Tailored interventions prove more effective

Personalized prevention messages may be twice as effective as one-size-fits all efforts.

By Beth Azar
Monitor staff

A n estimated 80 per- cent of all cancers could be prevented if people embraced healthier behaviors: no smoking, good eating habits, moderate exercise and consistent use of sun screen, to name a few.

The challenge for prevention researchers is discovering how to efficiently promote these healthy behaviors to an incredibly diverse population. That's why many have turned to the concept of tailoring cancer prevention programs based on what will best motivate each individual. Tailored programs come in many forms, from simple personalized letters to feedback reports and booklets to interactive computer programs.

"The tailored communication--for example, creating a booklet completely individualized about quitting smoking--might seem inefficient," says behavioral scientist Barbara Rimer, PhD, director of the National Cancer Institute's Division of Cancer Control and Population Sciences. "But if it's more effective then it becomes more efficient."

In fact, many studies find personally tailored interventions can be twice as effective as generic, one-size-fits-all interventions, says psychologist James Prochaska, PhD, of the Cancer Prevention Research Center at the University of Rhode Island. And computer software and other information technology are making tailoring efficient and cost-effective by allowing researchers and others to produce brochures, reports and newsletters based on a person's individual profile, says psychologist David Abrams, PhD, director of the Center for Behavioral and Preventive Medicine at Brown University School of Medicine.

Through brief telephone interviews, perusing medical records or self-administered questionnaires, researchers and clinicians collect information about people's habits, beliefs about the benefits and costs of a certain health behavior and readiness to change. And, based on the answers, a computer program in combination with a trained counselor can produce information and guidelines tailored to their needs, gender, ethnicity and other relevant.

Computers and information technology will provide tools for behavior-change research and practice "that are every bit as profound as the breakthroughs in the human genome have been for biomedicine," says Abrams.

Motivating change

To tailor cancer prevention messages, researchers must begin with general theories of behavior change, as well as specific theories about what motivates behaviors such as smoking and eating, says Rimer, who conducts cancer prevention research with her colleagues at Duke University. Behavior change researchers use a variety of theoretical models derived primarily from Albert Bandura's Social Cognitive Theory and the "Stages of Change Model," developed by Prochaska. Both theories put a person's motivation to change on a continuum of readiness.

More than 80 percent of people are either not ready to change or in the early stages says Prochaska. But the majority of one-size-fits-all interventions are geared toward people who are prepared to take action.

A tailored intervention works by speaking to people based on the stage they're in, in an attempt to move them on to the next stage. In both social cognitive theory and stages of change theory, one way to help motivate people, for example, is to increase their image of the benefits to changing. Then, as they move into action, a program must reduce the number of negative outcome expectations or "cons" they see to changing, says Brown's Abrams.

"For smokers who are not motivated to quit, the benefits of smoking are more important than the benefits of quitting," he explains. "A smoking-cessation program needs to present information that encourages people to rethink and rebalance that view."

For example, if people list many positive aspects of smoking--it's calming at work when the boss is being unreasonable and it's relaxing at home when things get hectic--a counselor or tailored pamphlet might provide ideas about other techniques for relieving stress. And if people can see only a few of the negative aspects of smoking (for example, they know it causes lung cancer), a counselor might mention that smoking is also the leading cause of heart disease.

After interviewing thousands of smokers over the years, researchers have developed "canned" responses to a particular profile. A person can fill out brief assessment forms that can be plugged into a computer that will produce a pamphlet tailored to that person's needs.

As part of a smoking-cessation intervention, Rimer, Bernard Glassman, PhD, and their colleagues had their program send out tailored birthday cards and newsletters that addressed people's readiness to change, previous attempts to quit and other aspects of their personal profile.

For example, a birthday card tailored for African-Americans included the message, "Each year, more Black Americans die from smoking than from car crashes, AIDS, alcohol, murder, heroin, cocaine and other drugs put together. If we count the number of people it kills, smoking is the number one problem facing the Black community."

Thirty-two percent of smokers who also received tailored print materials quit, compared with 12 percent of those who didn't receive the materials.

Promoting participation

Tailored interventions are not only more effective, says Prochaska, but they attract far more people than generic interventions. For example, a traditional smoking cessation clinic, even when offered free by a managed-care company, attracts only around 1 percent of eligible participants, and even home-based programs attract only 5 percent. In contrast, more than 80 percent of people invited, participate in Prochaska's tailored smoking-cessation program--regardless of how ready they are to quit.

His program approaches people either via mail, using a short questionnaire, or in person--perhaps at a health clinic or school--and provides an evaluation of their readiness to change. People then get a set of self-help manuals based on their stage of readiness, which guides them through the stages of change. Three months later they get a follow-up assessment with a report on their progress. Even if a person hasn't quit smoking yet, the report may say, "Congratulations! You've progressed one stage and increased the chance you'll quit within six months."

"This is a major breakthrough in reaching people with the number-one public health problem," says Prochaska.

In addition, around 24 percent of the people who participate in the program quit smoking and maintain abstinence two years later. Although somewhat low, that figure is equivalent to more expensive, much more intensive traditional interventions that reach far fewer people, says Prochaska. Based on the recruitment rate Prochaska sees in his research he predicts that "with a combination of computers and counselors, we can reach out and recruit 80 percent of smokers in the nation and get 20 percent to quit in two years," says Prochaska. "All of that for less than 4 percent of the tobacco settlement."

Integrating behavior and biology

Prevention programs will become even more powerful once they combine what's known about behavior and cognition with biology and social psychology, says Abrams. For smoking, that means tailoring prevention programs not only around a person's motivations and expectations about quitting but also around such factors as their genetic makeup, their level of physical addiction, their ethnicity and the social issues they face at home and in their neighborhood.

"We must integrate and synthesize the macro-sociocultural realm and breakthroughs in the biology of nicotine addiction into the best behavioral social cognitive theories," says Abrams. "It's not a matter of tagging on bits and pieces of other models. We need nothing short of a transdisciplinary synthesis."

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