Chapter 8: Interventions

Types of intervention Strategies

- Activities are laced in larger categories called strategies. - Strategy is defined as a general plan of action for affecting a health problem. - Categories of intervention strategies: health communication strategies, health education strategies, health policy strategies, environmental change strategies, health-related community service strategies, community mobilization strategies, and other strategies.

Introduction

- After goals and objectives are developed, planners decide on the appropriate means of reaching and attaining them. Adopt, adapt, design activity or activities that would permit the most effective (leads to desired outcome) and efficient (use resources in a responsible manner) achievement of the outcomes stated. - Size of the intervention - number of activities that make up an intervention; measured by multiplicity and dose.

Environmental Change Strategies

- Another way to meeting the goals and objectives of health promotion programs. These are most useful in providing opportunities, support, and cues to help people develop healthier behaviors. - Help remove barriers in the environment. Environmental barriers can make modifying unhealthy behaviors challenging. - These strategies are about creating health enhancing environments. Ottawa Charter for Health Promotion. Removing enneironemtnal barriers helps to make healthier choice the easier choice. - Characterized by changes around individuals and are not limited to the physical environment. Environments can include economic, service, social, cultural, psychological, and political. - Environmental change strategies have close relationship to health policy/enforcement strategies because policies changes may be needed to change the environment. Sometime may not require action on the part of the PP. Some strategies provide a forced choice. Activities may include health messages and environmental cues for certain types of behavior. Attention to built environment. - They are more effective when combined with interventions strategies foremother categories.

tailoring

- Any combination of information or change strategies intended to reach one specific person, based upon characteristics that are unique to that person, related to the outcome of interest, and have been derived from an individual assessment. - Takes more effort and resources than personalizing or targeting communication because it requires obtaining individual information on each member of the PP. - Tailoring used to change complex behaviors. Targeting best when behaviors is relatively simple. Personalizing helps to get an individual's attention.

Adapting a Health Promotion Intervention

- Can the intervention that was successful in another setting be adapted to work in a new setting? - Adaptation frameworks is a five step approach (226-227).

multidirectional communication model (MDC)

- Communication occurs through a combination of sender top-down (vertical messages, consumer created bottom-up messages, consumer shared horizontal (side to side messages) and consumers seeking information. - Says that consumers not only receives information but they seek, develop, and share information. - Underlying concept is that the sophistication of how health information is communicated has change because of new technology. - Must have working knowledge of communication technologies or have foresight to access those who provide the expertise. - Key characteristic of effective health communication campaigns is that they are people or audience centered. Requires planners to understand consumer tendencies, needs, and preferences before designing campaigns or messages.

Community Organization and Community Building

- Community organization been defined as the process by which community groups are helped to identify common problems or change targets, mobilize resources, and develop and implement strategies to reach their collective goals. - Community building is an orientation to practice focused on community, rather than a strategic framework or approach, and on building capacities, not fixing problems.

interventions

- Defined as planned actions that are designed to prevent disease injury and promote health in the PP - pre-program measure (observing before), incentive can be an intervention, combination as an intervention

Social Activities

- Easier to change behaviors. - Four types of social support: emotional, instrumental, informational, and appraisal. - Emotional: assistance from people close to a person that focuses on feelings. - Instrumental: providing material items and services to people - Informational: providing various forms of information such as advice, knowledge, and suggestions to people. - Appraisal: analysis and feedback that allows people to evaluate their station. - Support groups and buddy systems, social gatherings, and social networks.

interpersonal channel

- Examples are support groups and small classes. Same characteristic as intrapersonal BUT reaches a larger number of people with fewer resources.

systems approach

- Few people change their behavior based on a single exposure, instead multiple exposure are needed to change most behaviors. - Multiple level of influences would mean increases the the changes of making an impact. - Right combo of activities that will depend on the needs of the PP and specific planning situation.

built environment

- Generally refers to an interdisciplinary area of factors that describes the design, construction, management, and land use of human made surroundings as an interrelated whole, as well as their relationship to human activities over time. - Built environment can be structured to give people more and fewer opportunities to behavior in health enhancing ways. - Health impact assessments (HIAs)- a type of needs assessment to determine effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. Results of the HIA can lead to modifications or additions to the built environment that provide more opportunities for enhancing health (need seatbelts in cars and need to enforce it).

Support Groups and Buddy Systems

- Importance of people coming together to share their experiences and support one another's efforts. - Buddy system is a two person group: (1) both people are trying to change their behavior (2) one out of two is trying to change their behavior. - Uses contests to enhance motivation.

Incentives and Disincentives

- Incentives (carrots) and disincentives (sticks). - Incentive is an anticipated positive or desirable reward designed to influence the performance of an individual or group. - Disincentives is anticipated negative or undesirable consequence designed to influence the performance of individual or groups. - HIPPA, GINA, ACA

Health Policy/Enforcement Strategies

- Includes executive orders, laws, ordinances, judicial decisions, policies, regulations, rules, and position statements. All strategies share the fact that it is a decision made by an authoritative person, agency/organization, or body and that is presented in a statement or guidelines intended to direct or influence the actions or behaviors of others. - These are strategies that are mandated or regulated. Revolve around establishing some standard or requirement and associated sometimes with incentive or disincentives to encourage or discourage actions. Intervention strategy can regulate behavior of individuals, organizations, institutions, or communities. Can be used to affect built environment. - Some criticized this approach because it mandates a particular response from those governed by it. Takes away individual freedom and plays on pride, pocketbooks, and psyche. Runs counter to emphasis on property rights economic individualism, and competition in American political culture. Must be based on evidence and common good. Should protect the public's health; these exist for the protection of the community and individual rights. - Policymaking is complex and each setting in which policy is created has its own characteristics. Six phases of policymaking: (1) agenda setting - deals with determining what the health problem is, analyzing whether the cause of the problem can be best solved with a policy/enforcement strategy (2) policy formation - where the policy or mandated action is developed (3) policy adoption - approval, takes place when the authoritative individual or group approves the policy [politics can impact outcome] (4) policy implementation - assemble the necessary human and financial resources to make the policy work (5) policy assessment - making sure the policy is being carried out as written and that it is indeed working to solve the problem it was intended to solve (6) policy modification - judgment and action must be made to determine whether the policy should be maintained, modified, or eliminated. - Wording if policy is not east. The simplest language possible should be the goal.

Health-Related Community Service Strategies

- Includes services, tests, treatments, or care to improve the health of those in the PP. - Requires action on part of the PP > need to reduce the barriers to obtaining the service. Must be mindful of the affordability and accessibility of services. Planners must weight consequences of including this type of strategy in an intervention. - Often carried out by partnering organizations and are offered in a variety of settings.

Community Mobilization Strategies

- Involve helping communities identify and take action on shared concerns using participatory decision making, and include such methods as empowerment. - Two categories: community organization and community building; community advocacy.

motivational interviewing (MI)

- Is a collaborative, person centered form of guiding to elicit and strengthen motivation for change. - Used for individuals with a wide variety of health problems in which a behavior change was needed. Looks to resolve the ambivalence associated with behavior change. - Assumption is that ambivalent attitudes or lack of resolve is the primary instance to behavioral change, this making it a goal. - Four principals: express empathy, develop discrepancy, roll with resistance, and support self-efficacy.

dose

- Number of program units delivered. - Ex. how many times will class be offered? how many PSA or text messages. - Higher the hose of an intervention = greater chance for change.

quantitative literacy

- Numeracy. - The knowledge and skills to perform quantitative tasks like balancing a checkbook or calculating a tip.

Creating Health Promotion Interventions

- Once program planners have completed a needs assessment, written program goals and objectives, and considered different types of intervention strategies, they are in a position to begin designing an appropriate intervention. - There is no one best way of intervening to accomplish a specific program goal that can be generalized to all priority populations. - Common characteristics in success health promotion programs: (1) addresses more than one or more RF (2) theory driven (3) being based on the best possible evidence (4) adhering to professional ethical standards (5) culturally appropriate (6) being consistent with professional criteria, guidelines, or codes of practice (7) using resources efficiently (8) including an evaluation component. - Intervention Planning, Adopting a Health Promotion Intervention, Adapting a Health Promotion Intervention, Designing a New Health Promotion Intervention,

Community Advocacy

- Process in which those in the community become involved in the institutions and decisions that impact their lives. - Has the potential for creating more support, keeping people informed, influencing decisions, activating nonparticipants, improving service, and making people, plans, and programs more responsive. - Lobbying vs. advocacy. Lobbying is when individuals/organizations attempt to influence a specific piece of pending legislation by contracting elected officials or their representatives. Advocacy is trying to affect generalized change by expressing opinions for or against causes or positions. - Health advocacy.

social media channel

- Referred to as interactive media or Web 2.0. - Characteristics: (1) user or consumer generates (2) information can be revised or updated immediately (3) low cost in creation and maintenance (4) reach to broader, more diverse audiences (5) entertaining to use. - Different forms of for content management: content sharing, social bookmarking, social gaming, social journaling, social networking, social news, social video and photo sharing, and syndication. - Three uses: (1) Internet as a platform to deliver behavior change interventions, (2) Internet to promote health promotion programs, (3) Internet and mobile devices for community mobilization and advocacy. - Social media is about building relationships. - POST (assist program planners in creating health promotion interventions that include social media): people, objectives, strategy, and technology. - CDC Guide to Writing Social Media and The Health Communicator's Social Media Toolkit.

multiplicity

- Refers to the number of components or activities that make up the intervention. - Several interventions are more likely to make an effect on the PP than a single intervention. More effective if aimed at multiple level of influences, using the socio-ecological approach. Referred to as the systems approach.

literacy

- The ability to use printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential. - Need to consider literacy level of PP. Thought as currency in society because those with limited literacy skills are likely to find it more challenging to purse their goals. - National Assessment of Adult Literacy (NAAL). Prose - knowledge and skills to perform prose tasks like reading and comprehending a news story. Document - the knowledge and skills to perform document tasks like completing an application. Quantitative literacy. NAAL was the first ever national health literacy assessment of adults. - Four literacy levels: below basic (most simple concrete literacy skills), basic (skills needed to perform simple and everyday literacy activities), intermediate (skills needed to perform moderately challenging literacy activities), and proficient (skills needed to perform more complex and challenging literacy activities).

health numeracy

- The degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions. - Recognizes that there are degrees of health numeracy that fall along on a continuum and that health numeracy is more than understanding (processing and and interpreting) but functioning (communicating and acting) on numeric concepts in terms of health. - Four skills: basic (counting number of pills), computational (determining the number of consumers), analytical (normal range), and statistical (determine risk of probability). - To improve health literacy and health numeracy: National Action Plan to Improve Health Literacy, Simply Put A guide for creating easy-to-understand materials. Simply Put - document that make sure written materials are presented at an appropriate reading level for the PP. Americans on average read 7th grade reading level. Aim to write at the 6th grade reading level. Reading test includes Fog-Gunning Index, Flesch-Kincaid Grade Level Readability Formula, Fry Readability Formula, or SMOG (Simple Measure of Gobbledegook). The SMOG Readability Formula.

Health Communication Strategies

- The study and use of communication strategies to inform and influence individual and community decisions that affect health. - Defined by the form it takes in health promotion programs (media, public relations etc.). - All health promotion interventions include some form of communication. Useful in reaching goals and objectives; creates awareness change attitudes towards a behavior, encourage and motivate individuals to follow behaviors, reinforce attitudes and behavior change, increase demand and support of services, and build social norms. Have the highest penetration rate of any intervention strategies. More cost effective and less threatening than others. - Alone it is rarely sufficient to change behavior and reduce the risk for disease. - Traditional and multidirectional communication model.

Health Education Strategies

- There are some health communication strategies that could be classified as health education strategies; some health education strategies that can be health communication strategies. - No clear division line between health communication and health education strategies. They are not mutually exclusive categories. - Health communication strategies are those that inform people, while health education strategies are those that are planned learning experiences that provide knowledge and skills to the learners in a more formal educational setting. - 10 general principles of learning: Learning is facilitated (1) if several of the senses are used (2) if the learner is actively involved in the process, rather than a passive participant (3) if the learner is not distracted by discomfort or extraneous events (4) if the learner is ready to learn (5) if that which is to be learned is relevant to the learner and that relevances perceived by the learner (6) repetition is used (7) if the learning is encountered is pleasant, if progress occurs that is recognizable by the learner and if that learning is recognized and encouraged (8) if the material to be learned starts with what is known and proceeds to the unknown, while concurrently moving from simple to complex concepts (9) if application of concepts to several setting occurs that generalizes the material (10) if it is paced appropriately for the learner. - Adult learning principles include: (1) need to know why they are learning (2) motivated to learn by the need to solve problems (3) previous experience must be respected and built upon (4) need learning approaches that match their background and diversity (5) need to be actively involved in the learning process. - Makeup of health education intervention: They allow the PP to gain in-depth knowledge about a particular health topic. Takes understanding of educational process and take a great deal of effort to create . - Curriculum, scope, sequence, unit plan, lessons, lesson plan.

intrapersonal channel

- Used the most often. Most familiar and the most trusted. Effective communication channel but it involves more time and resource intensive channel for the number of people reached. Creating personal relevance includes personalizing, targeting, and tailoring. - Tailoring of intrapersonal communication has been enhanced by technology. - Health education through the phone can be classified as individual initiated (individual seeks contact and assistant from a hotline) and outreach (individual is called). - Developing telephone intervention includes designing the intervention protocol, selecting and training those delivering the intervention, and developing documentation and data collection protocol. - Health coaching. Uses motivational interviewing.

communication channel

- Used to subdivided activities. - Route through which a message is disseminated to the PP. Sometimes can be limited to setting where the communication will be delivered. - Four communication channels: intrapersonal (one on one), interpersonal (small group), organization and community, and mass media. Hierarchal - interpersonal reaches the fewest number and mass media reaches the most. Fifth channel is social media.

lesson plan

- Written outline of a lesson; include three components: introduction, body, and conclusion - Introduction provides an overview of what will be covered, the body presents the health content, and the conclusion reviews what has been presented. - Tell them what you are going to tell them (intro), tell them it (body), and tell them what you told them (conclusion). - Heart of a lesson is the body or the content portion. Nine Events of Instruction (Gagne) > modified into five stages: (1) gain attention (convey health threats and benefits) (2) present stimulus material (targeting or tailoring the information) (3) provide guidance (use models to demonstrate) (4) elicit performance and provide feedback (to enhance trainability, and develop proficiency and self-efficacy (5) enhance retention and transfer *provide social support and deliver behavioral cues). Application on 206.

Adopting a Health Promotion Intervention

1. Is their sufficient evidence to show that the intervention has been successful in dealing with the problem in question? 2. Is there sufficient evidence to show that the intervention has been successful in dealing with the problem in question in a population with similar characteristics? 3. Is there evidence to show that the intervention was successful in more than one setting? 4. Are there similar resources available in the new setting to ensure the fidelity of the intervention? 5. Is the new environment-setting similar to the environmental setting identified in the evidence?

Designing a New Health Promotion Interventions

1. What needs to be change? And where is the change needed? 2. At what level of prevention will the program be aimed? 3. At what levels of influence will the intervention be focused? 4. What type of interventions strategies are known to be effective in dealing with the program focus? best practices, best experience, best processes 5. Is the intervention an appraise fit for the PP? segmenting, culturally sensitive 6. Are the necessary resources available to implement the intervention selected? 7. Would it be better to use an intervention that consists of a single strategy or one that is made up of multiple strategies? typology for classifying interventions

culturally sensitive

interventions "that are relevant and acceptable within the cultural framework of the population to be reached"

Organizational Culture Activites

Aligned with environmental change strategies. Culture is associated with norms and traditions that are generated by and linked to a community of people and reflects a group's values, beliefs, and practices. Culture of organization is like personality. Nature of culture depends on the type go organization. Leadership of an organization could advance a culture that supports health or could advance a culture that includes health values, beliefs, and practices. cultural audit

cultural audit

Assessment associated with organizational culture. An evaluation of the assumptions, values, normative philosophies, and cultural characteristics of an organization in order to determine whether they support or hinder that organizations central mission. Audit helps to determine whether culture hinders or supports health. Influences on an organization's involvement in health: (1) shaping cultural health values (2) shaping cultural health norms (3) use of cultural touch points (4) encourage peer support (mobilize existing support systems, develop mutual support etc). (5) building a supportive cultural climate for health.

Other Strategies

Behavior Modification Activities, Organizational Culture Activities, Incentives and Disincentives, Social Activities, Support Groups and Buddy Systems, Social Gathering, Social Networks.

Intervention Planning

Can adopt or adapt an existing intervention that is supported by evidence. Design a new intervention.

health advocacy

Community advocacy that deals with health issues. Defined as the processes by which the actions of individuals or groups attempt to brig about social, environmental, and or organizational change on behavior of a health goal, program, interest, or population. - 7 different ways to advocate for health or health education: influencing voting behavior, electioneering, direct lobbying, integrating grassroots loving into direct lobbying efforts, using the internet, media advocacy (newspaper), and media advocacy (resource person). - Cell phones and social networking sites can be used to (1) recruit people to join the cause (2) organizing collective action (3) raising awareness and shaping attitudes (4) raising funds to support the cause (5) communicating with decision makers. Comparative qualities of social networking sites and cell phones in advocacy.

behavioral economics

Helps to understand the reasoning behind bad decisions. Method of analysis that applies psychological insights into decision making. neoclassical economics and traditional economics 7 behavioral economic insights that explains decision making.

Social Gatherings

Important social intervention. Bringing together people who may be confronting similar problems for the purpose of social interaction not related to the problem can indirectly help deal with the problem.

Behavior Modification Activities

Intrapersonal interventions. Intended to help those in the PP experience a change in behavior. Behavior modification is thought as a systematic procedure for changing a specific behavior. Process based on specific behavior that one wants to increase or to decrease. Then attention is given to changing the events that are antecedents and subsequent to the behavior that is to be modified.

Limitations of Interventions

Limitations associated with three major approaches to intervening to prevent injuries: innovations in engineering and technology, legislation and enforcement, and education for behavior change.

organization and community channels

Many receive a lot of information through these channels. Excellent ways to reach the PP.

mass media channel

Mass media interventions seek to influence people other directly or indirectly. Directly means to identify a problem of concern and targets the people who can change. Indirect means interventions seek to influence people by creating beneficial changes in the places or environments where people work.

best practices

Recommendations for an intervention, based on a critical review of multiple research and evaluation studies that substantiate the efficacy of the intervention in the populations and circumstances in which the studies were done, if not its effectiveness in other populations and situations where it might be implemented

traditional communication model

Sender relays a message through a channel to receivers (vertical or top-down). The sender is the gatekeeper of information while the consumer has a less active role in religion the message.

health literacy

The capacity to obtain, process, and understand basic health information and services needed to make appropriate health-care decisions. - Health literacy results: below basic, basic, intermediate, and proficient. 9 out of 10 people have difficulty using the everyday health information that is available.

Social Networks

Web of social relationships and the structural characteristics of that web.

curriculum

a planned set of lessons or courses designed to lead to competence in an area of study scope and sequence is used to help define the curriculum

contract

agreement between two or more parties that outlines the future behavior of those parties

unit plan

an orderly, self-contained collection of activities educationally designed to meet a set of objectives other terms include curriculum plans, modules, and strands ex. diabetes education curriculum: units on self-management, working with a health care professional.

scope

breadth and depth of the material covered in a curriculum; horizontal organization of the substance of the curriculum; scope of health education presented as unit plans

contests

challenges between two individuals/groups in with the object is to outperform the competitor

social media

interactive media; overarching term for any media that uses the Internet and other technologies to enhance social interaction for sharing and discussing information does not have a spot in the hierarchy because it cuts across different levels; can be used to generate social interaction at any of the levels

best experience

intervention strategies used in prior or existing programs that have not gone through the critical research and evaluation studies and thus fall short of best practice criteria

penetration rate

number in the PP exposed or reached

best processes

original intervention strategies that the planners create based on their knowledge and skills of good planning processes including the involvement of those in the priority population and the use of theories and models

lessons

the amount of material that can be presented during a single educational encounter units of study further subdivided into lessons

sequence

the order in which the material is presented; vertical relationship among the curricular areas

segmenting

the process of dividing a broader population into smaller groups with similar characteristics that are likely to exhibit similar behavior/reaction to an intervention

contingencies

what happens as a result of the contract's term either being met or not met