety management skills and further insight into what happens at screenings. E.g a coping booklet with info about the experience of the procedure, likely outcomes of procedure and relaxation techniques.Mass persuasion through the media - Public health initiatives targeted at whole populations. - First one used a hypodermic model of behaviour change, assuming a stable link between knowledge, attitudes and behaviour — ‘inject’ appropriate info to recipients, then their attitude would change and in turn influence their behaviour. Key to success was thought to be making it persuasive + from good sources.Mass persuasion through the media - Crosby et al. (2019), for example, revealed the questions asked in the planning process of a series of advertisements targeted at young smokers. - Despite this being published in a high impact health journal, while reading the list, note the absence of any clear link to psychological theory and practice: TT 4Mass persuasion through the media Will this be unexpected? Does the advert incontrovertible scientific data to support its message? include Does the advert address the problem in a novel manner? Is the message likely to surprise recipients? Does the intervention involve the innovative use of technology and/or media? Will this make young people stop and think? Does the intervention involve a new insight into the issue? Will this elicit an emotional reaction? Is the planned intervention likely to elicit a powerful emotional reaction? Is the idea so compelling that a young person will bring it to mind when they are offered a cigarette? Is the idea so compelling that a young person will bring it to mind when they are offered a cigarette? Will it be memorable? __ TT 7 7Mass persuasion through the media Will the planned programme elicit feelings of health threat, disgust, or guilt in the moment of smoking? Will it make young smokers rethink whether the immediate pleasure of smoking is worth its long-term health costs? Is there immediacy to the message? Does this execution make the health consequence feel more tangible, more contemporary, and more urgent? Could the ideas in the message be so relevant that they change how young people think, be parodied in other contexts or even become integrated into young people's idiom? Could it change social norms? Will young people reject the message on the grounds that bad things only happen to adults or long-term smokers? _ I 7Mass persuasion through the media Using the mass media Central route Peripheral route Figure. The elaboration likedhood model of persuasive communication _ TT 7 3Mass persuasion through the media Using the mass media - However... What is persuasive for each person? Different people trust different sources - One study attempted to increase walking exercise in scotland but to no avail - had no influence on 70% of people - Some argue that media campaigns are best used to raise awareness of health issues rather than attempt to engender significant behavioural change _ TT 7 7Mass persuasion through the media Using the mass media - Behavioural change is most likely when media campaigns form one element of a multimodal intervention or when the target behaviour is a one-off or episodic behaviour, such as attending a vaccination or screening clinic - Cumulative effects of repeated media campaigns may influence attitudes and behaviour _ TT 7Mass persuasion through the media Using the mass media - Those involved in using the media to influence behaviour have adopted a number of methods to maximise its effectiveness, including: + Refining communication to maximise its influence on attitudes; + The use of fear messages; + Information framing; + Specific targeting of interventions _ a T 6Mass persuasion through the media Refining the message - Majority of tests testing the elaboration likelihood model have shown that information containing carefully chosen peripheral cues can facilitate attitudinal change in people who are relatively unmotivated to consider particular issues, or that combining central processing with peripheral cues can enhance the effectiveness of some interventions _ TT 7Mass persuasion through the media Refining the message - The real limitation of the ELM and other models of attitude change is that although they can suggest means of maximising attitudinal change, many other factors will influence whether any attitudinal change or even behavioural intentions are translated into action _ TT 7 3Mass persuasion through the media The use of fear - Interventions based entirely on fear arousal are likely to be of little benefit. - Studies have found that using high fear m messages targeting aids prevention and safe sex practises found that althoufh the campaigns increased HIV-related anxiety in audiences who witnessed them, they didnt increase knowledge nor triggered any behavioural change. - If fear messages are used, they need to be accompanied with simple, easily accessible strategies of reducing the fear. E.g. warnings of risk for skin cancer on Australian beaches being accompanied by access to free sunscreen. TTT |Mass persuasion through the media Teaching coping strategies - One of the barriers to attending screening for risk of disease is concern about its outcome: ‘What will be found? Do I really want to know’? - Fear may both prevent people engaging in screening programmes and be an outcome of them, even when participants are found to carry no or low additional risk of disease. TTMass persuasion through the media Teaching coping strategies Marteau et al. (1996) considered the very specific impact of two booklets given to women referred for colposcopy following an abnormal cervical smear: 1. A medical information booklet provided details on the nature of cervical abnormalities, the procedure and its likely outcomes than the standard information booklet. However, it did not suggest any coping strategies that the women might use. 2. A coping booklet provided brief information about the procedure they were about to experience, information on the likely outcomes of the procedure, and instructions on relaxation and distraction techniques they could use to help them to cope before and during the procedure. — T/T 7Mass persuasion through the media Informational framing - More neutral approach - Either positive or negative outcomes emphasised - When time is short and people aren't motivated to change themselves, positive messages enhance information processing _ TT 7Mass persuasion through the media Informational framing - Evidence is very conflicted about which is better for what - one study found 40% people more likely to get HPV vaccinated if message was positive while one study found that negatively framed messages were more likely than positively framed messages to increase intentions of young women to have the human papillomavirus vaccine — but only among those who had multiple sexual partners and who infrequently used condoms. _ TT 7 3Mass persuasion through the media Informational framing - Overall, these data suggest that we can make no strong a priori judgements about what type of framing will affect particular populations _— TT 1Mass persuasion through the media Audience targeting - Audience targeting can be based on a number of factors, including: Three pricks. + Behaviour Why one + Age just isn’t enough. + Gender + Socioeconomic status 4 4 & each of which is likely to influence the impact of any message. Apes B information fr gry mem - Audiences may also be segmented along more —_ Me? nnwys.daneunronin at wont psychological factors such as their motivation to consider change. | T/TEnvironmental interventions - The health belief model provides a simple guide to key environmental factors that can be influenced in order to encourage behavioural change. - The model suggests that an environment that encourages healthy behaviour should: + Provide cues to action or remove cues to unhealthy behaviour; + Enable healthy behaviour by minimising the costs and barriers associated with it; + Maximise the costs of engaging in health-damaging behaviour . | TTEnvironmental interventions Cues to action - E.g. health warnings on cigarettes and nutritional information on food - May be of some benefit, although the evidence suggests that they reinforce existing behaviour rather than prompt consideration of behavioural change - Partially due to poor understanding of the issues raised and/or the low visibility of such cues _ TT 7Environmental interventions Cues to action - Cues reminding people to engage in health-promoting behaviours may also be of value. One simple example can be found in posters reminding people to use stairs instead of lifts or escalators - UK banned cigarette commercials in an attempt to reduce smoking TT 2Environmental interventions Minimising the costs of healthy behaviour - The environment in which we live can either facilitate or inhibit our level of engagement in health-related behavior. - E.g, poor street lighting, pollution, busy roads etc inhibit people from exercising outside. - Down to governmental legislation and town planning e.g shops that sell healthy food near housing estates - not just chip shops etc TTEnvironmental interventions Minimising the costs of healthy behaviour - Accessibility to tracks, sports equipment, gym classes etc all increase healthy behavioural change but not relaitistly possible to for example lower all prices of gym memberships. - Cycle lanes and more green space increase exercise levels but only modestly. - Another area is needle exchanges where addicts can exchange old needles and get new ones reducing the risk of cross-infection of bloodborne viruses, including HIV and hepatitis. _ TT 5Environmental interventions Increasing costs of unhealthy behaviour - Economic measures related to public health have been largely confined to taxation on tobacco and alcohol. - A more moderate approach = restricting the number of outlets for drugs such as alcohol - reduced nightclubs, bars etc as people have to travel further to them = less likely to go + less advertisements n shop windows BUT there was no association between outlet density and frequency of ‘sensible’ drinking. - A more direct form of control over smoking has been the introduction of smoke-free work and social areas. _ TT 7Public health programmes Community intervention programmes Stanford Three Towns project - One of the first public health 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. _ TT 3 5Public health programmes Community intervention programmes Stanford Three Towns project - 1s town received no intervention, 2" = year long media campaign targeting CHD relating behaviour (similar to stages of change model): + Started by alerting people to the need to change their behaviour, followed by a series of programmes modelling behaviour change - these were based on social learning theory 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. TT 3 3Public health programmes Community intervention programmes Stanford Three Towns project - 3 town this media intervention was targeted at a group of individuals at particularly high risk of developing CHD and their partners: + Received one-to-one education on risk behaviour change and were asked to disseminate their knowledge through their social networks _ TT 7Public health programmes Community intervention programmes Stanford Three Towns project The expected outcomes were found - by the end of the one-year programme, + Scores on a measure of CHD-risk status based on factors including blood pressure + Smoking and cholesterol level indicated that average risk scores among the general population rose in the control town + Fell among the general population who received the media campaign alone, and fell to an even more among those who lived in the town that received the combined intervention. _ TT 3Public health programmes Community intervention programmes Stanford Three Towns project - After a further year, risk scores in the intervention towns were still significantly lower than those of the control town, although because scores in the media-only town continued to improve + Ultimately there was no difference between the scores of the two intervention towns. _ TT 3 6Public health programmes Community intervention programmes - European equivalent = 5-year programme in Finland, in addition to media approach they also changed environmental factors e.g. local meat manufacturers and butchers to promote low-fat products, encouraging ‘no smoking’ restaurants, and so on. - It was generally considered to be a success, with reductions in a number of risk factors including blood pressure, cholesterol levels and smoking among men. BUT findings were less significant, showing reductions in risk factors were not consistently better than those in a control area. _ TT 7Public health programmes Community intervention programmes USA: The Minnesota Heart Health programme used the mass media to promote awareness and to reinforce other educational approaches. The programme had surprisingly little impact on health and health behaviourPublic health programmes Community intervention programmes Five-year Heartbeat Wales programme - Programme combined health education via the media with health screening and environmental changes designed to promote behavioural change. - “Control areas’ received whatever was local health education programmes being conducted at time. - Food labelling, exercise trails, no smoking areas in restaurants etc. TTT 3 5Public health programmes Community intervention programmes Five-year Heartbeat Wales programme: - Food labelling, exercise trails, no smoking areas in restaurants etc - 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 — this was due to a number of factors e.g food labelling spreading out across whole of UK at the same time, media had an ongoing conversation about CHD already etc. _ TTPublic health programmes Community intervention programmes Level Examples of interventions Individual Social environment - Establishing health-related messages through a range of media and other channels; - Making utensils necessary for healthy lifestyle available: including salt spoons and oil pots; - Providing free health screening and risk assessments for cardiovascular disease; - Providing fitness testing; - Encouraging health professionals to screen for risk and to provide (behavioural) prescriptions for health; - Starting social exercise groups such as walking clubs; - Encouraging dialogue between parents and children promoting healthy lifestyle; _—— 4 3Public health programmes Level Community intervention programmes Examples of interventions Physical environment Policy environment - Implementing smoke-free worksite environments; - Instituting smoking bans in public areas; - Using prompts to increase use of stairs and avoiding escalators/lifts; - Building walking trails with distance markers in easy walking contexts - Establishing a public bicycle service system; - Providing healthy eating choices in restaurants and workplace cafeteria; - Making food content and calorie information available to consumers in restaurants and other public eating areas; Smoke control regulation in public places Engagement with the WHO healthy city movement 3Public health programmes Reducing risk of HIV infection - More successful interventions than CHD ones. - Positive outcomes have been attributed to an approach called peer education - used worldwide; opinion leaders and other key players within specific communities are involved in projects and form a key part of the programme. - Draws upon social learning and diffusion theory. _ 7 3Public health programmes Reducing risk of HIV infection - Using people known and respected within a particular community makes their message salient and shows that appropriate change can be achieved. - This type of approach = crucial factor difference between HIV and CHD interventions. - Another difference = CHD being a developing over time thing, where as HIV is a one time only situation.Public health programmes Worksite public health - Way of dealing with the problems from large-scale interventions = target smaller, more easily accessible ‘controllable’ groups. - One of these examples = public health programmes in workplace: Majority conducted in USA perhaps because enhancing the health of the workforce reduces the cost of workers’ health insurance, often paid by the employer, and therefore benefits the company as well as the individuals in it. _ VV! 4Public health programmes Worksite public health One of these examples = public health programmes in workplace: - Targeted a range of health problems e.g diet, exercise, smoking, stress, using a variety of approaches: + Screening for risk factors for disease + Providing health education + Provision of healthy options, such as healthy food in eating areas + Providing economic incentives for risk behaviour change + Manipulating social support to facilitate individual risk behaviour change + Provision of no-smoking areas in the work environment _ TTY 6Public health programmes Worksite public health Mujtaba and Cavico (2013): outlined a range of interventions that have been applied in the workplace, categories ‘carrot’ or ‘stick’, carrots included: (i) providing gyms at work and/or free gym membership (ii) providing low-fat meals in the cafeteria, or (iii) making employer contributions to health insurance etc. _ 4Public health programmes Worksite public health Mujtaba and Cavico (2013): Sticks include: (i) higher health-care insurance premiums for unhealthy employees, (ii) increasing ‘deductibles’ for employees with unhealthy lifestyles who fail to meet health-care standards, and (iii) not hiring job applicants who are smokers, overweight or otherwise unhealthy _ TTY 9Public health programmes School-based interventions Perhaps the simplest intervention involves providing information on the nutritional and calorific content of food provided in dining areas. Providing free fruit/ veg = regular exposure increases consumption and encourages a taste preference for fruit Yc Photo 7.3 Attractive healthy food served inthe workplace can increase healthy eating ratesPublic health programmes School-based interventions WHO health-promoting schools initiative: - Schools should prioritise the health of their pupils and develop an integrated approach to enhancing health, preventing uptake of unhealthy behaviour and educating pupils about health-promoting activities - "Healthy policies”, such as a “no helmet, no bike at school” policy for cycle safety or an Australian ‘no hat, no play’ policy (to avoid sunburn), as well as more traditional policies such as no smoking on school premises and no tolerance of bullying _ TTSPublic health programmes School-based interventions WHO health-promoting schools initiative: - Establishing a safe, healthy physical and social environment - Teaching health-related skills - Providing adequate health services within the school - Providing healthy food || 3Public health programmes School-based interventions WHO health-promoting schools initiative: - School-site health-promotion programmes for staff - Availability of school counselling or psychology programmes - Aschool physical education programme S|Public health programmes School-based interventions - Only moderate success as too complex and limited uptake and implementation in schools - Effective sex education provides a powerful influence on sexual behaviour. - Countries where sex education is central to the curriculum, starts early and focuses on the social as well as physical aspects of sexual relations have lower unwanted pregnancy rates than countries where the sex education is less central and starts later in the academic curriculum - UK teaches it late in curriculum and not compulsory yet has highest rate of unwanted teenage pregnancy |S 3Public health programmes School-based interventions Peer education - Training influential pupils in a school about a particular health issue such as smoking, alcohol consumption or HIV education and encouraging them to educate their peers about the issues, hopefully in a way that encourages healthy behavior |_| S 7Public health programmes School-based interventions Using new technology - Internet based interventions + Pros: reach in terms of the number of people they can potentially access and effectiveness, flexibility, accessible - Texting + Pros: reminders, prompts and info for change, effective, personalised - BUT CONS: easy to ignore, relies on self help | TPublic health programmes School-based interventions Using new technology - Research focus: + Using facebook to enhance physical activity among young women. + Participants allocated to 2 conditions: self-monitoring and education, and self-monitoring and education plus membership of facebook exercise support group. + Participants in both conditions significantly increased exercise but no difference between both groups - was suggested that facebook doesn’t offer the necessary levels of social support. __ TT 6Summary 1. Risk factor screening may be of benefit to some individuals, but has not consistently been found to reduce risk for disease. And it may contribute to health anxieties 2. Motivational interviewing may be more beneficial in both motivating and maintaining health behavior change, although its impact is not guaranteed 3. Problem-focused approaches are significantly more effective than those that simply provide health informationSummary 4. Screening for health risk can result in significant anxieties. For some individuals, these may be alleviated by teaching simple coping strategies 5. Simple media campaigns have proven of little benefit in achieving behavioural change. Augmentation through refining communication based on theories such as the elaboration likelihood model, combing fear and fear reduction messages, appropriate information framing, and audience segmentation may be of benefitSummary 6. Environmental interventions may also be of benefit. These may provide cues to action or remove cues to unhealthy behaviour; enable healthy behaviour by minimising the costs and barriers associated with it; or maximise the costs of engaging in health-damaging behaviour. 7. Traditional CHD prevention programmes have achieved only modest health gains in the population targeted unless aimed at relatively naive populations. 8. Peer led interventions have proven more successful across a range of behaviours. 9. The worksite offers a key environment to foster and facilitate health behaviour change. Ce )THANK YOU FOR YOUR ATTENTION ! 60