Tuesday, May 4, 2010

‘Physical Activity. The Arthritis Pain Reliever.’ A Critique of a Public Health Intervention – Nichole Hinkley

Considering the disease prevalence and impact on the population, arthritis is a significant public health issue. An estimated 21.4 % of adults report having arthritis as diagnosed by their physician. Arthritis can have a substantially disabling effect on an individual, interfering with one’s ability to work, socialize, and care for family and friends. Arthritis is the most common cause of disability and 41% of persons with the disease report activity limitations (1). Physical activity may lower the disease burden and improve the quality of life for those living with arthritis (2). As such, increasing physical activity and promoting self-management in persons with arthritis have become top public health priorities. The Centers for Disease Control and Prevention (CDC) has been central to the public health response by providing funding and ready-made interventions to state health departments (1). “Physical Activity. The Arthritis Pain Reliever.” is one example of such an intervention.
“Physical Activity. The Arthritis Pain Reliever.” is a communication campaign promoting physical activity as a method of arthritis pain management (2, 3). The campaign targets lower-income, African-American and Caucasian adults (aged 45-64) who are already suffering arthritis-related activity limitations. Demonstration projects were concentrated in low-income neighborhoods and rural areas. Stated campaign objectives include a) Raising awareness of physical activity as a way to manage pain and increase function b) Increase understanding of how to use physical activity to ease arthritis symptoms and prevent further disability c) Enhance the confidence or belief of persons with arthritis they can become physically active, and d) Increase trial of physical activity behaviors. Ready-made intervention materials provided to state health departments include an audience profile, public service announcements and messages, radio advertisements, and print materials (2). A critique of these materials and the underlying objectives reveal numerous flaws in the intervention’s design and approach. This paper will identify and discuss three major issues that render this intervention inept: a) misalignment of the intervention’s goals and design with respect to the target audience b) the intervention’s approach is insensitive to the target population’s barriers, and c) the use of inappropriate and inadequate marketing techniques.
Misalignment of Intervention Goals and Design
“Physical Activity. The Arthritis Pain Reliever.” relies on the dissemination of educational materials to raise awareness of the benefits of physical activity on arthritis symptoms. The informational materials are designed to increase the understanding of how using physical activity can ease arthritis symptoms and prevent further disability while enhancing the confidence and belief of persons with arthritis they can be physically active (2, 3). Similar goals and strategies are found throughout social and behavioral models, indicating the intervention is modeled on fundamental behavior-change theories.
Two fundamental behavior change theories, social cognitive theory and social learning theory, stress the importance of observational learning and the concept of self-efficacy and are often utilized to develop public health interventions (3). For the CDC’s arthritis intervention, the concept of self-efficacy may be construed as the “confidence” and “belief” of persons with arthritis they can be physically active. Many public health interventions employ community education to increase awareness of risk factors based on the theoretical potential to modify factors through behavior change (4,6). However, such interventions are not always effective. The Pawtucket Heart Health Program, based heavily on social learning theory, was unsuccessful in demonstrating a decrease in the prevalence of physical inactivity when comparison to a similar, control community (4,5). In fact, studies found the intervention had virtually no measurable effect and suggested possible problems were related to a limited target population (5). Such public health failures may be suggestive of intervention design and outcome goal incompatibilities.
Educational campaigns with the objective to modify health behaviors are potentially problematic because the theories tend to oversimplify behavior determinants (7). Two theories frequently applied to public health intervention models, the Health Belief Model and the Theory of Planned Behavior, cite self-efficacy and weighing perceived benefits and perceived costs of a behavior as major factors in predicating health behaviors (6). In the case of arthritis, this cost benefit analysis would include the perceived susceptibility and severity of related symptoms. Thus, the success of such interventions depends on intention translating into behavior without considering other contextual factors (7). So, intervention failure may suggest the employed models are an inadequate basis to design an effective public health intervention. Therefore, the CDC’s design for “Physical Activity. The Arthritis Pain Reliever.” may be insufficient to achieve its stated objectives.
Moreover, the target population profile suggests an inappropriate application of the models. Formative research was utilized to establish the campaign materials and provide a profile of the target audience. Overall, research indicates the target population generally values good health, is concerned about the limitations of having arthritis, and values self-management. Four in five audience members agree that their health depends on how well they take care of themselves and over half say they do everything they can to stay healthy (2, 3). Based on this assessment, one could argue the target population already shows a high perceived susceptibility and severity of arthritis complications, key components of the Health Belief Model and Theory of Planned Behavior (6). This indicates the outcome expectations may be inappropriate for the intervention’s target audience. Furthermore, the campaign focus is on those with symptoms advanced to the point where arthritis is perceived as interfering with one or more daily life activities. This is also suggestive of the target population’s awareness of the perceived benefits and costs. As such, the campaign's potential benefits to the target population are substantially limited by design.
Barrier Insensitivity
Design flaws are also indicated by the campaign’s insensitivity to barriers. Although campaign background materials cite perceived barriers to disease self-management within the audience profile, the campaign makes little effort to address such barriers. For instance, the intervention does not address motivational barriers for the target population. Selling physical activity to people experiencing arthritis–related activity limitations may require stronger intervention efforts, especially if these individuals were generally inactive prior to onset of severe symptoms. According to Maslow’s Theory of Human Motivation, basic physiological and safety needs must be met before higher goals of motivation can realize (8). These basic needs may be jeopardized when pain begins to affect one’s ability to care for themselves. Thus, pain may create an impenetrable barrier for the entire target audience. Failure to address this significant complication may limit the campaign’s reach.
The intervention also ignores environmental barriers associated with certain characteristics of the target population. Populations most at risk for inactivity are those having lower income and education levels (9, 10) both of which are characteristics enumerated in the target audience profile. Moreover, research indicates lower income and rural neighborhoods have fewer physical-activity related outlets (10). Therefore, the target audience’s environment may not be supportive of physical activity. For instance, fitness facilities may be too expensive or inaccessible, or neighborhood attributes may be unsupportive of physical activity. Environmental supports for physical activity may include maintained sidewalks, streetlights, and positive perceptions of surrounding neighborhood. Unsupportive factors may include crime, heavy traffic, and other safety concerns (9-12). Some studies conclude that closer proximity and higher density of exercise facilities are significantly associated with an increase of physical activity (11, 12). Although the audience profile acknowledges physical activity-specific barriers of time, cost, location, and convenience, they are not addressed in the interventional design. This illustrates the intervention’s ignorance of contextual factors that may play a bigger role than self-efficacy and perceived costs/benefits in determining behavior. The importance of environmental variables as determinants to health behavior is consistent with the social-ecological theories of health behavior (9). In other words, the social-ecological perspective acknowledges that health behaviors are determined by a number of contextual issues that should be considered in designing an intervention to increase physical activity.
Campaign Marketing
Public health interventions may utilize basic marketing principles in order to promote the program. This requires formative research to define and frame the product in a way that speaks to the intended audience (13). In other words, marketing a public health program requires the identification of core values, desires, and needs of the target audience in order to promote the program. While valuable research data was obtained and conveyed in the campaign’s instructional materials, the advertisements and materials are not reflective of the research findings.
The target audience fears future loss of independence; reduced pain and ease of movement are intertwined with independence. In terms of marketing, independence may be viewed as the core value desired by the target population. This value is essential to packaging and framing the program to the audience in a meaningful way (13). Instead, campaign literature generally conveys a command, such as “take a walk.” For example, one brochure headline reads, “Take a Walk. Take a Bike Ride. Take a Swim.” It then goes on to explain how physical activity can decrease arthritis related pain. It also mentions that even though “it may hurt a little at first… most people begin to feel better within four to six weeks.” Though it may be truthful, this frames the issue in a most undesirable way. This message is essentially offering “pain” as its product. A second brochure states, “If you experience the pain and stiffness of arthritis, there’s something you can do about it.” Although this may engage the audience in a more meaningful way by offering empowerment to sufferers, the campaign failed to reinforce the core value supported in research findings. In fact, the majority of campaign media communications are centered on empowering the individual to self-manage.
The focus on empowerment has failed in a number of public health policies. For example, consumer empowerment was a failed policy approach to reducing health care costs. Proponents of these policies argue consumer insensitivity to health care costs contributes to overspending and therefore sought to modify patient behaviors by publicizing hospital cost and quality data (14). Ideally, consumers would utilize advertised data to select the lowest cost, highest quality product available and foster competitors to adjust price or production costs to meet the new demand (15, 16). Among other problems, these policies did not adequately market and advertise the information they were attempting to disseminate. The public was largely unaware of the data’s existence; therefore, the intervention did not achieve its cost cutting objectives. This policy failure highlights the importance of marketing principles in public policy ventures. So, although the campaign acquired requisite data in order to promote a successful public health campaign, it was not utilized to effectively frame the issue.
The CDC’s public health campaign, “Physical Activity. The Arthritis Pain Reliever.” displays a number of design concerns that individually and cumulatively lower its effectiveness. Three major concerns have been established with this intervention: the misalignment of the intervention’s goals and design, ignorance of target population’s barriers and finally, the inadequate use of marketing techniques. Poorly designed interventions will do little to address serious public health issues such as arthritis. In short, this campaign is representative of a failing approach to address a public health issue.
Redesigning for Success: An Intervention Proposal – Nichole Hinkley
Although research demonstrates the need for more innovative approaches to successfully achieving public health objectives, intervention failures are not uncommon. As indicated in the critique of “Physical Activity. The Arthritis Pain Reliever,” tragic flaws include the intervention’s misalignment of goals with design, an insensitive approach to the target population’s barriers and contextual issues, and the inadequate use of marketing strategies. The objective of this proposal is to provide an alternative approach to increasing physical activity behaviors in persons with arthritis than provided by the Centers for Disease Control and Prevention. A more successful intervention requires three modifications: integrating alternative behavioral models, addressing contextual barriers, and improving the marketing techniques. As this proposal will indicate, these modifications will address all major concerns with “Physical Activity. The Arthritis Pain Reliever.”
Aligning Goals with Design
The initial step to redesigning this intervention is to align the design strategy with its intended goals. To increase physical activity behaviors in persons with arthritis-related activity limitation, it may be beneficial to address a larger audience. A broadly-based intervention strategy yields greater outcome potential while allowing for the consideration of the target population’s characteristics and barriers. Better still, encouraging physical activity in the population at large places greater emphasis on prevention of arthritis pain thus reinforcing a public health ideal. Over time, this focus would mitigate pain as a significant barrier to activity. Already, this revised strategy addresses a number of the potential barriers presented by the original design.
According to the campaign goals, the social network theory would be an appropriate basis for the intervention design. Recent studies suggest that network phenomena are relevant to obesity-related behavioral traits. Obesity has shown to have an association with physical inactivity and both obesity and physical inactivity are shown to have an association with arthritis, so this approach should have similar interventional implications in terms of modifying behavioral traits (17). Thus, aligning outcome goals with appropriate design strategies is the first step to improving the effectiveness of public health interventions.
Addressing Barriers
Social-ecological perspectives of health suggest that social and environmental factors play an important role in increasing physical activity behavior (8). As such, significant social and environmental barriers should be addressed in redesigning the intervention. As mentioned, the social network theory approach involves intervening on a group level. Therefore, the intervention should operate through health clinics, community centers, centers for independent living, and other health facilities frequented by the target population. For example, new or already established arthritis/disability support groups or meetings could provide the base of the network cohort and an opportunity to communicate audience-appropriate campaign materials. Concentrating interventional activities may help to address a portion of the perceived environmental barriers such as location, time, and convenience, especially for those who may be experiencing arthritis related movement limitations. The social network created by this group-based strategy offers motivational support and may alleviate some of the aforementioned environmental barriers. For example, safety may be less of a concern if a group of individuals are able to coordinate fitness activities together. Similarly, peer-communicated advice may be a more effective motivational tool than educational materials. Although this partially addresses significant barriers that were ignored in “Physical Activity. The Arthritis Pain Reliever,” this intervention should also include efforts to develop low cost solutions to enhance environment to support physical activity, such as parks and recreation centers. As indicated by research, closer proximity and higher density of exercise facilities to be significantly associated with an increase of physical activity, indicating the importance of removing environmental barriers to achieve positive outcomes (10, 11). These efforts should be made at the level of each local network in order to provide the most effective and supportive modifications.
Promoting physical activity is a major public health priority across a number of populations. Interventional efforts via network levels would penetrate various populations and ideally spread desirable outcomes. Therefore, the social network theory approach to increasing physical activity in persons with arthritis could also benefit other populations. The spread of healthy behaviors may be further encouraged by incorporating an element of the diffusion of innovations theory. A “change agent” is a well-connected individual in the intervention who would serve as a positive role model for incorporating the desired outcomes for the rest of the network. Identifying “change agents” for strategic incorporation into cohorts might promote the uptake of healthy behaviors (18). Not only do alternative models suggest a greater success in achieving intended outcomes but in achieving broader public health objectives.
Successful Marketing
Perhaps most importantly, the intervention redesign should employ marketing techniques in order to successfully promote the campaign. Although the CDC’s intervention materials provided detailed requisite data to launch a successful public health campaign, it was not utilized to effectively frame the issue. Addressing the underlying values associated with the desired health behavior is essential to successful promotion. Data from the audience profile indicates independence and autonomy are core values and concerns for people with arthritis, therefore, campaign materials should be framed around these values. This may be accomplished by essentially “selling” autonomy and independence in campaign advertisements. For example, an alternative brochure headline may not contain any words at all but portray an image of age-appropriate individuals enjoying their freedom and autonomy amongst their friends. One image may include four, laughing women in a red convertible with the top down. This portrays an image of freedom, success, and happiness. Although physical activity is the health behavior associated with such emotions, it should not be the focus of campaign messages. Proper advertising and marketing strategies will help sell public health products.
Poorly designed interventions will do little to address serious public health issues such as arthritis. As such, innovative approaches are necessary to address the goals defined in “Physical Activity. The Arthritis Pain Reliever.” In summary, the proposed redesign uses the social network theory as basis for increasing physical activity in persons with arthritis while utilizing marketing principles to promote the public health campaign. In addition to the intervention’s increased sensitivity to barriers, the incorporation of alternative theories effectively addresses the dilemmas unearthed in the critique of the Center for Disease Control’s campaign. The proposal may also offer a more effective, sweeping approach to addressing a number of significant health problems while emphasizing prevention, a public health principle.
(1) Brady T., Jernick S., Hootman J., and J. Sniezek. Public Health Interventions for Arthritis: Expanding the Toolbox of Evidence-Based Interventions. Journal of Women’s Health 2009; 18 (12):1905-1917.
(2) Centers for Disease Control and Prevention. Arthritis Intervention Campaigns. “Physical Activity. The Arthritis Pain Reliever.” How to guide: http://www.cdc.gov/arthritis/docs/howto_guide.pdf
(3) Centers for Disease Control and Prevention. Arthritis Intervention Campaigns. http://www.cdc.gov/arthritis/interventions/physical/overview.htm
(4) Carleton R., Lasater T., Assaf A., Feldman H., McKinlay S. and the Pawtucket Heart Health Program Writing Group. The Pawtucket Heart Health Program: Community Changes in Cardiovascular Risk Factors and Projected Disease Risk. American Journal of Public Health 1995; 85:777-785.

(5) Eaton C., Lapane K., Garber C., Gans K., Lasater T. and R. Carleton. Effects of a Community-Based Intervention on Physical Activity: The Pawtucket Heart Health Program. American Journal of Public Health 1999; 89 (11): 1741-1744.
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(11) Sallis J., Hovell M., Hofstetter R. et al. Distance between homes and exercise facilities related to frequency of exercise among San Diego residents. Public Health Reports 1990; 105:179-185.

(12) Linenger J., Chesson C. and D. Nice. Physical fitness gains following simple environmental change. Journal of Preventative Medicine 1991; 7:298-310.

(13) Siegel M. Marketing Social Change: An opportunity for the public health practitioner (pp 45-71). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change (2nd edition). Sudbury, MA: Jones and Bartlett Publishers, 2007.

(14) United States Government Accountability Office. Comptroller General's Forum on Health Care: Unsustainable Trends Necessitate Comprehensive and Fundamental Reforms to Control Spending and Improve Value. U.S. Government Accountability Office: 2007.

(15) Nichols, L., Ginsburg, P., Berenson, R., Christianson, J. and R. Hurley. Are Market Forces Strong Enough to Deliver Efficient Health Care Systems? Confidence is Waning. Health Affairs 2004; 23 (2); 8-21.

(16) Poteliakhoff, E. Price data published by CMS: 'Payer Power Plan'. Health Policy Monitor. 2006. http://www.hpm.org/survey/us/c8/3

(17) Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine 2007; 357:370-379.

(18) Introduction (pp 3-14). In: Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Boston: Little, Brown and Company, 2000.

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