Challenging Dogma


...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

DON’T WORRY, BE HAPPY: Promoting the Public Health Through Stress Relief -Kimberly Clayton

Americans spend their lives in varying levels of stress. Stress about school, or work, or friends, or family or any number of other avenues wears down on us. Many negative health behaviors are often fueled by stress such as smoking, obesity and hypertension. What public health officials fail to realize is that by addressing stress directly, they can reduce multiple health problems at the same time. Social science theories can inform public health campaigns on how to go about addressing the under-recognized public health problem of stress in modern America.

Stress is a public health problem
The Miriam-Webster Dictionary describes stress as the “physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation”(1). There are many different social and individual contributors to individual stress. These may include race, especially as it relates to racial discrimination and tension, social status, workplace issues, emotional distress, and trauma. As these stresses are internalized, they have physical manifestations. High levels of stress can lead to high blood pressure, unhealthy eating, and self-medication through tobacco, illegal drugs, and alcohol (2).

Three prime examples of negative health implications of stressful lives are smoking, obesity, and hypertension. Most smokers report that one reason they smoke is to handle stress (3). In Empowering Neighbors for Health, a pilot smoking cessation program in a Boston housing development, many smokers trying to quit cite increased stress as a motive for relapsing into smoking (4). A recent study in the Journal of Adolescent Health found that even high levels of stress among adolescents increased risk of current smoking (5). As smoking is responsible for nearly 1 in 5 deaths in the United States (6), the contribution of stress to national death tolls from smoking alone should not be overlooked.

Obesity is a rising epidemic in this day and age. Recent National Health and Nutrition Examination Survey data shows that 32.9% of the nation’s adults age 20-74 are obese (7). There is also evidence of a biochemical pathway wherein stress not only causes cravings for “comfort foods” but also leads to increased abdominal fat deposits which have been shown to be associated with even more negative health effects than peripheral fat (8). Health implications of obesity are too numerous to list, but include type 2 diabetes, coronary heart disease and increased risk of some cancers (7).

While occasions of acute stress are known to raise blood pressure in the short term, chronic stress can cause hypertension, or increased overall blood pressure (9). Even raised blood pressure below the hypertension cutoff, known as prehypertension, is associated with increased risk of myocardial infarction and coronary artery disease (10). These three examples are by no means the only ways stress affects health. It also depresses the immune system, leaving people open to infection, and can lead to reckless driving from emotional consequences. For some, addressing stress can be a life-or-death issue.

Failure to address the problem
While stress prevention and reduction may seem the obvious solution, public health officials have been slow to target stress in their health campaigns. Too often specific behaviors are attacked, with too little attention to underlying motivators. The health belief model (11) is partly to blame for this misplaced focus. In the consideration of negative health behaviors, the health belief model takes the individual approach. Not only does it omit societal or emotional impacts in health choices, it neglects to take into account the other health behaviors in which each person is engaging. The public health program addressing smoking through the health belief model lens will emphasize the problems with lung cancer, and may even provide patches to get people to quit smoking. Then the public health program down the hall will try to address obesity by promoting the Fruit and Veggies Matter campaign, to encourage people to eat proportionally more fruit and veggies. Across the hall, public health officials are promoting low-sodium diets for hypertensives. Each of these programs is operating on a shoestring budget with minimal results. Without addressing underlying factors, people will be prone to go from one negative health category to another as they continue to struggle. In high stress for example, a person who quits smoking, but still struggles with stress, may fall into overeating, and hypertension. By taking the narrow, disease-focused approach, public health is missing out on a great opportunity to pool resources into combating larger themes that are pervasive across diseases.


What if all of those offices now got together to create a unified stress-reduction campaign? First of all, they would have the money to do it well. Secondly, there is research to support that it would have wide-ranging effects. A transcendental meditation intervention in a group of hypertensive patients found 23% reduced all-cause mortality in the intervention group (11a). A mindfulness-based stress reduction program for cancer patients found significant reduction in stress, mood disturbance, fatigue and sleep disturbance, and an increase in sleep quality (12). It is much more cost-effective to attack the root of these problems directly than address each of the symptoms individually. So one large stress-reduction campaign would simultaneously support smoking cessation, obesity prevention, and hypertension treatment efforts. Not only that, it will have positive effects on people of all kinds by improving quality of life, another major public health goal.

Before figuring out how to direct the campaign, it is important to know our specific message. I suggest combating the stress that leads to obesity, smoking, and hypertension with exercise, meditation, and interpersonal relationship. The benefits of including regular exercise are well known, and widespread. Increased exercise increases metabolism and reduces risk for cardiovascular disease (13, 14). There are numerous studies on the benefits of meditation and prayer for reducing blood pressure and stress, some of which have already been cited. A recent study from UCLA has shown maintaining social networks to be important in stress reduction in women in particular (15). Exercise, meditation, and positive friendships all not only counteract the stress that leads to a multitude of ills, but have health benefits of their own such as improved sleep and endorphin release. For this reason, I suggest focusing on these suggestions as modes of stress relief in the proposed campaign.

Concepts for stress-reduction campaigns
Once the desire to fund this cooperative campaign has momentum and methods of stress reduction to promote have been chosen, a great deal of thought must be put into the strategy of the campaign. Social and behavioral models can give some direction for stress interventions. While every social and behavioral health model contributes important perspectives, the three theories this paper will look at are Advertising Theory, the Theory of Self-Efficacy, and Social Learning Theory. Specifically, their contributions of promises, self-efficacy, and models are useful to consider in the initial design of this campaign.

Advertising Theory (16) says that promising people a benefit, and backing up the promise with support will result in people doing the suggested behavior. For our campaign, I propose advertising the benefit of good health and quality of life, and promising that reducing stress by our chosen strategies will produce that benefit. So a series of ads will promote exercise, quietness through prayer or meditation, and taking time to be with friends. Each ad will contrast stressful lives with restful lives and show the joy of reduced stress. Media Education Foundation made the point in one of their handouts, that modern advertising is already selling stress relief (17). Some of the products on the market that are advertised as relieving stress are cigarettes, alcohol, and high-calorie foods. As a public health campaign, we should adopt stress relief advertising as our own, but promote healthy alternatives instead. The advertising world must already be finding profit in selling stress relief, or else they would not continue these methods. This shows the public health world that stress relief is something the public is already looking for; a promising start to our forthcoming campaign.

When promoting healthy ways to reduce stress, it is important to take the Theory of Self-Efficacy (11) into account. If people have low self-efficacy, thinking that these methods are not in their power, they will not do them. So it is important to promote exercise, meditation, and social activities as within reach of everyone. Advertisements need to not emphasize high-impact exercise like running marathons, for example, but playing Frisbee in the park. Another aspect of the campaign could incorporate community activities such as a day in the park with sack races, relay races, and pickup soccer. This would promote both exercise as a fun activity and create a venue for previously isolated people to meet one another. The important piece self-efficacy teaches is to be sure to present these activities as being within reach of everybody.

The value of modeling, as proposed by Social Learning Theory (18), is the third crucial element of this stress-reduction campaign. Positive role models enjoying desired activities are not only helpful in encouraging children to participate, but adults as well. For children, bringing stress relief into the schools will be worthwhile. The campaign should encourage schools to promote deep breathing or a moment of silence especially in stressful situations such as preceding tests. Teachers in classrooms are excellent examples of role models for young kids, and if they practice stress relief, that will impact their pupils. A good example of classroom-based stress relief is Mary Maxwell’s unpublished yoga curriculum for classrooms (19). Teachers and students together doing light exercise to reduce stress and increase focus will give kids the skills they need to combat stress later in life in healthy ways. For kids and adults, advertisements and materials with famous positive role models coping with stress in healthy ways will be another element of this campaign. A recent anti-smoking advertisement in Boston reads: “When I get stressed, I reach for my running shoes instead of a cigarette,” and this is the concept I would like to expand for this campaign. Different famous or powerful people simply saying which positive stress-relieving behavior they choose in stressful situations would lead others to emulate them. But again, in keeping with self-efficacy, these ads should model attainable options, that cover a variety of skill levels and cost barriers. For example the exercise examples may include skiing and tennis, but should also include basketball and soccer: games that are more universally available and not as expensive.

So much can be done to target the underlying factors in negative health behaviors, that public health’s neglect to address them is a grievous oversight. As public health officials struggle with reduced budgets with which to address growing numbers of health problems, broader perspectives will become even more necessary to effectively make a difference in improving overall public health. While social and behavioral models are not perfect, they have a great deal to contribute to the world of public health, lending perspective not just on causes, but also on possible solutions to pervasive public health problems.

REFERENCES
1 Stress. Merriam-Webster Online Dictionary 2006-2007.
http://www.m-w.com/dictionary/stress
2 Goeders NE. The impact of stress on addiction. European Neuropsychopharmacology 2003; 13:435-441.
3 National Cancer Institute. Quitting Tobacco: Handling Stress … Without Smoking. U.S. National Institutes of Health.
www.cancer.gov.
4 Clayton KA, Brooks D. Empowering Neighbors for Health. Partners for Health Housing. Unpublished.
5 Finkelstein DM, Kubzansky LD, Goodman E. Social Status, Stress, and Adolescent Smoking. Journal of Adolescent Health 2006;39:678-685.
6 American Cancer Society. Cigarette Smoking. Prevention and Early Detection. American Cancer Society 2007.
http://www.cancer.org/docroot/PED/content/PED_10_2X_Cigarette_Smoking.asp?sitearea=PED
7 Centers for Disease Control and Prevention. Overweight and Obesity: Home. Atlanta, GA: Overweight and Obesity, 2007. http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm
8 Dallman MF, Pecoraro NC, la Fleur SE. Chronic stress and comfort foods: Self-medication and abdominal obesity. Brain, Behavior, and Immunity 2005;19:275-280.
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12 Schneider RH, Alexander CN, Staggers F, Rainforth M, Salerno JW, Hartz A, Arndt S, Barnes VA, Nidich SI. Long-Term Effects of Stress Reduction on Mortality in Persons≥55 Years of Age With Systemic Hypertension. Am J Cardiol 2005;95:1060-1064.
12a Carlson LE, Garland SN. Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. International Journal of Behavioral Medicine 2005;12(4):278-85.
13 Bays H, Blonde L, Rosenson R. Adiposopathy: how do diet, exercise and weight loss drug therapies improve metabolic disease in overweight patients? Expert Review of Cardiovascular Therapy. 4(6):871-95, 2006 Nov.
14 Lakka TA, Bouchard C. Physical activity, obesity and cardiovascular diseases. Handbook of Experimental Pharmacology. (170):137-63, 2005.
15 Taylor SE, Klein LC, Lewis BP, Gruenewalk TL, Gurung RAR, Updegraff JA. Biobehavioral Responses to Stress in Females: Tend-and-Befriend, Not Fight-or-Flight. Psychological Review 2000;107(3):411-429.
16 Trout J, VanAuken B, Daye D. Branding Strategy Insider The Branding Blog. The Blake Project. (2006-2007).
http://www.brandingstrategyinsider.com/brand_promise/index.html
17 Media Education Foundation. Substances as stress relievers: Deconstructing Advertisements. Northampton, MA. Media Education Foundation 2005.
http://www.mediaed.org/handouts/pdfs/SubstancesAsStressRelievers.pdf
18 Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
19 Maxwell MR. Yoga Curriculum for the Classroom. 2005. unpublished.




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