Challenging Dogma - Fall 2008

Friday, December 12, 2008

CheckUp America: Problems with the ADA National Prevention Initiative and a Proposal for Social Science-Based Solutions – Juli Martha

Background: Type 2 Diabetes as a Public Health Concern
Diabetes is a chronic condition that accounts for a major portion of the worldwide disease burden. The prevalence of diabetes was estimated to be approximately 7% of the United States population in 2005, and this number appears to be rising (1). The complications resulting from poorly managed diabetes are both serious and costly. These complications can include heart disease and stroke, kidney disease, retinopathy, neuropathy, nerve damage and poor circulation (1). In the year 2007, it was estimated that the total annual cost of diabetes was $174 billion, which was a 32% increase in diabetes medical expenses from 2002 (2). Type 2 diabetes, which accounts for approximately 90% of diabetes nationwide, is unique in that it is, to a certain degree, preventable (2). Risk factors and warning signs for type 2 diabetes can be identified early on, and by taking appropriate preventative action, the costly complications of diabetes can often be avoided. Thus, it would appear that interventions that identify at-risk individuals early in life would have opportunities for great success in decreasing the prevalence of type 2 diabetes.
The CheckUp America Initiative: A national prevention effort
In an attempt to identify individuals who are at risk for type 2 diabetes before they have developed the clinical disease, the American Diabetes Association is launching a program called CheckUp America, whose mantra is to ‘Know your risk, Lower your risk For diabetes and heart disease’ (2). CheckUp America is a national prevention initiative with the goal of helping individuals understand the risk factors for type 2 diabetes, assess the presence of those risk factors in their own life, and then take small steps towards reducing their risk. The program is largely based around an online risk assessment tool that will be called My Health Advisor. This tool will help an individual to identify modifiable risk factors, such as body mass index (BMI), blood glucose, blood pressure, cholesterol, physical activity level and smoking habits and non-modifiable risk factors, such as age, race/ethnicity, gender and family history. This website will be directly accessible to the general public via the internet, and will also be referred to patients by their physician or health care professional.
The main idea that is driving this national initiative is that “understanding and managing your risk factors can help you avoid diabetes and heart disease and live a longer, better life.” (3). Additionally, the CheckUp America program refers to recent research that has shown that many people believe that the lifestyle chances that are necessary to reduce disease risk are “too hard.” According to CheckUp America, this simply means that individuals are “uninformed about the small steps that can be taken to reduce… disease risk. Thankfully, changes to improve health aren’t too hard- they just require a little knowledge and determination.” (3). That is, individuals continue to develop diabetes because they lack the knowledge necessary to take a few simple steps that would prevent the onset of type 2 diabetes.
CheckUp America and The Health Belief Model
While the research that lead to the development of the CheckUp America initiative is not explicitly outlined on the ADA website, it is clear that this program follows one of the oldest and most widely used health behavior modification models. This model is known as the Health Belief Model, and was first introduced by a team of social psychologists in the 1950’s (4). According to the health belief model, an individual rationally considers the balance between the costs and benefits of performing a particular health behavior. These considerations include his or her susceptibility to the health problem, the severity of the health problem, and the perceived barriers. These factors are then weight to determine the individual’s intention to perform the behavior and, according to this model, intention to perform a behavior directly results in performing that behavior.
According to CheckUp America, by providing an individual with more information about the risk factors for diabetes (susceptibility), the consequences of living with these risk factors (severity), and by convincing an individual that modifying these risk factors is easily done (barriers), that individual will intend to make lifestyle modifications to decrease their risk for type 2 diabetes. This intention will result in effective lifestyle modification, and the prevalence of type 2 diabetes should decrease! Unfortunately, health behavior modification is far from simple. Despite the fact that this and many other interventions based on the Health Belief Model currently exist, the prevalence of diabetes continues to rise. There are several key flaws in the assumptions made by the Health Belief Model and the CheckUp America initiative that must be addressed before an effective intervention is implemented.
The First Misconception: Diabetes prevention should target an individual
While the CheckUp America initiative is strengthened by the fact that it uses evidence-based research to inform its program, the way that this evidence is utilized is flawed. As has been described, the ADA refers to research studies which have shown that individuals fail to reduce their diabetes risk factors because they feel that the necessary lifestyle changes are too difficult. However, by immediately jumping to the Health Belief Model to attempt to modify this and increase the likelihood of making lifestyle changes, the program bypasses any sort of group-level intervention and focuses on the individual.
The Health Belief Model focuses solely on modifying an individual’s behavior by considering factors that are thought to be key in an individual’s decision-making process. However, so many of the factors that influence a person’s behavior are acting on a much broader scope than the individual and are occurring much further from disease in the causal chain (5). To focus on the individual is to overlook the myriad of sociological, political, cultural and economic factors that play a key role in health behavior (6).
Furthermore, by designing an intervention on an individual level, CheckUp America is assuming that an individual is responsible for his or her behavior. This is not necessarily the case. One study conducted by Dan Ariely showed that an individual sitting at a table of friends would make a different beverage selection out loud than he or she would when the selection was made on paper, without the awareness of other members of the group (7). That is, a person’s perceived personal preference changed when that person made the choice as part of a group as opposed to as an individual. Assuming that an intervention should work on an individual level assumes that decisions related to health behavior are always made on an individual level. In today’s highly socialized society, full of social norms, mass media and peer pressure, this is rarely the case.
The Second Misconception: Individuals at risk for type 2 diabetes are rational
As has been previously discussed, costs and benefits are evaluated in a rational mental balancing exercise, and the side with heavier weight determines the health behavior according to the Health Belief Model. This idea has been employed in the CheckUp America initiative, which assumes that if people are told that they are at risk for type 2 diabetes and if they are taught that the lifestyle changes to reduce their risk are easily performed, they will rationally process this information and modify their lifestyle. However, humans are far from rational, and the decision-making process is rarely so succinct.
In his book Predictably Irrational, Dan Ariely discusses the many hidden forces that influence ones decisions, none of which are the rational, conscious individual (7). Ariely argues that individuals are not, as the CheckUp America initiative would require, consciously aware of why they make decisions, nor are they aware of the complex role that emotion plays in the decision-making process. He also argues that these subconscious factors are not totally random and while they may be irrational, they are not unpredictable. Thus, to dismiss this point as though it cannot be feasibly incorporated into a public health intervention is to be largely mistaken.
According to the field of psychology, human behavior is largely driven by a desire to conform to social norms. Social norms act as rules regarding how to behave in certain situations that are driven by social approval, rather than rational thinking. Research studies have shown that social norms create pressure towards group conformity and a desire for an individual to act in accordance with social expectations (8). Unfortunately, the CheckUp America initiative fails to take this social science theory into account, and assumes that pure rational analysis of new information regarding lifestyle change will drive people at risk for type 2 diabetes to modify their lifestyle.
The Third Misconception: A Dire Need for Contextualization
Type 2 diabetes is, to a certain degree, a social disease, having a differential impact on members of society who have a lower socioeconomic status and lesser education. These populations are known to have poorer health-risk behaviors, which lead to greater modifiable risk factors for diabetes (9). In addition, non-modifiable risk factors such as race/ethnicity and gender leave some population sub-groups at much greater risk than others. For example, African Americans, Hispanic/Latino Americans, American Indians and some Asian Americans and Other Pacific Islanders are at much greater risk for developing diabetes (1). While 8.7% of on-Hispanic whites have type 2 diabetes, 13.3% of non-Hispanic blacks have the disease (1). In addition, men are differentially affected, having 1.4-2.7 higher amputation rates as a result of diabetes complications (1). They also experience gender-specific complications such as impotence. In light of this information, it would appear that a blanketed intervention such as CheckUp America, which interacts with all members of the population in the same way, would be highly ineffective.
In recent years, the social sciences have called for contextualized interventions, but the field of public health has been slow to catch up. Link and Phelan discuss the vital importance of contextualizing risk factors and of addressing the social causes of disease, such as culture, gender, social class, age, and so on (5). In 2001, Lantz and colleagues conducted a compelling study that showed that the prevalence of health-risk behaviors among communities with low socioeconomic status is not the primary source of disparities in health amongst socioeconomic levels (9). While health-risk behaviors are undoubtedly associated with low socioeconomic status, they do not offer a full explanation. Complex social factors are at play and need to be accounted in any attempt to decrease disease prevalence.
In the case of type 2 diabetes, where both modifiable and non-modifiable risk factors create a differential disease risk for population sub-groups, contextualization is vital to successful programming. Simply notifying an individual that they are African American or Hispanic/Latino American and are therefore at greater risk for developing diabetes is useless, but this is the approach that CheckUp America has taken. This information might be helpful if it were used to funnel that individual into a culturally-respectful and specific intervention.
Closing Remarks
Type 2 diabetes is a growing public health concern, affecting the livelihood of millions of individuals and accounting for a large portion of health care expenditures. There is a need for interventions targeting individuals who are at risk for developing type 2 diabetes in order to curb the increasing disease prevalence. CheckUp America is a national prevention initiative organized by the American Diabetes Association. This initiative, like many current public health interventions, follows the Health Belief Model for health behavior change. Unfortunately, this model is deeply flawed in its individual focus, its assumption that humans behave rationally, and in its lack of contextualization. Diabetes is a complex disease and there are likely many social, political, cultural, and economic factors at play, resulting in differential disease risk amongst different race/ethnicity and socioeconomic levels. A successful intervention will need to address these issues, and take into account group-dynamics and the irrational nature of behavior- a feat which CheckUp America fails to accomplish.
Proposing a Social Science-Based Solution
One of the strengths of the American Diabetes Association’s CheckUp America national prevention initiative is that it takes a proactive and preventative approach the issue of type 2 diabetes. It is widely recognized that the American diabetes epidemic is of growing concern each year, and that perhaps the best form of treatment for this disease is not to treat it at all, but to treat the factors that increase the risk for developing type 2 diabetes later in life. These include sedentary lifestyle and poor diet- two major risk factors for type 2 diabetes. As has been previously discussed, a public health intervention addressing this issue should stay away from traditional health behavior modification models, which lead to an intervention which works on an individual-level, rather than a group-level, assumes that decisions are made consciously and rationally, and lacks social contextualization. In this proposal, we will analyze the following proposed intervention, which draws upon concepts from social science, in its ability to address the major faults of the CheckUp America initiative.
In the proposed intervention, a team of recent graduates from reputable schools of public health, consumer marketing professionals, public relations/advertising professionals, and social psychologists will be assembled. Together, this team will develop a multi-media campaign geared towards children and teens and affecting the way that they think about diet an exercise. The team will conduct formative research to determine which types of media are most relevant, but the list could include television, movies, popular magazines, social networking websites and other internet sites, billboards, and other print media. This could involve partnering with large companies such as Kraft foods, learning how food products are effectively marketed to children and teens, or with popular stores such as Target, working with their marketing teams to understand how lifestyle and product marketing are related, and how the two can interact with each other.
The primary goal of this campaign will be to merge the concepts of exercise and diet with popular culture and everyday life, thereby removing their association with rules and regulations enforced by parents, teachers and doctors. These concepts will then be applied to various mass media outlets. For example, a popular teen sitcom might feature teens heading to the gym or struggling with the difficulty surrounding motivation to get up an exercise. The issues of diet and exercise will be treated in the same way which other issues such as dating, driving, or getting along with siblings and parents are treated in popular media: as every-day life scenarios that viewers can relate to. Care will be to incorporate diet and exercise consciousness into everyday life, without driving home a specific message about how one out to eat or how one ought to exercise.
First Strength: Targeting groups, rather than individuals
As has been discussed, one of the major downfalls of the CheckUp America initiative is that it addresses the issue of type 2 diabetes on an individual level. The intervention focuses on changing an individual’s behavior in an effort to prevent that individual from developing type 2 diabetes. Thus, the focus is on sending a specific message, with instructions about how to change behavior to achieve a desired outcome. The message is very one-sided, and has a “right way/wrong way” type of message. The proposed mass media campaign, however, functions on a much broader scale.
By working through mass media, the campaign would simultaneously reach millions individuals. Rather than trying to convince each individual person who is watching or reading the relevant form of media to directly change their behavior, the campaign will try to indirectly approach the issues of diet and exercise, sending subtle messages over long periods of time. According to DeFleur et al., the “true significance of mass communication lies not in the immediate effects on specific audiences but in the indirect, subtle, long-term influences on culture and social life.” (10). This campaign would function on a much broader, open scale. It would acknowledge the fact that a group of people does not act in the same way as an individual, and that by communicating on a group-level, the likelihood of enacting a lasting change is greatly increased. It would not spend time trying to convince individuals to do the “right” thing, but would empower them to consider aspects of their life related to diet and exercise.
Second Strength: Harnessing the power of the ‘Predictably Irrational’
A second major area in which the proposed intervention differs significantly from CheckUp America is in the assumption it makes about the rationality of human behavior. Under the theories that support CheckUp America, humans are rational beings who make logical, conscious decisions. These decisions involve a weighing of the costs and benefits of performing a particular behavior. As we have seen, this is often not the case. Humans, according to Dan Ariely, are predictably irrational (7), and by garnering an understanding of the irrationality of human behavior, one is far more likely to be able to influence it. As Ariely points out, acting on the conscious mind is not effective, as most decisions are made on the subconscious level.
The proposed intervention utilizes social marketing theory, which uses marketing principles to disseminate ideas through various forms of media, allowing these issues to enter the social and political agenda (11). One of the theory’s greatest strengths lies in the fact that it does not convey a prescribed message about what to do or not to do; rather, it brings awareness to a particular issue, and allows human behavior to naturally take its course. The desired health outcome is, essentially, a product, and consumers are allowed to voluntarily “purchase” this product, or adopt this behavior, at will (12). By allowing the consumer-product relationship to determine who adopts the behavior, this intervention acknowledges that complex, and irrational factors play a role in the decision-making process.
According to social psychology, social norms, which are “rules” for human behavior driven by a desire for social approval, are one of the complex factors playing a role in decision-making. While an individual may be very aware of the benefits of performing a health behavior, he or she may decide not to perform this behavior if it does not conform with social norms. Even though rationally, it would seem to be in the person’s best interest, factors such as social approval introduce irrationality. The proposed intervention would attempt to integrate consciousness of diet and exercise and the role they play in every-day life into the social agenda, allowing society to create things like social norms related to diet an exercise. The intent would be to convey positive, empowering messages about diet and exercise, but the primary goal would be to incorporate these issues into social dialogue.
Third Strength: Cultural specificity
The third major place where the CheckUp America initiative fails to successfully prevent type 2 diabetes is in its complete lack of contextualization. As we have seen, diabetes does not equally affect all racial/ethnic groups or genders. There are social, cultural, political, and economic factors, to name a few, that are influencing who is at risk for type 2 diabetes. Therefore, an intervention must address these issues. The proposed campaign would use the concept of culturally specificity to contextualize its messages. Cultural specificity refers to the need to address the degree to which ethnicity/culture, attitudinal and behavioral norms, beliefs, values, history, environment, and other social forces are influencing a community (13).
As has been seen in a smoking cessation study, interventions that take into account things such as communication patterns, familial roles and unique stressors (such as racism) were far more effective (14). However the proposed campaign will differ from programs such as a culturally specific smoking cessation intervention in that it will not focus on one particular health behavior change. Rather, it will bring the idea of diet and exercise as part of everyday life to the social agenda in a culturally specific manner. This will require understanding which forms of media, such as social networking websites, church newsletters, or popular magazines, are being used by various ethnic or cultural groups, and ensuring that these forms of media are included in the campaign. It will require working with models and actors who represent a wider range of racial/ethnic groups, so that a wider range of “consumers” identify with the individuals portraying diet and exercise as essential elements of daily life. It will necessitate that different types of food and different settings for family meals are featured in popular media in order to ensure that individuals in various contexts are identifying with the message.
Challenges and Hopes for the Future
Undoubtedly, the proposed mass media campaign faces some major challenges. Obtaining funding to work with major television networks, popular teen magazines, internet sits, etc. will be challenging. However, the approach will be taken to partner with such organizations, affording them an opportunity to full their social responsibility, rather than buying a finite block of air time or page layout. Eventually, once this campaign is underway, as diet and exercise are adopted into social consciousness, it will be necessary for any successful marketing/advertising campaign to address these issues. A new television show will likely be more successful if it portrays individuals dealing with daily exercise or diet consciousness, similar to the way that current popular television shows portray individuals struggling with relationships. Media tends to reflect life, and life tends to reflect media, and this cycle will help to perpetuate diet and exercise consciousness, creating a long-term, sustainable intervention.

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