Comments on “Challenges to Improving the Impact of Worksite Cancer Prevention Programs”: Paradigm Lost? Richard A. Winett Virginia Polytechnic Institute and State University Linnan et al. (1) provided important analyses of the impact of different recruitment and intervention strategies on the reach, enrollment, and retention of participants in a large worksite dis- ease prevention program and offered potential ways to improve such programs. Within the data they presented, there are striking findings that warrant comments. These comments are not made to question the dedication of the researchers or to imply disre- spect but rather to question whether, as researchers, we should continue to move forward within the same paradigm that in- volves trying to reach large groups of people with relatively lower dose interventions delivered within communities and worksites. What is most striking was that in the worksites only about 19% of total employees enrolled (note that enrollment percent- ages are higher based on employees reached and then eligible employees), about 14% completed 12 months, and about 12% completed 24 months. Enrolling a relatively small percentage of employees seems reasonable if those enrolled employees are at very high risk or if the intervention is an intensive, high-dose program that can produce marked changes. However, if this is not the case, then the overall public health impact of the inter- vention is not likely to be that high. Perhaps for the last 25 years as noted by Linnan et al. (1) community and worksite interventions have not been that effec- tive because the basic paradigm is faulty. We do not seem to have the means to either interest or recruit a very high percent- age of population segments, and more modest, lower dose inter- ventions do not seem very effective. The idea of mass lower dose behavioral health interventions, at least in their present form, may not be tenable. This may be even more the case if it becomes apparent that minimal changes in some health behav- iors may not be sufficient to decrease risk. For example, a good level of cardiorespiratory fitness seems protective against can- cer mortality (2), and a good level of fitness requires systematic and sustained exercise and not just physical activity (3). Although cardiorespiratory fitness can be appreciably increased through brief (10–15 min) protocols performed twice per week, such training requires precision and consistency with careful attention to maintenance procedures—that is, an intensive intervention (3). Perhaps we should change our focus. None of the following are offered as panaceas, and they doubtless have their own prob- lems, but we can consider (a) putting more emphasis on very in- tensive secondary prevention programs, particularly as the iden- tification of risk factors becomes more sophisticated; (b) primarily focusing on settings (e.g., churches and some civic or- ganizations) where higher enrollment rates and higher contin- ued contact rates may be possible; (c) exploring social modeling and diffusion models that involve more intensive training for people most receptive to change and the systematic influence of other people over time (4); and (d) where possible, changing en- vironments and institutional arrangements while still being mindful of the role of self-regulation in sustaining changes. REFERENCES (1) Linnan LA, Emmons KM, Klar N, et al.: Challenges to improv- ing the impact of worksite cancer prevention programs: Com- paring reach, enrollment, and attrition using active versus pas- sive recruitment strategies. Annals of Behavioral Medicine. 2002, 24:157–166. (2) Lee DL, Blair SN: Cardiorespiratory fitness and smoking-re- lated and total cancer mortality. Medicine and Science in Sports and Exercise. 2002, 34:735–739. (3) Winett RA, Carpinelli RN: Examining the validity of exercise guidelines for the prevention of morbidity and all-cause mortal- ity. Annals of Behavioral Medicine. 2000, 22:237–245. (4) Bandura A: Self Efficacy: The Exercise of Control. New York: Freeman, 1997. 221 Reprint Address: R. A. Winett, Center for Research in Health Behavior, Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061–0436. E-mail: rswinett@vt.edu © 2003 by The Society of Behavioral Medicine.