Sunday, December 17, 2006

Social Sciences Help Reveal Three Major Flaws in Public Health Intervention “Take a Loved One for a Check Up Day”- Laura Mottola

“Take a Loved One for a Check Up Day” is a national campaign with the intent of motivating those who usually do not go to the doctor other than in a moment of emergency to get a periodic screen at the end of September of each year. Those people are then encouraged to help their family members or close friends do the same. Even though the campaign is directed to everyone, it focuses on decreasing the healthcare gap between minorities and the rest of the American population. The idea is that “Take a Loved One for a Check Up Day” will help minorities have better health outcomes and a decreased mortality rate by increasing their access to healthcare.

From a Social Sciences perspective, there are six flaws that make this campaign a potential failure. First, the campaign seems to ignore the fact that health insurance coverage does not necessarily guarantee better health. The study done by C.E. Ross and J. Mirowsky has shown, in fact, that people with high SES have better health, not because of their medical coverage, but because of other factors. (A) Secondly, it does not take into consideration the fact that health access does not always equal care as one may encounter non-financial obstacles on his path. Regarding this matter, Kevin A. Schulman and others have proved that people of certain gender and race may receive less care than others with the same health insurance status. (B) Thirdly, the constant focus on individual factors, such as access leads to undermining the importance of social factors in influencing behavior, as discussed by Theodore Pincus and others. (C) Furthermore, this public health intervention fails at putting emphasis on behavior and its dependence on self-efficacy. Albert Bandura’s Social Cognitive Theory underscores the strong association between the two. (D) An additional flaw of the campaign consists in the lack of providing consistent support to patients in terms of providing care during the rest of the year. As a result, there is no possibility of creating strong self-efficacy as shown by Jim Grizzell. (E) Last, but not least, “Take a Loved One for a Check Up Day” gives an unintended message by communicating the idea that to improve one’s health it is sufficient to go to the doctor once a year and that the adoption of a healthy lifestyle does not require much effort. Wakefield M. et al. and Hart GJ et al. help clarify the effects of unintended message applied to other fields of public health. (F)

A. Health access does not guarantee better health outcome. The first flaw of the campaign is the idea that reduction of health access disparities between minorities and the rest of the American population will result in better health outcome for all. However, in their article, C.E. Ross and J. Mirowsky made the strong claim that medical insurance has no impact on health. (1) In their study, they found that people with a high SES tend to have better health compared to poor subjects. Then, they examined whether the finding resulted from ownership of medical insurance by high SES individuals. The shocking result was that access to care was slightly if not at all responsible for the association between high SES and good health. In fact, when doing a comparison with the uninsured, individuals who had public coverage reported worse health while health conditions of privately insured people were not significantly different from the uninsured. The final conclusion reached was that: “Insurance is not associated with better health outcomes in any case.” (1) On the other hand, economic hardship revealed a significant association with worse health in poor people. Specifically, the economic strain of having difficulty paying bills was strongly related to chronic health problems and physical disabilities. (1) This reveals the idea that there are other factors to be considered other than health access when trying to improve the public’s health. The Canadian healthcare system gives an additional example of the absence of association between better health outcome and universal access. In regard to the topic, Daniel Drezner says: “As many as 24,000 patients die in Canadian hospitals each year, while tens of thousands more are crippled, injured or poisoned in association with medical errors that could have been prevented”. (2) The high number of deaths and injuries reported above shows once again that access to all does not necessarily equal better health to all.

B. Health access does not equal care. A second flaw of the campaign is the assumption that health access always equals receipt of care. There is no consideration of the fact that even if one is offered access to care through insurance coverage, he may face other impediments to obtaining medical assistance. These are called non-financial barriers. As Thomas Bodenheimer and Kevin Grumbach assert: “Non-financial barriers include long distances between patients and healthcare facilities, language, literacy, cultural differences between patients and healthcare givers, and factors of gender and race.” (3) For example, even if one has good healthcare coverage, he may receive limited care due to his belonging to a specific race or gender. In regard to this matter, Kevin A. Schulman and others did a study concerning the differences in treatment of patients affected by cardiovascular disease based on race and sex. Actors used for the trials represented patients with equal medical conditions. The result was that doctor’s recommendations to undergo cardiac catheterization varied significantly with gender and race. The lowest rates of cardiovascular procedures were in fact seen among African-American women in support of the authors’ idea that: “Subconscious bias occurs when a patient’s membership in a target group…activates a cultural stereotype in the physician’s memory regardless of the level of prejudice the physician has.”(4) Furthermore, in support of the idea that racial discrimination may affect the provision of care, a recent study has proved that: “Despite similar insurance coverage and clinical status, white Medicare patients were 30%-50% more likely than African-American patients to undergo procedures, such as coronary angiography, bypass surgery, and angioplasty.” (5) This matter is of critical importance in this campaign, which is specifically oriented toward minorities.

C. Social Factors. A third flaw of the campaign is the lack of attention to social factors that affect the people in question. Social factors include environment, social economic status, and race. In the case of “Take a Loved One for a Check Up Day,” social factors may be particularly useful since the campaign focuses on a specific group of people, which belongs to a specific environment, has a specific income, and represents a specific race, mostly African-American. As Theodore Pincus and others say: “Focus on access to healthcare professionals ignores the most important determinant of health: the patient himself or herself in a sociocultural context.” (6) This concentration on health access in fact leads to ignorance of important variables, social factors, which are responsible to shape one’s behavior. Most times, it is possible to understand one’s actions better by looking at the environment in which he lives rather than his genetic make-up. Grenard JL and others show how the influence of social factors on behavior is a reality by examining the cause of smoking behavior in Chinese teenagers. During the study, these were in fact found to begin smoking due to peer smoking, cultural influences, and inter- and intra-personal influences. (7)

D. Behavior and its Dependence on Self-Efficacy. The campaign also fails to address behavior and its dependence on self-efficacy. Behavior is a better determinant of long-term health and self-efficacy is the driving force that leads to certain behaviors. As Michael McGinnis and William H. Foege say: “The three leading causes of death-tobacco, diet and activity patterns and alcohol-are all rooted in behavioral choices.” (8) The role of self-efficacy consists in influencing those choices through motivation, perseverance, thought patterns, and vulnerability. (8) Self-efficacy is defined as the belief that one has the capabilities to execute the courses of actions required to managing prospective situations. This has a very strong association with human behavior and behavioral change especially. In fact, where there is strong self-efficacy, behavior is more likely to change. This idea is confirmed by E. Meland and others who have shown in their study, in which they compared two interventions advising cardiovascular high-risk men of lifestyle changes in Norway, that: “Self-efficacy was a statistical significant predictor of smoking cessation success”. (9) Albert Bandura was the first to introduce the concept of self-efficacy, through his Social Cognitive Theory. This theory explains that: “Behavior change is affected by environmental influences, personal factors, and attributes of the behavior itself.” (10) Specifically, self-efficacy becomes the “single most important characteristic” (10), which leads to behavioral change because as Jim Grizzell says: “People’s behavior lead to certain outcomes… and their expected outcomes are filtered through a person’s expectations or perceptions of being able to perform the behavior in the first place.” (10)

E. One Day Only. Another flaw of “Take a Loved One for a Check Up Day” campaign is that it aims to give screening to minorities once a year. It wants to encourage these people to do prevention on one day, hoping then that they will suddenly become enlightened and take charge of their health without receiving consistent medical support throughout the year. However, even if one is aware of the risks, he may not necessarily perform the actual behavior. Even if one is aware that he has to begin exercising and quit smoking if he wants to lower his chance of having a heart attack, he may not do it. We now know how important strong self-efficacy is in changing one’s behavior from unhealthy to healthy. Thus, we can say that one day of screening is not of much help to those who have medical conditions related to smoking, physical inactivity, and eating fats because it completely misses the criticality of behavior and self-efficacy. As Jim Grizzell says: “One of the ways to increase self-efficacy is offering the opportunity for skill development and modeling the desired behavior.” (10) Doing a check up once a year will not likely result in strong self-efficacy.

F. Unintended Message. The sixth and final flaw of “Take a Loved One for a Check Up Day” is the unintended message presented to the audience. Unintended messages often result in a misunderstanding of the idea expressed by an ad or campaign. In the case of this intervention, which has minorities as its target, one may think that if he goes to the doctor once a year, his health will automatically improve as he will be screened and given medications in case those are needed. There are many examples of influence of unintended messages from other fields of public health. Two studies examine specifically the resulting optimism toward smoking cessation through nicotine replacement theory (11) and the effects of Anti-retroviral Therapy for treatment of AIDS (12). Both studies show how unintended message could increase a detrimental behavior, such as smoking in teenagers and sexual risky behavior among homosexuals. On that same path, “Take a Loved One for Check Up Day” may establish a level of optimism in those who adhere to it. In their minds, they may think that they can keep eating unhealthy, smoking, and not exercising as long as they go see the doctor once a year.

In conclusion, the six flaws of “Take a Loved One for a Check Up Day” show how this campaign will not succeed in the long run. In fact, it concentrates exclusively on the access factor without going to the root of the problem, behavior. It is obvious that behavior is the motor of people’s actions. Therefore if one could influence behavior, there would at least be a greater chance for minorities of having better health. To do that, first, “Take a Loved One for a Check Up Day” should have its name changed to “Take a Loved One to a Prevention Day.” Then, the event should take place once every other month rather than once a year so that those who adhere to it feel supported throughout the process. It would consist of education programs to stimulate people’s self-efficacy to eat right, exercise, and quit smoking by showing the advantages of a healthy behavior. Furthermore, participants would be required to at least eat healthy and not to smoke on the same day of the event. As a result, these would become aware that even though it takes effort to behave healthy, it is doable. Those people who have succeeded in the program should then talk about it with their friends and family and show its benefits. The reason behind it is that if healthy behavior becomes the social norm, most risk factors will be eliminated and more people will be healthy.

Bibliography:

1) Ross CE, Mirowsky J. Does medical insurance contribute to socioeconomic differentials in health? Milbank Memorial Fund Quarterly/ Health and Society 2000; 78: 291-321
2) Thomas Bodenheimer, Kevin Grumbach, Understanding Health Policy, 2002; 22
3) Daniel W. Drezner. Wow, my second healthcare post in less than a year. Home Page. Sat, May, 22,2004.
4) Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. New England Journal of Medicine 1999; 340: 618-626.
5) Thomas Bodenheimer, Kevin Grumbach. Understanding Health Policy, 2002; 24
6) Pincus T, Esther R, DeWalt DA, Callahan LF. Social conditions and self-management are more powerful determinants of health than access to care. Annals of Internal Medicine 1998; 129:406-411.
7) Grenard JL et al. Influences affecting adolescent smoking behavior in China. Nicotine and Tobacco Research. 8(2): 245-55. Apr. 2006
8) McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:2207-2212.
9) E. Meland, JG Maeland,E. Laerum. The Importance of self-efficacy in cardiovascular risk factor change. Scandinavian Journal of Public Health. 1999 March; 279(1): 11-7
10) Grizzell Jim, Behavior Change Theory and Models. 30 Sept. 2003
11) Wakefield M. Durrant R. Effects of exposure of youths at risk for smoking to television advertising for nicotine replacement therapy and Zyban: an experimental study. Health Communication. 19(3):253-8, 2006.
12) Hart GJ, Williamson LM. Increase in HIV sexual risk behaviour in homosexual men in Scotland, 1996-2002: prevention failure? Sexually Transmitted Infections 2005; 81:367-372.

3 Comments:

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1:35 PM  
Anonymous Anonymous said...

This essay highlights the weaknesses of common everyday life in America. This program of going to the doctor once a year is a mirage to unhealthy people and ultimately sets them up for failure. It has become commonplace to acknowledge a problem, and then to find a cheap and easy way out of it. One example is that you can be a big, fat, slobby, smoking couch-potato, but as long as you see the doctor every September, your health is ok. Our society has become so lazy and pathetic to address the real cause of these problems. Corporate America causes most of this, and then these worthless efforts are thrown in to try and make it better. I think this paper makes a strong point of the uselessness of this program and others like it.

9:18 PM  
Anonymous Luna Gargani, Institute of Clinical Physiology, CNR Pisa. said...

This is a very interesting work, underlining the potential problems of excessively easy approaches to healthcare. This issue is especially important, considering the increasing trend to suggest also instrumental screening examinations, without any appropriate indication, that may even be harmful to the patient.

1:09 AM  

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