Challenging Dogma

Sunday, May 6, 2012

Why Learn More? The Critique of National Heart Lung and Blood Institute’s Campaign to Improve the Lives of Individuals with COPD – Stanislav Henkin

            Chronic obstructive pulmonary disease (COPD), a disease characterized by airflow limitation that is not completely reversible, is the third leading cause of death and one of the top three causes of disability in the United States (1). While the rate for the other top causes of mortality (cardiovascular disease, stroke, and cancer) has been declining in the past 5 years, the mortality rate for COPD has been fairly stable (2). Well-identified risk factors for COPD include cigarette smoking, environmental and occupational exposure to toxic chemicals or gases, recurrent infection, and genetic factors; the most common symptoms consist of cough, wheezing, chronic mucus production, and breathlessness (2). The prevalence of COPD (11.8 million) has been stable for the past 10 years (3). Even though COPD has been previously viewed as a disease of men who smoke (4), women have had a significantly higher prevalence of COPD than men in the past 10 years – 6.1% of women compared to 4.1% of men, with women aged 65-84 having the highest COPD prevalence. Importantly, while the mortality rate due to COPD has slightly decreased for men in the past 9 years, the rate has not significantly changed for women, with 60,000 men and 65,000 women dying from COPD in 2007 (3). Racial and economic factors also play a role in the disease occurrence, as Puerto Rican and non-Hispanic white individuals have a higher prevalence of COPD than other individuals of other races; similarly, persons whose income is less than 100% of the poverty levels report higher COPD prevalence than individuals with higher income levels (3).    
            Sadly, the majority of individuals who are at risk for developing COPD have not heard of this debilitating disease and often overlook its symptoms, resulting in delayed diagnosis (4). To promote early diagnosis and aid in prevention of disability and mortality, the National Heart Lung and Blood Institute (NHLBI) launched a campaign in 2007: “COPD Learn More Breathe Better.” The campaign has three main goals: 1. “Increase awareness of COPD as a serious lung disease,” 2. “Increase understanding that COPD is treatable,” and 3. “Encourage people at risk to get a simple breathing test and talk to their doctor” (5). The campaign targets men and women over 45 years old who have risk factors for developing COPD – i.e. current or former smokers, individuals with a history of environmental exposure to harmful chemicals or second-hand smoke, and those with a genetic mutation that predisposes them to early development of COPD (4, 5).
            In its campaign materials, NHLBI reports that 12 million Americans are currently diagnosed with COPD while 12 million more may be undiagnosed (5). Through radio and print public service announcements, fact sheets, and educational videos, NHLBI encourages individuals with COPD symptoms to speak to their doctors and to ask about spirometry testing. Additionally, more than 20 partners, including American Academy of Family Physicians and Kaiser Permanente, have joined NHLBI in promoting the campaign to its members and staff.  One of the partners, the COPD Foundation tours health fairs, senior expos, community venues, and country music festivals, offering information provided by NHLBI in conjunction with free spirometry testing  (4). The spokeswoman for the campaign, Grace Koppel, has appeared on numerous TV and radio shows, including The View, Good Morning America, and The Diane Rehm Show, to promote the campaign and to encourage individuals at risk for COPD to talk to their physician (5). While the campaign has been running for the past five years and the awareness of the disease has increased, many individuals at risk never talk to their physician about their symptoms and thus remain undiagnosed (6). These facts are suggested by the stable prevalence of COPD over the last 10 years (3). This critique will examine the underlying issues that may be holding back the success of the campaign, including focus on individual behavior change, lack of promoting self-efficacy, and not understanding its target population. Ultimately, this paper will suggest methods to improve these limitations and to increase the success of the campaign.
Critique 1 – Focus on Health Belief Model
            The “Learn More Breathe Better” campaign is geared towards individuals at risk for COPD by trying to increase awareness and understanding of COPD and encourage individuals to talk to their primary care physician and get tested.  The campaign is modeled on the Health Belief Model, the oldest and most widely used model in public health, which focuses on the individual. The proponents of this model theorized that health behavior is motivated by six factors: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cue to action, and self-efficacy (7). The campaign describes to each individual the risk factors for COPD (smoking, environmental exposure, genetic factors) as well as the benefits of COPD diagnosis (breathing better). The perceived barrier is assumed to be absence of awareness about COPD, and the cue to action includes public radio announcements, advertisements in magazines and newspapers, and other outreach materials as previously described. The campaign assumes that by increasing awareness and understanding of the disease, people will have self-efficacy to talk to their physician and receive testing. Essentially, the success of the campaign is based on the rational thought process of individuals: “Since I am now aware of COPD and understand the disease, I will speak to my doctor.” Even though the Health Belief Model is a reasonable model for simple individual decisions, it has not shown to be as successful with complex decision making where conclusions may not be rationally made by weighing the risks against the benefits (8).
            The Health Belief Model focuses on individual rational choices, and therefore it does not take into account social and environmental factors (7). These factors are especially important in this campaign since significantly more individuals of lower socioeconomic status are at risk for COPD than others (3). Low socioeconomic status, both at individual and neighborhood-level, is generally associated with increased smoking prevalence (9) and individuals in this group may not be willing to quit smoking because of the neighborhood cultural standards (10). Additionally, individuals who may be exposed to harmful chemicals at work may not be able to avoid these chemicals because they need to stay at the job financially support their families. Unfortunately, previous use of newspaper advertisements encouraging COPD testing in a low socioeconomic status population has shown to be severely ineffective, with low recall of advertisements and extremely limited reach to the targeted high-risk individuals (11). 
Critique 2 – Low Self-Efficacy of High Risk Individuals       
            If a person decides to act after going through the individual components of the Health Belief Model, self-efficacy is necessary to complete the desired action. Even though self-efficacy is a component of the Health Belief Model, it is better described as part of the Social Cognitive Theory, which explores interactions between people, their environments, and behavioral factors. The theory postulates that health behavior is affected by three factors: self-efficacy, goals, and outcome expectations (12). The concept of self efficacy is especially important in this model as well as decision making. Bandura describes the importance of this concept: “Efficacy beliefs are the foundation of human agency. Unless people believe they can produce desired results and forestall detrimental ones by their actions, they have little incentive to act or to persevere in the face of difficulties…Such beliefs influence whether people think pessimistically or optimistically and in ways that are self-enhancing or self-hindering” (13). Self-efficacy (perceived control over COPD diagnosis and management) has been previously associated with positive behavior change, such as improved self-management of COPD (14-15). Creating sufficient self-efficacy may be done through remembering past personal accomplishments, verbal persuasion by others, and self-evaluation of one’s personal emotional state (16).
            With respect to the NHLBI campaign, it is important to examine how self-efficacy influences decisions about undertaking COPD risk factors and following up with a physician for appropriate testing. Low self-efficacy has been shown to predict smoking relapse in former smokers (17). Additionally, research has suggested that women, due to past socialization experiences, have lower self-efficacy than their male counterparts (18).  Other research has demonstrated that individuals of lower socioeconomic class also have lower self-efficacy, which may be mediated by their occupational conditions (19). High self-efficacy may be especially important in individuals at risk or already diagnosed with COPD because it is independently associated with prolonged survival (20).
            While the campaign provides each individual with many facts about COPD risk factors and diagnosis, it does nothing to empower individuals and increase their self-efficacy to make a change in their lives. Previous programs that have employed education as a primary means of improving breathing difficulty for individuals with COPD showed no improvement in self-efficacy from preprogram to 6 months after the end of the education program (21). This fact is especially troubling considering that the groups that have the highest risk of COPD (e.g. women and individuals of lower socioeconomic status) have low self-efficacy in general. Consequently, the campaign’s shortcoming to improve the self-efficacy of individuals who evidently need such improvement results in its inability to enact long-term change and achieve its main goals.
Critique 3 – Failure to Consult the Population at Risk in Design and Implementation of Campaign
            Even though COPD is highly prevalent, many individuals who are diagnosed and are symptomatic have low knowledge of COPD and are undertreated (22). One would expect that program developers would consult those individuals who are most at risk for COPD and are thus the most important targets for the intervention. However, NHLBI makes no mention of conducting pre-intervention research on its target population. After the intervention was implemented, a focus group with 13 individuals (6 females, 9 smokers, and 8 individuals diagnosed with COPD) was conducted a year later. Only one of 13 individuals in the group had previously heard of the campaign and no one had heard of Grace Koppel, the spokesperson for the campaign. Importantly, all individuals in the focus group mentioned lung cancer as the most important “lung disease,” but were unable to connect other diseases that might affect the lungs, such as COPD, with this label (23). With this information, it seems as though the campaign missed its target population likely correlating with its choice of spokesperson, who did not resonate with any individuals; and failure to mention lung cancer in any of its materials. The targeted individuals are less likely to follow the advice of a spokesperson who they do not know or with whom they do not identify themselves, even if the spokesperson appears on national television. Lung cancer should have been mentioned in the educational materials – ignoring the most significant “lung disease” in the eyes of the audience is not the way to educate individuals on another important lung pathology. Those who developed the educational materials could have used lung cancer as a way to frame the magnitude of COPD and show how it is a higher predictor or mortality and morbidity in the target population.
            In its educational videos, the information is narrated by a Caucasian male who is described as: “He is male around the age of 45 to 55. He is a “NASCAR dad”-type of guy, plain spoken and liable, dressed in khakis and plaid shirt” (24). It seems as though the only descriptive category that the developers got right in this video is the age. It is understandable that the host should appear as someone who is easy to be liked; however, the program developers could have chosen someone who is easy to like but also connects to the target population.  It appears that this host is part of a higher socioeconomic status, which may appear as patronizing to women and individuals of lower socioeconomic class. It is doubtful that this educational video was tested with the population that should be targeted the most. Thus, the failure of the program to appeal to its most important population undoubtedly played a role in its limited success.
Alternative Model – Expanding “Learn More Breathe Better”
            Evidently, the limitations of the campaign described above have been holding it back from reaching its true potential – not only increasing awareness, but namely encouraging individuals at risk to receive testing and thus obtain early treatment, which has extreme potential at improving outcomes, such as quality of life (25). Attempting to improve patient knowledge with the health belief model or without underlying theory in mind has been unsuccessful in improving outcomes (26). In turn, a successful program would combine knowledge while increasing self-efficacy, and successfully framing the intervention to the target population after doing rigorous pre-program research to discover the factors that govern the behavior of the target group (27). By focusing on group level intervention, improving self-efficacy, and targeting the population most at risk, the alternative intervention can be far more successful.
Intervention 1 – Focus on Group Level Intervention
            Focusing on group level intervention rather than on individual health behaviors can increase the success of this campaign. Individual models cannot explain group behaviors as beliefs of individuals do not sum up to beliefs of a group. An example is the Abilene paradox, which explains that a group of individuals may collectively make a decision contrary to the decision that a single individual would have made (28).  Since an important limitation of the health belief model is its assumption of rational behavior, the group model takes advantage of its assumption that behavior may not be planned and the decision to act is due to context and environmental circumstance of the targeted group.
            Group behavior may be modified with the use of the advertising theory, especially if applied in the right way to the target population. The theory states that successful advertising lays out a promise to the consumers with support and simultaneously appeals to core values and emotions of the target population (29). Advertising on television and radio may be especially successful as individuals have reported higher credibility of advertisement that appear on television and radio rather that in print (30). Importantly, the advertisement should have an explicit conclusion and should show how the product will improve the groups’ lives rather than leaving it for the individual to draw their own conclusion (29). In this case, the advertiser, which could be NHLBI or any of its partners, must advertise a promise – not having trouble breathing, being able to more spend time with family and friends (especially in neighborhoods that have characteristics of the target population), and being able to work without disability. The advertisements must back up these promises with support. Providing straight statistics (i.e. COPD is fourth leading cause of death and leading cause of disability) will not appeal to the emotions of the group (29). Instead, the advertisements should show a specific story of an individual at risk or with COPD and employ a catch phrase that is easy to remember (i.e. I learned to breathe better!).
Obviously, since appealing to the core values is an important component of a successful advertisement, pre-program research must assess the most important core values of the target population. Core values may be different for each population and the program implementers should assess as many different groups of people as possible in order to examine which core values permeate through all groups as well as which values separate one group from another. By conducting careful research, advertisements targeted toward specific populations may be created and shown on channels and radio stations that provide the greatest exposure. Television and radio advertisements take precedence over print advertisements. Ultimately, this proposed intervention of employing the advertisement theory is an key aspect to improve the previous public service announcements and educational videos that were based on the Health Belief Model.
Intervention 2 – Improving Self-Efficacy, “Yes I Can!”
            Providing individuals with knowledge without improving their self-efficacy has shown limited improvement in COPD outcomes (27). An individual’s perception of self-efficacy will determine whether he motivates himself and participates in the behavior that is advertised (31). Influencing and improving self efficacy can be achieved through an individual’s past experiences as well as current psychological status, witnessing the experience of others, and the power of persuasion (13).
            In this part of the intervention, showing the experience of others and employing persuasion in advertisements may also improve psychological state of the target individual in the group and thus enact the behavior. As previously stated, it is important for an advertisement to show true experiences of other individuals who are most similar to the target group. By illustrating the experience of individuals who have faced similar problems (both health and “life” problems) and how they have effectively overcome many of these challenges by going to their physician and getting tested for COPD, the individual who views this commercial should have an increased belief that he can achieve the same success by copying the behavior shown. The same individual who appears in an advertisement may use persuasive comments to improve the viewer’s self-efficacy; an example of such comments includes “Yes, I can! I learned to breathe better, and have shown many of my friends and family how they could do the same!” By appealing to the emotions of the group with individual stories and showing how enacting the behavior may reduce the stress in their lives (i.e. “Since I’m breathing better, I can work more hours or spend more time with my family”), the psychological status of the viewer may be improved.
            An additional component that may be used to improve self-efficacy is creation of self-help groups in the neighborhoods of target populations. Self-help groups have been shown to improve self-efficacy (31-32). The advertisement may show an individual participating in a self-help group and providing support as to how the self-help group helped achieve the promise. At the end of the commercial, information about the group may be provided (i.e. when and where a group meets). Employing several different strategies to improve self-efficacy by using the advertisement theory, the campaign will not only reach a larger target audience but will also be more successful to promote the desired behavior.
Intervention 3 – Know your population!
            Unlike the health belief model that tries to enact change in one individual at a time, the advertisement theory takes advantage of needs and desires of a group to endorse behavior change. It is extremely important for the program and advertisement developers to understand their target population in order to appeal to their basic core values. Pre-intervention research must delve into the experiences and desires of the target group.
The limited success of the current campaign is in part due to its inability to connect with the population. In a focus group, none of the participants had heard of Grace Koppel, the spokesperson for the COPD campaign (23), who has appeared on CBS Evening News, the View, and Good Morning America (5) to promote the campaign. Even though Mrs. Koppel is a woman with COPD, it is unclear if women of lower socioeconomic status, the group that is most at risk, can view a connection between themselves and the spokesperson; or if the target population even watches these television shows. In fact, the majority of the View audience is middle-class women who are housewives and retirees; most of these viewers also do not watch evening news (33). Consequently, the population that was reached the most was probably of higher socioeconomic class. Even though some of this population may be at risk or have COPD, it should not be the most targeted population. In fact, reaching out to this group may have created a larger “knowledge” gap between the populations, unethically depriving the target population of knowledge they must have in order to enact behavior change (34).  Campaign implementers should conduct several pre-program focus groups with the stakeholders and members of the target population to determine: 1) with whom do you connect (i.e. a celebrity, politician, etc); and 2) what channels and television shows do you tend to watch the most. In order to achieve successful exposure of the campaign, it should be known on which channels, shows, and times the advertisements would be most viewed by the target population.
The same idea also pertains to the choice of the narrator on educational videos. The individuals must be asked which characteristics connect them to the people that they see on television and in movies. The described attributes of the individual should be portrayed in both the educational videos as well as the advertisements. These features will make the videos and advertisements seem more realistic, which was one of the stated limitations of the current campaign (23). Accordingly, by truly understanding the target population, the disseminated advertisements, videos, and information would be more appealing and have a better chance to promote the desired behavior change.
            Considering that COPD is the third leading cause of death in the US and the mortality of women with COPD steadily rising, successful intervention to combat this public health issue is needed. NHLBI has undertaken an important campaign to improve the lives of individuals at risk or with COPD; unfortunately, their goals have come up short. The partnership of NHLBI with numerous foundations and associations shows that the campaign has an ability to reach a large audience. However, several factors have held back its success, including a focus on the health belief model, the inability to increase self-efficacy, and not understanding its target population. Still, not all is lost. The campaign may be improved by focusing on group level change through the advertising theory, promoting self-efficacy in its advertisements, and conducting rigorous pre-intervention research in order to understand its target population. By advancing the campaign with these improvements, it should be more successful in combating COPD morbidity and mortality. There is too much at stake for NHLBI to stay idle – millions of people are waiting to be diagnosed and treated. If COPD is to be conquered in the future, this public health campaign cannot fail now.

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