Frieden1 used a “potential health impact” pyramid to illustrate the relative influence each of five categories of interventions could have on public health status. We applaud the compelling case he makes for the bottom tiers having “the greatest potential to improve health”1(p594) because they direct interventions toward structural and socioeconomic determinants of health.
We are concerned, however, that using a segmented, hierarchical pyramid to make that case might create an “either/or” rather than an “and” mentality about intervention strategies, losing sight of their interdependence.2
A hierarchy of strategies based on evidence of potential population impact cannot be operationalized without blended hierarchies of feasible and politically viable strategies to guide an ecological3,4 or systems approach.5,6 For example, mass media and community-based public health education provide synergy to inform and ignite decision-makers and the electorate in building political will for the passage, funding and enforcement of policies and structural changes. In Frieden's pyramid model, those strategies are four tiers away, labeled as “generally the least effective type of intervention.”1(p592) So labeled, Tier 5 may be viewed by those who apply the model as ancillary rather than integral, superfluous rather than essential in building the informed and concerned electorate necessary to support the policies needed to affect the complex socioeconomic determinants of health.
Frieden acknowledges that reality:
Inevitably, some programs blur the distinctions between tiers. For example, mass media campaigns for tobacco control could be viewed as an educational intervention (tier 5), but if done effectively, such actions can change the context by altering the social norms related to tobacco use (tier 2).1(p593)
Such campaigns also helped to denormalize the tobacco industry and its advertising and promotional practices and helped to rally support for tax increases on tobacco products, for smoke-free workplaces, for restaurants, and ultimately even for public outdoor place legislation.7 Multicomponent community mobilization campaigns were identified first among Centers for Disease Control and Prevention's Best Practices for Comprehensive Tobacco Control,8 which cites the Task Force on Community Preventive Services as follows:
The strongest evidence demonstrating the effectiveness of many of the population-based approaches that are most highly recommended by the Task Force comes from studies in which specific strategies for smoking cessation and prevention of initiation are combined with efforts to mobilize communities and integrate these strategies into synergistic and multicomponent efforts.9(p22)
Frieden appropriately cites Rose's notion that political action is essential and inevitable in virtually any undertaking to redress the social and economic determinants of health. But Rose also noted the value of health education in that enterprise:
Political decisions are … complex and mostly hidden from public scrutiny… . Anything which stimulates more public information and debate about health issues is good, not just because it may lead to healthier choices by individuals but also because it earns a higher place on the political agenda. In the long run, this is probably the most important achievement of health education.10(p123–124)
Acknowledgments
We thank Karen Glanz and other colleagues for comments on earlier drafts.
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