Community-Based Health Promotion

Health is having quality of life in the physical, emotional, social, cognitive, and spiritual realms. The diseases that pose the most threat to achieving that quality of life are cardiovascular diseases, cancer, and diabetes. The factors that contribute to these diseases are integrally intertwined with the community and deeply connected to culture. Poverty, inadequate education, crime, and unemployment weaken the community, and these factors are associated with a higher prevalence of disease and higher mortality rates from diseases. The human and economic costs affect everyone, and these costs are soaring.

Yet, the factors that exacerbate disease are preventable or modifiable. Some factors are personal habits: smoking and chewing tobacco, overeating, sedentary lifestyles, and high consumption of polyunsaturated fats and sugars. Some factors are contextual: school-based soda vending machines, limited and overpriced healthy food choices in inner-city grocery stores or the lack of grocery stores in inner-city neighborhoods, unsafe streets that make walking dangerous, lack of adequate exercise facilities in rural areas, discriminatory practices toward minorities within the medical system, and the lack of insurance coverage for early detection of disease. Others emerge from culture-bound beliefs that inhibit health behavior change: language barriers, lack of engagement in preventive health practices, fatalism, use of emergency rooms as primary care facilities, inability to meld the medical system to the cultural beliefs of minorities, and attitudes toward certain behaviors, such as the link between smoking and status within a subculture.

Some community factors can be changed through advocacy efforts and community awareness. For example, many school systems in America are introducing higher nutrition standards for their lunch programs. The personal factors can be changed through personally engaging interventions and community support. Efforts, however, must be stepped up to develop and test culturally sensitive strategies for health promotion. Community health promotion is proceeding along two directions. One direction is toward more individualized interventions; the other toward reaching greater numbers of people, specifically, the underserved and minorities. The challenge we face today is their integration: accomplishing a wider reach while individualizing interventions to improve effectiveness.

The diseases that carry the highest costs are caused or exacerbated by poor diet, obesity, and smoking. Therefore, this entry synthesizes the research on those practices that are likely to have the greatest impact on health.

Smoking Cessation

Although social policy changes and media campaigns have reduced the rate of smoking in subsets of the population, smoking remains the single most preventable cause of serious illness. Despite tremendous efforts to develop and test efficacious smoking cessation treatments, only 10% to 28% of smokers achieve long-term cessation. Most treatments have been aimed at higher socioeconomic levels, yet smoking is more prevalent among those with low socioeconomic status. African Americans have higher rates of smoking, experience higher rates of tobacco-related diseases and at younger ages, and are less likely to receive physician recommendations to quit, and existing cessation programs do not address the differing beliefs, motivations, and patterns of smoking in minority populations.

At this juncture, successful treatment is too costly, impractical, and ineffective for widespread application. Community-based and workplace interventions have been shown to have limited effectiveness. However, these interventions typically focused on multiple behaviors rather than smoking alone. Low-intensity interventions such as physician reminders can affect the rate of smoking by raising awareness and educating smokers, but they have fallen short of causing successful long-term abstinence. Those treatments that have been successful combine pharmacological components, counseling, education, and follow-up contacts. Most people relapse within the first week of quitting. Therefore, counseling interventions must be front-loaded, providing numerous contacts within the first week. Individual counseling, including problem solving and skills training tailored to idiosyncratic smoking triggers, along with assistance in obtaining social support, increase sustained abstinence. Proactive follow-up by the provider also increases success rates.

Several conclusions can be drawn from the research on smoking cessation interventions. First, multicomponent treatment, including counseling, follow-up, education, and nicotine replacement therapy (NRT) is most effective. Second, NRT improves success rates when combined with other treatments; however, the reported effectiveness of NRT has diminished in studies conducted since drugs for NRT became available over the counter, from an average of 45% to 9%, which is only 2% better than self-treatment. Third, tailoring the intervention to the stage of change leads to higher abstinence rates and improves relapse prevention. Fourth, traditional counseling approaches alone, such as cognitive-behavioral mood management, do not boost the efficacy of a multicomponent treatment program. However, applications of specific counseling interventions are beginning to show promising results. These include motivational interviewing, treatment matching to degree of dependence, contingency management, and community reinforcement. Fifth, the creative use of technology is a promising method to reach more smokers and intervene in real-life situations. One example is the use of text-messaging reinforcers on cell phones and computer-tailored smoking cessation programs.

Obesity

Over two thirds of Americans are either overweight or obese, costing $117 billion in tax dollars and life years lost. In the United States, minorities including Hispanics, African Americans, and Native Americans are particularly affected. Obesity is a factor in diabetes, coronary artery disease, hypertension, degenerative joint disease, gallbladder disease, and certain cancers.

Weight reduction—whether pharmacologic, surgical, or behavioral—seeks to alter energy balance. Obesity treatments focusing on altering dietary intake result in 3% to 10% weight loss, but dropout rates average 58%, and fewer than 5% keep the weight off. The most promising treatments are behavioral, resulting in 5% to 20% weight loss and dropout rates of 20%; however, most people benefiting from these treatments return to baseline weight within 5 years. Not only is such nebulous success questionable, but gain-and-loss cycling is actually dangerous.

Behavioral treatments have been the most studied and provide the fewest barriers to implementation in a community setting. The goal of behavioral treatment is to help obese patients identify and modify eating, activity, and thinking habits that contribute to their excess weight and typically yield a 10% reduction in body weight during the first 6 months. Self-monitoring (i.e., keeping records of food intake) is the strongest correlate with weight loss in both short-term (12 weeks) and long-term (17 months) studies. Studies conducted over the past decade indicate that continued contact between the patient and the practitioner significantly enhances weight maintenance, and without continued contact, patients generally regain one third of this weight within 1 year.

Perhaps due to the ineffectiveness of most dieting interventions, nondieting and size acceptance build a foundation for a healthy lifestyle of exercise and healthy eating. In uncontrolled trials, the lifestyle approach has resulted in significant improvements in self-esteem, mood, and eating-related psychopathology, and these gains have been maintained for up to 2 years. Some studies show weight loss; others, weight gain.

The addition of individual behavioral counseling to the nondieting approach resulted in significant weight loss in morbidly obese women and as adjunctive therapy. In a study comparing CBT and size acceptance versus CBT and a diet-driven program, obese women in both groups demonstrated significant but modest weight loss, psychological improvement, low dropout rates, and cardiovascular improvements. Self-monitoring, stimulus control, cognitive restructuring, problem solving, goal setting, positive reinforcement, relapse prevention, nutrition education, and coping strategies for healthy eating were used in this multicomponent intervention. Promoting physical satisfaction resulted in improved weight loss maintenance. Psychological improvement in mood and self-esteem is instrumental in maintaining weight loss, and coping distinguishes dietary temptations from dietary relapses. Strategies that result in enhancing restraint are the most effective in weight loss maintenance.

Not every person requires all the components of a multicomponent intervention, and using a stepped-up approach that matches treatment intensity to the patient’s need is more cost-effective. Motivational interviewing techniques decrease dropout rates from weight loss programs.

The majority of interventions have been individual due to the fact that community interventions lack the intensity required for weight loss and maintenance, yet community efforts, such as faith-based programs, have been used most with minority populations. Tailoring interventions to the culture is essential.

Sedentary Lifestyle

The lack of physical activity is implicated in the four leading causes of death in the United States: heart disease, stroke, cancer, and diabetes. While television and electronic media constantly flood the public with promotional offers of gym memberships and popular articles on the vital role exercise plays in physical health and mental well-being, according to the American Heart Association, as of 2006, more than 24% of Americans were completely sedentary. In 2004, Americans spent more time watching television and movies than on sports and any other leisure-time physical activity combined. A recent survey by the American College of Sports Medicine found that 50% of Americans who commenced exercising in the past year have discontinued exercise.

Efforts to increase physical activity levels of Americans have been moderately successful. Those demonstrated to be effective are often time- and labor-intensive and require attendance at an exercise center, expensive equipment, and competent staff supervision. Consequently, there is a need for efficient and cost-effective methods for increasing physical activity for a diverse population within the United States. The Centers for Disease Control and Prevention notes that educational efforts alone have been ineffective in changing health behavior.

Many of the exercise interventions have been conducted with community groups; however, it would be misleading to suggest that the interventions are homogeneous. Most are tailored to different levels of motivation, physical condition, and cultural background. Tailored messages are based on the assumption that people respond differently to message presentation based on personal characteristics. Studies using tailored messages resulted in significant improvement in various health behaviors, ranging from 74% in improving health behaviors to 91% in intent to improve.

Interventions accommodating individual stages of change have resulted in increased exercise and long-term maintenance. Results of tailored-message outcome studies resulted in better health outcomes in both White and minority populations. Studies on ethnic minorities suggest that not only should material be culturally sensitive, but it should also be individually focused in order to have a greater impact. Several factors have emerged as predictors of adherence to an exercise program in ethnic minority communities; these include age, weekly caloric expenditure incurred from doing yard work, and a sense of community affiliation as well as preexisting level of fitness and concerns about health.

Behavior-based interventions in exercise adherence have produced mixed results and seem to be more efficacious when combined with financial incentives, telephone and e-mail reminders, and personal trainers. However, behavior-based interventions have been successful at isolating predictors of long-term adherence, such as higher existing fitness levels, perceived stress, lower education, life events, body mass index, exercise program format, cognitive functioning, and male gender.

Yet, change in exercise occurred in less than 20% of the participants, and the changes rarely reached significance. There is some evidence that control is an important issue in adherence to an exercise program. Researchers found that patients’ attitudes and perceived behavior control provide the strongest influence on adherence when participation was more volitional, during the latter part of a cardiac rehabilitation process, as opposed to when their participation was more compulsory, during the earlier part of the rehab program. Furthermore, self-monitoring often produces dramatic results. Telephone counseling has been shown to increase adoption of physical activity, while both telephone and “snail mail” have been shown to be effective in maintaining exercise adherence in older adults, and telephone and e-mail reminders have been shown to be effective in maintenance of physical activity. Self-efficacy has also been shown to improve exercise adherence.

Among the more promising efforts to improve exercise in the community are those that use technology. Computerized interventions are effective for increasing physical activity through self-monitoring and reporting. Using e-mail reminders increased adherence to a walking program to increase physical activity and make small, cumulative changes in food choices. At the 12-month follow-up point, Internet participants had increased daily steps by 2,021 over the baseline, while control participants had decreased steps per day by 38. In another study on rural Caucasians and inner city African Americans, those who used the system more frequently increased exercise significantly and demonstrated greater exercise capacity after 8 months. Yet another study, which examined the effects of music, television, and combined entertainment on exercise adherence, showed that a distraction through entertainment from the physical discomfort of exercise tended to foster adherence.

Whereas a sedentary lifestyle remains problematic and posits great health risks to the American population, emerging trends in behavioral medicine suggest that the utilization of individually tailored messages, communication technology such as telephones and e-mail, and cultural considerations that take into account the ethnic, religious, and racial background of the participants can contribute to the overall health and wellness of the American population. When coupled with psychoeducational interventions, community support, and behaviorally based interventions that target health beliefs and self-efficacy, these multifaceted interventions have the potential to improve health across all of its dimensions.

Healthy People 2010 challenges Americans to reduce lifestyle-related diseases. This is a formidable task. Despite a concerted search for solutions to the problems of adherence and maintenance of exercise, weight loss, and smoking cessation, the epidemic continues. Data from numerous studies consistently indicate that efforts must be made on all fronts—individual, social group, and community—in order to reach this goal.

References:

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