How can health problems be prevented? - Chapter 7

Although an individual approach often has a positive effect on a person's health, it is virtually impossible to reach an entire population in this way. This would be far too time-consuming and expensive for governments or authorities. Large groups must therefore be approached differently than individuals.

How can mass media be used?

The most obvious way to reach many people at once is probably to use mass media. When that happens, it is important that the information comes from adequate sources. People trust a source sooner when the message is conveyed by an expert or by someone with whom they can identify properly. An individual who talks about his lung cancer victory will be even more powerful than the expert or a neutral person. It often pays also to take into account which populations are sensitive to information and which groups are not (anymore). A generation in which hygiene has not been of primary importance in childhood and later will be less prone to information about dental care, for example at an older age.

Despite the popularity of the media campaigns, one has to wonder if they result in different behavior among the target group. There are those who say that campaigns only lead to the identification of certain health issues. Others say for example that media campaigns that are multimodal can achieve something.

Research has shown that the cumulative effects of repeating media campaigns can change people's beliefs and behaviors. To optimize the effect of mass media, a number of points have been formulated that you can pay attention to.

Refining the message

This includes the use of speakers that make people feel involved, based on the so-called Elaboration Likelihood Model (ELM ). This model was discussed in the previous chapter, and research shows that information that contains carefully chosen peripheral cues can facilitate attitude change in people who are relatively unmotivated, or a combination of peripheral cues and central processing can increase the effectiveness of certain interventions.

The use of fear

Health organizations and politicians are increasingly discovering that the use of terrifying messages can have a great effect on people who should improve their health. However, when the frightening aspect is exaggerated, or is too prominent, it has no or even the opposite effect. You can find an explanation for this in the Protection Motivation Theory. This theory says that people's response to information depends on the severity of the threat and their ability to do something about it. For example, when they are warned of the danger of unprotected sex and the risk of AIDS, they will only do something with that information if they are afraid of AIDS and think they can (in the future) have safe sex. The impact of a message is already less strong when people know how to have safe sex, but think that they will not keep it up. When people think they are unable to change their behavior, they will avoid the subject (more).

Information framing

What is also important is the difference between positive and negative messages. Positive messages emphasize the positive results related to action. Negative messages emphasize the negative outcomes that are related to lack of action. Messages are often more effective when they focus on the positive aspects of behavior. There is a substantial difference between the following messages:

• Healthy food has a positive effect on your health.
• Unhealthy food is harmful to health.

Research into the use of sun protection shows that this theory is correct. However, research into participation in breast screening showed that women who were made aware of the dangers of not discovering breast cancer had a mammography made earlier than women who were made aware of the positive aspects of participating in screen research.

These data suggest that we can make no strong a priori judgements about what type of framing will affect particular populations. 

Audience targeting

To reach many people, a message must be general. But the danger of this is that many people do not feel addressed. When a message about the importance of protected sex focuses on bachelors and homosexual men, people with a permanent relationship do not feel appealed, while protected sex may be just as much important to them. It is better to choose to make a separate message for each group or to have each group covered in the message.

Environmental interventions

Cues for action: environmental cues are used to promote healthy behavior, for example by introducing larger and clearer warnings on cigarette packs. This makes people more aware. Posters that remind people to take the stairs can also be effective. However, environmental cues can also serve as a reminder to behave unhealthy. Frequent exposure to relevant advertisements increases the perception of the prevalence of smoking as well as an increase in cigarettes and alcohol consumption.

Minimizing the costs of healthy behavior makes this more attractive. If the right changes have been made to the environment, this has an impact on healthy behavior. An example of this is the stimulation of jogging and walking through the right street lighting, the presence of trees and a good road surface.

Making unhealthy behavior less accessible is usually due to price changes. Examples of this are the taxes on cigarettes and alcohol. This intervention has a modest influence on the consumption of alcohol and drugs. Moderate alcohol drinkers are most affected by this measure.

What do public health programs entail?

Coronary Heart Disease (CHD)

The first health programs focused on behavior that increases the risk of CHD. One of those projects, the Stanford Three Towns Project, focused on three cities in California. This project consisted of three intervention levels. The first city received no intervention, the second city received all kinds of media campaigns focused on CHD for a year and in the third city a number of people with increased risk received one-on-one intervention. These people were asked to spread the information through their social network.

After a year, the CHD risk scores were examined and it was found that the score was higher in the first city, while the scores in the other two cities had fallen, considerably more in city number three than in city number two. Another year later there was no difference anymore between city two and three, because the positive effects of the media reports had grown.

A similar study, with the only difference that in addition to the media reports, also the environmental factors were adjusted, it was found that the improvements were comparable to those in the control group. Several studies came up with such results, and other studies only found a difference in one or a few parts. It must be borne in mind that a control area is not a 'real' control area in the aforementioned studies. In these areas there are also supermarkets that try to offer healthy products or posters that show the harmfulness of smoking.

Reducing risk of HIV infection

Prevention programs focused on HIV and AIDS are generally more successful than the programs for reducing CHD risks. One reason for this may be that AIDS prevention programs make more frequent use of communication between friends. Another reason may be the nature of the disease. CHD develops slowly, one beer is not the direct cause of cardiovascular disease. While once unprotected sex can already result in HIV infection.

Events in (soap) series on television can also have an effect on people's behavior. Many individuals feel emotionally involved with the characters. When something happens to one of those characters, many viewers start thinking about that subject. Soap series can also be used to teach people about certain topics.

Worksite public health

As a result of the problems that approaching large groups entails, scientists have started looking for ways to approach smaller groups.

One way to do this is through the workplace of people. Many employers are interested in this because it reduces health insurance costs and people stay sick less often. A number of options are:

• Screening for risk factors for disease (when applying or later).
• Providing health education.
• Provision of healthy options (such as healthy food in the canteen).
• Providing economic incentives for risk behavior change. This is a fairly influential option. For example, monthly lotteries were held at a company among people who had stopped smoking and lasted for at least a year.
• Manipulating social support to facilitate individual risk behavior.
• Provision of no-smoking areas in the work environment.

The effect of screening programs in the workplace is no different from the effect of screening in other contexts. The effects of a number of interventions in the workplace are not clear. When interventions are combined, such as offering healthy food, demonstrations and counseling, better results are often achieved than a single intervention.

School-based interventions

Just like the workplace, school is a good environment to make people aware of their health. Because young people are coming to schools who are still developing, school is perhaps the most important place for (preventive) health intervention.

Ways in which schools can contribute to health are:

• Applying certain rules, such as no candy to school or the use of a bicycle helmet.
• Establishing a safe, healthy physical and social environment.
• Providing adequate health services within the school.
• Provide education on health-related topics.
• Offering healthy food.
• Health promotion programmes for staff.
• Availability of school counselling or psychology programmes.
• A school psychical education programme. 

This approach implies that information about healthy behavior will have the most effect when the environment makes behavioral change easy.

An important aspect of the health programs within schools is peer education. If children have information about HIV, smoking, alcohol and unsafe sex, it is hoped that they will tell other children. The methods used for this vary enormously. Class discussions can be held or conversations one-on-one.

How can new technology be used?

There are a lot of people who use the internet and is therefore a suitable 'place' to promote health. It is quite difficult to measure the results of such a study. There was a significant difference between a control group and the intervention group from the study by Winett et al. (2007) on food and exercise. For example, in the intervention group there were improvements in the diet compared to the control group. If the internet really wants to be useful for interventions, then it must contain an interactive aspect. One has to be careful to throw traditional approaches completely overboard. An internet-based program is more effective than printed material in producing improvements in the field of nutrition, but not more effective in reducing stress or improving physical activity. Other studies find that printed material is more effective. However, no interactive aspect was used in these programs.