This is a brief extract from the Health Report, broadcast on ABC Radio National on Monday 9 November 1998 and repeated in late 1999. The complete transcript is available at the ABC Radio National web site: http://abc.net.au/rn
[The interviewer, Norman Swan, and his guest, Len Syme, have been talking about sending people information to encourage changed behaviour.]
Norman Swan: ... somebody handing you a book called The Wellness Guide, 'I haven't got time for this; I've got three kids, my husband's out of work etc. How am I going to have time to do this?' How do you get over those barriers? Is there anybody working on that area?
Len Syme: Well I think this is the major area in health promotion. It's absolutely clear that providing information to people is, I don't want to say it's useless, but it's close to useless. It turns out, for example, we think we've done well with the reduction in smoking in the adult population, and we have. They don't quit smoking in our clinics, they quit smoking on their own. But behind our backs, the kids are now smoking at an alarmingly increasing rate. When we do surveys of those kids, it turns out they know all about the hazards of smoking, they have 100% understanding of all the issues and they smoke anyway. The idea that you can give people a pamphlet or a poster with the idea that it will change behaviour, just simply doesn't work. In fact I can give you the classic example of all time of where I got that lesson.
Many years ago, we did the most expensive, elaborate, ambitious clinical trial that the world has ever seen, on heart disease. It was in the 1970s when we first really accumulated solid evidence about risk factors for heart disease. And the first factors about which we had information that was absolutely clear, was the importance of cigarette smoking and high blood pressure and serum cholesterol. And we decided to recruit a group of people in very high risk categories for those reasons, and to help them reduce that risk to show the difference it would make. Unfortunately the statisticians told us that we would have to have 12,000 men in order to do this study, half of whom would work with their doctors and half of whom would work with us in the clinic. In order to recruit those 12,000 men, we had to screen 500,000 men in 22 different cities in the United States. It cost $180-million. So we did this elaborate study --
Norman Swan: The Mr Fit study?
Len Syme: Exactly. Ten years of my life. And what we did was we said to these men, they went through three elaborate screenings of ten hours,- we told these people, 'Look, you may be eligible for this trial, but do not volunteer unless you really are clear about the terms. The first consideration is, you're going to be asked to work with us in the clinic, or work with your own doctor, a random decision. And if that's not acceptable, don't volunteer. If you work with us in the clinic, you're going to have to come in with your family for many sessions, you're going to have to come in frequently at the beginning; we're going to ask you to stop smoking, take pills for blood pressure, change your diet, and you're going to have to come in to the clinic for six years.'
Then we had a psychologist get rid of people that we thought would be faint of heart. So we ended up with these highly motivated, highly knowledgeable, informed people who knew they were in the top 10% of risk and who were currently free of heart disease. And then we did the best intervention that I've ever been involved with. I mean we brought all the families in and showed them in the clinics how to do low fat cooking; we took them to the supermarket to show them how to read the labels in the market; we went to their homes and cooked with them in their homes with things they already had in their home; we did that with all the issues, and it was really intense and elaborate. And after six years of intervention there was no difference in the two groups. The special care group didn't change enough, but the control group changed too much.
It turned out that when we informed these people of their circumstance and dismissed them, we energised a whole generation of people to say, 'By God, if you're not going to help me, I'm going to do it myself.' And they did. It turns out the only way you really make important life decisions and changes in behaviour, all of us, is sitting down in a dark room and coming to terms with the reality of our circumstance. We don't do it with brochures. You have to make the hard decision.
I went back over the Mr Fit experience, I was a smoking counsellor at that time, and I think what we did was interfere with the Mr Fit people in coming to that kind of term. What we did was have them get involved in all the smoking cessation tricks, the rubber bands and the diaries and other exercises. We had them so busy doing those things that I think they mistook those activities as what smoking cessation is all about. And it's not.
Norman Swan: So they missed out on the revelation on the road to Damascus which you gave to your control group inadvertently.
Len Syme: Yes. You have to come to this decision on your own, and to put it bluntly, I think you have to reach bottom. You do have to say 'You know, I'm not going to do this any more.' And I think we professionals interfere with that hard decision by 'helping' people. So we have lots of experience now of failures to get people to change their ways by doing what we think is right.
Norman Swan: You're coming back to a sense that if you actually equip people with a sense of mastery and you give them the information they need that creates a sense of crisis in a sense, they'll use the mastery to make their own decisions, and they'll find the information if it's available.
Len Syme: Exactly correct. And I have dozens and dozens of stories of massive interventions by the best people in the world, that have failed completely. Whereas the kind of interventions that are the kind you describe, are the ones that succeed.
Norman Swan: If you are a State or Federal politician, a Minister, or you're a senior bureaucrat, you handle large sums of money, what does it mean?
Len Syme: It means that if you're going to work with communities, you have to somehow get the communities to participate in the events that they're involved in. You can't do top down. The exception for that is making laws. You can require a speed limit or require that cars be designed safely, that's one way to make things happen, and that works. But if you want people to change their behaviour, you can't do it with proclamations from the top down by experts. Experts need to learn a new way of being an expert, to empower people to participate in the events that impinge on their life. The evidence from WIC is overwhelming and I think it's now becoming clear in our every day lives as well.
Norman Swan: The amazing Len Syme, who's Emeritus Professor of Epidemiology at the University of California, Berkeley.
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