Report of the Expert Panel on Awareness and Behavior Change to the Board of Directors, American Heart Association
The Board of Directors of the American Heart Association charged the Expert Panel on Awareness and Behavior Change to:
Evaluate the available data on the strengths and limitations of health education strategies targeted at increasing awareness of the benefits of cardiovascular risk factor management compared with strategies that specifically promote behavioral change.
Consider the relative role of alternative strategies such as policy making and media campaigns in achieving the AHA’s educational mission. The panel was asked to evaluate the AHA Strategic Plans for Consumer Nutrition Education and Promoting Physical Activity.
Address the following questions: How can the AHA best invest its finite resources? Should the AHA’s educational goals focus on and measure success through public knowledge and awareness of cardiovascular risk factors or behavioral change related to specific risk factors?
Develop recommendations on how the AHA can best allocate its limited resources for health education and identify appropriate new methods of evaluating the effectiveness of its programs.
Panel members reviewed background material on the structure and function of the AHA, then met in Dallas on October 17, 1995. Extensive discussions and the subsequent deliberations clarified the purpose of the decisions to be made by the Board of Directors. The panel spent a substantial amount of time and effort evaluating alternatives and assessing the strengths and risks or limitations of each. These alternatives are presented in Tables 1 through 5⇓⇓⇓⇓⇓. This report presents the recommendations of the Expert Panel to the Board of Directors.
Throughout these discussions the American Heart Association mission, “To reduce disability and death from cardiovascular diseases and stroke,” was kept in mind. Consideration of the mission and the charge to the panel led to discussion of influences and steps toward fulfillment of this mission by the American public. This process is depicted in the Figure⇓ as an arrow.
The central core of the arrow illustrates a sequence of change by individuals, groups of individuals, segments of the population, or the entire population. The arrow depicts a sequence from awareness (Table 1⇑) of a modifiable health-related problem, through acquisition of skills to change behaviors that influence health, to actual altered behaviors (Table 2⇑) that lead to a modification of risk factors, and finally to a decrease in disability and death from cardiovascular disease. The Figure⇑ also recognizes several powerful influences on risk (Table 3⇑) and, ultimately, on disease: the physical environment in which we live; the social environment that influences our actions and behaviors; national and local policies that impact behaviors; and the role of the healthcare system itself in the entire sequence.
The AHA’s programs and messages (Table 4⇑) are designed to fulfill its mission by reaching and favorably influencing the awareness, knowledge, behavior, risk, and health of all Americans. The panel has reviewed many of the principles of reaching large audiences. Programs can be targeted at individual, group, organization, community, or population-wide levels. The data clearly indicate that it is easier to arouse awareness than to change behavior. Yet behavioral change is a major step in fulfillment of the AHA mission. The panel recognizes the efficacy of programs targeting individuals and small groups. The panel also reviewed the evidence that suggests that community-based programs have achieved modest results, at best. The panel analyzed the evidence of the remarkable success of the AHA and its allied agencies, both governmental and nongovernmental, in producing favorable trends in most behaviors, cardiovascular risk factors, and age-adjusted death and disability rates. Many of these changes reflect programs, policies, and practices implemented at the national level through coalition building and advocacy.
Accordingly, the panel does not recommend that the AHA seek an “either/or” decision concerning emphasis on awareness or behavioral change. Similarly, the AHA should not focus exclusively on either small-group programs or state- or national-level advocacy efforts. Instead, the panel recommends that many strategies and tactics have a place in moving the population toward achievement of the AHA mission (Table 5⇑).
Careful consideration of these factors has led the panel to present the following recommendations to the AHA Board of Directors for approval. These recommendations involve the program, evaluation, and structure of the AHA.
1. Programs, messages, and educational strategies should be designed and implemented with the expectation that they are likely to move the population toward fulfillment of the AHA mission. There is no need to focus on any one element to the exclusion of others.
2. The AHA should continue to use social marketing principles to identify the element to be influenced, specific target audiences, optimal educational strategies, and the most effective means of meeting the specific needs of the target audience.
3. Programs should be based on tested theory whenever possible but can and should vary in expected outcome. Efforts to seek behavioral and risk factor change in population groups at higher risk of disability and death from cardiovascular disease is not only important but cost-effective. Those in the early stages of behavioral change may be moved by awareness and increased knowledge toward adopting more healthy behaviors.
4. Programs to enhance the visibility of the AHA and generate resources are in keeping with efforts to move the population toward fulfillment of the AHA mission. Such messages, when combined with actual behavioral change, enhance a social environment that promotes good health.
5. Program messages that are based on sound scientific evidence and consensus within the AHA must also be understood by the public. Nutritional information deemed appropriate by the AHA’s science component may not be communicated at the level of comprehension required by the AHA’s program component. For example, a catchy, yet scientifically sound message such as “5-a-day” may be a better program message than “Eat five servings of fruits and vegetables daily.” Similarly, use of the terms “skim” or “1%” to describe low-fat or low–saturated fat dairy products may be more comprehensible to certain population segments. Describing a 3-ounce portion of meat as being the size of a deck of cards may be helpful to others.
6. To optimize the use of its resources in fulfillment of its mission, effective AHA programs and messages (as judged through internal or external evaluation) delivered through the appropriate channels to responsive audiences are needed. Similarly, ineffective or unproved programs of limited reach (inappropriate or unresponsive audiences) should be discontinued.
7. When feasible, coalitions with other organizations that share the AHA’s goals in programming, visibility, and fund-raising should be formed and nurtured to present concerted rather than discordant or confusing messages to the public. An excellent example is the Coalition on Smoking OR Health. Previous efforts to develop a sustained multiagency coalition effort promoting an all-American diet should be resumed, even if the messages used originate from other agencies. Messages about nutrition and other behavioral changes should be communicated by several agencies in the same terms to avoid confusing the public.
1. Precise evaluation is costly. Given its limited resources, it is appropriate for the AHA to use a variety of methods to evaluate its programs and messages. Programs clearly indicated by previous data as successful in generating awareness, changing knowledge, or changing behavior (or even image enhancement and fund-raising) do not require additional evaluation. Program evaluation should be used to the extent required to show that products are effective and that they reach targeted individuals. Product designs based on previously tested principles may require only limited formative pretests with targeted individuals, coupled with process tracking to ensure delivery. When evaluation data are limited, pilot testing is necessary. Formative evaluation is particularly important for new approaches, such as interactive computer programs. Subsequent versions of the same approach do not require outcome assessment (eg, awareness or behavior).
2. It is recommended that the AHA not use its resources to conduct long-term follow-up of behavioral change by all program participants. Extrapolation from pilot data or data obtained from other sources is a practical measure of the effectiveness of such efforts.
3. It is recommended that the AHA not expect to be able to conclusively attribute long-term risk factor or cardiovascular disease disability or death trends to a single program or even its own global efforts. To be part of a movement toward fulfillment of the AHA mission is sufficient.
4. Proper topics for AHA research support, in addition to basic molecular and clinical science, include public health disciplines such as health communications, health marketing, health services, behavioral medicine, program evaluation, and evaluation of individual and collective behavior. Research in these disciplines will enhance understanding of formulation, delivery, and evaluation of effective programs and messages within the AHA and elsewhere.
5. Collaborative efforts in evaluation, as in program delivery, are worthy of consideration. Industry partners (eg, members of the Pharmaceutical Roundtable or other pharmaceutical/medical equipment manufacturers) may want to support program evaluation. A partnership with the Centers for Disease Control and Prevention (CDC) may provide opportunities to use or even add questions to the Behavioral Risk Factor Surveillance System on a national, regional, or state basis. In turn, pilot tests of programs or messages on a state or regional basis may facilitate evaluation through such a partnership. The National Center for Health Statistics National Health and Nutrition Examination Survey (NHANES) may also provide low-cost evaluative resources.
6. Consider creation of a mechanism to set aside a portion of AHA research funds to support rigorous program evaluation as needed through a Request for Proposals, developed cooperatively by the science and program components of the AHA.
1. Continued use of market teams to reach specific target audiences and the flexibility to create new teams or modify existing teams is recommended.
2. Program and channel prioritization processes should continue to include analyses of population segments, their risk level, ease and cost of access, cost-effectiveness, and likelihood of useful outcomes based on stage of change. This prioritization matrix should be reevaluated at least biennially.
3. It is important that AHA staff and volunteers in the areas of science, program, and communications have effective ongoing communication, common goals, and common messages. Accordingly, the Science Advisory and Coordinating Committee should include as regular members persons with expertise in community program design and delivery as well as persons with a public health communications background.
4. The Board of Directors must ensure better communication among these groups so that credible and comprehensible awareness and behavioral change programs and messages are delivered to and received by the public. In the event of disagreement, the Board should decide how scientifically credible programs and messages are best delivered.
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