Health Education Research, Vol. 17, No. 6, 700-703,
December 2002
© 2002 Oxford University Press
LETTER TO THE EDITOR |
Response to Connelly
First at the Gates of Fire: can there be any survivors?
Department of Clinical and Social Sciences in Psychology, College of Arts, Sciences and Engineering, University of Rochester, PO Box 270266, Rochester, NY 14627, USA
I first read Connelly’s review of the Behavior Change Consortium (BCC) studies while on a family trip to Greece. I was engrossed in my reading Gates of Fire (Pressfield, 2000
), an historical novel about the battle of Themopylae in 480 BC. Reportedly, 300 Spartans held off an estimated 2 million Persians for 7 days in defense of a narrow mountain pass, where superiority in the numbers of invaders was partially neutralized by the geography. Before all the Spartans were killed, they took the lives of perhaps 20 000 Persians. Pressfield describes the Persian commanders ordering their archers to shoot through their own soldiers to hit, by chance, a Spartan. My initial reaction to Connelly’s review was to feel as I imagine the Persian soldiers at the front of the battle might have felt when wounded by arrows fired by an ally. Although I continue to believe that some of his points were wrong or inappropriately narrow, I have with time, come to find some value in his comments.
I am one of the principal investigators in the BCC and am also a practicing physician. I had the privilege of training under George Engel’s influence at the University of Rochester. Dr Engel was devoted to being scientific in the human domain (Engel, 1996), and to broadening the view of medical students, attending physicians and health care practitioners of all types to consider psychosocial factors in their patients’ illnesses. He introduced the term ‘biopsychosocial’ and taught it as an alternative to the traditional biomedical model used by health practitioners in the care of patients (Engel, 1977). It is through my understanding of the biopsychosocial approach to health that I interpret Connelly’s remarks, and I agree that more widely based approaches need investigation, scientific discussion and translation into policy and practice if we are to unravel the mystery of human behavior and its relation to disease and illness. However, Engel’s (Engel, 1987) essay, entitled ‘Where you think you stand determines what you think you see’, comes to mind as I struggled to integrate the message of Connelly’s ‘attack from behind’ into the fray of the battle ahead.
Clearly, Dr Connelly’s remarks address a broader view on the origins of disease and human behavior than that being investigated by most BCC research projects. His criticisms identify some of the limitations in the theories and populations being studied, as well as in the methodologies being used. To a person, I believe the investigators would encourage support and funding for research described in his commentary. From where he stands, he believes he sees a missed opportunity for the study of the public health with his emphasis on the social and economic determinants of disease and its prevention. To this end, he advocates excluding the biological and psychosocial levels of disease prevention. Further, his narrow focus entirely excludes individual-, family- and group-level approaches to the treatment and prevention of disease. Thus, his broad societal approach to disease has the paradoxical effect of creating perhaps an even narrower view than the one he so heavily criticizes in our studies.
From our (the BCC investigators) perspective, we see an opportunity to take 15 steps forward by attempting to link theories of human behavior to the three health-related behaviors of smoking, exercise and diet. To the extent that ‘narrowness’ exists in our approaches, it remains reflective of the current state of our science. Connelly fails to acknowledge this unique and important foundation—the BCC studies were intended to provide for future health behavior research. This narrowness also reflects the limited funding that has been available for health behavior research relative to the enormity of the disease burden caused by these behaviors [i.e. 3–4% of NIH budgets are devoted to health behavior compared to 40–50% of premature mortality caused by unhealthy behavior in the US (McGinnis and Foege, 1993)]. The theories being compared to explain variation in one health behavior and the theories being studied as predictors of two health behaviors are those seen by reviewers as being most developed and ready for in-depth investigation. Studies of these two types were requested because they would begin the process of scientifically identifying specific variables that mediate between interventions and outcomes, and thus linking these psychological theories to actual behavior. The BCC studies were not intended to answer all of the questions related to this topic nor were they meant to study all theories that might apply. The methodologies (e.g. randomized controlled trials) represented in this ‘front line’ of studies reflect the culture in which the studies will be interpreted and applied. Currently, that culture in the US is evidenced-based medicine delivered at the individual, family and group levels of care, and empirical social science. Connelly’s review casts too wide a net for these 15 studies to fill. From where I stand, the BCC studies have a good chance of making a meaningful contribution to the scientific base linking behavior and health. Further, I agree with the REAIM perspective (Glasgow et al., 2002) that one core issue by which the BCC intervention studies should be evaluated is their potential for eventual translation and overall public health impact.
The investigators with whom I work at the University of Rochester—Edward Deci and Richard Ryan—have developed a general theory of human motivation, called Self-Determination Theory (SDT) (Deci and Ryan, 1985), that has not been extensively studied in the health domain. We chose SDT because it assumes humans to be innately oriented toward health and growth. Previous research has indicated that social environments that support human needs for autonomy, relatedness and competence results in patients becoming more motivated (Williams et al., 2002). We chose to study how the health care environment could be constructed to support these needs in the context of individual treatment of tobacco dependence and hypercholesterolemia. Central to SDT is the patient’s perception of autonomy. In our study, perceived autonomy is measured and it is hypothesized to energize smoking cessation attempts and dietary change in both our intervention group and our community care group. The intervention was designed to support autonomy and relationship by providing a positive caring interpersonal climate, and by eliciting and acknowledging each patient’s perspective, providing options for treatments including not changing, providing a rationale for change, and minimizing control. If patients decide to try to change, our practitioners support competence by skills building and problem solving delivered in a patient-centered style. Another important aspect of our choice to employ SDT in our study is that support of autonomy is wholly consistent with principles of clinical bioethics (Beauchamp and Childress, 2001). Further, any evidence we obtain about enhancing patient autonomy would remain consistent with the ethics of clinical practice and would therefore increase the chance of successful translation into practice.
Connelly points out that humans actively construct an interpretation and meaning of their condition (this was Engel’s point as well). The current generation of health care practitioners in the US has been trained in evidence-based approaches, and they work daily on individual and family levels for the provision of care for individuals. The typical physician will conduct 200 000 individual consultations in his or her career. Patients who use tobacco, fail to exercise and eat an unhealthy diet constitute a greater number of those visits (e.g. smokers see their doctors more frequently than non-smokers because of the diseases smoking causes, such that 70% of smokers see their doctor each year). To the extent that randomized controlled trials of health behavior-related interventions demonstrate that meaningful behavior change has happened, health care practitioners (and possibly administrators) will be motivated to act in the ways demonstrated to have facilitated healthy behavior. Interest generated from the BCC studies is likely to stimulate curiosity and interest in further study and behavior change within the practitioners and policy makers (Prochaska et al., 1992; Williams and Deci, 1996; Cormuz et al., 2002;Williams et al., 2003).
Contrary to Connelly’s concluding paragraph, most health care practitioners already accept that, if smokers stop, if people exercise and if people eat moderately to manage their weight, health improves (Blair et al., 1995; Diabetes Prevention Program Research Group, 2002; Manson et al., 2002; Rigotti, 2002; Stampfer et al., 2000; Taylor et al., 2002; Tuomilehto et al., 2001). Indeed, the Request for Applications asked us to assume these relationships were true. The individual level of care represents only one important context that BCC studies are studied within. Other studies address these links between behavior and health in the context of school, worksite or family/home environments. The rationale for health care practitioners, in particular, and health systems, in general, to adopt tobacco, diet and exercise interventions at the individual level already exist (Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 1998; Coffield et al., 2000; Fiore et al., 2000; Executive Summary of the Third Report of the National Cholesterol Education Program, 2001). These changes in health behavior are effective in reducing mortality relative to other standard medical interventions (Woolf, 1999) when focused on single behaviors. Intervening on multiple behaviors may be even more effective, yet Connelly ignores the important contribution of several of BCC sites that are systematically studying multiple-risk behavior interventions. Thus, if Engel and Connelly are correct that humans construct meaning from ‘where they stand’, the BCC studies have at least the probability of supporting the construction of meaning for health care practitioners, and thus will further the process of integrating social, psychological, behavioral and biological aspects of health into the day to day care of patients.
Over time, who knows what the findings of the BCC studies may stimulate at the World Health Organization? I can only hope to witness how the WHO will come to grips with the worldwide smoking epidemic, as tobacco becomes the world’s leading cause of death by 2030 (Murray and Lopez, 1996). From where I stand, I think I can see that individual-level encounters between patient and health care practitioner will be a valued method for promoting healthy behavior worldwide. I think I can also see that social scientists like Dr Connelly will offer many other important perspectives and many interventions that succeed.
In conclusion, as Connelly and other future reviewers fire their arrows of criticism at the BCC studies, I shall try to survive and to think like one of the Spartans named Dienekes, who was considered to be the bravest of all Spartans at the battle of Themopylae. Herodotus credits him with this response on the eve of the battle to being told that the Persian archers were so numerous that, when they fired their volleys, the mass of arrows blocked out the sun. Dienekes said with a laugh, ‘Good. Then we’ll have our battle in the shade’. The BCC studies are only a small part of what we need to understand the complex link between health and behavior. I think that any attention being paid to the BCC studies is positive, because the attention will further the process of science and believe that funding agencies should broaden the scope of the funding for health behavior research to include some of the issues raised by Connelly. However, we feel our studies represent solid (though narrow) ground on which health behavior research can move forward and be translated into practice.
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J. Connelly Reply to the Behavior Change Consortium researchers: the real issue is health promotion Health Educ. Res., December 1, 2002; 17(6): 704 - 705. [Full Text] [PDF]
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