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Promoting Health: Intervention Strategies from Social and Behavioral Research PAPER CONTRIBUTION F Behavioral and Social Science Contributions to the Health of Adults in the United States Karen M.Emmons, Ph.D. The purpose of this paper is to briefly review the major causes of morbidity and mortality during adulthood and to provide a selected review of the literature that addresses efforts to reduce the prevalence of preventable disease among adults in the United States. Substantial progress has been made in reducing risk factor prevalence among adults. The premise of this paper is that the social and behav- Dr. Emmons is associate professor, Department of Adult Oncology, Dana-Farber Cancer Institute, Dana-Farber/Harvard Cancer Center, and associate professor, Department of Health and Social Behavior, Harvard School of Public Health. This paper was prepared for the symposium, “Capitalizing on Social Science and Behavioral Research to Improve the Public's Health,” the Institute of Medicine and the Commission on Behavioral and Social Sciences and Education of the National Research Council, Atlanta, Georgia, February 2–3, 2000. The author would like to thank Edwin Fisher, Russ Glasgow, Ellen Gritz, David Hemenway, Bernard Glassman, Sue Curry, Barbara Rimer, Tracy Orleans, and Judy Ockene for their thoughts on the topic of this paper and the future directions of the field. The author would also like to thank Glorian Sorensen for her contributions to the conceptualization of this manuscript and her ongoing contributions to the author's research. Jocelyn Pan contributed significantly to reviewing the literature discussed in this paper, and Mary Eileen Twomley provided editorial and manuscript preparation assistance. Portions of this paper are drawn from the author's previous writings (Sorensen et al., 1998, 1999; Emmons, in press). This work was supported by grants from the Liberty Mutual Insurance Group, NYNEX, Aetna, the Boston Foundation, and NIH Grants 1RO1CA73242 and 1RO1HL50017 Best Beginnings: 5RO1 CA73242–04; PO1:1 PO1CA75308 –01A2; Polyp: 5RO1CA74000–02; CCSS: 1 R01 CA77780–02.
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Promoting Health: Intervention Strategies from Social and Behavioral Research ioral sciences have made a significant contribution to these improvements. These contributions include providing a broader perspective on disease causation that goes beyond biomedical approaches, utilizing theory-based interventions, evaluating intervention strategies that vary in intensity and cost, and utilizing population-based approaches that extend intervention research beyond high-risk populations. A great deal of what we have learned has considerable potential for yielding greater intervention outcomes than have been achieved to date. A number of issues will be discussed that need to be considered in the design and evaluation of health behavior interventions in order to further advance our progress. These issues are presented briefly here and discussed in further detail later in the paper. First, research is needed that connects and bridges individual, community, environmental, and policy-level interventions. Second, more research is needed in how to effectively target multiple risk factors for chronic disease and to take advantage of naturally occurring relationships between health behaviors. Third, behavioral scientists need to anticipate the impact that advances in computer technology may have on intervention development and delivery, and to be prepared to take advantage of the resources that this technology has to offer. Fourth, it is argued that while there have been a number of innovations emanating from the behavioral and social sciences related to intervention design and delivery, such strategies are not typically implemented outside the research setting. Significant attention needs to be given to the issues of sustainability and dissemination because current efforts to disseminate effective interventions are poor. Finally, increased attention to social contextual factors that influence the development and maintenance of health behaviors is needed. Major Risks to Health During Adulthood Leading causes of morbidity and mortality among adults vary by age and gender, but are largely preventable. A brief review follows of the three leading causes of morbidity and mortality during early to middle and middle to older adulthood (see Table 1). Leading Causes of Mortality in Early to Middle Adulthood (Ages 20 –45) In early to middle adulthood, the leading cause of mortality is unintentional injuries. Among very young adults (≤24 years), injuries account for 77% of all deaths. The homicide rate among young males is almost 20 times higher than that found in most other industrialized nations (MMWR, 1993; Rachuba et al., 1995; Rosenburg, 1995). Across all age groups during adulthood, motor vehicle accidents account for the majority of deaths due to injury, although the death rate per miles driven has been reduced substantially in the past three decades (Bonnie, et al., 1999). Death rates for motor vehicle accidents are nearly equi-
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Promoting Health: Intervention Strategies from Social and Behavioral Research TABLE 1. Leading Causes of Death and Numbers of Death, According to Age and Gender, United States, 1996 Age 25–44a Age 45–64b Malesc Femalesd Cause of Death Deaths Rank Deaths Rank Deaths Rank Deaths Rank Unintentional injuries 27,092 1 16,717 3 61,589 4 33,359 7 Malignant neoplasms 21,894 2 131,455 1 281,898 2 257,635 2 HIV 21,685 3 8,053 8 25,227 8 Heart disease 16,567 4 102,369 2 360,075 1 373,286 1 Suicide 12,602 5 7,762 9 24,998 9 Homicide and legal intervention 9,322 6 Chronic liver disease and cirrhoses 4,210 7 10,743 7 16,311 10 Cerebrovascular diseases 3,442 8 15,468 4 62,475 3 97467 3 Diabetes 2,526 9 12,687 6 27,646 7 34,121 6 Pneumonia and influenza 2,029 10 5,706 10 37,991 6 45,736 5 Chronic obstructive pulmonary disease 12,847 5 54,485 5 51,542 4 Alzheimer's disease 14,426 8 Nephritis 12,662 9 Septicemia 12,177 10 aAll cause mortality = 147,180. bAll cause mortality = 378,054. cAl1 cause mortality = 1,163,569. dAll cause mortality = 1,151,121.
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Promoting Health: Intervention Strategies from Social and Behavioral Research valent for black, white, and Hispanic men, although much lower for Asian men. Motor vehicle death rates among women are about one-third of those found in men. Fires also cause a substantial proportion of unintentional injuries; cigarettes are a major cause of residential fires (Baker et al., 1992). On average, one out of every 200 households experiences a fire each year; this rate is greater among poor households (National Center for Health Statistics, 1996b). Cancer is the second leading cause of death in early to middle adulthood. The death rate due to cancer among men and women is roughly equivalent for whites, Hispanics, and Asians; it is significantly higher among black men than black women, and is higher among Native American women than Native American men (USDHHS, 1998). In this age range, cancer morbidity is greater among women, especially those ages 35–44, and is most common among blacks, followed by whites. Similar patterns in morbidity rates by race or ethnicity are found among men. Cancer morbidity has also consistently been found to have an inverse relationship with socioeconomic status (SES) (Devesa and Diamond, 1980, 1983; McWhorter et al., 1989; Morton et al., 1983; Tomatis, 1992; Williams and Horm, 1977). The third leading cause of death in early to middle adulthood is HIV; incidence is clustered in large metropolitan areas. Gay and bisexual men still represent most prevalent HIV infections; although overall incidence is significantly lower now than in the 1980s; incidence among young and minority gay men remains high (Holmberg, 1996). Roughly half of all new infections occur among injection drug users (IDUs). Black and Hispanic IDUs are more likely to be HIV infected than are white IDUs (Friedman et al., 1999). In 1997, 22% of all new adult AIDS cases were in women. In the United States, AIDS cases among women have been concentrated in blacks and Hispanics (Kamb and Wortley, 2000). The primary routes of transmission among women are injection drug use and heterosexual contact with an HIV-infected male sex partner. Leading Causes of Mortality in Middle to Older Adulthood (ages 45 –64) The leading cause of death from ages 45 to 64 is cancer. Heart disease is the second leading cause of death in this age group; death rates are three times greater in men than women. Death rates due to heart disease are twice as high in black men as in white men, and slightly higher for Native American men than white men. Unintentional injury is the third leading cause of death in this age range (USDHHS, 1999). Leading Causes of Morbidity in Adulthood Morbidity related to a number of chronic conditions can cause substantial reductions in quality of life and contribute significantly to medical care costs. In the United States, 24% of adults have been diagnosed with hypertension (Burt et
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Promoting Health: Intervention Strategies from Social and Behavioral Research al., 1995); prevalence increases with age and is slightly higher among men than women (He and Whelton, 1997); age-adjusted prevalence is higher in non-Hispanic blacks than non-Hispanic whites (Burt et al., 1995; Hall et al., 1997). Among both blacks and whites, hypertension is higher among men than women. The prevalence of hypertension in Mexican Americans is lower than in non-Hispanic whites. Asian Americans have lower prevalence of hypertension compared to other ethnic groups. The severity of hypertension is greater among those of low SES (Moorman et al., 1991). The prevalence of diabetes has increased over the past decade (USDHHS, 1996a). It is estimated that 15.7 million persons in the United States have diabetes (MMWR, 1997; National Diabetes Information Clearinghouse, 1999). The overall prevalence of diabetes increases with age. The prevalence rate among blacks is more than 80% higher than for the total population; rates among American Indians or Alaskan Natives and Mexican Americans are also quite elevated, compared to the total population (Harris, 1998; MMWR, 1997). Heart disease is the leading cause of diabetes-related deaths. Type 2 diabetes, which accounts for more than 90% of all diagnosed diabetes, is associated with modifiable risk factors (e.g., obesity, physical inactivity) and nonmodifiable risk factors (e.g., genetic factors or family history, age, and race or ethnicity). Mental health problems are a major concern in adulthood. Between 10 and 15% of adults in the United States have a diagnosable mental disorder, and up to 24% of adults have experienced a mental disorder during the preceding year (MMWR, 1998; Regier et al., 1993a; Robins et al., 1981). The impact of mental health problems on functional disability and quality of life is profound (Wells et al., 1989a). Marital status (being divorced or separated) and having low SES are powerful correlates of mental health problems (Bebbington et al., 1981; Henderson et al., 1979; Hodiamont et al., 1987; Mavreas et al., 1986; Regier et al., 1993a; Surtees et al., 1983; Vazquez-Barquero et al., 1987). After controlling for other factors, there are no racial or ethnic differences in mental health disorders (Regier et al., 1993a). Substance use disorders are most common among very young adults, while affective disorders are elevated in early to middle adulthood; all mental disorders are less common during older adulthood than in the younger age group. Men are more likely to have substance use disorders and personality disorders; women are more likely to have affective and anxiety disorders (Kessler et al., 1994). Unintentional injuries are also the cause of significant morbidity during adulthood, as well as mortality as noted above. In addition to the morbidity associated with motor vehicle and other types of accidents, occupational injuries and exposures cause 13.2 million nonfatal injuries and 862,200 illnesses occurring among the American workforce annually (Leigh et al., 1997).
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Promoting Health: Intervention Strategies from Social and Behavioral Research Risk Factors for Primary Causes of Morbidity and Mortality During Adulthood Over the past three decades there has been extensive research into the causes of heart disease, cancer, and other chronic diseases. As noted above, age and gender are nonmodifiable risk factors for certain diseases, although the direction of this effect varies considerably across diseases. Genetic causes of chronic disease have become the focus of intense research attention in the past decade. Genetic factors have been implicated in certain forms of diabetes (Kahn et al., 1996), cancer (Easton and Peto, 1990), stroke (Rastenyte et al., 1998), and myocardial infarction (Marian, 1998). However, in most cases the overall contribution of genetics to disease incidence is likely to be relatively small compared to behavioral or environmental factors (Lerman, 1997). Social epidemiology has demonstrated the profound effect that social class has on health (Emmons, 2000). Although SES is typically thought of as a non-modifiable modifying condition in epidemiological and behavioral research, a growing body of work suggests that if we are ever to make a significant impact on economic disparities in health, we need to begin efforts in which we reconceptualize socioeconomic status as a modifiable variable, both in our research efforts and in political dialogue. Modifiable risk factors for chronic disease morbidity and mortality include individual and environmental-level exposures. Strong relationships exist between health behaviors and risk for all of the leading causes of morbidity and mortality during adulthood. For example, heart disease, stroke, and cancer have been linked to a number of modifiable risk factors, including physical inactivity, obesity, hypertension, cholesterol level, diet, smoking, and sun exposure (He and Whelton, 1997; Wilson and Culleton, 1998). For many diseases, screening and early detection strategies are available that can reduce the severity of disease and substantially increase survival time. Environmental or organizational-level risk factors include occupational exposure and work practices, motor vehicle and other product design, and environmental design (e.g., highway redesign). A number of recommendations have been put forth for the adoption of health-promoting behaviors in order to reduce the incidence of chronic disease morbidity and mortality (Greenwald et al., 1995; U.S. Preventive Services Task Force, 1996; USDHHS, 1996b, 1996c). The latest health promotion guidelines related to the primary causes of morbidity and mortality among adults are outlined in Box 1. WHERE DO WE STAND? There have been some significant improvements in morbidity and mortality rates over the past several decades; deaths from cardiovascular disease have declined dramatically (Cole and Rodu, 1996; USDHHS, 1996c), and cancer mortality has recently declined for the first time since such records have been kept (Heath et al., 1995). Recent data from the Framingham Heart Study suggest that
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Promoting Health: Intervention Strategies from Social and Behavioral Research there have been secular changes toward a less disabled and generally healthier population among adults aged 55 to 70 (Allaire et al., 1999). Of note, there have been improvements on 59% of the Healthy People 2000 target objectives (National Center for Health Statistics, 1996b). These successes should be celebrated, and social and behavioral scientists should be recognized for their contributions to these gains and to our understanding of the factors that influence health behaviors among diverse populations (Airhihenbuwa et al., 1996; Braithwaite et al., 1994; Kirsch et al., 1993; Kumanyika and Morssink, 1997; Kumanyika and Charleston, 1992; Pasick et al., 1996; Resnicow et al., 1999; Snow, 1974; Weiss et al., 1992). However, despite these gains, many diseases continue to have disproportionately high prevalence among minority groups. In addition, a number of studies highlight the importance of further improving behavioral risk factor prevalence on a population level, across all race, ethnicity, and gender groups. It has been estimated that community-based cholesterol interventions are cost-effective if cholesterol is reduced by as little as 2% (Tosteson et al., 1997). Other estimates suggest that implementation of currently available cancer prevention and early detection strategies at the population level could reduce U.S. cancer mortality by approximately 60% (Colditz et al., 1996; Willett et al., 1996). Given the encouraging estimates of the additional health gains that could be achieved from population-level adoption of recommended health behaviors, and the fact that many gains have been made, it is still disheartening that more than 50 years after the Framingham Heart Study demonstrated that behavioral risk factors greatly increase the risk of developing coronary heart disease, the prevalence of risk factors for this and many other diseases remains high. Only 24% of Americans engage in light to moderate physical activity at recommended levels (National Center for Health Statistics, 1996b). Racial and ethnic minority populations are less active than white Americans, with the largest differences found among women (Caspersen et al., 1986; Caspersen and Merritt, 1992; DiPietro and Caspersen, 1991). Physical activity patterns are also directly related to educational level and income (Caspersen et al., 1986; Centers for Disease Control and Prevention, 1990; Folsom et al., 1985; Siegal et al., 1993). Obesity is considered by some to be reaching epidemic proportions in the United States, with 18% of the U.S. adult population being obese and almost 60% being overweight (Must et al., 1999). Of particular concern is the recent finding that across most population groups, the prevalence of obesity and overweight is increasing rapidly (Mokdad et al., 1999). Significant improvements have been made in dietary habits over the past several years. Although the median intake of fruits and vegetables among adults is still less than five servings per day (Subar et al., 1995), intake has increased significantly since 1989 (National Cancer Institute, 1997). Consumption of red meat has also decreased substantially (U.S. Department of Agriculture, 1991). Fruit and vegetable consumption is higher among women than men at all ages, although the gender difference appears to increase with age. Lower-income households have significantly lower consumption of fruits and vegetables (Krebs-Smith et al., 1995), and have experienced less reduction in red meat con-
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Promoting Health: Intervention Strategies from Social and Behavioral Research sumption compared to higher-income households (Interagency Board for Nutrition Monitoring and Related Research, 1993). Recent data indicate that 24.7% of adults smoke in the United States (MMWR, 1999), which represents a dramatic reduction in smoking prevalence over the past 30 years (Centers for Disease Control and Prevention, 1996). However, overall smoking prevalence has been virtually unchanged in the past 5 years. Educational status remains the strongest predictor of smoking status (Novotny et al., 1988; Pierce et al., 1989). Of particular concern is the recent finding that smoking prevalence among very young adults (ages 18–24) has increased substantially. Although there have been many increases in the prevalence of safety and injury prevention behaviors, only 61% of people in the United States wear seat belts (Bonnie et al., 1999). Although 49 states have seat belt laws, such regulations are rarely enforced. Other areas where injuries remain high, such as injuries involving firearms, have been the subject of little regulatory action (Freed et al., 1998). Unfortunately, the higher-than-ideal prevalence of modifiable risk factors is not limited to disease-free groups. There is an astonishingly low rate of action taken to control disease among those who have already been diagnosed with a chronic disease. For example, only 30% of white hypertensive men and 50% of black hypertensive men take action to control their blood pressure (USDHHS, 1999). Only 50% of people who have undergone angioplasty comply with postsurgical regimens for diet and exercise. Among diabetics, only 43% attend diabetes management classes, although significant progress has occurred among blacks in the past several years, with 50% of black diabetics now receiving this type of education (National Center for Health Statistics, 1996a). The data presented in this section illustrate that clear progress has been made on many risk factors for chronic disease as well as morbidity and mortality among adults. Effective strategies are available for reducing most risk factors. If applied effectively at the population level, such strategies could substantially reduce risk and improve disease outcomes. However, population-level interventions have been limited, and preventable risk factors remain the primary cause of morbidity and mortality. INTERVENTION OUTCOMES—EXAMPLES OF EFFECTIVE INTERVENTIONS The next section of this paper provides a brief discussion of outcomes for selected interventions targeting the causes of morbidity and mortality in adults. In particular, examples of intervention outcomes in key channels (e.g., communities, work sites, churches) that may exert influence on adults' health are provided. The social ecological model offers a framework for much of the discussion in this section (Stokols et al., 1996b). An ecological framework recognizes that behavior is affected by multiple levels of influence, including intrapersonal factors (e.g., motivation, skills, knowledge); interpersonal processes (e.g., social support, social network, social norms); institutional or organizational factors
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Promoting Health: Intervention Strategies from Social and Behavioral Research (e.g., company management characteristics, workplace policies); community factors (e.g., social capital, neighborhood effects); and public policy (e.g., regulatory laws, tobacco taxes). A number of intervention studies have been conducted targeting health behaviors, occupational health, and injury prevention; the available literature for these targets varies by intervention level. For example, health behavior interventions often address intrapersonal and interpersonal levels, while occupational health and injury prevention interventions typically address policy and regulatory levels. Examples of interventions at each of the levels in the social ecological model are provided in Box 2. Examples of strategies for operationalizing the principles of the social ecological model at each level of influence are provided in Table 2. Reviews of behavior change interventions suggest that more intensive programs and those targeted at high-risk populations have the strongest outcome effects (Bowen and Tinker, 1995; Bowen et al., 1994; Sorensen et al., in press). These intervention strategies typically focus on intrapersonal factors and are studied in a reactive model, where participants who are ready to change are more likely to approach a specialty clinic or respond to advertisements for study programs. However, more recently many individual-level interventions have proactively recruited participants from a de- fined population. Common intervention modalities that have been utilized across a variety of intervention channels include individual counseling, group programs, telephone, computer-based interventions, and self-help or other mailed materials. These modalities vary in terms of their intensity, level of interpersonal interaction, and cost. Individual-level counseling interventions have come out of the medical model and psychological traditions, and generally have been found to be highly effective, while at the same time quite costly (Compas et al., 1998; Fisher et al., 1993). Individual counseling is limited in terms of its reach, and public health models are being developed that provide alternative strategies to intensive one-to-one counseling (Emmons and Rollnick, in press). Efforts to reach individuals who are at especially high risk have increasingly used home visitation models to deliver individualized counseling (Olds et al., 1986, 1997). One strategy is to combine a very limited number of counseling sessions with less costly intervention modalities (e.g., mailed materials, telephone counseling). Group sessions are also utilized as a way to deliver interpersonal counseling at a reduced cost. For some health behaviors, such as smoking and obesity, group programs have been found to outperform self-help materials, although their effectiveness relative to individual counseling has not been well evaluated (Hayaki and Brownell, 1996; Stead and Lancaster, 1999). Further, group approaches share the concerns about reach and generalizability that have been raised about individual counseling. Incorporating group sessions into community-based channels that attend to social contextual factors may be one way of improving generalizability. Telephone counseling has also become increasingly utilized as a modality for individual counseling (Ferguson, 1996; Glasgow et al., in press-b; Street et al., 1997). The impact of telephone-based interventions
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Promoting Health: Intervention Strategies from Social and Behavioral Research TABLE 2. Health Recommendations Related to Primary Causes of Morbidity and Mortality Among Adults Health Promotion • accumulation of at least 30 minutes of moderate physical activity on most days of the week • consumption of a prudent diet ⇒ 30% or less of calories from fat ⇒ 20–30 grams or more of fiber per day ⇒ five or more servings of fruits and vegetables per day ⇒ daily multivitamin ⇒ limit alcohol intake • avoidance of unprotected sun exposure • avoidance of weight gain • practice of safe sex Health Protection • use seat belts and other safely equipment • minimize exposure to occupational hazards • use of smoke detectors Screening • comply with age-appropriate guidelines and health care provider's recommendations for the following screening tests: ⇒ cholesterol, blood pressure ⇒ pap tests ⇒ mammography ⇒ colon cancer screening ⇒ prostate cancer screening ⇒ depression SOURCE: Adapted from U.S. Preventive Services Task Force Guidelines,Healthy People 2000 Objectives, and Healthy People 2010 Objectives. on long-term behavior change is somewhat equivocal, although continued evaluations of its impact are needed (Bastani et al., 1999; Lichtenstein et al., 1996). Research is also needed on the effectiveness of telephone counseling with underserved and low-income populations, because this group is less likely to have telephones and thus may be more difficult to reach effectively with this strategy. It is also unclear whether removal of the face-to-face contact diminishes the impact of telephone intervention, especially among lower-income populations that may already be somewhat disenfranchised. Self-help materials are another strategy for reaching large numbers of people. With most health behaviors, self-help interventions are more effective than
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Promoting Health: Intervention Strategies from Social and Behavioral Research no-intervention controls, although the overall intervention effects seen with self-help materials are generally small (Curry, 1993; Fiore et al., 1996; Glanz, 1997; Lancaster and Stead, 1999). However, the cost of self-help materials is low and the potential reach is high, which makes self-help an important component of many intervention programs. There is evidence for the contribution made by individual approaches to health behavior change. For example, Orleans and colleagues (Orleans et al., in press) evaluated interventions for six health-damaging behaviors, including tobacco use, alcohol abuse, drug abuse, unhealthy diet, sedentary life-style, and risky sexual practices. They conclude that at the individual level, there are reasonably effective interventions for these six risk factors. Minimal intervention strategies for several risk factors have produced clinically meaningful changes when extrapolated to the population level (Abrams et al., 1996; Calfas et al., 1996; Jeffrey, 1989; McLeroy et al., 1988; O'Malley et al., 1992; Velicer et al., 1999; Warner et al., 1997). However, there is also increasing recognition of the limitations of the individual perspective. Such approaches have contributed enormously to our understanding of health behavior, and they play an important role in a comprehensive approach to public health. However, individual-level approaches are limited in their potential for health behavior change if they are conducted in isolation without the benefit of interventions and policies that also address interpersonal and societal factors that influence health behaviors. McKinlay (1995) argued for the adoption of a population perspective to health promotion. He has proposed that effective behavior change at the population level requires concerted effort across the full spectrum of intervention levels posited by the social ecological model, which would include downstream interventions (e.g., individual-level interventions for those at risk or already affected); mainstream interventions (e.g., population-level or channel-based interventions that target defined populations for prevention); and upstream interventions (e.g., macro-level public policy and environmental interventions to create and strengthen social norms for healthy behaviors to reduce access to unhealthy products, and provide incentives for engaging in healthy behaviors). Population-based approaches to health promotion have arisen out of an interest in broadening the reach of prevention interventions. The work of Rose (1992) provided a particularly good illustration of the paradox of health promotion and prevention efforts. Individually based interventions may be more effective for the individual participants, particularly those at high risk, but have limited population coverage. In contrast, population-based efforts target a large percentage of the population, but typically have lower levels of effectiveness compared to individually based intervention approaches. However, as noted earlier, small changes at the population level can lead to large effects on disease risk. In evaluating health promotion interventions, the level of intervention impact must be judged as a function of the intervention's efficacy in terms of producing individual change, as well as its reach or penetration within the population (Abrams et al., 1996; Glasgow et al., 1999; Sorensen et al., in press). Focusing on impact and reach is a more useful dialogue than the increasingly
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