Behavioral Health Interventions: What Works and Why?

1 Given the limits of this paper, my discussion is necessarily brief. For a more complete discussion of many interventions, see Powell (2001). 2 Some interventions must ultimately be implemented to reduce racial, ethnic, and socioeconomic disparities in health. Designing such interventions is difficult, however, since not all interventions are equally efficacious. This paper reviews what is known about the success and failure of behavioral interventions and why some interventions succeed. By behavioral interventions, I mean interventions designed to affect the actions that individuals take with regard to their health. The typical medical intervention is a clinical trial of a particular drug, surgery, or device. In the trial, doctors provide different services to different people, and then evaluate the outcomes. Variation in patient behavior is generally shunned; a strong emphasis is placed on making sure that patients do exactly what is expected from them. With behavioral interventions, in contrast, patient behavior is the key and the goal is to change it. Behavioral interventions can be implemented at three levels. 1 The first are individual interventions. These interventions encourage people who are at high risk for a particular disease to do something about it. Examples are programs to encourage smokers to quit, or programs to encourage people at high risk for heart disease to take steps to reduce their risk. These steps involve lifestyle changes (eating well and exercising) and medical changes (regular testing of blood pressure and cholesterol). In both cases, though, the actions taken are controlled by the individual. The most important individual intervention is the the Multiple Risk Factor Intervention 3 Trial (MRFIT) conducted in the 1970s. MRFIT was designed to induce men at high risk for heart disease to lower their blood pressure and cholesterol, and to stop smoking. It enrolled over 12,000 men in a trial lasting 6 years. The men received counseling and help with behavior modification. As I discuss below, the trial was only partly successful. Risk factors changed by more in the treatment group than in the control group, but the impact was less than was hypothesized. Further, mortality outcomes for the treatment group improved only slightly more than did outcomes for the control group. The relative failure of individual interventions was interpreted by many as evidence on the importance of environmental factors in health. Individuals are products of their environment, the theory went, and thus one cannot change the individual without changing …