Home Engineering Behavioral Intervention Research: Designing, Evaluating, and Implementing
WHY BEHAVIORAL INTERVENTION RESEARCH IS IMPORTANT
The growing recognition and increased acknowledgment of the value and importance of behavioral intervention research for improving the health and well-being of the public can be attributed to several critical trends. The first is the growing recognition that the most pressing contemporary health issues that impose high societal and individual costs primarily involve lifestyle and behavioral factors, such as obesity, smoking, addictions, chronic disease, comorbidities, and functional consequences of diseases, social isolation, depression, delirium, mental illness, family caregiving, and health disparities. Developing and testing behavioral, nonpharmacological interventions that tackle these serious, persistent public health challenges is a widely recognized imperative (Lovasi, Hutson, Guerra, & Neckerman, 2009; Milstein, Homer, Briss, Burton, & Pechacek, 2011; Jackson, Knight, & Rafferty, 2010).
Second, the existing research evidence consistently suggests that behavioral and environmental factors exert a powerful and large influence on health and well-being. This is particularly the case for aging-related processes in which social and environmental factors are intertwined with the medical care of older adults. Take, for example, functional decline associated with growing older. Microenvironmental (individual) and macroenvironmental (family and cultural) effects have been found to contribute to age-related changes in functioning and to account for increasing heterogeneity in abilities even more than genetic factors (Finkel, Ernsth-Bravell, & Pedersen, 2015). The contribution of genetics to the rate of change in functional abilities among older adults >75 years of age is estimated to be only about 16% for women and 9% for men (Christensen, Gaist, Vaupel, & McGue, 2002; Christensen, Holm, McGue, Corder, & Vaupel, 1999). Even for dementia, the genetic heritability is small, with most causes due to age itself and possibly environmental factors, although these are poorly understood (Gatz et al., 1997). Furthermore, although genetics may contribute in part to early onset of chronic diseases, environmental factors and behaviors overwhelmingly account for the wide variation in outcomes after age 75 (Svedberg, Lichtenstein, & Pedersen, 2001). Thus, enhancing health and well-being through behavioral, lifestyle, and environmental modifications is critical to improving the health of the public overall, and the promotion of “successful aging,” in particular. The latter, in particular, is an issue of growing importance given the aging of the population, especially the increase in the “oldest old” cohort (85+ years.).
Third, despite an abundance of proven behavioral interventions, a gap of more than 17 years persists between the conduct of research and the production of evidence and the implementation of its yield. (Institute of Medicine [IOM], 2001). Only about 14% of evidence, including evidence-based intervention programs, is implemented in clinical and community settings, with Americans receiving only 50% of recommended preventive, acute, and long-term health care (McGlynn et al., 2003). Minority populations are at particular risk, receiving recommended evidence-informed programs less than an estimated 35% of the time (Balas & Boren, 2000; Brownson, Colditz, & Proctor, 2012; McGlynn et al., 2003; Riley, Glasgow, Etheredge, & Abernethy, 2013). This large gap appears to be due to system-level factors (e.g., policies that do not structurally and financially support the delivery of evidence-based programs), workforce-level factors (e.g., the lack of adequate preparation of health and human service professionals or others in using evidence-based programs), individual factors (e.g., the lack of awareness of available programs or inability to access programs), or mismatches between the needs of individuals, resources (financial and expertise) of service organizations, existing policies and practices, and the characteristics of tested and proven interventions.
It is unclear how to close the “chasm” between “knowing” versus “doing” that continues to haunt every part of health and human services for every age group and population. This chasm has led to the growing recognition of the need to reconsider traditional approaches to designing and testing behavioral interventions and to seek alternative approaches for developing interventions that have greater potentiality for being implemented more rapidly and sustained.
A fourth trend that heightens the importance of behavioral intervention research is the paradigm shift occurring in health care today. New approaches and expectations are emerging in health care to view patients and their families as active participants in the management of their own health (Bodenheimer, Lorig, Holman, & Grumbach,
2002). Health self-management may involve adherence to a diet, exercise or medication regimen, coordination of a care network, and use of medical technologies (e.g., activity monitor, blood glucose meter, blood pressure monitor). Self-management can be complex and involve the need for personal oversight of multiple wellness goals, chronic conditions, and medication regimes. Thus, there is growing recognition of the importance of behavioral interventions that can effectively instruct and support patients and their families in the practical skills for self-management. Furthermore, there is an increased awareness of the need for evidence-based approaches to foster adherence; promote engagement in wellness activities; facilitate care coordination, communications, and interactions with health care professionals; and manage transitions between health care practices, facilities, and professionals.
Finally, there is a societal push for the adoption of evidence-based practices in health service delivery settings and community agencies. Evidence-based practices are interventions that have been tested in high-quality research and that are unbiased, have strong internal validity, and in which the results are generalizable with a firm level of confidence in linking outcomes to interventions (Guyatt et al., 2000). Thus, behavioral intervention research is needed to uncover what treatment practices work best, for whom, and under what circumstances. At the same time, there is an emphasis on what is referred to as “translational research” or harnessing knowledge from science to inform treatments and ensure that evidence reaches the intended populations (Woolf, 2008). As a critical goal is to impact practice and health care, it has become imperative to understand how best to design interventions so that they can eventually be successfully applied to and adopted by individuals, clinical practices, services, organizations, and communities.
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