Small Steps Big Rewards…Continual Oversight Of Effective Behavior Change In Public Health Intervention Programs-Nicholas Lincoln
Small Steps, Big Reward: Preventing Type 2 Diabetes is a campaign that was launched in 2002 by the National Diabetes Educational Program. Implemented in print, radio, and television mediums it has promoted the idea that in those with pre-diabetes (higher than average glucose levels), losing approximately 7-10% of your weight can help prevent type-2 diabetes. This prevention program is an example of EBM interventions (evidence based medicine), the DPP (Diabetes Prevention Program) sponsored by the NIH provided the statistical findings for this campaigns message. The Small Steps, Big Reward campaign attempts to promote lifestyle behavioral changes, specifically in noted “at risk” populations including: African Americans, Latino and Hispanic Americans, Native Americans, Alaskan natives, and women with a history of gestational diabetes. The DPP was cut short because the increase in active lifestyle behaviors was seen to be a cost effective method to combat type-2 diabetes and no further review was needed(1). While utilizing clearly relevant scientific research to build an intervention is a seemingly formidable way to combat type-2 diabetes, there are a number of shortcomings to the campaigns design that are typically evident in public health outreach programs. Factors that make this outreach program less effective than possible include: its failure to identify and plan for problems arising from its unique target audience, the use of previously established models of behavioral change that have proved to be limited in some aspects, and overlooking the importance of framing when delivering information. It is these reasons that Small Steps, Big Rewards while in theory presents an effective means to curb type-2 diabetes, ultimately falls short of recognizing its full potential.
Small Steps, Big Rewards was designed to target the growing epidemic of diabetes that has arisen in the United States. The program is made up of several components: a fact sheet, the diabetes GAMEPLAN, and various PSA’s including posters, radio ads, and television spots. This program is based upon recognizing adults who have pre-diabetes (meaning high serum levels but not yet actually having diabetes), attempting to press the importance of delaying or avoiding the onset of diabetes, teaching about the benefits of a healthy lifestyle, and attempting to use the GAMEPLAN to get people on track for healthy and effective changes. The program uses a combination of PSA’s to attract the population into contacting their physician to find out the “next step” of the program. In addition Small Steps, Big Rewards depends on physicians accurately identifying their patients that meet inclusion criteria such as age, elevated glucose levels, and certain minority backgrounds.
While Small Steps, Big Rewards is one of the first diabetes campaigns that is targeted across a multi-ethnic/gender front, in doing so it also proves to be the first of its shortcomings. While it is surely necessary to focus diabetes prevention programs on the population as a whole, by not utilizing information established on interactions with their specific target populations this campaign is ineffective in fully reaching its audience. Particularly with at risk audiences including African Americans, Hispanic and Latino Americans, women, and the elderly this campaign program fails to take into account the intricate interactions and implications that have been recorded throughout numerous studies. One of the target audiences for this program is the African American community and there are well documented studies regarding mistrust and racism in American medicine. A particular problem has been in perceived communication; in one study only 59% of African Americans reported that they felt their physician did a good job at making sure they understood their medical diagnosis, treatment options, and other medical advice. In addition, only 58.8% of African Americans reported that their physician listened to their medical concerns with dignity and took them seriously(2). In a study that requires patient/physician trust not only to continue the program but to begin initial enrollment as well, this oversight is a flaw in the campaigns design. If a patient does not trust their physician and does not believe the physician will respect their medical concerns and provide the same level of care, the patient is less likely to follow through with the designed intervention plan and as a result the effectiveness of the program as a whole will be diminished. Small Steps, Big Rewards is correct to identify African Americans as having a higher risk for diabetes onset, but their campaign fails to recognize the difference in attitudes and opinions with regards to medical care and physicians that may prove to confound the results.
Another ethnic community that Small Steps, Big Rewards is targeted towards is the Hispanic and Latino American populations. While again, this campaign is monumental in that it is one of the first to provide cross cultural implementation and prevention strategies to reduce the onset of type-2 diabetes, the campaign fails to take into consideration the nuances of receiving medical care that has been researched and established within this defined population. Numerous studies have been established showing that Hispanic and Latino Americans demand, access, and willingness to seek out medical care have not been externally valid with the population as a whole. Since the Small Steps, Big Reward campaign is heavily reliant on utilization of physician services as well as self enrolling participants, from a point of effectiveness; this poses an eminent problem for this particular ethnic population. Hispanic and Latino Americans have been found to utilize health care services at much lower levels than their other ethnic counterparts. In one study, 33% of Latino Americans reported that they faced barriers to obtaining care. Further, 75% of these persons reported that the barriers were serious enough to prevent them from seeking out medical care(3). Small Steps, Big Rewards designed their campaign program to alleviate the effects that language had on barriers to care through the utilization of PSA’s that were in Spanish print or broadcasted on Spanish television and radio programs. They however failed to alleviate the lack of service utilization that was commonly cited in the Estrada et al article including: high costs, cultural and geographical isolation, and lack of a defined primary care physician or where to receive care. The study noted that language barriers to receiving care have become increasingly diminished in the last 10 years, depreciating the efforts of the campaign to support and promote heavy participation by the Hispanic and Latino American population.
Finally, the Small Steps, Big Rewards program includes a population of over 45 at risk with increasing age from this point indicative of exponentially higher risk. Again the campaign has done a fairly well job at designing material for an older population group, but again fails to take into account the specific health care disparities seen with this population, particularly with utilization of services. The Manitoba longitudinal study on aging notes that contrary to popular belief, the elderly utilize health care resources much less than the overall population(4). The elderly as a whole are a much more severely sick group when compared with the rest of the population. This results in a small proportion of the population spending most of the money on health care. Even though rates of utilization are not high in this group, when services are provided they tend to be more inpatient and intensive as a whole. Approximately only 1% of the yearly increase in health care expenditures can be attributed to the aging population(5). Even in the population covered by Medicare, utilization is still seen to grow at low rates, with expenditure increase projections at an annual rate of 0.14% from a span of 1992-2050(6). This data is evidence that the elderly as a group are in fact a minority in terms of health care utilization in comparison to the rest of the population. Again, for a campaign that relies on patient/physician interaction, having a target population that does not frequently interact with their physician could result in a disproportionately low number of enrolled persons of these age demographics. While Small Steps, Big Rewards makes the effort to market their product specifically to their target population of over 45 through printed, audio, and visual materials specially packaged and marketed for this group, it fails to effectively address problems with using care. The lack of knowledge is only one factor contributing to the lack of health care utilization in the elderly. Other key constitutes include geographical isolation (stemming from lack of transportation) and lack of income. The higher proportion of elderly without transportation makes frequent visits and checkups difficult to schedule and follow up with. The lack of income as a barrier to care is also important, having a strictly defined budget makes the utilization of health care services that are not ambulatory, but rather preventative seem less important when compared with basic living necessities. This campaign fails to take into account these age-specific barriers to health care utilization in the planning and implementation of their program and as a result will not see optimal levels of success for this particular target population.
The Small Steps, Big Rewards campaign is also flawed in the motivational theory of behavior change that it is built upon. The campaign utilizes PSA’s including print, radio, and television advertisements in an effort to educate their target audience about the severity of risk for developing type-2 diabetes. The campaign uses statistics published from the Diabetes Prevention Program and aims at instilling fear of susceptibility to motivate the population to follow the campaigns program. The use of this method as a chief motivator indicates that this campaign was based upon the Health Belief Model of social behavior change. The programs function on two basic “small steps”. The first is to know your risk and the second is to start your GAMEPLAN (the interactive guide handed out). This campaign is assuming that the PSAs used are marketed effectively, function to promote knowledge of potential risk, and imprint the severity of that risk onto its target population. It further assumes that these risks are effectively portrayed as severe enough to motivate the population to undertake the GAMEPLAN. The Health Belief Model is based on the platform that people will undertake action after careful consideration that there is a perceived susceptibility, severity, barriers, and benefits(7). A patient in other words will schedule an appointment with their physician after utilizing PSAs to learn their chance of developing type-2 diabetes, the negative health consequences of living with type-2 diabetes, and the benefits of a healthy lifestyle. The campaign is flawed with the use of this model in two major ways: the assumption that people behave rationally when it comes to their health choices(8) and by presenting perceptions that conflict with the ideology of the model directly. The assumption that people behave rationally and therefore are logical in their decisions on health care utilization is essential for this model and has continuously been disregarded by the general population in their health care choices. Furthermore this rationality assumes that a person adheres to a cultural norm of belief in the unfailing power of the capabilities of western medicine(9). Deviance from these assumptions is not built into the Small Steps, Big Rewards campaign and as a result the campaign is unprepared and less likely capable to handle deviations from rational behavior. Secondly the methods this campaign uses to portray their message of type-2 diabetes prevention contradicts the format of the model upon which it is based. The program attempts to impress a strong perceived risk and severity of type-2 diabetes while simultaneously downplaying efforts and benefits. The idea of “small step” insinuates a level of ease in which the guidelines can be followed. However this is counterintuitive with the models requirements that perceived risk and severity must be large enough to spark action. The catch phrase that this campaign uses “One small step: know your risk, one small step: start your GAMEPLAN” undermines the use PSAs to impact a real concern for well being. Conveying that the methods to solving this problem are easy undermines the effectiveness of promoting knowledge of perceived risk and severity. This contradicting pattern has been seen to negatively affect diabetes interventions in the past with the requirement of rational behavior being a chief marker for adherence failure(10). By utilizing the HBM to implement their campaign, Small Steps, Big Rewards loses the ability to accurately predict un-rational behavior and diminishes perceived risk through contradiction which ultimately will weaken the effectiveness of the program.
The final flaw in the Small Steps, Big Rewards campaign design is its disregard for the importance of framing educational material. The campaign focuses heavily on influencing the population to self identify themselves in an at-risk pool for developing type-2 diabetes. It also has physicians identify patients that have blood serum levels that put them clinically at risk and inform patients of the severity. The idea behind this is based upon the HBM, specifically that people must feel that they are susceptible to a risk and that if that undesired outcome occurs there are real consequences from it. However, the use of these PSA in an attempt to motivate the population to action by imparting concern has flaws; it promotes the use of negative labeling. By requiring people to self identify themselves in a certain category (at risk for diabetes/ not at risk) it can cause for people to carry out the roles of stereotypes. A person who realizes they are identified to a certain group may unintentionally pick up the behavioral characteristics associated with these stereotypes as a result of perceived judgments. One of the key elements that this campaign uses to promote self identification is risk that high blood pressure has on developing type-2 diabetes. Labeling persons, particularly those with hypertension has been documented as being a poor technique for promoting behavioral change. Persons labeled in a negative way are more likely to suffer from depressive symptoms and as a result have lower adherence to prescribed or desired medical interventions(11). It is the use of labeling which can lead to what is dubbed as a self-fulfilling prophecy(12), the phenomena seen where a person is labeled to a stereotype and is unable to break away from the cycle of negative behavior because they are socially conditioned to do what is expected from them. The Small Steps, Big Rewards campaign fails to prepare for the inevitable effects that negative labeling will have on patient participation and adherence to protocol. Using negative health labeling will ultimately contribute to the ineffectiveness of this diabetes prevention campaign.
The shortcomings of Small Steps, Big Rewards lie in its inability to predict irrational patient behavior, its disregard for the importance of framing presented information, and inability to take into account utilization discrepancies of their target audience. An effective alternative design would be one that utilizes social and behavioral science theories to rectify the mistakes made in past campaigns. Understanding your target audience and their habits of health care utilization is essential in developing and implementing a successful intervention program that will yield credible results. To meet the unique needs of a population at risk for diabetes, the use of successful advertising campaigns combined with personalized prevention plans designed and explained by physicians and dieticians would make a successful program. Global Appeal, Individual Needs System or GAINS would be a diabetes prevention program developed to recognize and fix the shortcomings of the Small Steps, Big Rewards campaign. This program would consist of an intensive marketing strategy specifically designed to address utilization discrepancies for each target audience to promote maximum patient enrollment. In addition this program would offer individually tailored prevention protocol, designed by physicians and dieticians to fit the goals and needs of each patient. These programs, based on lifestyle behavior change would utilize positive labeling and stress the importance of self efficacy to establish long term change. Consisting of goal-oriented check points set at a realistic level by the patient, backed by evidence driven levels provided by the physician and dietician, this program would prove an effective means in providing achievable, beneficial results in preventing type-2 diabetes. Furthermore this program would include a mobile unit designed to reach populations with trouble coming into clinics for various reasons (geographical & social isolation, finances, etc..). This program would utilize two separates social and behavioral sciences models to effectively convince the population at risk to schedule appointments with their physicians who then tailor a specific intervention that will provide the highest chance of compliance. Specifically, GAINS will use the Advertising Theory to promote population enrollment, targeting a multi-cultural, age, and gender background. The program will also use the Social Learning Theory for developing and implementing the actual prevention program once patients meet with their physicians. This program would use a successful ad campaign to draw as many people into physician offices as possible, but would also employ mobile screening and meeting units for areas that are at high risk for underutilization. This is beneficial in two-folds, it provides low cost outpatient services and education to those who may not be able to reach physician offices and it promotes a sense of trust in the community by showing a measure of devotion to the program and the people it serves. This program will be specifically aimed to resolve the issues that are apparent in the Small Steps, Big Rewards campaign by effectively promoting patient enrollment, planning and overcoming irrational behavior in medical decisions, and utilizing framing for positive effects.
The first issue, targeting and enrolling patients from diverse demographics (many of which have established rates of underutilization of care) can be achieved through careful application of the Advertising Theory. This theory is based upon three pillars: the promise, the support, and core values and is an excellent way to promote group level changes inside of a population. Recognizing that the individual differences do not make change, rather the choices of the group as a whole must be scrutinized to determine the best possible methods for instilling this change. To effectively utilize this theory, GIANS must employ strategic marketing research to find out what the core values of their target audience are and the best possible ways to go about motivating them. Once marketing research is completed data can be used in a successful advertising campaign to bring in people who are at risk for developing diabetes and getting them started on the prevention program. The use of successful advertising campaigns has been shown to be effective in targeting audiences and achieving higher levels of response from diversified demographics as well as higher levels of education retention(13). Based upon these past successes, GAINS could benefit greatly from utilizing the promise, support, and core values approach. A suggested promise for the ad campaign could be “with this program you can be carefree”. The support would be represented by interviews with a variety of persons talking about how preventing diabetes allowed them to be in control of their lives and not have to worry about the anxiety, pain, and responsibilities that come with diabetes. Specifically these ad campaigns would touch upon all of the disparities seen in the target populations such as promoting trust with physicians and African American populations(2), ease of locating services in Hispanic Americans (3),and the affordability in the elderly population(4). While resonating on core values of autonomy and security, these ad campaigns based upon advertising theory would effectively target and draw in populations that may have fallen through the cracks in the Small Steps, Big Rewards program.
GAINS would build upon the failures of Small Rewards, Big Changes by utilizing social and behavioral models that predict and account for irrational behavior in patient’s medical decisions throughout the planning and development stages of the intervention. The failure of SRBC to account for these irrational behaviors limits their abilities to effectively predict why some patients will enroll, why some won’t, and how the patient will most likely to adhere to protocol set down by their physician. Basing the intervention program on the Social Learning Theory (developed by Bandura) would be beneficial for the goal of preventing diabetes in a dynamic population because it allows for irrational behavior and has strong ties to observational learning(14). The theory stresses the importance that the individual, behavior, and environment all have in effecting one another. The GAINS model will take advantage of this theory throughout its design by incorporating these three pillars, utilizing advertising theory to promote observational behavior change (successfully targeting audiences), influencing the individual with personalized physician/dietitian created programs tailored towards specific needs, and promoting mobile screening/patient care to effect adverse barriers present in the populations environment. For this program it is imperative to enroll patients any way possible and convince them that they can effectively complete the program and that completing the program is something desirable. The irrationality of choices is based upon a series of elements and GAINS would be developed to take these into account. By marketing and providing health lifestyle as a positive, desired product that people can attain ownership of the population will likely be drawn in. Using a campaign revolving around “making time for health” would be beneficial for people to take context into account and understand the real risks. In addition having physicians and patients set realistic timelines for goals would keep the intervention on track and avoid procrastination (taking into account fundamental attribution error). GAINS ability to encompass irrational health behaviors which are often seen with regards to medical decision making will make it a more effective health intervention for preventing type-2 diabetes compared to the Small Changes, Big Rewards campaign which relies on models where the population is assumed to behave in a rational manner. Taking into account aspects of ownership, context, expectations, and fundamental attribution error throughout intervention design and implementation is what makes GAINS equipped to deal with populations that make irrational choices.
Finally the GAINS program would build upon the shortcomings of Small Changes, Big Rewards by utilizing the importance that framing has on the presentation of material to the population. How material is presented to the audience is just as if not more important than the information actually being presented. Framing is an important tool for public health issues because it has the ability to influence patient decisions on a very subtle level. Framing questions allows for the senders views to be represented within the material presented in a subtle way so that in essence the audiences interpretations are already made up for them(15). GAINS will move from a model of focusing on poor health effects and labeling as “bad” to positive health outcomes with labeling as “good”. This is in contrast with the Small Changes, Big Rewards program that labeled people at risk for developing type-2 diabetes in a negative light citing poor lifestyle decisions. GAINS would be focused on not labeling people as having done something wrong, but rather use framing to promote the decision to think about joining, prepare, and execute as a positive rather than pointing out the fact that it has not already been accomplished as a negative. GAINS would be a more effective intervention than SSBR in the prevention of type-2 diabetes because it would recognize and implement the power of framing and social stereotypes in order to promote enrollment and compliance.
Diabetes is growing in the United States at an alarming trend. Today there are 23.6 million people with Diabetes in the US (7.8% of the population) and 90-95% of these cases are type 2. As a result this disease costs the population an average of $174 billion per year(16). It is essential that the prevention and intervention programs designed and utilized be effective in curbing the rising trends of this disease. A successful campaign is one that effectively markets to their prospective target audience and utilizes working social and behavioral science modification theories to successfully change lifestyle behaviors and promote adherence to the program. While Small Steps, Big Rewards is an innovative campaign program in the fact that it has widespread demographics, it fails to recognize established underutilization trends in these populations, plan for and accommodate irrational behavior, and recognize and use the power of framing. The GAINS program has been designed to achieve the same diverse target population as SSBR, but utilizing effective social and behavioral theories to develop and implement an effective prevention program for type-2 diabetes. Using Advertising Theory and the Social Learning Theory this intervention program would launch a diverse demographic population marketing campaign effectively targeting each individual population. The campaign would address established barriers to care (using mobile care units to combat geographical isolation, lack of finances, and promote community trust and individually tailored physician/dietitian programs to promote provider/patient relationships). Once patients have been enrolled in GAINS, the intervention method, based upon Social Learning Theory will allow for the prediction of irrational behavior, utilize observational learning (seeing the success stories of other members), and promote reciprocal determinism (choice yields results and results influence the continuation of that choice). Using the power of framing to present the material in a positive light (conveying planning, joining, and achieving as positives) instead of the failure to plan and prevent as negative, this program will likely inspire more success stories. The effectiveness of the GAINS campaign lies in its adaptation of successful social and behavioral science behavior modification theories. Most public health interventions (such as SSBR) rely on less realistic models (HBM) and as a result will see less effective results. Through the application of proper behavior modification in tandem with the use of positive framing the population has the opportunity to “GAIN” a step up on preventing type-2 diabetes.
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