Report of the Expert Panel on Awareness and Behavior Change to the Board of Directors, American Heart Association
1996; Lippincott Williams & Wilkins; Volume: 93; Issue: 9 Linguagem: Inglês
10.1161/01.cir.93.9.1768
ISSN1524-4539
AutoresRichard A. Carleton, Terry L. Bazzarre, John D. Drake, Andrea L. Dunn, Edwin B. Fisher, Scott M. Grundy, Laura L. Hayman, Martha N. Hill, Edward Maibach, James O. Prochaska, Tom Schmid, Sidney Smith, Mervyn Susser, John W. Worden,
Tópico(s)Nursing Education, Practice, and Leadership
ResumoHomeCirculationVol. 93, No. 9Report of the Expert Panel on Awareness and Behavior Change to the Board of Directors, American Heart Association Free AccessResearch ArticleDownload EPUBAboutView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticleDownload EPUBReport of the Expert Panel on Awareness and Behavior Change to the Board of Directors, American Heart Association Richard A. Carleton, Terry Bazzarre, John Drake, Andrea Dunn, Edwin B. FisherJr, Scott M. Grundy, Laura Hayman, Martha N. Hill, Edward W. Maibach, James Prochaska, Tom Schmid, Sidney C. SmithJr, Mervyn W. Susser and John W. Worden Richard A. CarletonRichard A. Carleton , Terry BazzarreTerry Bazzarre , John DrakeJohn Drake , Andrea DunnAndrea Dunn , Edwin B. FisherJrEdwin B. FisherJr , Scott M. GrundyScott M. Grundy , Laura HaymanLaura Hayman , Martha N. HillMartha N. Hill , Edward W. MaibachEdward W. Maibach , James ProchaskaJames Prochaska , Tom SchmidTom Schmid , Sidney C. SmithJrSidney C. SmithJr , Mervyn W. SusserMervyn W. Susser and John W. WordenJohn W. Worden Originally published1 May 1996https://doi.org/10.1161/01.CIR.93.9.1768Circulation. 1996;93:1768–1772The Board of Directors of the American Heart Association charged the Expert Panel on Awareness and Behavior Change to:Evaluate the available data on the strengths and limitations of health education strategies targeted at increasing awareness of the benefits of cardiovascular risk factor management compared with strategies that specifically promote behavioral change.Consider the relative role of alternative strategies such as policy making and media campaigns in achieving the AHA's educational mission. The panel was asked to evaluate the AHA Strategic Plans for Consumer Nutrition Education and Promoting Physical Activity.Address the following questions: How can the AHA best invest its finite resources? Should the AHA's educational goals focus on and measure success through public knowledge and awareness of cardiovascular risk factors or behavioral change related to specific risk factors?Develop recommendations on how the AHA can best allocate its limited resources for health education and identify appropriate new methods of evaluating the effectiveness of its programs.Panel members reviewed background material on the structure and function of the AHA, then met in Dallas on October 17, 1995. Extensive discussions and the subsequent deliberations clarified the purpose of the decisions to be made by the Board of Directors. The panel spent a substantial amount of time and effort evaluating alternatives and assessing the strengths and risks or limitations of each. These alternatives are presented in Tables 1 through 5. This report presents the recommendations of the Expert Panel to the Board of Directors.Throughout these discussions the American Heart Association mission, "To reduce disability and death from cardiovascular diseases and stroke," was kept in mind. Consideration of the mission and the charge to the panel led to discussion of influences and steps toward fulfillment of this mission by the American public. This process is depicted in the Figure as an arrow.The central core of the arrow illustrates a sequence of change by individuals, groups of individuals, segments of the population, or the entire population. The arrow depicts a sequence from awareness (Table 1) of a modifiable health-related problem, through acquisition of skills to change behaviors that influence health, to actual altered behaviors (Table 2) that lead to a modification of risk factors, and finally to a decrease in disability and death from cardiovascular disease. The Figure also recognizes several powerful influences on risk (Table 3) and, ultimately, on disease: the physical environment in which we live; the social environment that influences our actions and behaviors; national and local policies that impact behaviors; and the role of the healthcare system itself in the entire sequence.The AHA's programs and messages (Table 4) are designed to fulfill its mission by reaching and favorably influencing the awareness, knowledge, behavior, risk, and health of all Americans. The panel has reviewed many of the principles of reaching large audiences. Programs can be targeted at individual, group, organization, community, or population-wide levels. The data clearly indicate that it is easier to arouse awareness than to change behavior. Yet behavioral change is a major step in fulfillment of the AHA mission. The panel recognizes the efficacy of programs targeting individuals and small groups. The panel also reviewed the evidence that suggests that community-based programs have achieved modest results, at best. The panel analyzed the evidence of the remarkable success of the AHA and its allied agencies, both governmental and nongovernmental, in producing favorable trends in most behaviors, cardiovascular risk factors, and age-adjusted death and disability rates. Many of these changes reflect programs, policies, and practices implemented at the national level through coalition building and advocacy.Accordingly, the panel does not recommend that the AHA seek an "either/or" decision concerning emphasis on awareness or behavioral change. Similarly, the AHA should not focus exclusively on either small-group programs or state- or national-level advocacy efforts. Instead, the panel recommends that many strategies and tactics have a place in moving the population toward achievement of the AHA mission (Table 5).Careful consideration of these factors has led the panel to present the following recommendations to the AHA Board of Directors for approval. These recommendations involve the program, evaluation, and structure of the AHA.Program1. Programs, messages, and educational strategies should be designed and implemented with the expectation that they are likely to move the population toward fulfillment of the AHA mission. There is no need to focus on any one element to the exclusion of others.2. The AHA should continue to use social marketing principles to identify the element to be influenced, specific target audiences, optimal educational strategies, and the most effective means of meeting the specific needs of the target audience.3. Programs should be based on tested theory whenever possible but can and should vary in expected outcome. Efforts to seek behavioral and risk factor change in population groups at higher risk of disability and death from cardiovascular disease is not only important but cost-effective. Those in the early stages of behavioral change may be moved by awareness and increased knowledge toward adopting more healthy behaviors.4. Programs to enhance the visibility of the AHA and generate resources are in keeping with efforts to move the population toward fulfillment of the AHA mission. Such messages, when combined with actual behavioral change, enhance a social environment that promotes good health.5. Program messages that are based on sound scientific evidence and consensus within the AHA must also be understood by the public. Nutritional information deemed appropriate by the AHA's science component may not be communicated at the level of comprehension required by the AHA's program component. For example, a catchy, yet scientifically sound message such as "5-a-day" may be a better program message than "Eat five servings of fruits and vegetables daily." Similarly, use of the terms "skim" or "1%" to describe low-fat or low–saturated fat dairy products may be more comprehensible to certain population segments. Describing a 3-ounce portion of meat as being the size of a deck of cards may be helpful to others.6. To optimize the use of its resources in fulfillment of its mission, effective AHA programs and messages (as judged through internal or external evaluation) delivered through the appropriate channels to responsive audiences are needed. Similarly, ineffective or unproved programs of limited reach (inappropriate or unresponsive audiences) should be discontinued.7. When feasible, coalitions with other organizations that share the AHA's goals in programming, visibility, and fund-raising should be formed and nurtured to present concerted rather than discordant or confusing messages to the public. An excellent example is the Coalition on Smoking OR Health. Previous efforts to develop a sustained multiagency coalition effort promoting an all-American diet should be resumed, even if the messages used originate from other agencies. Messages about nutrition and other behavioral changes should be communicated by several agencies in the same terms to avoid confusing the public.Evaluation1. Precise evaluation is costly. Given its limited resources, it is appropriate for the AHA to use a variety of methods to evaluate its programs and messages. Programs clearly indicated by previous data as successful in generating awareness, changing knowledge, or changing behavior (or even image enhancement and fund-raising) do not require additional evaluation. Program evaluation should be used to the extent required to show that products are effective and that they reach targeted individuals. Product designs based on previously tested principles may require only limited formative pretests with targeted individuals, coupled with process tracking to ensure delivery. When evaluation data are limited, pilot testing is necessary. Formative evaluation is particularly important for new approaches, such as interactive computer programs. Subsequent versions of the same approach do not require outcome assessment (eg, awareness or behavior).2. It is recommended that the AHA not use its resources to conduct long-term follow-up of behavioral change by all program participants. Extrapolation from pilot data or data obtained from other sources is a practical measure of the effectiveness of such efforts.3. It is recommended that the AHA not expect to be able to conclusively attribute long-term risk factor or cardiovascular disease disability or death trends to a single program or even its own global efforts. To be part of a movement toward fulfillment of the AHA mission is sufficient.4. Proper topics for AHA research support, in addition to basic molecular and clinical science, include public health disciplines such as health communications, health marketing, health services, behavioral medicine, program evaluation, and evaluation of individual and collective behavior. Research in these disciplines will enhance understanding of formulation, delivery, and evaluation of effective programs and messages within the AHA and elsewhere.5. Collaborative efforts in evaluation, as in program delivery, are worthy of consideration. Industry partners (eg, members of the Pharmaceutical Roundtable or other pharmaceutical/medical equipment manufacturers) may want to support program evaluation. A partnership with the Centers for Disease Control and Prevention (CDC) may provide opportunities to use or even add questions to the Behavioral Risk Factor Surveillance System on a national, regional, or state basis. In turn, pilot tests of programs or messages on a state or regional basis may facilitate evaluation through such a partnership. The National Center for Health Statistics National Health and Nutrition Examination Survey (NHANES) may also provide low-cost evaluative resources.6. Consider creation of a mechanism to set aside a portion of AHA research funds to support rigorous program evaluation as needed through a Request for Proposals, developed cooperatively by the science and program components of the AHA.Structure1. Continued use of market teams to reach specific target audiences and the flexibility to create new teams or modify existing teams is recommended.2. Program and channel prioritization processes should continue to include analyses of population segments, their risk level, ease and cost of access, cost-effectiveness, and likelihood of useful outcomes based on stage of change. This prioritization matrix should be reevaluated at least biennially.3. It is important that AHA staff and volunteers in the areas of science, program, and communications have effective ongoing communication, common goals, and common messages. Accordingly, the Science Advisory and Coordinating Committee should include as regular members persons with expertise in community program design and delivery as well as persons with a public health communications background.4. The Board of Directors must ensure better communication among these groups so that credible and comprehensible awareness and behavioral change programs and messages are delivered to and received by the public. In the event of disagreement, the Board should decide how scientifically credible programs and messages are best delivered.BibliographyCommentary/PerspectivesFisher EB Jr. The results of the COMMIT trial: Community Intervention Trial for Smoking Cessation. Am J Public Health. 1995;85:159-160.Fortmann SP, Flora JA, Winkleby MA, Schooler C, Taylor CB, Farquhar JW. Community intervention trials: reflections on the Stanford Five-City Project Experience. Am J Epidemiol. 1995;142:576-586.Green SB, Corle DK, Gail MH, Mark SD, Pee D, Freedman LS, Graubard BI, Lynn WR. Interplay between design and analysis for behavioral intervention trials with community as the unit of randomization. Am J Epidemiol. 1995;142:587-593.Koepsell TD, Diehr PH, Cheadle A, Kristal A. Invited commentary: symposium on community intervention trials. Am J Epidemiol. 1995;142:594-599.Lefebvre RC, Lurie D, Goodman LS, Weinberg L, Loughrey K. Social marketing and nutrition education: inappropriate or misunderstood? J Nutrition Ed. 1995;27:146-150.McAlister A. Behavioral journalism: beyond the marketing model for health communication. Am J Health Promotion. 1995;9:417-420.Mittelmark MB, Hunt MK, Heath GW, Schmid TL. Realistic outcomes: lessons from community-based research and demonstration programs for the prevention of cardiovascular diseases. J Public Health Policy. 1993;14:437-462.Murray DM. Design and analysis of community trials: lessons from the Minnesota Heart Health Program. Am J Epidemiol. 1995;142:569-575.Susser M. The tribulations of trials: intervention in communities. Am J Public Health. 1995;85:156-158.Vanden Heede FA, Pelican S. Reflections on marketing as an inappropriate model for nutrition education. J Nutrition Ed. 1995;27:141-145.Research ReportsAirhihenbuwa CO, Kumanyika S, Agurs TD, Lowe A. Perceptions and beliefs about exercise, rest, and health among African-Americans. Am J Health Promotion. 1995;9:426-429.Blum A. Paid counter-advertising: proven strategy to combat tobacco use and promotion. Am J Prev Med. 1994;10(suppl 3):8-10.Campbell MK, DeVellis BM, Strecher VJ, Ammerman AS, DeVellis RF, Sandler RS. Improving dietary behavior: the effectiveness of tailored messages in primary care settings. Am J Public Health. 1994;84:783-787.Cardinal BJ, Sachs ML. Prospective analysis of stage-of-exercise movement following mail-delivered, self-instructional exercise packets. Am J Health Promotion. 1995;9:430-432.Carleton RA, Lasater TM, Assaf AR, Feldman HA, McKinlay S. The Pawtucket Heart Health Program: community changes in cardiovascular risk factors and projected disease risk. Am J Public Health. 1995;85:777-785.Community Intervention Trial for Smoking Cessation (COMMIT), I: cohort results from a four-year community intervention. Am J Public Health. 1995;85:183-192.Community Intervention Trial for Smoking Cessation (COMMIT), II: changes in adult cigarette smoking prevalence. Am J Public Health. 1995;85:193-200.Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700-705.Emont SL, Zahniser SC, Marcus SE, Trontell AE, Mills S, Frazier EL, Waller MN, Giovino GA. Evaluation of the 1990 Centers for Disease Control and Prevention smoke-free policy. Am J Health Promotion. 1995;9:456-461.Farquhar JW, Fortmann SP, Flora JA, Taylor CB, Haskell WL, Williams PT, Maccoby N, Wood PD. Effects of communitywide education on cardiovascular disease risk factors: the Stanford Five-City Project. JAMA. 1990;264:359-365.Gemson DH, Sloan RP. Efficacy of computerized health risk appraisal as part of a periodic health examination at the worksite. Am J Health Promotion. 1995;9:462-466.Goodman RM, Wheeler FC, Lee PR. Evaluation of the Heart To Heart Project: lessons from a community-based chronic disease prevention project. Am J Health Promotion. 1995;9:443-455.Holt MC, McCauley M, Paul D. Health impacts of AT&T's Total Life Concept (TLC) Program after five years. Am J Health Promotion. 1995;9:421-425.Luepker RV, Murray DM, Jacobs DR Jr, Mittelmark MB, Bracht N, Carlaw R, Crow R, Elmer P, Finnegan J, Folsom AR, et al. Community education for cardiovascular disease prevention: risk factor changes in the Minnesota Heart Health Program. Am J Public Health. 1994;84:1383-1393.Requests for reprints should be sent to the Office of Scientific Affairs, American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231-4596.Download figureDownload PowerPoint Figure 1. Influences and steps toward fulfillment of the American Heart Association mission. CVD indicates cardiovascular disease. Table 1. Awareness and Knowledge as Elements of Heart-Health PromotionStrengthsLimitations• Programs or messages that increase awareness and knowledge may be all that some segments of the target population are ready to attend or receive.• Studies and surveys suggest that many respondents already have a high level of awareness and knowledge but lack the skills for or need additional information on how to make behavioral changes.• Increased awareness and knowledge is often a necessary first step before behavioral change.• Awareness and knowledge are universally perceived as insufficient for promotion and maintenance of long-term behavioral change.• People are motivated and helped to change their behaviors.• Lack of impact on many population segments limits benefit.• Changes in awareness and knowledge can be relatively easy to measure.• Documented changes in awareness and knowledge do not ensure that risk factors or disease rates will change.• It is relatively easy to reach large numbers of people.• "Dose" is usually low.• Readiness to learn can change over time and vary across situations and behaviors.• The benefits of awareness and knowledge programs are dependent on the readiness of the audience to learn and individual learning styles. Acceptance of programs is also influenced by cultural norms.• Information can be presented in stepped levels of complexity and adapted to specific audiences.• If too complex, some programs or messages can be ineffective.• Use of information is influenced by the credibility of the source. The AHA is viewed as a very credible source. This view can be enhanced through better communication between the AHA's science and program components.• In the interest of maintaining its credibility, the AHA may be slow to respond to or be associated with issues without 100% consensus. Such a consensus can be difficult to achieve when bridging the science and program components of the AHA.• The effectiveness of a program or message is often proportional to the strength of the science on which it is based.• A weak, incomplete, or inconsistent science base limits choices of program topics and program effectiveness (eg, trans fatty acids, antioxidants).• The visibility of programs for change in awareness and knowledge enhance public perception of the AHA and facilitate fund-raising.• Too great a focus on fund-raising may dilute the message of change. Table 2. Cardiovascular Disease Risk Factor–Related Behavioral Change as an Element of Heart-Health PromotionStrengthsLimitations• Behavioral change is a necessary and often sufficient step toward changing risk and reducing disease and thus is near the "bottom line."• Behavioral change is more complex and usually requires awareness, knowledge, and skill.• Behavioral change may be the only appropriate outcome for certain programs or approaches.• The intensity and cost of successful behavioral change programs is relatively high.• Programs can be targeted to a segment of the audience: for example, "overexposed," ready-to-change population segments can create a social environment of "exemplars" who influence later "adopters."• Behavioral change may miss population segments that are less ready to change but at greater risk.• Behavioral change can be targeted differently to reach those for whom behavioral change is cost-effective.• It is impractical to aim programs and messages at those who will not or who do not need to change or for whom behavioral change will not alter disability or disease outcomes.• Strong messages from multiple agencies and sources, with similar phrasing and imagery are likely to influence the social-informational environment and foster greater change (eg, the "5-a-day" message from the USDA, the AHA, the National Institutes of Health, the American Cancer Society, and industry).• Coalitions require effort and resources to build. Table 3. Influencing the Physical and Social Environments and the Healthcare System Through Advocacy and Policy Changes as Elements of Heart-Health PromotionStrengthsLimitations• Policy changes through effective advocacy can be a powerful force for change in social environment.• It is difficult to conduct focal evaluation permitting causal attribution.• Policy changes are effective for changing physical and social environment and powerfully influencing behavior (eg, smoking disincentives by policy, regulation, law, or economic means).• Some initiatives create antagonism in some segments of society (eg, users of tobacco products).• Policy changes are effective on the societal and environmental levels.• Limited knowledge, especially of second- or third-level effects of policy or legal changes, limits ability to gauge effectiveness (eg, does the dairy subsidy now enhance lower or higher milk-fat consumption?).• Policy changes are applicable at multiple levels of society and organizations such as worksites or clubs and community, state, and national programs. They are available at the national, affiliate, and divisional levels and through multiple channels: legislative, regulatory, marketing, lobbying, and proclamations.• Policy changes are especially controversial in a political environment favoring fewer governmental directives or regulations. Effectiveness is influenced by soundness of the science; social, political, and financial costs; and advocacy skills.• Implementation at multiple levels or in stages is possible:−Restricted or facilitated production−Restricted or facilitated sale of products−Raised or lowered taxes on products• The best effect, often requiring multiple levels simultaneously, can be difficult to achieve.• Specific locations (restaurants, airlines), regions (eg, the Northeast, the Southwest), and population segments (eg, young black men, older white women) can be targeted.• Creation of a class of "pariahs" is possible, causing isolation, lowered self-esteem, and possible antagonism toward certain population segments (eg, smokers).• All elements or organizations can be influenced from management down or across disciplines, and multiple organizations or multisite organizations can be linked to a common goal.• Coordination of AHA resources at all levels under the direction of the Board of Directors is required.• Simple messages can be used to create action orientation. A gradual or staged approach can be used to foster evolution rather than revolution.• Clear policy development, ability to focus on simple messages, and endorsement by the Board of Directors are needed. Table 4. Media, Other Information Paths, and Social Marketing as a Means of Influencing Heart-Health PromotionStrengthsLimitations• Population analyses can identify special audiences by characteristics such as age, demographic features, literacy, etc.• Analyses to identify narrow audience segments can be costly.• Information, programs, and products can be developed, tested, and delivered to meet the needs and interests of specific target audiences.• Product targeting requires special expertise and resources.• The media represents only a single important channel for social marketing.• Reception varies by the medium used; selecting the best media channels for each targeted population segment is difficult.• Simple messages implemented with multiple exposures and follow-up activities are often the most effective and powerful.• Simple messages may not convey the entire scientific base or complete accuracy, posing concern for some segments of the AHA. Ongoing investment for repetition is required.• Frequency and reach can be measured.• Accuracy of inferences about impact may be suspect but improved if accepted marketing methods are used.• Impact of information transmitted can be estimated.• Accurate measurement of impact is more costly.• Adaptation for delivery through the information superhighway is possible.• Reach and impact are more difficult to assess. Assessment is limited to certain audience segments at present.• Large numbers of people can be reached, and the program can be designed to reach the "hard to reach."• Audience research and multiple special programs or messages can be costly.• Some options, such as public service time, may be free or low cost.• Purchased space or time can be costly, but equivalent public service time is often available.• There is potential for sponsorships and partnerships with industry, governmental agencies, and other voluntary health agencies.• Ensuring that messages and programs are acceptable to all partners may involve compromising the accuracy or completeness of the message.• It is possible to develop powerful and memorable visual or audible images.• Simple concepts may require careful design and testing to avoid compromising the integrity of the science base.• Modeling of behaviors can be displayed or described to narrowly defined audiences.• Use of audience-specific models may limit reach or impact on targeted subpopulations.• Some channels (eg, interactive computer programs) are compatible with the learning styles of a relatively small segment of the total population.• Some distribution channels are not effective or are unavailable for many others.• Many channels (eg, infomercials, public service announcements, paid advertising, entertainment programs and documentaries, and on-line chat rooms) are available.• Effective use of each distribution channel requires development, implementation, and evaluation by staff with relevant experience. Table 5. Evaluation as a Means of Measuring Progress in Heart-Health PromotionStrengthsLimitations• Measurement of risk factors provides accuracy and assurance and is directly relevant to the AHA's mission. Self-reported data are also useful.• Cost for actual risk factor measurement is highest. Cost for self-reported behaviors is lower.• Adding on or adapting ongoing AHA Random Digit Dialing surveys is a cost-effective approach.• Add-ons may infringe on the purpose of the survey.• Adding on to surveys by potential partners (eg, the CDC's Behavioral Risk Factor Surveillance System) by region, state, or nation, or adopting or adding queries to other data sources such as NHANES are other possibilities.• Cooperative efforts with other agencies, such as the American Cancer Society, the American Lung Association, and the American Diabetes Association, may be required.• Some programs can be formatively evaluated only and results, if obtained in pilot testing, generalized to subsequent versions of the program.• Generalization of results will be limited if new groups of participants differ demographically.• Measuring distribution of materials or messages can be an inexpensive alternative for measuring change in awareness or knowledge.• Low cost is paralled by low precision in estimating impact. Distribution may not be an adequate alternative, especially among population segments with low education or receptivity.• Trends in risk factors and disease provide a measure of efficacy.• The ability to discern the specific impact of AHA efforts from those of other agencies is limited.• A registry of program participants permits audience characterization and follow-up.• Registries can be costly in terms of staff time and participant burden.• Evaluation is critical to learn what works and to avoid wasting resources on what doesn't.• Accurate evaluation data that meet standards of validity and reliability are often expensive.• It is desirable to evaluate changes in various population subgroups.• Evaluation resources are limited and require a focus on testing audiences likely to make changes.CDC indicates Centers for Disease Control and Prevention; NHANES, National Health and Nutrition Examination Survey. 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