Individuals and Families: Models and Interventions - Health and Behavior - NCBI Bookshelf
together and discussed (very usefully) in the one document – a real tour de force. ” Rob Gründemann . A. Evidence For Effectiveness of Occupational Health & Safety Interventions.. . B. Evidence .. seem to pay more attention to problems relating to male-dominated . Second Meeting of WHO Collaborating Centres in. A workplace health and safety program is a process for managing the Meet regularly with your staff and discuss health and safety issues. In contemporary working life, health and safety problems are becoming increasingly complicated, thereby posing new challenges for preventive interventions.
Addressing Psychosocial Risk Factors As described in Chapter 2depression is a risk factor for mortality from multiple causes. These problems make the development of programmatic interventions to provide psychosocial support both humane and expedient. Thus, providing appropriate psychotherapeutic and psychopharmacologic treatment for them not only can improve coping and reduce patient discomfort but also can make the delivery of medical care more efficient.
The contributions of clinical behavioral and psychosocial interventions to diabetes, cancer, and heart disease are explored briefly.
A recent chapter Baum, from an Institute of Medicine IOM report provides further discussion of the influence of stress in cancer and cardiovascular disease. To reduce the incidence and severity of complications of diabetes, including vascular, coronary, renal, and neurologic disease, blood sugar must be carefully regulated.
Adherence to medication regimens, glucose testing, exercise, and diet influences medical outcomes. Research indicates that coping skills and family stresses influence the management of diabetes see Glasgow et al. Furthermore, depression is a serious co-occurring problem in diabetes Glasgow et al. Several reviews and meta-analyses have demonstrated the effectiveness of educational approaches aimed at increasing knowledge, control, and self-efficacy among diabetics Brown, ; Hampson et al.
On the other hand, education did not consistently improve metabolic control Grey, Psychosocial interventions for example, enhancing coping skills and peer support seem to provide greater success in improving both metabolic outcomes and quality of life Grey, ; Grey et al.
Educational interventions could be more effective when used in combination with behavioral psychosocial interventions e.
However, concerns exist that the beneficial changes might not be sustained long beyond the intervention Brown, There is evidence that psychosocial interventions can improve quality of life, psychological adjustment, health status, and survival of cancer patients see reviews by Andersen, ; Blake-Mortimer et al.
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A meta-analysis of studies on the effects of psychoeducational care provided to adult cancer patients concludes that interventions affect anxiety, depression, and mood Devine and Westlake, Another analysis of 45 psychosocial interventions showed statistically significant emotional benefits in adults Meyer and Mark, Various interventions have been tested, including teaching specific methods of coping with the stress of cancer Edgar et al.
Their relative effectiveness has been difficult to assess Devine and Westlake, ; Fawzy, ; Meyer and Mark, Some evidence supports the effectiveness of psychosocial interventions to improve medical outcomes and prolong survival for reviews, see Creagan, ; Greer, Spiegel and colleagues found that psychosocial group treatment in metastatic cancer patients doubled survival time to an average of 18 months, from the point of randomization.
A study by Richardson et al. The effect was sustained even when differences in medication adherence were controlled. In a study of patients with metastatic melanoma, quality of life was found to be associated with duration of survival Butow et al. A randomized controlled trial of 6 weeks of intensive group therapy aimed at developing active coping among 80 malignant melanoma patients significantly reduced mortality at 6-year follow-up Fawzy et al.
The mechanisms through which psychosocial interventions exert their effect is unknown, but it has been suggested that depression exacerbates symptoms Evans et al. These results should be explored further and confirmed. Although the potential of psychosocial intervention to slow the progression of cancer is promising, the literature is limited and several reports refute the hypothesis for example, Cunningham et al.
One meta-analysis Meyer and Mark, showed a small effect of psychosocial interventions on medical measures that was not statistically significant. Carefully designed studies are needed to clarify this issue.
Primary prevention can reduce the incidence of coronary disease Chapter 3but psychosocial interventions also can affect morbidity and mortality in at-risk patients. As described in Chapter 2several studies have recently demonstrated that social isolation, depression, and type A personality traits—especially hostility—can mediate medical outcomes for patients with coronary disease also see Rozanski et al. Evidence is increasing that psychosocial interventions after the onset of disease are effective supplements to routine cardiac care.
One recent meta-analysis of 37 studies Dusseldorp et al. Another meta-analysis Linden et al. The interventions included in the analysis by Linden et al. Powell and Thoresen found that counseling designed to reduce hostility and impatience typical in type A people reduced mortality among acute myocardial infarction patients who had less serious cardiac disease.
Many studies support psychosocial interventions, but other evaluations show no significant effects. A clinical trial by Jones and West revealed no benefit from relaxation training and stress management. In contrast to the results of an earlier study that indicated that simply monitoring for psychological distress in cardiac patients reduced mortality Frasure-Smith and Princea follow-up study Frasure-Smith et al. The discrepancies among studies probably result from methodologic limitations, including small study sizes, varied interventions some of which may not be behaviorally effectiveindefinite clinical endpoints, and lack of intention-to-treat analyses.
To address these limitations, a national multicentered clinical trial has been initiated Enhancing Recovery in Coronary Heart Disease [ENRICHD],to determine the effects of psychosocial interventions on patients. Interventions will target depression and social isolation in patients with a recently diagnosed myocardial infarction.
Endpoints will include mortality, nonfatal infarctions, cardiovascular hospitalizations, and changes in risk factor profiles Blumenthal, b ; ENRICHD, Addressing Behavioral Risk Factors The primary care physician is in an optimal position to provide advice on healthy behaviors. Many studies have indicated that counseling by a primary care physician can be effective in changing the behaviors of patients but the approaches are varied.
Several fundamental characteristics contribute to the effectiveness of these interventions. Recognition of differing patient needs is one fundamental characteristic of practices dedicated to enhancing beneficial behavior change.
Some patients need only visual cues as a reminder to ask for help with smoking cessation, to obtain timely mammograms, to exercise more regularly, or to follow up for management of depression Pronk and O'Connor, ; Rogers, Others respond more favorably to printed materials, coaching via telephone-based counseling, or classes.
Some patients cannot change health-related behavior without one-on-one structured education and counseling supplemented by frequent reinforcement from their physicians. Multiple modalities of support are used in the practices that are most heavily committed to encouraging beneficial behavior change and that target individual patients Oxman et al.
Similarly, multiple methods are necessary to communicate with physicians and other clinical staff to encourage behavior change on their part that reinforces patient behavior change Green et al. Chart reminders, computerized medical records with automated protocols, and physician and other staff education have all shown promise Buntinx et al.
A second beneficial approach to behavioral intervention is the organizational leadership to decide to focus on a problem and devote energy and resources to it Greer, ; Hammer and Champy, ; Oxman et al. A clinical practice that has an enhanced capacity to change patients' health-related behavior has leadership able to relate to the physician staff members and to engender enough emotional, internal, political, and economic support to drive behavior-change efforts toward success Davis and Taylor-Vaisey, That presents a major challenge because most clinical practices are organized to deliver acute care rather than to change patients' behavior to prevent illness Walsh and McPhee, Engaging busy practices to reach into new health promotion endeavors for which there is little economic reward is challenging, no matter how dedicated the leadership and clinical staff Fishman et al.
Rising to such a challenge tests the leadership and organizational adaptability of any practice that also must comply with innumerable legal, business, and clinical regulations and requirements.
Many variables peculiar to a given practice—such as physician attitudes, local competitive pressures, staff morale, and socioeconomic needs of the patient population—can enhance or inhibit change in the practice toward a greater focus on prevention or other innovation Crabtree et al.
For example, changing practice patterns to document brief but consistent efforts to encourage smoking cessation initially proved beyond the reach of many good practices Kottke et al. Health care systems and practices in the United States are moving toward use of methods to increase the predictable quality and efficiency of medical care Berwick, ; Carlin et al. Current quality improvement models propose a more active and continuous method of identifying problems and testing interventions.
This is a change from traditional methods of identifying faulty practices and practitioners by investigating clinical cases that have unsatisfactory outcomes Balas et al. Rather than a list of poorly performing health providers, the result of a continuous improvement model can be a testable hypothesis that outlines a series of steps for caring for patients with specific problems that can result in measurable improvement in outcomes or processes Crabtree et al.
A simplified continuous-improvement model has four steps: Working with two large managed-care organizations, Solberg et al. Previous research showed that even when external technical assistance succeeded in increasing preventive services, the services declined to baseline when the assistance ended Magnan et al. The intervention facilitated the formation of continuous improvement teams that instituted prevention processes Solberg et al.
However, the extent to which patients in the intervention practices are actually receiving more preventive services has not been determined. Clinical practice guidelines are formal statements that provide guidance to health care practitioners regarding specific clinical circumstances.
Ideally, guidelines are based on the best available scientific evidence and clinical judgment. They should lead to the best patient outcomes and should steer clinicians away from unnecessary or extravagant interventions. The appeal of practice guidelines has led to remarkable growth in their development.
An editorial in Lancet Fletcher and Fletcher, describes beleaguered clinicians faced with more than sets of guidelines. However, guidelines lack standards of quality and have been developed by fragmented groups that might have different goals, motivations, and capabilities. Furthermore, guidelines are often outdated by the time they are released, often ignore patient preferences Eddy,and often emphasize peer consensus rather than outcome evidence.
Many focused interventions to encourage health-related behavior change would benefit from population databases that keep track of patients' medical histories, behaviors, and attitudes. One fundamental factor for practice-based interventions is the availability of a database that defines the population served, accepts searches of health parameters or disease targets, and allows tracking of measurable changes in the defined health behavior or health outcome. An ideal database can link names, addresses, telephone numbers, diagnoses, pharmacy use, and other use of health care visits and educational resources Redding et al.
An example of a practice-based intervention that requires such a database is improving the diet and exercise patterns of poorly controlled diabetes mellitus patients and tracking their metabolic-outcome measurements for improvement Thomson O'Brien et al. However, there has been little systematic research on the benefits of such databases in the United States. Practice databases are available primarily in large, well-organized practices and in staff model health-maintenance organizations whose physicians or other providers are paid salaries.
They are not often used in smaller group practices because of the cost and personnel required to maintain them. Their use also raises major legal and ethical issues of privacy and confidentiality that have been the topic of several reviews Gostin, ; Sweeney, ; Woodward, Need for Research on Practice Much of the information in this section is based on evidence from uncontrolled trials and one-time interventions in large multispecialty group practices and well-organized staff model health maintenance organizations.
Some of the information is based on the opinions of experts. Little of what is known about dissemination is based on well-controlled trials wherein a practice-level intervention is compared with reasonably controlled and parallel practice. Only occasional studies e.
Little research funding in the past has been applied to systematic evaluation of fundamental systemic changes in clinical practices that might support health-enhancing behavior change in defined populations.
Future efforts should test various hypotheses that would encourage experimentation and practice-level interventions. Population-Based Interventions This section examines a sampling of studies that are representative of population-based intervention trials in a community, worksite, or school that are focused on changing individual behavior for primary prevention of disease.
Given the importance of shifting the population distribution of disease risk, the effectiveness of interventions must be measured among the entire population for whom the intervention is intended, and not only among program participants. In addition, because of the importance of accounting for the influence of secular trends and for other factors not associated with the intervention that could affect behavior change, the studies discussed here included intervention and control conditions alike.
Finally, to narrow the field of potential studies, a focus was given to those interventions conducted in the United States that targeted primary prevention of cancer or coronary heart disease, although the committee recognizes that considerable progress has been made using community interventions to address other public health problems. For subsequent intervention studies, however, funding did not permit following participants long enough or in sufficient numbers to determine long-term costs and consequences of the interventions for survival, quality of life, or disease incidence.
Instead, subsequent population-based intervention research rests on prior evidence linking behavioral outcomes to health benefits, such as reductions in morbidity and mortality Chapter 3. Thus, for most population-based trials, behavior change is the primary outcome. The behaviors examined include dietary changes, tobacco use, and physical activity.
Community-wide Trials Large-scale studies. Two early studies targeting cardiovascular disease prevention set the stage for population-based community intervention trials: Although the North Karelia Study was not done in the United States, it is included here because of its importance as a groundbreaking study of community intervention trials.
The North Karelia Project grew out of that community's concern about having the highest heart attack risk world-wide Blackburn, ; Keys, ; Verschuren et al. Results of a community-wide intervention implemented in North Karelia were compared with a reference area in eastern Finland. After 10 years, the net effects among middle-aged males included significant reductions in smoking, mean serum cholesterol concentrations, mean systolic blood pressure, and mean diastolic blood pressure; significant declines in mean systolic and diastolic blood pressure were observed among women Puska et al.
Initiated inthat study demonstrated the feasibility and potential effectiveness of mass-media-based educational campaigns combined with intensive instruction of individuals in group or home classes directed at entire communities Farquhar et al. Significant reductions in cholesterol and saturated fat were reported at the conclusion of the intervention and were sustained during a 1-year maintenance period Fortmann et al.
In the late s, three large community-wide intervention trials were funded by the National Heart, Lung, and Blood Institute: SFCP Farquhar et al. All targeted change in risk factors for coronary heart disease CHDincluding high blood pressure, elevated blood cholesterol, cigarette-smoking, and obesity.
None was randomized; rather, communities were matched to optimize comparability of study conditions Murray, The multiple-risk-factor intervention trials varied in length from 5 to 7 years, and they tracked changes in morbidity and mortality beyond the intervention period. The interventions were aimed at raising public awareness of CHD risk factors through media education.
Other objectives were to change risk-related behaviors through public education in schools, worksites, and other community organizations; educate health professionals; and initiate environmental change programs, such as labeling of foods sold in grocery stores and restaurants. For SFCP, significant effects were observed in blood cholesterol, smoking, and systolic and diastolic blood pressure; and decreases in risk—shown in composite risk factor indices— were significantly larger in the intervention than in the comparison communities Farquhar et al.
At the 3-year follow-up, the possibility was suggested of sustaining at least some observed outcomes, although the magnitude of the long-term effects was small Winkleby et al. MHHP reported significant effects for smoking prevalence among women and for physical activity Luepker et al.
PHHP resulted in smaller increases in body mass index in the intervention communities than in the controls; no other significant results were reported Carleton et al. The trial used 11 matched pairs of communities across North America, and it was designed to test the effectiveness of a multifaceted, 4-year community intervention to encourage smokers, particularly heavy smokers, to achieve and maintain cessation COMMIT,a.
A significant effect was observed among light-to-moderate smokers, and it appeared to be greater among a less-educated subgroup of participants COMMIT, a. Although not a randomized, controlled intervention trial, the American Stop Smoking Intervention Study ASSIST was a large-scale, 7-year demonstration project building on randomized community-wide intervention trials. The intervention was implemented in 17 states through a partnership among NCI, the American Cancer Society, state health departments, and other organizations.
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The primary goal was to reduce smoking prevalence and cigarette consumption. Comprehensive tobacco control programs emphasized policy interventions, including indoor air, pollution, youth access, advertising, and tobacco taxes, as well as mass-media interventions and program services such as cessation classes Manley et al. The intervention also included guidelines for raising cigarette excise taxes as a means of reducing consumption. Inflation-adjusted cigarette prices were nearly identical in both groups of states before Several recent community-wide studies have borrowed principles from the early large cardiovascular disease prevention trials, but they have been implemented on a smaller scale and with smaller budgets.
It might be difficult for such studies to achieve the necessary intensity and reach to show significant intervention effects. The Bootheel Heart Health Project, for example, was conducted in a six-county area in southeastern Missouri Brownson et al. This rural area has the largest African American population in Missouri, and it is characterized by high rates of poverty and low education levels.
The intervention was tailored to the community through the participation of local coalitions, each establishing its own priorities for intervention. The researchers conducted population-based cross-sectional surveys before and after the intervention to compare results in communities where there were coalitions against results from communities that did not have coalitions. Physical inactivity decreased and the prevalence of self-reported cholesterol screening increased in communities with active coalitions.
Differences observed in self-reported weight gain were in the right direction, although not statistically significant. No differences were found for fruit and vegetable consumption or for smoking prevalence. Similar results were observed in the Heart to Heart Project, which reported decreases in dietary fat consumption and increases in cholesterol screening Croft et al.
Baseline assessments confirmed the low levels of physical activity in the target population. Despite using community residents as interviewers, however, there were substantial problems in obtaining participation from randomly selected households, particularly in the initial survey.
Pre- and post-intervention physical activity scores were not significantly different in the intervention and control communities. In a move toward ensuring greater community input, the Kaiser Family Foundation's Community Health Promotion Grant Program CHPGP offered communities substantial flexibility in developing program targets that were responsive to local needs and priorities.
This program was designed to foster community health promotion efforts targeting cardiovascular disease, cancer, substance abuse, adolescent pregnancy, and injuries Tarlov et al. Comparisons among 11 intervention and 11 control communities, however, indicated little evidence of positive changes in the outcomes selected by the intervention communities Wagner et al. The ability to draw conclusions on the basis of these trials is limited by their designs and methods.
Only a few included an adequate number of communities to provide sufficient statistical power. Most studies used random samples for project evaluation, but the response rates varied widely, and few studies had adequate response rates. Most studies used nonvalidated self-report of behaviors as outcome measures. Few studies reported the results of process tracking. The assignment of multiple communities is expensive, and ultimately might require multicenter collaborations, such as that used in the COMMIT study.
Worksite Trials In the past 15 years, an increasing number of health promotion studies have been conducted in workplaces and worksites are now considered important channels for delivery of interventions to reduce chronic disease among adult populations Abrams, ; Abrams et al.
Many worksite trials have targeted cancer and cardiovascular disease risk factors either as discrete trials Byers et al. Most of those studies used individual behaviors as the primary outcome.
Intervention methods included strategies to incorporate employee input and a variety of activities based on tested behavior change theories. The reported interventions ranged from more intensive group behavioral counseling sessions of varying duration and number and supervised exercise prescriptions to less intense interventions with a wider reach, such as mailed self-help materials and newsletters. Several of the programs achieved statistically significant effects on smoking cessation Jeffery et al.
Jeffery and colleagues reported that where worksites changed from unrestrictive to restrictive tobacco control policies during the course of the intervention, there were significant reductions in smoking among employees. In the Working Well trial Sorensen et al.
That study center was unique in that it integrated an occupational health focus into the health promotion intervention, thereby targeting a key concern of workers in the participating worksites Sorensen et al.
The Working Healthy Project WHPa multi-risk-factor study that was part of the Working Well trial, showed significant increases in self-reported exercise behavior in the intervention group as compared with controls Emmons et al. Dishman and colleagues reviewed 26 studies of worksite interventions targeting physical activity, including those that did and did not use the worksite as the unit of analysis.
The poor scientific quality of the studies precludes judgment about whether such interventions can increase physical activity, and the researchers concluded that there is a need for studies that use valid designs and methods. School Trials Over the past two decades, extensive attention has been paid to health promotion and disease prevention among youth, particularly in schools. Schools provide an established setting in the community for reaching children and their families Best, ; Perry et al.
Several reviews summarize school-based smoking, physical activity, and nutrition education intervention trials from the s and s Best, ; Contento et al.
Some of those trials and analyses are reviewed here. Reviews of youth smoking-control interventions generally conclude that social influence interventions can curb smoking onset Best et al. The first Bruvold, found that effect sizes were largest for interventions that focus on social reinforcement, moderate for those with either a developmental orientation or a focus on increasing social norms, and small for interventions with a health information focus.
A second meta-analysis Rooney and Murray, reviewed 90 studies of school-based smoking prevention programs published in — They concluded that the influence of peer or social programs could be improved if they were delivered early in the transition from elementary to middle school e. The Life Skills Training LST program, a school-based intervention that teaches personal coping and social skills, has shown promising effects in both immediate and longer-term outcomes Botvin et al.
Recognition of multilevel influences on smoking in youths has led to multifaceted interventions, including schoolwide media campaigns in combination with individual approaches. Such programs have been effective in reducing smoking prevalence throughout secondary school Perry et al. A trial focusing on high-risk youths tested a combined program of mass media and standard school smoking prevention programs.
This program was implemented in two schools; two other schools the controls had only the school program. At the 2-year followup, prevalence of smoking in the schools was compared; participants in the combined program showed a significantly lower prevalence of smoking than the controls Flynn et al. A recent school-based smoking prevention program Peterson et al.
Students were followed from grade 3 until 2 years after high school. No significant differences between the control and experimental groups were evident at grade 12 or 2 years after high school suggesting that the intervention had little, if any, impact.
The highly controlled, and well-designed nature of the study, including the high follow-up rates, high compliance with the intervention, the maintenance of the randomization by the school districts, well-matched control and treatment groups, and appropriate statistical analysis, strongly suggest that the failure to achieve change was a result of a failed intervention and not poor methodology. This conclusion implies that future interventions need to take a different approach, critically rethinking the interactions of biological, behavioral, and psychosocial risk factors at social and cultural contexts.
A review of the literature of school-based physical activity intervention research in s and s Stone et al. In general, the studies found significant intervention effects for student knowledge and for psychosocial factors related to physical activity. Develop a safety plan. Tell your employees what you will do to ensure their safety and what you expect from them.
Make sure your employees have access to a first aid kit. Regularly check all equipment and tools to ensure that they are well maintained and safe to use.
Also check storage areas and review safe work procedures. Are boxes in your storage area stacked in a safe manner? Are your employees instructed how to lift heavy goods without injuring themselves? Do your employees know where the fire exit is and where they should gather if there is a fire?
Proper training is necessary for all employees, especially if there is a risk for potential injury associated with a job. Provide written instructions and safe work procedures so they can check for themselves if they are unsure of a task or have forgotten part of their training. Supervise your employees to ensure that they are using their training to perform their job properly and safely. By not providing the correct training for your employees you are not only endangering the safety of your employees but you will be held liable for the incident which could have serious consequences.
Talk regularly with your employees. Meet regularly with your staff and discuss health and safety issues. Encourage them to share their ideas and thoughts on how to improve safety in the workplace.