Methodologic Advances and Ongoing Challenges in Designing Community-Based Health Promotion Programs

Abstract

s Abstract Community intervention trials continue to attract researchers as potential ways to achieve widespread, long-term change in health behaviors. The first generations of community studies were somewhat unsophisticated in design and analysis, and their promise may have been overstated. As design and analysis issues were better defined, as secular trends caught up with the behaviors that researchers were trying to change, or as other unknown variables affected community studies, small effects of interventions were observed in community trials. Discussions were held in professional meetings and reported in the literature: Should community trials be discontinued? In general, the answer was a qualified no. In this paper, we briefly review some of the many advances made in community intervention trials, and address in more detail the challenges ahead. INTRODUCTIONMuch of the risk for chronic disease is behavioral and can be controlled. Many cancer factors, for example, are related to diet, smoking, and sexual behavior; these lifestyle behaviors account for up to 70 percent of all cancers (44, 70,110). Lifestyle behaviors are similarly important in the prevention of cardiovascular disease (CVD), much of which is attributed to the behavioral factors of diet, smoking, and uncontrolled hypertension (48, 56, 61). Other chronic diseases, including diabetes (13,100,133), arthritis (9, 92), and osteoporosis (3, 92), may be prevented by behavioral changes in diet and exercise. Numerous experimental studies designed to modify health-risk behaviors have been conducted. Success rates of such programs are generally determined in randomized trials, and the great bulk of such trials have focused on the individual, i.e., they rely on volunteers to participate in the experiment. Such trials may have an effect on the individual participants but have limited ability to achieve widespread, large-scale changes in the health-risk behaviors of the population as a whole.The past three decades have seen a change in the manner in which many lifestyle behaviors are viewed. Increasingly, smoking is perceived not as an individual problem, but as a public health problem, in need of policies to control where smoking is allowed (59, 77). Similarly, fluoride is added to water to reduce dental caries (72,96). Seat belt usage is required by law in many states (43, 62,119), as are helmets for motorcycle riders (8,90,97). Dietary habits also are no longer considered purely individual matters. The U.S. Food and Drug Administration and the United States Department of Agriculture have produced a report recommending reform in food and nutrition labeling (6,104,130).This approach to behavior is familiar to many public health and health-promotion researchers. The increasing focus on "the public" in health promotion is due, at least in part, to growing recognition that behavior is greatly influenced by the social environment in which people live. Local values, norms, and behavioral patterns have a significant effect on shaping an individual's attitudes a...

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