Structural interventions for addressing chronic health problems.

THE CHRONIC HEALTH PROBLEMS OF OBESITY, DIABEtes, heart disease, and cancer commonly affect adults living in developed countries and are both difficult to treat and costly, leading experts to stress the importance of prevention. Elimination of the 3 behavioral risk factors of sedentary lifestyle, poor diet, and smoking would decrease mortality by 35%. But how do we get individuals to exercise more, eat better, and stop smoking? Health education has been effective in diminishing these risk factors, especially smoking, but education alone is unlikely to bring further progress. In fact, it would be difficult to find a sedentary obese smoker who did not know that he should exercise more, eat less, and stop smoking. Intensive one-to-one and group behavioral interventions have been demonstrated to increase activity, reduce obesity, and promote smoking cessation, but effects have been modest and difficult to maintain. Moreover, translating these findings into practice has been hampered by insufficient funding and difficulty reaching those persons in greatest need. Structural interventions offer a complementary approach to improving health by focusing on changing the physical, social, and economic environment. The interventions are structural in that, unlike individualized interventions, persons do not enroll or even know that they are participating. Structural interventions are not a new idea. The increase in longevity that occurred in the early 20th century was largely due to physical improvements in the environment (eg, sewage treatment) and at work sites (eg, safer equipment). Other successful structural interventions include seat belts in cars, road safety standards, elimination of toxins such as lead in paint and gasoline, and water fluoridation. What is new, and potentially more challenging, is the use of structural interventions for chronic diseases.