Psychosocial Interventions To Improve Successful Aging

The goal of research to understand the determinants of health is developing interventions to promote health and prevent disease. Several types of interventions are possible. One type consists of developing government policies and laws that influence health; another type involves medical or surgical treatments. Both types involve the behavior of people, but neither relies heavily on behavioral changes as the basis for implementation. This paper examines a third type of intervention, which requires that people change their behavior to lower disease risk. This type of psychosocial intervention is very difficult. Even when people know about their disease risk factors, they do not necessarily change their behavior to reduce that risk. Of course, many factors affect health. The availability and quality of medical care are clearly important. But, as McGinnis and Foege (1) note, perhaps more than 50% of the factors that influence health are due to behaviors such as cigarette smoking, eating and drinking habits, and exercise patterns. If differences in health are due, at least in part, to differences in behavior, intervention programs might be developed to help people change harmful behaviors. One component of such programs would be provision of information that helps people make such changes. If people knew, for example, that a particular behavior was injurious to their health, and if they were given advice on how to change that behavior, they might do so. Much money and effort have been expended on the basis of this rationale. While some psychosocial programs have been successful, the results have been overwhelmingly disappointing. Even when people have complete information about health risk factors, they do not often change behaviors to lower their risk. However, some people make important changes in behavior on their own, without formal intervention programs. For example, while many people quit cigarette smoking, most do so on their own, not in smoking cessation clinics. The information that psychosocial programs provide about smoking appears valuable, but this does not explain why some people can quit while others cannot (2). Intervention Programs Directed toward Individuals One of the most important intervention programs directed toward individualsthe Multiple Risk Factor Intervention Trial (MRFIT)shows the difficulty people have in changing behavior (3). That trial, begun in 1971 and ending in 1981, tried to reduce the death rate from coronary heart disease in the United States by getting men in the top 10% risk group to change the behavior that led to that risk. A massive screening of 361 662 men in 20 cities identified men at highest risk using high serum cholesterol levels, cigarette smoking, and high blood pressure as determinants. After three intensive screening examinations, 6428 men were selected and randomly assigned to intervention in MRFIT clinics; another 6438 men, chosen at random, were sent back to their own physicians with a report of their risk factors. The MRFIT participants were highly selected, highly motivated, and highly informed. Before randomization, these men were told about the following requirements: They had to agree to be randomly assigned to a MRFIT clinic or to their own physician. Those assigned to the clinic had to be willing to stop smoking, change their diet, take medication for high blood pressure, agree to come to the clinic once or twice a week during the early phases of the trial, bring family members when requested, and continue participation for 6 to 8 years. Participants were urged not to enter the trial if they had any doubts or reservations about these terms. In addition, staff psychologists rejected some volunteers because they thought these men might not be good participants. The MRFIT study cost $180 million (in 1980 dollars). It was probably the most intensive and expensive clinical trial ever developed to educate people and get them to change their behavior. The results were disappointing. Each clinic in the trial had a large staff of specially trained counselors who worked closely with each participant for the entire period; after 6 years, however, 65% of the participants were still smoking, only half of the participants with hypertension had their blood pressure under control, and few participants changed their diet. Men in the control group had very similar results (4). The MRFIT study exemplifies a long list of problems in promoting and maintaining change in an individual's behavior. Furthermore, even if all MRFIT participants had changed their behavior, new at-risk people would soon take their place because we rarely intervene on the fundamental forces in society that cause behavior-related health problems in the first place. Community Intervention Trials Relative inability to change individual behavior led many researchers to explore new and different intervention alternatives. One of the most interesting of these was development of community intervention programs rather than programs that focused on individuals. Researchers thought that if we cannot get individuals to change their behavior, perhaps we can succeed by changing the communities in which people live. Changes would involve community norms and values, laws and regulations, and the physical environment. These changes would, in turn, influence individual behavior. My colleagues and I developed one of these community-based intervention programs in Richmond, California. At the beginning of the project, we assessed smoking behavior and knowledge and attitudes about smoking in a random sample of residents living in a targeted area of Richmond. At the end of 5 years, we surveyed a random sample of people living in the area to assess changes in behavior, knowledge, and attitudes. Between the two assessments, we implemented an ambitious and intensive antismoking program. We worked with business and government leaders and identified a local captain on every block of the research area. At the urging of a large group of teenagers in the area, we agreed to help them make an antismoking video featuring their own dancers and musicians performing their own music. This video was shown in a large auditorium to a standing-room-only audience. Data from an extensive process evaluation study confirmed that each phase of the project was implemented effectively. Unfortunately, after 5 years of work, the smoking cessation results in Richmond were no better than cessation results in the two comparison cities (San Francisco and Oakland). We do not entirely understand why this carefully designed project failed. One possibility is that Richmond is a low-income community that has problems with unemployment, crime, drugs, severe air pollution from several nearby oil refineries, and an absence of community services. Cigarette smoking is very low on Richmond residents' list of priorities. Our research group descended upon them with a set of plans and priorities as if our problems were their problems. The children's video project, based on the children's initiative, may have been the most successful part of the intervention. Unfortunately, since our National Institutes of Healthsponsored project focused on adults and not children, and since this phase of the project was not part of the original plan, funds to evaluate the video project were not available. The nationwide Community Intervention Trial for Smoking Cessation (COMMIT) followed the same design as the Richmond project (5). This trial involved more than 10 000 heavy smokers in 11 intervention cities. A matched group of another 11 cities served as the control group. In the intervention cities, the goal was to create a social climate that did not support tobacco use. Efforts were made to implement smoke-free policies at work sites and elsewhere in the community, provide a newsletter and other information, and train people to become smoking counselors. At the end of this massive and ambitious nationwide trial, the quit rate among heavy smokers did not differ between the intervention and control communities. Approximately 18% quit in both communities. Among light to moderate smokers, 31% quit in the intervention cities while 28% quit in the control communities (5). This well-conducted study involved some of the best smoking cessation interventionists in the country. During the time of the MRFIT and COMMIT studies, three major coronary heart disease community intervention programs were also under way: the Stanford Five-City Coronary Heart Disease Project (6), the Minnesota Heart Health Program (7), and the Pawtucket (Rhode Island) Community Heart Health Program (8). These long-term trials involved intensive educational campaigns focused on coronary heart disease risk factors. Each was well designed and was implemented with skill and enthusiasm. Investigators have not yet reported morbidity and mortality data, but they have published their risk factor results. In Minnesota and Rhode Island, no differences were found between the intervention and control communities. Modest changes for two risk factors were seen in the Stanford study. Given the monumental effort involved in the studies, the results are disappointing. On the other hand, some community intervention programs have been successful. One of these took place in North Karelia, Finland (9). The North Karelia project was instituted as a result of demands from the community. These demands were based on a local newspaper report that North Karelia had the world's highest death rate from coronary heart disease. This article caused great consternation and prompted community leaders to demand that national public health authorities do something to help them. In other words, the priorities for intervention were established by the citizens, and not by public health professionals. An enthusiastic population warmly greeted the government team of investigators. The intervention itself focused on structural changes rather than just infor