Archive for the ‘Interventions’ Category

Public Health Approaches to Large Scale Behavioral Change

Monday, June 18th, 2012

Promoting Active Environments:  A Public Health Approach to Large-Scale Behavioral Change

Background

             The public health profession has developed theories and methodologies to promote behavior change on both the individual and population level. From reducing tobacco use to encouraging seat belt acceptance, many behavioral change campaigns have been successful.  This paper suggests ways these theories and methodologies could be used to create large-scale, nationwide change to promote active living.

Active living environments is used here to mean communities that foster walking, biking, and public transportation through mixed use, compact and dense development forms, and transportation systems that reduce car use. The alternative is conventional development: large lot zoning, strict separation of land uses, and streets heavily engineered for cars.

Evidence suggests that active environments promote physical activity, reduce obesity, improve mental health, and strengthen social capital.  These may increase health and reduce morbidity and mortality.

 Objectives

             This analysis aims to provide the beginning of a discussion of what a broad public health campaign to promote the creation and use of active living environments might look like.

Objectives include:

Identify models of behavioral change that might assist policy makers and advocates to promote active living environments with an emphasis on families with children and communities of color.

  •  Encourage efforts to change social norms that prioritize active communities.
  • Propose strategies for advancing the preference for active living.

Two outcomes were prioritized:

 

  • Increase demand.  How might we encourage individuals and families to choose to live in active environments?

 

  • Increase supply. How might we encourage governments to implement changes to codes and development guidelines that would result in more active communities?

 

Methods

 

This analysis included a scan of the public health literature on promoting behavior change.  In addition to broad theoretical models of change, it drew on experiences including reducing tobacco use as models for promoting change at both the individual and community level.

 

Results

 

Traditionally, public health has focused on promoting behavioral change on the intrapersonal, interpersonal, and population level.  All these levels must be addressed if we are to increase both the supply of and demand for active environments.  Specific examples include:

 

Intrapersonal Level. Health belief models of change suggest that public health efforts include working with individuals and families to help them understand that by living in active environments, they can increase physical activity and reduce obesity risk. Thus they should be educated regarding the ways that conventional environments can pose barriers to health, particularly for children, and that health may improve by living in active environments. These campaigns should utilize planned behavior theory and encourage changes in attitudes toward living in active environments, increase perceptions that moving to these environments would mean adopting new social norms that prioritize active living, demonstrate that families with children have the ability to live in these communities in ways that would enhance their health and well being, and identify specific neighborhood attribute choices that would promote health.  Stages of change theory suggest encouraging families to the point where they contemplate moving to an active environment and then help them make that move (a priority target would be people of color most at risk for obesity).  It also suggests that strategies to help those who already live in active environments not to leave (perhaps targeting inner-city residents considering moves to the suburbs).

 

Intrapersonal Level. Social cognitive theory suggests that campaigns to promote active living environments should aim to change expectations regarding the kinds of neighborhoods people should live in (for example, currently many families believe that conventional neighborhoods are the only appropriate place for children).  It would communicate the idea that individuals and families have the ability to demand and choose healthy neighborhood designs. Social network theory suggests changing norms of behavior so that conventional environments are seen as less desirable.  At the same time, living in active communities would be promoted as more healthy.

Population Level.  Communication theory suggests that information campaigns are necessary so that the public understands the health consequences of conventional development with special outreach to linguistic minorities.  Diffusion of innovation models would imply the targeting of key individuals (particularly in minority communities) as the starting point in changing social norms and behavior.  Community mobilization experience demonstrates the need for planning, coalition building, and action.

 

Conclusions

             If we are to move towards having a sizable portion of the US (and other countries) living in active environments, then there is a need to initiate large scale attitude and behavioral change strategies. These initatives should include working with individuals to increase the number of people who desire to live in active environments and to develop a constituency that supports changes in zoning and development guidelines. On the community level, these strategies would have the ultimate goal of creating more opportunities for active living.  Together, they may move societies toward better health.

Do people know how bad commuting is for their health?

Thursday, October 21st, 2010

There has not been a lot of research on the health effects of commuting, unfortunate given that commuting is a major feature of most adults below retirement age.  Commuting, the day to day travel to and from one’s worksite (and most likely similar to going to and from school), has been shown to cause stress, increase exposure to pollutants, and pose a potential problem of accidents.  Studies by Novacco and others suggest that it is not just the time spent on commuting but also the unpredictability of a commute (when is there going to be an accident or train delay to mess up your schedule?) or the amount of impedance, badly timed signals, traffic congestion, etc.  Most likely it is those with lower paying jobs who suffer the worst effects of commuting because they have the added stress of not being able to control their workplace conditions.  They can lose wages or their jobs if they are late.  Perhaps the only two things worse than commuting are unemployment or working at home – the social isolation is probably bad for one’s health as well.

Commutes are getting longer.  There are growing numbers of extreme commuters, people who spend over an hour traveling each way to and from work.  Why is this happening? One model of health risk behavior used by public health is that of health beliefs.  If people do not know or believe that something is bad for their health, they are more likely to do that behavior.  If people do not know or think that cigarettes are bad for them, they are more likely to smoke.  Thus one way to change behavior is to tell people something is a problem – hence warnings on cigarette packages and tobacco education programs.

So some people may choose to live far from their jobs because they don’t know that a long commute is bad for them.  They may think that the potential benefits of cheaper housing, larger yards, increased access to special amenities more than outweigh the time problem.  But they do not take into account the health implications because they do not know about them.

Thus there should be a public information campaign about the health problems of commuting.  Of course these leaves unresolved the issue of who would pay for a campaign.  It also points to the need for more research on commuting and health.

Behavioral norms can change

Thursday, June 10th, 2010

Sometimes students in my courses or audience members attending one of my presentations become discouraged by the difficulty in changing behaviors or social norms of the US public.  The task of persuading people to incorporate physical activity into daily living patterns or the public to value density and city living appear to be so enormous that there is a temptation to give up.  There is no way to get the public to change its ways.

But recent history suggests that there can be substantial change in social norms.  When I was a child, cars did not have seat belts.  Today, most adults use them and the use of special car seats for infants and children is the norm.   Indicative of these changes in social norms is  that most states now require car seats for children.   This change happened within a few decades.

Similarly, there was a major change in tobacco-related social norms.  When I was young, hostesses kept boxes of cigarettes available for guests’ use, many high schools had smoking areas, and people regularly smoked at work, home, restaurants and around children.  Today, while too high a percentage of people smoke in the United States, smoking behavior itself is highly frowned on.  Even in New Orleans, I noticed that many people stepped out of bars to light up despite that smoking is still allowed in bars.  Behavioral norms can change.

These kind of group or society-wide type of interventions are a major tool of  public health. Rather than accepting values, beliefs and behaviors as fixed, public health can seek to change them.  In contrast, though urban planners often try marketing of individual products and try to persuade the public or elected officials to adopt new ideas, they don’t, for the most part, try to modify the parameters in which they operate.  Could they?  Might they try to work with communities to drive less, adopt higher densities, or embrace mixed income development? Though these are skills that are not taught in planning school, they are not beyond their capacity.

Can we be physically active without walkable neighborhoods?

Thursday, April 22nd, 2010

A year or so ago, public health advocates were trying to boost a campaign to convince every US resident to walk 10,000 steps. The reasons for this campaign are obvious:  too many Americans are overweight or obese, too many are physically inactive or not getting enough physical activity.  But how easy is it to walk 10,000 steps in a day?  Thanks to the people at Active Living Research, I have a pedometer which I used for a couple of months to monitor my walking behavior.

How much do people walk now?  I’ve heard estimates as low as a mean of a quarter mile a day, or about 500 steps at 2.5 feet per step.  This seems way too low even for US physical activity, so I suspect the number refers to walking outside the home (probably reported from the National Household Transportation Survey).  Let’s give Americans the benefit of the doubt and say they are currently walking a mean of 2 miles a day, or about 4000 steps.  How are they going to get those other 6000 steps? This is about 3 miles, or given that people walk about 3 miles per hour, it means that they will need to spend an extra hour a day walking.  How is that going to happen?

Unfortunately, it isn’t going to happen at home, work or school. Most people live pretty sedentary lives and even if they boosted their physical activity while at these places by 25% – a huge increase, they would still be short about 5000 steps or 2.5 miles.  They will have only shaved 10 minutes off of that hour walking requirement.  Can they make it up after school/work? Well that’s an hour away from dinner, family time, sleeping, playing with the kids, updating their facebook accounts, watching television etc.  Not likely.

So they can only meet these extra steps by walking someplace, either to or from work/school or to and from some other destination.  And that is only going to be possible if their homes are within walking distance of suitable destinations and the streets are safe for walking.  I know this from my own experience with a pedometer. I only hit 10,000 steps on days I walked to work or walked around shopping or to my garden plot.  On days I had to drive, I did not make my walking quota.

This is an example of how well meaning health advocates can propose ineffective solutions when they ignore the proper level (looking at the individual level instead of the neighborhood level) at which these problems occur.  There may well be some physically inactive people who could walk to work/school or shop but don’t- these people could benefit from a campaign like the 10,000 steps program; but their number is most likely dwarfed by those who can’t walk to work/school because their worksite/school is too far to walk or it’s not safe to walk to these destinations.  There may be too much traffic, no sidewalks, an unsafe area, no street lights, etc.  The 10,000 program cannot motivate these people.  The correct level of action is to address the neighborhood, community, or metropolitan area environment.  This is where the problem originates and sets off a chain of causality that impacts people’s health.  Therefore this is where the problem needs to be addressed.