Transforming through behavior change

UNIVERSITY PARK, Pa. — At age 16, Libby injured herself on the soccer field. Three surgeries and innumerable physical therapy sessions later, the injury healed. Libby left behind her crutches and bandages.

But a lingering shadow from her injury remained: an addiction to opioid pain pills.

Though this particular tale is fictitious, the reality is that, according to the Substance Abuse and Mental Health Services Administration, in 2012 it was estimated that 2.1 million people in the United States suffered from substance-use disorders related to prescription opioid pain relievers, and an estimated 467,000 were addicted to heroin. A 2015 report from the Centers for Disease Control and Prevention said that number is trending up. 

This growing development has grabbed the attention of the health care industry, the media and lawmakers. It has also caught the attention of researchers in Penn State's College of Health and Human Development, and is one example of how an emergent body of research in the college is focusing on behavior change as a way to improve the health of people and the environment.

Max Crowley, assistant professor of human development and family studies, focuses on how to invest in healthy human development. He investigates the fiscal benefits of those investments and explores how behavior change could impact opioid misuse.

“When the opioid epidemic began, there were behavioral prevention strategies that could prevent common types of substance abuse such as smoking or drinking, but there wasn’t much evidence out there about whether universal strategies could prevent prescription opioid misuse and nothing about whether these strategies could be cost-effective,” Crowley said.

Common strategies concentrated on reducing the supply of opioids, such as prescription monitoring systems, but few focused on how to reduce demand by preventing misuse. 

“As a result of this need, we evaluated how four different behavioral prevention strategies could be used to prevent prescription opioid misuse and save public resources,” said Crowley.

Researchers identified an addiction-prevention strategy, known as Life Skills Training, that costs less than $650 per person. 

“This is less than many of the supply-side strategies being used and doesn’t restrict access to vulnerable populations, such as the elderly, veterans or those with chronic pain,” said Crowley. “This can translate into more than $2,900 saved per person who receives this program — or a return of more than $4 for every dollar spent.”

According to Crowley, it is clear that behavioral interventions reduce people’s likelihood of misusing drugs and offer a way to save lives without severely restricting access to a crucial pain-management tool.

In the spring of 2016, this research started to impact Capitol Hill. Crowley and his colleagues, with support from the Doris Duke Charitable Foundation and National Prevention Science Coalition, launched a pilot program for building collaborations between scientists and policy makers to translate behavioral-prevention strategies into evidence-based policy. 

Congressional offices started to request help from Crowley and his colleagues, seeking to understand the science behind prevention. These have included requests for legislative briefings, support for hearings, policy briefs and assistance crafting legislative language that reflects the current scientific understanding. Representatives from more than 40 congressional offices attended a June 2016 briefing on preventing opioid abuse held by Crowley and his team.

p.p1 {margin: 4.5px 0.0px 0.0px 0.0px; line-height: 11.0px; font: 9.5px 'Adobe Garamond Pro'} span.s1 {font-kerning: none}

“In general, we have found a great level of demand among the offices we work with, for not only education about the science, but as an active partner to help them use research to develop evidence-based policy,” Crowley said.

p.p1 {margin: 4.5px 0.0px 0.0px 0.0px; line-height: 11.0px; font: 9.5px 'Adobe Garamond Pro'} span.s1 {font-kerning: none}

Sex and alcohol use among college students is another area that could be impacted by the science of behavior change.

Kari Kugler, a research associate for The Methodology Center, specializes in epidemiology and works to develop programs that have an impact on public health, such as obesity, cardiovascular risk and drug use. 

Kugler is an investigator on a new National Institute on Alcohol Abuse and Alcoholism study with Linda Collins, director of The Methodology Center and principal investigator. The team is engineering an online, sexually transmitted infection (STI) prevention program to help reduce the number of STIs among college students. 

“Sexual-risk behaviors such as unprotected sex and alcohol use are risk factors for acquiring STIs,” Kugler said. “Few interventions exist for college students that explicitly target the role that alcohol plays in engaging in sexual risk behaviors. We wanted to build a very effective intervention that could be delivered online to increase the public health impact on STIs.”

Although the link between alcohol use and STIs is an indirect one, Kugler said alcohol use increases the likelihood of engaging in sexual risk behaviors that are associated with STIs, and excessive alcohol use decreases immune function, placing individuals at increased risk for infection. The college-aged population is an essential group to focus on. 

“We recognize that the transition from high school to college is an important time for individuals to figure out who they are,” Kugler said. “It is also an important time to establish healthy patterns that have lasting impact well into adulthood.”

Behavior-change methods can also protect the environment. Take, for example, a research project that looked to decrease recreation-related impact on public lands.

“Visitors seek nature-based recreational activities in parks and protected areas for exercise, stress relief, contemplation and much more,” said Derrick Taff, assistant professor of recreation, park, and tourism management (RPTM). “And many of these benefits can only be achieved or met in pristine and natural protected areas.” 

Taff and his colleagues are working on a project with the Leave No Trace Center for Outdoor Ethics, a non-profit that uses science-based education strategies to influence people to behave in a more ecologically friendly manner. Their focus was to decrease the usage of undesignated trails at the City of Boulder Open Space and Mountain Parks, 45,000-acres of public land in and around Boulder, Colorado.

“The natural protected area receives more than five million visitors annually, each attempting to seek their own benefits associated with leisure and recreation on these lands, such as outdoor exercise and nature-based restoration,” Taff said.

With so many people recreating on a relatively small amount of land, the city wanted to reduce the human impact on the environment in the Open Space and Mountain Parks lands due to undesignated trail usage.

“The proliferation of undesignated trails can result in damage, such as vegetation trampling, spreading of invasive species, displacing wildlife from crucial habitat areas or aesthetic degradation from the visitor’s standpoint,” Taff said. “All of these impacts degrade the natural condition of protected areas, aspects we seek as outdoor enthusiasts.”

According to Forrest Schwartz, an RPTM graduate research assistant and field coordinator with the project, public land areas are generally managed with a dual mandate: to provide for the ecological integrity and sustainability of the place, as well as opportunities for quality recreation experiences. 

“This is a delicate balance — equitable areas of land are allocated for human recreation and others set aside for the biological community,” Schwartz said. “When trail users regularly venture off trail, the balance can very quickly be thrown off.”

In an effort to decrease undesignated trail use, the team was tasked to come up with a solution.

“Across 20 types of undesignated trail junctions, our research team conducted a messaging study,” Taff said.

Through monitoring and visitor surveys, the researchers discovered that when the most effective messages were deployed, the protected area experienced a reduction in undesignated trail use by about 5.4 percent, which, when considering the area’s average visitation, equates to approximately 286,000 fewer people using undesignated trails annually. 

“We were able to significantly influence visitor behavior and better protect both the ecological well-being and visitor experiences through effective and targeted messaging,” Taff said. 

p.p1 {margin: 9.0px 0.0px 0.0px 0.0px; line-height: 11.0px; font: 12.0px 'Solomon Normal'} p.p2 {margin: 9.0px 0.0px 9.0px 0.0px; line-height: 11.0px; font: 12.0px 'Solomon Normal'} span.s1 {font-kerning: none}