Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Thursday, December 13, 2007

Critique of the National Diabetes Education Campaign - Shreya Patel

An epidemic is defined as a disease with a strikingly high incidence rate that supercedes the expected rate of occurrence (1). Few may realize that the Centers of Disease Control and Prevention have termed the chronic condition, Diabetes, as an epidemic in the United States (2). To address the epidemic, the National Institute of Health and the Centers of Disease Control and Prevention have launched a massive public health intervention, The National Diabetes Education Program (NDEP). NDEP consists of educational campaigns which focus on diabetes prevention and management (3). Although its campaigns are informative, the intervention is weak because it seems to rely on the concepts of individual behavior change, behavioral intention, and narrow social networks. These principles are reflective of three popular theoretical models used by public health practitioners to design interventions. Specifically, NDEP seems to reflect the incorporation of the Health Belief Model (HBM), Theory of Reasoned Action (TRA), and Social Network Theory (SNT) (4). However, diabetes has a multi-causal societal origin (1). Therefore, an intervention which seems to be based on individualistic principles is unlikely to generate a successful outcome.
Individual Behavior Change - HBM
The HBM states that preventative behavior is contingent upon one’s perception of the susceptibility and severity of an illness and the perceived benefits and barriers of taking preventative actions. If one realizes that the benefits outweigh the severity of an illness, then the individual will make an effort to prevent it. Therefore, interventions based on the HBM are informative, with the objective of making individuals aware of their vulnerability and the greater benefits of prevention. NDEP’s campaigns seem to reflect these principles (4). One of NDEP’s campaigns entitled: “Be Smart about Your Heart, Control the ABCs of Diabetes” emphasizes that the management of blood glucose, blood pressure, and cholesterol will reduce diabetes induced strokes and heart attacks. Like HBM interventions, this campaign emphasizes the greater benefits of disease management as opposed to the negative consequences of inaction (5). Also, one of the campaigns entitled “Small Steps. Big Rewards. Prevent Type 2 Diabetes,” provides self assessment tools to help one determine if he or she is pre-diabetic. This reflects the HBM component of perceived susceptibility (5). HBM interventions also promote self-efficacy, an individual’s faith in his or her ability to take action. The principle of self efficacy was added to the HBM in 1988 after social learning theories became influential. (4). It seems that self efficacy is integrated in a campaign entitled: “We Have the Power to Prevent Diabetes.” This segment encourages susceptible populations that they have the ability to take control over their health. Fact sheets and motivational articles are provided to induce confidence. (6). However, NDEP’s basis on what seems like HBM principles is not the best strategy to induce behavior change.
By focusing on preventative education, NDEP does not seem to integrate social context. Because they are a strong determinant of peoples’ behaviors, social factors must be taken into consideration (1). For example, studies indicate that African Americans with a lower socioeconomic status (SES) are more likely to prematurely develop diabetes (7). Therefore, any intervention to reduce the prevalence of diabetes must address the conditions associated with different SES gradients. To elaborate, NDEP advises individuals to eat a healthy diet, but this may not be feasible for those who have lower SES and reside in areas where grocery stores are scarce, as seen in low income African American communities (1). Furthermore, evidence indicates that HBM public health interventions that do not consider social factors fail to attain their mission. For example, a study to examine the shortcomings of a HIV intervention among Asian and Pacific Islander American Men exemplifies that the intervention was not as successful because it failed to take into consideration the effects of families, communities, and racism(8). The analysis indicates that simply education was not sufficient and that future interventions must integrate social factors (8). Similarly, NDEP campaigns are primarily educational. This similarity reflects why the NDEP lacks potential in succeeding.
Do Intentions Lead to Behaviors?
It appears that NDEP’s tactic is to also modify behavioral intention, the central concept of the Theory of Reasoned Action (TRA). The TRA states that an action is derived from behavioral intention, which is shaped by attitudes and subjective norms. Behavioral intentions are then translated into behavior. (4). NDEP’s campaigns seem to attempt to change attitudes towards healthy behavior. For example, one of its awareness campaigns is entitled: “Small Steps. Big Rewards.” It emphasizes that one does not have to work excessively hard to engage in a healthy lifestyle. Instead small steps such as simply talking with one’s doctor about diabetic risk are beneficial. Another small step is to reduce snack intake (9). It seems that the campaign attempts to modify individuals’ attitudes towards healthy behavior in order to make them believe that prevention does not require overbearing effort. As a result, the campaign seems to attempt to positively shape behavioral intentions, in hopes people will intend to carry out healthy behaviors. (9). However, this may not be the best technique for at risk populations that reside in close-knit communities.
NDEP’s design appears to assume that after learning how easy it is to be healthy, one will intend to do so. Then, once the intention is established, will behave accordingly. However, research indicates that intentions do not translate into expected behavior (10). One may intend to engage in healthy behaviors but cultural influences may intervene and prevent the behavior from occurring. Research indicates that one’s intentions are highly influenced by cultural contexts. A published review of the patterns of diabetes in Great Britain indicates that dietary habits, which stem from cultural beliefs, could help explain why in particular, Asian Americans, are vulnerable to developing diabetes (10). In this example, the group of Asian Americans, may intend to eat healthy but due to their customary dietary habits, the intention may not translate into the healthy behavior. Similarly NDEP seems to excessively focus on behavioral intention without integrating cultural contexts. Therefore, past research implies that NDEP’s campaigns will most likely be ineffectual.
Narrow Social Networks
By focusing on the patient provider and student-teacher networks, NDEP seems to incorporate Social Network Theory (SNT). SNT interventions focus on developing projects that will suit the specific characteristics of a given social network (4). NDEP has resources for providers which advise them on how to consult diabetic patients and how to practice efficient disease management. In addition, there is a guide for school personnel on how to provide aid to students with diabetes (5). However, NDEP’s focus on these networks is narrow. Like all individuals, diabetic people interact with larger social groups other than providers and teachers. Important networks include peers, religious groups, professional groups, and ethnic communities. (4) For an individual, another social group’s influence may take precedence over the advice of a single doctor or teacher. Therefore, NDEP should address broader networks because individuals are influenced by a variety of greater groups.
Clarification of Critique
This paper is not a critique of the theoretical models. It is the critique of NDEP’s supposed concentration on certain individualistic principles to resolve a problem that seems to stem from structural causes. The models are not ineffective, for they have many useful strategies. However, the models’ strategies are not directly transferable to diabetes interventions. With regards to their positive attributes, the HBM is well structured in outlining perceived susceptibility, severity, benefits and barriers (4). Vulnerable populations must be initially informed of these components as a first step to influencing them to make a rational decision. However, informative campaigns are not sufficient. The TRA attempts to positively shape behavioral intention. Such an influential component is also necessary in order to make an impact on the target population. The TRA also takes into consideration subjective norms, which are the beliefs of social groups and how they influence intentions (4). However, NDEP seems to fail to incorporate this social component in its campaigns. Lastly, as the SNT states, interventions should target other audiences that the target population interacts with. This is also a very effective strategy in an intervention because it targets other social groups who may have an influence on the at risk populations (4). But heavily focusing on patient- provider and student-teacher interactions, NDEP seems to fail to take into consideration broader networks such as cultural and religious communities. Overall, the theoretical models do have effective principles, but given the complex societal context associated with diabetes, they may not be as applicable.
A significant debate has been ongoing in the field of social and behavioral sciences regarding whether to shape interventions to target individuals or social groups (11). Many have come to the resolution that a combination of social and individual level efforts will be the most effective. In a study examining the shortcomings of an HIV intervention targeting AIDS among Asian and Pacific Islander men, a conclusion was reached to integrate individual and environmental components to design a more effective program (8). Nonetheless, NDEP will encourage individuals to make healthier decisions. However, as studies on similar interventions have indicated, the incidence of diabetes will remain high as long as social factors are not taken into consideration (8). Consistent education, promotion, and motivation will most likely not translate into healthy behavior. In order to be truly effective, NDEP must undergo reform.
1. Weitz R. The Sociology of Health, Illness, and Health Care. Belmong, CA: Thomson Wadsworth, 2007.
2. Diabetes Data and Trends. Atlanta, GA: Centers of Disease Control and Prevention.
3. National Diabetes Education Program. Bethesda, MD: Department of Health and Human Services.
4. Edberg M. Essentials of Health Behavior. Boston, MA: Jones and Bartlett Publishers, 2007.
5. National Diabetes Education Program. Bethesda, MD: Department of Health and Human Services.
6. National Diabetes Education Program. Bethesda, MD: Department of Health and Human Services.
7. Gaillard, TR, et al. The Impact of Socioeconomic Factors on Cardiovascular Risk Factors in African Americans at Risk for Type II Diabetes. Implications for Syndrome X. Diabetes Care. 1997; 20: 745-752.
8. Choi, K. HIV Prevention among Asian and Pacific Islander American Men Who Have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention 1998; 10:19-30.
9. National Diabetes Education Program. Bethesda, MD: Department of Health and Human Services.
10. Hawthorne, K, et al. Cultural and Religious Influences in Diabetes Care in Great Britain. Diabet Med 1993; 10(1):8-12.
11. Marks, D. Health Psychology in Context. Journal of Health Psychology 1996; 1(1):7-21.

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