COMMENTS

From evidence to results, does our behavior condemn us?

http://dx.doi.org/10.5546/aap.2013.5

There is no doubt regarding the impact of chronic diseases on the global mortality and burden of disease, both in developed and developing countries. According to the WHO,¹ 52% of the deaths that occur each year around the world are from ischemic heart disease, stroke, respiratory infections, chronic obstructive pulmonary disease, diarrhea, HIV, lung and airway cancer, tuberculosis, diabetes mellitus, and injuries, accounting for, in absolute numbers, approximately 30 million deaths.
Similarly, respiratory infections, diarrhea, depressive disorders, ischemic heart disease, HIV, cerebrovascular disease, prematurity and low birth weight, neonatal asphyxia, traffic accidents, and neonatal infections constitute the top ten causes of disease accounting for a higher morbidity burden.
Over the last years, the knowledge on their characteristics, mechanisms involved, risk factors or determinants has remarkably increased, as well as the evidence on the source of many of the diseases that occur at an early age. Only a few factors, conditions or determinants are accountable for one fourth of the 60 million deaths that occur every year around the world: childhood underweight, unsafe sex, alcohol consumption, lack of drinkable water, sanitation and hygiene, and high blood pressure.² While some of these conditions are related to environmental factors, such as air or water quality, many of them, such as alcohol or tobacco consumption, inadequate dietary patterns, hyperglycemia, hypertension, high body mass index, hypercholesterolemia or sedentariness, among others, are clearly related to specific individual habits and behaviors.

The article by Kovalskys³ et al. in this issue of the Archivos Argentinos de Pediatría describes the prevalence of overweight and obesity in school-aged children and their inadequate dietary patterns. The situation reflected in the article is alarming and consistent with what has been observed in other populations and age groups mentioned by the authors. The promotion of healthy habits and behaviors since an early age, and especially in relation to those habits associated with the priority health problems mentioned above, constitutes one of the most relevant challenges for public health for the next years. This is a challenge not only in terms of reducing the burden of disease, particularly at an early age, but also given the complexity of achieving a change in behavior and practice, because such habits or behaviors are the cover for more complex underlying conditions, multiple factors and influences that sustain them at an individual, family, social or other level, in spite of their adverse consequences.
Behind risk factors or determinants, there are underlying behaviors and conducts that might exert a "healthy" or an "unhealthy" role. These may be individual behaviors, including unsafe sex, eating habits, or sedentariness, that expose them to specific risks, or certain health team practices that may contribute or limit the achievement of results, such as inadequate hand washing, inappropriate oxygen management in newborn infants, etc.
Therefore, the obstacles or hurdles to making changes and promoting healthy behaviors in the population are a great challenge. How could we effectively promote healthy eating habits, increase physical activity, avoid tobacco consumption, etc.? Is it just the general population that requires to essentially modify its behaviors in order to promote healthy or effective habits and practice? There is high quality evidence on the interventions sustaining its applicability on health problems in children and adolescents; however, its implementation is far from what is expected.⁴
The availability of information for making decisions is critical in every situation and context. As mentioned earlier, there is information available on the rate and distribution of most health problems in the different populations. There is also information available on the efficacy of different specific interventions targeted at such problems. However, is the approach to problems wide enough to include the analysis of factors and determinants that influence certain conducts, behaviors or practices? When factors involved in the development of such conditions are related to human behavior, its approach becomes highly complex, and the use of specific analysis strategies and techniques that, from a standard biomedical research perspective are usually not adequately assessed, becomes essential. Such underassessment is critical in terms of problem analysis and health outcomes, and also in relation to processes and practices of health teams.⁵
As a consequence, what approach will be more effective for issues related to behaviors and practices, both of individuals as well as of the health team? Although it is becoming more frequent, the approach and analysis of problems as determinants, and not only as risk factors within a conceptual framework, and its relation to other determinants at different levels --individual, familiar, social, economic, etc.-- will allow to identify those conditions associated with or sustaining the practices to be modified. The translation from recognizing evidence-based interventions into evidence- based practices clearly implies a change in scope. Therefore, such change in scope implies the implementation or complementation with other analyses and study techniques approaches.
There are currently no signs of the discovery of a sedentariness vaccine or a drug treatment of unsafe sex in adolescents, so the assessment of such influences should lead to implementing other types of interventions. As long as evidence provides information on the factors or determinants sustaining such practice in individuals, it will be easier to outline these interventions.
But there is an additional aspect that may be relevant when considering the above mentioned change in scope. When considering major health problems such as overweight and obesity, as in the case of the article written by Kovalskys et al., or other problems related to behaviors and practices with important social and cultural influences, the implementation of interventions from a level other than the individual one may yield better results. Examples of this include the implementation of interventions targeted at reducing tobacco consumption by the impact on its price, tax implementation, advertisement regulation and event sponsoring, or the design of packaging and labeling as a means to disseminate messages.⁶ Similarly, the implementation of interventions targeted at food consumers or producers by the enforcement of taxes and subsidies to foster the manufacturing of healthier foods, the communication and the selective promotion of specific foods.⁷ Therefore, the incorporation of interventions from other levels and means other than the individual level will quite likely bring about positive public health results.⁸
Available information and evidence about population health problems and the strategies to reduce them is encouraging in one sense: there are interventions applicable for many of the prevailing problems, and most of them do not imply high costs or advanced technologies. At the same time, we are facing a great challenge: it is essential to promote behavioral change, both in individuals and health teams.
This is a complex but key field for achieving results related to population health and to which stakeholders from different domains may contribute a lot.

Dr. Pablo Durán

Assistant Editor

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