tag:blogger.com,1999:blog-89804589583753092522024-02-20T13:09:49.534-08:00Challenging Dogma - Fall 2009Michael Siegelhttp://www.blogger.com/profile/09937031813339167454noreply@blogger.comBlogger94125tag:blogger.com,1999:blog-8980458958375309252.post-76929673340672335532010-12-16T18:37:00.000-08:002010-12-16T18:39:23.566-08:00The failure and solutions to the Food Allergen Labeling Consumer Protection Act and MA Allergen Awareness Law—Felix I. ZemelIntroduction<br />A recent report by the National Institute of Allergy and Infectious Diseases stated that as many as 5% of children under 5 years old and 4% of teenagers and adults currently suffer from food allergies in the United States [1]. These numbers are nearly double those that were estimated merely one decade ago [6]. Food allergies annually result in about 30,000 patient visits to hospital Emergency Departments, 2,000 hospitalizations, and 150 deaths [2,10]. 90% of these adverse health effects are caused by one of 8 “major food allergens”: peanuts, tree nuts, milk, soy, crustacean shellfish, fish, eggs, and wheat [8]. It was also determined that about half of the allergic reactions occurred as a result of prepared foods, and of those about 75% resulted from food prepared at a restaurant [28]. As a result of these startling numbers, the First Session of the 108th U.S. Congress enacted the Food Allergen Labeling Consumer Protection Act of 2004, which requires packaged food manufacturers to properly label products with the common name of any of the major food allergens that the food could potentially have had cross-contact with.<br /> The Commonwealth of Massachusetts took allergen awareness regulation a step further when Governor Patrick signed the Act Relative to Food Allergy Awareness in Restaurants into law in January 2009. In this new amendment, the legislature required “all food establishments that cook, prepare, or serve food intended for immediate consumption either on or off the premises” to comply with multiple requirements related to posting a specific allergen notice on the establishments menu and menu board; post an allergy awareness poster in a conspicuous place for all food handlers to see; and for all certified food protection managers to view a 30-minute training video and for all other food handlers to view a 10-minute video about allergen awareness [3,11]. These regulations were to be implemented at various points in time (October 1, 2010 for the poster and signage; Feb 1, 2011 for the video).<br />Critique of the FALCPA and the MA Allergen Awareness Law<br /> Both the FALCPA and the MA Allergen Awareness law have similar a similar goal: to decrease the morbidity and mortality of individuals resulting from accidental exposure (more specifically, ingestion) of food allergens to which they may be allergic. The method by which they each plan to achieve this goal is rooted deep within the Health Belief Model and the Theory of Reasoned Action.<br />The Health Belief Model, the basic premise of which is described by Rosenstock (1974) is that “…in order for an individual to avoid action to a disease he would need to believe (1) that he was personally susceptible to it, (2) that the occurrence of the disease would have at least a moderate severity on some component of his life, and (3) that taking a particular action would in fact be beneficial by reducing his susceptibility to the condition or, if the disease occurred, by reducing its severity, and that it would not entail overcoming important psychological barriers such as cost, convenience, pain, embarrassment” [17]. Salazar (1991) described the Theory of Reasoned Action by explaining that “behavioral change ultimately is the result of changes in beliefs, and that people will perform behavior if they think they should perform it…” [18]. Following the Health Belief Model, the logic behind the FALCPA and the MA Allergen Awareness Law was that if individual consumers was warned of the risks inherent in the consumption of particular packaged or prepared foods, that they would inherently choose not to consume those foods because their susceptibility to have an allergic reaction would be much greater and less beneficial than avoiding the food altogether. This would also follow the Theory of Reasoned Action, whereas once the belief is put in place that consumption of these particular foods is harmful, that the consumer would choose not to take the risk, and would thus forgo consuming the product.<br /> The FALCPA has now been in effect for approximately 6 years. A variety of research studies have been performed in recent years to determine the effects (if any) that mandatory labeling of packaged foods has had on the behavior of individuals with food allergies [7,14,15,24,28]. The result of the research is startling. Researchers found that individuals with food allergies were significantly more likely to purchase a product with an allergen warning label in 2006 (after the enactment of the FALCPA) than in 2003 (prior to the enactment of the FALCPA) [7]. The research further showed that there were significant differences in the individuals’ likelihood of avoiding particular products based on the types of labeling that was placed on the packaging. Food manufacturers, especially large ones, have one big thing in common with large tobacco manufacturers: they “want to help the community”. The labeling on packaging for food originally started as a voluntary addition to food labels by manufacturers. Similar to the anti-smoking campaigns, where tobacco companies like Phillip Morris donated millions of dollars to fund inherently flawed campaigns to stop children from smoking, food manufacturers placed labels with allergen warnings ranging from “may contain…” to “may contain traces of…” to “manufactured in a facility that also uses…” to the greatest extreme of “packaged in a facility that also packages products containing…” [7]. As can be understood, the marketing specialists at large food manufacturing companies understand the basics of advertising theory and framing. Ogilvy (1964) said it well when he stated “a good advertisement is one which sells the product without drawing attention to itself. By utilizing different forms of framing, the food manufacturers were able to balance their perceived interest in preventing allergic reactions to their products while also not jeopardizing their bottom lines.<br /> The US Food and Drug Administration (FDA), who is the enforcing authority for the FALCPA stated that “advisory labels must be truthful and not misleading” [15]. After the adoption of the FALCPA, the food manufacturers took advantage of this requirement even more. Pieretti et al (2009) found multiple violations of the FDA where manufacturers labeling packages with nonspecific verbiage, such as those described above, but then included derivatives of one of the top 8 allergens in the ingredients list. The manufacturers technically are not lying or misleading, because they are still warning the consumer of the risk of exposure to a potential allergen, but they are also downplaying the severity of the risk. When applying this to the Health Belief Model, the downplayed severity makes the individual consumer feel less susceptible to the adverse health effect and causes him/her to decide that maybe the risk is worth taking—resulting in him/her purchasing and subsequently consuming the food (following the Theory of Reasoned Action). Examples of this deceptive practice are when the ingredients list items like gelatin, but do not specify if it is pork, beef, or fish gelatin—as fish is one of the top 8 allergens. Another common practice was listing lecithin in the ingredient line, without listing its source (soy, sunflower seeds, eggs, or rice [15].<br /> Similar to the fact that manufacturers are misleading individuals into believing that their risk of ingestion of a food that they may be allergic to is low, but they also list these items in understanding that individuals do not necessarily know all of the foods and other products that are derived from common allergens. If food manufacturers properly apply advertising and marketing theory through framing products’ perceived risk in particular settings, then they gain the trust of the individuals. A common item that the lack of labeling specific items as allergens has is that it also attempts to account for individuals not knowing if a particular ingredient is a derivative of one of the allergens that must be labeled. This is the major flaw of the MA Allergen Awareness Law. Although retail food establishments must post notice in all of their menus and on their menu boards telling the consumer “before placing your order, please inform your server if a person in your party has a food allergy” and have their staff be trained in allergen awareness, the law does not account for lack of basic knowledge on the part of both ends of the transaction. There is a common misconception that mayonnaise is a dairy product, leading many people to avoid due to milk allergy or lactose intolerance. In actuality, mayonnaise is based on eggs, which is a totally different food allergen (although 72% of individuals with an egg allergy also have a milk allergy [20]).<br />If neither party in the transaction knows that a particular food is a derivative of specific allergens, then the labeling requirement mandated by Massachusetts law is pointless. When applying the Health Belief Model and the Theory of Reasoned Action to a situation where neither party knows that an item like mayonnaise is derived from eggs, the following situation can be potentially fatal to the consumer: (1) the consumer notifies his/her server that (s)he is allergic to eggs, and asks the server if the tuna salad sandwich had eggs in it; (2) the server asks the cook if the tuna salad sandwich has eggs, the cook thinks that mayonnaise is dairy-based and tells the server that there were no egg ingredients in the tuna salad sandwich; (3) the server relays this message to the consumer, who subsequently purchases the tuna salad sandwich, has an anaphylactic reaction to the eggs in the mayonnaise resulting in respiratory arrest. In the preceding scenario, the consumer used the Health Belief Model to frame his risk in ingesting eggs. When he was told that there were no eggs in the tuna salad sandwich, the Theory of Reasoned Action made him decide that the potential risk of an allergic reaction was low resulting in him purchasing and consuming the tuna salad sandwich and having a severe allergic reaction to the egg that he did not know was even in the product.<br />These flaws are inherent in an intervention that relies so heavily on individual knowledge and understanding. It is also because of this lack of understanding of the differences and the lack of specificity in the labels that are places on packages of food that consumers are paying less and less attention to the labels. The Health Behavior Model and Theory of Reasoned Action were originally required in order to make it simpler for individuals who have particular food allergies to know which foods to avoid and which ones are safe. The fact that there is no consistency in the verbiage used on labels and that manufacturers are not listing (or framing in such a way that the individual consumer perceives a smaller risk than actually exists) decreases confidence of individuals who have food allergies, resulting in them not paying attention to the labels at much higher levels that existed prior to the enactment of the FALCPA. The lack of knowledge by food handlers makes is impossible for consumers to make a proper reasoned choice of purchasing/consuming the food item or not.<br />A new intervention must be developed that builds upon the existing interventions by eliminating their flaws of misleading labeling of which ingredients are actually allergens, lack of knowledge of the ingredients in particular items by consumers and/or food handlers, and the lack of consistency in the verbiage of labels on packaged foods—which allows manufacturers to frame the perception of risk to the consumer however the manufacturer wants. These practices show application of a large variety of social and behavioral theories that manufacturers utilize in order to manipulate decisions made by consumers [13]. If an intervention is successful at addressing these flaws, then its odds of effectiveness are greater.<br />A proposed intervention<br /> As stated earlier, the three lethal flaws in the FACLPA and the MA Allergen Awareness Law were manufacturers’ use of misleading labeling information, a lack of knowledge by individuals and food handlers, and inconsistency in the labeling verbiage. A successful intervention can utilize the basic framework and social and behavioral theories that exist in the original flawed ones, but improve them by applying other theories and practices in order to eliminate the inherent flaws. In order for this to happen, a comprehensive view of the problem must be observed. The flaws described above were rooted in the ability of food manufacturers to utilize social and behavioral science theories in an effort to subvert the intentions of laws. These same social and behavioral science theories are used in the following intervention to subvert the subversions by food manufacturers in order to get closer, if not totally, to decrease or eliminate the number of deaths and injuries of individuals caused by accidental ingestion of food products to which they are allergic. This intervention addresses the flaws by implementing the following items: creation of a series of “symbols” indicating the allergen of concern; standardizing the verbiage permitted for use on FALCPA-mandated labels; and mandatory review of all menus (and changes thereof) by the local board of health (or other government subdivision charged with enforcement of food service codes) before the implementation of a new menu or any changes thereof. Through the addition of these interventions to the FALCPA and the MA Allergen Awareness Law, the flaws that are causing gaping holes in the effectiveness of those regulations can be resolved, resulting in a potential decrease of the incidence of morbidity and/or mortality of individuals as a result of accidental allergic reactions to food allergens.<br /> The use of universally-accepted symbols has been successfully implemented in a variety of public health campaigns through the years. Two symbols that come to mind the quickest are the universal symbols of two hands being washed with soap and water, and the international symbol for no smoking. When people see these two symbols, they can be expected to think about the meaning of the change and then weigh their options and use reasoned action to make a final decision leading to a final action. This application of the Theories of Reasoned Action and the Health Belief Model can be directly applied to the concerns about allergen awareness. Many restaurants list items on their menus with different asterisks, stars, check-marks, or other symbols to send the reader a particular message without wasting the space for words. A common symbol used for this is the () symbol used in menus to indicate an item is heart-healthy. An easy to implement intervention is to first develop what is to become a universally accepted indicator of a particular food allergen—say an picture of an egg, soybean, fish, peanut, tree nut, or crustacean shellfish (like a lobster), a gallon of milk, or a stalk of wheat—and then mandate that restaurants and producers of packaged foods label each of their menu [or packaged] items with one or more of the symbols in order to portray which allergen a consumer is at risk of coming into contact with.<br /> The creation of these symbols will have benefits on multiple levels. The first benefit is that it will better illuminate the potential risks if the particular food item is consumed. This can then be translated through cognitive functioning into a belief about if the person should choose to make one action or another, letting the Theory of Reasoned Action take control. Although there are many factors, such as herd behavior, that can confound the reasoning process, the basic premise of the Health Behavior Model and Theory of Reasoned Action still stand. It can be assumed that if a person is a member of a particular group that is heading to a restaurant, (s)he is more likely to take heed of a warning that is blaring on the menu next to the name of the item than of wording that tells the consumer to notify his/her server if (s)he has a food allergy or a label on a bag of chips that states “this product was packaged on a line that also packages soy products” when lecithin is listed as one of the ingredients just a couple of lines above. Herd behavior often takes control over the individual when in a group setting, invalidating many of the theories that make up individual behavior change models, but the potential of their strength is potentially significantly lessened with proper signage and forced awareness [23,25].<br /> Another intervention that will decrease the numbers of people ignoring the allergen warning labels on food packaging is forced consistency. At the onset of the MA Allergen Awareness Law, many foodservice companies did exactly what large food manufacturers still do about labeling the allergen warnings on the packaging: they applied advertising and marketing principles in order to frame the apparent risk in a much lower light. In anticipation of this behavior occurring the MA legislature added verbiage into the actual statute that all foodservice establishments in the Commonwealth of Massachusetts must have on all of their menus in order to maintain compliance with the law. The FALCPA must be amended where the law should mandate specific verbiage for labels on packaged foods.<br /> Framing is used to bias individuals into thinking a particular way about a particular topic [4]. Its effects can be devastating to an improperly designed or implemented public health intervention, as is seen with the FALCPA. Research shows that people had much higher rates of paying attention to labels that stated “may contain…” or “may contain traces of…” labels versus ones that had convoluted statements like “packaged in a facility that also packages products containing…” (89% and 85% in 2006 versus 59% in 2006, respectively) [7]. Based upon the startling differences in responses between the three ways of saying the same thing (with different implications), the legislature should only allow one or two versions of the allergy warning label on packaged foods.<br /> In addition to the consistency in the verbiage, the government must give further guidance in order to avoid what can easily be construed as misleading and untruthful labeling practices by food manufacturers. Regulations must be strengthened along with the verbiage too also require that derivatives of the 8 top food allergens be placed under the same category as the main food allergen. This would be alleviated somewhat if the wording so convoluted as “packaged in a facility that also packages products containing…” would be eliminated and the standardized labeling verbiage were put into place instead.<br /> This leads into the final prong of the new intervention: local approval of menus and menu labeling for foodservice establishments. This is both its own intervention, but it brings the previous two together as well. Currently in Massachusetts, each of the 351 cities and towns has its own board of health that has the ability to create its own regulations, as long as they do not conflict with state or federal laws or regulations by weakening them. One of the primary responsibilities of local boards of health or health departments is the licensing and subsequent inspection of all foodservice establishments within its perimeter. Among the duties included in this is plan review and annual renewal of foodservice licenses.<br /> Menus are a vital part of the foodservice establishment’s food service and safety plans. As was stated earlier, labeling of items containing major food allergens with symbols is imperative to bringing better awareness to the risks involved in consuming a particular food item. It was shown how this labeling plays into the decision making process by an individual consumer and applied to an action through use of the Health Behavior Model and the Theory of Reasoned Action. As was described earlier, food manufacturers use either deceptive practices or just lack the knowledge to know exactly what items contain major food allergens. Because of this, the verification must be made during the preliminary steps to the establishments’ opening: during plan review.<br /> Local boards of health and health departments must implement a regulation that all menus must be properly labeled with appropriate symbols to indicate risks of consumption, and should require that all foodservice establishments provide the board of health or health department with a list of all of the ingredients in each particular item on the menu in order for the person reading the plans to verify that the warning symbols are correct. Foodservice establishments should not be permitted to change items on their menu without the prior approval from the local board of health of the particular food items. This would not preclude establishments from having rotating specials or other food items, if the list of ingredients for each of the rotating items was submitted and approved during the plan review.<br /> The mandatory approval from the local board of health or health department will also eliminate any bias resulting from framing or other advertising methods utilized by businesses to subvert the attempts at improving the public’s health. Maintaining and improving the public’s health should be a priority of not just the policymakers or individual activists, but also of those who are interfacing with the public. Businesses have shown that they favor market forces much more than the potential for improving health. Marketing campaigns by businesses frame items in such a way that not only do they subvert the law, but they also place susceptible members of the public at risk of serious adverse health effects or death due to their negligence and greed. A public health intervention that counteracts the marketing and framing techniques utilized by businesses benefits the public’s health dramatically.<br />References<br />(1) Boyce JA, Assa'ad A, Burks AW, Jones SM, Sampson HA, Wood RA, et al. Guidelines for the diagnosis and management of food allergy in the United States: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol 2010 December;126(6, Supplement 1):S1-S58. <br />(2) Buchanan R, Dennis S, Acheson D, Assimon SA, Beru N, Bolger P, et al. Approaches to establishment thresholds for major food allergens and for gluten in food: A report by the Threshold Working Group. The Center for Food Safety and Applied Nutrition, Food and Drug Administration 2006 March. <br />(3) Bureau of Environmental Health/Food Protection Program, Massachusetts Department of Public Health. Q&As for MDPH Allergen Awareness Regulation. 2010 19 August. <br />(4) De Martino B, Kumaran D, Seymour B, Dolan RJ. Frames, biases, and rational decision-making in the human brain. Science 2006 4 August; 313:684-687. <br />(5) Fleischer DM, Conover-Walker MK, Matsui EC, Wood RA. The natural history of tree nut allergy. J Allergy Clin Immunol 2005 November; 116(5):1087-1093. <br />(6) Green TD, LaBelle VS, Steele PH, Kim EH, Lee LA, Mankad VS, et al. Clinical characteristics of peanut-allergic children: Recent changes. Pediatrics 2007 December;120(6):1304-1310. <br />(7) Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol 2007 July; 120(1):171-176. <br />(8) Hefle SL, Taylor SL. Food allergy and the food industry. Curr Allergy Asthm R 2004 January; 4(1):55-59. <br />(9) Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav 1995; Extra Issue:80-94. <br />(10) Lowey N. Public Law 108-282: Food Allergen Labeling and Consumer Protection Act of 2004. 2004 2 August; H.R. 3684(108th Congress, First Session). <br />(11) MA Department of Public Health. 105 CMR 410.500: State Sanitary Code, Chapter X--Minimum sanitation standards for food establishments. 2010 9 June. <br />(12) McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993 10 November; 270(18):2207-2212. <br />(13) Ogilvy D. How to build great campaigns. In: Ogilvy D, editor. Confessions of an advertising man New York: Atheneum; 1964. p. 89-103. <br />(14) Ong PY. Are allergy advisory statements helpful to patients with food allergy? J Allergy Clin Immunol 2008 3 January; 121(2):536-537. <br />(15) Pieretti MM, Chung D, Pacenza R, Slotkin T, Sicherer SH. Audit of manufactured products: Use of allergen advisory labels and identification of labeling ambiguities. J Allergy Clin Immunol 2009 August;124(2):337-341. <br />(16) Rona RJ, Keil T, Summers C, Gislason D, Zuidmeer L, Sodergren E, et al. The prevalence of food allergy: A meta-analysis. J Allergy Clin Immunol 2007 July 12, 2007;126(3):638-646. <br />(17) Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974;2(4):328-335. <br />(18) Salazar MK. Comparison of four behavioral theories: A literature review. AAOHN Journal 1991 March;39(3):128-135. <br />(19) Savage JH, Kaeding AJ, Matsui EC, Wood RA. The natural history of soy allergy. J Allergy Clin Immunol 2010 March;125(3):683-686. <br />(20) Savage JH, Matsui EC, Skripak JM, Wood RA. The natural history of egg allergy. J Allergy Clin Immunol 2007 December;120(6):1413-1417. <br />(21) Sicherer SH, Munoz-Furlong A, Sampson HA. Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: A 5-year follow-up study. J Allergy Clin Immunol 2003 December;112(6):12-3-12-7. <br />(22) Skolnick HS, Conover-Walker MK, Koerner CB, Sampson HA, Burks W, Wood RA. The natural history of peanut allergy. J Allergy Clin Immunol 2001 February;107(2):367-374. <br />(23) Sornette D. "Herd" behavior and "crowd" effect. In: Sornette D, editor. Why stock markets crash: critical events in complex financial systems Princeton: Princeton University Press; 2003. p. 91-114. <br />(24) Taylor SL. Reply: Are allergy advisory statements helpful to patients with food allergy? J Allergy Clin Immunol 2008 21 January; 121(2):537. <br />(25) Thaler RH, Sunstein CR. Chapter 3: following the herd. In: Thaler RH, Sunstein CR, editors. Nudge: improving decisions about health, wealth, and happiness New Haven: Yale University Press; 2008. p. 53-71. <br />(26) U.S. Food and Drug Administration. Food allergen labeling and Consumer Protection Acto of 2005 questions and answers. 2009; Available at: http://www.fda.gov/Food/LabelingNutrition/FoodAllergensLabeling/GuidanceComplianceRegulatoryInformation/ucm106890.htm. Accessed December 5, 2010. <br />(27) Vadas P, Wai Y, Burks W, Perelman B. Detection of peanut allergens in breast milk of lactating women. JAMA 2001 4 April; 285(13):1746-1748. <br />(28) Vierk KA, Koehler KM, Fein SB, Streeet DA. Prevalence of self-reported food allergy in American adults and use of food labels. J Allergy Clin Immunol 2007 25 April;119(6):1504-1510.Christinehttp://www.blogger.com/profile/14848177219392201947noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-33148630997324191522010-12-16T18:35:00.000-08:002010-12-16T18:37:04.184-08:00Analysis of Click It or Ticket and The Comprehensive Approach to A New, More Effective Campaign- Heather ValerioEvery hospital in every city in the United States has seen the effects of neglecting to use an automobile’s built in safety belts. Safety belt use is and has been an issue in the United States for quite some time. The use of safety belts significantly reduces the chance of serious injury or death when in an accident, yet some people continue to disregard them and not utilize them when driving or riding in a car. According to the National Institute for Highway Safety Research and Communications, roughly forty thousand people died from car accidents each year in 2009 (13). Their data states that this is the number one cause of death for individuals under the age of 35 and accounts for a disproportionately high number of deaths in the 16-19 year old age group. The NIHSRC goes on to report that the use of safety belts in this age group is only around 41% in drivers of all reported accidents and only 29% of passengers. Passengers are more likely than drivers to refrain from using safety belts, and the highest percentage of those who choose to refrain are 14-20 years old in both passengers and drivers. This data is striking, and indicates a need for intervention. <br />In the 1980s American health officials noticed the need for intervention and developed the “Click It or Ticket” campaign (13). Although public officials see the success in this program, when it is closely looked at and critiqued, the flaws become quite evident. Because of its flaws, Click It or Ticket does not reach an optimal number of people and therefore does not achieve its full potential as a public health campaign. The Click It or Ticket campaign has seen success in only those who respond to threats from law enforcement and those who care about their current health outcomes. This indicates a strong need for a campaign that focuses on teenagers, as motor vehicle accidents are the number one cause of death for this age group, and are more prone to psychological reactance (4). The Click It or Ticket campaign is focused on the legality of wearing a safety belt, when in reality it should be framed as a public health issue (13). This campaign also focuses only on safety belts, when there are a lot of other contributing factors to motor vehicle injuries and deaths. The need for a comprehensive, group prevention program that takes psychological and social theories into account is evident and should be made a state and nationwide priority.<br />Most Click It or Ticket commercials are mainly focused on the law enforcement consequences of refraining to wear a seatbelt (13). These television announcements show images of police pulling over and ticketing those who are not wearing a seatbelt. The announcements state that there is no way to avoid a ticket, and that if a person is not wearing a seatbelt, they will most definitely be caught (13). The remaining small minority of commercials focus on the health benefits of wearing a seatbelt stating that if you are not wearing a safety belt and get into an accident, you will most definitely die, and on the other hand if you are wearing a safety belt and get into an accident you will most certainly live (13). Everyone knows that this is not the case. These television commercials rely on scare tactics, whether it be from law enforcement or death (13). This flawed campaign strategy does reach a small amount of people, but fails to reach the population that needs an intervention most: teenagers (13).<br />Failure to adapt to age group that is most prone to neglect safety belts <br />Teenagers, more than any other age group, are more likely to disregard the Click It or Ticket campaign. This is due to the fact that this campaign relies heavily on the effects of law enforcement and makes it seem like the police are taking away freedom when making it necessary to wear a safety belt when riding in cars. Reactance theory states that when one perceives their freedom to be in danger, he or she will act out in the opposite way, in order to preserve their liberty (2). Teenagers are prone to reactance theory, other wise known as psychological reactance (4). This is important to consider because it has been found that an increase in psychological reactance increases one’s risky decision making, especially in adolescence (7). This means that teenagers or adolescents will do whatever they can in order to maintain their freedom and that this threat to freedom will cause these adolescents to act out in a risky behavior. If someone of authority tells adolescents to do something, they are most likely going to do the exact opposite in order to take a stand for their freedom (7). It is of vital importance to take into account when building a public health campaign. One should not build a campaign meant to target an entire population that uses a do this or else strategy (6). <br />Neglect to take other aspects of dangerous driving into account, in order to prevent automobile crashes.<br />Drivers in the sixteen to nineteen year old age group are more likely to be “distracted drivers,” (10). Distracted drivers are those who engage in other activities along with driving such as talking on a cell phone, texting, or letting car conversation effect your focus on the road (10). This data indicates that this group, more than ever, needs an intervention that successfully tackles safe driving and usage of seatbelts. The Click It or Ticket campaign focuses only on seatbelt use and not on preventing those things that cause accidents in the first place (13). This campaign should be broadened in order to incorporate a prevention plan for distracted driving. Data has shown that, distracted driving is the number one cause of fatal or injury causing motor vehicle accidents (10). More and more state officials are hoping to cut down on the amount of distracted drivers by passing laws that ban talking on a cell phones and texting while driving . According to the Governor’s Highway Safety Association (GHSA), talking on a hand held cell phone use is banned in eight states (California, Connecticut, Delaware, New Jersey, New York, Oregon, and Washington), (11). This means that citizens in these states cannot hold a phone up to their face and drive, but use of a bluetooth device is acceptable, though these too are arguably distracting. In addition to talking, The GHSA reports that thirty states ban text messaging and driving (11). Some states enforce this law to all ages and others just target teenagers (11). While these laws have the good intention of reducing distracted driving, they still create a psychological reactance type of response. Those laws that target teenagers only seem unfair to them, and they will be more prone to act out, and therefore to text, talk, and not wear a safety belt. <br />Failure of the Health Belief Model<br /> The Click It or Ticket safety belt campaign is built and based on the health belief model. The health belief model is a balancing act between the perceived benefits and the perceived severity of a certain behavior (9). According to this model, whatever side has more weight reigns supreme and the actions that follow that side will be taken (9). This is an individually based model that assumes that people act rationally and always take both views into account when making a health decision (9). This model has some positive attributes, as it calls to attention the need for education and prevention before a positive health behavior can be initiated. The health belief model is also good for predicting one time decisions such as whether or not to get immunized. The health belief model, however, is not a good predictor of habitual behaviors such as putting on a safety harness upon entering an automobile. Because safety belt use is a habitual behavior, an intervention or public health campaign that targets this topic should not be based around the health belief model. <br /> Because the health belief model is individually based it should not be used with the intention of changing behaviors of a population. This is a major mistake in the Click It or Ticket campaign. The makers of this campaign believe that people will change their behavior based on solely facts (13). They believe that after seeing their ads, viewers will weigh the costs (death or monetary loss) and benefits (life), and that all viewers will see the overwhelming benefit in life and choose to wear their seatbelt (13). In this model, the person must take into account his or her perceived susceptibility, perceived severity, perceived barriers, and perceived benefits in order to make a health changing decision. Teenagers are not likely to sit down and weigh out options of susceptibility, severity, barriers, and benefits (9). Teenagers are also not likely to be motivated by health outcomes, as they are prone to a false perception of invincibility (3). Adolescent males are notoriously egocentric and have a false perception of invincibility (5). This fact contributes to both lack of following guidelines for safe driving and failure to wear a safety belt. These particular teens believe that they will not fall victim to a crash—so why bother looking uncool in a seatbelt, or following traffic laws (5). The makers of this campaign believe that the legality of “buckling up,” through phrases such as “the cops are cracking down,” is enough to persuade anyone to wear use a safety harness (13). Along with health outcomes, legal issues are non-motivators to many adolescents (3). Adolescent’s false perception of invincibility translates to legality; they believe that if they break the law, they have a lesser chance of being caught than someone else (3). <br /> The Click It or Ticket campaign utilizes both mass media and highway signs to get their message to the masses (13). The flaw in this, however, is that the programming they choose to show their commercials in programs that are not watched by any target population. Unless shown during a major sporting event, their advertisements are sporadically placed in adult programming, making them nearly unseen by adolescents. The Click It or Ticket highway signs are small and go relatively unnoticed by passers by (13). When looked at the signs only read “Click It or Ticket,” and are accompanied with a picture of a stick figure or the representing state with their respective dollar fines (13). Few people can identify with a stick figure, and most wish not to be reminded of potential fines they can incur on the road. These bland signs and random commercials do not create a sense of familiarity and instead they get overlooked or disregarded. This campaign fails to recognize the need for different media outputs for different age groups and target audiences. <br /> The Click It or Ticket campaign does not take adolescent’s psychological factors or reactions, such as perceived threat to freedom or flawed sense of invincibility, into account (13). This neglects to reach the demographic that needs an intervention most (13). The campaign’s sole use of the health belief model makes it look like an outdated program with an intense need for rethinking their approach. While the Click It or Ticket campaign has good intentions, it is not utilizing the right behavior change theories or techniques to promote the safest driving possible. As shown, the campaign only focuses on one aspect of safe driving instead of encompassing everything that goes into the responsibility of operating a motor vehicle (13). The campaign also has a series of flaws that surface when considering it was designed in order to change the behavior and effect the overall morbidity and mortality rates of the general population. As indicated, the campaign also fails to account for the many age groups of driving. Many changes must be implemented to this campaign in order for it to be most effective. <br />Proposal of New Campaign Plan <br /> As seen, there is a great need for a new way to address both safe driving and safety belt use. The following proposed program is fictional, but provides a more concise and new approach to this issue. This program will include all aspects of safe driving: safety belt use, cell phone use, and everything that goes along with distracted driving. The new campaign will use group based intervention models, as it is trying to change the behavior of a population (1, 8). Because there really is no clear cut campaign for teens to utilize safety belts, this proposed campaign will focus mainly on the adolescent age group. This safe driving and safety belt promotional campaign will be called “Let’s Get It On”. This campaign will utilize a few psychological strategies of health behavior change, instead of focusing on just one like Click It or Ticket.<br />Utilization of Alternative, Group-Based Behavior Change Models: Advertising Theory and Marketing Theory<br /> Campaigns such as Click It or Ticket should be broadened from the individually based health belief model to a group-based model. The Let’s Get It On safety belt campaign aimed at teens will use advertising theory to adequately deliver its message of safety belt use. Campaigns that utilize advertising theory should adopt the techniques of advertisement executives when creating their commercial (15). Television advertisements for the Let’s Get It On campaign will deliver a promise and back it up with images (15). Let’s Get It On will deliver the promise that being safe can be part of the fun. The campaign will back up this message with laughing teens getting into an automobile and buckling their seatbelts in a rhythmic fashion. The commercial will go on for thirty seconds showing different teens getting into cars and bucking their seatbelts in this same rhythm, signifying that they are part of this “rhythm of life.” The commercial will then end with the key phrase of the campaign, “Let’s Get It On.” Some of these commercials will include images of teens turning off, closing their cell phones, or handing them to passengers, thereby adding to this rhythm. This advertisement is predicted to be better received than the traditional Click It or Ticket campaign because it does not establish a sense of psychological reactance in the viewer. The phrase “Let’s Get It On” will be well received in the adolescent community because it is nonthreatening and fun. <br /> Throwing health statistics or legal fines at viewers is unnecessary, as this campaign takes psychological reactance into account. These advertisements will also be loosely based around marketing theory (14). Campaign directors will first identify what our target audience, adolescents, identifies as core values (14). Upon research, campaigners should utilize the values of friends, fun, feeling as part of the group, freedom, and humor. Friends are an important element in the adolescent world, therefore the advertisements will show teenagers getting into the car with other teenagers, not authorities figures. This will work to reduce the amount of psychological reactance felt by the target audience, as no one in these advertisements is blatantly telling them what to do. Most adolescents would much rather be having fun or going out than going to school, therefore these commercials will show teenagers getting together to head somewhere social—the mall, a football game, or someone else’s house. The advertisements will utilize the core value of acceptance and feeling as part of the group through the creation of a rhythmic flow throughout the commercial. This shows that the teens are a part of something bigger than just buckling up every time they get into a car; as indicated, it shows them that they are part of this rhythm of life. As explained through the theory of psychological reactance, adolescents feel the need to express their freedom in any way possible. This core value of freedom will be respected in this campaign. As stated, advertisements will only show teenagers getting into the car with people they wish to be with, and going somewhere they wish to go. The last core value this campaign will use, humor, will be in the campaign name itself: “Let’s Get It On.” <br />Utilization of Modeling <br /> This campaign will work with the idea of modeling, and getting people to emulate what they see. When adolescents see people they look up to doing something, they are more likely to do it (8). In order to effectively use modeling, the campaign will first contact the major television networks and ask them to feature more safe driving snippets in shows. Ideal shows would be ones that teenagers watch such as Glee or How I Met Your Mother. Writers of these shows can subtly include scenes where a character gets in a car, puts on a safety belt, and refrains from cell phone use. Teen Mom, a show on MTV, should also receive this message as they are constantly showing these teenage mothers driving their children around and talking on cell phones, and sometimes neglecting to use safety belts on themselves. Implementing this strategy will instill a modeling effect in watchers and they will therefore be more likely to use more precautionary measures when behind the wheel. This tactic can even start in shows that preteens and children watch. This will create a habitual effect so that when these children are old enough to drive, they know they have to do so safely.<br />Liking, Familiarity, Social Learning Theory and Celebrity endorsements <br /> Modeling can also come in another form: celebrity endorsements. While taking the easy road out and using a celebrity endorsement is seen as cheesy or like a reach, they will be effective in this instance (8). It has been shown that celebrity endorsements have the ability to sway young people’s behavior in whatever way people want them to act (1). In the Let’s Get It On campaign, some advertisements will use celebrities to get their message across. Ideally, this will cover the majority of the print messages. Attractive celebrities will be pictured with just the line “Let’s Get It On” under them, and with a message in smaller print that reads “[name of the celebrity] gets it on every time he/she is in a car.” These celebrity endorsements can be broadened to fit the visual campaigns. Famous musicians that are popular in the adolescent community will be asked for permission of their songs and possibly their time to use in the television advertisements. Ideally, these popular songs will be used in the commercial and the buckling of the safety belts will follow the beats of these famous songs and the artist will make a cameo appearance. If a commercial were to go on the air today, makers of the Let’s Get It On campaign would find it in their best interest to sign today’s popular artists such as Cee Lo Green and use his song “Forget You.” This will instill a liking and familiarity effect in the target audience and they will be more likely to respond positively to the messages that are being presented. <br />Conclusion <br /> The Click It or Ticket campaign needs a major facelift if they want to effectively reach all age groups of drivers and change their behavior. The campaign also neglects to take into account the need to stop behavior that gets drivers into accidents in the first place. There is an obvious need for a more comprehensive plan that takes all areas of safe driving into account, that targets the population that needs it most, and that does not use scare tactics to get them across. The Let’s Get It On campaign does all that. This campaign makes it look like when you are wearing a safety belt, you are part of the crowd. This campaign also takes into account the core values of its target population and effectively delivers its message. Let’s Get It On subtly hints at putting away your cell phones or giving them to your passengers to man for the ride. This campaign is well thought out and if instated, will be received positively. So next time you get in a car, disregard threats from the National Highway Traffic Safety Administration and think like Marvin Gaye… get it on. <br /> <br /> <br />References<br />Journal Articles:<br />1. Austin, E. W., Pinkleton, B. E., Van de Vord, R., & Epstein, E. (2008). Celebrity endorsements and their potential to motivate young viewers Mass Communication and Society<br />2. Brehm, S. S., & Weinraub, M. (1977). Physical barriers and psychological reactance: 2-yr-olds' responses to threats to freedom. Journal of Personality and Social Psychology, 35(11), 830-836. doi:10.1037/0022-3514.35.11.830<br />3. Crook, M. W. (2005). Tool development to measure the adolescent perception of invincibilityProQuest Information & Learning). Dissertation Abstracts International: Section B: The Sciences and Engineering, 65(9-) Retrieved from http://search.ebscohost.com.ezproxy.bu.edu/login.aspx?direct=true&db=psyh&AN=2005-99006-187&site=ehost-live&scope=site. (2005-99006-187)<br />4. Drivers aged 16 or 17 years involved in fatal crashes -- united states, 2004-2008. (2010). MMWR: Morbidity & Mortality Weekly Report, 59(41), 1329-1334. Retrieved from http://search.ebscohost.com.ezproxy.bu.edu/login.aspx?direct=true&db=cin20&AN=2010836898&site=ehost-live&scope=site<br />5. Drucker, A. D. (2000). Egocentrism and invincibility in adolescent male automobile drivers: An applied perspectiveProQuest Information & Learning). Dissertation Abstracts International: Section B: The Sciences and Engineering, 61(1-) Retrieved from http://search.ebscohost.com.ezproxy.bu.edu/login.aspx?direct=true&db=psyh&AN=2000-95014-017&site=ehost-live&scope=site. (2000-95014-017)<br />6. Frank, S. J., Jackson-Walker, S., Marks, M., Van Egeren, L. A., Loop, K., & Olson, K. (1998). From the laboratory to the hospital, adults to adolescents, and disorders to personality: The case of psychological reactance. Journal of Clinical Psychology, 54(3), 361-381. doi:10.1002/(SICI)1097-4679(199804)54:3<361::AID-JCLP6>3.0.CO;2-S<br />7. Miller, C. H., & Quick, B. L. (2010). Sensation seeking and psychological reactance as health risk predictors for an emerging adult population. Health Communication, 25(3), 266-275. doi:10.1080/10410231003698945<br />8. Nangle, D. W., Erdley, C. A., Adrian, M., & Fales, J. (2010). A conceptual basis in social learning theory. In P. J. Norton (Ed.), Practitioner's guide to empirically based measures of social skills. (pp. 37-48). New York, NY US: Springer Publishing Co. doi:10.1007/978-1-4419-0609-0_3<br />9. Rosenstock, Irwin M, Hochbaum, Godfrey M. (1961). Some principles of research design in public health American Journal of Public Health Nation's Health, 51(2), 266-277.<br />10. Wilson, F. A., & Stimpson, J. P. (2010). Trends in fatalities from distracted driving in the united states, 1999 to 2008. American Journal of Public Health, 100(11), 2213-2219. Retrieved from http://search.ebscohost.com.ezproxy.bu.edu/login.aspx?direct=true&db=cin20&AN=2010833940&site=ehost-live&scope=site<br /> <br />Websites: <br />11. Governors highway safety association: State laws and funding. (2010). Retrieved 12/5, 2010, from http://www.ghsa.org/html/stateinfo/laws/index.html<br />12. National highway traffic safety administration: Click it or ticket. (2010). Retrieved 12/5, 2010, from http://www.nhtsa.gov/CIOT<br />13. National institute for highway safety research and communications. (2009). Retrieved 12/5, 2010, from http://www.iihs.org/research/fatality_facts_2009/default.html<br />Books: <br />14. Lovelock, Christopher & Wirtz, Jochen. (2004). Services Marketing: People, Technology, Strategy. Upper Saddle River, NJ. (8)<br />15. Percy, L. (1980). In Percy L., Rossiter J. R. (Eds.), Advertising strategy: A communication theory approach (1st ed.). New York: Praeger Publishers.Christinehttp://www.blogger.com/profile/14848177219392201947noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-74507134708628315322010-12-16T18:33:00.000-08:002010-12-16T18:34:56.817-08:00Graphic Warning Labels For Cigarette Packs Using The Health Belief Model- Chris SardonIntroduction<br /> Smoking has become one of the biggest health issues affecting the United States of America. Its devastation not only affects those who smoke, but also the people around smokers. According to the Centers for Disease Control and Prevention (CDC), tobacco use is responsible for 1 in 5 deaths with about 443,000 deaths due directly to tobacco use and 49,000 deaths due to second hand smoke (5). Smoking causes cancer, lung diseases, heart disease, and stroke and for every person who dies from a smoking related disease, twenty people suffer from a serious illness due to smoking (5). Clearly, cigarettes have catastrophic consequences thus making smoking a prime target for public health interventions. <br /> Recently, a law was passed that gave the Food and Drug Administration (FDA) the power to regulate tobacco products through warning labels. Nine graphic warning labels will be chosen and they will take up half of the surface area of a carton or pack of cigarettes and a fifth of any advertisements. The graphic labels aim to get smokers to quit by vividly demonstrating the dangers of tobacco use. Amongst the potential labels are: a man blowing smoke through a hole in his neck, women blowing smoke into their baby’s faces, and people in coffins. <br /> <br /> This public health intervention to combat smoking is based on the health belief model. The intervention assumes that people are weighing the perceived benefits with the perceived barriers to quitting smoking and making rational decisions based on that balance. It assumes that people plan their behavior and it aims at helping the individual, not a group of people. This model for a public health intervention is significantly flawed and will most likely fail to reach its intended purpose.<br />Critique Argument 1: Assumes Behavior is Rational<br /> The main flaw of this intervention is that it assumes behavior is rational. The interventionists expect smokers to see these labels and weigh the perceived benefits and barriers of behavior change. After this balancing act, it assumes that the balance will shift to smokers intending to quit and eventually changing their behavior towards quitting smoking. But the intervention does not factor in that intention to do a behavior doesn’t always lead to the behavior. The health belief model relies on the individual taking in information and making an educated decision. This is not effective because it does not take into account the social factors that people encounter. This intervention, and the health belief model in general, does not answer the question: why do people smoke? Any intervention that does not factor in this essential question will not be successful.<br /> Individual behavior is not rational because often times people follow a crowd. This is called the herd mentality. One person might be smart, but a group of people can be stupid. When individuals frame their behavior based on what a group of people are doing, it can often lead to irrational behavior. In this case, people see a group of others smoking and follow suit. The social network theory (6,7) demonstrates that the people they are connected to affect peoples’ behavior. In this theory, people won’t just quit smoking by seeing these labels; rather they will quit smoking if others are also doing it. They will quit in clusters instead of as individuals. Because the warning label intervention is based on the health belief model, it is aimed at affecting the individual and not a group, thus rendering the intervention likely to fail. <br /> The health belief model is incapable of affecting the barriers to behavior change. Thus, this intervention does not make it easier for smokers to overcome the obstacles stopping them from quitting smoking. The model and intervention can only affect the perceived severity and susceptibility of the diseases caused by smoking. The label intervention aims to make smokers perceive that they are more susceptible to the diseases associated with smoking but this is a flawed assumption because the human perception of perceived risk is irrational. The optimistic bias theory states that people may have an accurate impression of getting an adverse health problem, but they believe that their personal risk is less (1,12). Therefore, smokers will underestimate their risk of developing lung cancers, heart disease, and strokes (1,10,11). The illusion of control theory also adds to this idea. It states that people tend to overestimate the degree to which they have control over events, which leads to an inaccurate perception of risk (9). Both of these theories lead to a lessened perceived susceptibility and severity of disease associated with smoking, consequently not shifting the balance between perceived benefits and barriers enough to theoretically alter behavior.<br />Critique Argument 2: Doesn’t Relate to Youths<br /> Another major flaw of the label intervention is that it does not relate to youths. The intervention assumes that youths will be more affected by pictures than written warning labels and, as a result, be more likely to weigh the benefits and barriers to quitting smoking. This is an ignorant assumption. Any parent can tell you that their children’s’ behavior is often driven by rebellion. Rebellion is based on the theory of psychological reactants. The theory of psychological reactants makes the claim that people will rebel when they lose control or freedom (3). These labels are telling youths not to smoke. Youths will perceive being told not to smoke as a threat to their freedom to choose to smoke. These labels will not stop youths from smoking; they will rather increase the amount of smoking in youths because the youths will be trying to restore their control. <br /> Once again, this intervention concentrates on the individual making an educated decision about behavior change. It does not take into account any social factors. Social factors are a big determinant driving the behavior of youths. The theory of social proof backs this assertion. It states that people will do an action if they see other people doing it. People will model their behavior after the norms of those around them. A terrific example of this is the “Bystander Effect.” The “Bystander Effect” is the phenomenon that people will not help a person in need because they see that other people aren’t doing it (2). They know that a person needs help but do not give it to them because it is against the norm of the people around them. This comes into play for teenagers. If they see their peers smoking, they are going to model their behavior after their peers in order to stay with the social norms around them. <br /> The label intervention also does not approach the reason why youths smoke. Often, a person’s behavior will be attributed to their attributes and character. The fundamental attribution error theory shows that this is a poor way to approach this issue. The fundamental attribution error states that behavior is significantly affected by the context of the situation (8). Youths do not smoke because they have character flaws. They smoke because the environment they are in makes it “cool” to smoke. As demonstrated earlier, the context that contributes to a youth’s behavior is based on the social structure surrounding them.<br /> Youths will also do dangerous behaviors even when they know the risks. They do this because they feel that they are invincible. This thought process is based on the theory of optimistic bias and the theory of illusion of control. As stated previously, the optimistic bias leads to people believing that they are at less risk than others. This is evident in the behavior of youths, as they believe their dangerous actions will not affect them. Youths also believe that they have complete control over their lives. This is consistent with the theory of illusion of control. Youths believe that they have more control over their events and accordingly perceive that they are at a smaller risk. Both of these theories demonstrate why youths believe that they are at a lower risk than others when it comes to the effects of smoking. Thus, this intervention is not going to work on youths because their perceived risk due to smoking is quite low. They know the consequences that come with smoking, but they believe that is for everyone else in the world but them. This is why this intervention is going to be useless on the youth of America.<br />Critique Argument 3: Does Not Deal With Addiction<br /> A major limitation of the health belief model is that it does not deal with addiction. People who are addicted to smoking are affected by the stereotype or label they are given which leads to irrational behavior. This is based on labeling theory. People take on the characteristics of the label they are given (4). Smokers know what the risks of smoking are but choose to do actions based on the expectations of their label. People addicted to smoking are expected to smoke. Because they are expected to smoke they choose to behave in a way that meets these expectations. By knowing the consequences of smoking but choosing to meet the expectations placed on them, smokers are making the irrational decision to continue their unhealthy habit. <br /> People also have the fundamental inability to control their actions. This lack of self-control leads to irrational behavior. Many smoking addicts have tried multiple times to quit but do not have the self-control to succeed. By seeing labels like these, it makes them feel defeated. This feeling decreases their self-efficacy to quit. It lessens their belief that they can quit their addiction. This is a fundamental problem to this intervention. People NEED to believe they can quit. Without that confidence, changing ones behavior is nearly an impossible task to accomplish. The other problem with this intervention pertaining to addicts is that it gets to them too late. These labels are hardly seen until someone is actually in the process of buying the cigarettes. People have already made the decision to smoke and at the point when they buy the cigarettes, it will be too late to change their behavior.<br /> The theory of optimistic bias again factors in with addicts. These people have been smoking for a long time and have not seen the effects that the statistics claims are happening. If it has not happened to them over the years, they feel as if they are at a decreased risk. They do have an accurate perception of what could happen, but they believe that it won’t happen to them. They now perceive a much lower risk of illness due to smoking based on their own personal experience. The theory of illusion of control also factors in here. Many addicts believe that they have the control to stop whenever they want. Sadly this is not true. They have the belief that they can in fact control their actions, therefore leading to an inaccurate perception of risk. These two theories again demonstrate that smokers will believe that the risk to them is significantly less than the statistics show.<br />Conclusion<br /> This smoking label intervention is simply not going to work. People who smoke already know what the risks associated with their actions are. This approach is too simplistic. It assumes that people are rational beings and are not affected by the people around them. This is a naïve belief. Initially, there is going to be a big shock to the public once the intervention is implemented. This will last a limited time, as people will become used to the new packaging. The same thing happened when the written labels were first placed on cigarette packs. People noticed them at first, but now people don’t even recognize they are there. I also believe that people will develop ways to block out these images. People use koozees on beer cans. Who is to say that the tobacco companies aren’t going to make a similar product for cigarette packs? As people naturally adapt to their environments, people will adapt to these new packages rendering the intervention useless. This intervention fails to acknowledge why people smoke. Without taking on that question, any intervention to get people to quit smoking will likely not succeed.<br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br />Proposed Intervention<br /> As we observe society, we can conclude that people are not rational. A person can be given all of the statistics and data in world about smoking, but will still probably behave in an irrational manner. Previous interventions have relied on people’s reasoning skills and have proven to be unsuccessful. The optimal way to change a person’s behavior when it comes to smoking is to make it personal. If you can hit a person in the heart, they will be more likely to make behavior changes towards a healthier life. <br /> I believe an effective intervention to get smokers to quit and to stop people from starting to smoke would be through a personalized commercial. In each region of the country, I would air a commercial starring a well-respected celebrity from that area with a personal story about how smoking has affected his or her own life. This approach is based on the law of small numbers. This law says that the perception of risk for people is related to the people they see around them or the stories that they hear, not through statistics. In this commercial, I would try to use a celebrity that can relate to young and old people. They will discuss how smoking personally affected their life and say that the tobacco companies have control over you when you smoke. This will hit people in the hearts as they can relate to this person as well as trigger the viewers desire to regain their freedom and control. At the end of the commercial, the celebrity would encourage people to talk about why they smoke and how they can quit with their family and friends while also providing the phone number and website for a smoking hotline. The closing of the commercial will be the celebrity making a promise to the viewer that cutting smoking out of your life will make you a happier person.<br /> This approach is based on advertising theory, the health belief model, and the social network model. These different models and psychological theories allow the commercial intervention to influence a broad range of people. It will affect the common irrational person, youths, and smoking addicts. By taking into account multiple social psychology approaches, this intervention will be more successful than the current package labeling intervention. This approach factors in social aspects, personal stories, and the desire for control in order to appeal to a large audience.<br />Defense of Intervention: Plays to Predictably Irrational Behavior<br /> This intervention does factor in that people do not make rational decisions. The health belief model portion of this intervention aims at the balance between perceived benefits and barriers. Normally smokers don’t believe that they are at much of a risk because they have a skewed perception about the risk they are at. They see the statistics of illnesses associated with smoking, but do not have personal affiliations with these diseases. This commercial will get the smokers and potential smokers to see a personal story, thus making the risks of smoking more close to “home.” This will make the perceived benefits of quitting seem larger, therefore shifting the balance towards healthier behavior. These personal stories will reduce the optimistic bias that a person feels. People will now have a more accurate perception of what their own personal risk is. This will also decrease the illusion of control. Viewers might see a former professional athlete who is suffering from smoking related illnesses. If a phenomenal athlete like that can’t have control of their own body, than how can a normal person have control. This will get the viewer to realize that they have less control over events than they previously thought. This commercial is taking advantage of this by selling control, not health.<br /> This intervention also factors in that people are affected by society around them. People tend to follow groups and want to fit in with the crowd as stated by the social network theory. By getting smokers to talk to friends and family about why they smoke, they could potentially find support in others who don’t smoke and want to follow their lead. Also getting a smoker to come to the realization as to why they smoke is key to behavior change. If a person doesn’t understand their own reasoning for a behavior, it will be harder for them to change that behavior. The first step to changing the behavior of smoking is to identify the reason for smoking. Once the reasoning has been pinpointed, the smoker can concentrate on that point and try and correct it with the support of their family and friends.<br />Defense of Intervention Section 2: Relates to Youths<br /> A strong point of this intervention is that it plays to youths. First off, by using a prominent celebrity from the local region, the youths will have a better time relating to that person. This is based on the principle of liking. If a youth likes or relates to a person giving a message, he or she is more likely to follow that message. Basically, the more similar a person is, the more likely they are to respond to the message. <br /> As stated earlier, teenagers thrive on rebellion. This intervention, with its advertising theory basis, plays to this phenomenon. The key here is to convince kids not to trust the tobacco industry. When the celebrity that they are familiar with talks about how the tobacco industry controls you when you smoke, the youths will want to rebel to restore their control and freedom. Advertising theory has a foundation in promises and support. By promising the viewer that he or she will live a happier life without smoking, they are appealing to the core value of happiness. This will motivate people to think about changing their behavior regardless of if the promise is true. The way this works is by supporting it with a story, which the commercial does. The promise of the core value of happiness and control is the key to stopping and preventing children and teenagers from smoking. <br /> As previously stated, this intervention factors in the societal environment that the people are in and the newly acquired perception of personal risk due to minimization of optimistic bias and the illusion of control.<br />Defense of Intervention Section 3: Approaches Addiction<br /> Addiction to smoking is a tough dilemma to approach. Many people are set in their ways and are in denial of their addiction. The commercial intervention relies somewhat on the social network theory. It assumes that the people they are connected to influence people’s behavior. If the commercial does its job, it will convince smokers to talk to the people around them. This can help them realize that they have an addiction and come to a conclusion as to why they smoke. This is a big step for addicts because it gets them to admit that they have a problem. By hearing a celebrity’s story and talking amongst friends, an addict will see the support that he or she has. This realization of support, along with the minimization of optimistic bias and the illusion of control, will increase the addicts’ self-efficacy to quit smoking. This is a huge step for any addict. They need to believe that they have the power to quit. This newly found self- belief combined with a support system would help the addict change their behavior. Addicts are the toughest group to appeal to and I believe this intervention could help their progression to a healthier life.<br />Conclusion<br /> There is not a single social psychological theory that can solve the smoking epidemic on its own. Every theory has its benefits and flaws. The commercial intervention attempts to take multiple theories and combine them in order to affect the most people possible. It acknowledges peoples’ predictably irrational behavior, youths desire to rebel, and addicts’ inability to recognize their problem. If implemented correctly, this intervention could have a dramatic effect on smoking simply because it confronts the reasons as to why people smoke. Finding the reason is the key to an interventions’ success and I firmly believe that this intervention is a step in a positive direction.<br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br />REFERENCES<br /><br />1. Ayanian J. and Cleary P. Perceived Risks of Heart Disease and Cancer<br />Among Cigarette Smokers. JAMA 1999; 281 (11): 1019-1021. <br />2. Bickman L. The Effect of Another Bystanders’ Ability to Help on<br />Bystander Intervention in an Emergency. Journal of Experimental Social Psychology 1971; 7 (3): 367-379.<br />3. Brehm S. and Weinraub M. Physical Barriers and Psychological<br />Reactance: 2-yr-olds’ Responses to Threats to Freedom. Journal of Personality and Social Psychology 1977; 35 (11): 830-836.<br />4. Bustamante J. The “Wetback” as Deviant: An Application of Labeling<br />Theory. The American Journal of Sociology 1972; 77 (4): 706-718.<br />5. Centers for Disease Control and Prevention. Smoking and Tobacco<br />Use: Fast Facts. Atlanta, Georgia: Centers for Disease Control and Prevention. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm.<br />6. Christakis N. Social Networks and Collateral Health Effects. British<br />Medical Journal 2004; 329: 184-185. <br />7. Christakis N and Fowler J. The Collective Dynamics of Smoking in a Large<br />Social Network. New England Journal of Medicine 2008; 358 (21): 2249-2258. <br />8. Harvey J. et al. How Fundamental is “the Fundamental Attribution Error”? <br />Journal of Personality and Social Psychology 1981; 40 (2): 346-349.<br />9. Langer E. The Illusion of Control. Journal of Personality and Social<br />Psychology 1975; 2: 311-328. <br />10. Stretcher V. et al. Do Cigarette Smokers Have Unrealistic Perceptions of<br />Their Heart Attack, Cancer, and Stroke Risk?. Journal of Behavioral Medicine 1995; 18: 45-54. <br />11. Weinstein N. Accuracy of Smokers’ Risk Perceptions. Annals of Behavioral<br />Medicine 1998; 20: 135-140. <br />12. Weinstein N. Unrealistic Optimism About Future Life Events. Journal of<br />Personality and Social Psychology 1980; 39 (5): 806-820.Christinehttp://www.blogger.com/profile/14848177219392201947noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-11249569602428712992010-12-16T18:31:00.000-08:002010-12-16T18:33:15.157-08:00Why Transtheoretical Model is Making Small Step Campaign Have a Small Impact: A Critique Based on . . .. . . Social Marketing and Integrated Theory of Health Behavior Change – Annie Peer<br /><br /> For a limited time only the price to get you 640 calories and 39 grams of fat will get you double - nearly 1300 calories and 80 grams of fat! Soon you too will be on your way to craving this many calories at every meal until you are in the “select” group of 72 million Americans in the obesity club. (1). If Burger King advertised their new buy one Original Chicken Sandwich and get one free offer in this way, obesity would not be such an issue as it is in America today. Instead Burger King focuses on people getting people what they want, how they want it, and with bigger portions than they imagined. The sandwich is described as being “unchanged since 1979, which no other burger can say” and “not a handful but a handsful”. Even the website allows the consumer to decide how much food, fun, and king images they want on the main menu as seen below: <br />Figure 1 www.bk.com<br /> This is what public health intervention against obesity is up against. “Obesity is the second leading cause of preventable premature death in this country, with some researchers predicting it may soon outpace smoking as the leading cause of preventable death. A solution will likely be multi-faceted, with emphases on prevention, improvements in treatments, policy change, and environmental changes, among others” (1). One attempt to make exercise and healthy living more “do-able” is the Small Step campaign that was started by the government. This makes exercise look easy by just getting into the habit of small changes everyday that will make you healthier such as taking the stairs instead of the elevator.<br />Using the six-stage behavior change theory (transtheoretical model) to plan their approach, researchers determined that the public is aware of the dangers of obesity but remains complacent about it (has yet to take action, see rewards from doing so, and commit to ongoing change). Why? Because people want a quick-fix in modern life and none of the promised "quick-fix" diet plans actually work, so consumers have concluded that it's impossible to get healthy.<br />The transtheoretical model shows the six stages that a person must pass through to achieve behavioral change: <br />Consciousness/Awareness<br />Emotional Arousal/Interest<br />Self-evaluation/Preparation<br />Commitment/Action<br />Reward/Positive Reinforcement<br />Self Liberation/On-going Commitment to Change<br />(2)<br />Critique 1 – Transtheoretical Model Does Not Account for Everyone <br />The primary use of the transtheoretical model is the first mistake this campaign makes. This model “integrates two interrelated dimensions of change, stages of change and processes of change, along with the constructs of self-efficacy and decisional balance. Stages of change represent when an individual is ready to change. Self-efficacy refers to the conviction that one can successfully execute the behavior required to produce the desired outcomes, and decisional balance encompasses the pros and cons or perceived benefits and barriers of making the change” (3). The stages of change reflect a person’s intention to change or the degree to which a person gives serious consideration to change. Individuals may progress through stages at varying rates, may regress, and may reenter the continuum of change at carrying points.<br />Cons to the physical exercise model showed that “precontemplators” see physical activity as having nearly as much cost as it has benefits and score highest on the cons of engaging in physical activity. (3). A study by Marcus, et al. (4) found that, similar to self-efficacy, pros and cons of physical activity were related to physical activity behavior only indirectly. The pros and cons constructs were related to stage of physical activity readiness (intention), and stage of physical activity readiness served as the mediator influencing actual physical activity patterns. Compared to individuals who were not regularly physically active, individuals who engaged in regular physical activity used physical activity to cope with unpleasant emotions such as stress and fatigue, rewarded themselves for engaging in physical activity, made a commitment to be physically active, and employed reminders to be physically active. Furthermore, these regularly active individuals had more confidence in their ability to be physically active and placed greater emphasis on the benefits of being physically active. It appears that those who were not physically active had less confidence in their ability to be physically active and perceived the barriers to engaging in physical activity as outweighing the benefits. (3).<br /> Transtheoretical Model posits that decisional balance, self-efficacy and processes of change are the most important stage transition determinants. (5). The evidence for the importance of these constructs is mostly based on cross-sectional data and more convincing evidence based on longitudinal data or experimental research is mostly lacking. <br />Critique 2- Food Ads Dominate in Exposure Time over Small Campaign <br />The fact that unhealthy food advertisements are dominant and result in fatter people is the second critique. Small Steps’ handful of ads and website isn’t nearly enough to counteract the pervasiveness of advertisements for unhealthy food -- particularly for teens. A study (6) found that fast-food restaurant advertisements were found to make up 23.1% of all food ads seen by adolescents (21.5% and 23.6% for African-American and white teens respectively), and McDonald’s and Burger King advertisements made up approximately 44% of fast-food ads seen by teens. Sweets and beverages ads counted for 22% and 17% of all food ads, respectively, while cereal ads made up 11%.<br /> <br />Figure 2 shows the distribution of the advertisements seen by a group of adolescents in a study done by Powell et al. (6). <br /> Food advertising that promoted snacking, fun, happiness and excitement (i.e., the majority of children’s food advertisements) directly contributed to increased food intake. In addition, these effects occurred regardless of participants’ initial hunger. (7). Furthermore, the amount of calories consumed by the participants after viewing snack advertisements was completely dissociated with the adults’ reported hunger. This was particularly true for men and those attempting to diet. (7). In addition, the effects persisted after the viewing session. <br /> It is not even as simple as restricting television advertising of calorie-dense, nutrient-poor foods… one study (8) proposed a food marketing defense model that posits four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability and motivation to resist. While it is extremely complicated and involved to control the effect of advertising, is it suggested here under the understanding category, to propose a way to effectively market foods and healthy behaviors is a way to defend against food marketing. The way to successfully achieve this will be discussed later in the improved intervention. Psychological theories predict that food marketing, in all its forms, has a profound negative impact on public health among young people and adults. Similarly they predict that proposals by the food industry, such as increased marketing of “better for you” foods or the inclusion of physical activity in food advertising, would not even begin to counteract these effects, and could make them worse. (8). <br />Critique 3- Health Belief Model Does Not Account For Social And Environmental Factors<br />The last critique is that the website is based on the health belief model and that people just need education to adopt a healthier lifestyle. This idea of the public simply needing information about nutrition is very wrong. A study (9) showed that providing calorie information at the point-of-purchase on a fast food restaurant menu had little effect on food selection and consumption among a sample of adolescents and adults who eat regularly at fast food restaurants. <br />Even when people are familiar with a specific risk, social norms and support play a huge role in a campaign’s success. When looking at diabetes prevention in Latino and other racial/ethnic populations (10) they found that integrating cultural factors into prevention interventions involves a proactive analysis of the needs of a specific cultural sub-group, and of how specific cultural factors (perceptions, attitudes, skills in self-regulation, family obligations, low social supports for a healthy lifestyle, etc.) may operate as personal or cultural barriers (or a facilitators) of sustained behavior change. <br />Broad contextual factors found that cultural influence included aspects of the built environment, as well as local norms and national policies that influence lifestyle choices. Consideration of these factors may augment cultural sensitivity, ideally facilitating program participation and thus enhancing the efficacy of interventions designed to change dietary and exercise behaviors. The Small Step program’s website focuses on educating the public about nutrition, while social norms and individual environments are not addressed. <br />The consumeR Campaign <br />The “consumeR” campaign will show how consumerism in America has made Americans fat. The blame for being fat will be placed on the companies’ campaigns to manipulate people into eating more thereby making them more money. This campaign will have people rebelling against fast-food by creating their own independent thoughts. The person that is a member of this “I am not a consumeR” web group will live up to this rebellious title according to the labeling theory. The R in consumeR will always be capitalized to emphasize that resisting consumption at these types of establishments relates to the second part of the campaign called “Reality check”. The “Reality” will take people behind big business to have people question the messages behind the ads and why they are getting bigger sizes or second hamburgers for free. <br />Since public health campaigns do not typically have large budgets, the considerable amount of the influential food advertisements would be combated by this rebellion against big food companies. Additionally, a website will be made where people can sign up for text messages to motivate them to exercise and stay away from fast-food. A section of the website will be a forum where members can post a ridiculous ad put out by companies designed to get them to eat more. When told that these companies are trying to get the consumers to not think and just be followers, they will rebel. <br />Solution 1- Segmentation to Appeal to Each Segment of the Population<br />Since the Small Step campaign does not appeal to “precontemplators”, the new campaign will take into account that all people need to be healthy and will use a variety of mediums to appeal to a diverse population. Developing interventions that are indeed stage-matched requires knowledge about important and modifiable stage transition determinants…making specific action plans may help people to turn their intentions into health promoting action. (5). The Transtheoretical model used in Small Step does not account for all people. It assumes that everyone watching is at point of being willing to make the changes necessary to live a healthier lifestyle. <br /> There are nearly 66% of Americans who are overweight and they do not form a homogeneous group - attitudes, demographic characteristics and lifestyle choices vary greatly within this subset of the US population. (11). Segmentation theory tells us that a “one size fits all” approach to marketing social change may not meet the needs of all people. Further, marketing research has revealed the importance and effectiveness of tailoring messages and incentives to meet the needs of different population segments. Social marketing is defined as “a social change campaign organized by a group which intends to persuade others to accept, modify or abandon certain ideas, attitudes, practices or behavior” (11). Just as the “truth” campaign was able to appeal to the teens’ need for a feeling of independence and rebellion using the social marketing theory against smoking (11), this new campaign for obesity prevention will target different segments too. While overweight adults will primarily be the television ad viewers, teens and kids will be more into the website design. Looking at the following screen shots of the facts pages on the “truth” and “Small Step” campaign, it is easy to see which one is more appealing to teens.<br /> <br />Figure 3 www.thetruth.com <br /><br />Versus:<br /><br /> <br />Figure 4 www.smallstep.gov <br />Another way to appeal to more people is through the use of more technology. A study (12) found that text messages were shown to be highly effective and used in several ways: to promote interaction with the intervention, send motivational messages (e.g., reminders of the benefits of exercise), challenge dysfunctional beliefs, or provide a cue to action. Use of communicative functions, especially access to an advisor to request advice, also tended to be effective. It may be that, although the Internet provides a suitable medium for delivering interventions, personal contact via email, online, or text message helps to support behavior change. <br />Solution 2- Marketing Healthy Behaviors <br />Social marketing of health behavior change posit that educational interventions may help to improve motivation to change, but that better opportunities for healthy behavior are needed to move people to action. (13). Findings suggest that in contexts like physical activity, condom use and recycling, negative messages about non-enactment will be inherently less efficient than positive messages about enactments. In contrast, in substance abuse-related contexts, the use of positive messages will be inherently less efficient than negative messages due to the negated linguistic form of the target, anchoring concepts denoting non-enactment. (13). While the consumeR campaign with not directly focus on physical activity and labeling people with being active, it will focus on encouraging people to not fall prey to big food chain advertisements by thinking for themselves. <br />One possible solution to the inefficiency problem is to utilize affirmative brand names to anchor associations with non-enactment concepts. A predominate example of this strategy is “truth” campaign, which was intended to establish “truth” as an aspirational nonsmoking brand. (14). Teens’ social images of smoking (e.g., promoting the appeal of nonsmoking as a way of achieving a desired personal image of independence or rebelliousness) appears to be a useful framework within which to understand intended campaign effects. Evaluation of the campaign’s effectiveness suggests that “truth” has affected social imagery about nonsmoking, achieved high brand equity among its target audience, and contributed to reduced rates of smoking initiation. (15). In other words, blame company instead of yourself. <br />The campaign should have people revolting against the ridiculousness of unhealthy food commercials since they have been shown to increase food consumption. Therefore, the campaign that sells exercise, as way for people to maintain their freedom and youth will be successful because it focused not on the product but on the desires of the audience. Key core ideals that people do not want taken away include youthfulness and freedom.<br />Solution 3 – Social Support and Environment Addressed <br />To assist people working to live healthier lifestyles, the Integrated Theory of Health Behavior change has been found (16) to be helpful. The ITBC is an integration of past successes and makes substantive contributions to understanding health behavior by combining knowledge and beliefs, self-regulation processes, and social facilitation. According to this theory, persons will be more likely to engage in the recommended health behaviors if they have information about and embrace health beliefs consistent with behavior, if they develop self-regulation ability to change their behavior, and if they experience social facilitation that positively influences and supports their engagement in preventative health behaviors. <br />Knowledge and belief systems impact behavior-specific self-efficacy, outcome expectancy, and goal congruence. Self-regulation is the process used to change health behavior and includes activities such as goal setting, self-monitoring and reflective thinking, decision making, planning for and engaging in specific behaviors, and self-evaluation and self-managing physical, emotional, and cognitive responses associated with health behavior change. Social facilitation includes the concepts of social influence, social support, and negotiated collaboration between individuals and families and healthcare professionals. <br /> Figure 5: Integrated Theory of Health Behavior Change (16).<br />Another study found that one of the strongest correlations with a child’s BMI was a parent’s BMI. (17). Since the environment in America is so commercialized with a heavy emphasis on food, the social norms and environment must be accounted for in obesity intervention. Although altering American social regarding fast-food will not be an easy task, a website that challenges these norms will be a good start. Members will be a part of a rebellious group going up against food companies that prey on their vulnerabilities. <br /> Competing against huge corporations that have succeeded in controlling the emotions of a majority of Americans is a difficult task. However, the “consumeR” campaign will draw attention to unnoticed unhealthy behaviors by highlighting the absurdity of food advertisements. Social support is given through a fun and resourceful website with forums and text/email motivation. The “consumeR” campaign will draw attention to the lack of thought that Americans put into food and exercise choices. The campaign’s revelation that people are merely blind consumers getting tricked into making harmful personal choices by the advertisements of multibillion-dollar food companies will motivate rebellion. Furthermore, allowing people who never considered themselves as unhealthy - merely because they are not obese- to think differently, will be a huge benefit in setting them on healthier paths and preventing a worsening obesity epidemic in America. <br />REFERENCES <br /><br />1. Bean, M. K., Stewart, K., & Olbrisch, M. E. Obesity in america: Implications for clinical and health psychologists. Journal of Clinical Psychology in Medical Settings 2008; 15(3): 214-224.<br />2. Woods, C., Mutrie, N., & Scott, M. Physical activity intervention: A transtheoretical model-based intervention designed to help sedentary young adults become active. Health Education Research 2002; 17(4): 451-460. <br />3. Barrett, B. S. An application of the transtheoretical model to physical activity. Ph.D. dissertation, University of Minnesota, United States -- Minnesota. 2007. Retrieved December 3, 2010, from Dissertations & Theses: Full Text.(Publication No. AAT 9815016).<br />4. Marcus, B. H., Eaton, C. A., Rossi, J.S., & Harlow, L. L. Self-efficacy, decision-making, and stages of change: An intergrative model of physical exercise. Journal of Applied Social Psychology 1994; 24:489-508. <br />5. Gollwitzer, P.M. Implementation intentions: strong effects of simple plans. American Psychologist 1999; 54: 493-503. <br />6. Powell, L. M., Szczypka, G., & Chaloupka, F. J. Adolescent exposure to food advertising on television. American Journal of Preventive Medicine 2007; 33(4, Supplement 1): S251-S256.<br />7. Harris, J. L., Bargh, J. A., & Brownell, K. D. Priming effects of television food advertising on eating behavior. Health Psychology 2009; 28(4): 404-413. <br />8. Harris, J. L., Brownell, K. D., & Bargh, J. A. The food marketing defense model: Integrating psychological research to protect youth and inform public policy. Social Issues Policy Review 2009; 3(1): 211-271. <br />9. Harnack, L. J., French, S. A., Oakes, M., Story, M. T., Jeffery, R. W., & Rydell, S. A. Effects of calorie labeling and value size pricing on fast food meal choices: Results from an experimental trail. International Journal of Behavioral Nutrition and Physical Activity 2008; 5(63). <br />10. Castro, F. G., Shaibi, G. Q., & Boehm-Smith, E. Ecodevelopmental contexts for prevention type 2 diabetes in Latino and other racial/ethnic minority populations. Journal of Behavioral Medicine 2009; 32(1): 89-105. <br />11. Kolodinsky, J. & Reynolds, T. Segmentation of overweight Americans and opportunities for social marketing. International Journal of Behavioral Nutrition and Physical Activity 2009; 6(13). <br />12. Webb, T. L., Joseph, J., Yardley, L., & Michie, S. Using the Internet to promotes health behavior change: A systematic review and meta-analysis of the impact of theoretical basis, use of behavior change technique, and mode of delivery on efficacy. Journal of Medical Internet Research 2010; 12(1): e4. <br />13. Brug, J., Conner, M., Harré, N., Kremers, S., McKellar, S., & Whitelaw, S. The transtheoretical model and stages of change: A critique. observations by five commentators on the paper by adams, J. and white, M. (2004) why don't stage-based activity promotion interventions work? Health Education Research 2005; 20(2): 244-258. <br />14. Freeman, D., Shapiro, S., Brucks, M. Memory issues pertaining to social marketing messages about behavior enactment versus non-enactment. Journal of Consumer Psychology 2009; 19(4): 629-642. <br />15. Evans, W. D., Wasserman, J., Bertolotti, E., Martino, S. Branding behavior: The strategy behind the Truth campaign. Social Marketing Quarterly 2002; 8: 17-29. <br />16. Ryan, Polly. Integrated theory of health behavior change: Background and intervention development. Clinical Nurse Specialist 2009; 23(3): 161-172. <br />17. Elder, J. P. et al. Individual, family, and community environmental correlates of obesity on Latino elementary school children. Journal of School Health 2010; 18(1): 20-31.Christinehttp://www.blogger.com/profile/14848177219392201947noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-12887464758797309962010-12-16T18:28:00.000-08:002010-12-16T18:31:49.829-08:00Critique of the Delaware Based Public Health Campaign to Reduce Childhood Obesity: Potential Weaknesses in the Application of . . .. . . Ecological Perspective Theory – Beth Morse<br /><br />INTRODUCTION<br />The Delaware based Nemours Health and Prevention Services (NHPS) 5-2-1-Almost None intervention describes itself as a social marketing campaign that fights childhood obesity (1) yet it fails to adequately influence the public to develop healthy behaviors. The intervention appears to be based on an Ecological Perspective approach described by McLeroy et al. (1988) as an overarching public health approach that includes interpersonal, intrapersonal and community levels of intervention (2). The NHPS campaign fails at each level of intervention to make an impact on the lifestyle choices of families and children.<br /><br />BACKGROUND: Nemours Health and Prevention Services 5-2-1-Almost None Campaign and Ecological Perspective Theory<br />The NHPS campaign to fight childhood obesity is a multiyear statewide campaign to improve the health of children in Delaware through policy change and social marketing for lifestyle improvement (1). The campaign promotes itself using the slogan “5-2-1-Almost None.” The numbers stand for 5 servings of fruit and vegetables a day, no more than 2 hours of screen time per day, 1 hour of physical activity, and almost no sugary beverages,” (1). The program reaches out to caregivers and policy makers with the message that children cannot develop healthy habits on their own and that they need adults to help. The campaign is split into two main parts; the first part focuses on policy and practice changes while the second part provides resources and tips to help caregivers teach their children to live a “5-2-1-Almost None” lifestyle. The teaching materials are not spread by NHPS itself but are made available online for groups or organizations who can use the resources to educate the public on a healthy lifestyle (1). The program advertises itself through billboards and radio adds that send the message ‘Children cannot do it alone, they need our help to live a healthy lifestyle,’ (1). The website does not appear very user friendly to the public but does offer a link for kids to play video games or watch episodes of The Mighty Timoneers, a group of cartoon pirates who battle a candy filled Sea and learn to eat healthier diets (1). Along with the cartoon program, the NHPHS website offers other useful materials for educating children and families on healthy lifestyle behaviors.<br />The major flaw in the NHPS campaign is that it fails to market itself in an effective manner. The campaign attempts to advertise itself through billboards and radio ads so that other groups will pick up the message and send out the educational materials thus creating a social network for the public health intervention. The problem here is that NHPS fails to adequately reach these social groups. Beyond the basic marketing failure of this campaign, the intervention is based on a combination of faulty social science theories. There are holes in the multiple social science theories upon which the Ecological Perspective theory bases its approach. <br /> The NHPS intervention is based on an ecological perspective theory that encompasses multiple levels of intervention including intrapersonal, interpersonal and community (2,3). The goal is to change the physical and social environment that surrounds diet and physical activity in Delaware by influencing personal, social and community attitudes towards adopting healthy behaviors. An analysis of the NHPS campaign finds that intrapersonal attitudes are targeted with the health belief model, interpersonal attitudes are targeted with social learning theory, family relationships, and modeling, and finally community attitudes are targeted with organizational policy changes. There are failures within the basic social theory upon which each of these three levels are based. This paper will examine these failures.<br /><br />INTRODUCTION TO THE CRITIQUE <br /> The NHPS intervention is based upon an Ecological Perspective Theory (2). The basic assumption of the theory is that changes in the social environment will lead to changes in the individual and that individuals should be supported within the population in order to implement the environmental change (2). This applies to the NHPS intervention because the goal of the intervention is to change the social environment to bring about an individual’s focus on healthy lifestyle behaviors, and then to have those individuals support an increase in health behaviors and activities within the community. <br />There are three levels of analysis in the ecological theory that can be applied to the NHPS intervention: intrapersonal, interpersonal and community. The theory operates under the assumption that each level of analysis is based on existing effective psychological theory of health promotion. The basic failure of the NHPS intervention is that it fails to use adequate and effective social theory on each level of behavior change. The NHPS program fails to change the social environment because the basic theories upon which it is based are inappropriate for the intervention. <br /><br />CRITIQUE #1: Failure to Reach Individuals at the Intrapersonal Level of the Ecological Perspective Theory though the Health Belief Model <br />As described by McLeroy et al., (1988) the Ecological Perspective Theory suggests that public health interventions should aim to change individuals at the intrapersonal level before there can be changes at the interpersonal and community levels. The NHPS intervention uses the Health Belief Model (4-8) to target caregivers and children at the intrapersonal level regarding their knowledge and beliefs toward a health behavior. This marks the first failure of the NHPS intervention. The Health Belief Model is ineffective in targeting caregivers and children because it cannot adequately address all of the contextual issues surrounding the audience and is unable to reach or influence the irrational element of human behavior (4-8). <br />The basic postulates of the health belief model as it is applied to the NHPS intervention are described below (2,4). It is important to note that the intervention takes the Model one step further by convincing caregivers that the health of their child is at risk, and using the caregivers to change the child’s behavior. The model applies to the NHPS campaign as follows: <br />o The individual must perceive that his/her child is susceptible to the poor health outcomes that may be caused by poor lifestyle behaviors and resulting obesity (2,4-8).<br />o The individual must perceive that poor diet and inadequate physical activity can lead to childhood obesity and that obesity can be a serious health threat (2,4-8).<br />o The individual must perceive that there is a low barrier cost in helping their children develop healthy lifestyle behaviors (2,4-8).<br /><br />As seen in other interventions, the Health Belief Model contains certain limitations that contribute to failure of the model (8-10). A basic assumption, and weakness, of the Health Belief Model is that all people carry a central set of core values and will react rationally to information that targets these values (8-10). The NHPS campaign relies on the Health Belief Model in its assumption that the provision of information should be enough to convince caregivers that their child is at risk for poor health outcome (5). However, researchers have found that presentation of information does not always lead to intention. According to Thomas (1995) the Health Belief Model operates under the faulty assumption that all people will be similarly affected by the use of traditional scientific fact. It is not surprising that the NHPS campaign fails to create an ‘it could happen to my child’ attitude in the caregivers because the Model assumes that all people share the same value system for health and will respond uniformly to a traditional scientific approach (8). A better intervention would take the value systems of sub-units of the population into account before attempting to reach people at a statewide level.<br />Thomas (1995) cited that one of the assumptions underlying the Health Belief Model is that it only considers knowledge to have been gained if the behavior has been changed. This infers all adults will be changed once they learn that a behavior can affect their health. The faultiness of this approach is evident in the NHPS campaign where scare-statistics were cited to convince caregivers that their child needs a health intervention (1). The campaign provides this information to the caregivers with the intent that it will then relate the health issue, childhood obesity, to be something that is relevant to their own children’s health (3). The campaign fails to address the potential effect of environment context where individual subgroups may operate with unique core values (3).<br />Assuming that some people may respond straightforward effort of the NHPS campaign, the Health Belief Model remains ineffective because it does not provide sufficient motivation for caregivers to perceive their children as highly capable of improving their lifestyle choices. The Health Belief Model postulates that individuals will change their behavior when they hold the belief that following a certain health recommendation will reduce the risk of a perceived threat and that there is a low cost to implementing the new behavior (3). The NHPS intervention teaches caregivers that their children are at risk for poor health outcomes and that following the 5-2-1-Almost None model will reduce their risk of disease. The intervention operates on the basic assumption of the Health Belief Model that if the caregivers believe that there is a low barrier cost to changing behavior that they will work with their children to improve lifestyle choices. This aspect of the Health Belief Model is inappropriate for the NHPS intervention because it fails to address social or political barriers that may prevent some subsets of the population from seeking healthcare and other health behaviors (9,10). For example, some subsets of the population may be less likely to seek policy change within their schools or for available spaces for physical activity (3). The campaign must address these issues instead of assuming that all children have access to nutritious food and spaces for recreation.<br /><br />CRITIQUE #2: Failure to Reach Individuals at the Interpersonal Level of the Ecological Perspective Theory <br />According to McLeroy et al. (1988), the Ecological Theory assumes that interventions at the interpersonal level will occur when social relationships have an influence on attitude and behavior change. The NHPS intervention focuses its interpersonal intervention on two elements. The first targets caregivers through relationships with caregivers who desire a healthy lifestyle for their child. The second is an interpersonal intervention using Modeling theory through the Mighty Timoneers interactive video games. The intervention fails to produce the appropriate interpersonal influence to create a sustained behavior change in children.<br />The interpersonal sector of the Ecological Perspective theory can only be effective if individuals are affected at the intrapersonal level before moving on to influence others at the interpersonal level (3, 5). The hypothesis that parental influence will lead the child to develop healthy behavior is based on the assumption that the caregivers were adequately influenced by the information provide by NHPS to make a change in their child’s lifestyle (5). As discussed in critique #1, this may not necessarily be the case. The failure to change behavior on one level may reduce the effectiveness of the intervention as a whole (3). For purpose of critiquing of the interpersonal approach, we will assume that the intrapersonal level of the intervention was effective.<br />The campaign attempts to target children at the intrapersonal level by using Social Learning Theory in networked video games where the child observes a social norm among cartoon children whose health behavior they can model (1,5). Social Learning Theory is used in the Mighty Timoneers video to accomplish behavior change through the child’s expectancies and incentives (5). The theory is intended to influence an individual’s expectancies about how a behavior may affect a certain health outcome and to convince the individual that they are capable of achieving that behavior change (5). The theory takes into account the factor of self-efficacy, reinforcement from past behaviors, and modeling those who have performed the behavior (5). The Mighty Timoneers video teaches children to model cartoon characters who are capable of fighting off the evils of unhealthy foods by being physically active and eating fruit and vegetables (1). Although the interactive video program may enforce some aspects of social learning theory, such as modeling the character’s behaviors and incentives for children to gain experience through food trials (5), it fails to address what may happen when the children are confronted with others who have not been exposed to the intervention. As described in Marks (1996) critique of the Social Learning Theory, the theory focuses too heavily on the individual and fails to take the effect of social and environmental context into account.<br />The NHPS video creates an influential social context within the parameters of population who plays the video game but fails to take outer social networks into account. McLeroy et al (1988) point out that a common flaw in public health interventions is that they often use interpersonal theory to change behavior through social influences while interventions may do better if they focus on changing the norms or social groups to which individuals belong. The NHPS campaign attempts to change the social norm by offering the Mighty Timoneers video to a wide social network that could potentially have an influence over the broad social environment of children in Delaware. However, because the intervention was not adequately marketed, it fails to compensate for what may happen when the child returns to siblings, classmates, or family who may continue to serve as an influence toward unhealthy behaviors. <br /><br />CRITIQUE #3: Failure of Ecological Perspective Intervention to Address Social Influences at the Community Level<br />The NHPS campaign attempts to influence policy in Delaware for improving nutrition in school lunches and expanding locations for physical activity. The campaign uses little advertising and appears to rely on theories such as the Diffusion of Innovation Theory to spread its message across the state. The intervention fails because it does not support the maintenance of existing networks of communication and fails to create awareness within social networks and norms (3).<br />The environmental phase of the ecological perspective includes an intervention that aims to change organizations in order to support individual behavior changes (3). As previously discussed, the ecological perspective model is built so that the efficiency of one level of the model is dependent on those that come beforehand. McLeroy et al. (1988) suggest that the effects of interpersonal relationships are the first step to changing behavior through environment because interpersonal relationships exist outside the individual and can lead to implementation of changes in the community. <br />The basic failure of NHPS at the community level intervention is that its message was not properly diffused. For example, members of the community may not be aware of supplemental opportunities for physical activity even if they do exist. A study by Cevita & Dasgupta (2007) examined the use of the Diffusion of Innovation Model for development of a diabetes management program. The authors found that this model can only be effective if there is a maintenance of the network from which the information was first diffused (12). In other words, if the early adopters of health behaviors fail to communicate their achievements, the intervention will go nowhere. In the NHPS example, a neighborhood association who creates a recreational space but does not communicate their achievement to other communities is not helping propel the behavior change across the state. If there is no tipping point (12), then those who have not yet adopted the change may fail to do so.<br /><br /><br />ALTERNATE APPROACH: Improving the NHPS Intervention<br />The NHPS intervention can be considered a strong campaign because it is based on Ecological Perspective Theory, which combines multidisciplinary efforts at the individual, social and community level (5, 11). There are weaknesses, however, in using this Ecological Perspective. The overarching issue is that the approach is dependant upon the campaign having had an effect on the individual level before it can affect the interpersonal and then community level. The campaign will not work if it targets only the community but fails to have a strong foundation in its effect on the individual or interpersonal level. There are areas within each of these three phases that need improvement before the campaign can be effective. The following proposal will describe alternate approaches to reach children and caregivers at the intrapersonal, interpersonal and community levels. These approaches include: introducing Optimistic Bias, creating new social relationships, and introducing the ‘social’ in a Socioecological Theory. <br /><br />DEFENSE OF NEW INTERVENTION #1: Use Elements of Optimistic Bias as well as the Health Belief Model to Support Behavior Change <br />The intrapersonal element of the NHPS ecological approach should be expanded to include Optimistic bias (13) to the Health Belief intervention in order to effectively influence caregivers to initiate behavior change. The health belief model assumes that if caregivers believe their child is at risk for poor health, they may make a change. If Optimistic Bias is introduced to the intervention, then the caregivers will become overly optimistic that they are capable of using the available resources to help improve their child’s chance for a healthy life. This optimism can serve as the spark to ignite a behavior change among families and children.<br />Weinstein (1980) cites that individuals tend to be unrealistically optimistic about future life events if they perceive the event as highly desirable, probable, and controllable. The author also cites that an individual may have optimism about an event based on prior experiences (13). This theory can be used to influence caregivers and children to become optimistic about their ability to improve their health through lifestyle behavior change. For example, the intervention can remind a caregiver who has had successful weight loss in the past that their child may be able to easily follow in their footsteps. The intervention should send the message that caregivers can easily control their child’s health behaviors and that this will increase the probability for a healthy and happy life. If caregivers and children believe that they can easily achieve a healthy lifestyle then they may be motivated to begin to make the necessary behavior changes. Some health behavior studies have shown that people are often intimidated by the amount of effort that they perceive is required to improve health (14,15). If the intervention can implement optimistic theory to supplement the health belief model, then this will lower the perceived barriers to entry (8) and may motivate caregivers and children to initiate a change in behavior that could ultimately lead to a healthier life.<br /><br />DEFENSE OF NEW INTERVENTION #2: Create a New Social Role for Children<br />According to McLeroy et al. (1988), Ecological Theory should aim to change the nature of existing interpersonal relationships so that the relationship can become one that nurtures healthy behavior. The current NHPS intervention aims to create a nurturing relationship between caregivers and children, but has failed to make a difference. This lack of change can be traced back to the fact that caregivers are not properly influenced at the intrapersonal level to actively try to help their children improve healthy behaviors. A solution for this could be to target both the children and caregivers to change their interpersonal relationship, and not just the caregivers. It might be mutually beneficial if both the caregivers and children are pushing each other toward a healthy lifestyle.<br />McLeroy et al. (1988) suggest that social relationships can provide access to new social roles and that social interactions can have an influence on attitude and behavior change. This can be observed in the NHPS intervention where caregivers are urged to develop a social role where they help their child develop healthy lifestyle behaviors. Children are given the opportunity to create a role for themselves where they can choose to perform health behaviors by modeling the cartoon characters from The Mighty Timoneers (1). Yet the intervention fails to produce adequate social influence to maintain behavior change. A new intervention should capitalize on the effect of social relationships and role-playing by allowing the children to create a new social role for themselves where they influence their caregiver and/or peers. This new social role will create a reciprocal relationship where the child is influencing others while at the same time creating a space for social support within the group.<br />The interactive Mighty Timoneers video can be a useful aide for implementing social behavioral theories to improve health behaviors of children if it reaches children in the correct manner. According to Leiberman (1992), properly implemented video games have been found to improve mediating factors for health behavior change among children. One of the factors that Leiberman (1992) mentions is that the game should improve the communication that a child has with their peers and caregivers who can provide social support for making the behavior change. A good way ensure that a peer or caregiver can provide the necessary social support is to create a mutually supportive relationship where the child can motivate the caregiver or peer with the new information while gaining personal health motivation from that relationship. Research has found that direct experience, such as role-playing, can strengthen the relationship between a newly developed attitude towards health and the health behavior (17). Perhaps children can improve upon their lifestyle choices by role-playing as the teacher to influence others around them as well as reinforcing their personal attitude toward health behaviors.<br /><br />DEFENSE OF NEW INTERVENTION #3: Introduce Social Elements to Ecological Perspective Theory via Socioecological Theory <br />The ecological perspective is useful in that it encompasses a wide range of behavior change theories at various personal and community levels of the population (18). The NHPS program should continue to use the Ecological Perspective Model, but supplement it by combining a sociological model. Stokols (1996) describes a Socioecological Theory as it applies to community health promotion. The Socioecological Perspective Theory operates under the assumption that health is a product of the relationship between individuals and the environment (17). As previously discussed, an individual benefits when there is a mutual relationship where he or she is able to influence others toward taking up a health behavior while reinforcing the behavior on a personal level. This can be expanded to the community level where the individual can develop a neighborhood exercise program as a way to participate in making a difference. This is mutually beneficial for the individuals and the community and, if communicated properly, can expand on itself through the Diffusions of Innovation Model described in the above critique. The goal is to give the individual a personal attachment to the changes in their community so that they will want to spread those achievements on a public level (17).<br />According to McLeroy et al., (1988), interventions can effectively promote health by creating opportunities for large groups of people to gain access to the health behavior in the space where they spend most of their time. It might be useful if the campaign to introduces voluntary organizations within neighborhoods and communities to create opportunities for physical activity such as kickball teams and more.<br /><br />CONCLUSION<br />A new intervention should maintain the strengths of the Ecological Perspective Model by continuing to target the campaign at the intrapersonal, interpersonal, and community levels (3). Critiques of the Ecological Perspective Model cite that it assumes interventions are effective at each level of the ecological framework. (3,17). As described in the defense of the new intervention, social influence can broadly affect the community at both large and small interpersonal and group levels. It may be useful to introduce more of a social focus to the ecological perspective theory. <br />A Socioecological Perspective Theory may be more effective than a basic Ecological Perspective Theory. In the future, public health professionals who use this approach should keep in mind that if done correctly, the Socioecological Perspective can be very influential but that it is important to ensure that each level of the intervention is effective. <br /><br />REFERENCES:<br />1. Nemours Health and Prevention Services. 5-2-1-Almost None. Newark, Delaware. Nemours Children’s Health System. <br />2. McLeroy KR, Bibeau D, Steckler A, & Glanz, K. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly, 1988; 15, 351-377<br />3. Stokols, D. Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion, 1996; 10, 282-298.<br />4. Rosenstock IM. Historical Origins of the Health Belief Model. Health Education Monographs. 1974; 2,(4).<br />5. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education Quarterly. 1988; 15(2), 175-183<br />6. Marks DF. Healthy psychology in context. Journal of Health Psychology 1996; 1:7-21<br />7. Edberg M. Essentials of Health Behavior. Social and Behavioral Theory in Public Health. 51-54<br />8. Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995; 11:246-252.<br />9. Cotton D. A comparison of protection motivation theory and the health belief model for explaining smoking cessation [e-book]. US: ProQuest Information & Learning; 1994. Available from: PsycINFO, Ipswich, MA. Accessed November 28, 2010.<br />10. Knight R, Hay D. The relevance of the Health Belief Model to Australian smokers. Social Science & Medicine [serial online]. 1989;28(12):1311-1314. Available from: PsycINFO, Ipswich, MA. Accessed November 28, 2010.<br />11. Marks DF. Healthy psychology in context. Journal of Health Psychology 1996; 1:7-21<br />12. Cevita MD, Dasgupta K. Using diffusion of innovations theory to guide diabetes management program development: an illustrative example. Journal of Public Health. 2007; 29(3): 263-268.<br />13. Weinstein ND. Unrealistic optimisim about future life events. Journal of Personality and Social Psychology 1980; 39:806-820<br />14. Kreitler, S. Cognitive orientation and health-protective behaviors. International Journal of Rehabilitation and Health; 1997 3(1).<br />15. Baranowski, T. Beliefs as Motivational Influences at Stages in Behavior Change. International Quarterly of Community Health Education. 1992; 13(1).<br />16. Lieberman, D.A. Interactive video games for health promotion: Effects on knowledge, self- efficacy, social support, and health. Mahwah, NJ: Lawrence Erlbaum Associates<br />17. Jackson, C. Behavioral Science Theory and Principles for Practice in Health Education. Health Education Research. 1997; 12(1).<br />18. Edelman & Mandle. Health Promotion Throughout the Lifespan. St. Louis, Missouri: Elsevier, 2006Christinehttp://www.blogger.com/profile/14848177219392201947noreply@blogger.com1tag:blogger.com,1999:blog-8980458958375309252.post-90203373137725884412010-12-16T18:27:00.000-08:002010-12-16T18:28:43.368-08:00A Critique on Abstinence-Only Sexual Education –Stephanie HortonIntroduction:<br /> The federal government has been supporting abstinence programs since 1981 when the Adolescent Family Life Act was implemented, but since 1996, there have been major expansions in federal support for abstinence programming and a shift to funding programs that teach only abstinence and restrict other information (1). In fact, federal funding for abstinence-only programs has increased from $60 million in 1998 to $168 million in 2005 (1). <br /> Abstinence, as defined by policy makers, is not often clearly defined. In behavioral terms, abstinence is defined as “postponing sex” or “never had vaginal sex,” or refraining from further sexual intercourse if sexually experienced. Other sexual behaviors may or may not be considered within the definition of “abstinence,” including touching, kissing, oral sex, mutual masturbation or anal sex (1). Abstinence, according to government policies and local programs, is often described in ethical terms, using phrases such as “chaste” or “virgin” and framing abstinence as a positive attitude or commitment. A study by Goodson et al. found that abstinence-only educators in Texas and the youth in abstinence-only programs defined abstinence in moral terms, such as “making a commitment,” and “being responsible” (2). Overall, the term is often confusing and loaded with insinuation, which adds to the controversy it bares in abstinence-only sexual education programs. <br /> While many schools in the United States provide sexual education consisting of both education about abstinence as well as other forms of birth control and sexually transmitted infection (STI) prevention, a number of curriculums in the U.S. continue to employ “abstinence-only” sexual education. Under the Welfare Reform Act Title 5 Section 115, abstinence-only sexual education must teach that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, STI, and other associated health problems, and no other form of sexual education is permitted (1). In Corpus Christi, Texas, the Communities In Schools (CIS) program implements abstinence-only programs that target the prevention of teenage pregnancy and premarital sexual activities by using three components including case management, curriculum, and parental involvement (3). The curriculum, called Choosing the Best, and its educational materials taught to adolescents 12-18 years old are consistent with Title 5 Section 115 Federal Guideline in that it teaches abstinence only. This program serves the following school districts in Texas: Corpus Christi Independent School District, Flour Bluff Independent School District, Tuloso-Midway Independent School District, Calallen Independent School District, West Oso Independent School District, Gregory-Portland Independent School District and Sinton Independent School District (3). Students enrolled in schools in these districts will receive the abstinence-only sexual education, which does not include education about contraceptive use and does not provide guidelines on how to practice safe sex. <br /> This abstinence-only sexual education program is flawed in three major ways. First, abstinence is not 100% effective in preventing pregnancy or STIs as many teens fail in remaining abstinent. Secondly, the current federal approach focusing on abstinence-only raises serious ethical and human rights concerns. Finally, the implications of abstinence-only programs on the gay, lesbian, bisexual, transgender (GLBTQ) population may have adverse and potentially fatal outcomes. This paper aims to critique the abstinence-only sexual education public health initiative and will provide an alternative strategy for a sexual education curriculum for adolescents aged 12-18 years old. <br /><br />Abstinence is not 100% Effective<br /> It is not only misleading, but also potentially harmful to imply that abstinence from sexual intercourse is fully protective against pregnancy and sexually transmitted infection. This concept confuses theoretical effectiveness with actual practice. In other words, abstinence is not in fact 100% effective, because those who take a vow of abstinence often fail. In fact, most Americans initiate sexual intercourse during their adolescent years, the mean age for females being 17.4 and for males 17.7 (4.). Moreover, some STIs may be spread via other forms of sexual activity, such as kissing or manual or oral stimulation (1). The most useful data in understanding the efficacy of abstinence come from the National Longitudinal Survey of Youth (Add Health), which examines virginity pledgers and their adherence to abstinence (5-6). This data suggests that many teens who intend to remain abstinent, fail to do so, and that when abstainers do initiate intercourse, many fail to protect themselves with contraception (5-6). The study conducted a 6 year follow up during which the authors found that the prevalence of STIs was similar among those who took the abstinence pledge and those who did not (6). Therefore, pledging abstinence is not necessarily a 100% effective measure, and in fact, those who do not receive information about contraception but are educated on abstinence-only are actually put at increased risk. <br /> In 2006, the Academy of Pediatrics released a position statement on sexual education. This statement concludes that adolescents are constantly exposed to sexual messages in the media, including social networking sites, television, movies, magazines and internet sites. The paper explains that American children and teenagers spend more than 7 hours per day with a variety of different media that contains sexual messages (7). According to the authors, the most recent studies on adolescent sexual behavior and media influences have resulted in four main conclusions: 1) Listening to sexually degrading lyrics is associated with earlier sexual intercourse, 2) Black female teenagers’ exposure to rap music videos or X-rated movies is associated with the likelihood of multiple sexual partners or testing positive for an STI, 3.) Teenagers whose parents control their TV-viewing habits are less sexually experienced, and 4.) Exposure to sexual content in the media is a significant factor in the intention to have sex (7). All adolescents are exposed to this type of media. Therefore, those who are receiving abstinence-only education are put at a disadvantage, because as the Add Health data suggested, teens rarely remain abstinent and if they did not previously receive education about other forms of contraception, they are less likely to protect themselves during sexual activity. <br /><br />Abstinence-only Education is Unethical<br /> It is a paradoxical observation that while abstinence education is often based on morality, the current federal approach on abstinence-only education is ethically flawed. The U.N. Committee on the Rights of the Child has emphasized that children’s right to access adequate sexual health information is essential to securing their rights to health and information (8). Therefore, since the federal approach to abstinence-only education prevents sexual education about contraceptive use as well as gay sexual education, it can be concluded that abstinence-only programs violate basic human rights. This type of sexual education does not provide the full spectrum of information that adolescents, and all people, have the right to learn. If a student in one of the Texas school districts under the abstinence-only curriculum desires knowledge about contraceptive use or safe sex practices, that student has to seek educational material out of the school. Not only will these children feel moral conflictions but often these adolescents will be unaware of the resources available as they are only being taught one form of sexual behavior: 100% abstinence from sex.<br /> Governments have an obligation to provide accurate information to their citizens, and by omitting an important part of sexual education, the abstinence-only program outlined by the federal government is putting thousands of students at risk. If the adolescent is not equipped with the proper tools to protect himself/herself, the teachers of that adolescent have perpetrated a serious ethical injustice. <br /> An international treaty called The International Covenant on Economic, Social and Cultural Rights specifically outlines the obligation of the government to provide its citizens with the information necessary for the “prevention, treatment, and control of epidemic…diseases,” such as HIV/AIDS (9). In additional to this international call for ethics, the United National Guidelines on HIV/AIDS and Human rights also provides guidance, “ensure that children and adolescents have adequate access to confidential sexual and reproductive health services, including HIV/AIDS information, counseling, testing, and prevention measures such as condoms” (10). The abstinence-only education programs are directly going against this guidance by not educating students about condom use and other preventative measures. <br /><br />Gay Lesbian Bisexual Transgender (GLBTQ) Population and Abstinence-Only Education<br /><br /> Abstinence-only sex education has the potential to have profound negative effects on adolescents of the GLBTQ population. As many as 1 in 10 adolescents struggle with sexual identity and abstinence-only classes are likely to ignore the needs of this population, as homosexuality is often stigmatized and viewed as deviant behavior in this curriculum (1, 11). Therefore, it is important to consider the effects of homophobia, which include health problems such as suicide, feelings of isolation and loneliness, HIV infection, substance abuse, and violence among GLBTQ youth (1). It is not far-fetched to conclude that abstinence-only problems may indirectly cause these feelings and/or conditions in the GLBTQ adolescent student. <br /> Under the federal requirement of abstinence-only education, emphasis must be placed on heterosexual marriage only and is defined as the only appropriate context for a sexual relationship. Lifelong abstinence as an implied alternative, therefore, holds this group of youth to an unrealistic standard which is extremely contrasting to that of their heterosexual peers. Not only does it put “moral” stress on these students, but it may teach them that their feelings toward sex are ethically wrong or even “grotesque,” and in some cases, sacrilegious. <br /> Those youth who live in the school districts in Texas where this abstinence-only program is being implemented are put at risk for these potentially fatal consequences which result from the nature of abstinence-only sexual education. <br /><br />A Flawed Social Behavioral Model<br /><br /> The Theory of Planned Behavior (TPB) behavioral model is a good tool to use when understanding the flaws of the abstinence-only education programs. This model explores the relationship between behavior and beliefs, attitudes, and intentions. The most important determinant of behavior according to this model is behavioral intention, which is influenced by a person’s attitude toward a behavior and by beliefs about whether individuals who are important to that person approve or disapprove of the behavior. This model also includes perceived behavioral control, meaning it assumes the person believes he/she has control over his/her behavior (12). The concept of perceived behavioral control is similar to the concept of self-efficacy. It describes an individual’s perception of his/her ability to perform the behavior and his/her control over the opportunities, resources, and skills necessary to perform that behavior. This is believed to be a critical aspect of this behavioral model (13). <br /> This theory can be applied to the goals of abstinence-only programs. These programs assume that adolescents will remain abstinent because 1.) Their attitudes and beliefs can be molded so that they feel abstinence is the only accepted form of sexual behavior, and 2.) They care deeply about the approval of their peers, parents, and teachers. The abstinence-only sexual education guidelines also assume that if adolescents receive education about abstinence-only, they can be influenced to perceive strong control over their own behavior, which has been shown to have an influential effect.<br /> This theory, as well as this curriculum plan, has limitations. First, the theory does not allow for decisions to change based on context and environment. In other words, students who receive abstinence-only sexual education may be influenced one way or another depending on their environment, such as sexual messages in popular media as The Academy of Pediatrics pointed out (7). Without acknowledging this fact, abstinence-only seems like it would work. However, realistically, these students are not likely to remain abstinent, and if they do not receive education about safe sex, they are more likely to suffer the consequences of unprotected sex compared to their counterparts who receive complete sexual education (4). <br /> TPB assumes that behavioral intention will lead to the behavior, but it does not consider the time between the behavior intention and the actual behavior (12). In other words, the abstinence-only program does not consider the time between the adolescent’s intention to behave a certain way and the actual way the adolescent behaves. As seen in the Add Health data, often adolescents who take the virginity pledge fail to remain abstinent (5). This is a major limitation in this type of sexual education and can be seen clearly when TPB is applied.<br /> This type of sexual education assumes that behavior is rational and static, a major limitation that is also seen in TPB. Adolescents are constantly changing, and their values are constantly molding. In their state of growth, behavior and attitude are anything but rational and static. Emotions are often elevated in these individuals, and so we cannot assume that when faced with the decision to remain abstinent, these adolescents will behave in the way they have been taught. This theory and plan simply ignore the adolescent’s feelings of rebellion and curiosity, thereby putting them at serious health risk. If these students learn nothing but abstinence as a form of sexual protection, they are not equipped with all the materials to keep them safe from the consequences of risky sexual behavior. <br /><br />Proposal for National Comprehensive Sexual Education<br /><br /> A safer, more reasonable and realistic approach to sexual education is a standardized comprehensive sexual education curriculum implemented nationally. This curriculum will include the following topics: abstinence, puberty and the changes that occur, contraceptive use, where/how to obtain contraceptives, instruction on condom use, access to condoms, information on “how babies are made,” sexually transmitted infections, abortion, masturbation, homosexuality and sexual identity, oral sex, and a complete guide to resources available to help students practice safe sex. <br /> Comprehensive sexual education should be available to all adolescents age 12 to 18 in all schools. The curriculum should cover each year these adolescents are in school and should remain current in its information and delivery. These programs should provide clear definitions of abstinence free of propaganda. This type of sexual education will make all sexual health information available to adolescents through the school system and will not discriminate based on sexual identity. <br /> Public polls have expressed a need for a national comprehensive sexual education curriculum. These polls suggest that while abstinence is certainly a favorable behavior goal for adolescents, there is strong national support for education about contraception and for access to contraception for sexually active adolescents (14-15). More specifically, data from these polls found that 90% of parents believe it is very or somewhat important that sex education be taught in school, and only 15% of parents wanted an abstinence-only form of sexual education. 99% of parents polled believed that it was appropriate to provide high school and middle school students with broad information on sexual issues, including STI, the physiology of pregnancy and birth, having intercourse at an older age, making responsible sexual choices based on individual values, how to use and where to get contraceptives, abortion, masturbation, homosexuality, oral sex, and 71% of parents believe that teens should be able to obtain birth control pills from clinics and doctors without parental permission (15). <br /> Over 800,000 adolescents become pregnant each year, and 80% of these pregnancies are unintended and/or end in abortion (16). In addition to these compelling statistics, an estimated 18.9 million STIs occur each year in the United States, and almost half of these cases occur in adolescents and young adults under the age of 25 (17). Long term consequences of STIs can include infertility, tubal pregnancy, fetal and infant demise, chronic pelvic pain, and cervical cancer (17). <br /> The statistics and polls mentioned are compelling to say the least. They not only demonstrate a need for a national curriculum of comprehensive sexual education, but also a widespread acceptance of sexual education among parents. As stated, only 15% of American parents want abstinence-only sexual education (15). That means that 85% of American parents are supportive of sexual education that includes a comprehensive overview of all available safe sex practices. Therefore, a national standardized program would be well received and would prevent teens from engaging in risky sexual behaviors.<br /> Two recent systematic reviews examined the evidence supporting abstinence-only programs and comprehensive sexual education programs. Both of these reviews demonstrated that comprehensive sexuality education effectively promoted abstinence as well as other protective behaviors among adolescents. Both reviews found no scientific evidence that abstinence-only programs demonstrate greater efficacy in delaying initiation of sexual intercourse. Therefore, a comprehensive sexual education program would not sacrifice any benefits that are believed to exist in abstinence-only programs.<br /> Although federal abstinence-only education funding language requires teaching that sexual activity outside of marriage is likely to have harmful psychological and physical effects, there is no scientific evidence suggesting that consensual sex between adolescents is harmful. There are no reports in the scientific literature that address whether the initiation of adolescent sexual behavior itself has an adverse impact on mental health (1). Therefore, it is not unreasonable to question the government’s focus on abstinence-only education programs. This emphasis on abstinence-only is not just ineffective, but it may also be harmful to other public health efforts such as family planning programs and HIV prevention efforts. A comprehensive approach to sexual education would actually enhance these programs and would not discriminate against GLBTQ youth the way abstinence-only programs do. <br /> Not only will national comprehensive sexual education provide teens with the necessary tools to prevent unwanted pregnancies and sexually transmitted diseases, but it will also allow parents to trust that their children are receiving complete educations through the school system. U.S. adolescents will have the knowledge they need to practice safe sex, and through the scientific literature discussed in this paper, it can be concluded that comprehensive approaches to sexual education do not lead to earlier initiation of sexual behavior. In fact, they have been shown to delay sexual behavior similar to or even more so than abstinence-only programs.<br /> It is strongly suggested that Title 5 Section 515 of the Welfare Act be amended to recommend comprehensive sexual education to all U.S. adolescents through the education system. By doing this, we will protect our adolescents from harmful sexual consequences. A comprehensive sexual education is more ethical, more effective, and less discriminatory than an abstinence-only program, and in this free country where we strive to fulfill the rights and needs of our citizens, it is the only appropriate form of sexual education for our nation’s children and adolescents. <br /><br />References<br /><br />1. Santelli J, Ott M, Lyon M, Rogers J, Summers D, Schleifer R. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 2006; 38;72-81.<br /><br />2. Goodson P, Suther S, Pruitt B, Wilson K. Defining abstinence: views of directors, instructors, and participants in abstinence-only until marriage programs in Texas. J Sch Health 2003;73(3):91-96<br /><br />3. Communities in Schools Website. http://www.ciscc.org/abstinence.cfm Accessed on December 4, 2010<br /><br />4. Abma J. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2002. Vital Health Statistics 2004;24:1-48.<br /><br />5. Bearman PS, Bruckner H. Promising the future: virginity pledges and first intercourse. American Journal of Sociology 2001;106:859-912<br /><br />6. Bruckner H, Bearman PS. After the Promise: the STD consequences of adolescent virginity pledges. Journal of Adolescent Health 2005;36:271-278<br /><br />7. Strasburger V. Sexuality, Contraception, and the Media. Pediatrics 2010;126;576-582. <br /><br />8. Committee on the Rights of the Child. General Comment No. 3 (2003a) HIV/AIDS and the rights of the child, 32nd Sess. (2003), para. 13. 2003. <br /><br />9. International Covenant on Economic, Social and Cultural Rights. Adopted December 16, 1966, entered into force January 3, 1976, GA Res. 2200A (XXI), 21 UN GAOR, 21st Sess., Supp. No. 16, at 49, UN Doc. A/6316 (1966)<br /><br />10. United Nations. Report of the International Conference on Population and Development (Cairo, 5-13 September 1994). New York; 1994. Report No.: A/Conf.171/13.<br /><br />11. Kemper ME. Toward a Sexually Health America: Abstinence-Only Until Marriage Programs that Try to Keep Our Youth ‘Scared Chaste’. New York, NY: Sexuality Information & Education Council of the United States, 2001. <br /><br />12. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. National Cancer Institute Website 2005;2:9-21. http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf Accessed on December 6, 2010.<br /><br />13. Refugee Well Being Website. Health Promotion and Disease Prevention: An introductory Article. http://www.refugeewellbeing.samhsa.gov/PDF/Toolkit/7_Health_Promotion_Article.pdf Accessed on December 6, 2010. <br /><br />14. Albert B. American Opinion on Teen Pregnancy and Related Issues. Washington DC: National Campaign to Prevent Teen Pregnancy 2004. <br /><br />15. Dailard C. Sex education: politicians, parents, teachers, and teens. Issues Brief 2001;2:1-4.<br /><br />16. Henshaw SK. U.S. Teenager Pregnancy Statistics with Comparative Disease Surveillance, 2003. Atlanta, GA: U.S. Department of Health and Human Services, 2004. <br /><br />17. Weinstock H, Berman S, Cates W. Sexually Transmitted Diseases among American Youth. Perspective on Sex and Repoductive Health. 2004;36:6-10.Christinehttp://www.blogger.com/profile/14848177219392201947noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-57951116184763026202010-12-16T18:25:00.000-08:002010-12-16T18:27:24.878-08:00The Boston Miracle: A Step, Not a Solution – Annette GIntroduction<br /> The intent of this paper is to critique The Boston Gun Project’s Operation Ceasefire public health intervention and offer theories on why aspects of the approach were flawed. Suggested alternatives to the intervention will be discussed as well as the applicable supporting social and behavior science principles. <br /><br />The Climate within Boston in the 1990’s<br />Like many large cities in the United States, Boston experienced an epidemic of youth homicide between the late 1980’s and early 1990’s. Homicide among persons ages 24 and under increased by 230 percent – from 22 victims in 1987 to 73 in 1990 – and remained high well after the peak of the epidemic. (6) Boston experienced an average of 44 youth homicides per year between 1991 and 1995. (6) Although 1990 marked the peak, the problems continued. Youth homicide rates remained at historically elevated levels and the streets were unsafe. In 1992, gang members invaded a memorial service of a rival gang member at the Morningstar Baptist Church and attacked mourners with knives and guns. (6) In a 1995 Centers for Disease Control (CDC) survey of 10 cities claimed 15 percent of Boston’s junior high school students sampled said that they had avoided school in the past month because they were scared – the highest such response rate among the cities surveyed. (6)<br />In early 1995, the National Institute of Justice provided a grant to fund the Boston Gun Project. The effort was initiated and guided by David M Kennedy, Anthony A Braga, and Anne M Piehl from the John F Kennedy School of Government within Harvard University. With cooperation from the Commissioner of the Boston City Police Department, the project was initiated to create an intervention via a problem-oriented policing initiative directed toward the issue of youth violence and homicide in Boston.<br /><br />The Research<br /> A working group was formed to research, evaluate and provide guidance on the strategy for the intervention. The group was diversified and included representation from Boston Police, The Youth Violence Strike Force (YVSF), Department of Youth Services (DYS) personnel, probation officers, school police, the US Attorney’s Office, the Office of the Suffolk Country District Attorney, the Boston Regional Office of the ATF, and Streetworkers. The Streetworkers were City of Boston social workers whose goals were to connect the most at risk youths to available services and mediate disputes. The Ten Point Coalition, a group of black ministry formed after the attack at the Morningstar Baptist Church, participated as well as members from the John F Kennedy School of Government.<br /> At the beginning, the initial thought process was that the problem could be tackled from two perspectives – the supply side and the demand side. Gun trafficking and other illegal means of acquiring firearms were considered the supply side while fear and other factors on the streets driving youth to acquire firearms would be considered the demand side. The data and research delivered from the Working Group forced a different view. The real problem was violence among chronic gang-involved offenders; it was mostly but not exclusively firearm violence and it wasn’t predominately juveniles but also offenders well into their 20’s. (6) Most of the incidents were not about drug trafficking or other business as initially thought. They were more personal and reflected long standing feuds between gangs. These conclusions forced the group to focus on the demand side of the equation.<br /> The Working Group started to focus on a historical police intervention that was driven by the YVSF targeting a gang on Wendover Street. It first appeared to be the classic crackdown strategy – one that put all attention and resources on the problem of gang violence in the Wendover street area and didn’t stop until peace finally resulted. There was one unique difference in the Wendover approach versus other crackdowns in the past – communication. The YVSF communicated clearly to the gang on Wendover Street why the crackdown was occurring and what would have to happen to make it stop. If the violence did not cease, the constant pressure would remain. The violence was eventually suppressed and the area had remained quiet for nine months. <br /> After much consideration, review of the data and utilizing the years of experience within the Working Group, the Wendover approach became the foundation for Operation Ceasefire.<br /><br />Operation Ceasefire<br /> From a public health perspective, Operation Ceasefire was a different approach to gang violence. The foundation was a powerful and strategic use of authority; not the usual facilitative strategy involving training for dispute resolution, violence prevention, etc. The operation had four basic levels of intervention available for use:<br />• Level One was a warning through forums or other means to a particular group or groups to stop the violence.<br />• Level Two was a near term street enforcement focused on a group delivered largely within the means of the YVSF and police department and potentially support from the other local agencies (probation, DYS, DA, other police) where deemed necessary.<br />• Level Three was the large, interagency, heavily coordinated operation that was apparent to the target group with sanctions on the State side.<br />• Level Four was for the groups that were both violent and deemed essentially unsalvageable resulting in undercover, gang-wide investigations making heavy use of Federal sanctions and designed to permanently dismantle the group. (6)<br /><br /> The “pulling levers” strategy of Operation Ceasefire was one that allowed law enforcement to use all the various resources available as appropriate for the target audience. It was designed to focus on the youth identified by the Working Group; the core of the city’s violence problem. This was a strong deterrence strategy. It advertised its ability to utilize all members of law enforcement and tailored its approach to a particular gang and its individual members.<br /><br /><br /><br />Flaws within the Operation Ceasefire Intervention<br /><br />Communication:<br /> In May of 1996, the Working Group convened their first communication forum held at the Dorchester Court House. The attendees included representation from all agencies involved in the Working Group plus others. DYS brought gang members out of confinement, still in restraints, and had them sit to the side of the discussion. Posters were displayed summarizing what had happened to either a specific individual or to the members of a particular gang. Each member of the Working Group explained their role and responsibility within the operation. For many in attendance, a sobering component of the meeting was the Federal presence. It was made clear that the operation had federal attention and resources such as the Federal Bureau of Investigation (FBI), Drug Enforcement Administration (DEA) and Bureau of Alcohol, Tobacco and Firearms (ATF) were on board with the new strategy. It was clear the violence was no longer a local matter and being found guilty on federal charges would carry much longer sentences with potentially no chance of parole.<br /> As evident via the Working Group and agencies involved, communication to the gang members was entirely authoritative. Even with the community involved, such as the Ten Point Coalition, the figureheads delivering the message were senior and most likely from a different socio-economic background. The gangs and the members of the Working Group had established relationships; many that were tenuous.<br /> Attachment 1 is an example of a flier that was distributed during the meeting at the Dorchester Court House. Freddie Cardoza was regarded by the Boston Police as one of the most dangerous gang members on the street. Cardoza was arrested by YVSF with one round of handgun ammunition in his possession. In an effort to both remove him from the street as well as make a statement to the other gang members about the effectiveness of the interdisciplinary forces, Cardoza was charged by the ATF and US Attorney’s office as an armed career criminal. As the poster shows, he was sentenced to 19 years and 7 months with no chance of parole. He was moved to a maximum security prison in New York. Visitation from his family and friends would be difficult.<br /> The challenge with this type of communication is the threat of backlash and rebellion. One component of the Psychology of Persuasion Theory revolves around the message learning approach. In accepting and receiving a message, there are four variables involved in one’s ability or willingness to fully grasp or want to grasp the message. (3) They are source, message, channel and recipient. As it applies to the Working Group’s communication, the source was entirely authoritative. Messages will be better received when it is conveyed by someone that the individual can relate to. The tone of all the communication was not only authoritative but also could easily be interpreted as threatening. The gang members could feel they had no options. No matter what the circumstance, they would be vigorously prosecuted. A greater risk here is the risk of rebellion or retaliation. With the Theory of Psychological Reactants, when people think that a freedom is threatened, they experience reactance: a motivation state aimed at restoring the threatened freedom. (10) Youth is a stage of life where rebellion is innate. Disadvantaged youth feel that they don’t have much to lose. This style of communication risked a reverse reaction. The possibility of violent out-breaks all over the city was real; resulting in increased chaos. Gangs uniting against the newly established controls would have been disastrous.<br /><br />Changing the Climate of the Neighborhood:<br /> A guiding idea behind Operation Ceasefire was that if gang violence was generating gang violence then in the absence of constant fear and provocation, the temperature on the streets might go down and “peace will beget peace”. (6) The goal was to stop the violence long enough to have the neighborhoods experience a time frame of peace and adapt to this new environment. Deemed the firebreak hypothesis, the hope was if violence could be quelled for a meaningful period, it might not naturally reemerge. (6)<br /> The “peace will beget peace” assumption is loosely based on the Social Expectations Theory. This theory encompasses many aspects of social expectations including social roles, media and stereotypes. Social norms evolve and these norms provide the basis of how we conduct ourselves everyday within our surroundings. The behavior that we observe around us impacts our individual behavior. Social norms can evolve to, where at times, our behavior feels obligatory. People tend to adopt these norms and behave accordingly. <br /> Being able to affect the cultural and social norms was the aspect of the Expectations Theory the Working Group was counting on. Although there is research available providing results on the effects of the media, social roles, and stereotypes and how they affect society, little research is available in understanding the effectiveness or strength of The Social Expectations Theory when applied to a complex, multivariate, explosive situation. It was a simplistic assumption applied to not only a complex and difficult problem, but one that is also part of our instinctual nature. The risk of failure was high and a strategy to address the next phase of the project had not been established.<br /><br />Context for Behavior:<br /> Extensive research was done by the Working Group to understand, in incredible detail, all the aspects of the gangs and their members. There was historical knowledge among the Working Group of the youth involved in the gangs, their history, criminal record, family environment, etc. The immediate need and focus within Operation Ceasefire was to stop the violence and the resulting deaths. <br /> The Working Group recognized that most of these kids were in situations that were beyond their control. They were in a socioeconomic status of poverty or near poverty, broken homes, abuse, poor family structure and other challenges. In referencing Maslowe’s Hierarchy of Needs, these kids did not have their basic and fundamental needs met. Maslowe states there are at least five sets of goals which are basic needs – physiological, safety, love, esteem and self-actualization. (7) The first basic need is physiological and once that need is met, the focus shifts to safety; once the safety need is met, the focus shifts to love and so forth. It was clear from the CDC survey; youth in the city were worried about safety. Whether interested in gangs and gang retaliation or not, youth felt it was necessary to carry a gun for their own safety. It is doubtful members of the gangs were getting their basic physiological needs adequately met. When the violence and the chaos was under control, there was no discussion about researching and understanding the core reasons that gang violence was an issue in the city.<br /><br />Opportunities for Improvement <br /> In evaluating Operation Ceasefire, I would not propose a new intervention but consider modifications and additions to the intervention that was developed by addressing the shortcomings that have been discussed. In summary, the authoritative tone of communication should have been complimented with peer level communication. Although potentially risky, reformed gang members should have been a part of the program. The use of the Social Expectations Theory was the equivalent of hoping for peace; research was required to understand the core causes of gang violence and then a plan developed for the proposed next steps. Lastly, understand the factors interfering with the potential for a normal childhood for the youth in these neighborhoods, address these needs and understand what is overlapping with the impetus of gang formation. <br /><br />Communication:<br /> There was a missed opportunity to bring peer participation to the communication strategy. Although potentially risky, considering the theories around the Psychology of Persuasion and Psychological Reactants, it would have been beneficial to involve previous reformed gang members or imprisoned gang members that were willing to reach out and aid with reform. It was an opportunity to build credibility with the gangs. Former gang members could have discussed the experience of prison time, what it does to your family and your life. In building an effective public health initiative, it is critical to understand your client. Although the Working Group had extensive experience in this field and with the gangs themselves, the gang members were the client for this initiative. The support of peer to peer level communication could help the Working Group understand all the perspectives on a strategy and the potential reactions of the gangs. Options would have been to have reformed gang members work the streets with a member of the Streetworkers or involve Freddie Cardoza and have him talk about the effects of being convicted a career armed criminal. His perspective could have been interesting for everyone. Therefore, it was a missed opportunity to involve peer level communication and provide credibility to the program.<br /><br />Changing the Climate of the Neighborhood<br /> I would have put no credibility into The Social Expectations Theory as it applies to cultural and social norms of gang violence. The Working Group had enough experience in the field to understand the nature of gangs and that they have been in existence for years in various shapes and forms. There is no solid body of evidence supporting the strategy of such a huge change in city dynamics and the society/community that had formed in the neighborhoods of Roxbury and Dorchester. The hope that once the violence stopped peace would be the new social norm in the neighborhood was blind faith. <br /> This shouldn’t have been an option or theory considered by the Working Group for the Operation Ceasefire program. As the team on the ground was executing, the Working Group, with the help from another representative from Public Health, should have formed a branch committee and initiated effort to craft the next steps of the plan. <br /> The interdisciplinary team was effective but it was formed and more importantly funded as a prototype. Therefore, as soon as the team saw progress and success, they needed to move to the next stage of their strategy and it wasn’t created. Ownership of the program needed to be designated. The process and protocol needed to be identified, documented and implemented around the tasks, roles and responsibilities of the Working Group<br /><br />Context for Behavior<br /> As mentioned several times within the discussion, the causes of gang violence are multi-faceted. The problem is intertwined with many facets of life and society. Gangs have been in existence, in one form or another, for hundreds of years. The context for gang behavior is complex and constantly evolving. The basic needs of many of these youths are not met. Although Operation Ceasefire created the jolt that brought a significant decrease in homicide, it wasn’t built to last. There was no plan to address the basic needs of these kids who were struggling and resorting to gang membership.<br /> Addressing gang violence and the root cause of gang membership is daunting. The solution for the context of behavior dovetails with changing the climate of the neighborhood. There needed to be a strategy beyond temporary peace. I would have used the same level of creativity that was pulled together for Operation Ceasefire and the same brain power that solicited funding and made the best possible effort to develop a Phase 2. <br /> There was a great opportunity to ride the successful wave from Operation Ceasefire. A parallel working group could, through research, propose different programs and solicit funding. Options could have included involving other community project and non-profit organization, prioritize and pin-point the greatest area of need in these neighborhoods and initiate efforts, praise the gangs for the peace and even consider putting them to work – get them involved in the community. The temporary outbreak of peace was their success as well.<br /><br />Conclusion<br /> It is difficult to critique an initiative that worked so diligently to solve a dangerous and complex problem facing the city of Boston. The reduction in the city’s yearly youth homicide numbers certainly suggests that something noteworthy happened after Operation Ceasefire was implemented in mid 1996. In 1996, the number of youth homicides decreased to 26 and in 1997, it decreased to 15. (6) The leaders of the Working Group as well as David Kennedy will be the first to admit – it was not a miracle. A miracle is sustaining. Nor will they claim that Operation Ceasefire was the sole responsible effort for the decline in the homicide rate. It is a disheartening lost opportunity to be able create the temporary peace within Boston’s most disadvantaged neighborhoods and not take the next steps to attack gang violence at its core.<br /> <br /> <br />Attachment 1<br /> <br /> References:<br />1. Allis S. “How to Start a Cease-Fire: Learning From Boston,” Time. July 21, 1997. www.time.com<br />2. Cialdini, Rober B, “Introduction and Chapter 1: Weapons of Influence,” Influence: The Psychology of Persuasion, New Youk: Harper Collins Publisher, 2007. Pp. xi-xiv, 1 – 16.<br />3. Cameron, Kenzie A, “A Practitioners Guide to Persuasion: An Overview of 15 Selected Persuasion Theories, Models and Frameworks,” Patient Education and Counseling 74, 2009. Pp. 309 – 317.<br />4. Defleur M and Ball-Rokeach S, “Chapter 8: Socialization and Theories of Indirect Influence,” Theories of Mass Communication 5th Ed., New York: Longman 1989. Pp. 202-227.<br />5. Gang War: Bangin In Little Rock. Why is the Boston Miracle the only tactic proven to reduce gang violence being dissd by the LAPD, the FBI, and Congress? http://www.gangwar.com/blog/2006/02/straight-outta-boston.html.<br />6. Kennedy D, Braga A, Piehl A. “Reducing Gun Violence. The Boston Gun Project’s Operation Ceasefire,” Research Report, US Department of Justice, Operation of Justice Programs, National Institute of Justice, 2001.<br />7. Maslow AH. “A Theory of Human Motivation,” Psychological Review, 1943. Pp. 376 – 396.<br />8. Rambaud M, “Behind the Guns: The Failure of Boston’s Operation Ceasefire Intervention to Address the Root Causes of Youth Homicide,” http://sb721.blogspot.com/2006/12/behind-guns-failure-of-bostons.html<br />9. Ritter N, “CeaseFire: A Public Health Approach to Reduce Shootings and Killings,” NIJ Journal, 264. Pp 20 – 24.<br />10. Silivia P, “Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance,” Basic and Applied Social Psychology, 27(3) 2005. Pp. 277 – 284.<br />11. WBUR. http://www.wbur.org/2010/01/01/gang-violence-in-bostonChristinehttp://www.blogger.com/profile/14848177219392201947noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-3417249040533331642010-12-16T18:23:00.000-08:002010-12-16T18:25:22.131-08:00Roll Back Malaria: Rolling out the Resources without Rolling out the Behavior – Ashley DunkleIntroduction<br /> Many international public health initiatives use innovative technologies developed in the West that need to be implemented in a developing context, often requiring behavior change of communities and individuals. One major international health problem that has been the target technological initiatives by many public health campaigns is that of malaria. Malaria is a leading global killer, particularly of children under 5 years of age (1). Over half of the world’s population is at risk of malaria while 350-500 million illnesses occur each year (1). A multitude of studies have shown the substantial economic, social, and health burden of areas of high endemic malaria (2,3). <br /> Roll Back Malaria (RBM) is a partnership campaign that was formed in 1998 in order to align global health and development advocates in the fight against malaria (1). Recently RBM has developed a Global Malaria Action Plan (GMAP), which outlines techniques for partners to use in programming in prevention and treatment of malaria (4). One of the most important factors in preventing morbidity and mortality of malaria is vector control, reflected in the main intervention for prevention promoted by RBM: the scaling up of use of insecticide-treated bed nets (ITNs). ITNs are a technology developed to cover the beds of individuals in malaria endemic regions in order to prevent mosquito bites at night, when most malaria transmission occurs (5). This innovative technology is relatively cheap and has proven to be an effective prevention measure for the spread of malaria (6). Around 120 studies have shown the effectiveness of ITNs in reducing malaria transmission, and as a result, morbidity and mortality (6). In order to promote ITN use, RBM states they are working to a) organize public education campaigns in malaria-endemic areas, b) lobby for the reduction or waiver of taxes and tariffs on mosquito nets, netting, materials, and insecticides, c) stimulate local ITN industries and social marketing schemes so ITNs are available at a price affordable by everyone, and d) to capitalize on the potential of newly developed long-lasting treated mosquito nets (5). However, despite large donations and wide disbursement of ITNs and the implementation of RBM’s GMAP, malaria continues to be a major problem worldwide with little overall change in morbidity and mortality (7). This analysis will look at why RBM has largely failed in preventing malaria through its ITN initiative and offer ways in which the GMAP strategy could be improved to increase the use of ITNs worldwide. <br />CRITIQUE 1 – Assuming Induced-Demand Reflects Intended Use - Application to the Theory of Planned Behavior<br /> RBM’s major indicator for use of ITNs among its beneficiaries is ownership of a net (1). Because ITNs are so effective at preventing transmission of malaria, many initiatives have targeted getting ITNs to the people in endemic, high-risk areas. In order to increase ownership, RBM’s methods involve inducing demand through social marketing (4). This first means inducing an increase in supply of ITNs by manufacturing organizations. After doing so, RBM focuses on getting ITNs to the people by giving ITNs away for free, subsidizing the cost, or delivering vouchers to exchange for ITNs, all of which is intended to induce demand (1). Recent reports by RBM has shown impressive scaling up in ITN ownership among individuals in endemic areas (1). However, despite widespread availability and possession of ITNs by people in malaria endemic areas, malaria is continuing to be a problem (7). <br /> The major fallacy in RBM’s GMAP regarding ITNs is that they are only focusing on the possession of ITNs, not the actual behavior of use. In many of their reports, they provide accolade of the amount of nets disbursed throughout the world without measurement of the actual use of the nets (4). It is as though RBM is assuming that the “demand” they are seeing, which they induced, will lead to an intention to use the ITNs. We can apply this assumption to the Theory of Planned Behavior (TPB), an individual-based behavioral theory that focuses on rational, cognitive decision-making which presumes that people think about what they do before they do it (8). This theory states there are four factors leading to the intention to perform a behavior and that intention will lead to actual behavior. These factors are: 1) attitudes - the person’s belief about the outcome of the behavior and whether it is good or bad, 2) subjective norms - the person’s belief that other people in their social group approve of the behavior and there is motivation to conform, 3) perceived behavioral control – the person’s belief about the existence of factors that promote or prevent the behavior, and 4) perceived power – the person’s belief in the amount of power they have over the behavior. TBM assumes all of these factors influence behavioral intention and that behavioral intention then results in behavior (9). <br /> What RBM seems to be assuming is that the demand they induced reflects attitudes that owners of ITNs believe there is a positive outcome from use (attitude) and that other people in the social group approve of its use, as ITNs are now widespread (social norms). They also appear to assume that by providing ITNs, RBM is reducing the difficulty of performing the behavior (perceived behavioral control) and the person believes they have power to perform the behavior now that they posses an ITN (perceived power). As ownership of ITNs is presupposed to reflect these aspects of the TBM, RBM believes these individuals will intend to use the ITNs regularly (behavioral intention) and that intention will lead to behavior. However, these factors that lead to behavioral intention are not necessarily existent among new ITN owners. For example, just owning something does not mean you have a positive attitude about its intended use. Many people will take free things because they are free and may not value them for their intended use (10). In fact, regarding bed nets, a study evaluating their use in a village in Kenya found 25% of individuals used the ITNs for alternative purposes, such as fishing netting and hanging fish to dry (11).<br />Likewise, rational decision-making does not always result in performing the intended behavior. Other factors beyond conscious cognition motivate behavior, such as environmental and social factors (8). Many reports have shown that barriers to use exist beyond obtaining ITNs. One study revealed a statistically significant reason for lack of adherence to ITN use, among participants who were given free nets, was temperature (12). One participant stated that it was “too hot” sleeping under the nets (12). Social reasons also influence use such as the disruption of normal sleeping arrangements for various reasons such as visitors or multiple beds (12). Additionally, technical factors can be a barrier such as people stated, “cannot hang the net properly, difficult to spread net over mat, returned home too late to put up the net,” and “net is too hard to put up and take down,” (12). RBM’s assumption that ownership will lead to intended use via the TPB and ultimately result in ITN use is false. Demand does not reflect behavioral intent and there are other factors, social, environmental, and technical, that can prevent ITN use by beneficiaries of ITN social marketing. <br />CRITIQUE 2 – Focusing on Education Campaigns - The Fallacy of the Health Belief Model<br />Another error in RBM methods for increasing ITN use is reliance on the Health Belief Model (HBM) through community-based education to encourage use of ITNs. HBM, like TPB, is a theory based on cognitive decision-making about what motivates health behavior. It assumes beliefs concerning perceived risk, costs, and benefits to participate in a healthy behavior, such as bed net use, are considered in a rational way, and will influence health behavior (13). There are six factors in the HBM which will be explained in relation to malaria and ITN use: 1) perceived susceptibility – the degree to which the person feels they are at risk of contracting malaria, 2) perceived severity – the degree to which a person believes the outcomes of contracting malaria are severe, 3) perceived benefits – perception of the positive outcome of using ITNs to prevent contracting malaria, 4) perceived barriers – the negative outcomes of using ITNs, 5) cues to action – an external event, such as someone in the community dying from malaria, that motivates use, and 6) self-efficacy – a person’s belief they are able to effectively use the ITN (8). <br />RBM’s GMAP proposes the use of community education programs in order to target these HBM factors assuming this will result in the behavior of ITN use. In fact, in the GMAP, Bill Gates, a major donor to RBM, is quoted as saying, “I believe that if you show people a problem, and then you show them the solution, they will be moved to act. The Global Malaria Action Plan lays out an achievable blueprint for fighting malaria – now it is time for the world to take action,” (1). RBM relies heavily on the HBM in that education of the susceptibility and severity of malaria, the benefits and limited barriers to ITN use, and promoting self-efficacy through educational cues to action will result in ITN use. <br />Like TPB, one of the major problems with HBM is its focus on individual decisions without addressing social and environmental factors (8). An individual’s cognitive and rational processes exist within a social and environmental context in which external influences affect behavior and can counteract rational thoughts and intentions (8). A randomized controlled trial performed in western Kenya evaluated adherence to ITN use with free ITNs and extensive educational activities focusing on many of the factors in HBM (12). These educational activities taught individuals about malaria, its prevalence in the area, the outcomes if adults and/or children contracted malaria, and ITN’s effectiveness in reducing transmission (4). Despite knowledge of malaria and ITN use, as well as free ITNs, “adherence” was still only around 70% (12). Teachers also emphasized to participants that malaria is a more serious ailment in children than older people and it was very important that children are a priority in sleeping under the nets. However, one of the statistically significant findings in this study was older people were more likely to sleep under the ITNs than children (p=0.0001) (12). Another important indication of ITN use by this study was that ITN use decreased over time, a factor that was observed in other efficacy trials surrounding ITN use (12). Allaii et al. states, “That this occurred in spite of our educational campaign illustrates how difficult it is to impact human behavior…” (12). This study shows the limitations of the HBM and RBM initiatives in education resulting in behavior change. This approach relies too much on the client and fails to take into account the wider social and environmental factors that influence behavior (14). Thus, knowledge alone does not always mean behavior change. <br />CRITIQUE 3 – Inducing Psychological Reactance Through Education <br /> As shown in the second critique, education is intended to teach individuals about why it is important to their health to use ITNs, but health education campaigns have not proven to be very productive in changing behavior. Whitehead and Russell reiterate the difficulty found of changing behavior in the Kenya randomized controlled trial by stating, “‘Fully’ informing individuals about health and health risk does not necessarily lead to a change in behavior” (14). In fact, sometimes it induces the exact opposite of what is intended, which in this case would motivate individuals to not use ITNs (14). Evidence that health education can sometimes be counterproductive is explained by the Theory of Psychological Reactance. This theory was developed by Jack W. Brehm in the 1960s and has been supported by a number of empirical studies, particularly those related to health behavior (15). This theory suggests that when someone is told what to do, the individual perceives a threat or reduction in their freedom, and will act in a way to restore that freedom, often doing the opposite of what was told to them (15). To explain in more detail, Brehm (16) states there are four elements fundamental to reactance theory: 1) freedom, 2) threat to freedom, 3) reactance, and 4) restoration of freedom (15). Individuals first have a perceived sense of freedom. In response to a stimulus, such as an authoritative voice, individual’s feel this freedom is threatened. Individual’s then react to the threat and are motivated to act in order to restore the freedom (17). While reactance can take many effects, often the result is a boomerang effect, in which the individual will engage in the behavior related to the challenge of freedom (18). For example, if a child is told not to eat a piece of candy, they will feel their freedom threatened and will want to eat that piece of candy to restore their sense of freedom. Education campaigns and programs are a type of social influence that often induce reactance and prompt freedom-restoring responses leading to rejection of the message, resulting in ineffective persuasion to change behavior(17). <br /> Psychological reactance theory may explain why some individuals do not use ITNs. When people are told to use ITNs, particularly when the source of the information are individuals from outside of the cultures of the individuals being taught, it is likely that a boomerang effect may occur. People value freedom and control and telling someone it is imperative that they sleep under ITNs violates these values by seemingly challenging their freedom to choose how they sleep and how they take care of their own families. By someone telling individuals to use ITNs at night, it is likely they feel these freedoms threatened, and in response, they may refuse to use the ITNs as a means of gaining back this challenged freedom, thus ignoring the rationale of the education campaign. RBM’s educational programs may therefore be causing individuals to not use the ITNs, by threatening their freedom through the intent of instruction – the opposite of RBM’s goals.<br />Proposal 1 – Market ITN Use, Not Just Ownership <br /> As this analysis has delineated, RBM has focused on increasing uptake of ITNs through inducing demand and encouraging their use through education. But as has been shown, ownership of a net and education do not necessarily lead to the behavior of using ITNs. Instead on inducing demand of ownership of ITNs and focusing on individuals’ rational, cognitive-decision making through education about malaria and ITNs, RBM could include in their GMAP, direct marketing of ITN use. Rather than inducing demand of the product, RBM would be marketing a behavior – the use of ITNs. Using principles in marketing theory, RBM could greatly revamp their action plan to reach many more people in numbers and reach them at heart - a much greater motivator than knowledge. <br />Marketing is defined as “human activity directed at satisfying needs and wants through exchange processes” (19). RBM wants their beneficiaries to benefit from the use of the ITNs they provide. However, RBM needs to consider the wants and needs of these beneficiaries. Marketing theory starts by looking at the wants and needs of individuals’, and then packages and promotes products for exchange based on these values (20). Effective marketers do not try to make the target audience accept their values and beliefs, as RBM has done, but rather start from the standpoint of the audience’s wants and needs, values, and perceptions (21). While RBM claims methods of social marketing, it really is only focusing on the exchange part, ignoring the wants and needs of their consumer. Marketing theory suggests that rather than telling people to use ITNs because the educator thinks it is the right thing to do, coming at ITN use from the audience’s point of view can be much more effective. <br />As RBM’s focus is a global initiative, there are many beneficiaries from various cultures and subpopulations. While some values tend to be universal, such as independence, freedom, control, respect, etc., values tend to vary across subgroups and they can vary across cultures. Marketers do not rely on intuition to know what the consumer wants and needs, but rather they perform formative research in order to understand the values, wants, and needs of the target audience (20). Essentially this requires, “getting inside the heads” of consumers (21). Formative research needs to be included in RBM’s marketing approach in order to have an empirical basis for their marketing efforts and marketing campaigns. <br /> Overall, marketing of a health behavior is different from traditional public health paradigms such as HBM and TPB, which tries to “sell” a behavior based on an individual’s desire for health and their rational cognitive processes. While health is generally valued, it is also generally misunderstood by those who possess it, and largely taken for granted. By using marketing theory and formative research in the GMAP, RBM could focus their efforts on the actual wants and needs of their beneficiaries and effectively redefine and packages the behavior of ITN use in a more effective way. <br />Proposal 2 – Expand on Marketing Theory - Branding ITN Use<br />By using marketing theory as proposed, RBM would be selling the behavior of ITN use based on the core values discovered through formative research. However, RBM needs to extend this marketing approach one step further. After performing formative research, marketers repackage, reposition, and reframe their product in a way that shows the target audience that they will benefit from its consumption in a way that reinforces their core values (20). One of the primary modes of presenting a product in this manner is through branding. Branding is a concept used by marketers that associates a product or service being sold with something the brand represents (22). In public health, generally it is a branded message to partake in a health behavior, rather than a symbol of a product (23). A branded message is a “strategic communication designed to elicit a particular set of beneficial associations in the mind of the consumer which become linked to the brand’s identity, providing…a sense of value (24). The best brands represent the core values, wants, and needs discovered through formative research (20). <br />Public health has co-opting branding as a means of marketing healthy behavior. Unlike commercial branding, public health does not intend to brand products or services. Alternatively a behavior is branded which leads to a benefit from engaging in or refraining from a behavior and its consequences. Whereas the HBM and TPB associate the outcome of “health”, branding a public health behavior will associate the outcome with a core value (22). These branded behaviors can then be “sold” as embodying a “lifestyle” of the healthy behavior, which will become part of the identity of those who partake in the branded behavior, such as the use of ITNs (23). Branding of a health behavior is often more effective than educating about a health behavior. This is because the purpose of healthy behavior is often abstract, complex, and it is difficult to appropriately convey the benefits to the target audience (23). In addition, healthy behaviors often do not have quick or noticeable results, thus branding a behavior with a value can be much more effective (23). In the case of ITNs, it may be difficult for people to use ITNs on a hot night, when comfort is their immediate concern, rather than use them for the purpose of preventing a disease of which they have never experienced and which they may not contract. The benefit of a net-free bed may be seen as much better in the immediate moment then preventing an abstract event such as malaria. However, by branding ITN-use, the owner of a net may partake in the use of the net because they associate the use with an “identity” and core value. Branding, therefore, can create a value-based association with the behavior that is more likely to induce “compliance” than an abstract “health” concept. <br />There are three basic concepts surrounding a brand: a) building a relationship b) adding value and c) beneficial exchange (22). First, the public health brand, in this case ITN use, must build a relationship with its beneficiaries to encourage the adoption of the health behavior. This is often through the development of positive associations offering a “brand promise”. The brand promise is something of value that the consumer of the health behavior will acquire if they respond to the proposed “call to action” (22). Building a relationship is essentially making the brand “promise” understood to the beneficiaries. In the case of ITNs, the call to action would be for people in malaria endemic areas to use ITNs each night for themselves and their family members. Thus, RBM would need to link this “call to action” with a “promise” that their brand represents. The promise must be something appealing to consumers, such as the values of the target audience discovered through formative research. <br />There are three persuasive mechanisms for making the brand appealing to consumers of the health behavior based on these values which include: a) aspiration to an appealing ideal, b) modeling of a socially desirable good, or c) association with idealized imagery (22). These mechanisms are related to the second aspect of branding: adding value. This is making explicit the relationship between the brand and the value it is associated with, linking the brand with the values, needs, and wants of the consumers. An association with an aspiration of an appealing ideal is that the brand may represent beauty, status, sex appeal, or power (22). Some examples would be “ITN use gives you control” or “ITN use is a sign of status”, thus linking the behavior with other “social goods”, though this “value” may not be directly related to the actual utility of the ITNs. <br />The third aspect of branding is providing a beneficial exchange. This is what the individuals actually receive from the adoption of the behavior and is generally based on the added value and the brand promise. An important factor in this aspect is the development of trust that the individual will gain the promise of status, beauty, or power, by performing the desired behavior (22). While education campaigns might use scare tactics such as teaching individuals about the biology of malaria and how it can cause morbidity and mortality, building a trusting branding relationship for promoting the use of ITNs would work much better, thus creating a positive approach. An example that RBM partners promoting ITNs could use may be, “Wrapping your family’s beds with ITNs each night makes you an excellent mother,” or “It’s sexy to use an ITN,” or “ITNs – only for high-society.” Positive associations help build trust and will induce the brand to be associated with positive social norms. As Dan Ariely suggests, “There are social rewards that strongly motivate behavior – and one of the least used…is the encouragement of social rewards and reputation,” (10). By building associations between the public health “brand” of ITN use and social values and rewards, individuals are much more likely to want to participate in the behavior in order to gain these social rewards if they understand the association of the promise and trust that the behavior will result in this reward. <br />Proposal 3 – Use Psychological Reactance To Roll Back Malaria– Mitigating Reactance and the Brand-Value of Freedom<br /> While the third critique of RBM’s GMAP showed how psychological reactance could induce non-compliance with ITN use, it is possible for RBM campaigns through branding to a) mitigate psychological reactance, and b) use psychological reactance in their favor to promote ITN use in branding. <br /> Although there is a compelling amount of empirical evidence to support psychological reactance, attempts at social influence does not always reduce compliance (16). Some studies have evaluated factors that do not decrease compliance, despite attempts at social influence that would likely induce psychological reactance. One fact that has been empirically shown to reduce psychological reactance is introducing similarity in the source of the influence. Paul J. Silvia performed a study evaluating how similarity may overcome the resistance to persuasion (25). He showed that having the message of persuasion coming from someone who is similar to the recipient in certain characteristics, such as age or gender, can increase the positive force by increasing liking and decrease the negative force by decreasing perceptions of threat, both contributing to decreased psychological reactance (24). Based on this factor, branded messages from RBM about the use of ITNs to its beneficiaries can decrease the amount of psychological reactance by delivering them from someone similar to the beneficiaries. This means that any educational campaign or advertisements involved in the branding of ITN use should come from people who are similar to the target audience. For example, if RBM partners were targeting increased use of ITNs to mothers, they would associate the brand with values of the mothers of this community, and could decrease psychological reactance by having the message come from a mother in the community and culture. <br /> Rather than reducing psychological reactance, RBM could actually use psychological reactance to their benefit and even combine it with their brand. Because psychological reactance often induces a boomerang effect, it is possible to induce psychological reactance as a means of promoting a desired behavior by challenging individual’s freedoms in the opposite manner. As described, psychological reactance is induced as a reaction to an influence that results in a perceived threat to freedom, causing the individual to perform the opposite behavior from what was asked. One way that RBM could use this to their advantage is by focusing on the value of freedom in their brand. This would first mean the overall association between the brand and the behavior of using an ITN would be the value of freedom. The ITN brand would thus need to “promise” that using the ITN would lead to freedom. However, first the target audience would need to believe there is a threat to their freedom, which would require support from the brand. One way in which RBM could do this is to present support in the advertisements of the ITN brand that the mosquito and malaria are a threat to their freedom, and that following the “cue to action” to use ITN nets would restore this freedom. Thus, RBM could use techniques of marketing theory, branding, and psychological reactance all to promote an increase in ITN use.<br />Roll Out Behavior Change<br /> Overall, RBM has done an incredible job at getting nets to those who need them. However, as was shown, owning a net does not necessarily lead to use of the net – what is ultimately necessary to prevent malaria. By changing their tactics from focusing on demand, using assumptions of TPB and the HBM, and potentially inducing psychological reactance through education programs, RBM could change minimal behavior influence into wide scale use of ITNs. Marketing theory and branding are impressive tools that have been greatly refined by the commercial sector. By co-opting these methods into public health behavior change, and utilizing psychological reactance in their favor, RBM could reach a lot more people on a much more influential level – by eliciting the core values of individuals, a much greater motivator of behavior. <br /><br /><br /><br /><br /><br /><br /><br /><br />References<br /><br />1. Roll Back Malaria. Key Facts, Figures, and Strategies: The Global Malaria Action Plan. Geneva, Switzerland: Roll Back Malaria Partnership, 2008.<br /><br />2. World Health Organization. The World Health Report 2000: health systems, improving performance. Geneva, Switzerland: World Health Organization, 2000. <br /><br />3. Gallup JL and Sachs JD. The economic burden of malaria. American Journal of Tropical Medicine and Hygiene 2001; 64: 85-96. <br /><br />4. Roll Back Malaria. Global Malaria Action Plan: For a Malaria-Free World. Geneva, Switzerland: Roll Back Malaria Partnership, 2008.<br /><br />5. Roll Back Malaria. Insecticide-treated mosquito nets. Geneva, Switzerland: Roll Back Malaria Partnership, 2008.<br /><br />6. Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database Systematic Review 2004; 2: CD000363.<br /><br />7. Yamey G. Roll Back Malaria: a failing global health campaign. British Medical Journal 2004; 328: 1086-1087.<br /><br />8. Edberg M. Chapter 4: Individual Health Behavior Theories (pg. 35-49). In: Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007. <br /><br />9. Fishbein M and Ajzen I. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley, 1975.<br /><br />10. Ariely D. Predictibly Irrational: The Hidden Forces That Shape Our Decisions. New York, New York: HarperCollins, 2008.<br /><br />11. Minikawa N, Dida GO, Sonye GO, Futami K, and Kaneko S. Unforeseen misuses of bed nets in fishing villages along Lake Victoria. Malaria Journal 2008; 7: 165-170.<br /><br />12. Allaii JA, Hawley WA, Kolczak MS, et al. Factors affecting use of permethrin-treated bed nets during a randomized controlled trial in western Kenya. American Journal of Tropical Medicine and Hygiene 2003; 68(supp 4): 137-141.<br /><br />13. Becker M. The health belief model and personal health behaviour. Health Education Monographs 1974; 2:1-146.<br /><br />14. Whitehead D and Russell G. How effective are health education programmes – resistance, reactance, rationality, and risk? Recommendations for effective practice. International Journal of Nursing Studies 2004; 41: 163-172.<br /><br />15. Brehm JW. A Theory of Psychological Reactance. New York, New York: Academic Press, 1966. <br /><br />16. Brehm SS and Brehm JW. Psychological reactance: A theory of freedom and control. New York, New York: Academic Press, 1981. <br /><br />17. Rains SA and Turner MM. Psychological Reactance and Persuasive Health Communication: A Test and Extension of the Intertwined Model. Human Communication Research 2007, 33: 241-269.<br /><br />18. Brehm JW and Sensenig J. Social influence as a function of attempted and implied usurpation of choice. Journal of Personality and Social Psychology 1966; 4: 702-707.<br /><br />19. Kotler P. Marketing management: Analysis, planning, and control (3rd edition). Englewood Cliffs, New Jersey: Prentice-Hall, 1976.<br /><br />20. Seigel M and Doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, Massachusetts: Jones and Bartlett Publishers, 2004. <br /><br />21. Andreasen AR. Marketing social change: Changing behavior to promote health, social development, and the environment. San Francisco, California: Jossey-Bass, 1995. <br /><br />22. Evans WD and Hastings G. Chapter 1: Public Health Branding: Recognition, Promise, and Delivery of Healthy Lifestyles (pg. 3-24). In: Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008. <br /><br />23. Blitstein JL, Evans WD, and Driscoll DL. Chapter 2: What is a public health brand? (pg. 25-41). In: Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008.<br /><br />24. Calder BJ. Designing brands. In: Kellogg on branding (pg. 27-39). Hoboken, New Jersey: John Wiley and Sons, 2005. <br /><br />25. Silvia PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005; 27(3): 277-284.Christinehttp://www.blogger.com/profile/14848177219392201947noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-8161647176923185792010-12-16T18:21:00.000-08:002010-12-16T18:23:30.257-08:00The Continuum of Care: Is It an Effective Way of Helping Homeless People with Mental Illness/Substance Abuse Recover? - Feng-Hang ChangIntroduction<br /> Homelessness is a growing social and public health problem in developed countries (1). In the U.S., approximately 3.5 million people experience homelessness, and the number is steadily increasing every year (2). Most people who are homeless have suffered severe hardship, including physical and sexual abuse, childhood trauma, poverty, disability, and disease (3). Moreover, homeless people showed a higher prevalence of mental disorders, such as schizophrenia (54.8%), bipolar disorders (19.8%), and substance-related problems (60.5%) compared with people who were not homeless (4). <br /> Helping homeless people with mental illness/substance abuse go back from the street to a stable and independent life is a big challenge. To help them improve and maintain their health and well-being, the intervention does not only have to aim on housing situation, but also have to stress on the treatment of improving their mental health or/and drug abstention(5). <br /> The Continuum of Care is a nationwide standard homelessness intervention strategy recommended by the Department of Housing and Urban Development (HUD) (6). It is a community plan which organizes and delivers housing and services to meet homeless people's needs, especially for those with mental illness and/or substance abuse disorders. The components of a Continuum of Care model include: 1) outreach, intake, and assessment, 2) emergency shelter, 3) transitional housing, and 4) permanent housing and permanent supportive housing (See figure1). <br /><br /> <br />Figure 1 Components of a Continuum of Care Homeless System<br /><br /> This approach includes two key characteristics: 1) the provider determines when a client is "housing ready," and 2) the participants are required to get psychiatric and substance abuse treatment. Additionally, two assumptions are contained in this model: 1) homeless adults need transitional and permanent housing in order to develop the daily living skills they either lost or never had; 2) housing readiness depends on a period of sobriety and compliance with psychiatric treatment if deemed necessary. If the individuals demonstrate more compliance with treatment and sobriety, they can get less restrictive residences; if they fail to comply or relapse, they will return to a more restrictive environment (7). <br /> Although the Continuum of Care is a linear process as stressing on restoring clients' mental health and stop using substance, the effect is not as good as we thought. First, clients report a lot of frustration and dissatisfaction in this program since the "journey" of graduating from the program is very long and complicated, which lead them to give up (8). In addition, comparing with other programs (i.e., Housing First or Pathways to Housing program), the Continuum of Care program shows lower effect on many aspects such as psychiatric symptoms, psychiatric hospitalization, substance use rate, and residential stability (7,9,10). Especially for homeless people with addiction, the Continuum of Care presents less than ideal result (11). These results indicate the program and the factors that contribute to its low effect need to be examined.<br /><br />The criticisms of the Continuum of Care<br />1. Disobeying Maslow's Hierarchy of Needs<br /> One of the most likely reasons that the Continuum of Care intervention does not work as well as expected is that it ignores the point that housing is one of the basic needs of human beings that need to be satisfied. <br /> Based on Maslow's Hierarchy of Needs, the fulfillment of the lower level needs is a prerequisite to addressing the higher needs (12). In Maslow's hierarchy, the first level of needs, we call it the physiological needs, including food, drink, shelter, sleep, and sex, is the foundation of human beings' motivation. The second level is safety, including security, stability, and protection. The third level of need is belonging and love. The fourth level is esteem needs, which are fulfilled by mastery of the environment and the prestige of social recognition. The fifth level is the need for self-actualization, is to maximize one's unique potential in life. Once the lower needs are satisfied, the higher needs can be pursued (12).<br /> For homeless individuals, apparently, the basic physiological and safety needs can hardly to be satisfied without stable housing. Stable housing forms the foundation on which an individual can establish daily routines and begin to address other issues (13). Contrarily, living in an unstable or bad environment may expose one to the cold, promote sleepless, and cause food shortage and cooking difficulties. Moreover, living on the street or temporary shelters can expose one to dangerous situations, which hardly offers security and stability, the safety needs. If those basic needs are not satisfied, how can we expect homeless people to pay attention on the mental health and substance abuse treatment?<br /> Many studies support this statement. Studies showed that Homeless people perceive the basic needs of food, shelter, and safety as higher priority needs than health issues (14-16). Gelberg and Gallagher (1997) found that competing priority is an important nonfinancial barrier to the utilization of health services homeless people tend to pursue the housing and necessity prior to anything else. Kyle and Dunn (2008) also found empirical evidence that stable and appropriate housing situation can benefit mental ill people's health and quality of life.<br /> Nevertheless, the Continuum of Care regards housing as an outcome, like employment, of therapeutic intervention rather than a precondition before healthcare (17). People cannot get permanent houses if they fail to comply with mental health/substance abuse treatment. However, this process disobeys the Maslow's Hierarchy of Needs and the empirical evidence. In fact, it seems to put the cart before the horse. If we want those people to comply with treatment, we have to let them see the value of treatment. But how can we expect them to value the treatment if their basic needs are not satisfied? The housing should not be seen as a "result" or "reward," but a necessity and human right.<br />2. Inducing the reactance<br /> The reactance theory can also explain the limited success of the Continuum of Care. The reactance is the psychological response that people may experience when they perceive their freedom is threatened (18). It motivates people to restore the threatened freedom by adopting or strengthening a view or attitude that is contrary to the threatening message (18). <br /> As an intervention focusing on recovery from disease and substance abuse, the Continuum of Care does not provide much autonomy to homeless people. First, the homeless people are "required" to attend treatment and have to "graduate" from the program. If they fail to show their capability of engagement and attendance in the treatment, they cannot get a permanent house (7). In the process, the treatment is like a mandate and requirement, which can probably become a freedom-threatening message to those individuals who want a house. Second, the providers are the ones to decide whether a client is "housing ready" or not. The client does not have much opportunity to get involved in the decision-making process but only wait for the judgment like a student or prisoner. This process may increase the sense of losing control. Some research supports this statement. Owen, Rutherford, and Jones (1996) found that clients feel dissatisfied and frustrated with a system that provides what it thinks they need, rather than what they say they need. Third, in the intervention process, if the clients relapse, they will be sent back to a more restrictive environment, such as a collective shelter, which may deprive their freedom and independence. Actually, most of emergency shelters and transitional housing are dirty, dangerous, disempowering, and associated with a range of negative outcomes such as negative affect and lowered independent functioning (19). It leads some clients to drop out of the system to resume their "normal lives," independently, on the street (8). <br /> As a result, the Continuum of Care may not only induce the clients' reactance by threatening their freedom, but also influence their independence and satisfaction. Further, the clients may choose to go back to the street due to fail to follow the "rules" and fear of losing their independence. These can all cause the intervention to fail.<br />3. Fail to address other factors which may influence the compliance with treatment<br /> Finally, the model regards the adherence to prescribed treatment and sobriety as the capacity of housing readiness. The client who is not able to maintain the compliance at any level or relapse into alcohol and drug use will be seen as lack of capacity. However, even if compliance with treatment is one indication of understanding whether a client is able to maintain his/her life, this postulation overlooks other factors which may influence a client's healthcare use, including taking prescribed medication and visiting the psychiatric clinic regularly.<br /> In fact, a lot of factors can influence one's healthcare use. Based on Andersen's Behavioral Model, the factors including demographic factors (such as age and gender), social structural factors (such as education, ethnicity, and culture), health beliefs, community and personal enabling resources (such as transportation, income, insurance coverage), illness level, and many other environmental factors (such as stigma, policy, and prevailing norms of the society) may all affect an individual's healthcare use and health behaviors (20). Although having a disadvantage on any of these factors may contribute to ones' difficulty of using healthcare, homeless people could be even more vulnerable on several aspects than others. For example, they are usually lack of health insurance, health related knowledge, and social resources like family support and community support, income, and are usually stigmatized (21). Among these factors, stigma is one of the biggest barriers that we need to highlight (3).<br /> Some researchers contend that homeless people face tremendous stigma in life and healthcare due to the stigma on poor and mental illness (4). The stigma may not only come from the social public, but also come from health providers. A phenomenological study shows that homeless people encounter serious barriers while entering healthcare services. These barriers include being labeled or stigmatized, being treated with disrespect, and feeling invisible to healthcare providers (3). Applying the knowledge to the adherence of treatment, the failure to comply wider treatment may due to the negative experience during the process of healthcare. While homeless individuals are facing stigmas and disrespects from the healthcare providers, it becomes extremely hard for them to seek help continually. Further, homeless people with mental illness tend not to consistently seek mental health care due to the fear of facing social reject (22). All these factors can affect a homeless individual's willingness and compliance with psychiatric/substance abuse treatment. As a result, while they fail to comply with treatment, it is unfair to postulate they lack "readiness" regardless of other personal and environmental factors. <br /><br />Intervening program: A Home with Rehab<br /> To develop a more effective intervention program for the recovery of homeless people with mental illness/substance abuse, we have to avoid making the same mistakes as the Continuum of Care does. The new intervention program I recommend is “A Home with Rehab.” This program has several new characteristics. First, when a client enters in the program, we help him/her get a home first by providing a safe apartment and necessities. The “home” is free for the first month, but after that, the client needs to pay for at least 30% of the rent and expenses, which can motivate him/her to manage his/her money or find a job. Second, if the client has mental illness/ substance abuse that needs treatment, rehabilitation will be offered after the client settles into the housing. A case manager will develop a relationship with the client, and discuss the rehabilitation plan with him/her in an empowering way rather than in a forcing way. Family members, if there is any, will also be invited to join the meetings. After completing counseling, the client can decide whether or not he/she wants to participate in psychiatric/substance abuse rehabilitation. Third, each client is cared for by a strong professional health team, including a case manager, physicians, psychiatrists, occupational therapists, nurses, rehabilitation counselors, and social workers. If the client has any health or life needs, he/she can seek help from the case manager, and the manager will call for the required personnel. For example, if the client wants to find a job, the case manager will gather the clients’ occupational therapist and rehabilitation counselor to discuss the issue with the client, make a job search or work skills training plan, and help him/her find a job. Fourth, health education group activities will be provided to the clients in the apartment. The health education goals include improving personal health behaviors, enhancing necessary health services use, and increasing their seeking and participating in psychiatric rehabilitation and substance cessation. The communication will decrease the reactance among the clients by sending unthreatened messages. Last but not least, the program stresses “anti-stigma” education for health providers. To make sure all of the health providers in our program have indiscriminate attitude and respect toward the clients, all of the providers need to take the anti stigma training and be evaluated before and after entering the program.<br /> To attain these goals, the execution of the program is very important. I will now elaborate the details of this program and discuss how this intervention avoids the flaws of the Continuum of Care. First of all, based on Maslow's Hierarchy of Needs, the basic needs should be fulfilled prior to other needs. Therefore, we will help the clients settle into the stable housing and get necessities before conducting psychiatric or substance abstention rehabilitation. After satisfying the basic needs, we can expect that clients will have more motivation to improve their health, well-being, and other higher level needs. Some studies have shown that homeless individuals with mental illness who are placed directly into permanent housing first are more likely to stay engaged in a program and be residentially stable compared to those who get treatment first (2). Furthermore, the types and conditions of housing should also be considered. A dirty, crowded, and disordered shelter may not make clients feel secure. To satisfy the clients' needs for safety, the program will offer an independent, comfortable, or at least well-organized, apartment. <br /> Next, the intervention will avoid inducing clients' reactance. The "mandate" of complying with treatment before getting a house will be eliminated since it threatens the clients' freedom of choice. Our message will not stress the need to complete rehabilitation before getting housing. On the other hand, we will let the clients know that they have the freedom to decide whether or not to engage in their treatment services. We will send positive messages such as "Wanna get rid off the pills? It's time to make your own decision." "The door to AA group is open for you anytime." "Wanna find someone to listen to your feelings? The Psych clinic welcomes you." These messages will be put in the flyers posted on the walls where clients can see easily, and in the health education groups that people can get when they participate in the activities. The healthcare providers will also provide those messages to clients during the meetings. <br /> Additionally, to increase the power of persuasion, we will invite some successfully recovered homeless people to speak to the clients, or show videos about their own recovery stories. Based on the study, the similarity between the communicator and the clients can increase the power of persuasion and decrease resistance (18). The modeling theory also asserts that people tend to imitate the behaviors from those whom they identify as models (23). Therefore, it is important to build up those "models," for example, those successful homeless people, and demonstrate their engagement in rehabilitation. If engaging in rehabilitation could be shown as problem-solving and rewarding, such as bringing a more independent life, more people may like to adopt this behavior (23). As a result, clients will more likely to comply with treatment.<br /> Finally, to encourage homeless people with mental illness/substance abuse to keep seeking treatment, we will aim to remove barriers that they may face in the healthcare system. The case managers will meet with the clients regularly and explore if they have any difficulty of using health services. If there are barriers which interfere with the clients' health services use, for example, the client is lack of knowledge about when and where to seek for rehabilitation; we will help them to eliminate the barriers, for example, by using health education. <br /> In addition, based on the problem I addressed before, one big challenge for homeless people is the stigma from healthcare providers. According to the stigma theory, a stigma is an attribute that is socially defined as “deeply discrediting,” spoiling one’s identity and disqualifying one from full social acceptance (24). The homeless population has been facing a public stigma for a long time based on people's negative perceptions related to the poor, the mentally ill, and substance abusers (24). Moreover, many people's perception of homeless people is influenced strongly by the media or by the unsavory behaviors of a few but highly visible homeless people (4). Unfortunately, healthcare providers show the similar negative attitudes toward homeless people when homeless people walk in and seek help (25, 26). Because of that, our primary task is to remove the stigma from healthcare providers. Ways to change attitude include education and direct contact, which both focus on increasing healthcare providers' familiarity with the homeless population and decreasing the unknowns (6). In addition, interaction with the stigmatized population is regarded as a key to reducing discrimination and prejudice (6). Based on that, delivering adequate knowledge about the homeless population to health providers is very important, as is helping them get in experience with treating homeless people (25). These are all effective ways of removing the barriers and helping homeless people enter and continue following the treatment.<br /> In conclusion, in helping homeless people with mental illness/substance abuse recover and return to the community, we should help them settle in a stable and safe house first in terms of satisfying their basic needs. Next, the health services should be provided in an acceptable way. We can offer abundant information and services and encourage them to comply with treatment by using some persuasive techniques, but the clients should have the right and autonomy to make treatment decisions. Even if they fail to comply with treatment, their needs and barriers need to be understood rather than blamed. One of the biggest barriers, stigma, especially needs to be addressed and removed to help clients comply with treatment. Therefore, education for health providers and increased opportunity for them to interact with homeless people is important.<br /> It is never easy to help homeless people recover from illness and return to their lives. That is why it is so important to develop an effective intervention program and make relevant policies. We may not be able to build up a "perfect" program; however, we can always improve the programs by examining the problems of the ones we are using. The process will help us find more possibilities in the future.<br /><br /><br /><br /><br /><br /><br /><br /><br />References <br />1. Henry, J., Boyer, L., Belzeaux, R., Baumstarck-Barrau, K., & Samuelian, J. (2010). Mental disorders among homeless people admitted to a French psychiatric emergency service. Psychiatric Services, 61(3), 264-271. <br />2. The National Coalition for the Homeless. (2009). How many people experience homelessness? Retrieved 04/26, 2010, from http://www.nationalhomeless.org/factsheets/How_Many.html <br />3. Martins, D. C. (2008). Experiences of homeless people in the health care delivery system: A descriptive phenomenological study. Public Health Nursing, 25(5), 420 - 430. <br />4. Folsom, D. P., Hawthorne, W., Lindamer, L., Gilmer, T., Bailey, A., Golshan, S., et al. (2005). Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. The American Journal of Psychiatry, 162, 370-376. <br />5. Hopper, K., & Barrow, S. M. (2003). Two genealogies of supported housing and their implications for outcome assessment. Psychiatric Services, 54(1), 50-54. <br />6. U.S. Department of Housing and Urban Development. (1999). Guide to continuum of care planning and implementation, 2010, from http://www.hudhre.info/documents/CoCGuide.pdf <br />7. Greenwood, R. M., Schaefer-McDaniel, N. J., & Winkel, G. (2005). Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. American Journal of Community Psychology, 36(3/4), 223-238. <br />8. Howie The Harp. (1990). Independent living with support services: The goals and future for mental health consumers. Psychosocial Rehabilitation Journal, 13, 85-89. <br />9. Gulcur, L., Stefancic, A., Shinn, M., Tsemberis, S., & Fischer, S. N. (2003). Housing, hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and housing first programmes. Journal of Community & Applied Social Psychology, 13(2), 171-186. <br />10. Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94(4), 651-656. <br />11. Kertesz, S. G., Crouch, K., Milby, J. B., Cusimano, R. E., & Schumacher, J. E. (2009). Housing first for homeless persons with active addiction: Are we overreaching? Milbank Quarterly, 87(2), 495-534. <br />12. Zalenski, R. J., & Raspa, R. (2006). Maslow's hierarchy of needs: A framework for achieving human potential in hospice. Journal of Palliative Medicine, 9(5), 1120-1127. <br />13. Kyle, T., & Dunn, J. R. (2008). Effects of housing circumstances on health, quality of life and healthcare use for people with severe mental illness: A review. Health and Social Care in the Community, 16(1), 1-15. <br />14. Gelberg, L., Gallagher, T. C., Andersen, R. M., & Koegel, P. (1997). Competing priorities as a barrier to medical care among homeless adults in Los Angeles. American Journal of Public Health, 87(2), 217-220. <br />15. Ball, F. L. J., & Havassy, B. E. (1984). A survey of the problems and needs of homeless consumers of acute psychiatric services. Hospital and Community Psychiatry, 35, 917-921. <br />16. Gelberg, L., & Linn, L. S. (1988). Social and physical health among homeless adults previously treated for mental health problems. Hospital and Community Psychiatry, 39, 510-516. <br />17. McLellan, A. T., & Woody, G. E. (1996). Evaluating the effectiveness of addiction treatments, Milbank Quarterly, 74(1), 51. <br />18. Silvia, P. J. (2005). Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic & Applied Social Psychology, 27(3), 277-284. <br />19. McCarthy, J., & Nelson, G. (1991). An evaluation of supportive housing for current and former psychiatric patients. Psychiatric Services, 42(12), 1254-1256. <br />20. Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), pp. 1-10. <br />21. Stein, J. A., Andersen, R. M., & Koegel, P. (2000). Predicting health services utilization among homeless adults: A prospective analysis. Journal of Health Care for the Poor and Underserved, 11(2), 212-230. <br />22. Kim, M. M., Swanson, J. W., Swartz, M. S., Bradford, D. W., Mustillo, S. A., & Elbogen, E. B. (2007). Healthcare barriers among severely mentally ill homeless adults: Evidence from the five-site health and risk study. Administration and Policy in Mental Health and Mental Health Services Research, 34(4), 363-375. <br />23. DeFleur, M. L., & Ball-Rokeach, S. J. (1989). Socialization and theories of indirect influence. In W. Plains (Ed.), Theories of mass communication (5th edition ed., pp. 202-227). NY: Longman Inc. <br />24. Phelan, J., Link, B. G., Moore, R. E., & Stueve, A. (1997). The stigma of homelessness: The impact of the label "homeless" on attitudes toward poor persons. Social Psychology Quarterly, 60(4), pp. 323-337. <br />25. Ugarriza, D. N., & Fallon, T. (1994). Nurses' attitudes toward homeless women: A barrier to change. Nursing Outlook, 42(1), 26-29. <br />26. Pescosolido, B. A., Martin, J. K., Lang, A., & Olafsdottir, S. (2008). Rethinking theoretical approaches to stigma: A framework integrating normative influences on stigma (FINIS). Social Science & Medicine, 67(3), 431-440.Christinehttp://www.blogger.com/profile/14848177219392201947noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-12018545889264926492010-12-16T18:18:00.000-08:002010-12-16T18:21:28.897-08:00The New San Francisco Happy Meal Ban Fails to Address Underlying Issues and May Backfire—Priyanka BearellyThe issue of childhood obesity is certainly not a new topic in the scene of public health; however, the severity of the issue is rapidly increasing as the rate of obesity in youth has more than tripled in the past 30 years (1). The prevalence of obesity among children of ages 6 to 11 years has increased from 6.5% in 1980 to 19.6% in 2008 (1). <br />Numerous organizations under the Department of Health and Human Services conduct various surveys and surveillance systems in order to gather information. Additionally, several interventions, such as the Body Mass Index Measurement in Schools, have been presented as means to combat this affliction (2). However, on November 9, 2010, a more dramatic change within the realm of fast food industries was passed and set to be implemented by December 2011 (3). In the city of San Francisco in Northern California, the Board of Supervisors banned the inclusion of toys in Happy Meals that do not meet certain requirements regarding nutritional value (3). These nutritional standards include reduced calories, salt, fat, and sugar as well as the addition of fruits and vegetables. With an 8 to 3 voting majority, the decision was practically unanimous (3). In fact, this ban goes beyond McDonalds and affects about a dozen fast food chains and some family-owned restaurants, which can all face fines up to $1000 per violation (3).<br />The idea behind this public health intervention is that children are not attracted to the food in the Happy Meal, but the toys. The subsequent conclusion is that in order to get those toys, the children will now only have the option of consuming foods with higher nutritional value. The original issue stems from the clever use of Marketing Theory by the fast food industry. “Packaging has become a form of advertisement, as companies innovate by putting food into “cool” new containers or adding licensed characters, games, and ads for other branded foods” (4). Therefore, children’s desires to follow the trend of collecting toys manifest as their desire for Happy Meals. Thus, this intervention tries to attack what the marketers do, by ensuring that the trendy thing to do is to eat healthy. However, there are several aspects of this approach that leave some room for potential failure.<br />The Happy Meal ban may inspire the opposite reaction.<br />The first problem can be explained by Reactance Theory. This idea, formulated by theorist Jack W. Brehm, addresses people’s reactions to threatened or eliminated freedoms and explains that people are likely to respond by reasserting their freedom (5). The theory suggests that they will do this by overreacting in the negative direction, usually doing the opposite of what they are told, also known as the Boomerang Effect (6). In the case of this intervention, consumers are losing this option of toys with their Happy Meals and may perceive this as a threat to their freedom. The actual consumers, in this case the children, may in fact still be too young to strongly react to this infringement on their freedom to choose, although psychological reactance does indeed begins at an early age. However, many parents undoubtedly will feel that they are being explicitly told how to be a good parent while further prohibiting them from purchasing the traditional Happy Meal. Essentially, they will lose their freedom to choose what to feed their children. Moreover, this ban will likely only draw more interest from children by presenting the traditional Happy Meals as forbidden. Therefore, these children will only be more attracted to the Happy Meal once it becomes unavailable.<br />The new law has been passed for only one month, and the backlash has already begun. In a letter to the board of supervisors who made the legislative vote, a frustrated parent wrote, “Do you really think the government needs to make these decisions for the citizens you represent? Are we not capable of deciding what we will eat and where we will take our children? Back off.” (7). This is a clear example of a person who does not appreciate being instructed by someone else how to live their own life and consequently feels a serious threat to their freedom. According to the Boomerang Effect, consumers will merely end up doing the opposite of what the government has aimed to achieve (6). According to a 1990 study examining nursing practices, one aspect of health education was the communication of information to certain people who were perceived to live “in ignorance” of their health (15). Patients did not appreciate being classified as such and were less receptive to any advice (15). It was concluded that this type of approach would be more likely to cause the individual to actively oppose the health intervention by even increasing their involvement in the unhealthy behavior (15).<br />Parents, as well as McDonald’s, can now respond to this threat in a variety of ways. For instance, the fast food restaurant can simply sell the toys separately, allowing for parents to regain their freedom to purchase the toy and meal of choice. This would certainly work against the efforts of the intervention. Thus, although parents may agree with the idea of combating obesity, they may in fact end up standing against the government as their own personal means of rebellion. Clearly, placing a prohibitory ban is not the most effective way to glean support among the population of interest.<br />The Happy Meal ban does not address the overall choice of diet.<br />The Health Belief Model (HBM) explains that people will essentially weigh the perceived benefits against the perceived barriers to engaging in a particular behavior (9). This decision is dictated by a person’s perceived susceptibility to the disease as well as the perceived severity of the disease, if contracted (9). In this case, the disease is obesity. According to the 2009 National Youth Risk Behavior Survey Overview, only 13.8% of high school students ate vegetables three or more times per day and only 22.3% had eaten fruits and vegetables five or more times per day (8). Moreover, 29.2% of students had drunk a can of soda, bottle, or glass of soda at least one time per day (8). Although the Happy Meals affect a much younger age group than is evaluated in this survey, their dietary behavior when young will still carry on to their choice of meals when older. Unfortunately, this current intervention addresses no aspect of the HBM. Just as before, the only factor affecting the consumer’s decision to purchase the Happy Meal is the toy. There is no certainty that the child will even eat the nutritionally improved food. There is no evaluation of the food being eaten—no recognition that the food is even healthier. Thus, neither the child nor the parent is taking an active role in making healthier decisions.<br />Moreover, the overall message of this new meal is telling people to eat fewer calories, as well as less sodium, fat and sugar. However, this is not a steadfast rule. For a growing child, it is important to get enough calories and fat, but the right kinds (23). In reality, kids older than 2 years-old should receive 30% of their calories from fat so that the brain and nervous system can develop correctly (23). This fat, or certain oils, can come from various products including peanut butter, fish, milk, etc. (23). This educational side of the obesity affliction is not merely a contributing aspect. It is crucial for the consumer to make the connection between the food he or she is eating and the subsequent health effects. People should be able to accurately recognize their susceptibility to obesity by being conscious of the quality and quantity of food that they are eating. However, this Happy Meal ban almost completely looks past the rudimentary, yet nonetheless important, values presented by the HBM. The intervention essentially forces consumers to select the healthier option and does not teach them to choose the healthy meal.<br />Although a rather simple model, the HBM has indeed proved effective in other diet-related settings. For instance, in the year 1982, the Food and Drug Administration along with the National Heart, Lung, and Blood Institute sponsored a sodium initiative in order to educate the public and increase awareness of the association of sodium consumption and the risk of hypertension (11). This was accomplished via display of sodium content on food labels (11). In fact, awareness in the American population across all societies of differing education levels increased by 38% in the following year and by 50% by year 1988 (11). As efforts to improve, or even merely maintain, such a level of dietary education began to diminish, people’s awareness slowly began to drop again (11). Similar studies regarding the associations between fiber consumption and the risk of cancer, between consumption of dietary fats and risk of heart disease, and between cholesterol and risk of heart disease all showed similar trends (11). Thus, while the values of the HBM may not be strong enough to serve as a sole solution, it is necessary and can be successful to use as a means of educating the population.<br />The Happy Meal ban is saying that it’s okay to eat the new Happy Meal?<br /> Not only is the new law prohibiting the marketing of nutritionally-poor food to children, but they are also setting nutritional standards for the new Happy Meal. Such close governmental regulations may make it appear as though the new meals are now no longer a threat to people’s overall health. This may translate into the idea that it is still okay to eat at fast-food restaurants now with these healthier menus, when in reality the truth is that it is only okay to eat at these places in moderation. In fact, when children of the age 7-17 eat out at restaurants, they consume on average 55% more calories than when they eat at home (12).<br /> This traces back to the very basic approach of using the principle of liking to sell a behavior. This stems as a subcategory of the Communication Theory, specifically as a topic termed Compliance Gaining Strategies by theorist Robert B. Cialdini (13). This refers to specific efforts that must be put in place in order to gain the compliance of the target population (13). One of these efforts is the principle of liking that “is based on warm ingratiatory behaviors and attractiveness” (13). <br />For instance, in 2005, Carl’s Jr. featured Paris Hilton in a commercial to promote their newest product. The target population, young males aged 18-34, tend to positively respond to the sexual appeal of attractive famous figures, such as Paris Hilton (10, 14). Therefore, their liking of Paris Hilton translates into their liking the new Carl’s Jr. product. According to the 2005 CKE Restaurants Sales Report, the sales for this particular burger rose 15.1 % over two years (22). The only difference in the case of this Happy Meal ban is that the government may not have intended to create this association. The primary restriction is that this phenomenon will predominantly only apply to the portion of the U.S. population that respects the government and tends to heed the advice given by political officials. Thus, it is possible that, according to this concept of liking, certain people will create this link between the government and the new and improved Happy Meal. With the belief that the government is a positive influence, they will view the new meal as a positive change and may eat it more frequently. Subsequently, they may end up eating at McDonald’s more often, which instead only exacerbates the issue of increased fast-food consumption. In the late 1970’s, children were eating 17% of their meals outside of the home, and fast food accounted for 2% of those meals (4). By the late 1990’s, children were eating 30% of meals outside, 10% of which being fast food (4). Clearly, it is important, at the very least, to not increase people’s attraction to fast food and hopefully sometime in the near future even reduce this appeal. Thus, for some people, this ban may only increase exposure to fast food restaurants as a result of people constructing this association between the government and the Happy Meal.<br />Proposal for improved intervention.<br /> This more appropriate intervention will no longer entail the existence of a ban. Instead there will merely be a healthier addition to the McDonald’s menu. This new meal will still adhere to the new nutritional requirements, but will also contain the same toy as the regular Happy Meal option. Moreover, a small informative booklet will be included in the packaging that serves to educate the parent and the child about the effects of their dietary decisions. Finally, with the implementation of the intervention, the government will release an information sheet regarding their position on obesity and fast food as well as “The Healthy List,” that aims to promote nutritional foods and to encourage eating at home.<br />New intervention provides solution to psychological reactance.<br /> The key idea behind any such resolution is to preserve the consumer’s ability to choose. Once this option vanishes, so does the increased efficacy of the intervention program. Therefore, the goal of this intervention is to present alternate choices to the consumer without them feeling as though the government is suggesting people’s freedom to choose should be limited.<br /> Whereas the current ban in San Francisco may in fact even increase demand for the traditional Happy Meal, at least this altered approach will ensure that people will not be more attracted to the original product. A classic example demonstrating the potential opposing results of these two different situations is seen in one of Brehm’s earlier studies. There were 3 design groups differing based on the availability of certain phonograph records, and one group under the impression that all records would be present, at the last minute was informed that one of the records was missing (6). This group showed an increased desire for this particular lost record in comparison to the control group that was free to choose from all records (6). Equating the missing record to the traditional Happy Meal, people will only show an increased desire for it. Therefore, by maintaining options, consumers will not feel this enhanced attraction to the original meal, much like Brehm’s control group.<br />One possible approach would be to add this new Happy Meal to the menu in addition to the more traditional one, both containing the same toys. This way, no one is directly telling the parents how to feed their children, but this option of a healthier choice will still cause the parents to acknowledge that this problem exists and that there are solutions. Instead of running in the opposite direction due to the oppression by rules and regulations, parents will feel that they are now finally presented with a more complete list of options. Similarly, the reactance would decrease on McDonald’s behalf. Although making additions to the menu will still require some force on the government’s part, board members can present this approach to McDonald’s administrators as a part of an effort to work together. This way, the fast food chain’s administrators would not feel as though the government is telling them how to run their restaurant, and would therefore be less likely to search for ways to work against the government.<br />New intervention provides solution to lack of health education.<br /> Even if people find themselves forced to choose a healthier option, they will fail to make more permanent lifestyle changes if they do not properly understand the consequences of their dietary decisions. Moreover, obesity rates are much higher in certain minority populations that include Hispanics as well as non-Hispanic blacks (16). According to measurements from 2006 to 2008, the overall prevalence of obesity in Hispanics across the United States was 28.7% and was 35.7% for non-Hispanic blacks (16). One of the explanations for this trend is that these minority populations have less access to healthy, affordable supermarkets. Furthermore, in low-income communities, their educational levels are much lower, and they do not necessarily understand how to evaluate the nutritional quality of their food (16). Therefore, it is clear that lack of proper education regarding nutrition is still an issue in some populations. <br />Alternately, it is certainly true that older age groups, not necessarily the target population of the Happy Meals, tend to have a better understanding of the overall importance of a healthy diet. A 1978 study concluded that 67% of the adult population acknowledged that they would be healthier if they ate better (17). However, in this case today with childhood obesity, parents are making dietary decisions for their young children who may be too young to make such evaluations on their own. Some parents may in fact be knowledgeable when it comes to their own dietary choices, but may not be as well-informed about the stark nutritional needs and limits of their children. In a 2001 study done in an Australian primary school to evaluate parental awareness of nutritional health, 42% of parents with obese children, 81% with overweight children, and 70% with underweight children did not report any concern (18). Certainly, this does not reflect a group of parents that can recognize the nutritional inadequacies from which their children suffer.<br />Therefore, in an effort to resolve this issue, small nutritional booklets may be included in both Happy Meals. These booklets, due to such a young target audience, will have to make more of an impact on the parents rather than the children. These booklets may include information regarding the nutritional quality of the food in the Happy Meal as well as the standard nutritional needs of growing children. According to the U.S. Department of Agriculture’s new Food Pyramid, these needs include five servings of fruit and vegetable per day, whole grain breads and cereals, fairly conservative amounts of lean meat or nuts and eggs as sources of protein, and the list continues (23). To ensure that the booklet is not simply thrown away along with the container, a coloring page or crossword can be included and advertised on the box. Moreover, specifically due to their young age, these children almost certainly do not know enough about their nutritional needs. In a 2010 study evaluating the effects of a health education program implemented in two Jewish schools in Chicago with grades 1 through 8, the results were significant (19). The students in grades 2-4, compared to their baseline knowledge from 2 years prior, were more capable of identifying the healthier foods after steps to improve health education were put in place (19). For instance, in the baseline survey, only 75% recognized that wheat bread is healthier than white bread, compared to 93% two years later (19). Thus, the younger age groups can also successfully respond to measures that promote health education. Therefore, this intervention can have a positive effect on both the parents and the children.<br />New intervention offers solution to government’s indirect perceived advocacy of the Happy Meal.<br /> Firstly, eliminating the prohibitory portion of this intervention, based on the aforementioned explanation concerning psychological reactance, will minimize the overall attention given to the legislation. Secondly, it will be difficult for the government to pass legislation while trying to remain neutral or trying to avoid creating any possible associations that the public might conceive. To avoid this ambiguity, the government should actively take a position about where they stand with the Happy Meal situation and be clear about it. Currently, most media and news regarding this ban fail to clearly explain the San Francisco board’s principal goals, leaving much room for interpretation. For instance, the most direct explanation given in an article by The Huffington Post is that the legislation “would limit toy giveaways in children's meals that have excessive calories, sodium and fat. It also requires servings of fruits or vegetables with each meal” (20). This is certainly the truth, but with incomplete information like this, the public will not fully understand the motivation behind this proposal.<br />Thus, the federal group that proposes this new intervention should also release an information sheet, explicitly stating their ultimate goals and the messages they hope to send. It should be clear that the new Happy Meal is not a new regulation, but rather a compromise between McDonald’s and the government, since federal officials cannot, nor do they wish, to control the fast-food restaurant business. In this sheet, they can also list foods and grocery stores that they believe actually do their best to cater to the health of consumers in a financially reasonable manner. Making such a list for restaurants would only encourage people to continue to eat out, thus only specific meals that can be made at home and particular grocery stores that provide healthy products should be the primary focus. For instance, the George Mateljan Foundation, a non-profit organization that has been in existence since the year 2000, has focused on what it calls “The World’s Healthiest Foods” (21). Offering new recipes, foods or ingredients of the week, tips on how to select fresh produce, and much more, the organization presents a healthier lifestyle as positive and enjoyable (21). Mateljan’s dietary advice over the years has achieved much popularity by gaining the support of the New York Times, ABC News, Yale University School of Medicine, and many other well-known associations (21). <br />The goal is that this new government-released list of healthy foods and stores will hopefully inspire similar support and attention as did Mateljan’s foundation. Examples of healthy, affordable foods include bell peppers, carrots, and garbanzo beans (21). As for the stores, most large local supermarkets, such as Stop n’ Shop in Boston, MA, have a wide selection of relatively inexpensive fresh produce, as well as other groceries. With this clear information provided to the public, it would be rather difficult for a person to believe that the government is in any way advocating McDonald’s or is coercively intervening in the fast food business.<br />Conclusion<br /> As mentioned before, the original issue of the Happy Meal is the extensive marketing of the product to the children. Therefore, it seems reasonable that this intervention would try to acutely attack this underlying problem by forcing the McDonald’s representatives to use their deceitful tactics, currently aimed toward children, to instead market healthier food. However, history has shown that force and implied obligations fail to play a positive role in improving communities. Moreover, an effective intervention should strive to change the intrinsic decision-making process involved in people’s dietary choices.<br /> The newly-designed intervention attempts to address all of these flaws present in the original proposal. It is certainly difficult for one single intervention to address all the issues of childhood obesity and attempt to resolve them. It is much more likely that a campaign that involves several interventions would be capable of encompassing all aspects of this problem. However, it is still crucial to strive for completeness with even just one intervention, as does this new intervention. Eliminating the greater possibility of immediate opposition, improving the nutritional knowledge of consumers, and avoiding any misconceptions concerning the opinions of any major players of this intervention, this proposal offers a more comprehensive solution.<br /><br />REFERENCES<br />1. Centers for Disease Control and Prevention. Childhood Overweight and Obesity. Atlanta, GA: Department of Health and Human Services, 2009.<br />2. Centers for Disease Control and Prevention. Body Mass Index Measurement in Schools. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, 2007.<br />3. McKinley, J. You Want a Toy With That? New York, NY: New York Times. http://www.nytimes.com/2010/11/04/us/04happy.html.<br />4. Schor, J.B., & Ford, M. From Tastes Great to Cool: Children’s Food Marketing and the Rise of the Symbolic. The Journal of Law, Medicine, & Ethics 2007; 35(1):10-21.<br />5. Brehm, J.A. A Theory of Psychological Reactance. New York, NY: Academic Press, 1966.<br />6. Clee, M.A., & Wicklund, R.A. Consumer Behavior and Psychological Reactance. The Journal of Consumer Research 1980; 6(4):389-405.<br />7. McConahay, P. Santa Clara’s Happy Meal Toy Ban Carefully Watched. Santa Clara, CA: California Healthcare Foundation. http://www.californiahealthline.org/features/2010/santa-claras-happy-meal-toy-ban-carefully-watched.aspx.<br />8. Centers for Disease Control and Prevention. Dietary Behaviors and Obesity. Atlanta, GA: National Youth Risk Behavior Survey Overview, 2009.<br />9. Glanz, K.. Rimer, B.K., & Lewis, F.M. Health Behavior and Health Education (3rd ed.). San Francisco, CA: Jossey-Bass, 2002.<br />10. Noe, E. How Well Does Pair Sell Burgers? New York, N: ABC News. http://abcnews.go.com/Business/story?id=893867&page=1.<br />11. Shapiro, R. Nutrition Labeling Handbook (Food Science and Technology). New York, NY: CRC Press, 1995.<br />12. Lynne, E., Bulmer, S., & De Bruin, A. Exploring the Link Between Obesity and Advertising in New Zealand. The Journal of Marketing Communications 2004; 10:49-67<br />13. Littlejohn, S.W., & Foss, K.A. Compliance Gaining Strategies (pp. 155-157). In: Littlejohn, S.W., & Foss, K.A., ed. Encyclopedia of Communication Theory, Volume 1. Thousand Oaks, CA: Sage Publications, Inc., 2009.<br />14. Sarracino, C., & Scott, K.M. Introduction (pp. ix-xx). In Sarracino, C., & Scott, K.M., ed. The Porning of America: The Rise of Porn Culture, What It Means, and Where We Go from Here. Boston, MA: Beacon Press, 2008.<br />15. Gott, M., O’Brien, M. Policy framework for health promotion. Nursing Standard 1990; 5(1): 90–92.<br />16. Centers for Disease Control and Prevention. Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults—United States, 2006-2008. Atlanta, GA: Department of Health and Human Services, 2009.<br />17. Louis Harris and Associates, Inc., Health Maintenance. New York, NY: Louis Harris and Associates, Inc., 1978.<br />18. Wake, M., Salmon, L., Waters, E., Wright, M., & Hesketh, K. Parent-reported Health Status of Overweight and Obese Australian Primary School Children: A Cross-Sectional Population Survey. International Journal of Obesity 2002; 26: 717-724.<br />19. Benjamins M.R., Whitman S. A culturally appropriate school wellness initiative: results of a 2-year pilot intervention in 2 Jewish schools. J School Health 2010; 80: 378-386.<br />20. Sterling, C. San Francisco Bans the Happy Meal. New York, NY: The Huffington Post. http://www.huffingtonpost.com/2010/11/02/san-francisco-happy-meal-ban-mcdonalds_n_777939.html<br />21. Mateljan, G. The World’s Healthiest Foods, Essential Guide for the Healthiest Way of Eating. Seattle, WA: George Mateljan Foundation, 2006.<br />22. Broussard, I. CKE Restaurants, Inc. Reports 26th Consecutive Period of Same-Store Sales Increases at Carl’s Jr. Carpinteria, CA: CKE Restaurants, Inc. http://phx.corporateir.net/phoenix.zhtml?c=117249&p=irolnewsArticle&ID=705243&highlight=<br />23. National Institutes of Health. Child Nutrition. Bethesda, MD: U.S. National Library of Medicine, 2010.Christinehttp://www.blogger.com/profile/14848177219392201947noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-29457476808286884272010-05-20T17:18:00.000-07:002010-05-20T17:20:29.259-07:00The ineffectiveness of current approaches on educating the severely mentally ill about sexual health and a proposal for change – Ivy ZangFew formal sexual health programs exist for the mentally ill. While much research has been done to demonstrate the need for such programs, little research has been done to determine the proper way to construct and deliver a program. The approaches documented in literature rely upon traditional public health models, which erroneously assume the individual to be rational and impervious to outside forces. The studied interventions also fail to discuss the unique needs of the mentally ill. An ecological approach incorporating predictable irrationality is necessary to minimize risky sexual behaviors among mentally ill adults. <br />Evidence of need for intervention.<br />Severe and persistent mentally ill (SPMI) adults experience major functional disabilities and undergo recurrent relapses requiring periodic stabilization and hospitalization (1). Since 1955, SPMI individuals have been deinstitutionalized from state hospitals into the community. This change in treatment has yielded a need to develop and improve sexual education programs for the mentally ill (2). <br />Historically, the SPMI were viewed as asexual, a view that stemmed from forced sterilizations and institutionalization. However, in a recent study of 400 SPMI adult patients of a outpatient clinic, 94% reported engaging in sexual intercourse (3). In addition to being sexually active, mentally ill adults often engage in high risk-sexual behaviors. Ten percent of the sexually active SPMI individuals in the study reported exchanging sex for housing, drugs, or money. More than half reported not using a condom in any of their last five sexual acts (3). Women with SPMI have more lifetime sexual partners than women without mental illness (4). Schizophrenic women have the same number of pregnancies as women without mental illness, but a greater percentage of them are unplanned and unwanted. Despite not wanting to become pregnant, sexually active women with schizophrenia often do not use birth control and lack basic knowledge of contraception (5). In a study of males with SPMI, nearly one-third reported engaging in sexual intercourse with a partner that they knew for less than twenty-four hours (6). HIV rates in the mentally ill are estimated between 5% and 7%, in contrast to 0.6% in the rest of the population, and 30% to 60% of SPMI individuals are at elevated risk for contracting HIV (7). <br />Critique 1. <br />The public health community fails to address the issue of high risk sexual behaviors among the mentally ill as sexual education programs targeting this population are few and far between. The Royal College of Nurses describes the sexual health care and education of people with SPMI as “inconsistent and inadequate” (8). This may be due to concerns about confidentiality, competency, and treatment responsibility (9). Only 38% of psychiatric hospitals have policies regarding sex relations. Only 58% of those policies include statements about contraception or sex education (10). Many facilities are opposed to offering sexual education programs, anticipating a resulting increase in sexually inappropriate behaviors on the unit, even though literature shows that most clients can tolerate exposure to sexually charged material without de-compensation or acting-out sexually (11). <br />This resistance to sexual health education stems from a “lack of knowledge about sexuality, conservative attitudes, and anxiety when discussing sexual issues” among mental health providers (12). In a study of British mental health home care nurses, the nurses felt that 41% of their patients would be comfortable discussing sexual issues with them, while only 50% of nurses felt comfortable discussing sexual issues with their patients (13). Although most mental health professionals believe that their patients will present the subject if necessary, most SPMI individual are not prepared to defy social and professional norms to bring up sexual health issues (14). Most adults with SPMI want to be informed about the social and environmental effects of illness on their sexuality and they want their providers to initiate this discussion (12).<br />Critique 2. <br />Where formal sexual education programs do exist, they are based on the framework of traditional public health models, most notably the Health Belief Model (HBM) and the Theory of Planned Behavior (TBP), which also predominate sex education programs for the non-mentally ill. Most sexual education programs investigated in the literature attempt to educate while promoting behavioral change. Most of the studies use small group interventions that rely on cognitive factors, behavioral skill factors, and external consequences in an attempt to change behaviors (15). Although some of the studies show reductions in risk behaviors, these effects are time-limited and repetition is necessary to maintain even short-term behavioral gains. Only a few studies examine actual behavioral change at the end of the intervention and even fewer follow-up with patients to determine the long term gains. As participation in the studies was voluntary, the examined samples were comprised of highly-motivated volunteers (7). <br /> A study of 35 group home residents involved three l-hour educational sessions, focusing on AIDS, risk behaviors, risk reduction, and condom use. Pre and post-intervention questionnaires assessed knowledge and did not reveal a change (16). <br />A three-session invention at an outpatient mental health clinic in Boston focused on sexual education, AIDS information, and condom use training. The study showed increased knowledge amongst participants, but did not assess behavioral change (17). <br />A study of 52 participants of a community support program in Milwaukee involved four 90-minute sessions focusing on HIV education, sexual assertiveness, negotiation skills, condom use, risk reduction and problem-solving. At a one-month follow-up, the rates of unprotected intercourse declined by 50% and the proportion of condom protected intercourse occasions increased from 18% to 53%. However, long-term changes were not assessed (18). <br />In a study of patients at a mental illness community center, six biweekly sessions focused on the transmission of STDs, HIV/AIDs myths, perceptions of the threat of infection, risky behaviors proposed by partners, screening sexual partners, and barrier contraception. Participants’ HIV information scores increased from 66% of questions correct during pre-intervention to 75% correct at post-intervention and remained at 75% correct at 1 month follow up. However, there was no significant change in participants’ attitudes towards condom use and the participants appraised their risk of infection as relatively low both before and after the intervention (19). <br />A study of 189 SPMI individuals at an outpatient clinic involved a 7-session small group intervention that focused on risk reduction, condom use, handling personal triggers for risky sexual situations, problem-solving, personalized plans to implement personal behavior change, communication, negotiation, and assertiveness. Men who attended the intervention only showed improvement in knowledge, while female participants changed their attitudes toward sexual behavior and increased their percentage of condom-protected vaginal intercourse occasions from 20% to 47%. This gain amongst females decreased substantially at the 12-month follow-up (20). <br />In a study of 97 chronically psychotic men with co-existing substance disorders living in New York City homeless shelters, subjects were randomly assigned to either a brief AIDS education or a 15-session risk reduction intervention incorporating condom use, communication skills, and risk management of situations known to be encountered by homeless men, including casual sexual contacts, sexual behavior while intoxicated, and same-sex contacts. Outcome analyses revealed greater reductions in unprotected intercourse and increases in condom use among participants in the intervention than the control group. Behavior changes remained observable through a 15-month follow-up, but weakened over time (21). Although this 15-session program proved effective, programs of this length are often not economically and logistically feasible. <br />In addition to the limited ability of the interventions noted above to elicit substantial behavior change, the health promotion literature has suggested many limitations to the traditional health care models. Many studies testing HBM and TPB-based interventions yield results that are inconsistent with the models’ constructs (22). Both models focus on individual decisions and do not address the multi-level ecological causes of behavior addressed in the next section of this paper. The basic assumption behind the models is that the individual has the ability to make rational and cognitive-based decisions; however, this inability is inherent in the diagnosis of mental illness (23). These models assume that health behaviors are simply based on attitudes and beliefs, failing to address the many other factors that influence health decisions (24). Psychosis and delusional thought amongst the SPMI may alter perception of real world events, but the mentally ill do not live in a vacuum. Even subtle changes in context and environment can drastically influence an individual’s health behavior decisions. For instance, the increase in motivation to have sex produced by sexual arousal is proven to decrease the relative importance of protecting oneself from unwanted pregnancy and STDs (25). An individual who has strong intentions to always wear condoms when engaging in intercourse with a new partner may spontaneously engage in unprotected sex if he is sexually aroused and condoms are not readily available. In addition, an individual with bipolar disorder may typically lead a monogamous lifestyle, but may engage in unprotected sexual encounters with multiple partners during an acute manic episode. By assuming that behavior is static, the models do not take into account the spontaneous actions that characterize most of human behavior (24). Lastly, these models assume that people value health highly (24). Health is a value that has a specific place in each individual’s value system, therefore the relative importance of health and its degree of influence on behavior varies among persons (26). Based on a randomly distributed survey of core values and preventative health behaviors, researchers determined happiness, pleasure, salvation, and a comfortable life to be the strongest core values for individuals who do not engage in preventative health behaviors. Those who do not engage health preventative behaviors rank health as a lesser core value than world piece and inner harmony (27). <br />Despite the obvious flaws with the models, health care practitioners continue to apply them to interventions. As these traditional health models serve as the basis for nursing and public health education, mental health professionals often rely upon these models when planning interventions (28). <br />Critique 3. <br />Sexual health interventions present in the current literature are based on generic cognitive-behavioral intervention models and have not been “specifically tailored to the special needs, risk situational circumstances, and change barriers likely to be encountered by the severely mentally ill” (7). The mentally ill face unique issues inherent in their diagnoses, their treatment, and the social and political consequences of their disease. The SPMI are unable to weigh costs against benefits when multiple ecological forces are in fact driving their decisions. <br />Although SPMI individuals are less sexually active than the rest of the population, those who are sexually active often engage in higher risk sexual behaviors. These high risk behaviors may be derived from poor interpersonal functioning, impaired psychosocial development, cognitive deficits, poor judgment, impaired decision making, labile mood, and impulsiveness leading to high levels of sexual vulnerability. Information processing deficits related to severe mental illness may inhibit people with SPMI from benefiting from preventive interventions that are based on traditional behavioral change principles (29). Hyper-sexuality, aggression, deep dependency needs, efforts to compensate for feelings of inferiority, response to auditory hallucinations, loneliness, and boredom may also be motivating factors for high risk sexual behaviors (30). The SPMI often have difficulty forming and sustaining stable sexual and social relationships. Sexual encounters amongst the mentally ill usually occur within casual relationships and some are “characterized by naiveté, abuse, and exploitation” (7). <br />Individuals with SPMI often have low levels of sexual health information, lack basic vocabulary of sexual terms, and have many misconceptions about sexual anatomy and physiology (5). In a focus group of rural women with SPMI, many held false beliefs, knew little about contraception and general women’s health, and did not receive regular gynecologic examinations (31).<br />The SPMI tend to be unemployed, impoverished, and overrepresented among the homeless, the incarcerated, and other disadvantaged groups at higher risk for STDs (9). Due to socioeconomic disadvantages, the mentally ill may also have tenuous and transient living arrangements and are often disproportionately concentrated in inner-city neighborhoods with higher rates of drug use, STDs, and HIV infections (7). Fifty percent of the mentally ill suffer from a dual diagnosis of chemical dependency which has synergistic implications for increased high risk sexual practices. Patterns of exchanging sex for drugs, lodging, and basic survival needs are not uncommon (7). Many SPMI individuals lack resources to purchase condoms and oral contraceptives (9). <br /> The general population often stigmatizes the SPMI, attributing mental illness to sin or lack of character or willpower (33). The media transmits multiple misconceptions about the mentally ill, including that they are homicidal maniacs or rebellious free spirits. This stigmatization decreases their self-esteem and hinders their ability to make friends and sustain social relationships, which may augment risky sexual behaviors (34). The SPMI lack political power and strong advocates, inhibiting change on community and governmental levels (9). Although organizations like the National Alliance of Mental Illness (NAMI) serve as powerful community resources, their legislative lobbying efforts are limited due to insufficient monetary funds (35).<br />Intervention.<br />Since multiple causes contribute to high risk sexual behaviors among individuals with SPMI, including the illness itself, an ecological approach is essential. Enhanced prevention strategies must extend beyond individually focused cognitive-behavioral interventions and address the broader psychosocial context in which risk behaviors occur (36). As behavior is affected by multiple levels of influence, interventions must be planned at an intrapersonal, organizational, community, and public policy levels (37). <br />The ecological model encourages educational programs, support groups, and counseling at the intrapersonal level (37). However, at the intrapersonal level, the ecological model does support the use of the traditional health promotion models determined earlier in this paper to be incapable of changing complex human behavior. This is an evident limitation of the ecological model; however, this level of the ecological model can be adapted with theories of predictable irrationality, most notably framing and ownership. Successful public health programs utilize “potentially effective combinations of established theory (38). <br />At the intrapersonal level, a sexual health program should be provided to patients during inpatient hospitalizations as most SPMI individuals have multiple hospitalizations over a lifetime, allowing for a broad target audience and multiple reinforcement sessions. On the inpatient units, staff nurses or mental health workers should lead a sexual health group multiple times during the week for the patients nearing discharge, as the ability to process information resumes when the acute phase of illness subsides (11). Groups should be informal with the ultimate goal of empowering the patients, not reprimanding or frightening them (39). To account for the cognitive impairment of many SPMI individuals, the group must start with a concrete discussion of sexuality, including reproductive anatomy and physiology, the transmission of disease, and contraception (15). During the educational session, instead of framing AIDS and STDs as severe and detrimental and trying to evoke fear as would be encouraged by the HBM, educators should reframe them as diseases preventable and controllable through communication with partners and avoidance of sexual risk (15). <br />Practicing condom use is a vital component of this intervention (11). When marketing condoms to male patients, the educators should, in addition to advertising the safe-sex benefits, reframe the action as a gain or a positive experience by reinforcing that condoms extend sexual performance and postpone ejaculation. By presenting the message as sex-positive and making condoms fun and erotic, the educator can reframe an individual’s perception, easing the process of seceding ownership of the high risk sexual behavior and increasing the likelihood of condoms use. When educating female patients on how to deal with male partners who refuse to wear condoms, the educator should describe the female condom as a tool capable of empowering women. The educator should reinforce the idea that the female condom is just as effective as the male condom, taking away the man’s power in the sexual relationship. When the female condom is reframed as a gain—a symbol of empowerment—safer sexual practices may emerge. Patients should be instructed to carry condoms with them at all times in the community, as people often underestimate their likelihood of having sex when in non-aroused states and will not make an effort to find condoms in an aroused state (25). Masturbation should also be discussed as a safe alternative to sexual intercourse. Traditionally, psychiatric units have had strict “no masturbation” policies and punish patients caught masturbating. This brings shame and embarrassment to the act. Masturbation should be reframed as a gain: a safe outlet for channeling normal sexual drives when done privately (30). <br />Additionally at the intrapersonal level, psychiatric facilities should employ women’s health nurse practitioners to counsel female patients of childbearing age about contraceptive options before discharge as SPMI women often have difficulties using community facilities for family planning (41). Mental health facilities are also more informed than family planning clinics as to how mental illness affects informed consent for family planning (42). On the day prior to discharge, the nurse practitioner should discuss the available contraceptive options. Injectable hormonal contraception, depo-provera, is the most appropriate contraceptive choice for use in this population. It lasts for three months and does not have significant clinical interactions with any anti-psychotic medications (5). Similar to the framing of the female condom, the nurse practitioner should frame the injectable contraceptive as a gain. It can be framed in terms of freedom and power: freedom from pill taking and a newfound power in the sexual relationship. The majority of patients who receive family planning counseling and are started on contraceptives in psychiatric hospitals continue contraception use after discharge and follow up with providers (5). As the SPMI often have difficulty utilizing community resources for contraception, have insufficient funds to purchase contraception, and underestimate their need to have contraception readily available, nurses should give condoms to both male and female patients at every discharge along with the discharge medication list. <br />Psychiatric facilities can utilize changes in organizational characteristics to support the behavioral changes of its patients. This includes changes in institutional commitment, policy and procedures, actions of staff members, and learning opportunities (37). As long as mental health professionals do not feel comfortable discussing sexual issues with their patients, the diffusion of comprehensive sexual health programs across psychiatric facilities will be unsuccessful (13), (14). In order to increase the comfort of mental health professionals, psychiatric facilities should provide continuing education programs that encourage providers to introspectively examine their attitudes and sensitivities to various aspects of sexuality in order to become more comfortable sexual issues (42), (43). <br />For program diffusion to be successful and behavioral change among SPMI individuals to be possible, the policies and corporate culture of psychiatric facilities must change. Policies must not rely on the personal judgment of staff, but should be sensible, sensitive, and validate the sexual rights of the mentally ill. Formal guidelines for sexual education, birth control, and capacity to consent must be devised (44). Organizational attitudes towards sexual practices must change along with new policies; staff members must not allow personal biases, fears, moral beliefs, and stereotypical beliefs to obstruct the implementation of new policies (45). <br />Community level interventions use existing social networks as mediating structures to influence community awareness (37). Depression and Bipolar Support Alliance (DBSA) is the leading patient-directed national organization for individuals with SPMI and has a strong social network (46). Through a system of peer-run support groups, DBSA educates SPMI individuals on the impact and management of mental illness. The organization has been a success, as 86% of its members remain compliant with their psychiatric medications (46). This existing social network can be used to increase sexual knowledge amongst the mentally ill and encourage members in engage in protective health behaviors. As DBSA relies on peer-to-peer communication, the sexual health message delivered would be one of considerate concern from a friend, instead of a provider’s paternalistic educational message. DBSA creates a community of trust, reciprocal support, and positive self identity where healthy behavioral changes can occur (47). Peer-mediated sexual health interventions have proven to effectively reduce risky sexual behaviors in other high-risk populations and may serve as an effective tool in eliciting behavioral change amongst the mentally ill . <br />Regulatory policies are essential in protecting the health of the community (37).<br />Local departments of mental health (DMH) should develop policies to control many of the external factors that lead to impulsive sexual behaviors amongst the mentally ill. Local DMHs should increase their funding of intensive case management services, which have proven to positively affect functional level and quality of life, while preventing exacerbation of illness (48). With an increase of funding, more case managers could be hired and individual case managers could spend more time with their clients ensuring medication compliance, temperance, and stable living situations to decrease likelihood of risky sexual practices. Case managers can work with the local Social Security offices to appropriately budget their clients’ finances and prevent the exchange of sex for lodging and food. DMH should allocate increased funds for supportive housing. Supportive housing gives SPMI individuals that are particularly prone to sexual exploitation or risky sexual practices a unique opportunity to learn about and to practice safer sexual activities in a supportive context (49). DMH should expand substance abuse services for the mentally ill as substance use is the strongest correlate of high risk sexual practices in this population (50).<br />Defense of Intervention 1. <br />The ecological model is an appropriate basis for the development of a sexual health intervention for the mentally ill as it encompasses the multiple physical and social factors that influence the healthfulness of a situation and the well being of its participants. Based on the model, efforts to promote health should emphasize the advantages of multilevel interventions that combine behavioral and environmental components, like facilitating psycho-educational group interventions while changing the professional culture of psychiatric units (51). The ecological model focuses on population-level prevention and includes individual level interventions aimed at persons with certain risk factors, interventions mediated through important organizational channels, and public policy interventions that redirect societal counter forces (52). The proposed intervention operates on all of those levels. Effective interventions create therapeutic micro-environments that facilitate and reinforce desired health behaviors, instead “arm[ing] patients with behavioral control strategies and then send[ing] them off into society to maintain their treatment gains, leaving them at the mercy of a social system that encourages, rewards, and profits from high risk behaviors” (52). This is done by beginning the intervention in the hospital with groups and reproductive counseling and continuing the intervention in the community with case management and supportive living services. Extensive research has been done using the ecological model as a framework for understanding behaviors and despite the fact that current evidence supports multi-level interventions, only a relative few number of studies involving the ecological model as a framework for intervention are published in the health promotion literature (53), (54). Many published papers discuss successful interventions that utilize the ecological model, but do not test the intervention in a formal study (55), (56). Despite this dearth of research, a multi-level intervention will yield greater benefit to SPMI individuals than a sole intrapersonal level intervention. <br />Defense of Intervention 2. <br />Frames are an effective way of promoting protective sexual behaviors at the intrapersonal level, as health care promoters can manipulate frames to alter the judgments and opinions of the targeted population. A frame is a way of packaging and positioning an issue to convey a certain meaning. By packaging an issue in a more desirable way, health care promoters can change attitudes towards health behaviors and the likelihood of behavioral change (57). A meta-analysis of framing experiments in relation to health promotion proved framing to be a successful tool for interventions that involving safer sex (58). People are sensitive to whether an intervention is framed in terms of its associated costs (loss frame) or in terms of its associated benefits (gain frame), even when the two frames describe the same situation (59). Gain frame interventions are more persuasive than fear-inducing frames when it comes to implementing preventative behaviors, like condom use (60), (61). Threat or fear appeals advocated by traditional health models are ineffective in sexual health interventions as many people fear STDs or HIV without feeling that they are personally vulnerable and will downplay their own personal risk in comparison to risks of others (62). <br />Messages that are framed in unexpected ways or do not match participants’ experiences or concerns can be more effective as they lead to greater message processing (63). Instead of presenting a message of sexually transmitted disease and health effects, the proposed intervention delivers an unexpected sex positive message of freedom and empowerment. By changing the definition of the problem, it is thus possible to change the response. Although health is a core value for some, successful public health interventions must utilize frames that appeal to the same compelling core values being tapped into by the opposition (57). In a state of arousal, sexual pleasure is a much more compelling core value than health. By reframing condom use as a way to improve sexual activity, instead of a way to prevent disease, a more compelling core value is utilized. <br />Defense of Intervention 3. <br /> As individuals quickly come to own their health behaviors, behavioral change is dependent upon their ability to give those behaviors up. When a health promoter is able to offer the individual a new behavior coupled with a compelling core value, behavioral change may be possible. Psychological ownership is the state in which individuals feel that a target of ownership is theirs. A target of ownership may be an object or a non-physical entity, such as ideas, words, or behaviors. The cognitive state of ownership is tied with emotional and physical sensations, including the rise of pleasure, efficacy, and self-identity. This leads to an intimate relationship between self and possessions; the entity may become part of the extended self (64). People tend to place a larger value on an entity when it is in their possession and resist to part with their possessions as they allow people to keep to the status quo. Over time, individuals come to own their health behaviors, thus their health behaviors become an extended part of themselves and are difficult to give up (65). As duration of ownership increases, the owned behavior increases in value (66). Despite the unattractiveness of risky sexual behaviors, owners still see parting with them as a loss (65). As people are “more reluctant to give up an attainment than they are eager to acquire it,” they must be persuaded with something that they value even more (66). As discussed earlier, pleasure has shown to be the most valuable of possessions for those who do not engage in preventative health behaviors, so for a person to give up risky practices, he or she must be offered pleasure in return (27). For men to give up sex without a condom, they must be given the pleasure of improved sexual performance. For women to give up passivity in sexual interactions, they must be given pleasure of empowerment. <br />Conclusion. <br />“Sexual activity among the [mentally ill] is a reality and one with which we must deal and not put our heads in the sand” (10). The mentally ill are sexually active and do engage in high risk sexual activities due to lack of education, the complexities of mental illness, and social and behavioral factors. Due to attitudes and beliefs of health care professionals, the sexual practices of the mentally ill have long been unaddressed. High-risk sexual activities are a reality that traditional models of health promotion cannot change. An ecological approach along with the principles of framing and ownership could serve as an effective way of dealing with sexual activity amongst this vulnerable population. <br />References<br />1. Muhlbauer S. 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Neuroleptic medication and sexuality:The forgotten aspect of education and care. Journal of Psychiatric and Mental Health Nursing 2005; 12:439-446. <br />41. Abernethy V and Grunebaum H. Toward a family planning program in a psychiatric hospital. American Journal of Public Health 1972; 62:1638-1646. <br />42. Dobal, M. and Torkelson, D. Making decisions about sexual rights in psychiatric facilities. Archives of Psychiatric Nursing 2004; 18:68-74. <br />43. Solursh D, et al. The human sexuality education of physicians in North American medical schools. International Journal of Impotence Research 2003; 15:S41-S25. <br />44. Buckley P and Hyde J. State hospital's responses to the sexual behavior of psychiatric patients. Psychiatric Services 1997; 48:398-399. <br />45. Torkelson D and Dobal M. Sexual rights of people with severe and persistent mental illness: Gathering evidence for decision making. Journal of the American Psychiatric Nurses Association 1999; 5: 150-160. <br />46. Depression and Bipolar Support Appliance. About the Depression and Bipolar Support Alliance (DBSA). Chicago, Il: Depression and Bipolar Support Alliance. http://www.dbsalliance.org/site/ PageServer?pagename=dbsa_aboutdbsa. <br />47. Campbell C and MacPhail C. Peer education, gender and the development of critical consciousness: participatory HIV prevention by South African youth. Social Science and Medicine 2002; 55:331-345. <br />48. Gorey K, et al. Effectiveness of case management with severly and persistently mentally ill people. Community Mental Health Journal 1998; 34:241-250.<br />49. Kloos B, et al. Neogotiating risk: Knowledge and use of HIV prevention by persons with serious mental illness living in supportive housing. American Journal of Community Health 2005; 36:357-371. <br />50. Raj A, et al. Associations between alcohol, heroin and cocaine use and high risk sexual behvaviors among detoxification patients. 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An ecological model for premature infant feeding. Journal of Obstetrical, Gynecological, and Neonatal Nursing 2009; 38:489-90. <br />57. Menashe C and Siegel M. The power of a frame: An analysis of newspaper converage of tobacco issues- United States, 1985-1996. Journal of Health Communication 1998; 3:307-325. <br />58. O' Keffe D and Jensen J. The relative persausiveness of gain-framed loss-framed messages for encouragingg disease prevention behaviors: A meta-analytic review. Journal of Health Communication 2007; 12:623-644. <br />59. Rothman A and Salovey P. Shaping perceptions to motivate health behavior: The role of message framing. Bulletin 1997; 121:3-19. <br />60. Albarracin D, et al. A test of the major assumptions abotu behavioral change: A comprehensive look at the effects of passive and active HIV-interventions since the beggining of the epidemic. Psychological Bulletin 2005; 131:856-897. <br />61. Kiene S, et al. Why are you bringing up condoms now? The effect of message content on framing effects of condom use messages. Health Psychology 2005; 24:321-326. <br />62. Canin L, Dolcini M and Adler N. Barriers to and facilitators of HIV-STD behavior change: Intrapersonal and relationship based factors. Review of General Psychology 1999; 3:338-371. <br />63. Devos-Comby L and Salovey P. Applying persausion strategies to alter HIV-relevant thoughts and behaviors. Review of General Psychology 2002; 6:287-304. <br />64. Pierce J and Kostova T. The state of psychological ownership: Integrating and extending a century of research. Review of General Psychology 2003; 7:84-107. <br />65. Brenner L, et al. On the psychology of loss aversion: Possesion, valence, and reversals of the endowment effect. Journal of Consumer Research 2007; 34:369-378.<br />66. Strahilevitz M and Lowenstein G. The effect of ownership history on the valuation of objects. Journal of Consumer Research 1998; 25:276-289. <br />67. Pinkerton S, et al. Cost-effectiveness of an HIV prevention intervention for mentally ill adults. Mental Health Services Research 2001; 3:45-55.<br />68. Rele K and Wylie K. Management of psychosexual and relationship problems in general mental health services by psychiatry trainees. International Journal of Clinical Practice 2007; 61:1701-1704. <br />69. Koen L, Niehaus D and Emsley R. Negative symptoms and HIV/AIDS risk-behavior knowledge in schizophrenia. Psychosomatic 2007; 48:128-134. <br />70. Meade C and Sikkema K. Psychiatric and psychosocial correlates of sexual risk behavior among adults with severe mental illness. Community Mental Health Journal 2007; 43:153-169. <br />71. McKinnon K. Research on AIDS, HIV, and severe mental illness: Recommendations from the NIMH national conference. Clinical Psychology Review 1997; 17:327-331. <br />72. McCandless, F. and Sladen, C. Sexual health and women with bipolar disorder. Journal of Advanced Nursing 2003; 44:42-48. <br />73. Higgins A, Barker P and Begley C. Sexual health education for people with mental health problems: what can we learn from the literature? Journal of Psychiatric and Mental Health Nursing 2006; 13:687-697. <br />74. Sheild H, Fairbrother G and Obmann H. Sexual health knowledge and risk behaviour in young people with first episode psychosis. International Journal of Mental Health Nursing 2005; 14:149-154. <br />75. Murthy S and Wylie K. Sexual problems in patients on antipsychotic medication. Sexual and Relationship Therapy 2007; 22:97-107. <br />76. Cook J. Sexuality and People with Psychiatric Disabilities. Sexuality and Disabilities 2000; 18:195-206. <br />77. Grassi L. Risk of HIV infection in psychiatrically ill patients. AIDS Care 1996; 8:103-116. <br />78. Perehinets I, Mamary E and Rose V. Conducting HIV prevention programs for the severely mentally ill: An assessment of capacity among HIV prevention programs providers in the city and county of San Francisco. 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Health Education Research 2000; 15:283-291.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-14692072245691702232010-05-20T17:17:00.000-07:002010-05-20T17:21:39.575-07:00Advertising Moguls in Public Health: How Advertising Theory Can Help Inform the National Youth Anti-Drug Media Campaign - Krupa VithlaniAdolescent drug use in the Unites States has been a cause of major concern over the last quarter of the twentieth century, with lifetime prevalence among youth continuing to increase throughout high school for some drugs such as marijuana, cocaine, and other stimulants (1). In 1975, a majority consisting of 55% of the nation’s youth had used an illicit drug by the time they graduated from high school, a trend that rose to 66% until the 1980s and returned to a previous high of 55% by the year 1999 (2). More recently, a 2007 study found that just under half (47%) of the nation’s high school students have tried an illicit drug by the time they graduate, which is still a considerably high rate of incidence (3). Though the annual prevalence rates of youth drug use are currently below their recent peaks, no significant further decline has occurred in 2007 as compared to previous years. The use of marijuana, on the other hand, is reported to be most pervasive, with approximately 20% of youth engaging in the activity as of 2007 (3-4). <br />In 1998, the U.S. Congress created the National Youth Anti-Drug Media Campaign (the campaign), in an attempt to curb the use of illicit drugs among the nation’s youth. The campaign’s stated primary goals are to prevent as well as to reduce the use of illicit drugs, with a central strategy using nationwide paid advertising to disseminate anti-drug messages to target youth populations (ages 9 to 18) and their parents (5). Administered by the White House Office of National Drug Control Policy (ONDCP), the campaign is the nation’s largest anti-drug media campaign and is generally regarded as the single largest source of drug-prevention messaging directed to youth. Although the campaign was initiated in 1998 with the overall aim of educating youth about the ill-effects of illicit and licit substances such as alcohol, methamphetamine, ecstasy and marijuana among others, it shifted its primary focus towards preventing teen marijuana use between 2002 and 2004.<br />According to the Government Accountability Office (GAO), however, the government’s investment of 1.4 billion dollars from 1998 to 2006 has yielded no significant favorable effect on marijuana initiation among non-drug-using youth or on discontinuing or declining use among prior users (6). What is more, the GAO, basing its conclusions on research conducted by Westat Incorporation, believed that the campaign may have even encouraged more teens to use marijuana (5). In spite of the GAO’s recommendation to stop funding for the campaign unless new strategies can be applied, the Bush administration sought an additional 120 million dollars in funding for the campaign in 2007, an increase in 20 million dollars from the campaign’s 2006 budget appropriations (6). In 2005, the campaign shifted focus from targeting parents and peers as the “Anti Drug” to encouraging teens to live “Above the Influence.” However, this shift in theme has not bought about a change in philosophy, as the campaign still erroneously conforms to the Theory of Reasoned Action (TRA) rationale in order to convey its anti-drug messages to youth. <br />The Theory of Reasoned Action (TRA) is an individual-centered model that views human behavior as a function of interactions between individual attitudes, social norms, and intention. A person’s intention is determined by weighing their personal attitude against perceived social norms. This intention then directly leads to behavior (7). Individual attitude towards a specific behavior is comprised of his or her opinion whether performing the behavior is good or bad. This attitude is influenced by the beliefs of the individual towards that behavior, referred to as behavioral beliefs (7). Social norms are comprised of the individual’s perceptions of the social pressures put on him or her to perform or not perform the behavior in question (7). These social norms, in turn, are influenced by individuals’ normative beliefs. It should be noted that the TRA model presumes behavior to be a rational process whereby individuals deliberate, whether consciously or unconsciously, the costs and benefits of performing a particular behavior. Additionally, it also assumes that behavior is planned and logically pre-analyzed, leaving little room for consideration of spontaneous behavior or a momentary change of mind on the individual’s part (7 & 8). <br />The TRA may be considered a reasonable theory to utilize when creating anti-drug interventions as it takes into consideration the power of social norms in shaping individual behavior. That is, the TRA model accounts for the individual’s intrinsic attitude as well as his or her social environment as embodied in the attitude of others. The individual’s own attitude towards drug use and his or her perception of the opinions of others (including peers and parents), are arguably two of the most important factors in shaping one’s intentions regarding drug use. A TRA-based intervention could potentially seek to manipulate the target youth’s personal attitudes and their perceived social norms in order to affect behavioral change. As such, anti-drug campaigns could attempt to instill a negative attitude in teens regarding marijuana use, expecting to negatively reinforce the use of drugs by depicting the use of marijuana as an undesirable social norm. Or conversely, a TRA-based intervention could be designed so as to positively influence youth by presenting social norms that promote a healthy, drug-free lifestyle. It appears that the Above the Influence campaign focuses on the former strategy of negative reinforcement, but it largely fails to do so effectively. A part of the failure of the campaign to effectively convey anti-drug messages to youth stems from basic limitations of the TRA model. This conventional logic model is mathematically structured such that it fails to appreciate the true dynamics of decision-making and is ineffective when it comes to predicting spontaneous behavior. Hence, TRA-based interventions cannot prevent or reduce risk behaviors such as smoking, drinking or drug use in social situations where teens, in an irrational or “hot” state of mind (9) that comes with their age-defined need for peer approval and social popularity, are unlikely to stop to carefully weigh the costs and benefits of the behavior they are about to engage in. Such is the case with the National Youth Anti-Drug Media Campaign and its Above the Influence message brand. <br />Above the Influence: Enduring Obstacles to Effective Campaign Messaging<br /> One major setback of the campaign is that the commercials depict negative social norms associated with marijuana use in a highly exaggerated manner. It is important to recognize that health risks associated with substance abuse, sexual behavior and general well-being nevertheless rank low among the average adolescent’s other concerns (10). For the most part, an under-assessment of the risks related to drug use on the part of the youth presents a challenge in their ability to accurately relate to the negative consequences depicted in these commercials. What is more, several Above the Influence commercials portray negative consequences of drug use in an unrealistic fashion, such that they further undermine their own credibility and relevance to the reality of their target population. For instance, the “Not again” ad shows a couple with the ‘boy’ smoking marijuana as the ‘girl’ looks on in disappointment, with the words “not again” appearing next to her head. A space ship subsequently appears out of the sky, and an ‘alien’ emerges from it. It approaches the couple, and the boy offers him marijuana, which it turns down saying “no thanks.” The girl is pleasantly surprised by this gesture – as suggested by the heart symbol blinking near her head – and she decides to fly away with the alien instead, leaving the boy pondering at what just happened (11). <br />In accordance with the principles prescribed by the TRA model, the “Not again” commercial tries to influence the behavior of teenagers by showing that society (including the extraterrestrial civilization) disapproves of individuals who smoke marijuana. This negative social norm against the use of marijuana is primarily represented in the unfavorable reaction of the girl. Moreover, her abandonment of the boy is an attempt to manipulate the perceived social norms of adolescent marijuana users by indicating that their friends will leave them or avoid them if they continue their drug habit. While the message of this commercial may be reasonable, the manner in which it is communicated is highly unrealistic. The presence of an alien itself takes away any semblance of reality that the commercial might have otherwise held, leaving teens unable to relate with it. Additionally, this commercial might even be offensive to adolescents who may feel that it underestimates their intelligence, believing them to be foolish or naive. Whereas the use of stick or cartoon figures in this commercial might be appealing to elementary children, they are further likely to undermine the commercial’s credibility and serious message among its target teenage population.<br />An equally unrealistic Above the Influence commercial is the “Stop looking at me” ad, which depicts a pet dog reprimanding his adolescent owner for using marijuana (12). This commercial also fails to resonate with its target population, not taking into account that adolescents are less likely to take the idea of a talking dog seriously. The depiction of social norms against the use of marijuana – in this case the pet dog being disappointed – also represents an ineffective communication strategy of the campaign’s intended anti-drug message. That is to say, targeted adolescents are less likely to identify with negative social norms that come from a talking dog due to its sheer discrepancy with reality. Thus, a combination of the unrealistic depictions of negative social opinions regarding drug use and the tendency of the Above the Influence ads to underestimate teenagers’ sophistication and intelligence levels has resulted in anti-drug messaging that adolescents are largely unable to relate to. Consequently, commercials in the Above the Influence portfolio, such as “Not again,” “Stop looking and me,” and others, are not inclined to produce the desired change in behavior, whether prevention or reduction of drug use. <br />Another significant flaw in the Above the Influence campaign is that its commercials focus solely on the negative effects of smoking marijuana without presenting adolescents with any positive activities they can engage in as sound alternatives to drug use. Peers have an enormous impact, both negative and position, on the actions and behaviors of an adolescent with regard to risk behaviors such as alcohol consumption and marijuana use (8 & 10). A study conducted on this subject showed that adolescents, who had friends that were involved in ‘deviant’ behaviors such as marijuana use, were more likely to engage in such behaviors themselves (8). On the other hand, teens whose friends engaged in numerous school and community activities (like athletics, drama or volunteering) were less likely to engage in harmful behaviors like marijuana consumption (10). According to these studies, in order to be effective, anti-drug campaign ads need to portray teenagers involved in positive social activities instead of negative ones such as drinking or using drugs. Unfortunately, as they currently stand, most Above the Influence campaign ads are in complete contradiction to these findings. A majority of these commercials – “Dog,” “Not again,” “Shadow,” “Fire,” “Cocoon,” to name just a few – portray teenagers who are using marijuana, as opposed to showing positive examples of adolescents actively staying above the influence by engaging in alternative activities. The single exception to this trend is the “Fitting in” ad, which I believe is the only Above the Influence commercial that seeks to positively reinforce anti-drug attitudes in teenagers. This commercial shows an adolescent boy actively maneuvering to “fit” into different frames of various social situations and activities such as hanging out with friends at a café or skateboarding. However, when a frame depicting two youth engaging in marijuana use approaches the forefront of the screen, the protagonist makes the choice to walk away. The commercial then begs the target viewer to consider: “is everything worth fitting into?” (13). Unlike other ads in the Above the Influence campaign, “Fitting in” sympathizes with adolescents’ age-appropriate need to “fit in,” but it sends a strong message of youth empowerment by indicating that not all activities, especially drug use, may be worthwhile as there are always other “frames” or alternative activities one can opt for in order to gain social acceptance or peer approval. <br />A third important drawback of the Above the Influence campaign is that it does not effectively change individual attitudes towards marijuana use. That is to say, it fails to appeal to the core values adolescents commonly subscribe to, including independence, control, social or peer acceptance, and rebellion against authority. Studies have shown that teenagers, due to the influence of puberty and hormonal changes associated with it, are more likely to engage in rebellious, sensation seeking behavior than any other age group (14). Sensation seeking behavior, in turn, is directly proportional to the early onset of alcohol and drug abuse amongst teenagers (15 & 16). Most adolescents have positive personal attitudes towards marijuana because the use of it allows them to engage in sensation seeking, rebellious and risky behavior – values that they aspire or closely associate with. Thus, in order to prevent teenagers from partaking in the risky behavior of drug abuse, anti-drug campaigns like Above the Influence are burdened with off-setting adolescents’ pull towards marijuana use. <br />However, until now, the Above the Influence campaign has largely failed to take advantage of or associate its anti-drug messages with the aforementioned core values that adolescents strongly adhere to. In fact, unfortunately most of the campaign commercials do the exact opposite. These ads project the act of using marijuana as one that society (by extension authority figures such as parents, educational & professional institutions, and the law) disapproves of, thus unintentionally associating its use with core adolescent values of rebellion and independence. For instance, the “Not again” commercial conveys societal disapproval of drug use in the reactions of the ‘girl’ as well as the ‘alien’ who eventually abandon the ‘boy’ using marijuana. Unfortunately, it is the very condemnation of drug use that so widely appeals to the core teen value of rebellion, and is viewed in a positive rather than a negative light by most adolescents. The combination of such rebellion-conducive messages and portrayal of adolescents smoking marijuana without facing any realistic negative consequences may be contributing factors to the GAO/Westat Inc. report’s findings of higher propensities to use marijuana amongst youth. Ultimately, the inability of the Above the Influence campaign to alter individual attitudes towards marijuana use has rendered it ineffective in controlling the growing rates of drug use amongst adolescents.<br />The Use of Advertising Theory to Bolster Campaign Messaging<br />In order to effectively reduce marijuana consumption and use of other illicit drugs amongst U.S. teenagers, extensive changes in intervention models are required in the field of public health. Instead of relying on traditional public health models, such as the theory of reasoned action, which overlook essential social factors influencing the decision-making process of teenagers indulging in high-risk behavior, focus needs to shift on newer and more comprehensive alternative models that cater to the core values of the target population (17).<br />The creators and supporters of the campaign tend to distinguish it from previous efforts of its kind by emphasizing that it is “…modeled on advertising industry and market research best practices.” As part of its initial phases, the campaign executed “exploratory research” which includes literature reviews, expert opinions, scientific claims, interviews of affected communities, and communication with an “expert panel.” Subsequent best practices that the campaign professes to have employed include qualitative or “focus group” testing, quantitative or “copy” testing, as well as tracking ad assessment studies measuring teen awareness and memory of the commercials (18). <br />At first glance, many Above the Influence ads strike one as being well made and unique; almost all commercials follow a story or message directly related to youth, while many hold the attention of the viewer well. For instance, the “Stop looking at me” ad depicts an engaging dialogue between the dog and its adolescent owner that compels the viewer to follow their exchange, conveyed in the form of scribbled writing above stick drawings of the protagonists. Though this ad is at first visually appealing and can capture the attention of its target audience, the use of comic images and the idea of a judgmental pet dog separate it from reality, consequently undermining the ability of teenagers to identify with the substance and content of the message. <br />Although the visual quality of most Above the Influence commercials indicates consultation of advertising industry experts, a deeper evaluation of the campaign on the basis of “the advertising theory” is called for. Two principles of this theory form the essence of all commercial advertisements: “the Promise,” and the “Support” for that promise. According to this theory, the Promise is a fundamental element of all ads and is essentially the selling point of any commercial (19). On the other hand, the Support refers to the combined effect of select images, words, symbols, metaphors, background music, and overall feel of the commercial to support that Promise and persuade the viewer that they want the product being advertised. The Promise is the center-piece of any advertisement; and the best ones are carefully crafted such that “[p]romise, large promise is the soul of the advertisement.” (19). In other words, the larger the Promise, the more effective the advertisement. In the world of commercials, even a Promise so huge that it is absurd has the potential to be enormously successful if it offers the consumer something he or she aspires. Conversely, the key function of the Support is to reinforce “the promise of happiness engineered by advertisers through the consumption of images which appeal to human needs and sensuality” (20). It should be noted that with the simple formula of the Promise and the Support, commercial advertisements calculatingly appeal to the core values of its target population. In other words, successful commercials rarely sell the material product they are representing; instead they seek to assimilate with human aspirations and values such as love, freedom, independence, beauty, youth, acceptance, accomplishment, and control. <br />The ultimate objective of public health, on the other hand, is usually to discourage or encourage a particular health behavior or lifestyle choice among its constituents. However, years of failed or vaguely successful public health campaigns have proven that health does not sell. In light of this, the market strategy of appealing to core human values has an incredible potential to bolster such public health campaigns that often experience difficulty on the account that they are lacking a material product to “sell” to their target population. <br />As it currently stands, the Above the Influence campaign just scratches the surface of advertising and marketing principles, focusing more on the outer appearance and attractiveness of the ads as opposed to critically analyzing what most appeals to adolescents. The advertising theory, if used wisely and constructively, has the potential to transform the Above the Influence campaign into a successful endeavor capable of reducing marijuana use amongst youth. In order to strike a chord among its target population, the campaign must consciously utilize core youth values such as rebellion, independence, control and social acceptance. <br />To begin with, the social consequences of marijuana consumption need to be more realistically depicted. Current campaign commercials such as “Not again,” “Dog,” and “Don’t look at me” are ineffectual. Teenagers cannot relate to the consequences of marijuana consumption depicted in these commercials, since they are not reasonably portrayed. That is to say, that although their central message or Promise may be reasonable, the Support for these ads is weak and unrealistic. Your girlfriend leaving you for an alien because you are using marijuana or your talking pet dog reproaching you for the same are exaggerated consequences of marijuana use that teenagers can not relate to. One key way in which the consequences can be made more realistic is by fortifying the Support for these commercials. Campaign ads such as “Not again,” “Stop looking at me,” and “Dog” need to be replaced with commercials that depict real-life teenagers delivering the anti-marijuana message. By showing other youth – rather than cartoon stick figures and animals – delivering the anti-drug message, these commercials will better connect with marijuana users who will be able to relate to the intended message. Additionally, marijuana using teens will be more accepting of an anti-marijuana message delivered by peers who are similar to them in that they are experiencing the same everyday conflictions and emotional ups and downs. In addition, this strategy incorporates a compelling personal story and a face into the commercial, further strengthening the Support for the anti-drug message. Thus, using teenagers as familiar conveyers of the message is an effective way of presenting the consequences of using marijuana more persuasively. <br />There are, in fact, several Above the Influence commercials, such as “Fire” and “Achievements” for instance, that do portray other teenagers delivering the anti-marijuana message. However, these commercials remain ineffective because the content of the message is negative, rather than positive. Instead of expressing an appealing Promise by depicting teenagers participating in healthy, alternative activities these commercials focus solely on the negative outcomes of marijuana use. On the contrary, improved ads that employ a positive Promise with appropriate Support are more likely to succeed in empowering youth and reinforcing a positive identity of adolescents that resist drugs. <br />The “Achievements” commercial shows several marijuana using teenagers talking about how they abandoned their friends, disappointed their mother or got failing grades because they were addicted to marijuana (21). This commercial portrays marijuana users in a negative light, labeling them as irresponsible and reckless. Additionally, it fails to provide them with any alternative healthy activities they can engage in. Likewise, the “Fire” commercial depicts three teenagers abandoning the activities that they are involved in because of marijuana. The girl burns her athletic certificates in the fireplace, one of the boys chars his guitar on the grill, meanwhile the other sets fire to his car (22). The commercial attempts to show that using marijuana will eventually lead to the individual giving up healthier hobbies that he or she was once interested in. Again, though both these commercials have strong Support due to the memorable and jarring images used to convey their anti-drug message, the Promise they both offer is weak in that they focus on the negative aspects of smoking marijuana without highlighting any positive outcomes of not smoking marijuana. <br />As mentioned before, teenagers are easily influenced by their surrounding environment. Research has shown that youth who had friends that were involved in undesirable behaviors – such as using marijuana – were more likely to indulge in such behaviors themselves. In contrast, teenagers whose friends were involved in alternative activities such as sports or community service were more averse to using marijuana. Accordingly, it is essential that Above the Influence campaign commercials focus on portraying teenagers partaking in desirable alternative activities, rather than depicting teens who are using marijuana. For this reason, campaign commercials would be more successful by presenting teens involved in activities like playing sports, participating in the school musical, creating artwork and other such enjoyable and healthy activities. As mentioned earlier, the sole Above the Influence campaign that has succeeding in doing so is “Fitting in.” Alternatively, the “Try football” ad, as suggested by its title, also tries to urge youth in participating in alternative activities, but it does so rather ineffectively. This ad depicts a tall boy smoking marijuana who smugly tells a smaller boy passing by with his dog that he uses drug to “impress the ladies.” The smaller boy simply responds by suggesting that he “try football” instead (23). Though the message of this ad is positive and sound, it has been made with poor Support in that it employs unrealistic and childish images (cartoon stick figures of the same style that was used for the ads “Not again” and “Stop Looking at me). <br />In addition to focusing on positive outcomes of not using marijuana, it is important for the campaign to affect change in individual attitudes towards marijuana use. Hence, the message relayed through the campaign needs to appeal to the core values of the target population. As previously stated, teenagers are more likely to engage in rebellious, sensation-seeking which drives them to try risky, and at most times, unhealthy activities such as alcohol use and drug abuse, including marijuana consumption (15 & 16). Consequently, in order for campaigns like Above the Influence to be effective in changing individual attitudes towards marijuana, it needs to abandon conventionality and opt for an element of vigor and rebellion. On the contrary, current Above the Influence commercials – “Not again” being a prime example – present the act of marijuana consumption as a negative activity that society frowns upon. While this message appears to be reasonable to adults with the expectation that it would lead to the logical conclusion that marijuana should not be used due to the negative social opinions associated with it. However, to the average adolescent who gains satisfaction from rebelling against societal norms that they view as authority, this message encourages them to use marijuana simply because that makes them a rebel, a desirable teenager trait. <br />The Above the Influence campaign can draw from the example of the anti-tobacco Truth campaign in appealing to the core values that teenagers strongly adhere to. The anti-smoking message delivered by this campaign is peppered with essential youth core values. The campaign ads depict mature and sophisticated youth rebelling against big tobacco, exposing their research as biased, and challenging them to reveal the facts about smoking. These commercials portray non-smoking youth as smart, cool and independent individuals who are defying the authority – in this case, the tobacco industry – that is pushing them towards smoking. The Truth campaign depicts the act of not smoking, rather than that of smoking, as the rebellious thing to do, thus appealing to the important core value of rebellion that teenagers hold dear. Moreover, these campaign commercials do not just show one individual, but instead a group of like-minded individuals who are all committed to fighting big tobacco. The objective behind such imagery is to instill a desire amongst teenagers to become part of a continuously growing movement, providing them with a feeling of independence and belonging, both essential teen core values. The Above the Influence campaign needs to similarly depict groups of young non-marijuana users as independent, unique and intelligent individuals rebelling against the norm of smoking marijuana amongst teenagers. Such positive labeling of non- users will encourage teenagers to not consume marijuana, leading to a reduction in the high rates of teenage marijuana use.<br />The Above the Influence campaign is based on traditional public health models that are obsolete and inadequate for designing effective health interventions. In order to be successful, campaign creators and administrators need to rethink their advertising strategy to ensure that all future ads are comprised of both a powerful, positive Promise as well as age-appropriate Support that does not leave the target youth with the feeling that the ad is an insult to his/her intelligence and hence inapplicable or irrelevant to them.<br /><br /> <br /><br /><br /> <br />REFERENCES<br />1. Oetting, E. R., Beauvais, Fred. (1990). Adolescent Drug Use: Findings of National and Local Surveys, pp. 385. Journal of Consulting and Clinical Psychology 1990, Vol. 58, No. 4, 385-394. <br />2. Johnston, L. D., O'Malley, P. M., & Bachman, J. G. (2000). Monitoring the Future national survey results on adolescent drug use: Overview of key findings. Bethesda, MD: National Institute on Drug Abuse, 1999.<br />3. Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2008). Monitoring the Future national results on adolescent drug use: Overview of key findings, pp. 6. Bethesda, MD: National Institute on Drug Abuse, 2007.<br />4. Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use and Health: National Findings. (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293).<br />5. United States Government Accountability Office. Contractor’s National Evaluation Did Not Find That the Youth Anti-Drug Media Campaign Was Effective in Reducing Youth Drug Use. Washington, DC:GAO 06-818, 2006.<br />6. Leinwand, D. (August 2006) Anti-drug advertising campaign a failure, GAO report says. USA Today. Retrieved December 6, 2009, from: http://www.usatoday.com/news/washington/2006-08-28-anti-drug-ads_x.htm.<br />7. Ajzen, I., & Fishbein, M. Understanding attitudes and predicting social behavior. New York: Psychology Press, 1980.<br />8. Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. 2007.<br />9. Ariely, D., Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: HarperCollins, 2008.<br />10. Eme, R., Maisiak, R., Goodale, W. Seriousness of adolescent problems. Adolescence 1979; 14 53: 93–99.<br />11. Above The Influence. “Not Again” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav <br />12. Above The Influence. “Stop Looking At Me” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav<br />13. Above The Influence. “Fitting in” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav<br />14. Zuckerman, M. Behavioral Expressions and Biosocial Bases of Sensation Seeking. New York: Cambridge University Press, 1994. <br />15. Ball, S.A., Carroll, K.M., Rounsaville, B.J. Sensation seeking, substance abuse, and psychopathology in treatment-seeking and community cocaine abusers. Journal of Consulting and Clinical Psychology 1994; 62:1053–1057.<br />16. Kosten, T.A., Ball, S.A., Rounsaville, B.J. A sibling study of sensation seeking and opiate addiction. The Journal of Nervous and Mental Disease 1994; 182:284–289.<br />17. Siegal, M., & Donner, L. Marketing Public Health: Strategies to Promote Social Change. Sudbury: Jones and Bartlett Publishers, 2004. <br />18. National Youth Anti-Drug Media Campaign. Washington, DC: White House Office of National Drug Control Policy (ONDCP). http://www.mediacampaign.org/about.html. <br /><br />19. Ogilvy, D. How to Build Great Campaigns (pp. 98-103). In: Confessions of an Advertising Man. New York, NY: Atheneum, 1964. <br />20. Harms, J., Kellner, D. Toward a Critical Theory of Advertising. Southwest Missouri State University & University of Texas at Austin. Retrieved December 8, 2009, from http://www.uta.edu/huma/illuminations/kell6.htm. <br />21. Above The Influence. “Achievements” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav<br />22. Above The Influence. “Fire” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav<br />23. Above The Influence. “Try Football” commercial. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.abovetheinfluence.com/the-ads/default.aspx?path=navUnknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-31081129841688308952010-05-20T17:15:00.000-07:002010-05-20T17:16:49.519-07:00Gardasil: Improving the Intention to Vaccinate Rate amongst the Targeted Population – Sonia MarwahThe Vaccination Sensation<br />Vaccination is perhaps one of the greatest public health success stories as seen by the reduced rates of infectious diseases. Since the introduction of vaccines, smallpox has been eradicated throughout the world, and wild polio virus is also near elimination. Although vaccines are the greatest weapons that exist to combat infectious diseases, no vaccine is 100% safe or effective (5). The propaganda for vaccination has become so effective that many parents choose to overload their children with any vaccine that becomes available, no matter the price or availability. For certain diseases, such as polio, measles-mumps-rubella (MMR) and hepatitis, vaccinations are mandatory. Today, many more vaccines have become available. However, these innovations have come with a price and their fair share of criticism. In television entertainer, Jenny McCarthy’s book Louder Than Words: A Mother’s Journey in Healing Autism, she makes the point that “Many people aren’t aware that in the 1980s our children received only 10 vaccines by age 5, whereas today they are given 36 immunizations, most of them by age 2” (19). McCarthy’s book, as well as other sources of scientific and clinical evidence, has shown that the MMR vaccine in particular may be linked to autism in children (9).<br /> Despite this critique, Public Health experts note that vaccines generally work best when everyone gets them. The principle of "herd immunity" states that when more people are protected against a particular virus, the more likely it will disappear from the population (22). Cervical cancer is a serious mortal threat for women caused by a virus known as HPV (Human Papilloma Virus), and a public health threat to all populations. Almost all (more than 99%) cervical cancers are related to HPV. Of these, about 70% are caused by HPV types 16 or 18 (1-2). Approximately 20 million Americans are currently infected with HPV. Another 6 million people become newly infected each year. This virus is so common that at least 50% of sexually active men and women acquire HPV at some point in their lives. On average, there are 9,710 new cases of cervical cancer and 3,700 deaths attributed to it in the United States each year. Some types of HPV can cause genital warts, whereas other types can actually cause cancer of the cervix. HPV is passed from one person to another by skin-to-skin contact, usually through having unprotected sex, especially at a young age. Although many women may have HPV, very few women will actually get cervical cancer because the body is able to fight of the virus on its own. Pap Tests are a diagnostic tool to detect HPV. Although there is no cure for HPV, the abnormal growth of cells can be treated (2, 4-6). Gardasil, developed by pharmaceutical giant Merck & Co., is a vaccine used today to prevent certain types of HPV, specifically HPV 16, 18, 6 and 11. Gardasil was approved by the Federal Drug Administration (FDA) for girls and women aged 9-26 on June 8th, 2006 (23). <br />Gardasil’s “One Less” Campaign – A Fearless Strategy <br />On November 23rd, 2006, Merck announced the launch of an advertising campaign for the world’s first cervical cancer vaccine, Gardasil. The campaign, called “One Less”, intends to encourage girls and women aged 9-26 who are eligible for the vaccine to begin their vaccination series, yet continue to see their physician for a regular Pap Test and screening. The campaign focuses on a strong and positive message designed to empower girls and women to become “one less” person who will battle cervical cancer by featuring young women and girls engaged in a variety of activities -- playing soccer, shooting baskets, skateboarding, drumming, and dancing. (20). Although this campaign is well-intentioned, it does not send an effective message about cervical cancer, because the message is not fearful enough for young girls. Witte and Allen argue that strong fear appeals with high-efficacy messages produce the greatest behavior change, whereas strong fear appeals with low-efficacy messages produce the greatest levels of defensive responses and reactance (25). The “One-Less” campaign, with its upbeat commercials and attractive website, does not make the targeted audience feel threatened enough by the possibility of developing HPV and cervical cancer. The advertising does not discuss the threat or severity of acquiring cervical cancer; instead, the commercials are overloaded with girls smiling, laughing and singing a catchy, rhyming tune. Dr. Michael Siegel and Lynne Doner Lotenburg have outlined two basic marketing strategies that Public Health should adopt. The first is to use market research to identify the basic needs, desires and core values of the target audience. Secondly, public health should sell basic values and reinforce these values by support with compelling, emotional stories, not merely statistics and data (21). The Gardasil ad effectively sells the core value of freedom to youth by sending the message that ‘if you vaccinate, you will free yourself of HPV and cervical cancer’. However, neither the ads nor the website offer any emotional stories of young women who actually have cervical cancer, and who may have been too casual about sex in their youth. The “One Less” campaign, and other forms of Merck’s advertising for Gardasil does seem to target mothers of young women effectively, but there is not enough done to inflict fear in the minds of teenage girls (18). Mothers are generally the figure head who will be able to consent their children to receive vaccination, and they are also the ones supplying the funds for the vaccination. Still, the promotional materials are not as effective as they should be to help girls understand the natural history, transmission and prevention of HPV, and the true meaning of living with cervical cancer. Therefore, the campaign does not follow the guidelines of an effective persuasive fear-based message, as concluded by Witte and Allen (25).<br />A false promise to protect <br />Gardasil’s “One Less” multibillion dollar campaign is designed to use highly strategic tactics to win over health professionals, state governors and legislators, and obviously, women who will potentially use the vaccine. However, marketing itself as “if you receive the Gardasil vaccine, you will be one less statistic of HPV and cervical cancer”, may in fact be giving false hope for women across the nation. Gardasil’s entry into the market represented the first time a vaccine could offer the hope of cancer prevention. Gardasil is not a cervical cancer vaccine, it is actually a vaccine for HPV, and this is not emphasized enough in Gardasil’s advertisements and promotions. Also, Gardasil’s ads emphasize the impact of HPV on cervical cancer rather than its role in causing genital warts, which is not as serious, but still a concern for girls and women who are sexually active. The “One Less” campaign cleverly creates an image that becoming vaccinated with Gardasil means empowerment – their “guard” against cancer. By letting their “guard” down about unprotected sex, and thinking “Now that I’ve received the vaccine and am protected from cancer, I can be less careful about my sexual encounters”, is creating a false sense of protection and greater exposure to other aggressive variants of HPV or other sexually transmitted infections (STIs) if sex becomes unprotected. One study highlights the results of highly active anti-retroviral therapy (HAART) on the sexual behaviors of persons with HIV/AIDS, and suggests that there is an increase in high risk sexual behavior related to the initiation of HAART (24). This association may be directly relevant to HPV vaccination. Teens may engage in this irrational thinking, and neglect the fact that there are many other harmful STIs/STDs for which Gardasil offers no protection. CDC research suggests that vaccine protection will last a long time, the question is: how long is a “long time”, and will girls believe they are protected for their entire lives? It is also still unknown whether booster shots will be needed to provide long-term protection against HPV infection beyond the initial vaccination (6). This suggests that in order to remain effective, women will need to monitor how long it’s been since they’ve received the HPV vaccine, and then go in again to receive another shot after ‘X’ amount of years to maintain immunity against immunity. Some women may fail to get that booster shot and subsequently forget they may no longer be protected from HPV. <br />Barriers for Gardasil Vaccine Acceptance <br />The widespread use of routine HPV screening and cervical cancer vaccines can be expected to decrease the mortality of cervical cancer worldwide (15). Nonetheless, despite the high prevalence of HPV infection in the population, many surveys have documented low levels of knowledge about the virus or its consequences. To a lay audience, this message may be confusing. One study found that despite the high prevalence of HIV infection in the American population, 70% of women had never heard of HPV and almost 90% had never discussed HPV with their health care provider. This impedes maximization of vaccine rates, especially when people don’t understand the exact anti-viral purpose of the vaccine (18). <br />Secondly, there are those parents who have specific concerns about their children receiving an STI vaccine, and this concern is not sufficiently addressed by Merck and Public Health in general. In a study of U.S. mother, 48% of participants reported they would likely to vaccinate a daughter under 13 years of age against HPV (16). There was higher intention to vaccinate daughters over the age of 13. This data was collected from a pool of nurses, who are considered more educated about the advantages of vaccination. The intent to vaccinate is not quite as high as it needs to be in order take advantage of a cancer vaccination that is out on the market intended to protect 70% of women from cervical cancer. This evidence contrast with the national recommendation to target 11 and 12 year old girls for vaccination. Much higher rates of intention are needed in order to prove Gardasil efficacious and create the “herd immunity” effect. One study exposed the five clusters of reasons that non-accepting parents, usually tending to be conservative or minorities, who did not want to vaccinate their daughters due to pragmatic concerns about effects on sexual behavior, specific HPV vaccine concerns, moral concerns about sexual behavior, general vaccine concerns, and denial of need (8). Opponents of the vaccine fear that by hearing about sex, and a sexually transmitted disease, young girls might be less likely to abstain and more likely to become sexually active (7). Mandating such a vaccine may be premature and insensitive to those who feel negatively towards the HPV vaccine. Although mandating the vaccine may reduce disparities, the voices of conservative groups must be heard and addressed to help reduce any confusion and send a more positive moral message. The resistance amongst states and parents to vaccinate may be attributed to the concern of increased chance promiscuity amongst these young girls. The idea of mandating “unprotected sex” as some conservatives would say, has been too premature and insensitive to those who feel negatively towards the HPV vaccine. The question also becomes, how far can the government intrude into a person’s privacy in the name of public health? (13). <br />Lastly, although immunizations can be a cost-effective intervention for disease by advancing the quality of lives, the cost of the HPV vaccine is exceedingly higher than other childhood vaccines. The HPV vaccine costs around $360 dollars, some girls and mothers believe this cost is worth the price of cervical cancer Prevention. Nonetheless, there is the population of women who are most vulnerable to HPV, but would be least likely to receive it because of the high cost, creating further chasms in health equity (18).<br />A Shift in Focus for HPV Vaccination Campaigns <br />Merck’s marketing of Gardasil does not effectively inform the teenage youth about the dangers of acquiring HPV. Results indicate that the vast majority of participants learned about Gardasil from television advertising, so the focus of altering media to improve campaign effectiveness should be on marketing via advertising. There is a lack of fear instilled in the campaign’s message. Hale and Dillard note that an “effective fear appeal must include a severe threat, evidence suggesting the target is especially vulnerable to the threat, and the solutions are both easy to perform and effective”. This campaign falls short of the recommendations of the fear appeal message construct. The nation’s youth needs more convincing information to be able to make decisions about vaccinations. Practitioners should also be aware of how different age groups react to messages in order to maximize effectiveness. A study by Friedman and Shepeard showed that knowledge of HPV is low across all age groups, regardless of gender, location, or ethnicity. Social marketing is a behavior change strategy that offers a promising, population-level approach towards maintaining consensus for immunizations and potentially increase vaccination rates. By using emotional, compelling stories coming from women who are living with cervical cancer, this may be able to capture attention and motivation change, as explained through behavior change theory. Emotion is an appropriate way to influence the target audience to achieve the desired goal of increased vaccination rates (10). This serves as a comprehensive approach to educating girls at all levels about the reality of HPV and cervical cancer, and also accurately portraying HPV risk in a manner that would simultaneously induce fear about acquiring HPV. This will take the spotlight off of attempting to induce fear about not receiving the vaccine for HPV, which is not effectively performed anyway in Merck’s “One Less” campaign. Before advocating and mandating a vaccine, Public health officials should collaborate with pharmaceutical companies, along with other sources, such as journalists, health educators, healthcare providers, and women's health advocates to ensure that future educational initiatives explain the complexity of the association of HPV and cervical cancer and to stress the importance of continued cervical cancer screening (3).<br />Moving towards a more accurate promise <br />In order for consumers to make a choice regarding the Gardasil vaccination, it is important for pharmaceutical companies to mention the importance of alternatives or supplementary activity to the HPV vaccine. Offering alternatives and supplements in a public health intervention will diminish the line between a false promise and what choices exist in reality that can reduce any chance of acquiring HPV. The various alternatives to the Gardasil vaccination include abstinence and regular Pap Tests. The Gardasil campaigns do not recognize these alternatives in their ads. This message of alternatives would be important information, particularly for conservatives to believe that safe sex or no sex is preferred to any vaccination used to reduce HPV infection. Although the Gardasil advertisements do recognize that “it is important to continue routine cervical cancer screenings”, the ads do not specify what is mean by “cervical cancer screenings” and how to obtain these screenings (14). Therefore, advertising should provide a more clear definition of what HPV is, how it causes cervical cancer, and that Pap Tests are used for cervical cancer screening. Advertising should also note that that Pap Tests are still effective, and should not be used an alternative to vaccination, but rather a supplementary activity that must be completed by a caregiver to eliminate the chance of getting HPV. This especially pertains to those who have already received HPV vaccination and believe they are in the clear for getting HPV. Research is still pending about whether a booster shot is needed, implying that the effectiveness of the vaccine may wear off. Thus, it is highly important to acknowledge that the vaccine is not a substitute for a routine visit to the doctor or safe sex. In addition to this, in order to prevent sexual disinhibition and the tacit consent for teens to engage in sex, it is important to provide strong guidance counseling in schools, at home and in doctor’s offices regarding the importance of maintaining safe sexual behaviors (12). For example, some studies suggest that sex education programs in schools are most effective to delay the initiation sexual encounters of when they are based on social influence approaches and social learning theory. School based sex education programs would be a good place to start empowering youth about the consequences of unprotected sex (17).<br />Optimizing Outcomes for Cervical Cancer <br />The nature of the Gardasil vaccine as a vaccine for an STI automatically creates a stigma that the young girls and women who receive the vaccine are sexually active or intend to be sexually active, and find the need to protect them because they are putting themselves at risk due to their behaviors. However, the vaccine does not necessarily need to be viewed in that light. In the future, vaccination campaigns should be more aware how the vaccine is framed and how this may influence how receptive the audience is to cancer prevention and control. For example, HPV advocates should emphasize the vaccine as a cancer prevention tool instead of marketing the vaccine for HPV and feeding into the negative emotions associated with STIs (18). Reframing HPV will also help alter the ideology of a conservative’s view towards an STI vaccine. A CDC study validated that focus group participants believed they were at low risk of contracting an STI and associated words such as “infidelity,” “promiscuity,” “shame,” and “divorce” with an STI (11). Although the idea that the vaccine may lead to sexual promiscuity among those vaccinated may have no effect on intention to vaccinate, the framing of the vaccination message still must be sensitive to conservatives in order to maximize vaccination rates. Therefore, reframing the vaccine as a cancer prevention tool can alleviate the social stigma associated with STIs. In addition to reframing, a reform in HPV and cervical cancer education is three-pronged. First, before educating the youth about the HPV vaccine, Merck should alter their campaign to blend the marketing of their product, along with empowering the youth with information about HPV. At the same time, marketing should emphasize what cervical cancer is and what it really means. Reform must also occur in order to combat the barriers of vaccination cost. The HPV vaccine is the most expensive of all recommended childhood vaccines. Those who are most impacted by the cost are women between the ages of 18-26, who are typically not covered by a subsidy program, and are most likely to be uninsured. Instead of mandating the vaccine itself, mandating statewide insurance coverage may make HPV vaccination programs affordable for the uninsured who are interested. Reducing the cost of the vaccine will make intention to vaccinate high amongst all age groups (18).<br /><br />CONCLUSION<br />There are numerous reasons as to why HPV vaccination intention may remain low, even with Public Health, in collaboration with policymakers, providers, health plans, and pharmaceuticals are advocating improving HPV vaccination rates. There is room for improvement in the areas of inducing more fear into the campaigns directed towards young teens, providing a more accurate promise of protection for women, and addressing the barriers to obtain a vaccine. This paper argues that these factors can be remediated. To invoke fear, HPV vaccine campaigns, such as the ad depicted in Gardasil commercials should tell more compelling stories from women who actually have cervical cancer. Gardasil, and other HPV vaccine campaigns should also stress the importance of supplements to HPV vaccination, such as Pap Tests and abstinence for a more comprehensive approach to prevent critical cancer. Lastly, certain obstacles should be addressed in regards to HPV vaccination, such as making the vaccine more affordable, tailoring to the concerns of conservatives, and improving sex and STD education. Looking forward, providing HPV vaccination for boys and men may serve as another controversy, but the same tactics should be applied towards tailoring the vaccine to the opposite sex.<br />REFERENCES<br />1. American Cancer Society. Human Papilloma Virus (HPV), Cancer, and HPV Vaccines. Atlanta, GA: American Cancer Society. http://www.cancer.org/docroot/cri/content/cri_2_6x_faq_hpv_vaccines.asp.<br />2. American Cancer Society. What Causes Cancer of the Cervix? Atlanta, GA: American Cancer Society. http://www.cancer.org/docroot/CRI/content/CRI_2_2_2X_What_causes_cancer_of_the_cervix_Can_it_be_prevented_8.asp<br />3. Calloway C., Jorgensen CM, Saraiya M., Tsui J. A content analysis of news coverage of the HPV vaccine by U.S. newspapers. Journal of Womens Health 2006; 15(7): 803-9.<br />4. Centers for Disease Control and Prevention. Genital HPV Infection – CDC Fact Sheet. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/std/HPV/STDFact-HPV.htm<br />5. Centers for Disease Control and Prevention. History of Vaccine Safety. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/vaccinesafety/basic/history.htm. <br />6. Centers for Disease Control and Prevention. HPV Vaccine Information for Young Women. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/std/hpv/STDFact<br />HPV-vaccine-young-women.htm.<br />7. CNN. Stop a killer, but promote sex? That is the question…Atlanta, GA: CNN. http://www.cnn.com/HEALTH/blogs/paging.dr.gupta/2007/01/stop-killer-but-promote-sex-that-is.html<br />8. Constantine NA, Jerman P. Acceptance of human papillomavirus vaccination among Californian parents of daughters: a representative statewide analysis. Journal of Adolescent Health 2007; 40(2): 108-15. <br />9. Currenti S. Understanding and Determining the Etiology of Autism. Cellular and Molecular Neurobiology 2009; Review Paper. <br />10. Douglas J. et al. Social Marketing as a Strategy to Increase Immunization Rates. Archives of Pediatric & Adolescent Medicine 2009; 163(3): 432-437. <br />11. Friedman, A., Shepeard, H. Exploring the Knowledge, Attitudes Beliefs, and Communication Preferences of the General Public Regarding HPV: Findings From CDC Focus Group Research and Implications for Practice. Health Education & Behavior 2007. <br />12. Haber, G., Maslow R., Zimet, G. The HPV Vaccine Mandate Controversy. Journal of Pediatric and Adolescent Gynecology 2007; 20: 325-331.<br />13. Harrell H. HPV Vaccines, Privacy, and Public Health. The Journal of Law, Medicine & Ethics 2009; 37: 134-8. <br /><br />14. Henry J. Kaiser Family Foundation. National survey of public knowledge of HPV, the human papillomavirus. Washington, DC: Henry J. Kaiser Family Foundation. http://www.kff.org/womenshealth/upload/The-HPV-Test-Coming-Soon-to-a-Doctor-s-Office-Near-You-Is-It-Better-than-the-Pap-Smear-for-Detecting-Cervical-Cancer-Chart-Pack.pdf<br />15. Herbert J, Coffin J. Reducing patient risk for human papillomavirus infection and cervical cancer. Journal of the American Osteopathic Association 2008; 108(2): 65-70. <br />16. Kahn J. et al. Mothers' Intention for Their Daughters and Themselves to Receive the Human<br />Papillomavirus Vaccine: A National Study of Nurses. Pediatrics 2009; 123: 1439-1445. <br />17. Kirby D. et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports 1994; 109(3): 339-360.<br />18. Leader A. et al. Effects of Information Framing on Human Papillomavirus Vaccination. Journal of Women’s Health 2009; 18.<br />19. McCarthy, J. Louder Than Words: A Mother’s Journey in Healing Autism. New York, NY: Dutton, 2007. <br />20. Medical News Today. Merck Launches National Advertising Campaign For GARDASIL®, Merck's New Cervical Cancer Vaccine. East Sussex, United Kingdom: Medical News Today. http://www.medicalnewstoday.com/articles/57419.php<br />21. Siegel M. and L. Lotenberg. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers, 2007.<br />22. Time. Defusing the War over the “Promiscuity” Vaccine. Atlanta, GA: Time. http://www.time.com/time/nation/article/0,8599,1206813,00.html#ixzz0Z2HYuSU4.<br />23. U.S. Food and Drug Administration. Gardasil Vaccine Safety. Silver Spring, MD: U.S. Food and Drug Administration. http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/ucm179549.htm.<br />24. Vlahov D., M. Safaien and S. Lai et al. Sexual and drug risk-related behaviors after initiating highly active antiretroviral therapy among injection drug users, AIDS 15 (2001), p. 2311.<br />25. Witte K. and M. Allen. A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns. Health Behavior and Education 2000; Vol. 27, 5, 591-615.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-71262497022383646412010-05-20T17:14:00.000-07:002010-05-20T17:15:47.221-07:00Social Marketing and HIV Stigma: The Need of Community Help with Marginalized Populations – Nicolas KarrIn 2008, 33.4 million people had a positive HIV status (1). Through out the year, 2.7 million new infections joined the tally and 2 million left because of AIDS-related deaths (1). The infection devastates low-resource populations. Prevention programs intervene to help these populations and provide the resources that could change the tide of infection. Unfortunately, while HIV/AIDS prevention programs provide the tools to fight infection, the populations do not necessarily change their behaviors. Content-rich interventions fall short when the target community does not use the resources. <br />In a summary analysis and critique of 21 interventions to reduce HIV/AIDS stigma, Brown, Trujillo, and Macintyre stated that HIV/AIDS stigma “undermines public health efforts to combat the epidemic” (2). They found that stigma affects the magnitude of reactions to epidemics and causes violence against infected people (2). Populations affected by stigma might fear societal attitudes and could deny their risk of infection. This denial could lead to inaction and ignoring risk factors; inaction could manifest as not using condoms, not testing for HIV, and not disclosing HIV status (2). Stigma can trigger actions to avoid a loss of a job, health benefits, or social ostracism (2). These actions on the part of the stigmatized could cause harm to themselves and the surrounding population. Acting in fear, marginalized populations experiencing HIV/AIDS stigma could endanger their relationship networks. <br />Stigma has prevailed throughout generations as an impediment to public health. When confronting disease, stigma causes negative views and reduces access to care. Stigma embeds itself within a population and breeds a culture of fear. In order to reduce infections in high-risk populations, interventions need to address stigma. In a meta-analysis of twenty-four studies, occurring between 2000 and 2007, of people living with HIV/AIDS in North America, Logie and Gadalla found that marginalized populations experienced higher stigma levels (3). Specifically, the researchers found stigma highly associated with low social support, poor physical health, poor mental health, lower income, and younger age (3). Consequently, according to Herek and Capitanio, who looked at behaviors towards people living with HIV/AIDS, stigma causes reduced access to care due to discrimination through violence and exclusion (4). <br />Marginalized populations endure the most stigma and these misunderstandings lead to low resources, poor funding, and inconsistent interventions and treatments. In order to help these populations the current interventions need to make changes. This paper focuses on three specific sub-populations at high-risk for HIV/AIDS and stigma: young black men, female substance abusers, and young men who have sex with men (MSM). The first section presents critiques on interventions targeted at each group and the second section provides ideas for improvements upon the current interventions. To stop the spread of HIV/AIDS, health interventions need to reach the high-risk, marginalized populations; interventions need to mitigate stigma to facilitate proper care.<br />Young Black Men: Bearing the Brunt of New Infections<br />According to the Centers for Disease Control and Prevention (CDC), African-Americans make-up 13% of the U.S. population, but account for 50% of all new HIV/AIDS cases, demonstrating a highly prevalent, yet underserved population (5). Along with high prevalence among the entire population, African-American men continue to acquire more infections than their female counterparts (5). HIV/AIDS prevention programs tend to show effectiveness in controlled settings, but the transfer to the real world has less than promising results. <br />When developing improvements for a current intervention to target young black men, O’Donnell et al. found that interventions have too many requirements and attrition sets in(6). This issue arises specifically with stigmatized populations who choose to avoid over exposure in HIV/AIDS programs. Dworkin, Pinto, Hunter, Rapkin, & Remien found that research tested the efficacy of prevention programs, but failed to design programs acceptable, affordable, sustainable, and adaptable to the population (7). HIV/AIDS has greatly affected young black men, but interventions have failed to address this issue. In order to reach the population O’Donnell et al. stressed the importance of tailoring the intervention for population penetration (6). The prevention programs fail to address barriers to care; HIVS/AIDS stigma limits accessibility to care and the interventions fail to reach the high-risk population.<br />O’Donnell et al. noted that a significant level of HIV/AIDS stigma develops from internalized and externalized homophobia (6). This stigma leads young black men to test late or avoid testing at all (6). O’Donnell et al. found that African-American females would seek medical care while young black males, more commonly, self-treat (6). This could explain why interventions fail to reach young black males, due to the medical services involved with HIV/AIDS testing. In addition, issues of stigma related to medical services inhibit access to care. Stigma of medical services among the population interacts with HIV/AIDS stigma and makes seeking care significantly less likely.<br />In order to overcome these obstacles, interventions need to address these issues of avoiding care. If evaluations of these prevention programs only focus on the efficacy in controlled settings, they fail to deal with issues of adaptability. The population at risk avoids medical services and HIV/AIDS care because of stigma. Until the interventions acknowledge this stigma surrounding the access to care, the programs cannot effectively reach those at high risk for infection.<br />HIV/AIDS interventions have many flaws, but simple changes in approach can lead to greater success. Evaluations of prevention programs need to address the dynamics within each high-risk population. Without adjustments to target different contexts, interventions cannot reach the populations. As stipulated, population penetration remains an important factor in all HIV/AIDS interventions (6); interventions must change to understand their population or fail in trying to reach them.<br />Female Substance Abusers: Inequality and Instability<br />HIV infection might come directly from sharing needles, but injecting and non-injecting drug use has developed as a risk factor for risky sexual behavior, a risk factor for HIV/AIDS. Among female substance abusers, risks for violence and HIV increase. Due to gender-specific inequality and violence, female substance abusers need interventions tailored to their issues. <br />Interventions of the past failed to address the gender-based issues of substance abusers. Wechsberg found, through a survey of past and present HIV/AIDS interventions for women, that past interventions did not account for low status in the culture and community, low education levels, and high rates of unemployment among female substance abusers (8). These factors significantly stigmatized the population. The interventions never reached the people because they could not access medical services. Beyond low access to health care caused by these factors, the high unemployment rates led the women to sell sex (8). The factors that increased stigma also increased the likelihood of acquiring HIV/AIDS. <br />With the increased stigma surrounding female substance abusers, the difficulty in reaching them increases. Wechsberg noted that failed interventions did not provide knowledge and personal enhancement training specifically targeted to changing behaviors (8). These behavior specific interventions could change behaviors when issues such as substance abuse, violence, and sexual risk arise (8). Culturally specific interventions targeted at females could improve the success of the programs. Unfortunately, the failed interventions did not acknowledge cultural specificity. The women find themselves without any power to act. The interventions fail to reach women who cannot make the decisions themselves or fear losing social support. <br />Interventions have low compliance to condom use because the programs ignored community context. In the case of sex worker interventions, Evans and Lambert, through an ethnographical study of HIV/AIDS community interventions, found that their noncompliance stemmed from lack of control over their work and social conditions (9). If prevention programs cannot change the dynamics within high-risk populations, distributing condoms makes no difference.<br />Evans and Lambert also observed that government policy and bureaucrats often disrupt interventions (9). Interventions unable to adapt to changing political tides must confront possible failure; police raids due to changing political temperaments could easily ruin months or years of community-building (9). Prevention programs must adjust to the changing political, cultural atmosphere in order to succeed. <br />The dependence the women have on the men controlling their lives continues to impede interventions. Failure to address gender inequality means more unsuccessful prevention programs. In order to aid female substance abusers, interventions need to provide ways to increase access to care. The women need to have feelings of safety and support if they choose to seek medical services. Without stability, predominant stigma and fear prevents access to care.<br />Young MSM: New Generations Facing Decade Old Problem<br />Stigma has been an impediment to care for all people living with HIV/AIDS. Among men though, internalized and externalized homophobia has led to fear of negative social consequences (10, 11). Valdiserri noted in his review of HIV/AIDS stigma literature that internalized homophobia led to lower self-esteem and consequently, a reduced sense of self-protection (10). This lack of self-protection leads to higher risk sexual behaviors and increased susceptibility to infection (10). These factors impede public health interventions that provide tools for safer sex, but ignore the inaction by participants.<br />The stigma surrounding young MSM and HIV/AIDS interact and result in negative self-feelings. According to Valdiserri, young MSM experiencing self-doubt seek validation through multiple partners (10). The environments where these encounters occur also facilitate alcohol and drug use and reduced inhibitions to practicing unsafe sex (9). Interventions fail to address young MSM dealing with negative self-feelings. Prevention programs do not work if the participants assimilate information, but make different choices in the heat of the moment. <br />Dowshen, Binns, and Garofalo studied the effects of HIV/AIDS stigma on four psychosocial measures among MSM. The measurements included depression, self-esteem, loneliness, and social support (11). They found some correlations between perceived stigma level and psychosocial measures, but due to a small sample size, could not declare significance (11). Among their study participants though, they found a correlation between perceived levels of stigma and discovery of a positive HIV status; both of these measures highest at the beginning and reducing with time (11). <br />Current interventions targeted at young MSM fail to change behaviors because they do not acknowledge how MSM incorporate stigma into their decisions (10). From sexuality to gender identity to HIV/AIDS, these young men deal with multiple levels of stigma (10). Until current interventions address how MSM deal with all levels of stigma, the ability to change behaviors significantly drops.<br />Prevention programs fail when they ignore the needs of the population. Many programs plan interventions based on best practice protocol. In the case of people living with HIV/AIDS, the programs focus on distributing prevention tools and education. The ethnographical research of Evans and Lambert found that different dynamics influence the decisions individuals make (9). These dynamics include context, practice, agency, and power (9). The researchers found that intervention evaluations review content and the relationship to the results (9). This traditional critique leads evaluations to base success on effectiveness of distributing project resources; grading the efficacy of interventions based on the number of condoms distributed or the prevention classes taught does not demonstrate the true intervention results.<br />Many problems dealing with population dynamics develop from transferring intervention models from one context to another. Evans and Lambert found that evaluations of efficacy for HIV/AIDS interventions lead to best practice protocols that ignore the context and dynamics of populations (9). Best practice guidelines fail to account for distinct circumstances of marginalized populations (9). <br /><br />A New Design: Ideas for Change in HIV/AIDS Interventions<br />Stigma involves many different issues and they affect all facets of an intervention. However, interventions that deal with stigma can change the behaviors of high-risk populations. Valdiserri states that HIV/AIDS interventions need to empower people about health issues, mobilize communities to solve the health problem, develop policies and plans in support of individual and community health, and conduct research to find innovative solutions to health problems (10). By accomplishing these health services public health can mitigate the effects of stigma and effectively reach populations (10). <br />Behavioral theory remains an important part of affecting change among HIV/AIDS populations. Interventions that focused only on distributing resources to combat infection need to adjust for population-level behavioral dynamics. In a review of the AIDS Community Demonstration Projects, Yzer, Fishbein, and Hennessy found that behavioral theory plays an important role in designing HIV interventions; theory identifies thoughts and feelings that can determine behaviors (12). The researchers also determined that evaluations of interventions need to measure effects of behavior change associated with the variables the intervention modified (12); evaluations should look at how the intervention changes behaviors based on the targeted variables. This way the evaluation determines how the methods of intervention truly affected the population (12).<br />In their ethnographic study of community HIV/AIDS interventions, Evans and Lambert found that success developed from peer education, community mobilization, and structural interventions (9). These key points emphasize the importance of involving the target community in the intervention. Community involvement ensures individual empowerment and this leads to behavior changes. Brown, Trujillo, and Macintyre note that many of the successful interventions in developing countries utilized community-based approaches opposed to the individual level approaches employed in the U.S. (2). They speculated that the use of community-based approaches reflects an understanding that confronting stigma involves both collective and individual level action (2). <br />With these factors in mind, new HIV/AIDS interventions should utilize social marketing campaigns within high-risk communities to find opinion leaders and start programs for peer education, community involvement in promoting prevention techniques, and individual enhancement to mitigate HIV/AIDS stigma. An important focal point involves finding respected community leaders to lessen the fear of stigma. With proper influential leaders among the intervention, the programs can more effectively reach the target population. In the following sections, this paper focuses on specific techniques for intervening with young black men, female substance abusers, and young MSM.<br />Lessening the Burden of Young Black Men<br />In developing a new HIV intervention for young black men, O’Donnell et al. found that successful interventions must overcome barriers to disseminating information (6). The researchers also stated that the failure of medical services remains the inability to link young black men with needed medical services (6). Available resources do not translate to effective interventions. <br />O’Donnell et al. stresses the importance of a community review of program components before implementation of the intervention (6). This step makes sure the community understands the intervention approach and, more importantly, the design fits with community dynamics. The next step in a successful intervention includes social marketing. O’Donnell et al. used the community meetings to identify potential spokespersons that have influence (6). Along with recognizing leaders in the community, the discussions identified people young black men would listen too. The discussions determined peers had the greatest impact (6). Utilizing opinion leaders helped get young black men to seek medical services, but the next step involves reducing the requirements of the screening test. If the men find the screening test invasive, time-consuming, or overly demanding they might avoid testing (6). O’Donnell et al. noted the value of using context-pertinent learning models. The intervention utilized computer-based modules that the men found interesting and engaging. The learning module incorporated videos, games, and an overarching storyline that kept the interest of participants (6). Lastly, O’Donnell et al. stressed the importance of developing individual risk reduction plans. This allotted for population dynamics and allowed the men to voice their concerns (6).<br />Overall, the intervention proposed by O’Donnell et al. focuses on the effects of social marketing. Without the social marketing element, the men would never reach the screening test, learning module, or individual risk reduction plan. Most importantly, the social marketing approach involved the community. The community discussed each approach and component and aided in the successful implementation of the program.<br />Providing Stability and Equal Footing for Female Substance Abusers<br />In situations where a person living with HIV/AIDS has dependency issues, interventions fail to change behaviors. This problem stems from a persons’ inability to give up control, but interventions focus on their unwillingness to change. Resources do not aid those who need stability to utilize prevention methods. HIV/AIDS interventions focusing on female substance abusers need to incorporate personal enhancement programs into their prevention methods.<br />Commercial sex work, violence, and substance abuse usually intersect and complicate the issue of HIV/AIDS infections. Wechsberg found that interventions incorporating knowledge enhancement and hands-on skills training strategies could change behaviors in this population (8). The intervention needs to focus on empowering the woman to make assertive decisions. <br />Sex facilitates a main conduit for infection and improved condom use could come from enhanced negotiation skills (8). The women of this marginalized population tend to deal with inequality issues. This inequality leads to contexts with high risk of infection. Wechsberg notes that the ability to empower and enhance negotiation skills increases the likelihood of assertiveness with sex partners (8). The disparate contexts these women live in causes dependency and lack of power. In order for prevention resources to find use, the women need a feeling of stability. Effective enhancement and empowerment interventions could overcome the treatment barriers.<br />Utilizing community support in these situations could prove difficult. If the women do not have a network connecting them, peer influence might have little effect. With the right approach, communities could develop for these women. Sometimes, the health workers need to think creatively to piece together a network or community. If possible, this social support could improve the chances of behavior change after empowerment and enhancement training strategies. <br />A New Solution for Young MSM<br />The stigma surrounding MSM develops from both HIV/AIDS and sexuality. The issues intertwine and result in added fear of negative social consequences. In order to address MSM, interventions need to mitigate the stigma surrounding both HIV/AIDS and sexuality. Valdiserri noted that young MSM might avoid clinicians because of fear of judgment (9). If public health officials expect at-risk men to screen for HIV, they must account for worries of social ostracism. Brown, Trujillo, and Macintyre state that information, counseling, coping skills acquisition, and contact demonstrated effectiveness in interventions (2). The researchers also found that different approaches to coping skills acquisition occurred in several interventions and each showed effectiveness in the specific population (2). This point demonstrates the importance of tailoring the intervention to the community. The prevention program must work with the community to reach the target population. <br />Brown, Trujillo, and Macintyre present a different concept for interventions: contact. This method involves combating stigma through inducing empathy for people living with HIV/AIDS (2). They saw positive results associated with the contact method, but overall the method failed to provide lasting reductions in stigma overall (2). However, a community-based approach provides a means of utilizing contact (2). The influence of opinion leaders in a community and the use of community discussions on interventions could lead to changing attitudes towards infected people.<br />As with the other high-risk populations, interventions need to employ the power of the community and social networks. The community can help develop effective programs that target the at-risk populations. In order to affect a difficult to reach group the intervention needs to utilize the community to adapt to the group dynamics. No individual health official understands the community as well as the members.<br /><br /><br />Conclusion and Discussion<br />While many factors affect the behaviors of at-risk populations, perceived levels of stigma can predict possible behavior change. The presence of stigma has negative effects on public health interventions and leads people living with HIV/AIDS to avoid health services. Sivaram et al., when looking at social capital and HIV stigma in consideration for HIV/AIDS prevention intervention design, stated that stigma manifests from “social norms that render an attribute or condition inferior or inappropriate” (13). These social norms lead to reactions of fear and perceived threat (13). Under this perceived threat, people living with HIV/AIDS find difficulty in seeking health and medical services. <br />Beyond perceived threat, Sivaram et al. found situations where clinicians refused care to infected people (13). When an example such as this happens, stigma finds a new hold among the population. Trepidation can cause victims of stigma to avoid health and medical services. This not only makes intervention efforts ineffectual, but also creates a high risk dynamic. Stigma leads people to develop negative self-feelings and these feelings lead people to seek validation. Engaging in high-risk behaviors because of feelings of low self-worth not only puts the individual in danger, but the rest of the population. Sivaram et al. speculates that individuals hesitate to engage in prevention and care-seeking behaviors because they anticipate discrimination and possible violence (13).<br />HIV/AIDS interventions need to focus on community-level approaches. Most importantly, interventions should involve the community in the development of prevention programs. In this way, the program can identify key community members and opinion leaders. These influential leaders can help adapt the intervention to the group dynamics. Outside of opinion leaders, the community can help develop proper implementation methods for the intervention. Community members understand how the population digests information and ideas; their ideas can help the intervention penetrate the population (6). Key to intervention success, social marketing helps open the door for prevention programs. Without social marketing, the key components of a successful intervention cannot find their audience.<br />In summary, interventions need to utilize opinion leaders, peer education, enhancement training, and prevention techniques to change behaviors in people living with HIV/AIDS. These techniques help to mitigate stigma among the population and surrounding community. The interventions must involve the community every step of the way to reduce fear of exposure. Stigma exemplifies a real fear of people living with HIV/AIDS and a true deterrent to successful interventions. Prevention programs can reach marginalized populations if confronting stigma becomes a focal point of HIV/AIDS intervention.<br />References<br />1. UNAIDS. (2009). AIDS Epidemic Update 2009. UNAIDS. http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp<br />2. Brown, L., Trujillo, L., & Macintyre, K. (2008). Interventions to Reduce HIV/AIDS Stigma: What Have We Learned? Horizons Program Tulane University.<br />3. Logie, C., & Gadalla, T. (2009). Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care, 21(6), 742-753.<br />4. Herek, G.M., & Capitanio, J.P. (1999). AIDS stigma and sexual prejudice. American Behavioral Scientist, 42(7), 1130 – 1147.<br />5. Centers for Disease Control and Prevention. (2008). HIV/AIDS Surveillance Report, 2006. Atlanta, GA: U.S. Department of Health and Human Services. http://www.cdc.gov/hiv/topics/surveillance/resources/reports/<br />6. O'Donnell, L., Bonaparte, B., Joseph, H., Agronick, G., Leow, D., Myint-U, A., et al. (2009). Keep It Up: Development Of A Community-Based Health Screening And HIV Prevention Strategy For Reaching Young African American Men. AIDS Education & Prevention, 21(4), 299-313.<br />7. Dworkin, S., Pinto, R., Hunter, J., Rapkin, B., & Remien, R. (2008). Keeping the Spirit of Community Partnerships Alive in the Scale Up of HIV/AIDS Prevention: Critical Reflections on the Roll Out of DEBI (Diffusion of Effective Behavioral Interventions). American Journal of Community Psychology, 42(1/2), 51-59.<br />8. Wechsberg, W. (2009). Adapting HIV Interventions For Women Substance Abusers In Internationalsettings: Lessons For The Future. Journal of Drug Issues, 39(1), 237-243.<br />9. Evans, C., & Lambert, H. (2008). Implementing community interventions for HIV prevention: Insights from project ethnography. Social Science & Medicine, 66(2), 467-478.<br />10. Valdiserri, R.O. (2002). HIV/AIDS Stigma: An Impediment to Public Health. American Journal of Public Health, 92(3), 341-342. <br />11. Dowshen, N., Binns, H., & Garofalo, R. (2009). Experiences of HIV-Related Stigma Among Young Men Who Have Sex with Men. AIDS Patient Care & STDs, 23(5), 371-376.<br />12. Yzer, M., Fishbein, M., & Hennessy, M. (2008). HIV interventions affect behavior indirectly: results from the AIDS Community Demonstration Projects. AIDS Care, 20(4), 456-461.<br />13. Sivaram, S., Zelaya, C., Srikrishnan, A., Latkin, C., Go, V., Solomon, S., et al. (2009). Associations Between Social Capital And HIV Stigma In Chennai, India: Considerations For Prevention Intervention Design. Aids Education & Prevention, 21(3), 233-250.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-38877746007554348622010-05-20T17:10:00.000-07:002010-05-20T17:23:15.845-07:00Don’t Be a Patsy: A Critique of The Partnership for a Drug-Free America’s Campaign to Connect Parents with their Teens – Adam J. TapplyI. Introduction<br />The war on teen drug use is one that has no end in sight. In one of the most recent studies, the Monitoring the Future Study asked high school seniors, "On how many occasions, if any, have you used drugs or alcohol during the last 12 months or month?"( ). Of high school seniors in 2008, 42.6% reported having ever used marijuana, 7.2% reported having ever used cocaine, and 1.3% reported having ever used heroin ( ). The rates for all illicit drugs have varied over the years, but the trend remains rather steady ( ). The increase in marijuana use (past-month use) has been especially pronounced. Between 1992 and 2008, past-month use of marijuana increased from 12% to 19% among high school seniors, 8% to 14% among 10th graders, and 4% to 6% among 8th graders ( ). The Monitoring the Future study also found high percentages of students reporting they could obtain certain drugs fairly easily or very easily in 2008 with marijuana having the highest percentage at 83.9% followed by amphetamines at 47.9% and cocaine at 42.4% ( ). In 2007, 22% of all students in grades 9 through 12 reported someone had offered, sold, or given them an illegal drug on school property ( ). Data from a 2007 survey showed that marijuana and cocaine use is the most prevalent among persons age 18 to 25 ( ). Teen and young adult drug use is not a new issue, but the fact that the combined might of all the public health interventions implemented over the years has failed to make a pronounced impact is alarming.<br /> The majority of teen drug interventions target the teens themselves. Some studies have found, however, that interventions centered on the parents may be more effective in curbing teen drug use. One study used data from substance abuse surveys of 7th to 12th graders to explore the relationship of parent-child communication to drug involvement and found that (a) parents are most often identified as the individuals who have talked to a child about drugs; (b) youth consider parents to be credible sources of information about drugs; (c) as perceived family sanctions go up, drug involvement goes down; (d) youth with the highest levels of drug involvement are the group most likely both to have had no one talk to them and to have had the largest number of people talk to them about drugs; and (e) perceived family sanctions increase dramatically for highly drug-involved youth once they have been talked to by one person ( ). Another survey found that teens with “hands on” parents – parents who have established a household culture of rules and expectations for their teen's behavior and monitor what their teens do – are at one quarter the risk of using drugs as teens ( ). Another study, at the time the largest study ever of U.S. teenagers, found that adolescents are far less likely to use alcohol and drugs, or engage in other dangerous behavior, when they feel loved and nurtured at home ( ). The importance of quality parental interaction with teens is unquestionable and this has been the focus of one of the Partnership for a Drug-Free America’s most recent campaigns.<br /> Beginning in October of 2008 and continuing to this day, the Partnership for a Drug-Free America has run an anti-drug ad campaign focused on getting parents to seek advice on how to talk to their teens about drugs. They relied on data from the 2007 Partnership Attitude Tracking Study (PATS), which found that half of all parents (51 percent), with kids in 6th-8th grade, feel they lack the tools and information to prevent drug and alcohol use ( ). The research found, in general, that there is an increased need for parents to find a way to talk with their kids. The main platform for this campaign has been a series of television commercials starring Patsy, a well-intentioned, high-energy mother with a Midwestern accent, ready to go to any length to keep her kids from using drugs and alcohol. <br />The “Patsy” campaign consists of four 30-second and two 15-second TV spots (which can all be found on the drugfree.org website: http://www.drugfree.org/parent/ConnectingWithYourKids/), five “webisodes” for YouTube, one radio spot and 2 print executions. Each commercial has the premise of having Patsy act as a renegade Youtube-style blogger showing the audience via home-video how she communicates with her children about drugs. In the commercials, Patsy not only uses a drug-sniffing dog, she sneaks up on her teen son in the shower, drills him on drug facts, and demonstrates a benevolent, police-style “Patsy pat-down.” Patsy also shows off her own method for preventing abuse of prescription medications – she removes the labels from every bottle in the medicine cabinet ( ). Patsy is deliberately positioned as a well-intentioned mother who is mistaken in how best to communicate with her children about drugs, thus the prompting at the end of each ad: “Don’t be a Patsy. Learn a Better Way at Drugfree.org.” Alon Shoval, the executive creative director of the campaign, says, “By creating Patsy, a mom who gets it all wrong, we allow real moms to laugh at themselves and realize they don’t have all the answers” ( ). In effect, when parents laugh at Patsy, they get her point without having to hear a lecture. The underlying purpose is to get parents to access the content on drugfee.org website – an expansive “Parent Resource Center” that offers “Advice by Age”, help “Understanding Teens”, “Protecting Your Kids”, advice on “How to Spot Drug & Alcohol Abuse”, and “How to Help if They’re Using”, among other resources.<br />This paper will focus on the TV / Youtube portion of the ad campaign rather than the online content. Though I’m not one myself, I found the online content to be an excellent source of resources for parents. The ad campaign that is supposed to draw attention to this content, however, is flawed in my opinion. In the next section, I will detail these flaws and describe how and why they detract from the effectiveness of the commercials. In the final section, I will illustrate how the commercials could be changed in accordance with social and behavioral science principles to be more effective.<br />II. A Critique of the “Don’t Be a Patsy” Ad Campaign<br />This section argues that the Partnership for a Drug-Free America’s “Don’t Be a Patsy” campaign is flawed for three main reasons. First, the campaign fails to incorporate basic principles of advertising theory into its message. Second, the campaign fails to consider spontaneous situations. Third, the campaign underestimates the importance of context.<br />A. The “Don’t Be a Patsy” Campaign Fails to Incorporate Basic Principles of Advertising and Marketing Theory<br />The “Don’t Be a Patsy” campaign is based around the idea that parents will (Step 1) watch these commercials, (Step 2) laugh at them, and then (Step 3) go to the online website. The idea is that, when they laugh at Patsy, the mother in the commercial, they are really laughing at someone like themselves who doesn’t really know how to talk to her children about drugs. In my opinion, Step 1 and Step 2 work, but Step 2 does not connect effectively to Step 3. The campaign therefore fails because the parent doesn’t access the important content on the drugfree.org website, which is the entire purpose of the campaign.<br /> Watching Patsy, the parent is supposed to laugh, but it’s an uncomfortable laugh. There’s a veiled threat in the message of this campaign: parents do not know how to talk to their children about drugs, so they may be able to get away with anything. This may not be the intended message, but there is clearly no explicit message. The campaign is using an implied threat to inspire a level of fear in parents, which, as I will discuss, can be effective as long as it’s employed correctly.<br /> Advertising theory is based around a “Promise” and “Support” for that promise. The promise generally concerns the product being advertised and its promised benefits ( ). The next step is to support the promise with an example of its benefits in the form of a story, images, symbols, and/or metaphors ( ). The “Don’t Be a Patsy” campaign’s commercials make the promise that, if you act like Patsy, your children will not connect or communicate with you and will therefore be more likely to do drugs. This is basically the support provided in the commercials set up as a quick example / story, though the teens are never actually shown doing drugs. One could also look at the promise this way: parents are completely clueless when it comes to their children and drugs and they (the children) can get away with anything. Because there’s no explicit message, it’s up to the viewer to figure out what the message is and here it is simply not coming across as it should.<br /> The Persuasive Health Message (PHM) Framework offers another approach for creating a persuasive message. A persuasive health message should contain a threat message and an efficacy message ( ). The threat portion of the message tries to make the audience feel susceptible to a severe threat. The efficacy portion tries to convince individuals they are able to perform the recommended response (i.e. self-efficacy) and that the recommended response effectively averts the threat ( ). Evidence from fear-appeal research suggests that messages are most effective when there are high levels of both threat and efficacy ( ). Applying this to the “Don’t Be a Patsy” ads, we see a low level threat that’s implied, not explicit: you don’t know how to communicate with your children about drugs; and no efficacy at all. The efficacy portion would only emerge if the parent was inspired to go to the online content, which is unlikely since the threat message is so weak.<br /> The message of the “Don’t Be a Patsy” ads doesn’t effectively sell parents on the idea of logging onto the online website. They merely provide a humorous example of what not to do without giving the viewer any pressing reason to learn how they should make a change in their own behavior. <br />B. The “Don’t Be a Patsy” Campaign Fails to Consider Spontaneous Situations<br />The nature of the “Don’t Be a Patsy” ads are, by design, planned. Each ad starts off with Patsy speaking to the camera about how she is about to interact with her child. In most of these situations, the child is simply walking by: coming down the stairs in one ad, coming through the front door in another. The behavior of Patsy looks to follow the Theory of Reasoned Action. This theory suggests that a person's behavior is determined by his/her intention to perform the behavior and that this intention is, in turn, a function of his/her attitude toward the behavior and his/her subjective norm ( ). This theory assumes that behavior is planned and is static. To a degree, Patsy’s behavior in the commercials is probably a little accurate: many parents do not know how to talk with their children about drugs and resort to “traps” – planned confrontations – like the ones employed by Patsy. Life and human behavior is generally not like this, however, and the drugfree.org online content recognizes this.<br /> The parent toolkit on the drugfree.org website encourages parents to take advantage of “teachable moments”: this refers to using every day events in your life to point out things you’d like your child to know about, including drug situations going on in your own neighborhood, drug-related headlines in the news, and other situations on TV and in the media ( ). This behavior (the correct behavior) is far more spontaneous than the behavior demonstrated by Patsy. The audience should clearly understand that Patsy’s behavior is wrong, but what should they do about it? The correct behavior is not illustrated, so therefore the audience has no idea how to perform a behavior that actually works.<br /> The Theory of Planned Behavior adds self-efficacy to the Theory of Reasoned Action equation. Self-efficacy relates to the belief that you’re capable of doing a particular behavior ( ). I cannot apply how Patsy is affected by self-efficacy because she is a fake person, but, as I mentioned in the previous section, self-efficacy is an important part of the viewer’s experience here. There is no self-efficacy present in these messages, however, because Patsy performs an improper behavior that clearly doesn’t work. It would have been far more effective to show a Pasty-type character demonstrate one of the teachable moments described on the drugfree.org website and show how the correct behavior causes the appropriate reaction in her child. The self-efficacy would come across and the viewer would gain confidence that they could themselves perform that correct behavior.<br />C. The “Don’t Be a Patsy” Campaign Underestimates the Importance of Context<br />Darley and Batson’s classic study on helping behavior (the “good Samaritan” study) demonstrated how much of an effect context can have on behavior. The results of this study showed that a person in a hurry is less likely to help people, even if he is going to speak on the parable of the Good Samaritan. This shows, basically, that behavior is strongly affected by the context in which it occurs. Consider the context in which the “Don’t Be a Patsy” commercials take place: most of the ads have Patsy cornering her child in a normal, relatively context-free situation (coming down the stairs or entering in the front door, as mentioned before). Is this the right time to talk to your child about drugs? The Partnership for a Drug-Free America clearly doesn’t believe so, as evidenced by the online parenting guide, which directs parents to make use of “teachable moments.”<br />The fundamental attribution error is a common type of cognitive bias in social psychology. Essentially, the fundamental attribution error involves placing a heavy emphasis on internal personality characteristics to explain someone's behavior in a given situation, rather than thinking about external situational factors ( ). When we see Patsy fail in her attempt to communicate with her children, the fundamental attribution error would argue that the audience blames Patsy and her personal characteristics for her communication failure. This is rather misleading, because the context of the situation in these ads also plays a part in determining the outcome of her little interventions. The Partnership for a Drug-Free America clearly intends to highlight this failed context because it shows parents how to use context to their advantage in the “teachable moments” section of its website. Their ad backfires, however, because the audience is not receiving the failed context message. The fundamental attribution error explains that the audience is going to interpret the overall failure as due to Patsy’s personal characteristics instead. In addition to being an overall ineffective message, the parent viewing this commercial may simply reflect on the ad they’ve just seen and think, “I’m not like Patsy. This won’t happen to me.” Therefore, when faced with a situation where they would talk to their children about drugs, the parents are more inclined to think that their own behavior is more important to the outcome than the context of the situation in which the interaction is taking place. The end result is the parent is far less likely to respond to the prompt to go online and access the drugfree.org website’s content containing helpful tips for parents.<br />III. A Reformulation of The Partnership for a Drug-Free America’s “Don’t Be a Patsy” Ad Campaign<br /> The critiques of the Partnership for a Drug-Free America’s “Don’t Be a Patsy” campaign suggest subtle changes in the format of the ads may make them more effective. For my reformulation of the campaign, I am going to stick with the general format of the ads (home-video with a mother figure and a child), but alter the content of the ads so they are in line with the critiques I made in the previous section. Like the “Don’t Be a Patsy” ads, the goal of the new ads will be to convince the parents in the audience to go online and access the drugfree.org content geared towards parents.<br />The message of the original “Don’t Be a Patsy” ads was garbled – it didn’t come across loud and clear that parents need help in figuring out how to communicate with their children and that they should go to the drugfree.org website for help. The reasons for this were (1) the ad’s “promise” wasn’t clear, and the “promise” wasn’t backed by proper support, (2) the ad lacked a sufficient threat message, and (3) the ad didn’t incorporate self-efficacy into its support.<br />A. The Campaign Should Have a New, Clearer Message<br />A good persuasive health message contains a powerful threat message and an accompanying efficacy message ( ). The threat portion of the message tries to make the audience feel susceptible to a severe threat. The efficacy portion tries to convince individuals they are able to perform the recommended response and that the recommended response effectively averts the threat ( ). The threat in these ads is targeted at parents and should be created accordingly. A good threat message is simply: “your children will do drugs.” Adding self-efficacy to the messages results in the final message: “your children will do drugs unless you can communicate with them about the dangers of doing drugs.” The threat is clear, as is the recommended response that can effectively nullify the threat. How this message is conveyed through the ad will determine how effectively the message is received by the audience. Accordingly, the direction of the ads – meaning the scenes they show – should be changed. <br />B. The Campaign Should Have a New “Promise” and Proper “Support” in Accordance with Advertising Theory<br />Shifting to Advertising Theory, the message conceived in the previous section can be translated into a “promise”: “if you communicate effectively with your child about drugs, he/she will be less likely to do drugs.” Next, support needs to be designed that conveys this promise effectively to the parent viewing the ad. I envisage these ads taking place in three scenes. In Scene 1, a teenager is making an arrangement with a friend (via texting, for example) to go drink some alcohol or smoke some marijuana. Scene 2, presents a situation between the time the arrangement is make and when the drug activity actually takes place. This, in my opinion, is the perfect time to apply one of the Partnership for a Drug-Free America’s “teachable moments”. A parent can be shown talking to her child, who is intending to go do drugs soon afterwards, in a teachable moment. For example, they’re watching TV together when a news update pops on the screen about a local teen that just died of a drug-related condition (maybe alcohol poisoning or a heroin overdose), which leads to a conversation about the dangers of drugs. Or maybe the parent is actually driving the child to his/her friend’s house and the parent points out a homeless man drinking from a liquor bottle on the side of the road, which leads to a conversation about the dangers of drugs. The final scene seals the promise of the ad. The child meets up with the friend with whom he/she was intending to do drugs and simply chooses not to engage in that behavior.<br />Over the course of a 30 second commercial, the audience is shown (1) intention to do drugs, (2) the intervention, and (3) no intention to do drugs. The parent watching the ad is clearly shown that the intervention – communicating effectively with the child about the dangers of drugs – can change the behavior of the child in the intended way: there’s no longer an intention to do drugs. This is all done by telling a simple 30 second story that could happen to any parent with a teen any day of the week. Furthermore, self-efficacy is incorporated into the ad, here, by showing how the recommended response to the threat (communicating with your child about the dangers of drugs) effectively averts the threat (changed intention). It helps that all of these “teachable moments” presented by drugfree.org website are examples that can truly happen in day to day life; there’s no special skills needed outside of ordinary parenting skills. Showing the parents in the audience how a “teachable moment” can be correctly and effectively employed should effectively convey the message of the ads: “if you communicate effectively with your child about the dangers of drugs, your child will be more likely to choose not to do drugs… learn more effective strategies at drugfree.org”<br />C. The Context of the Campaign’s Ads Should be Changed<br />Most of the changes to the ads’ context have already been discussed in the previous section. The main purpose of this change in context is to get the ads out of the mentality of staged interventions employed by Patsy. The setups used by Patsy – grilling her son with questions while he’s in the shower, patting down her daughter as she’s coming down the stairs, forcing her son to pass a drug-sniffing dog as he enters the house – are simply unrealistic and detract from the effectiveness of the message.<br />The changes I described in the last section make use of real life situations (or potential real life situations, at least). The parent isn’t charged with planning out the behavior of communicating the dangers of drugs to her child; she is simply taking advantage of a spontaneous situation (like a news report, or something seen while driving) and using it to frame a certain context. This is a much better model of human behavior. It doesn’t assume behavior is planned like Patsy does. Furthermore, the new ad accounts for spontaneous events and understands how context can affect the outcome of a conversation.<br />IV. Conclusion<br /> The Partnership for a Drug-Free America’s “Don’t Be a Patsy” campaign ads are pretty funny, there’s no disputing that. This humor directed at parents, however, is misplaced. There’s little evidence to suggest that laughing at yourself is a good model for encouraging behavior change. Using established social and behavioral science models it is possible to create a more effective ad campaign that employs the same goal as the “Don’t Be a Patsy” campaign. The Partnership for a Drug-Free America may have been aiming for a so-called viral marketing campaign (whether or not it ever reached that status is debatable), but which is really more effective at teaching parents how to talk to their children about drugs: a viral campaign that is ineffective at getting parents to go online and learn about communication techniques? Or a well-designed, though perhaps not as funny, that effectively convinces parents that they need help talking to their kids? In my hypothetical campaign, I’m investing in the latter.<br /><br />REFERENCES<br /><br />1. Press release: Various stimulant drugs show continuing gradual declines among teens in 2008, most illicit drugs hold steady, University of Michigan News and Information Services, December 11, 2008, http://monitoringthefuture.org/pressreleases/08drugpr_complete.pdf<br /> 2. Bureau of Justice Statistics Drugs and Crime Facts: Drug use in the general population, http://www.ojp.gov/bjs/dcf/du.htm<br /> 3. Id.<br />4. University of Michigan, Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings 2008, May 2009, http://monitoringthefuture.org/pubs/monographs/overview2008.pdf<br />5. Id. at Note 1.<br />6. BJS jointly with the U.S. Department of Education, Indicators of School Crime and Safety, 2008, NCJ 226343, April 2009, http://www.ojp.gov/bjs/abstract/iscs08.htm<br />7. SAMHSA, Office of Applied Studies, 2007 National Survey on Drug Use and Health: National Findings, September 2008.<br /> 8. Kelly, KJ. “Parent Child Communication, Perceived Sanctions Against Drug Use, and Youth Drug Involvement,” Adolescence 2002; 37; 148.<br /> 9. National Center on Addiction & Substance Abuse (CASA) at Columbia University, Report: CASA 2000 Teen Survey: Teens With "Hands-off" Parents at Four Times Greater Risk of Smoking, Drinking and Using Illegal Drugs as Teens With "Hands-On" Parents, Sep 18, 2002.<br /> 10. Epstein, JH. "Nurturing teenagers to a better future: massive study confirms importance of parental care." The Futurist Mar. 1998; 32; 2. <br /> 11. Press Release: Foundation for a Drug-Free America, “Patsy” Teaches Parents How to Talk with Their Kids About Drugs, October 3, 2008, http://www.digital50.com/news/7657<br /> 12. Partnership for a Drug-Free America: Connect With Your Kids Ad Campaign Videos: http://www.drugfree.org/parent/ConnectingWithYourKids/<br /> 13. Id. at Note 11.<br /> 14. Ogilvy, D. Confessions of an Advertising Man, New York: 1964, p. 93-94.<br /> 15. Id.<br /> 16. Id.<br /> 17. Witte, K. “Using the Persuasive Health Message Framework to Generate Effective Campaign Messages”, in Designing Health Messages by E. Maibach and R. Parrott (Eds.), Sage Publications, California, 1996: p. 146.<br /> 18. Id. at p. 147.<br /> 19. Id.<br /> 20. Ajzen, I. “The theory of planned behavior.” Organizational Behavior and Human Decision Processes, 50, 1991: p. 179-211.<br /> 21. Partnership for a Drug-Free America: Online Content: http://www.drugfree.org/parent/ConnectingWithYourKids/Articles/Dont_Be_A_Patsy.aspx<br /> 22. Id. at Note 20.<br /> 23. Darley, JM, and Batson, CD, "From Jerusalem to Jericho": A study of Situational and Dispositional Variables in Helping Behavior". JPSP, 1973, 27, 100-108.<br /> 24. Ross, L. The intuitive psychologist and his shortcomings: Distortions in the attribution process. 'In L. Berkowitz (Ed.), Advances in experimental social psychology, 1977, vol. 10: pp. 173–220.<br /> 25. Id. at Note 17. <br />26. Id.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-61355884986709484152010-05-20T17:08:00.000-07:002010-11-09T11:38:48.572-08:00Oversimplification of a Complex Problem : A Critique of the Boston Public Health Commission’s New SexED CampaignI. Introduction:<br />There are over two dozen infections and diseases that can be transmitted through sexual contact. (1) In the United States there are approximately 65 million people with one or more viral sexually transmitted infections (STI) and there are approximately 19 million new cases of STIs every year.(1,2) There are 56,000 new HIV infections each year and currently 1-1.2 million people in the United States live with HIV/AIDS. (1) In 2009, 56 percent of Boston Public High School students reported having sex and 40% of students younger than 16 reported being sexually active. (2) Only 71% of those reporting sexual activity indicated that they had used a condom during their previous sexual encounter. (2) One in two sexually active persons will contract an STI by the time they turn 25 (3) and nearly ½ of all STIs occur in people ages 15-24(4,2). A 2008 report indicated that 1 in 4 female teens has an STI/STD and half of all African American teen girls has an STD. (4) Condom use has been shown to significantly reduce the risk of many STIs. (3,5) Contrary to popular belief, being at higher risk for contacting an STI does not necessarily indicate risky behavior. The risk of contracting an STI increases in areas with high levels of poverty, unemployment, social and economic discrimination and poor access to healthcare. (1,6,7)<br />The Boston Public Health Commission (BPHC) has recognized the threat that STIs and teen pregnancies have on Boston youth. In an attempt to lower the STI incident rates in Boston teens, a new campaign called “SexED in Boston” has been introduced. (7) This is the first time major funding from BPHC has been spent to target STI prevention in sexually active teens. (2) The campaign includes print ads that can be seen in Massachusettes Bay Transportation Authority (MBTA) buses, trains and stations and in newspapers. (2) BPHC has produced TV ads that have run on local cable stations and can also be viewed on Youtube and on the SexED facebook page. (2,8,7) <br />The print ad consists of two teen girls leaning on a desk and the words “A prefect score on the SATs might be hard, but preventing STIs isn’t. Do your homework. Protect yourself. Don’t get infected”. (7) In the background is a chalkboard with the words “Mrs. Tinkleberry Health 101”. (7) A different ad simple says “Don’t confuse the SATs with STIs” (7) Below are examples of some of the print advertisements with Mrs. Tinkleberry in the glasses and Janay in the t-shirt.<br /><br /> <br />The television commercial opens with a young teen pretending to be a strict and obnoxious teacher; Mrs. Tinkleberry. This teacher proceeds to ask the students what an STI is and no one answers. In an angry and accusing voice she calls on “Janay” and the student incorrectly answers that “Isn’t it that test you take when you want to get into college?”. (7) Everyone in the class laughs at her and Mrs. Tinkleberry explains in a condescending voice that that is the SATs. Mrs. Tinkleberry proceeds to explain what an STI is and that it may not cause symptoms and that to prevent this you should always wear protection and then she holds up a condom. The class is dismissed and Janay confronts “Jeffrey” who is clearly a teen girl dressed in drag pretending to be a teen boy. Janay says “Jeffrey you said we didn’t need no condoms”. He says “Ya but it was good though. It was worth it right?”. Janay says “No I didn’t know you were going to give me the SATs”. Mrs. Tinkleberry was listening and says in an exasperated voice as she rolls her eyes “STI Janay”. The commercial end and the words “Do your homework. Protect yourself. Don’t get infected” appear. <br />This critique is on the BPHC SexED campaign as a whole but focuses on the print and TV ads since they are the most prevalent part of this campaign. The second section of this paper outlines three fundamental flaws of this campaign. The third section of this paper focuses on what could be done to improve on this campaign and provides support for why these changes could improve the campaign’s success.<br />II. Critique of the Theories, and Lack of Theories, Used in the SexED Campaign.<br />There are three fundamental errors that the BPHC made when creating this campaign. The first is that they used the Theory of Planned Behavior to model a behavior that cannot be captured using this theory and ignored visceral influences. (9) The second critique is that BPHC did not follow any advertising or marketing theories when creating their advertisements. Instead, they relied on assumptions and guesswork which can be fatal to any campaign. (10) Finally, this paper will critique the BPHC for failing to consider important environmental and social factors that influence teen’s decision to have safe sex since research has shown these factors put a teen a greater risk for infection. (6)<br />A. BPHC Uses the Theory of Planned Behavior to Explain Irrational/Spontaneous Actions and Ignores Visceral Influences:<br />The BPHC clearly used the Theory of Planned Behavior to guide their campaign. The Theory of Planned Behavior says that before people change their behavior they weigh their attitudes and the importance of those attitudes and then weigh what people think and the importance of what those people think. This leads to an outcome expectancy and if they think they can do the behavior they will intend to and then they will follow through with the behavior. (9) When used to understand STI prevention the Theory of Planned Behavior would predict that to get teens to use condoms they must have negative attitudes about the outcomes and must strongly weigh the importance of that outcome. The teen must also consider what other people think and consider how important that person’s opinion is to them. Finally, this will lead the teen to develop an outcome expectancy. If the STI is considered very bad, they are deeply concerned about the negative consequences and the people they care most about think using condoms is good they will want to use condoms and practice safe sex. However, they must have self efficacy and really believe they can adopt that behavior. The teen would then decide they would intend to use condoms and then they would use condoms. (9,11,12,) <br />The BPHC uses this theory and attempts to influence the attitudes about condom use by giving facts. This is done both on the website, and in the TV ad. (7) This is an attempt to make teens understand that the outcomes for STIs can be very bad and very serious and that they are at risk. The BPHC uses the influence of what others think by using teens to deliver the message and using a Facebook page to show that their peers think using condoms is good. (7) The self efficacy is reinforced in the sexED slogan “A prefect score on the SATs might be hard, but preventing STIs isn’t”. (7) This slogan hopes to encourage teens to adopt the belief that they can do things to prevent STIs. <br />On the surface there doesn’t appear to be anything wrong with the message. However, in one study they found that 97% of adolescents had reported receiving STD education. (13) What can explain the high infection rates of teens if all they need are the facts? Theory of Planned Behavior is an individual level model that assumes the decision whether to use condoms is rational, it assumes this choice is also planned and that it is static. (9) Unfortunately, because of optimism bias – people’s tendency to feel that bad things are unlikely to happen to them and more likely to happen to other people, it may be easy to convince teens that STIs are dangerous and severe, but very hard to convince them that they will get one if they are not careful. (14)<br />It is also true that people often believe they are at risk, can do something to prevent that risk, fully intend to do it, but then do not follow through with the behavior. (15) There are many reasons that a teen might choose not to use a condom. There could be pressure from their partner to not use one. A condom might not be readily available in the heat of the moment. They may simply prefer not to use one because they feel it could interfere with pleasure. (15) At the moment when a condom is actually needed both parties involved are reacting to those visceral influences. A visceral influence is a natural human urge such as hunger, pain, thirst, sexual desire, etc. (15) When faced with these visceral factors people tend to ignore all else and their attentions and behaviors are focused at satiating that hunger, pain, sexual urge etc. (15) It makes people act in seemingly irrational manners. It has been found that people often will act against their own self-interest and fully know that they are doing so when visceral factors are involved. (15) Unfortunately, we underestimate the power of these visceral factors on both our behaviors and the behaviors of others. (15) <br />The Theory of Planned Behavior and other commonly used theories in public health do not take these natural human drives into account. In the case of condom use, teens are making a short-sighted tradeoff of sexual pleasure even though they know that it could lead to an STI tomorrow. This is an example of how visceral factors produce attention-narrowing.(15) These visceral factors also tend to make people selfish. (15) With that in mind, why would someone mention that they have an STI to their partner in the heat of the moment? The Theory of Reasoned Behavior would ignore these visceral factors and assume good information and good intentions would work. However, because of this very important issue, this campaign is missing the real problem entirely and setting the teens up for failure. The BPHC assumes condom use is a rational behavior when in fact it is irrational but in a predictable way. (16)<br />B. BPHC Violates Marketing and Advertisement Theories:<br />One of the most important rules that has been learned from research done on how to build a good campaign is that “The selection of the right promise is so vitally important that you should never rely on guesswork to decide it” (10) BPHC did do some research before embarking on the campaign but did not research the promise. In an interview with the Boston Globe Margaux Joffe, who was involved in the campaign, she said “They told us, ‘We don’t want some old 40-year-old woman telling us about sex and STIs…We laughed, but it makes sense. You may not trust the advice of an adult as much as you would someone in your peer group.’’(17) <br /> The results from their research were easily explained by Reactance Theory. This theory outlines that using a communicator that is as similar to the target audience as possible can increase compliance and reduce resistance. (18) BPHC did take into account who would deliver the message but instead of an adult they used a teen dressed as “some old 40-year-old woman” named Mrs. Tinkleberry who acts condescending and scoffs at Janay’s stupidity. BPHC also made the fatal error of trying to sell health. Ogilvy was clear that a large promise that appeals to people’s core values is the key to any successful advertisement. (10) Although it may seem counterintuitive, health is not a core value. It has been shown that often the deepest distress that illness causes is due to loss of control and the loss of independence. (19) These core values can differ slightly by age and culture but for American teens some of the most powerful core values that they hold are freedom, rebellion, control, and independence. (19) These are the “products” that the teens want to buy into. <br />The ads done in the campaign were done by a 16 year old girl who had her video chosen out of submissions done by local students. (2) To me, it is clear that this is a better example of how we have failed the students than it is an example of an advertisement for condom use. The teen produced a scene that is an exaggeration of the way sexual education is taught in school. It was a groundbreaking idea for BPHC to have students give input and become involved because they have knowledge about Boston teens that no adult does. However, a successful campaign involves using advanced Psychology, Marketing and Advertisement theories that students at this age group could not be expected to know. <br />C. The BPHC Ignored Important Social and Environmental Factors<br />Teens in Boston are influenced by their peers, teachers, parents, the community, socioeconomic status, ethnicity/race, and many other external factors. These environmental and social factors have a tremendous impact on the likelihood of a teen becoming infected with an STI. In fact, socioeconomic status, race/ethnicity, unemployment and discrimination are risk factors for STIs. (1,6) While white Americans generally get STIs through risky sexual behaviors, black Americans tend to get them from both high and low risk sexual behaviors. (1) This can be attributed to the fact that the levels of infections are much higher in blacks. (1,6) The infections rates are also higher in areas with poverty, high unemployment, poor access to health care, and social and economic discrimination etc. (1,6) The simple fact is that many of Boston’s schools are in neighborhoods where these environmental and social factors are prevalent. The BPHC did not attempt to address any of these problems. The focus of the campaign was to relay information and impress upon them the importance of practicing safe sex or abstaining altogether. <br />It has long been understood that teenagers can succumb to peer pressure. One study investigating this notion found that females were more strongly influenced by peer pressure and that peer pressure influenced both males and females attitudes about sexual activity. (20) It is not trivial that it was females most affected by peer pressure. Condoms are worn my males and despite requests, it is the male who decides if he will wear one. Female condoms are available but they are more expensive and less well known. The BPHC uses females in their video and ads to promote condom use when it is males who must wear them and they must do so in that “hot” state and we have seen that people tend to be selfish in that state. (15) This gives the male the option of trying to pressure the woman into sex without condoms. There is the additional problem of being viewed negatively by your partner/peers if you have a condom because Social Outcome Expectancy could lead your partner to wonder why you were carrying one with you and wonder if you anticipated casual sex. (21) This could be particularly damaging for women who would carry a condom because wanting lots of sexual partners is seen as a “male trait” and women are viewed negatively if they appear to be promiscuous. (21)<br />III. Proposed Intervention<br />The first part of the intervention I propose is also the most controversial. I propose that condoms not only be readily available to teenagers free of charge but that there be a campaign to encourage teen boys to use condoms to masturbate. I have heard in popular culture of men using lubricated condoms for masturbation because it is pleasurable and convenient.(22) These would seem like something a teen boy might be curious about. This could be included on a “fun tips” card that comes with a condom goodie bag. It could also be made into print ads or TV ads but that must be carefully thought out, considered, studied and planned to avoid any unforeseen problems. If these advertisements were done tastefully and with tact, they could have the potential to be widely influence this behavior in teens. <br />In order for this to work condoms should be freely available in many places that teens go and can access privately. They could be in locker rooms, bathrooms, the nurse’s office, youth centers, etc. To make it more successful there might be variation with the type of condom that is provided. There are dozens on the market and each one promises a different pleasurable benefit.<br />The intervention would also need to create a better advertising and marketing campaign. My goal is to re-frame and re-package the “product” of sexual health. I would use teens as the communicators in all of the advertisements but while they would provide important insights, they would not write the actual advertisements. I would also attempt to use famous teens to support these ads in the hopes that they would be viewed as early adopters of the messages in the campaign and create a tipping point. (23) The overall messages would be simple. “I am in control”, “I am independent”. I would also backup these promises with stories, symbols, and images that reinforce the promise. (19)<br />I am impressed by BPHC’s use of a Facebook page. I would create a Facebook page and use it to build the brand and to better the chances that the campaign would reach that critical tipping point. (19,23)<br /> The campaign that I would plan would also be particularly unusual because part of it would put a focus on programs not normally associated with lowering STIs. In addition to the free condoms, encouragement of condoms for masturbation, and ad campaigns with a big promise, I would try to improve the environment that the teens in Boston must live in. I would put aside money to pay for after school programs. One program would be an empowerment program designed to encourage teen girls to be active members of the community and go to college. The program would also encourage empowerment among all teens. I would also put an effort into literally cleaning up the neighborhood with a special focus of keeping the mile radius around the school very clean. The teens would be encouraged to help in this effort to help increase pride in the community.<br />Other social/environmental programs would include a course on how to improve on the SAT’s. These SAT preparation courses are currently offered but at a high cost at private tutoring centers. I would also offer courses that specialize in practical advice on how to get into college. They could receive help on their entrance essays, resumes, applications and with scholarship searches. The hope of this program is that it would lead to more students going to college and then getting jobs and lessening unemployment and poverty in the community. <br />i. Support For Using Visceral Influences<br />The purpose of encouraging condoms for masturbation is that it has been found that interventions done when in a “hot” state were more effective than an intervention done in a “cold” state. (16) If a teenage boy always reaches for a condom when he is in that hot state he would probably be more likely to associate that hot state with condoms and think of it when he was with a partner.(16) This is one way to actually provide an intervention when the teen is influenced by visceral factors. This is particularly important since males are the ones who must wear it. The Social Learning Theory (9) would predict that the teen would use a condom and if they have a positive reinforcement of a pleasurable experience they would be more likely to reach for a condom again. The environment would be conducive to acquiring a condom because they would be in many places free of charge. It would likely cause a buzz and if a teen thinks others might be trying or doing it he would be more likely to try it because people base many behaviors on social norms (Social Expectations Theory). (24) It is a simple step and since another partner is not involved they would have a great deal of self-efficacy. (9) The simple fact that the teen used it once for masturbation is in itself a reinforcement of the behavior and makes it more likely that he will use it again. (9) <br />This would do many things. It would mean that teen males might seek out condoms and possibly have condoms with them or in their room. This greater accessibility to condoms would mean that if in a hot state with a partner the condoms would already be there. This easy accessibility, even when visceral influences are at play, leads to, not perfect, but better condom use. (16) It allows for irrational behavior and creates a positive reinforcement between sexual pleasure and putting a condom on. It also gives teens experience with how to put a condom on. It can require some planning (getting the condom) but hopefully that will be less of an issue if they are free. (9)<br />ii. Support that investing in Marketing Theory and Advertising Theory pays off.<br />I do not pretend to know what slogan would resonate most with Boston youth but this is why I would invest heavily in research. This use of Advertising Theory, Marketing Theory and framing is a subtle but important difference in this campaign. It re-frames the issue so I am no longer selling health. (19) I am selling control and freedom. I would also work towards making images of condoms be closely associated with core values. <br />These core values in teens have been studied and teens care most deeply about are rebellion, control and independence. (19) The Truth campaign was hugely successful in re-framing a public health issue and creating a valuable brand. (22,23) The Truth campaign team did research and discovered that what teens valued most was rebellion. They then used this to encourage teens to rebel against the tobacco industry and they had amazing results. (25) In just two years current cigarette use dropped in teens from 18.5% to just 11.1%. (26) A 7.4% decrease is tremendous in such a short period of time. Although it is difficult to rebel against a disease it is easy to reframe sexual health to be about control and independence. I would use Advertising Theory and Marketing Theory and make those three core values as my big promise. (10,19) I would also try to use symbols and hopefully make condoms a symbol of rebellion, control and independence.<br />iii. Support for Social and Environmental Interventions:<br />My hope is that this project would extend beyond what traditionally would be thought of as a “sexual health intervention” but at the same time be uniquely successful. There is only so much that condom use can do. If a community has a high level of infected adults it puts everyone at risk, including those practicing low risk sexual behaviors. (1,6,21) The after school programs are aimed at making the community better and stronger as a whole. This should decrease poverty and unemployment which tend to lead to communities with higher STI rates. (6,21)<br />The Theory of Gender and Power postulates that inequalities between genders are due to divisions of power, labor, and the structure of cathexis. (6,21) Some of these disparities and inequalities produce certain exposures that increase women’s risk for diseases such as STIs. (6,21)<br />As discussed earlier, Black teens are more likely to become infected with an STI and also more likely to give in to pressure from peers. (1,20) Socioeconomic status, discrimination and unemployment are just a few more environmental factors that actually increase risk. (1,6) My program would address some of these problems with after school programs to encourage college educations. This is important because social and environmental issues are at the root of the problem and no amount of harping about condom use can influence these problems. <br />The Theory of Broken Windows would predict that garbage, graffiti, etc would create a general sense of disorder. (9) This method of cleaning up to prevent crime was used successfully in NYC subway stations. (9) The physical cleaning of the community should create a sense of order and stability. It should discourage the idea that “anything goes” and again, work towards the promotion of a healthy community and thus, healthy teens. <br />IV Conclusion:<br />One of the main strengths of the proposed intervention is that it is multifaceted and uses strategies that are rarely, if ever, used in STI/STD interventions. The new campaign avoids common pitfalls that the SexED campaign bought into and uses emerging theories based on the understanding that behaviors are not always, planned, static or even rational. This program has the ability to be tweaked and then implemented in other cities. The underlying issues outlined in this paper must be realized, understood and addressed before any progress can be made in the fight against STIs in teens.<br />References:<br />1. Guttmacher Institute. Washington, DC. Facts on Sexually Transmitted Infections in the United States. http://www.guttmacher.org/pubs/FIB_STI_US.html<br />2. The Boston Public Health Commission. Top Stories View. Boston, MA. http://www.bphc.org/Newsroom/Pages/TopStoriesView.aspx?ID=101<br />3. American Social Health Association. STD/STI Statistics > Fast Facts. Research Triangle Park, NC. http://www.ashastd.org/learn/learn_statistics.cfm<br />4. National Public Radio. Study: 25 Percent of Teens Have STDs : NPR. http://www.npr.org/templates/story/story.php?storyId=88140117<br />5. Crosby RA., DiClemente RJ., Wingood GM., Lang D., Harrington KF. Value of consistent condom use: A study of sexually transmitted disease prevention among African American adolescent females. American Journal of Public Health. 2003 Jun;93(6):901-902.<br />6. Wingood GM, DiClemente RA. The Theory of Gender and Power: A Social Structural Theory for Guiding Public Health Interventions. In: Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. Jossey-Bass; 2002. p. 313-346.<br />7. Facebook. sexED in Boston | Facebook. http://www.facebook.com/bostonsexED<br />8. Youtube. Health 101: STIs. San Bruno, CA. http://www.youtube.com/watch?v=0JC8ijpW5iI&feature=youtube_gdata<br />9. Siegel, M. Class Lecture, Session 5. 2009 Oct 1;<br />10. Ogilvy D. Confessions of an Advertising Man. Revised. Atheneum; 1988.<br />11. Edberg M. Individual health behavior theories. In: Essentials of Health Behavior: Social and Behavorial Theory in Public Health. Jones and Bartlett; 2007. p. 35-49.<br />12. Theories and applications. In: Theory at a Glance. National Cancer Institute; 2005. p. 147-160.<br />13. Lane T. Despite having received relevant education, youth lack knowledge of STDs. Perspectives on Sexual and Reproductive Health. 2003 Feb;35(1):51-52.<br />14. Neil d. Weinstein. Unrealistic optimism about future life events. Journal of Personality and Social Psychology. 1980;39(5):806-820.<br />15. Loewenstein G. Out of control: Visceral influences on behavior. Organizational Behavior and Human Decision Processes. 1996;65(3):272-292.<br />16. Ariely D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. 1st ed. HarperCollins; 2008.<br />17. Smith S. The Boston Globe. Cautions for and from teens. Boston, MA. http://www.boston.com/news/health/articles/2009/08/04/safer_sex_campaign_makes_use_of_peers_on_facebook_youtube_cable/<br />18. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology. 2005;27(3):277.<br />19. Siegel M, M.D, Doner L. Marketing Public Health. Jones & Bartlett Publishers; 2004.<br />20. Brown BB. The extent and effects of peer pressure among high school students: A retrospective analysis. Journal of Youth and Adolescence. 1982 Apr 1;11(2):121-133.<br />21. Raj A. Class Lecture, The Theory of Gender and Power. 2009 Dec 3;<br />22. Hamburg J. I Love You Man. DreamWorks; 2009.<br />23. Gladwell M. Introduction. In: The Tipping Point. Back Bay; 2002. p. 3-14.<br />24. Siegel M. Class Lecture, Session 9. 2009 Oct 29;<br />25. Hicks JJ. The strategy behind Florida's “truth” campaign. Tobacco Control. 2001 Mar 1;10(1):3-5.<br />26. Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA. 2000 Aug 9;284(6):723-728.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-3813841566885389422010-05-20T17:07:00.000-07:002010-05-20T17:08:35.103-07:00Turning The Tide On HIV In Young Men Who Have Sex With Men – Steven RalstonOne hates to begin paper with a cliché, but sometimes a picture really is worth a thousand words:<br /> <br />This graph comes from the Centers for Disease Control and Prevention (CDC) and clearly demonstrates the failure of Human Immunodeficiency Virus (HIV) prevention strategies to reach young men who have sex with men (MSM) (1). From 2001-2006, the incidence of HIV/AIDS cases in every other age group decreased, but in the adolescent age group, the number HIV cases continued to rise. Sadly, we see this trend despite clear indications and predictions that this group was particularly vulnerable to such a resurgence (2).<br />Traditional HIV prevention programs aimed at young MSM have usually involved advertising and educational campaigns encouraging one of three behaviors: abstinence, condom use, or HIV testing. And while some of these campaigns may have been more effective than others, and while some interventions have been based on sound theoretical bases (3-5), the overall result has been a dismal failure as the CDC data demonstrate: HIV infections continue to rise in this age bracket (1). I posit that these campaigns have failed in this demographic because behavioral change in this group cannot be achieved through traditional rational choice models of health behavior for several reasons: the young men who are the targets for these campaigns have a sense of invulnerability and a natural distrust of authority and they are making decisions about condom use at the wrong time, i.e. when they are already having sex; the messages we send young men are inconsistent and contradictory; and, finally, the stigma of being gay or having sex with other men is so great that it renders ineffectual any public health campaign that is based on a supposed rational framework that adolescents might use to make decisions.<br />Promoting Abstinence, Condom Use and HIV Testing: The Traditional Public Health Approach<br />Attempts to change the sex behaviors of men at risk of acquiring HIV have not been very successful overall. Even very intensive interventions aimed at preventing risky behaviors have achieved only modest changes that tend to dissipate with time (6). Young men, especially, are likely to be resistant to such interventions due to their self-perceived invulnerability and their distrust of authority. Condom ads exhorting them to “Respect Yourself, Protect Yourself” may have catchy rhyme, but probably do not resonate with young men who perceive themselves as invincible (7). And abstinence-only education has been a dismal failure for this demographic (8).<br />In addition, young men do not make sound decisions in the heat of passion. This is compounded in a particularly problematic fashion by the well-documented fact that risky behavior in MSM is directly tied to alcohol and substance abuse (10-11). It is not clear, therefore, how effective the rational framework based models can ever hope to be in affecting behavior at the time of a sexual encounter that is so patently wrought by emotion and irrationality.<br />The Problem of Mixed Messages<br />Other salient aspects of the public health thrust for abstinence, greater condom use, and HIV testing are the inherent contradictions in these campaigns. On the one hand, condom use is promoted as the means of protecting oneself from HIV and other sexually transmitted infections (STIs); however, this information is often couched within the context of an abstinence-based curriculum. There is a striking incongruity between being told that “waiting is best” and that condom use is crucial. <br />In those campaigns targeting at-risk youth, the reason often given to make HIV testing seem worthwhile (the theory being you are more likely to spread HIV if you don’t know you have it) is that there are now effective treatments for HIV available. This seems to be saying at once that HIV is bad (i.e. you don’t want to spread it), but actually, not so bad because there are good therapies. In fact, it may be this perception (i.e. that HIV can be avoided with post-exposure prophylaxis and that HIV is now a treatable illness) has contributed to the increase in unsafe sex practices and HIV rates in young MSM (12). It is no wonder, therefore, that the messages of abstinence, condom use and testing have become diluted or lost amidst these contradictory messages from educators, politicians, and public health authorities.<br />The Problem of Stigma<br />My final argument as to why the traditional behavioral changing models and public health campaigns have failed to adequately reach young MSM is that the context within which these men are living in the world is one of stigma and discrimination and this makes it difficult for them to perceive a rational basis for their behavioral change. In many of the individual change models (e.g. the Health Belief Model or the Theory or Reasoned Action), there is a rational calculation required of the actor – a balance of needs, inputs, risks, benefits, etc. – that results in the behavior modification towards greater health. But, MSM are growing up in a world replete with unequivocal messages – both overt and covert – that their lives will be miserable: full of loneliness, social isolation, and perhaps even eternal damnation. Any campaign to convince these men that abstinence or condom use or HIV testing is worthwhile will fail unless these perceptions can be changed and they can believe in a happy future for which saving themselves is desirable.<br />Stigma theory was originally described in the 1960s by Erving Goffman (13) and has been used to explain behaviors and health outcomes in disease ranging from psychiatric illness (14) to epilepsy (15) to STIs (16). Goffman defined stigma as an attribute that discredits persons who possesses it; these individuals are seen as different and deviant. Stigmatization thus leads to discrimination and internalized self-hatred which both act as barriers to healthy behaviors. Later theorists moved to “reframe our understanding of stigmatization and discrimination to conceptualize them as social processes that can only be understood in relation to broader notions of power and domination” (17). Stigma theory, as it applies to people with HIV or those at risk for getting HIV explains the difficulty in effecting behavioral change in these oppressed populations.<br />And while some programs to promote safer sex practices have been framed as empowering MSM, this is usually within the narrow context of a particular sexual encounter or a particular health behavior being promoted, and not as broad-based notion to combat a systematic pattern of discrimination and marginalization in society. And without addressing these more far-reaching aspects of stigma, public health initiatives to promote healthy behaviors may be hampered as intimated by Parker and Aggleton:<br />“Precisely because they are subjected to an overwhelmingly powerful symbolic apparatus whose function is to legitimize inequalities of power based upon differential understandings of value and worth, the ability of oppressed, marginalized and stigmatized individuals or groups to resist the forces that discriminate against them is limited”. (19) <br />Thus, without addressing the underlying world of stigma and discrimination in which young MSM find themselves, public health authorities are left with a panoply of cognitive-behavioral or social-cognitive models for behavioral change which will only be marginally effective at best.<br />A New Path: Empowerment as a Precursor to Change<br />My proposal for a strategy to combat increasing HIV infections in young MSM is not to reject the behavioral change models that have been used in the past, but to continue them in a context in which change is more likely to occur. This context is one in which being gay or bisexual or having sex with other men is less stigmatized and that the message of having healthy sexual relationships is equated with having both healthy loving relationships and fulfilling lives despite being gay or bisexual. <br />My vision is one of a public health campaign whose goal is to bolster the self-esteem of young MSM by providing them a framework in which to see their lives as having purpose and a bright future. Instead of a life of isolation, fear, misery and disease, we should be offering them a future of professional and personal success. Such a campaign might consist of a series of ads that highlight the lives of successful gay or bisexual men. (Success in this context could be financial, professional, or personal.) These could be men playing sports, or graduating from college, or running their own businesses, or flourishing in supportive relationships, or having families of their own. The promise would be one of access to the American Dream, one of possibility, one of acceptance. If there were even a hint of traditional behavior modification in these ads, I would certainly not specifically mention condoms or HIV testing, but would favor keeping it vague: e.g. “I take care of myself, and those I care about, so I can keep my future safe.”<br />I also envision a series of more political ads which highlight the successes of the gay rights movement from discrimination law to civil rights and, now, even to marriage rights. This part of the campaign may need to come from private sources of funding, through foundations and gay-rights groups (e.g. the Human Rights Campaign), but is yet another means of shifting the context in which our public health messages are heard. <br />Now, I am not so naïve to think that the stigma of being gay, or bisexual, or being a MSM can be eliminated with a public health campaign, but I believe the effects of discriminatory societal pressures can be ameliorated through well-planned communications, marketing, and public relations strategies. And that without a change in how young MSM perceive themselves and their futures, any effort to change individual behavior will likely be ineffectual.<br />A Move Away From Individual Change Models<br />One of the strengths of this strategy is that the target is not necessarily an individual, but a group or social network of individuals. Attitudes about sex and safer sex practices may be largely influenced by the social networks in which individuals find themselves, as Fisher states:<br />“A social network theory approach to STD/HIV prevention suggests that individuals function within social networks that establish norms for behaviour [sic], including safer sexual behaviour [sic] and that these social networks enforce adherence to these norms”. (3)<br />If young men see themselves as part of a group that has a future worth staying healthy for, then they are more likely to make choices that will protect that future. And this will only be reinforces as they see others around them making similar choices. <br />Similarly, the use of gay leaders as a focus for the campaign will help to create role models for young MSM. But at the risk of seeming elitist, I would steer the campaign towards featuring role models that seem accessible to the target audiences: not just movie idols and star athletes, but regular guys who happen to be gay or bisexual and have managed to build successful lives. Such role models can be a source of opinion that can influence the behaviors of those men in similar social networks, as intervention models have used “community popular opinion leaders” to help propagate new ideas and behaviors (20). I think this strategy will be especially crucial in trying to reach the young men in the African American community whose HIV rates have increased the most in recent years.<br />A Consistent Message<br />A second strength of my proposed campaign is that its message is both clear and consistent. There is no incongruity between the promise of a better life and the facts presented: decent, admirable role models; broadening legal protections for gay and bisexual men; and increasing societal acceptance of these lifestyles. The message is clear, on point, even redundant. But consistent. In contrast to the many ads and campaigns promoting condom use and HIV testing, there is no waffling on the bottom-line message being sent to the target audience: protecting your future is important, because you have a future. The details of how the future is protected – whether by safer sex, or delayed intercourse until marriage – are less important than the promise of the future itself. It is the possibility of a future that is being sold, not the HIV test, not the condom, and certainly not the delay of sex until marriage. The product – the future – needs to be one that young men will want.<br />Challenging Stigma as Inevitable<br />Finally, the ultimate goal of this campaign is to shift the context of these young men’s lives and thus improve their self-esteems. And, the enduring power of improving these young men’s self esteem cannot be underestimated. Or, conversely, the adverse effect of continued discrimination will be immense. If MSM experience the world as one where marriage and committed relationships are impossible or stigmatized, how can they ever be motivated to protect themselves for such a bleak future? But in a world where gay marriage, civil unions, and committed monogamy are not just European curiosities, but part of mainstream – (think Iowa ) – American ideals, these young men might be motivated to reframe their decisions and choose healthier alternatives to unprotected sex. <br />Caveats<br /> My campaign poses several challenges for any organization that seeks to implement it. The political and public discomfort with addressing issues of sex and sexuality are readily apparent in reviewing the difficulties public health authorities had in addressing the AIDS crisis during the 1980’s and 1990’s (21). Civic equality for homosexuals is far from mainstream in many parts of the country. Because of this, it may be that much of the funding for this program will need to come from private sources or begin in some of the more liberal parts of the country.<br /> Finally, the difficulty in reaching African American youth needs to be addressed. One explanation why African American men seem to have been left behind especially by our current educational tools is that they are already stigmatized and marginalized by their race. And this compounded with the stigma of homosexuality (especially harsh in many African American communities) will likely make the young African American MSM a particularly intransigent population to be affected by this campaign. So, great effort will need to be made to include and keep this group in the sights of any agencies or organizations addressing this issue. <br /> Nevertheless, despite these challenges, the long-term benefits of this campaign could be profound and long lasting. Establishing the legitimacy of gay and bisexual lifestyles in our society is crucial to enabling young men to see themselves as having futures in which they have more choices available them than short-term sexual conquests in the context alcohol or drug use. These men need the promise of a brighter future and the accessibility of the American Dream; the need a reason to stay healthy. <br /><br /><br />REFERENCES<br /><br />1. www.cdc.gov/healthyyouth<br />2. Wolitski RJ, Valdiserri RO, Denning PH et al. Are we headed for a resurgence of the HIV epidemic among men who have sex with men? Am J Public Health 2001;91:883-888<br />3. Fisher WA. A Theory-Based Framework for Intervention and Evaluation in STD/HIV Prevention. Can J Hum Sexuality 1997;6(2).<br />4. Eke NA, Mezoff JS, Duncan T, et al. Reputationally Strong HIV Prevention Programs: Lessons from the Front Line. AIDS Education and Prevention 2006;18(2), 163-175<br />5. DiClemente RJ, Crittenden CP, Rose E, et al. Psychosocial Predictors of HIV-Associated Sexual Behaviors and the Efficacy of Prevention Interventions in Adolescents at-Risk for HIV Infection: What Works and What Doesn’t Work? Psychosomatic Medicine 2008;70:598-605<br />6. The EXPLORE Study Team. Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomized controlled study. Lancet 2004:364:41-50<br />7. www.advocatesforyouth.org <br />8. Santelli J, Ott MA, Lyon M, et al. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 38 (2006) 72– 81<br />9. Ariely D. Predictably Irrational New York: HarperCollins, 2008. <br />10. Koblin BA, Husnik MJ, Cofax G, et al. Risk factors for HIV infection among men who have sex with men. AIDS 2006, 20:731-739<br />11. Koblin BA, Chesney MA, Husnik MJ, et al. High-Risk Behaviors Among Men Who Have Sex With Men in 6 US Cities: Baseline Data from the EXPLORE Study. Am J Public Health 2003;93:926-32<br />12. Morin SF, Vernon K, Harcourt JJ, et al. Why HIV Infections Have Increased Among Men Who Have Sex With Men and What to Do About It: Findings from California Focus Groups. AIDS and Behavior 2003;7(4):353-362<br />13. Goffman E. Sigma: Notes on the Management of Spoiled Identity. New York: Prentice Hall, 1963. <br />14. Yang LH. Application of mental illness stigma theory to Chinese societies: synthesis and new directions. Singapore Med J 2007;48(11):977<br />15. Westbrook LE, Bauman LJ, Shinnar S. Applying Stigma Theory to Epilepsy: A Test of a Conceptual Model. J Ped Psychology 1992;17(5):633-649<br />16. Breitkopf CR. The Theoretical Basis of Stigma as Applied to Genital Herpes. Herpes 2004;11(1):4-7<br />17. Parker R and Aggleton P. HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Social Science & Medicine 2003;57:p16<br />18. http://www.aids.gov/takecontrol/factssheets/nhmtc_flyer.html<br />19. Parker and Aggleton, ibid. p.18<br /><br />20. The NIMH Collaborative HIV/STD Prevention Trial Group. The community popular opinion leader HIV prevention programme: conceptual basis and intervention procedures. AIDS 2007, 21(suppl 2):S59-S68<br />21. Shilts R. And the Band Played On: Politics, People, and the AIDS Epidemic. New York: St. Martin’s Press, 1987Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-79643308214411695582010-05-20T17:05:00.001-07:002010-05-20T17:07:02.839-07:00Applying social marketing theory to skin cancer prevention efforts - Busayo K. ObayanSince the early 1970s the carcinogenic effects of UV exposure have been known and prevention and awareness efforts were initiated. These first efforts included the creation of educational websites and databases, which were spearheaded primarily by the American Academy of Dermatology (AAD), and the Center for Disease Control (CDC). In addition, research was undertaken to learn more about the different types of skin cancer predominantly exacerbated by UV exposure: basal cell cancer, cutaneous squamous cell cancer, and malignant melanoma. Malignant melanoma is currently the fastest rising cancer in the U.S. It spreads rapidly, often without symptoms, and is more likely than not to result in death (1). Two thirds of cases of melanoma are believed to be caused by excessive exposure to UVA and particularly UVB, the radiation used on tanning beds (1). The CDC estimates that 50,000 people are newly diagnosed each year with melanoma and 7500 die from it (2, 3). Young people comprise a large share of those affected and dying from skin cancer with ½ of all melanoma cases being individuals less than 50 years old (1). These key research findings about the potentially fatal effects of excessive UV exposure led to further prevention efforts in the early 1990s that focused on educating youth in schools and introducing state legislation to require teens to present parental permission before using tanning beds (1, 4). Unfortunately these past attempts at prevention have had a minimal effect on decreasing the rates of skin cancer- in fact, the incidence of melanoma has risen progressively over the years (8). I argue that by passing unsound tanning bed regulations, relying on models of individual behavior change such as the health behavior model, and by taking away such a valued commodity, the desirable glow of a tan, and not replacing it with an alternative, equally appealing commodity, public health efforts to prevent skin cancer were minimally effective.<br />State legislation to regulate youth UV exposure via tanning beds focuses primarily on requiring parental permission to use a tanning bed, which has not significantly decreased the prevalence of tanning by youth. Many studies have shown that 80% of UV damage to the skin which contributes to skin cancer occurs before the age of 18(6). In addition, evidence supports the fact that persons who begin tanning when under the age of 30 increase their risk of skin cancer by 75% (9). Because of these findings, and the fact that melanoma is the first most common cancer in persons 25-29 and the second most common cancer in those 15-25 (9), public health advocates and physicians have doubled skin cancer prevention efforts targeting youth. As part of endeavors to decrease the incidence of skin cancer many public health advocates and dermatologists began to dialogue with their state representatives about introducing legislation to restrict youth access to tanning beds. Currently in America, at least 31 states have regulations in place to restrict youth access to tanning beds (4). Unfortunately, the majority of these regulations consist mainly of requiring tanning facilities to post warnings in the venue and neccesitating a range of ages from under 14 to under 18 to require parental consent to use tanning services. These parental consent requirements vary from requiring the youth to provide a signed document form to parent, which can be forged, to requiring a notarized document, to requiring the parent to come into the tanning facility and sign a document. Some more extensive parental consent procedures require the parent to remain in the tanning facility the entire time while the youth uses the services (4). Unfortunately, these attempts to restrict the availability of tans to minors have proven insufficient (7). <br />Studies have shown that states that require a minor to be a certain age in order to use the tanning facilities have been much more successful in decreasing the state-wide prevalence of tanning (7). In the U.S. the most restrictive tanning bed regulation was recently passed in Texas in April of this year. The Texas law prohibits all persons under the age of 16.5 from using tanning beds unless they have a doctor’s note require tanning bed use for medical condition (4). In Wisconsin, a similar law prohibits youth under the age of 16 from using tanning beds. Other states restrict younger ages from using tanning beds. The ideal piece of legislation would be one that restricts tanning bed use to those under the age of 18. As this is the legal age restricted from tobacco consumption, it seems an acceptable cutoff. In addition, several other countries have passed tanning legislation restriction youth under the age of 18 from using tanning beds. In the Australian states of Victoria and South Australia, tanning has been prohibited by those under the age of 18 as well as anyone with the fairest skin, type I, which tends to freckle and burn instead of tan(10). France has also prohibited anyone under the age of 18 from using tanning beds since 1997(11). <br />The primary reason the U.S. legislation is unsuccessful in decreasing the prevalence of skin cancer is that, unlike other international pieces of legislation, U.S. state legislation have few or no provisions for the enforcement of the regulations. In public health anti-tobacco efforts, many studies noted that the mainstay of an effective tobacco bill were its enforcement provisions ( (7). The tobacco bills included provisions that called for random monitoring and checks of establishments that sold tobacco to prevent selling of tobacco products to minors. This was accomplished in many states by using decoys who were minors and planting them at tobacco shops. Early after the initiation of these activities, store owners caught on and began to require ID from all customers appearing under the age of 30. This enforcement provision greatly decreased youth access to tobacco products. In addition, establishments that were caught selling to underaged customers were fined, and those fines were used to maintain the monitoring of these establishments. These methods could be utilized in efforts to restrict youth access to tanning beds as well. Enforcement provisions are the hardest to pass because they require a fiscal note, which many states, in these hard economic times, are unlikely to pass. Although it can be difficult to include these enforcement provisions, they are of the utmost importance in creating an effective bill that will bolster public health prevention efforts. As the efforts in tobacco have show, enabling the fines collection from tanning establishments that do not abide to the regulations can be used to further efforts to actively monitor and enforce tanning bed regulations.<br /> Past methods of skin cancer prevention have been heavily based on models of individual behavior, particularly the health belief model. Educational methods of public health efforts to prevent skin cancer have relied heavily on the dated concepts illustrated in the health belief model. The model explains only individual-level behavior based on the premise that: 1) The person believes he/she is susceptible to the disease, 2) The individual believes that the disease will have at least a moderate to severe impact on their lives, 3) The prior beliefs will lead to a perceived threat of the disease, which would lead to 4) the individual taking action to prevent the occurrence of disease (12). Other important aspects of the model include the idea that there are modifying factors, such as race, social class, and knowledge about the disease, which will lend to the individual’s perceived threat of the disease (12). Finally, the model includes a component that is necessary to push the individual from perceiving the threat of the disease, to taking action to prevent the disease; this cue to action can vary from family illness to media campaigns about the disease (12). In past public health attempts to prevent skin cancer, advocates have utilized this model extensively by designing programs heavily based in education (1). The assumption being that by educating youth, the greatest group at risk, this will either provide a “cue to action,” that will push these youth from tanning to refraining from tanning. An additional way the model was applied in an attempt to change behavior was by using education as “modifying factor” that would increase the perceived threat of the disease, and thus lead to individual modifying behavior of sun protection and avoiding tanning.<br /> Unfortunately, because of the flaws inherent in the model of individual behavior change, the public health interventions centered on this model have not been successful. Flaws that exist within the health belief model include the fact that it assumes that people who intend to change their behavior will actually change. Young people know that tanning and excessive exposure to the sun will increase their chances of skin cancer because this notion has been introduced to this generation at a young age by both educators and parents (13). Research has found that youth have a high knowledge base about skin cancer, its causes, and how to prevent it, but this does not correlate with a reduction or decreased desirability of tanning (13). Applying the health belief model to explain this behavior leaves one at a loss. This is because this classic model of health behavior does not account for the facts that: 1) human behavior is inherently spontaneous and irrational, 2) Just because a youth knows tanning will lead to skin cancer does not mean that they will take steps to prevent it, and 3) Among youth, there is more of a herd mentality, and tanning is a behavior perceived by groups of teenagers to be aesthetically pleasing and undertaken as a group activity. For example, an individual among a group of 16 year-old Caucasian females at a Boston beach is less likely to slather sunscreen in an attempt to prevent the future consequences of skin cancer because, as her friend applies tanning oil to achieve a look that is rare in the Boston winter months, the pressure to conform and the added perception of a tanned look will lead to her making a decision based on the group’s behavior. When around her parents however, the 16 year old would be more likely, especially if encouraged by her parents, to apply sunscreen to protect her skin. The health belief model poorly explains this spontaneous, paradoxical behavior. Also, as previously mentioned, the majority of youth know the damaging effects of UV exposure and still continue to tan. This finding is supported by several studies that have shown that youth attitude towards tanning places great emphasis on the value of tanning, and inexplicably, the greater the knowledge base of the youth, the higher the perceived value of tanning(13). This is because education efforts have made youth highly aware of the dangers of tanning, but even as education efforts increase, there is still an unchanged attitude about the value of tanning. <br /> Lastly, skin cancer prevention efforts failed because they neglected to replace the idea that a bronzed look of skin is desirable with an equally desirable alternative. As illustrated in various irrational principles of behavior discussed during lecture, human behavior is highly irrational, and the desire to tan despite a high knowledge of the risk of associated skin cancer is a fitting example of the irrationality of human behavior. One of the examples of irrationality discussed included the idea of aversion to loss. The idea consists of the concept that once people have something (in this case, a tan during the summertime), they are loathe to give it up (14). Classic behavioral health theories cannot account for this behavior because they haven’t considered the irrationality of human behavior. So when public health interventions like skin cancer prevention education heavily rely on classical theories of human behavior, they are not taking into account the irrationality of human behavior and are likely to fail. In August, the World Health Organization issued a statement raising the carcinogenic level of tanning beds to Level 1- definitely carcinogenic to humans (15). Even with this announcement, making tanning beds equivalent to cigarette smoke, people nationwide continue to tan and there continues to be resistance to passing anti-tanning legislation. If this is not irrational behavior, I don’t know what is. <br />As discussed earlier, youth place great emphasis on the importance of the look of tanned skin (12). When education efforts were increased, youth were found to have a higher level of knowledge about actions to prevent skin cancer, but their attitudes were unchanged. The reason that this method failed is that the basic issue at hand is changing the attitude of youth. Education methods do not change teen attitudes toward tanning (12), instead they employ the strategy that increasing youth education about skin cancer will either increase their perceived threat of disease or push them from a state of the perceived threat to protective actions against the disease. Instead of replacing the outlook that tanning is desirable with images of role models with natural, untanned, beautiful skin, public health interventions urge youth to stop tanning but continue to use “sunless tanning products” (5). These sunless tanning products do have the added benefit of not exposing youth to UV light, but if a sun-protective lotion is not used, they are still exposed to UV from sunlight. By replacing a tan from the beach or a tanning bed with sunless tanning, which is more expensive, the basic issue at hand, youth attitude towards tanning, remains unchanged and the skin cancer prevention efforts are still at risk of failing. The answer: An alternative and equally appealing replacement to the bronzed, sun kissed, skin cancer inducing tan.<br />Proposal:<br />Marketing theory is based on the premise that by researching a target audience and revealing that group’s wants and needs one can successfully market a product to that group that would fulfill their most intimate needs and desires. The initial component producing a successful product using marketing theory is the idea of “preprogramming idea gathering,” which is when those who plan on marketing the product gather data about the target group (16). The second step is “audience segmentation,” which is the enrollment of a sample of the target group to answer important questions about the group’s needs and wants (17). The third component of the marketing strategy is resource management, assessing and utilizing the program’s budget effectively, the fourth component is the most important, program development. The program development phase consists of the 4 P’s: 1) Product (also known as the “promise”)- The offer made to the target audience through images and messages, 2) the Price- cost of the product, financial as well as psychological and social, the strategy entails using methods to lower the cost of the product so that people will participate in beneficial health-changing behaviors, 3) Place- how the product is delivered- the channels that are used, 4) Promotion- How the product is promoted to the target audience- by use of media, person to person contact, etc (16). The fifth component of an effective marketing strategy consists of evaluation of the program to assess its successes and failures (17). A successful marketing strategy to promote a public health intervention would incorporate the mainstays that make commercial marketing so successful and apply it in a way that would be socially beneficial. <br /> Marketing theory can successfully be applied to skin cancer prevention targeting youth by employing the strategies outlined in successful commercial marketing, which hasn’t often been employed in this area. The first step of a successful campaign would be the preprogramming idea gathering. Advocates interested in preventing skin cancer by targeting youth should research the interests of that group as well as the factors that may prevent them from undertaking the public health message. Many interests of youth have not been taking into account in formulating skin cancer prevention strategy- these interests include that of sports, fashion, music, and entertainment. By gathering data about youth interest in these activities, public health interventionists can get greater insight into what type of message and delivery would greatly appeal to youth. Other important data such as the most effective environment in which to deliver the message should also be thoroughly researched. Most preventative efforts focus on education in schools, assuming that it is an effective learning environment in which the message could be relayed and internalized, but further research would reveal alternative environments that could be much more effective. The next step would be for public health interventionists to enroll a representative group to collect data about the needs and desires of the target population. Because most interventions targeted at youth are created by individuals who are significantly older than the target audience, these interventions are less likely to incorporate the wants and needs of an individual under the age of 18. By assessing the true wants, needs, and desires of this population, public health interventionists will find the true desires consist of the need to be accepted by others (namely- wanting to be perceived as attractive and conforming to group behaviors). This finding would reveal why past prevention efforts have failed- they have not addressed this basic need and want of this target population. The third step would be effectively utilizing the program budget. This may be difficult as public health programs have a significantly lower budget than commercial marketing ventures. However, by being creative by formulating a message that can be disseminated by multiple non-profit organizations such as the American Cancer Society, American Pediatric Society, Nation-wide melanoma foundations, and skin cancer foundations, this barrier would be surmountable. The fourth and most important step of program development should consist of a “product” desirable to our target audience. <br />The “product” would be an advertisement with a message in white against a black background stating: Tanning salons make 1 billion dollars annually. The advertisement would then show multiple media images of those who were young and tan, for example: Liza Minelli, Coco Chanel, and the Versaces, immediately followed by pictures of what they look like now. I would use a highly popular song to play while the images are being shown, this song would likely be chosen based on responses from the audience segmentation stage. Then the advertisement would show images of more pale or freckeled people such as: Marilyn Monroe, Anne Hepburn, and other famous media images, with following images of what they look like aged, which is much better than those who tan. The end of the message should have a voice over saying: “tanning is associated with a 80% risk in skin cancer. The choice is yours.” I would call this campaign “the choice campaign.” This concept is similar to the marketing methods used in the “truth” campaign against tobacco and would be highly effective in reaching our target population. This message effectively incorporates the need and desire of the target population to be attractive by turning the standard image of attractiveness, the tanned, bronzed look, into the wrinkled prune-like reality of the appearance that age will bring with continued tanning. It also replaces this old standard of attractiveness with one youth can strive for by avoiding tanning: the graceful and naturally pale appearance of natural, untanned skin. The “price” of the product would be giving up idea of a tan as the overriding idea of beauty, but the “cost” would be low because we would be replacing it with a new concept of beauty- the beauty of natural skin. How the product is delivered and promoted will depend on the budget of the public health program- but delivery could be expanded to billboards, pamphlets using images from the “choice” advertisement, key chains and other trinkets frequently used by youth, as well as websites and dissemination of the product to skin cancer organizations nation-wide. The last leg of this marketing strategy, which current public health interventions almost never utilize, is evaluation of the program. Provisions should be made during the initial planning of the budget for assessment of the impact of the product through surveys and evaluations of the target population. The product can then be continuously altered to achieve the most effective end result: the cessation of tanning.<br /> There are many benefits to using the marketing theory to create skin cancer prevention programs targeted at youth. Firstly, it would address the paucity of effective legislation currently being used to regulate youth access to tanning beds by disseminating the message of skin cancer prevention nationwide. Legislators who were previously against bills to regulate tanning may be more likely to support these bills when they are exposed to the marketed message. In addition, by including testimony from past survivors of melanoma in the product, citizens nationwide would be more likely to write to their respective legislators to support the bills. Nationwide, skin cancer organizations can disseminate this information, increasing the education and impact of the message on citizens, the target audience, and legislators. Hopefully, this more effective message would lead to the inclusion of enforcement provisions in current tanning legislation as well as initiation of tanning regulation efforts in states that currently have no legislation. Secondly, the marketing theory is not an individual-level model, like the health belief model used to plan prior public health prevention programs. As such, the model will be able to incorporate research to figure out what the target populations’ needs and desires are before planning an intervention. It would be able to account for the irrationality of human behavior by using responses from the target audience to plan the intervention. Instead of assuming these responses will be rational, the marketing model would be able to collect these irrational responses and benefit from them by using them to create an effective prevention program. As in most successful commercial marketing efforts, this intervention based on marketing theory would rely on the fact that the way the message is framed, and not necessarily the message itself, should be the primary focus of successful public health campaigns. Framing is a large part of what commercial marketing is all about. The “frame” is developed by the needs and wants of the target population, and a “product” presented within that frame is much more likely to be “bought” than previous skin cancer prevention “products.” Thirdly, the marketing theory replaces the previously accepted idea of a tan as beautiful with a new concept that natural, untanned skin is indeed beautiful and highly valued. Human beings, being irrational creatures, are loathe to give up what they already have if it’s not replaced by something else that is not equally or exceedingly appealing (14). By giving youth an alternative and equally appealing replacement to the bronzed, sun kissed skin, a healthy glowing look that popular actors and actresses throughout Hollywood and general media are utilizing, we address the irrationality of human behavior, and are more likely to succeed in our public health interventions. A prime example of the success of the application of social marketing theory to the issue of tanning and skin cancer prevention is illustrated in Victoria, Australia’s SunSmart program (18). This is a program in which youth are primarily targeted and includes a television campaign and a national skin cancer week. The television campaign called “The Dark Side of Tanning,” will include an illustration of what actually occurs to the skin as someone tans as well as interviews with young people affected by malignant melanoma. In addition, the Victorians are initiating a campaign called “Fashion to die for,” targeting women age 18-30, the largest group that visits tanning salons. The purpose of the campaign will be to make this group more aware of the dangers of tanning using vivid images and video. These innovative social marketing efforts in combination with Victoria, Australia’s ban of tanning among youth under age 18, the number of tanning salons has decreased by a staggering 32% (18). Similar efforts initiated in the U.S. would go a long way to reaching youth and effectively decreasing the incidence of skin cancer.<br /><br />References<br />1. Center for Disease Control. Guidelines for School Programs To Prevent Skin Cancer. Accessed Dec 5 2009. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5104a1.htm<br />2. American Cancer Society. Cancer Facts and Figures 2008. Accessed Dec 5 2009. Available at: http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf<br />3. Health physics society. Ultraviolet radiation and public health. Accessed Dec 5 2009. Available at: http://www.hps.org/documents/ultraviolet_ps011-1.pdf<br />4. National Conference of State L. Tanning Restrictions for Minors: A State-by-State Comparison. Available at: http://www.ncsl.org/programs/health/tanningrestrictions.htm. Accessed March 30, 2009.<br />5. American Academy of Dermatology Press Release. Teens and tanning, a dangerous combination. Accessed Dec 5 2009. Available at: http://www.medi-smart.com/derm-tanning.htm.<br />6. Whiteman DC, Whiteman CA, Green A. Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes & Control. 2001;12:69-82.<br />7. Cokkinides V, Weinstock M, Lazovich D, Ward E, Thun M. Indoor tanning use among adolescents in the US, 1998 to 2004. Cancer. 2009;115(1):190-198.<br />8. SEER Cancer Statistics Review, 1975-2004 (NCI) Link.<br />9. The International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: Asystematic review. International Journal of Cancer 2006; 120:1116-1122.<br />10. Australia S. Radiation Protection and Control (Cosmetic Tanning Units) Regulations 2008 Available at: http://legislation.sa.gov.au/LZ/C/R/Radiation%20Units)%20Regulations%202008/current/2008.23.UN.PDF. Accessed on May 25, 2009. 2008.<br />11. Décre. 97-617 du 30 mai 19977, Article 4 Available at: http://www.legifrance.gouv.fr/WAspad/RechercheSimpleLegi.jsp. 1997.<br />12. Salazaar, Mary. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.<br /><br />13. Dennis LK, Lowe JB, Snetselaar LG. Tanning behavior among young frequent tanners is related to attitudes and not lack of knowledge about the dangers. Health Education Journal. 2009; 68; 232-243.<br /><br />14. Dan Ariely. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: HarperCollins Publishers, 2008.<br /><br />15. Boyles, Salynn. WHO: Tanning beds cause cancer. WebMD. July 28, 2009. Accessed Dec 8 2009. Available at: http://www.webmd.com/skin-problems-and-treatments/news/20090728/who-tanning-beds-cause-cancer. <br /><br />16. P. J . Svenkerud and A. Singhal. Enhancing the Effectiveness of HIV/AIDS Prevention Programs Targeted to Unique Population Groups in Thailand : Lessons Learned from Applying Concepts of Diffusion of Innovation and Social Marketing. Journal of Health Communication, Volume 3, pp. 193. 1998.<br /><br />17. Lefebvre, R. C., & Flora, J. A. (1988). Social marketing and public health intervention. Health Education Quarterly, 15, 299.<br /><br />18. The cancer council Victoria. “Young Victorians targeted in hard-hitting skin cancer television campaign.” Accessed Dec 8 2009. Available at: http://www.sunsmart.com.au/news_and_media/media_releases/media_release_20091119.htmlUnknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-56250646865823913442010-05-20T17:03:00.000-07:002010-05-20T17:05:14.747-07:00BMI Report Cards: Pass or Fail? – Jenna D. LovaasI. Introduction<br /> Obesity is a major public health concern and is quickly becoming an epidemic, as evidenced by rapidly increasing prevalence rates (1, 2). Rates of obesity are increasing across all age groups, but the rise in childhood and adolescent obesity is of particular concern. Obesity in youth is defined as greater than the 95th body mass index (BMI) percentile for age- and sex-specific growth charts (3). Between the 1960s and the 1988-1994, the prevalence of obesity among children and adolescents more than doubled, going from 4 percent to 11.3 percent in 6- through 11-year-olds and from 5 percent to 10.5 percent among 12- through 19-year-olds (4). Estimates calculated with measurements obtained through the 1999-2000 NHANES show that the prevalence of obesity is 10.4 percent among 2- through 5-year-olds (up from 7.3 percent in 1988-1994), 15.3 percent among 6- through 11-year-olds, and 15.5 percent among 12- through 19-year-olds (4). More recent estimates show that in 2003-2004, 17.1 percent of U.S. children and adolescents were overweight (5). There is recent research suggesting that the overweight and obesity trends among children and adolescents are leveling off, but the proportion of these populations classified as obese are still high (3, 6). Furthermore, the prevalence of severe obesity in youth, defined as greater than the 97th BMI percentile, continues to rise (7).<br /> This continued trend of obesity and overweight places children and adolescents at risk for developing a number of adverse health conditions that are likely to continue into adulthood, including cardiovascular, gastrointestinal, pulmonary and orthopedic complications (3). Hyperlipidaemia, hypertension and abnormal glucose tolerance are occurring with increasing frequency among obese youth (8). In addition, children are now presenting with type 2 diabetes mellitus, which has previously rarely been seen in children (4, 8). Childhood obesity is also known to be an independent risk factor for adult obesity, and there is evidence of an association between adolescent obesity and increased health risks as adults, independent of adult weight (8). In addition to physiological disorders, overweight and obese youth are at increased risk of developing psychological complications, such as depression, behavioral problems and low self-esteem (9). These psychological disorders can potentially affect a child’s adherence or self-motivation to adopt healthier behaviors (3). <br /> Considering the severe health consequences, both physiological and psychological, effective public health interventions are necessary to address the problem. Schools can have an important role in youth obesity prevention because the majority of young people are enrolled in school; therefore, the CDC has identified a number of strategies that schools can use for obesity prevention (10). Although it is not one of the strategies recommended by the CDC, a number of school districts have begun implementing BMI-screening programs in schools (11). Screening results are often sent to parents and include the child’s BMI-for-age percentile and an explanation of the results. Additional information in the report may be healthy eating and physical activity tips, and any recommended follow-up actions (10). The school health policies and programs study performed by the CDC in 2006 found that 22 percent of states required schools or school districts to measure and assess height and weight or body mass; 73 percent of those states required parent notification of the results (10). As an example, Arkansas, California, Illinois, New York, Pennsylvania, Tennessee and West Virginia use BMI report cards for parent notification (12), while districts in other states have also piloted similar programs. <br /> This paper focuses on school-based BMI measurement and BMI report cards. Section II presents three critiques of this approach to overweight and obesity in youth. Section III then proposes and provides support for an alternative multi-level intervention to address childhood overweight and obesity, taking into consideration the flaws of the BMI report card intervention.<br />II. A Critique of School-based BMI Measurement and BMI Report Cards<br /> BMI report cards are likely to raise awareness of the importance of childhood overweight and obesity prevention, but the intervention has the potential to do more harm than good. This section presents three arguments for why school-based BMI measurement and report card programs are flawed. First, BMI report cards lack tools to promote self-efficacy; second, this intervention fails to consider the importance of self-esteem in behavior change; and third, BMI report cards neglect to consider the potential for negative labeling. <br />A. BMI Report Cards Do Not Promote Self-Efficacy<br />Self-efficacy is one component of Albert Bandura’s Social Cognitive Theory (SCT), which describes dynamic interactions between personal and environmental factors and human behavior. According to Bandura, self-efficacy, goals and outcome expectancies are the three main factors that influence behavior change (13, 14). Self-efficacy, or the belief that one can successfully implement the behavior required to achieve the outcome, can determine whether or not the individual engages in that behavior (13, 15). If individuals have a feeling of self-efficacy, they are capable of behavior change regardless of potential obstacles. On the other hand, if they do not feel like they have any control over their lives or health, individuals are not motivated to work past the challenges (13).<br />Some BMI report cards simply report the child’s status as underweight, normal weight, at risk for overweight or overweight (16). If parents are expected to help their children deal with the problem of obesity, they need more information and advice than their child’s weight status. A pilot study in Cambridge, MA included suggestions for daily lifestyle changes in their BMI report cards; these suggestions consisted of watching less than two hours of TV, getting one hour of physical activity, and eating five fruits and vegetables (11). While providing this information is certainly a step in the right direction, it is not enough by itself to promote self-efficacy. Both parents and children need to feel that they can be successful at making healthy lifestyle changes. <br />In the Cambridge study, approximately half of the families who received report cards stating their child was overweight were somewhat or very concerned about their child’s weight status (11). While concerned parents were more likely to plan weight-control strategies, they were not more likely to engage in the suggested preventive measures than less concerned parents. In addition, almost twenty percent of families reported planning diet-related activities to control their child’s weight, regardless of the amount of anti-diet information included in the materials sent home. These results would support the fact that more is needed than reporting a child’s weight status along with suggestions for lifestyle changes. This strategy does not bridge the gap between knowing what to do and actually doing it, a gap that can only be filled by the belief in the ability to perform the behavior (15).<br /> Additional barriers to achieving self-efficacy and behavior change are the schools themselves; the school environment must support the desired behavior in order for the intervention to be successful. Despite state mandates, a recent audit of New York public schools found that few provide the required physical education hours and many violate their own policies by providing vending machines that sell junk food and sugar-sweetened drinks (17). In addition, in a survey of middle school children in two public schools in the Northeast, a study found that competitiveness hampered physical activity, as children who were overweight or not as skilled were less likely to participate during physical education classes and open gym periods. Lack of nutritious food and time to eat prevented healthy nutrition choices (18). School environments with unhealthy food choices and low physical activity do not promote self-efficacy, because overweight children are not able to model the successful, healthy behaviors of their peers, nor are they likely to receive encouragement from teachers and peers to pursue such choices themselves. <br />B. BMI Report Cards and the Importance of Self-Esteem <br /> BMI report cards fail to take into consideration the importance of self-esteem in motivation and behavior change. Abraham Maslow’s Hierarchy of Needs describes different levels of human needs and how those needs affect motivation and behavior (19). According to Maslow, all needs and drives do not exist in isolation and every drive is related to level of satisfaction or dissatisfaction of other drives. Maslow describes what he calls “deficiency needs”, which include physiological, safety, social and esteem needs, that must be satisfied before a person can beginning achieving the higher-level need of self-actualization (19). Humans have a desire to be accepted and valued by others. Fulfillment of the esteem need leads to feelings of self-confidence, capability, worth, strength and purpose. However, if this need is not met, it produces feelings of helplessness, weakness and inferiority, which can lead to discouragement or compensatory unhealthy behaviors (19).<br /> As evidenced by this theory, children whose self-esteem need is not met are unable to undertake the healthy lifestyle changes necessary to prevent overweight and obesity. Research has shown that young girls who consider themselves overweight are especially vulnerable to low self-esteem (16). Although one study found that many adolescents report using healthy weight control practices, such as decreasing fat intake, they also found a high prevalence of binge eating and unhealthy or extreme weight control behaviors in overweight youth, especially girls; body dissatisfaction, which is closely tied to self-esteem, is a strong predictor of unhealthy weight control practices (20). Regardless of actual BMI, children or adolescents with high levels of body dissatisfaction have lower feelings of self-worth, poorer self-esteem, and more dissatisfaction with other areas of their lives (16, 21). In addition, obese children with low self-esteem are more likely to experience sadness, loneliness and nervousness, as well as more likely to experiment with high-risk behaviors (22).<br /> BMI report cards may actually decrease self-esteem by making children feel they are being judged by their weight. Additionally, the concept of a report card for a health factor such as weight implies that a child can fail (23), which is not the best motivational message. BMI report cards could also increase weight-based teasing in school, further lowering the self-esteem of overweight children and further decreasing their ability to make healthy behavior changes. As Maslow discussed, without self-esteem, people often feel helpless and discouraged. Therefore, to successfully combat childhood obesity, interventions must address the issue of self-esteem.<br />C. Negative Labeling as a Consequence of BMI Report Cards<br /> Negative labeling is closely tied to self-esteem, as being labeled often leads to teasing and lower self-esteem. The goal of BMI report cards is surveillance and prevention of obesity in children. However, by basing the program in schools and focusing on the individual, this type of intervention not only brings attention to the issue of weight, it also increases the risk that a child will be labeled as fat. Labeling theory was developed in the 1960’s to explain deviance, with Howard Becker’s Outsiders (1963) being the most frequently cited source. According to Becker, one of the most important steps in the development of a deviant career is being labeled as a deviant. Once a person is labeled, he/she is cut off from participation in more conventional groups, leaving the individual no choice but to pursue his/her expected deviant activities (24, 25). This theory has often been applied to mental illness as well. One study of patients discharged from mental hospitals found that stigma was a persistent problem in their lives, and experiences of social rejection were a constant source of stress. The patients’ efforts to cope with the labels resulted in further social isolation and reinforcement of negative self-concepts, and diminished motivation and recurrent psychological problems (26).<br /> These concepts can easily be applied to youth and being labeled as ‘fat’. Overweight girls report experience direct and intentional stigmatization from peers, family members, employers and strangers; the most common place of occurrence for these experiences was school (16). Being labeled increases the risk that youth will be exposed to hurtful experiences, such as teasing or bullying, that have a negative impact on self-esteem. Overweight children have more trouble making friends and are often teased about their appearance (27, 28). Even children as young as five-years-old express a preference for thin figures (29). As Becker discussed, the label of ‘fat’ can result in children conforming to the label in a self-fulfilling prophecy. BMI report cards could, therefore, perpetuate obesity as children who feel they have been labeled as fat resign themselves to the role of the ‘fat kid’ and participate in activities, such as overeating and not exercising, that they feel are expected.<br /> Being labeled can also result in pressure from peers, family and society to engage in harmful weight loss practices that could potentially lead to eating disorders (30). Studies done on the BMI report card program in Arkansas show that dieting and dietary restriction has been increasingly encouraged by parents and practiced by students; this is troubling because research has shown that dieting predicts weight gain in adolescents (31). The 2005 Youth Risk Behavior Survey (YRBS) found that approximately 1 in 6 high school students engaged in unsafe weight loss practices, such as fasting, inducing vomiting, or using diet pills or laxatives (30). However, overweight children are not the only ones at risk for these unhealthy behaviors. The focus on weight created by BMI report cards and the negative attitudes towards overweight children may increase fears that healthy-weight children have about being labeled as fat; this could then push them into adopting unhealthy dieting practices to avoid the socially unacceptable ‘fat’ label.<br />III. An Alternative Multi-Level Intervention to Address Childhood Obesity<br /> While schools provide an excellent setting to address healthy lifestyle changes since 95 percent of youth are enrolled in school (31), in order for an intervention to be successful, the program also needs to target the community and family levels. Parents are particularly important in any youth obesity intervention because they control much of a child’s food consumption, influence physical activity opportunities (32), and control access to television, computer, and video games. Additionally, there is much evidence suggesting that the eating behaviors of children are shaped by parental feeding behaviors and parental eating behaviors, as well as by parental weight status (33). The nutritional knowledge of mothers and their concern about disease prevention is positively associated with children’s fruit and vegetable consumption and negatively with children’s total fat and energy intake (33). It is therefore important to provide extensive parental education on the importance of providing healthy food choices in the home, especially beginning at an early age since food preferences are learned through repeated exposure to foods. It is also important to educate parents about the importance of eating at home as a family; this has been shown to improve children’s dietary quality, even in adolescence when children tend to make more independent food choices (33).<br /> In terms of physical activity, children with parents who are more physically active are more likely to be physically active themselves (33). Parental encouragement is also related to increased or continued physical activity in youth. However, family resources can also influence physical activity levels; children whose parents transport them to after school activities, or pay fees for lessons or community sports organizations have higher levels of physical activity (33). To remove the disparity in access, schools or community organizations could provide similar activities for free or at reduced costs for families with limited resources.<br /> For the family-based part of the intervention, it is important to emphasize reasonable goals for parents and children to work towards together, as well as to incorporate positive reinforcement. Research has also shown that nutrition education combined with behavior modification results in greater relative weight loss, and increasing problem solving capabilities is also important to successful changes in lifestyle habits (33). A successful intervention would, therefore, include not only nutrition education, but also educate parents about self-monitoring, social reinforcement, modifying their family’s environment for a healthier lifestyle, and problem-solving strategies for themselves and their children.<br /> The school-based part of this intervention would have different levels for the different age groups. Teaching children early about good nutrition choices and the importance of physical activity is key to a healthier lifestyle as they get older. Children at the elementary school level would need fun, entertaining and interactive activities to keep their attention engaged and absorb the information. A pilot program in Missouri is trying such an approach, and something similar would be appropriate for this intervention. The Missouri program works to incorporate brief periods of exercise into the students’ day in addition to regularly scheduled physical education classes and recess (34). The nutrition part of their program teaches students how to read food labels, identify and choose healthy foods and identify deceptive marketing practices. Physical education classes could also incorporate fun games, rather than traditional sporting activities, to engage children who may not be as athletically talented.<br /> At the middle and high school level, nutrition education should continue, along with problem-solving strategies to increase self-efficacy. Children are particularly vulnerable to teasing and bullying at the middle school level, so strategies for dealing with this type of harassment could also be useful; positive reinforcement from teachers, and ideally peers, would also help promote healthy lifestyle habits. Many states have a required number of hours of physical education, but as mentioned previously, not all states fulfill that obligation. It is critical that physical education continue through middle and high school, and it is equally important that these classes incorporate many different types of physical activity to encourage life-long habits. Rather than only incorporating traditional sporting activities, schools should consider adding units on yoga, kickboxing, Pilates, Tai Chi, swimming (if a pool is available), dance, and even walking to name a few. This would allow students to explore more options and potentially find something that suits their needs better. <br />At all levels of school, there need to be healthy eating options. Lunches provided in cafeterias need to have decreased levels of fat and increased levels of fiber, especially fruits and vegetables. The unhealthy snacks and sugary beverages available in vending machines should be replaced with healthier options. In this way, the school environment will support what the students are learning in class and at home.<br /> The community level of this intervention would be focused more on promoting awareness of the issue of childhood overweight and obesity, as well as awareness of the school and family-based parts of the intervention (35). With community support for the campaign, there is likely to be increased community involvement in schools, increased promotion of healthy behaviors, and development of health and fitness partnerships for schools and families.<br />A. Tools to Promote Self-Efficacy<br /> The alternative multi-level intervention has numerous ways to promote self-efficacy. One way in which it does this is by approaching behavior change in small steps to ensure the success of those changes (13). Rather than suggesting immediate drastic changes in lifestyle habits, this intervention would promote gradual change through steady modifications in nutrition at home, slow increases in daily physical activity, and promotion of less time spent watching television or playing video games.<br /> In addition, the alternative intervention addresses the four sources of information that provide the basis for expectations of personal self-efficacy (15). The first source is performance accomplishment, or the successful mastery of skills. By teaching skills in problem-solving, self-monitoring, and alternative physical activities, this intervention increases confidence in one’s abilities, thereby increasing self-efficacy. The next source of information is vicarious experiences, which refers to learning from observing others performing difficult activities. Watching parents and other students make healthy food choices and watching their peers successfully involved in daily (fun) physical activity will enhance one’s expectations of mastering those skills. <br />Verbal persuasion, the third source, will come from both educators and parents as they teach the children about healthy lifestyle choices and encourage their efforts. Finally, emotional/physiological arousal also influences expectations of self-efficacy. People are more likely to expect success when they are not adversely aroused. This alternative intervention would ideally keep emotional stress to a minimum by not focusing solely on weight, as BMI report cards do, and decreasing the amount of potential teasing overweight children may experience. Since the children are then less likely to feel discouraged, they are more likely to expect, and experience, success when they attempt the desired behavior changes. <br />B. The Importance of Self-Esteem<br /> It is difficult to promote healthy self-esteem in a society that bombards children with images of thin, beautiful people. However, this intervention has the potential to at least give self-esteem a boost for many youth, not just those that are overweight. The education component can not only provide information about healthy nutrition, but can also focus on images and discussions of ‘real’ people and emphasize the importance of healthy rather than thin in an effort to decrease body dissatisfaction. Also, by removing the report card format, the intervention would eliminate those feelings children may have that they are being judged by their size. As mentioned above, the focus on healthy living rather than weight has the potential to decrease teasing and bullying of overweight children, thereby significantly decreasing the feelings of helplessness and discouragement that can interfere with successful behavior change. The self-esteem of individual children is also likely to increase as their feelings of self-efficacy increase, as they successfully work towards the goals that have been established by the program. <br />C. Removal of Negative Labeling<br /> Negative labeling and self-esteem are, as previously mentioned, closely related. Again, removing the report card-type intervention eliminates the label children may feel they are assigned when their parents receive the report. Removing this label reduces the risk that children will fall into the self-fulfilling prophecy of being ‘fat’, and will instead feel they are capable of eating right and being physically active. Also, the alternative intervention focuses on group activities that engage all children rather than only those with athletic talent, so children will not be excluded and feel isolated. There is much less risk of labeling with this intervention because the issue of weight is rarely, if ever, the focus; instead the focus is on living a healthy lifestyle. Removal of negative labeling also decreases the risk of healthy weight, and overweight, children engaging in harmful weight loss practices by decreasing the level of stigma attached to weight. <br />IV. Conclusion<br /> While BMI report cards may be successful at bringing attention to the issue of childhood overweight and obesity, they are a number of potential unintended negative consequences. In addition to those outlined in this paper, BMI report cards also fail to identify a large population of children with normal BMIs but unhealthy lifestyle habits (23). The alternative multi-level intervention outlined not only address the negative consequences of BMI report cards, it also promotes healthy lifestyle behavior changes for all children in effort to ensure the children grow up into healthy adults.<br />References<br />1. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics 2007; 120:S164-S192.<br />2. Mitka M. Experts weigh pros and cons of screening and treatment for childhood obesity. Journal of the American Medical Association 2008; 300:1401-1402.<br />3. Bennett B, Sothern MS. Diet, exercise, behavior: the promise and limits of lifestyle change. Conference on Chronic Diseases in Childhood Obesity - Risks and Benefits of Early Intervention. Columbus, OH, 2009:152-158.<br />4. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. Journal of the American Medical Association 2002; 288:1728-1732.<br />5. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. Journal of the American Medical Association 2006; 295:1549-1555.<br />6. Ogden CL, Carroll MD, Flegal KM. High body mass index for age among US children and adolescents, 2003-2006. Journal of the American Medical Association 2008; 299:2401-2405.<br />7. Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The epidemiology of obesity. Gastroenterology 2007;132:2087-2102.<br />8. Summerbell CD, Waters E, Edmunds LD, Kelly S, Brown T, Campbell KJ. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews 2005.<br />9. Erermis S, Cetin N, Tamar M, Bukusoglu N, Akdeniz F, Goksen D. Is obesity a risk factor for psychopathology among adolescents? Pediatrics International 2004; 46:296-301.<br />10. Nihiser AJ, Lee SM, Wechsler H, et al. BMI Measurement in Schools. Pediatrics 2009;124:S89-S97.<br />11. Chomitz VR, Collins J, Kim J, Kramer E, McGowan R. Promoting healthy weight among elementary school children via a health report card approach. 130th Annual Meeting of the American Public Health Association. Philadelphia, Pennsylvania, 2002: 765-772.<br />12. Wadas-Willingham V. Six states get an 'A' for work against kids' obesity. CNN, 2007. http://www.cnn.com/2007/HEALTH/diet.fitness/01/30/obesity.report/index.html?eref=rss_health<br />13. National Cancer Institute . Theory at a Glance: A Guide for Health Promotion Practice, Part 2. Bethesda, MD: National Cancer Institute, 2005.<br />14. Bandura A. Self efficacy mechanisms in human agency. American Psychology 1982; 37:122-147.<br />15. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.<br />16. Ikeda JP, Crawford PB, Woodward-Lopez G. BMI screening in schools: helpful or harmful. Health Education Research 2006; 21:761-769.<br />17. Crowley C. Targeting bad food choices. Times Union. Albany, NY, 2009. http://www.timesunion.com/ASPStories/story.asp?StoryID=860902<br />18. Bauer K, Yang Y, Austin S. Promotion of physical activity and healthy food choices was hampered by competitiveness, lack of quality food, easy access to non-nutritious food, and time constraints. Evidenced Based Nursing 2004; 7:123-124.<br />19. Maslow A. A Theory of Human Motivation. Psychological Review 1943; 50:376-396.<br />20. Neumark-Sztainer D, Story M, Hannan PJ, Perry CL, Irving LM. Weight-related concerns and behaviors among overweight and nonoverweight adolescents - Implications for preventing weight-related disorders. Archives of Pediatrics & Adolescent Medicine 2002; 156:171-178.<br />21. Eisenberg ME, Neumark-Sztainer D, Story M. Associations of weight-based teasing and emotional well-being among adolescents. Archives of Pediatrics & Adolescent Medicine 2003; 157:733-738.<br />22. Strauss RS. Childhood obesity and self-esteem. Pediatrics 2000; 105:art. no.-e15.<br />23. Scheier LM. Potential problems with school health report cards. Journal of the American Dietetic Association 2004; 104:525-527.<br />24. Becker HS. Outsiders: Studies in the Sociology of Deviance. New York: The Free Press, 1963.<br />25. Orcutt JD. The Labeling Tradition: Interpersonal Reactions to Deviance. 2002. http://deviance.socprobs.net/Unit_3/Theory/Labeling.htm<br />26. Wright ER, Gronfein WP, Owens TJ. Deinstitutionalization, social rejection, and the self-esteem of former mental patients. Journal of Health and Social Behavior 2000; 41:68-90.<br />27. Neumark-Sztainer D, Falkner N, Story M, Perry C, Hannan PJ, Mulert S. Weight-teasing among adolescents: correlations with weight status and disordered eating behaviors. International Journal of Obesity 2002; 26:123-131.<br />28. Strauss RS, Pollack HA. Social marginalization of overweight children. Archives of Pediatrics & Adolescent Medicine 2003; 157:746-752.<br />29. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body size stigmatization in preschool children: The role of control attributions. Journal of Pediatric Psychology 2004; 29:613-620.<br />30. Nihiser AJ, Lee SM, Wechsler H, et al. Body mass index measurement in schools. Journal of School Health 2007; 77:651-671.<br />31. Evans EW, Sonneville KR. BMI report cards: will they pass or fail in the fight against pediatric obesity? Current Opinion in Pediatrics 2009; 21:431-436.<br />32. Eisenmann JC, Gentile DA, Welk GJ, et al. SWITCH: rationale, design, and implementation of a community, school, and family-based intervention to modify behaviors related to childhood obesity. BMC Public Health 2008; 8.<br />33. Golan M, Crow S. Parents are key players in the prevention and treatment of weight-related problems. Nutrition Reviews 2004; 62:39-50.<br />34. Arias DC. Missouri targets child obesity in schools. The Nation's Health 2007:12.<br />35. Gentile DA, Welk G, Eisenmann JC, et al. Evaluation of a multiple ecological level child obesity prevention program: Switch (R) what you Do, View, and Chew. BMC Medicine 2009; 7.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-22203878110748017782010-05-20T16:58:00.000-07:002010-05-20T17:03:23.479-07:00Live Healthy, Live Freely: A Critique and Reformation of Georgia’s Live Health Georgia Campaign – Sabrina DeveikisI. Introduction <br /> In the last decade a marked increase in obesity and other chronic diseases has become a cause of concern (1-4). Not surprisingly, the last decade has also shown a drastic decrease in some healthy behaviors, in particular physical activity (1,2). Studies have shown unhealthy lifestyles are an important contributor to chronic diseases such as cardiovascular disease (5,6). <br />In 2005 the Georgia Department of Community Health Division of Public Health sponsored a program called the Live Healthy Georgia campaign (7). The primary goal of the campaign is to encourage George residents to engage in healthier lifestyles to prevent chronic diseases (8). The program recognizes many challenges facing residents of Georgia in being able live a truly healthy lifestyle. Thirty percent of Georgia is classified as rural (9) and as a result, are more limited in their access to healthcare (10). Other factors include lower education levels, poverty, and race (8). Finally, already existing poor health behaviors are a challenge for any program. In particular, obesity, lack of physical exercise, and smoking present unique challenges (10). <br />The Live Healthy Georgia campaign adheres to the philosophy that prevention is the best method in preventing chronic disease and morbidity (8). The campaign is essentially an education program to teach the following messages: <br />· Get Checked (Receive appropriate health screenings) <br />· Be Smoke Free (Eliminate tobacco use) <br />· Be Active (Increase physical activity) <br />· Eat Healthy (Maintain a healthy diet)<br />· Be Positive (Maintain a healthy mental/spiritual outlook) (8).<br />The program hopes to promote Georgia’s Department of Human Resources as the best resource in Georgia for its messages and as the key resource in prevention of chronic diseases (8). With its website, outreach projects, and partnerships with other programs as part of the Take Charge of Your Health, Georgia! Georgia's 10-year Nutrition and Physical Activity Plan Georgians residents are to be provided with the educational resources to life healthier lives, less burdened with chronic disease (7,11). <br /> This paper presents three critiques of Georgia’s Live Healthy Georgia campaign in Section II. In section III, an alternative campaign is proposed which takes into consideration of Maslow’s hierarchy of needs and marketing theory. <br />II. Critique of Georgia’s Live Healthy Georgia Campaign<br /> The program launched by the Georgia Department of Community Health Division of Public Health to promote healthier lifestyles for Georgia residents is flawed for three reasons. First, the primary objective of the campaign is to educate or raise awareness of perceived susceptibility even though the campaigns own pilot studies have shown the majority of its target audience is already aware of the benefits of healthy living in terms of chronic disease prevention. Secondly, the primary tool the campaign hopes to instill into its target audience is self-efficacy but fails to address the larger environmental and social factors contributing to the unhealthy lifestyles. Finally, the program fails the basic concept of advertising and marketing theory of offering an attractive promise. <br />A. Raising Awareness When it Already Exists<br /> The campaign appears to be very individual based attempts to spark behavioral changes through education by increasing awareness of risks and dangers of unhealthy life choices in relation to chronic diseases. The Health Belief Model defines four factors influencing individual behavior. Perceived susceptibility and perceived severity are weighed against the perceived benefits of the action and the perceived barriers of taking that action (12). The perceived susceptibility the campaign wants to education its target audience about is the increased risk of chronic disease and morbidity through unhealthy behaviors (7). The perceived severity would be a lifelong illness requiring daily medication and even mortality. The benefits of adhering to a healthier lifestyle would be fuller, healthier life, free from the burden of disease. The barriers in being healthy are both individual and environmental. The Live Healthy Georgia campaign was launched in March of 2005 and on April 1, 2005 the Georgia Department of Human Recourses released a report of findings of studies performed to serve as a baseline to evaluate the effectiveness of the new campaign (13). The study found that not only were Georgia residents aware of which health behaviors were the most beneficial to overall health but the majority of participants reported very frequent exposure to the very messages the campaign sought to convey (13). <br /> In terms of the second message of the campaign, that of elimination tobacco use, the transtheoretical model is combined with the health benefit belief model in the campaigns approach in assisting people to quit smoking. The transtheoretical model defines the stages involved in a behavioral change and is usually applied to addiction interventions. The first stage is precontemplation when an individual is either not planning on taking an action or is unaware of the existence of a problem (14). In the second state, contemplation, the individual is weighing the perceived benefits and costs of taking a course of action (14). Preparation, or the third stage, marks the stage where a decision to act has been made and a plan for implementation is being formulated for the fourth state of action (14). The fifth stage is maintenance when the behavior has been changed but effort is required to ensure a permanent change. Finally, termination is when the change has been permanent and maintenance is no longer required. <br /> On the campaigns’ website the only resource it provides for smoking cessation is a quit help line (7). The benefits of quitting are clearly outlined on the website and seem like the primary motivational tool to quit smoking offered by the campaign. The quit line offers information of the various cessation aides and even has a special intervention for teens seeking to quit (7). It merely attempts to walk smokers through the stages of change and does little beyond education of the benefits of not smoking and the aids available for quitting. It has been shown that the dangers of smoking are not only known by nonsmokers but smokers, themselves have had the dangers of their habit ingrained into their minds (15). Clearly, other methods must be utilized to cause more smokers to quit.<br /> The campaigns goal of raising awareness of the benefit of healthy behaviors in the prevention of chronic diseases had been achieved before the program was even launched. In fact, the interventions target audience reported frequently receiving the program’s messages without any exposure to the program itself. The money and resources allocated to increasing the awareness of the benefits of a healthy lifestyle and trying to increase awareness in the susceptibility of its target audience can be better spent in ways that might illicit more of a wide spread behavioral change across the population of the target audience. <br />B. The Failure of Self-Efficacy<br /> At least from the standpoint of the campaigns ads, the lesson instilled by the program to Georgians is, “You can do it,” (7). In other words, the intervention is attempting to give people the feeling of self-efficacy. Self-efficacy is a person’s belief that they can make the behavioral changes (16). The Live Healthy Georgia Campaign makes its target audience aware of all the benefits and makes it seem possible to achieve good health by following their simple guidelines to healthy living (2). Those guidelines are the five simple messages the program wants to convey. Unfortunately, it is one thing to say to get checked by your doctor regularly, it is another thing entirely if you’re in a rural community and the nearest doctor is twenty miles away and either cannot afford to take the time off of work or do not even have health insurance. These problems face many of Georgia’s residents and challenge the programs message. <br /> Georgia faces several different challenges and factors, which can alter a person’s sense of self-efficacy. With thirty percent of the state residing in rural communities, the access to health care in those areas is less than in more urban areas (10). The level of education also plays a key role, and Georgia has the lowest rate of graduation in the country (17). Poverty is another important contributor. A quarter of the children in Georgia are living in poverty and 8% are living in extreme poverty (18,19). When faced with poverty, the cost and benefits of living a healthier lifestyle pale in comparison to the challenges of day to day life when perhaps even the means to get something to eat, not necessarily part of a well balanced diet, is a challenge, the messages of the program may fall on deaf ears. <br />C. The Promise?<br /> The promise offered by the campaign may excite the insurance agencies more than Georgia’s general population because the promise is that prevention is more cost-effective and you can live healthier (7). Being healthier and saving the insurance company you have already given more of a portion of your paycheck than you were really willing to part with in the first place is not one of the core values in advertising and marketing theory (20). The one television ad available online is a cartoon character trying to walk up an incline with a second voice offering words of encouragement (7). The basic message is people can quit smoking, it will just take practice (7). There are no ads relating to the campaign’s four other messages, which undermines the efficacy of the campaign as a whole. The target audience of the ad is but a subset of the target audience of the Live Healthy Georgia intervention. Little branding has been done for the campaign itself and the ad has no indication it is part of a larger program, which promotes anything other than not smoking. Branding is an important part of marketing any campaign and the failure of this program to do so undermines the amount of success it can hope to achieve in changing the lifestyles of Georgia’s residents. (20). <br /><br /><br />III. A Reformulation of Georgia’s Live Healthy Georgia Campaign<br /> Taking the aforementioned flaws into consideration, the following reformulation of the existing campaign is proposed. The proposed intervention takes more community based approach rather than the individual based approach currently being used. <br />A. Raising Access, Not Just Awareness<br /> Where the current program sought to illicit behavioral changes through education, the new reformulation will promote greater access to the resources needed to live healthier lives. With the target audience being all adults living in Georgia, a more community-based approach will be more effective in generating a healthier population. The Socio-ecologic model will be useful in achieving the desired result. The individual and interpersonal results have already been seen thanks to the efforts of other state and national campaigns to raise awareness of the benefits of healthier living in relation to chronic diseases. Success in the upper levels of the model is the key to obtain a truly healthy Georgia. <br /> Allocating the resources previously used at raising individual awareness will be diverted to create a means for the lifestyle changes necessary to becoming healthy to actually be possible. Incentives can be given to employers to have sports teams for their employees after work. High schools gymnasiums can be open after school hours for the public in a way that does not interfere with high school sports but provides a convenient and cost effective fitness option for working adults. Organizes sports or other physical activities can be offered by the local communities in parks. Finally, the state can provide funding and land for more parks and walking trails.<br />B. Increasing Self-Efficacy By Increasing State-Efficacy<br /> In Maslow’s hierarchy of needs, if the lower, more basic human needs are not meet, an individual will not be able to allocate resources for the higher levels (22). Since Georgia struggles with poverty, low education, and restricted access to medical services, the more basic needs must be met before Georgians can start looking at their lifestyles and making changes. <br /> The proposed intervention will promote, at the very least, affordable transportation in the rural communities. Other programs to try to draw more doctors away from the cities will need to be initiated, such as lower taxes on medical buildings in rural areas. Traveling doctors who make periodic visits to the larger employers will provide more options and convenience for both employer and employee. <br /> To deal with the low level of high school graduation rates more money should be given to the schools. Programs to assist academically struggling students early on to help prevent the challenged students from slipping through the academic cracks and dropping out of high school out of frustration. More scholarships for both colleges and private high schools can help shift the level of education of Georgians in a more positive direction. <br />C. The Promise – Freedom<br /> Clearly the promise of a healthier life does not promote many to action. For decades, the dangers of smoking have been widely known and still the tobacco industry is making billions off of a notoriously unhealthy habit. The promise has to appeal to one of our core-values, something we would be willing to pay or sacrifice for (27). The new promise of the proposed intervention will be freedom. Making healthier choices will not just make you healthier but will give you freedom. Freedom from the demanding toils of chronic diseases. Freedom to play with your kids without being sore. Freedom to run several blocks to catch the bus without a loss of breath. An hour doctor visit each year combined with a few simple choices can unlock the freedom to be all that you can be. The campaign to create a recognizable branding will also take place. Live Healthy Georgia will become synonymous with the promise of freedom offered in its advertising. <br />IV. Conclusion<br /> In the campaign’s current incarnation, the Live Healthy Georgia program contains three flaws which interfere with it’s ability to effectively instigate changes in the behavior of its target audience. The first flaw is the primary goal of the intervention is to increase awareness of the benefits to healthier lifestyles but the resources of the program are being wasted on what has already been achieved prior to the launch of Live Healthy Georgia. The second flaw is the program promotes and encourages self-efficacy through its messages but the sense of self-efficacy falls flat when the extenuating circumstances surrounding the lives of many Georgia residences has them struggling to make ends meet. The final flaw is the program fails to take into account the tenants of advertising and marketing theory with making the promise of only a healthy life which is not a core-value most people will actively seek. A reformulation of the campaign seeks to amend the flaws of the current program by taking a more community-based approach and helping Georgia residents meet their basic needs giving them the opportunity to focus on being healthier. Finally, the message of a better promise, the promise of freedom will reach out to more people and have a far greater impact in changing the behavior of people in Georgia.<br />REFRENCES<br />1. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2008].<br />2. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [1998].<br />3. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 288:1723-7. 2002.<br />4. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 295:1549-1555. 2006.<br />5. Mokdad AH, Marks JS, Stroup DF, Gerderding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245.<br />6. Stampfer MJ, Ju FB, Manson JE, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. New England Journal of Medicine. 2000;33;16-22.<br />7. http://www.livehealthygeorgia.org/<br />8. http://health.state.ga.us/pdfs/healthtopics/lhg.overview.2005.pdf<br />9. U.S. Bureau of the Census. U.S. Census 2001 Total Population Estimate. Washington: The Bureau; 2002.<br />10. Silliman SL, Quinn B, Huggett V, Merino JG. Use of field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. Stroke. 2003;34:729-733.<br />11. http://health.state.ga.us/pdfs/familyhealth/nutrition/NutritionandPhysical ActivityPlanFINAL.pdf<br />12. Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974;2:Entire issue.<br />13. Georgia Department of Human Resources Assessment and Evaluation Study (April 2005) http://health.state.ga.us/healthtopics/lhg.asp<br />14. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Rimer BK, Lewis Fm, eds. Health Behavior and Health Education, 3rd Ed. San Fransico, CA: John Wiley & Sons; 2002.<br />15. Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. JAMA 1999; 281:1019-1021.<br />16. Individual health behavior theories (chapter 4), In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury. MA: Jones and Bartlett Publishers, 2007, pp 35-49.<br />17. Manhattan Institute for Policy Research. High School Graduation Rates in the Country. Available at: http://www.manhattan-institute.org/cr_baeo.pdf.<br />18. Kaiser Family Foundation. State Health Facts Online, Individual State Profiles. Georgia: Poverty Rate by Age, state data 2000-2001, U.S. 2001. Available at: http://www.statehealthfacts.kff.org/cgi- bin/healthfacts.cgi?action=profile&area=Georgia&category=Demographics+and+the+Economy&subcategory=People+in+Po verty&topic=Poverty+Rate+by+Age. <br />19. Kaiser Family Foundation. State Health Facts Online, Individual State Profiles. Georgia: Poverty Rate by Race/Ethnicity, state data 2000-2001, U.S. 2001. Available at: http://www.statehealthfacts.kff.org/cgi-<br />20. Siegel M, Lotenberg LD. Marketing public health—An opportunity for the health practitioner. In: Siegel M, Lotenberg LD, eds. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones & Bartlett, 2007.<br />21. McLeroy, et, al, an ecological perspective on health promotion program a Health Education Quarterly 1988, 15:351-77 <br />22. Maslow AH. A theory of human motivation. Psychological Review 1943; 50;376-396.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-89527509860326954602010-05-20T16:55:00.000-07:002010-05-20T16:58:31.587-07:00“Steps to a Healthier You” Holds No Big Promises: A Critique of MyPyramid – Adiana CastroThe United States Department of Agriculture (USDA) and the Center for Nutrition Policy and Promotion (CNPP) adopted a new pyramid named MyPyramid in 2005 that would be accessible online (1). MyPyramid replaces the old Food Pyramid from 1992. The old food pyramid consists of the five food groups’ vegetables, fruits, dairy, meat and grains. The old food pyramid had a standard recommended serving size for each food group with grains at the widest and lowest level of the pyramid, then fruits and vegetables on the second level, dairy and meat on the third level and sweets sparingly at the highest and smallest level (1). The old food pyramid gave general guidelines and was similar to a one-size fits all design for individuals. Furthermore, the old food pyramid was a poster that was placed in schools, hospitals, building etc. MyPyramid uses the internet as its form of media instead of a poster. This version of the pyramid contains vertical color bands to represent the food groups as well as a person climbing the stairs to promote physical activity. The vertical color band widths that represent the food groups vary the recommended serving sizes depending on one’s age, gender, height, and weight. The goal is to create a personalized nutrition guide to acknowledge the fact that people have different dietary needs. It is not a diet but rather a suggested eating pattern. The recommendations were based on the 2005 Dietary Guidelines and are touted as an evidence-based approach to promote healthy eating and living (1).<br /><br />Over 300 million people live in the United States and yet there are only 3 million registered users for MyPyramid that is less than 1% of the population (1). An individual can browse the site without becoming a registered user but a registered user visits the site frequently to use the nutrition tools. Millions of dollars have been spent to address the nutritional deficit knowledge yet our waistlines keep growing and the website is not frequently visited.<br />According to the National Center for Health Statistics from 2006, two-thirds of adults are overweight or obese.2 The state obesity maps from 2005 to 2008 have shown in overall increase in obesity across the nation (Figure 1, 2) (3,4). All of the states either maintained or increased their prevalence of obesity. According to the five-a-day campaign there has not been in increase in fruit and vegetable consumption since 2005 (5).<br /><br />The MyPyramid program does state the importance of variety and moderation with the food groups as well as promote physical activity. In addition, MyPyramid is web-based which encourages access and convenience for the public. The goal of MyPyramid is to educate the American public on healthy food selection and support physical activity (1). However, it fails to address the lack of health interest that the population has, assumes individual responsibility for food choices and fails to support self-efficacy. Since these considerations were failed to be met the intervention has proven to be ineffective in helping individuals stay healthy since it was released in 2005.<br /><br /><br />MyPyramid Assumes Health as a Main Priority for Americans<br /><br /> In general, immediate health is a basic need. According to Maslow’s Hierarchy of Needs, individuals have needs that are prioritized on different levels with physiological needs being the starting point and include sex, homeostasis, food, breathing, water, sleep (6). The second level is safety which includes health (not health behaviors), family and resources. The third level is love/belonging, followed by esteem and ending with self-actualization (Figure 3) (6). The health behaviors that MyPyramid is trying to change are poor eating habits and physical inactivity. However, Michael Siegel supports the idea that health behaviors are needs that occurs in the last level known as self-actualization (8). Maslow said a person that has a desire for self-fulfillment and can act on his/her full potential are characteristics of the self-actualization level (6). However, this need can’t be actualized unless there is complete satisfaction with prior levels. MyPyramid has a logo that states “Steps to a Healthier You” (1). This message does not resonate with individuals that do not have a roof over their head, food if any on the table, clothes on their back, do not feel safe, loved, or with self-esteem. In this recession, Americans have put health on the back-burner because they feel there are more pressing matters to be addressed. The MyPyramid program should have packaged a message aside from health behaviors since Maslow’s states individuals will not make it a priority. Human behavior is not motivated by health (8).<br /><br /> MyPyramid like many other government programs has followed the traditional health paradigm that asks the question “What is the product that people should want?” and then sells that product and in this case the desire for eating well and being healthier. However, health is not a core value for people unless they are on the verge of becoming sick (8). Using Marketing Theory, the marketing paradigm asks the questions “What is it that people want?” and then creates and packages the product so that it fulfills those needs and wants.7 Using this alternative theory it appeals to more basic core human values for American culture such as control, security, love, freedom, family, hope and independence (7,8). However, MyPyramid did not follow this rationale. The CNPP used intuition to sell the MyPyramid design instead of researching the target audience and then launching a campaign. The basis of MyPyramid was evidenced-based scientific studies and then public health practitioners designed a new version of the pyramid (1). Then MyPyramid was unveiled to the public. Marketing theory incorporates an intensive psychosocial profile for potential customers which the CNPP and USDA do not do thus creating a failed public health intervention. <br /><br /><br />MyPyramid Assumes Individual Responsibility for Food Choices <br /><br />Although MyPyramid is personalized and demonstrates that dietary needs are individualized, it assumes foods choices are also individualized. MyPyramid does not take into account individual control, cost of healthy foods and the food environment/culture in the Unites States. The MyPyramid structure acts on the principals of Theory of Reasoned Action, which states people, are rational and static beings. The theory does say perception of other people matter and takes into account social norms influence human behavior (8,9). However, there is no room for spontaneity, and assumes that character, beliefs and traits do not change. This antiquated theory has been a staple in many public health programs including MyPyramid. People’s daily lives are a dynamic process, especially when it involves food. In a fast paced country like the United States where context plays a big role in where and when you get your food it is not fair to assume food decisions are made in advance. Many meals are not planned and individuals tend to feel not in control when making food choices.<br /><br />MyPyramid can also be intimidating for families that can’t afford the fruits and vegetables. Farmer’s markets are growing around the country and are providing a great resource to find fresh produce. However, these markets are typically not in low-income neighborhoods where people would benefit from the savings. Furthermore, many inner-city neighborhoods do not have supermarkets and rely on the corner store for their groceries (10,11). For example, Whole Foods Supermarkets are located in upper- middle class neighborhoods because that is there target population (10). Corner stores in low-income neighborhoods have little variety for produce that is if they carry produce at all. MyPyramid does not address the accessibility of the foods they are recommending. Since the program focuses on the responsibility of the individual to make healthy choices it limits the impact since individuals don’t live in a bubble. Individuals can be affected by their finances, neighborhood and the corporate food industry. <br />MyPyramid fails to address the power of the food industry and how influential these companies are in the United States. Consumers spend about $1 trillion dollars annually on food, almost 10 percent of the Gross Domestic Product (12). The food industry is a profitable business yet MyPyramid places all of the responsibility on the consumer and does not make recommendations for the food companies to make healthier products. Corporate responsibility could play a huge role in health policy (13.) <br /><br />The CNPP did not include monitoring corporate practices or implementing strategies, including public education to enable the consumer to make a healthy choice that would fit within the guidelines of MyPyramid. Food companies put labels on products that state 3 cups of fruits or contain half of a cup of vegetables. However, these products may have enormous amounts of added sugar or high sodium. The consumer is led to believe they are making a healthy choice if they see that positive claim however in reality it may be a poor food choice. In short, MyPyramid should have created regulations on the food companies so individuals could make correct decisions without confusion or bias.<br /><br /><br />MyPyramid Fails to Support Self-Efficacy <br /><br /> MyPyramid does not address an individual’s desire for self-efficacy. According to the Theory of Planned Behavior, self-efficacy is the belief that you are capable of performing a behavior and it is a critical component to behavioral change.8,9 Individuals may have the intention to act but will fall short if they don’t believe they can do it. For instance, if a web-surfer were to visit the MyPyramid website and enter their personal data they would receive numerical recommendations for each food group (1). Then it is the responsibility of the individual to incorporate those recommendations. This could be a daunting task if a person does not have a nutritional background. It also may leave an impression that the numbers for each of the food groups can’t be modified or changed.<br /><br />MyPyramid endorses high fruit and vegetable consumption but the message is not being realized. According to the five-a-day campaign, participants realize high consumption of fruits and vegetables are important yet for some reason they still did not consume them. Some of the reasons reported were healthy foods were expensive, supermarkets not in the area and difficulty in preparing vegetables (5). MyPyramid does not give suggestions to help give people control on food choices. It reiterates what they should be doing instead of how they can do it. This message has the potential to leave a lasting feeling of hopelessness and guilt. <br /><br />American culture has many holidays and events around food. As such, the diet of an individual will be dynamic and will vary from day to day. Without the supplemental education and tools needed to help make an individualized nutritional plan a reality, the person is less confident in themselves to make the behavioral change (14). If the person does not feel capable of changing their eating habits then MyPyramid has failed the consumer. <br /><br /><br />MyPyramid Gets a Make-Over: An Alternative Public Health Intervention for MyPyramid<br /><br /> The current version of MyPyramid places all of the responsibility on the individual and sells health as the product. In this proposal, MyPyramid is designed and implemented using principals of advertising theory, ecological systems theory and control theory (15,16,17). These alternative social science/psychological models can correct the flaws in the program that have been argued above. MyPyramid could be a more successful public health campaign if they sold a promise that is desired, used a multi-level approach, and acknowledged that a person likes to be in control. These points will demonstrate that a public health intervention is compelling when many theories are used and can target a person’s wants, needs, and abilities. <br /><br /><br />Advertising Theory – An Alternative Model to Apply to MyPyramid<br /> <br />MyPyramid is selling health as the promise for the product. As discussed earlier, health is not a great selling point for the consumer.15 Ogilvy states a good advertisement is one which sells the product without drawing attention to itself (18). The consumer should think “I never knew that before, I must try this product.” The promise is at the core of Advertising Theory and states the bigger the promise the more effective the campaign, where the product is defined by the benefits (15,1819). In order to support the promise, advertisers tell stories, use symbols/metaphors and use images to demonstrate the promise. MyPyramid did not package their message in a desirable way to the public since their promise was health. The CNPP did not get to know their consumers.<br />In advertising theory, what you say is more important than how you say it. Framing in a campaign is crucial (15). Instead of saying steps to a healthier you, why not say steps to a sexier you? Draw on societal values of youth, fitness, sex, physical attraction and acceptance. This is the promise, values that are sought-after. The selection of the right promise is so vitally important that you should never rely on guesswork; if the target audience is the American people than the CNPP should have researched what they wanted. Holding focus groups, filling out surveys that rate different promises and asking them which of them would be most likely to make them buy into the product (18,19). For example, MyPyramid could have created consumer cards that listed: Improves Health, Clean and Clears Skin, Prevents Dry Skin, Keeps your Figure, Makes Skin Look Younger, Improves Hair Growth, Improves Nail Growth, Increases Life Expectancy, Increases Physical Strength, Improves Mental Clarity, and Increases Quality of Life. All of these promises can occur from eating healthy. However, the American public would not know this due to the ill-packaging of MyPyramid. If MyPyramid had given out these consumer cards and used the voting to drive the slogan it would have read more like “The Secret to Looking Young” instead of “Steps to a Healthier You” (15).<br /><br />Give the facts. Consumers are not dumb. MyPyramid should have touted all the research behind the image. It should have been clearly stated next to the image that 25+ scientific studies were used to formulate this model (1). It gives the consumer a benchmark of the amount of work in creating this product. It also shows the consumer that the creators did their homework so they didn’t have to. Consumers like honesty and it is only sensible to let them know about all the grunt work behind the final product (18).<br /><br />Advertising must stay contemporary. MyPyramid wanted to target the whole population. However, during the designing phase of the policy only public health practitioners drew up the image and marketing plan. If they had invited consumers of different ages to help during the designing phase then they would have better understood the psychology of consumers instead of assuming they know the psychology of the consumer.<br /><br />Lastly, MyPyramid has to sell the brand in way that is a consistent image to the world. As stated by Evans “the significance of the brand is in the associations they represent, and the resulting behavior they can engender.” (19). MyPyramid is brand that is associated with USDA and that can affect how consumers respond. In short, MyPyramid should stop selling health as a product and redefine their marketing to the deep aspirations that people want such as youth, acceptance, freedom and sex (8).<br /><br />Ecological Systems Theory – An Alternative Model to Apply to MyPyramid <br /> MyPyramid places all the responsibility on the individual (1). It assumes individuals are static, walking bubbles. However, real-life is a constant dynamic process that can change from minute to minute. Uri Bronfenbrenner developed the ecological system theory that takes into account all of the systems that dictate our lives. Coincidently, social norms arise from the surrounding environment of one’s society. MyPyramid did not look at an individual as part of a greater environment that at times influences their health behavior. The premise of the theory states there are 4 systems including microsystem, mesosystem, exosystem and macrosystem that govern human behavior (16). The microsystem involves our immediate environment, which may include family, school and neighborhood. The mesosystem speaks to the connection between immediate environments such as a child’s home and school. The exosystem states that there are external environmental settings which indirectly affect the behavior of a person (i.e. a place of work). The macrosystem describes the larger Western culture of the United States and shapes the economy, politics, religion and values of a person. In other words, an individual is affected by many places, people and things (8).<br /><br />MyPyramid does not speak to the many systems we live in. Advertising theory speaks to the core human values while the ecological systems theory describes how those core human values arise. Therefore another approach for MyPyramid would have been a multi-level intervention that addresses the complexity of each system (21). MyPyramid could have launched a campaign in communities across the nation related to healthy eating. Public health professionals and public officials could have joined forces to bridge the gap between the microsystem, mesosystem and exosystem. Some example include creating education spots using different types of media, performing cooking demonstrations with families, nutrition classes in school with a newsletter to bring home, working with office cafeterias to offer healthy food choices and offering recipes from work to bring home. When the systems are connected with each other social norms are likely to be affected because healthy behavior becomes a critical component of life. <br />Lastly, the government is part of the macrosystem. They should lead by example by setting healthy nutrition as a primary agenda goal. In order to do this, government officials could create policies that promote healthy eating, giving incentives for grocery stores to offer affordable healthy options, tax-breaks for local farmers, increasing access to healthy foods in low-income neighborhoods. <br /><br /><br />Control Theory – An Alternative Model to Apply to MyPyramid<br /><br /> William Glasser created control theory with the fundamental idea that individuals control their behavior to maximize their need for satisfaction (17). My Pyramid assumes self-efficacy therefore it does not include components to help improve self-efficacy. However, these components are important because not everyone realizes their self-efficacy. MyPyramid tells the individual what to do and expects them to do it. Self-efficacy is assumed to be a trait everyone has. Individuals with self-efficacy feel that they are in control (8).<br /><br />Glasser explains that people with control have six basic needs, survival, power, love, belonging, freedom and fun (17). MyPyramid should have incorporated those values into the MyPyramid design to promote control. MyPyramid could have listed options for food likes/dislikes, an opportunity to list what hinders them for eating correctly, applauding them for healthy choices they are making, allowing them to choose what would fit in their schedule and making it fun by using games within the site. Furthermore, since self-efficacy is not just a product of individual supports and rewards but also includes have access to healthy, affordable food and clean, safe places to exercise, which requires environmental/systems level change.<br /><br /><br />Conclusion<br /><br /> MyPyramid was created to integrate science-based evidence from the 2005 Dietary Guidelines for Americans and convert nutrient recommendations for the food groups into household measurements (1). Since its inception it has not proven to be a successful public health intervention. Americans still do not know how to eat right and poor weight management continues to increase. MyPyramid has glaring flaws in particular it assumes that health is a main priority for Americans, assumes individual responsibility for food choices and fails to support self-efficacy. Public health practitioners should revisit the design and try to correct the flaws mentioned in order to create an effective nutritional policy.<br />MyPyramid has the potential to be a great public health intervention. However, the creators have to be open to the idea of alternative models that illustrate that individuals have core values that impact their behavior, at any moment are affected by context/environment and require self-efficacy and control to make healthy behavioral change. <br /><br />Figure 1 (3)<br /><br /><br /><br /><br />Figure 2 (3)<br /><br /><br /><br />Figure 3 (3)<br /><br /><br />References<br /><br />1. United States Department of Agriculture: MyPyramid. Accessed on November 27, 2009. http://www.mypyramid.gov/<br />2. National Center for Health Statistics. Chartbook on Trends in the Health of Americans. Health, United States, 2006. Hyattsville, MD: Public Health Service. 2006.<br />3. Center for Disease Control: Overweight and Obesity. Accessed on November 28, 2009 http://www.cdc.gov/<br />4. National Institute of Diabetes and Digestive and Kidney Disease – Weight Control Information Network Statistics Accessed on November 28, 2009 http://win.niddk.nih.gov/statistics/<br />5. Subar AF. Five-A-Day Campaign Fruit and Vegetable Intake in the United States: The Baseline Survey of the Five a Day for Better Health Program. American Journal of Health Promotion 1995; 9:352-60<br />6. Maslow AH. A theory of human motivation. Psychological Review 1943; 50:376-396.<br />7. Alderson, Wroe (1957), Marketing Behavior and Executive Action: A Functionalist Approach to Marketing Theory. Homewood, IL: Richard D. Irwin.<br />8. Siegel, M. Social and Behavioral Sciences for Public Health Lecture Notes. Fall 2009<br />9. Individual health behaviors theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp.35-49.<br />10. Whole Foods Locations. http://www.wholefoodsmarket.com Retrieved 1 December 2009.<br />11. Stop and Shop Peapod. http://www.peapod.com Retrieved 1 December 2009.<br />12. Food Industry Overview, www.plunkettresearch.com , Plunkett Research. Retrieved 30 November 2009.<br />13. Wiist WH. Public Health and the anticorporate movement: rationale and recommendation. Am J Public Health. 2006; 96:1370-5.<br />14. Balko R. Private matters and ‘public health’. Available at http://www.cato.org/research/articles/balko-050206.html, accessed 1 December 2009.<br />15. Evans WD, Hastings G. Public Health branding: Recognition, promise, and delivery of healthy lifestyles (Chapter 1). In Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008, pp.3-24.<br />16. Bronfenbrenner, U. (1989). Ecological systems theory Annals of Child Development, 6, 187-249.<br />17. Glasser, W. The Quality School, Harper & Row, 1990.<br />18. How to build great campaigns (Chapter 5). In: Ogilvy D. Confessions of an Advertising Man. New York: Athenaeum, 1964, pp. 89-103.<br />19. Blitstein JL, Evans WD, Driscoll DL. What is a public health brand? (Chapter 2). In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008, pp.25-41.<br />20. Siegel M. Marketing social change: An opportunity for the public health practitioner (Chapter 3). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change (2nd edition). Sudbury, MA: Jones and Bartlett Publishers, 2007, pp 45-71.<br />21. Wu J, David JL. A spatially explicit hierarchical approach to modeling complex ecological systems: theory and applications. Ecological Modelling 2002; 153: 7-26.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-8413233331204670922010-05-20T16:42:00.000-07:002010-05-20T16:50:16.857-07:00The Scapegoating of Trans Fats: the Newest Fad of the Anti-Obesity Campaign and Why it Won’t Work – Emily Benjamin<span style="font-weight: bold;">I. Introduction</span><br />America, as has become abundantly clear, is in the midst of a nutritional crisis. Three in every ten American adults are clinically obese (BMI>=30), and the rate is higher for those clinically overweight (BMI 25-29.9)(1). Overall, upwards of two-thirds of American adults are overweight or obese. In addition, 16.3% of American children are clinically obese.(1) As of 2000, there were up to nine million morbidly obese Americans (BMI >=40)(2). <br /><br />Given that obesity is strongly associated with diabetes, various forms of cancer, cardiovascular disease, stroke, and hypertension, calls for action to stop the epidemic have intensified as obesity continues to spread (2,3,4). Further support for curbing the epidemic is the enormous cost that obesity is exacting on America’s health industry. More than 25% of the nation’s health care spending is related to obesity, and upwards of $61 billion are spent each year directly because of obesity (1). <br /><br />Due to the increased health risks and striking economic costs of obesity, many domestic public health interventions have been implemented with the goal of controlling the spread of the epidemic. These have taken various forms, from requiring restaurants to post calorie counts, to sending elementary-school children home with BMI ‘report cards’, to airing educational media campaigns (5-8). These interventions have seen varied levels of success, but many have been misguided, and have ultimately failed to achieve their goals (9). <br /><br />One such recent and ineffective form of intervention has been the regulation of trans fats, which have recently been labeled a main contributor to the spread of obesity. The premise of the regulations is that by removing the option of consuming trans fats, we will not consume them, and thus, overall, we will be healthier (4). <br /><br />Trans fat regulations have taken two primary forms. Trans fats have been banned in restaurants in some cities, states and countries, and the labeling requirements for packaged foods that contain trans fats have become more explicit (4). Over the past several years, a number of countries and cities worldwide, including Denmark, New York City, Philadelphia, and Boston, have mandated that all food sold in restaurants must be free of trans fats (4,12). In general, the media and general public have reacted to these regulations positively. Supporters view these bans as promising methods through which the morbidity and mortality associated with obesity will decrease (4).<br /><br />Despite the generally positive reception that these regulations have received, opposition does exist. Some challenge that saturated fats are equally culpable in the obesity epidemic; others contend that government does not hold the power to limit personal choice in this manner (4). However, the strongest argument against focusing on trans fat as the perpetrator is the fact that these policies ignore the actual causes of the obesity epidemic (15-17). We are not all fat because we consume too many grams of trans fats; regulating trans fats, as is becoming more and more popular, is not going to make us all thin on its own. Obesity is spreading because of the lifestyle that has pervaded America, that of eating too much and not being active enough (9). Obesity is allowed to arise when energy expenditure is surpassed by energy consumption (9). Given the practices that have become normalized in our society – the prioritizing of sedentary activities over physical activity, and having access to many, and inexpensive, food options – energy consumption has continually increased nationwide while energy expenditure has decreased (9).<br /><br /><span style="font-weight: bold;">II. A Critique of the Trans Fat Regulations </span><br />There are two overarching shortcomings of the trans fat regulations that explain why the regulations will ultimately fail in their goal to control the obesity epidemic. Firstly, trans fats are not the problem. This issue can be analyzed from two separate perspectives: one, the regulations inappropriately and misleadingly frame the problem; and two, through fundamental attribution error, the character of trans fats have been identified as the culprit, thereby ignoring entirely the context of the obesity epidemic. The second main problem with the trans fats regulations as they stand presently is that the government, by taking away an individual’s right to choose what s/he eats, risks reactance by these citizens in the form of eating more unhealthily in an attempt to reclaim that freedom.<br /><br /><span style="font-weight: bold;">A. Trans Fats Regulations Incorrectly Frame the Issue of Obesity</span><br />By focusing so strongly and singly on trans fats, government is telling its citizens that trans fats are the cause of the obesity epidemic. The regulations further imply that by not consuming trans fats, we, as both individuals and a general population, will immediately become healthier. This is not entirely incorrect – studies have confirmed that consumption of trans fats can increase risk for coronary artery disease and Type II diabetes, and increase HDL (‘bad’ cholesterol) and decrease LDL (‘good’ cholesterol) (10). However, french fries are not a healthy food, regardless of what kind of oil they are fried in and whether that oil contains trans fats. By policing restaurants and not allowing them to cook with trans fats, these regulations are, in effect, telling potential patrons that the foods available to them at these restaurants are now healthy enough for consumption. This could lead unwitting consumers to continue eating these foods, believing that they are eating healthier, when in fact their health may only be marginally improved, if at all, by eating french fries cooked in oils without trans fats (13). <br /><br />The focus on trans fats has also allowed the food industry to portray itself as contributing to a healthier America. In 2006, Wendy’s International made news headlines across North America when it instituted a new company policy that regulated all stores to begin cooking with more healthful oils. Shortly afterwards, Kentucky Fried Chicken Corporation, McDonald’s Corporation, and Burger King Brands, Inc. all announced the same intention (11). These changes have been heralded as positive responses to consumer demand (11). However, not nearly enough research has been done to examine the actual healthiness of these replacement oils. A similar dearth of research in the 1970s led to the replacement of palm oil with trans fats in many processed foods, as it was then believed that trans fats were healthier than palm oil, which has a high saturated fat content (10). Now, two decades later, trans fats are being held responsible for the obesity epidemic. If we do not start examining with what food corporations are replacing trans fats, we could be consuming foods made with equally or more unhealthy ingredients (10).<br />By continuing to frame the issue in this way – by focusing on trans fats only – we as public health practitioners are effectively putting on blinders, not allowing ourselves to consider the larger, stronger causes behind obesity that we can affect. If we are to be successful in the fight against obesity, we as public health practitioners need to take a broader approach how we view obesity and its causes.<br /><br /><span style="font-weight: bold;">B. Trans Fat Regulations Incorrectly Assign the Causes of Obesity</span><br />Public health practitioners’ failure to take a step back and view the larger causes of obesity is a classic example of fundamental attribution error. By focusing on the character of trans fats as our culprit, we miss the larger picture – the context in which the obesity epidemic is blossoming. There are multiple and varied causes of obesity’s spread throughout a population, beyond simply what foods individuals are consuming and if they are exercising. <br /><br />The environment in which we live plays a profound role in the spread of obesity in America, where inexpensive food is readily available, and physical activity is being actively replaced with sedentary behavior (14). This shift away from physical activity towards more inactive behavior has stemmed in large part from changes in the workplace. Technological advances precipitated movement away from manual labor, leading to a dramatic decrease in physical activity required at work (15). <br /><br />Further, the spread of increasing portion sizes at restaurants (including ‘supersizing’ at fast food outlets), has drastically increased consumption (16). The proportion of food consumed away from home, as compared to that prepared in-home, has increased from 18% from 1977-1978 to 32% from 1994-1996 (16). The combination of more frequently eating food prepared outside of the food with larger portions being offered outside of the home has led to an increase of an average of 1854 calories per person per day to 2002 calories per person per day, which results in weight gain of 15 pounds per person per year (16).<br /><br />In developed countries, socio-economic status (SES) is a major component in the obesity epidemic. As SES increases, obesity tends to decrease (17). This is due to low-nutrient foods being most affordable, and gym membership and healthy foods, including fruits and vegetables, being more, at times prohibitively, expensive (17). Furthermore, poorer areas can be less likely to have sidewalks, thereby further discouraging physical activity (17).<br /><br />By focusing as the public has done on a molecule as slight as trans fats, we are ignoring the comparatively enormous societal contexts in which obesity exists. It is far easier to devise ways to moderate consumption of trans fats than it would be to moderate the environmental causes contributing to the spread of obesity. Perhaps this is why trans fats have become the latest offender in the anti-obesity movement.<br /><br />By ignoring the more distal causes of the spreading obesity epidemic, we as public health practitioners are severely limiting the impact we can exert on the epidemic. Our efforts will prove futile if we continue to target this proximal and arguably insignificant factor contributing to the spread. <br /><br /><span style="font-weight: bold;">C. Trans Fat Regulations Draw Reactance </span><br />Psychological reactance theory states that, upon perception of a threat to one’s freedom, an individual may adopt one of three reactant behaviors: ignoring the threat, disparaging the source of the threat, or demonstrating their freedom from the threat by deliberately performing the behavior being threatened (18,20).<br /><br />These reactions could quickly incapacitate an intervention if it is perceived to be presenting such a threat. Although the bans already instituted have overall been deemed ‘successes’, based on the fact that high percentages of restaurants have complied with the bans and increasing numbers of food producers are decreasing the amount of trans fats in their products, these regulations have led to significant concern across the country (4,11,19). <br /><br />There are many Americans who believe that government oversteps its bounds in a number of ways (18,19). We as Americans are accustomed to being able to purchase what we want when we want, including decisions about what foods we are going to eat (4). Many individuals see the trans fats regulations as the government overstepping its bounds for purely paternalistic reasons in dictating what we can and cannot put into our bodies (4,18,19). Further claims have been leveraged against the regulations on the grounds that they impede the free speech of restaurants and food producers (19).<br /><br />The measurement of success discussed above, which is being used to determine how effective the bans and labeling requirements, is an incomplete measurement. If we measure the effectiveness of the bans solely by decreasing trans fat consumptions, then the bans will obviously be successful: if there is no trans fat in foods available at restaurants, then patrons cannot consume trans fats at restaurants. Similarly, food producers are facing pressure to decrease the trans fats in their products, as industry leaders such as Oreo’s are now trans fat free and consumers are demanding a healthier product. The amount of trans fat that could possibly be consumed is continually decreasing nationwide (21).<br /><br />However, the larger goal of the trans fat regulations is to help lead to an overall healthier America. Thus, this should be the scale by which the success of these regulations is measured. Further, the success of the regulations needs also to be considered in the context of reactance. If individuals feel that their ability to consume the foods they want to consume, regardless of their fat content, is being threatened, those individuals, according to reactance theory, are likely to go out and consume more high fat-content foods to display their continued control over their freedom to eat what they like. Data on actual levels of reactance to trans fat regulations are deficient (22); however, it can be assumed that reactance theory would play a similar role in these regulations as it has in others (23-25), given that the threat to an individual’s freedom is present.<br /><br />The creators of the trans fat regulations do not appear to have considered reactance to the regulations when they were creating them. Given the influence that reactance has played in the past on various interventions, including interventions aimed at decreasing alcohol consumption, increasing patient compliance, and increasing anti-pollution measures (23-25), it is likely that the trans fat regulations will be severely hindered by individual’s reactance to the threat of their freedom to eat what they want to eat.<br /><br /><span style="font-weight: bold;">III. The Trans Fat Regulations Reshaped</span><br />By examining the shortcomings of the regulations surrounding trans fat, there are a number of possible alternative solutions to America’s obesity crisis. These alternative solutions will be far more effective if they examine obesity from the lens that the trans fat regulations are lacking. Successful solutions to enable the halting of the spread of obesity will need to approach the epidemic from an environmental and social context, rather than from an individual behavior model. <br />The proposed intervention incorporates solutions to the three shortcomings of the current trans fats regulations, as detailed above. By providing incentives coupled with education to individuals, public health practitioners put the adoption of healthier lifestyle choices back in the hands of the individuals themselves, rather than removing the control of such decisions altogether.<br /><br /><span style="font-weight: bold;">A. A Brief Description of the Intervention</span><br />The use of incentives has been shown to change individuals’ behaviors regarding HIV prevention (26) and reducing household waste (27), and to change firm behavior in promoting pollution control (28). Several interventions have examined the effect that financial or material incentives can have on behavior change, and most have found that such incentives can in fact successfully change an individual’s behavior to reflect healthier decisions (29,30). Indeed, in one literature review, nearly 75% of randomized trials aiming to increase healthy behavior through financial incentives achieved successful outcomes (30). However, another study found that though these financial and material incentives led successfully to behavior change, they had no impact on the attitudes of the participants – individuals were purchasing healthier foods simply because they were more affordable, not because of the increased nutritional value that they offered (29).<br />The proposed reformulation of the trans fat regulations involves the provision of differential financial incentives to individuals who not only reduce their consumption of trans fats, but who consume healthier foods overall and/or who increase the regularity with which they are physically active. One arm of this incentive will focus on trans fats, due to their recognized detrimental and deleterious health effects (10,31), by providing incentives to those individuals who can prove that they have purchased trans fat free foods in both supermarkets and restaurants. However, similar incentives will be provided for similar restrictions of saturated fat consumption and overall caloric consumption, on a graduated scale: saturated and trans fats consumption reductions will be linked to a smaller incentive than will overall caloric consumption. Further, individuals who can prove that they are increasing the regularity with which they are physically active will receive a financial incentive on the scale of the overall caloric consumption. Insurance companies, the government, and the anti-obesity movement will together finance the incentives provided, at percentages to be determined. <br /><br /><span style="font-weight: bold;">B. Support for the Proposed Intervention </span><br />1. The Proposed Intervention Frames the Obesity Epidemic Correctly<br />As described above, the proposed intervention is far more likely to be successful in combating the spreading obesity epidemic than are the trans fats regulations currently in existence because it frames the obesity epidemic more appropriately. By including not only provisions directed at reducing consumption of specific and proximal causes of obesity (trans fat and saturated fat), but also specifications for broader, more distal individual causes (consuming too much food, not exercising enough), the proposed intervention includes a more precise frame from which we can examine the problem of obesity. <br /><br />The proposed intervention will not directly affect the broader environmental causes of the spread of obesity, but if the intervention is successful, it can be expected to have later indirect and more residual affects on these most distal causes. As people adopt these healthier behaviors, we can expect, through the application of network theory, that these healthier behaviors will spread through the individuals’ networks as has been seen with the spread of obesity and cessation of smoking (32,33). As these behaviors become adopted by more individuals, we can expect that these individuals’ new behavior decisions will put collective pressure on various industries, forcing provision of healthier options for consumption. Therefore, though the proposed intervention will lead to behavior change on an individual level most immediately, it can be expected to lead to greater change on a social level with time.<br /><br />2.The Proposed Intervention Accurately Attributes the Causes of the Obesity Epidemic<br />Through its provision of financial incentives for much broader behaviors than those simply surrounding trans fat consumption, the proposed intervention offers a more comprehensive and accurate recognition of the broader causes associated with the spread of obesity. Rather than focusing on the consumption of trans fats as the primary cause of the obesity epidemic, the proposed intervention encompasses recognition of a far broader set of origins of the spread of obesity. By focusing on two singular nutrients – trans fats and saturated fats – the proposed intervention recognizes the significance of the role of consumption of these two nutrients on obesity in America. However, by recognizing the larger and stronger individual factors at play – notably, consuming too much food and not being physically active enough – the intervention promises to be more successful, given the higher incentives for these broader causal identifications.<br /><br />Again, as discussed above, the intervention will likely not affect the more socially and economically ingrained distal causes of the epidemic at first. However, it promises, through promoting individual behavior change across an entire society, to lead to greater change on a social and economic level in the future. Further, since it will be the consumers themselves driving this broader change, as discussed above, it is more likely that the changes that occur on a social level will remain in place for longer than they would be if forcibly imposed, as the trans fat regulations do.<br /><br /><span style="font-weight: bold;">3. The Proposed Intervention Avoids the Issue of Reactance</span><br />Thirdly, the proposed intervention entirely removes the issue of reactance, which promises to plague the trans fats regulations as they stand currently, as discussed above. Because the intervention allows for individuals to create the behavior changes that they themselves want, this intervention will lead to the intended and desired adoption of new behaviors, rather than the imposed and potentially unwanted adoption of such behaviors that the trans fats regulations enforce. This will allow for those who do not want to make such changes to continue with the same behavioral profile as they had before, but will also make it possible for those who do indeed want to change to be able to. Since no behavior is being threatened, only encouraged, we can expect that reactance will not pose a problem for this proposed intervention. Further, since these behavior changes are being implemented on an as-wanted basis, by the individuals themselves who want to make the changes, it is likely that these changes will be more long-lasting than those imposed by an outside force, as discussed above. <br /><br />In addition, the proposed intervention will help to encourage those who have been thinking of making these changes through increasing their sense of self-efficacy, a crucial component of behavior change as stipulated in Bandura’s Social Cognitive Theory (34). Self-efficacy must be present in this model for individual behavior change to take place and to be continued, and the proposed intervention increases individuals’ self-efficacy by making healthy lifestyle changes more affordable and more achievable.<br /><br />IV. Conclusion<br />The current trend of imposing trans fats regulations in cities, states, and countries worldwide will likely fail in their efforts to stop the spread of obesity. There are several reasons for this future failure, including the improper framing of the obesity epidemic, inaccurate attribution of the causes of the obesity epidemic, and the likelihood of inciting reactance against the regulations. A newly proposed intervention that encompasses encouragement of reducing the consumption of trans fats in a larger scheme intended to incentive healthier lifestyles in a broader sense will likely be more successful in combating obesity. This new intervention correctly and accurately frames the obesity epidemic and its causal factors, and also decreases the likelihood of reactance to such encouraged behavior changes, and for these reasons it is likely that the proposed intervention will be more successful than the current imposition of regulations.<br /><br />References<br />1. Levi J, Vinter S, St. Laurent R, Segal LM. F as in Fat: How Obesity Policies are Failing in America. Washington, DC: Trust for America’s Health, 2008.<br />2. Peskin GW. Obesity in America. Archives of Surgery. 2003; 138:354-355.<br />3. Ogden CL, Carroll M, McDowell M, Flegal K. Obesity Among Adults in the United States-No Statistically Significant Change Since 2003-2004. Atlanta: CDC, 2007.<br />4. Gostin LO. Law as a Tool to Facilitate Healthier Lifestyles and Prevent Obesity. Journal of the American Medical Association. 2007; 297:87-90.<br />5. Kuo T, Jarosz CJ, Simon P, Fielding JE. Menu Labeling as a Potential Strategy for Combating the Obesity Epidemic: A Health Impact Assessment. American Journal of Public Health. 2009; 99;1680-1687.<br />6. Berman M, Lavizzo-Mourey R. Obesity Prevention in the Information Age: Caloric Information at the Point of Purchase. Journal of the American Medical Association. 2008; 300;433-435.<br />7. Scheier, LM. School health report cards attempt to address the obesity epidemic. Journal of the American Dietetic Association. 2004; 104;341-344.<br />8. Beaudoin CE, Fernandez C, Wall JL, Farley TA. Promoting Healthy Eating and Physical Activity: Short-Term Effects of a Mass Media Campaign. American Journal of Preventive Medicine. 2007; 32;217-223.<br />9. Hill JO, Peters JC, Wyatt HR. The Role of Public Policy in Treating the Epidemic of Global Obesity. Clinical Pharmacology and Therapeutics. 2007; 1-4<br />10. Unnevehr LJ, Jagmanaite E. Getting rid of trans fats in the US diet: Policies, incentives, and progress. Food Policy. 2008; 33:497-503.<br />11. Stein K. Many Companies making More Healthful Choices for Consumers. Journal of the American Dietetic Association. 2007; 107:550-552.<br />12. Niederdeppe J, Frosch D. News Coverage and Sales of Products with Trans Fat: Effects Before and After Changes in Federal Labeling Policy. American Journal of Preventive Medicine. 2009; 36:395-401.<br />13. Borra S, Kris-Etherton PM, Dausch JG, Yin-Piazza S. An Update of Trans-Fat Reduction in the American Diet. Journal of the American Dietetic Association. 2007; 107:2048-2050. <br />14. Brownell KD. The Chronicling of Obesity: Growing Awareness of Its Social, Economic, and Political Contexts. Journal of Health Politics, Policy and Law. 2005; 30:955-964.<br />15. Finkelstein EA, Ruhm CJ, Kosa KM. Economic Causes and Consequences of Obesity. Annual Review of Public Health. 2005; 26:239-257.<br />16. Wellman N, Friedberg B. Causes and consequences of adult obesity: health, social and economic impacts in the United States. Asia Pacific Journal of Clinical Nutrition. 2002; 11:S705-709.<br />17. Poston WSC, Foreyt JP. Obesity is an environmental issue. Atherosclerosis. 1999; 146:201-209.<br />18. Clee MA, Wicklund RA. Consumer Behavior and Psychological Reactance. Journal of Consumer Research. 1980; 6:389-405.<br />19. Mello MM. New York City’s War on Fat. New England Journal of Medicine. 2009; 360:2015-2020.<br />20. Burgoon M, Alvaro E, Grandpre J, Voulodakis M. Revisiting the Theory of Psychological Reactance: Communicating Threats to Attitudinal Freedom (pp. 213-232). In: Dillard JP, Pfau M, ed. The persuasion handbook: developments in theory and practice. Thousand Oaks, CA: Sage Publications, 2002.<br />21. Frank TH. A Taxonomy of Obesity Litigation. ULAR Law Revew. 2006; 28:427-441.<br />22. Faith MS, Fontaine KR, Baskin ML, Allison DB. Toward the reduction of population obesity: Macrolevel environmental approaches to the problems of food, eating, and obesity. Psychological Bulletin. 2007; 133:205-226.<br />23. Allen DN, Sprenkel DG, Vitale PA. Reactance theory and alcohol consumption laws: Further confirmation among collegiate alcohol consumers. Journal of Studies on Alcohol. 1994; 55:34-40.<br />24. Fogarty JS. Reactance theory and patient noncompliance. Social Science and Medicine. 1997; 45: 1277-1288.<br />25. Mazis, MB. Antipollution measures and psychological reactance theory: A field experiment. Journal of Personality and Social Psychology. 1975; 31:654-660.<br />26. Lamb ML, Rhodes F, Hoxworth T, Rogers J, Lentz A, Kent C et al. What about money? Effect of small monetary incentives on enrollment, retention, and motivation to change behavior in an HIV/STD prevention counseling intervention. Sexually Transmitted Infections. 1998; 74:253-255.<br />27. Thogerson J. Monetary Incentives and Recycling: Behavioural and Psychological Reactions to a Performance-Dependent Garbage Fee. Journal of Consumer Policy. 2003; 26:197-228.<br />28. Milliman SR, Prince R. Firm incentives to promote technological change in pollution control. Journal of Environmental Economics and Management. 1989; 17: 247-265.<br />29. Anderson JV, Bybee DI, Brown RM, McLean DF, Garcia EM, Breer ML et al. 5 a day fruit and vegetable intervention improves consumption in a low income population. Journal of the American Dietetic Association. 2001; 101:195-202.<br />30. Kane RL, Johnson PE, Town RJ, Butler M. A structured review of the effect of economic incentives on consumers’ preventive behavior. American Journal of Preventive Medicine. 2004; 27:327-352.<br />31. Ascherio A, Willett WC. Health effects of trans fatty acids. American Journal of Clinical Nutrition. 1997; 66:1006S-1010S.<br />32. Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. New England Journal of Medicine. 2007; 358:2249-2258.<br />33. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine. 2007; 357:370-379.<br />34. Bandura A. Human Agency in Social Cognitive Theory. American Psychologist. 1989; 44:1175-1184.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-73239036601901257352009-12-21T18:42:00.000-08:002009-12-21T18:50:42.374-08:00Parents: The Anti-Drug – A Critique and Rethinking of Parent-focused Anti-Drug Campaigns<span style="font-family: Georgia;"><b>– Kevin Delaney<o:p></o:p></b></span> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><b>Introduction</b></span><span style="font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>The United States government has long sought to control and eliminate drug use by its citizens, particularly by adolescents. Traditionally, this has been done through the criminal justice system, in the announcement of the “War on Drugs” by President Nixon in 1971 (1). These efforts focused on instituting harsh penalties on users of drugs, hoping to create a strong negative incentive, by which users would rationally choose to abstain. However, over the last thirty years, there has been a move to use public health initiatives to accomplish this goal. The anti-drug messaging ramped up in the 1980’s with Nancy Reagan’s “Just Say No” campaign and the establishment of the D.A.R.E. campaign, two public health initiatives to reduce and eliminate drug usage amongst teenagers that showed limited effectiveness (2,3). These measures focused on creating awareness amongst teenagers of the health risks of drug use through education, and focusing on kids making rational choices. However, particularly with the D.A.R.E. campaign, the emphasis was still on the negative incentives of drug use, as the education program is done in conjunction with local police forces (4). Recently, the federal government’s initiatives have focused more on the social aspects of teen drug use and acknowledging the strong social forces that influence it. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>In this vein, the government has created the “Parents: The Anti-Drug” campaign. This initiative is aimed at taking advantage of the parent-child relationship to curtail drug use: “TheAntiDrug.com was created by the National Youth Anti-Drug Media Campaign to equip parents and other adult caregivers with the tools they need to raise drug-free kids” (5) Since parents are so integrally involved in the lives of their children, it would make sense to use them as a resource for anti-drug messaging. In addition, parents have a natural incentive to protect their children from the harmful effects of drug use. In a lot of ways, this initiative makes good sense. Indeed, there are studies that indicate that the level of monitoring that parents perform does have mitigating effects on their children’s drug use (6). However, when viewing this campaign within the framework of certain behavioral theories, the claim of parents being the “anti-drug” is exaggerated, and the potential effectiveness of this campaign is dubious. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><b>Peers Have More Influence Than Parents – Social Expectations Theory<o:p></o:p></b></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>Despite the wishes of their parents, teenagers are often much more influenced by the behavior of their peers than the rules or guidelines of their parents. A constant theme throughout history is the adolescent who acts out against the strictures of his parent: the rebellion of the child. This social phenomenon, while causing much angst to the parents of America, has its roots in a well-established behavioral construct: social expectations theory. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>While most of the population of the United States believes that freedom and autonomy guide their decisions, and that rational choices can be made, there is a lot of evidence that human behavior is as much determined by the social environment of the group as by the inner thought processes of the individual. Within society, social norms, roles and expectations guide how people make decisions. “Roles permit people acting collectively in a coordinated manner to accomplish goals that could not be achieved if each member acted independently” (7). Indeed, it seems that socialization is an adaptive trait that enhanced the evolution of humanity. However, it can have some maladaptive qualities. <o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-family: Georgia;">Within the context of teenagers and drug use, there are powerful social dynamics that make drug use more common. As teenagers create social bonds, they do so in schools with their age-stratified cohort. As anyone who has survived the American high school experience can attest, cliques arise, within which there are heavily stratified social roles. Some members have a powerful role and set the norms of the group, whereas others strive to mitigate their dissonance from the group by performing compliant behavior (8). As drugs are seen as a dangerous and “bad,” they become the way that teenagers are allowed to rebel against their parents. From there, social dynamics take over. The powerful of the group can set the agenda for the others by using drugs. The members of the group that react in a compliant way will either feel overt pressure to take part, or will do so without any prodding. The influence of the peer taking precedence over the influence of the parent in drug use has been well established (9)<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-family: Georgia;">Within this social dynamic, there is no role for the parent. They are generally not part of the social group, and therefore do not have much influence over the behavior during the time that the group is using drugs. In fact, while at home, teenagers can perform an entirely different role within the family social group, one that can be entirely dissonant to the role within the peer group. Because of this, the Parents: The Anti-Drug” has major barriers to overcome to be effective. The campaign’s main drive is to communicate to parents to take a more active role in their child’s lives, which is supposed to result in decreased drug use. The main tool is a series of commercials reminding parents of their role. There is also a website that gives parents a lot of information about drugs and advice about how to talk to their kids about drugs. While this information is critical for any parent to know, there is only little mention about how influential the social interactions that teenagers have within their peer groups. There is a section of the website devoted to chronicling the “pressure to fit in,” but there is no mention of what to do about it (10). The only advice that parents have to relate to their teenagers is to learn how to “talk teen.” However, this advice can backfire if parents attempt to transform their social role from parent to friend without authenticity (7). <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><b>Marketing the Anti-Drug Message to Parents Subverts Teenager Autonomy<o:p></o:p></b></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>Another potential misstep by this campaign is that it has the potential to communicate the wrong values to teenagers. The tenets of marketing theory hold that in order for a messaging campaign to be successful, it must appeal to the values of its target audience (11). In the “Parents” campaign, the target audience is the parent. In this respect, the campaign is successful, in that it appeals well to the values that parents hold: that they are integral to the behavior of their children. By making parents feel that they have some level of control over the drug use of their children, the campaign gives them hope and should be successful in getting parents to have a greater level of involvement in their children’s lives. This will no doubt have a certain level in reducing the drug use of children, as there is evidence that decreased parental monitoring of children is associated with increased health risk behaviors (6).<o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>However, this has the large potential to backfire in the true intention of the “Parents” commercials, which is to curtail the drug use of teenagers. While parental monitoring does have an effect on the behavior of teenagers, as mentioned above, the effects of peer groups have a larger effect on these behaviors (9). In addition, teens strive to increase their autonomy as they get older. In fact, this desire for autonomy is a crucial factor in their rebellious behavior: teens can demonstrate their autonomy by acting in a way that their parents forbid. Most of the marketing messages that are aimed at teenagers by consumer product companies create a feeling of freedom and autonomy in the brands. The strength of the “truth” anti-smoking campaign was in its ability to portray tobacco companies as agents of control over the lives of teenagers. The “truth” brand was successful in creating a feeling of rebellion against tobacco companies and smoking (12). The “Parents” commercials may have the opposite effect, as there should be no doubt that teenagers see these messages on television. While they are aimed at parents, teenagers may associate their parents as agents of control over their decisions to use drugs. <o:p></o:p></span></p> <span style="font-size: 12pt; font-family: Georgia;"> </span> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><b>The Campaign Communicates the Wrong Message of Who Controls Drug Use<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-family: Georgia;">Closely associated with the other two failings of this campaign is the issue of control, which is a subtle relation to autonomy. By marketing the concept of teenage drug use to parents, the campaign ignores the role that teenagers have in controlling drug use. It puts the decision to not use drugs in the purview of parents, who are in a different social group, so that teenagers have no control over it. This creates an incentive problem for teenagers to participate in their own abstinence from drug use. As Langer writes in explaining the illusion of control, “[p]eople are motivated to control their environment” (13). In fact, the issue of control is very often a motivation for teenagers to begin using drugs, as it is one way that they can express their personality. <o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-family: Georgia;">Children have very little legal standing, as they are the responsibility and the dependents of their parents. For very good reasons, parents control a lot of what their children do. However, teenagers most likely do not understand this legal argument, and only understand that they are not in control of many aspects of their lives, as many decisions are made for them. Therefore, the areas that they can control are very important to them. This is why teenagers focus a lot of energy on their friends and their personal products. The decision to use drugs is also an area that they can manage. Therefore, using drugs in reaction to their parents’ wishes is a way to feel that they make their own decisions. Even though, as mentioned above, people make their decisions within a social context, they still feel as if they are autonomous. By communicating to parents, the campaign inadvertently subverts the autonomy of teenagers and bypasses them in the anti-drug message. <o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-family: Georgia;">Currently, the National Youth Anti-Drug Media Campaign, which is run by the Office of National Drug Control Policy and is in charge of the “Parents” campaign (14), has a concurrent marketing message named “Above the Influence” (15). This campaign is geared towards teenagers and attempts to use the tools of social networking that they utilize in their peer groups. While there are some good items on this website, and in this campaign, the intervention can be strengthened. Mostly, this website focuses on giving teenagers information about what to do with friends who use drugs and empathizing over the pressures that they face: <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: Georgia;">Our goal is to help you stay above the influence. The more aware you are of the influences around you, the better prepared you will be to stand up to the pressures that keep you down. We're not telling you how to live your life, but are giving you another perspective and the latest facts. You need to make your own smart decisions.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in;"><span style="font-family: Georgia;">You might even consider this Web site an influence. We know that you're very smart when it comes to the messages you see and hear. That's great and you should question us, too. One way to do that is to review our sources. The numbers at the end of many of the facts are footnotes. You can click on them to find out where we got the information. (16)<o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;">Unfortunately, this website and the concomitant ads still rely on the messaging that drugs are bad and for teenagers to make individual decisions based on facts. While this may appear to give teenagers a level of control, it relies on the individual health belief model to weigh choices (17). It doesn’t offer a social solution to replace the feeling of being part of a group and controlling the social outcomes of losing the control of drug choice. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><b><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></b></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><b>The Proposed Intervention<o:p></o:p></b></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>In order to effectively combat teen drug use, teenagers need to feel empowered to make decisions that affect their lives, and given the autonomy to do so. In addition to this, the aspects of social interactions amongst teenagers need to be incorporated in any campaign. In a paradoxical way, the empowerment of teenagers to control their decisions has to be created at the group level. Therefore, the proposed intervention will be a social media campaign that is focused on reaching and targeting the intended audience: teenagers. It will act as a revision of the “Above the Influence” campaign and will supersede the “Parents” campaign. Instead of targeting parents, which might have a deleterious effect, the campaign will be a positive outreach effort that will take advantage of the social roles and norms that occur within teenage groups. In addition, the campaign will attempt to create a movement using social networks to make the anti-drug message a “teen thing.” <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p><b>Utilize Social Norms and Roles To Propagate Anti-Drug Message<o:p></o:p></b></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>As mentioned above, Social Expectation theory states that individuals often make choices based on the roles and norms of the group of which they are a part. The traditional method to combat teen drug use, which is utilized by the “Above the Influence” campaign, is to enable teens to stand up to these roles and norms. In other words, teenagers should break out of the role of reactance behavior and make an active decision based on facts that agencies provide. Unfortunately, while this approach may be laudable, it will have limited effectiveness, as it is asking teenagers to go against their natural instincts. Instead, public health agencies should use those instincts in their campaign. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>In a study conducted to research the social dynamics of smoking, researchers found that social networks play a large part in health behaviors, both in the decision to smoke as well as the decision to quit. “This finding suggests that decisions to quit smoking are not made solely by isolated persons, but rather they reflect choices made by groups of people connected to each other both directly and indirectly at up to three degrees of separation” (18). This dynamic should be used in crafting a mechanism for an anti-drug campaign. If the members of the social group that set the agenda are recruited into a potential anti-drug movement, then there will be a cascading effect through social groups. In the smoking cessation study, it was found that “connected clusters within the social network stopped smoking roughly in concert” (18). This effect can be duplicated if social networking sites are used to bring in entire groups into the movement. As upperclassmen in high school have a large influence on the social norms on younger students, there should be sponsored programs that recruit seniors for this message. In addition, key media influencers, such as teenage movie stars, should be recruited to be a part of this movement. Of course, this has been used in the past to convince kids to not use drugs, so the actual messaging is very important. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p><b>Create a Movement that Emphasizes Freedom and Autonomy<o:p></o:p></b></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>Simply putting out a traditional anti-drug message will not work any better, even if it is using modern social networking sites. Therefore, the message needs to change. Traditionally, anti-drug messages have focused on how bad drugs are for kids, e.g., the brain on drugs message. While this is true, these scare tactics have not been effective, and should be abandoned. Using Marketing theory, a movement emphasizing freedom and autonomy, while de-emphasizing the actual anti-drug message, should be created. This message will focus on emphasizing the positive aspects of a teenager’s life without drugs, as opposed to how drugs limit one’s autonomy. Presenting positive images of a movement that is led by teenagers will go a long way to establishing new social norms. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>In addition to this new message, the public health agency should establish partnerships with consumer product companies that advertise to teenagers. In the partnership, the commercials that are advertised to teenagers should show how the products that teenagers consume are part of a drug-free life. This message should be subtle and not overwhelm the message of the product ad. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>Another way to capture the effects of Marketing theory would be to be to capitalize on the success of the “truth” campaigns against tobacco companies. While there aren’t any illegal drug companies to target, the current unrest in Mexico over the drug trade could offer a way to produce outrage in teenagers. This message cannot emphasize that teenager drug use kills people in Mexico, which would cause guilt feelings. Similar to the “truth” campaign, teenagers should be seen as leaders of outrage against crimes that are committed by Mexican drug lords. There is a tenuous balance here, as the drug war is a very dangerous affair, but if used effectively, teenagers could see that their use of drugs is a limit of their autonomy by drug cartels. These messages should not be in concert with the positive messages described above. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><b>Create a Feeling of Control of the Anti-Drug Message by Teenagers<o:p></o:p></b></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>The main failing of the “Parents” and “Above the Influence” campaigns is that there is the sense that adults are creating the message and teenagers are simply participants in the battle over drug use. While there is reason for this dichotomy, teenagers should be empowered to feel control over the anti-drug / positive-life movement. Not only are they empowered to make individual decisions, but there should be messaging that they to have the power to influence the decisions of other teenagers. In other words, instead of “Parents: The Anti-Drug,” it should be “Friends: The Anti-Drug.” The focus of this new message should be on helping teenagers realize that they have influence over others, and that they be a source of positive changes in the lives of others. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><b>Conclusion<o:p></o:p></b></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>While the “Parents” campaign has laudable goals, its targeting and labeling of parents as the anti-drug is misdirected. This message, in concert with the weak “Above the Influence” campaign, reinforces social norms and roles that propagate drug use amongst teenagers. Campaigns to dissuade teenagers from using drugs are now 30 years old, and the message that these campaigns have used have only been revised slightly in that time period. While there has been some variation in teen drug use from the early 1980’s, it is hard to say that these campaigns have been successful (3). It is hard to deduce that these campaigns have done anything at all. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><span style=""> </span>In order for the stated goals of the media campaign to be successful, the entire message and approach must be overhauled. The hackneyed reiteration that drugs are bad and will ruin your life, while dubious in truth as it lumps all drugs together, should be shelved, and approaches that emphasize teenage freedom and control in positive lifestyles should be adopted. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-family: Georgia;"><b>References<o:p></o:p></b></span></p> <p class="Bibliography"><span style="font-family: Georgia;">(1) National Public Radio. (2007 2-April). <i>Timeline: America's War on Drugs</i></span><span style="font-family: Georgia;">. </span><a href="http://www.npr.org/templates/story/story.php?storyId=9252490"><span style="font-family: Georgia;">http://www.npr.org/templates/story/story.php?storyId=9252490</span></a><span style="font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="Bibliography"><span style="font-family: Georgia;">(2) United States General Accounting Office. <i>Youth Illicit Drug Use Prevention: DARE Long-Term Evaluations and Federal Efforts to Identify Effective Programs.</i></span><span style="font-family: Georgia;"> Washington, DC, 2003. <o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(3) Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the national youth anti-drug media campaign on youths. <i>American Journal of Public Health</i></span><span style="font-family: Georgia;"> 2008; 98:2229-2236.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(4) Drug Abuse Resistance Education. <i>About D.A.R.E.</i></span><span style="font-family: Georgia;"> </span><a href="http://www.dare.com/home/about_dare.asp"><span style="font-family: Georgia;">http://www.dare.com/home/about_dare.asp</span></a><span style="font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="Bibliography"><span style="font-family: Georgia;">(5) Parents: The Anti-Drug. <i>About Us</i></span><span style="font-family: Georgia;">. Washington, DC: The Office of National Drug Control Policy. </span><a href="http://www.theantidrug.com/about.asp"><span style="font-family: Georgia;">http://www.theantidrug.com/about.asp</span></a><span style="font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(6) DiClemente, R; Wingood, G; Crosby, R; Sionean, C; Cobb, B; Harrington, K; Davies, S; Hook, E; Oh, M. Parental Monitoring: Association With Adolescents’ Risk Behaviors. <i>Pediatrics</i></span><span style="font-family: Georgia;"> 2001; 107:1363-1368. <o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(7) <span style="color: black;">DeFleur ML, Ball-Rokeach SJ. <i>Theories of Mass Communication</i></span><span style="color: black;"> (5<sup>th</sup> edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.</span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(8) <span style="color: black;">Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. <i>Basic and Applied Social Psychology</i></span><span style="color: black;"> 2005; 27:277-284.</span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(9) <span style="color: black;">Grube, J; Morgan, M. Attitude-Social Support Interactions: Contingent Consistency Effects in the Prediction of Adolescent Smoking, Drinking, and Drug Use. <i>Social Psychology Quarterly</i></span><span style="color: black;"> December 1990; 53: 329-339. </span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(10) Parents: The Anti-Drug. <i>Pressures on Teens</i></span><span style="font-family: Georgia;">. Washington, DC: The Office of National Drug Control Policy. </span><a href="http://www.theantidrug.com/advice/teens-today/navigating-the-teen-years/pressures-on-teens.aspx"><span style="font-family: Georgia;">http://www.theantidrug.com/advice/teens-today/navigating-the-teen-years/pressures-on-teens.aspx</span></a><span style="font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(11) <span style="color: black;">Siegel M. Marketing social change: An opportunity for the public health practitioner (Chapter 3). In: Siegel M, Doner L. <i>Marketing Public Health: Strategies to Promote Social Change (2<sup>nd</sup>edition)</i></span><span style="color: black;">. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 45-71.</span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(12) <span style="color: black;">Hicks JJ. The strategy behind Florida’s “truth” campaign. <i>Tobacco Control</i></span><span style="color: black;"> 2001; 10:3-5.</span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(13) <span style="color: black;">Langer EJ. The illusion of control. <i>Journal of Personality and Social Psychology</i></span><span style="color: black;"> 1975; 32:311-328.</span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(14) National Youth Anti-Drug Media Campaign. <i>Resources</i></span><span style="font-family: Georgia;">. Washington, DC: The Office of National Drug Control Policy. </span><a href="http://www.mediacampaign.org/resources.html"><span style="font-family: Georgia;">http://www.mediacampaign.org/resources.html</span></a><span style="font-family: Georgia;"> <o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(15) Above the Influence. <i>Above the Influence. </i></span><span style="font-family: Georgia;">Washington, DC: The Office of National Drug Control Policy. </span><a href="http://www.abovetheinfluence.com/"><span style="font-family: Georgia;">http://www.abovetheinfluence.com/</span></a><span style="font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(16) Above the Influence. <i>About Us. </i></span><span style="font-family: Georgia;">Washington, DC: The Office of National Drug Control Policy. </span><a href="http://www.abovetheinfluence.com/"><span style="font-family: Georgia;">http://www.abovetheinfluence.com/</span></a><span style="font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(17) <span style="color: black;">Rosenstock IM. Historical origins of the health belief model. <i>Health Education Monographs</i></span><span style="color: black;">1974; 2:328-335.</span><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal"><span style="font-family: Georgia;">(18) <span style="color: black;">Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. <i>New England Journal of Medicine</i></span><span style="color: black;"> 2008; 358:2249-2258.</span><o:p></o:p></span></p> <!--EndFragment-->Evahttp://www.blogger.com/profile/02501334564882777513noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-73970716509707791402009-12-21T18:41:00.000-08:002009-12-21T18:52:59.301-08:00Parents Can’t Do 'We Can!': A Critique and Redesign of 'We Can!' Program<span style="font-family:Georgia;"><b>– Siyang Liu<o:p></o:p></b></span> <p class="MsoNormal" style="text-align: justify;"><span style="font-family:Georgia;"><b><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>Introduction<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">In the past decade, overweight and obesity have arguably become the primary childhood health problem in the United States. According to the results of National Health and Nutrition Examination Survey (NHANES), prevalence of overweight increased from 7.2 to 13.9% among 2-5 year olds and from 11 to 19% among 6-11 year olds between 1988-94 and 2003-2004 (1). The most recent NHANES (2003-2006) indicate that on average 16.3% of children ages 2-19 years are overweight, and an additional 15.6% are considered at risk of becoming overweight (2). <o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Overweight in childhood can add up to health problems, often for one’s whole life. As with adults, obesity in childhood causes hypertension, dyslipidaemia, chronic inflammation, increased blood clotting tendency, endothelial dysfunction, and hyperinsulinaemia (3). Particularly, type II diabetes is increasingly being seen in children and adolescents, particularly among minority communities. Moreover, the 2005-2006 NHANES data show that about 16 percent of these youth have pre-diabetes. In a recent national study, 58 percent of children diagnosed with type II diabetes were overweight (2).<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Studies indicate that lack of physical activity, excessive television watching (4), and diet pattern are three of major contributing factors to childhood overweight. To fight against those causes, on June 1<sup>st</sup> 2005, National Heart, Lung and Blood Institute (NHLBI) of National Institutes of Health (NIH), in collaboration with other three NIH institutes, launched a science-based national education program – Ways to Enhance Children’s Activity & Nutrition (<a href="http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/index.htm">We Can!)</a>. We Can! program brings together what have been learned from years of NIH-funded research into practical resources (e.g. toolkits, instructions, tips etc.) for communities and parents to fight childhood obesity among ages 8-13. It focuses on three key behaviors that families can adopt together to maintain children’s healthy weight: improving eating habits, increasing physical activity and reducing recreational “screen time”—time spent watching TV or playing video or computer games. We Can! program forms partnership with local communities, NGOs and corporations nationwide to let them help disseminate the message to employees, consumers and residents, hoping to increase the program’s exposure. Parents are the final recipients of the message and the major executors who actually promote healthy life style to their kids.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">This paper focuses on the We Can! program. The following section cast doubt on the effectiveness of the program by presenting three drawbacks using social and behavioral science theories. The third section proposes and provides support for some improvements of the program mainly based on social norms theory, which specifically targets the three weaknesses mentioned in the previous section.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>Critique of NHLBI’s We Can! Program<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">This section argues that the effectiveness of We Can! program is weakened by three main reasons. First, it overestimates the role<b> </b></span><span style="font-family:Georgia;">of parents and community in shaping children’s health behavior. Second, it assumes parents’ behavior to help transform children’s lifestyle is rational and controllable by themselves. Third, it fails to use basic principles of advertising and marketing theory to attract and influence more people.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>I. We Can! Program Overestimates the Role of Parents and Community in Shaping Children’s Healthy Lifestyle.</b></span><span style="font-family:Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">In We Can! program, all the materials are for parents and other adults in the community, such as school teacher, caregiver and community leaders. The only three activities that sound like designed for kids, CATCH Kids Club After School Program (the Child and Adolescent Trial for Cardiovascular Health, geared toward grades K-5); SMART (Student Media Awareness to Reduce Television, targeted for grades 3-4) and Media-Smart Youth (geared towards ages 11-13), are actually curricula for didactic purpose. In consequence, the program may not attain the best result since it overestimates the role of adults in shaping children’s healthy lifestyle.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">First, Parents’, caregivers’ and teachers’ instruction or order may have limited influence on children ages 8-13. According to the Psychological Reactance Theory, people tend to disobey order or even act in an opposite way in response to threats to perceived behavioral freedom (5). Freedom here is not an abstract consideration, but rather a feeling associated with real behaviors. For a behavior to be free, the individual must have the relevant physical and psychological abilities to partake in it, and must know they can engage in it at the moment or in the near future (5).<span style=""> </span>As we can see, crunching snacks, drinking soda, watching TV and playing video games perfectly satisfy the definition of free behavior, and it might be the most important free behavior in their spare time perceived by many children. One rule of Reactance Theory is the more important a free behavior is to a certain individual the greater the magnitude of the reactance. Therefore, those unhealthy behaviors of children might be very difficult to reduce or eliminate by parents, caregivers or teachers.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Second, We Can! program overlooks the power of peers in behavior formation process of children. Researches have indicated that peer behavior is a strong indicator of individual behavior during school age. One study deemed peer drug use as universally labeled the factor most likely to influence current drug use (6). It has also been shown that peer influence is especially instrumental in initiation and continuation of smoking marijuana (7). Although the above studies are regarding drug use among older kids, similar peer effect may also exist among 8-13 years old children on eating diet, less TV and games, and more exercise. It is hard to imagine one child could play balls on court along while most of his friends are playing and talking about PSP games around the corner. In addition, peer effect can be explained by Reactance Theory as well. Study has shown that similarity of the communicator and the audience can reduce reactance of the audience by increasing compliance and by reducing resistance (8). Hence, a program directly targets children, if designed properly, might be more effective because the message might be more acceptable among peers.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Third, many parents are not able to act like a role model in front of their kids, since they can’t give up junk food and soda and shorten screen time themselves. Social learning theory stresses that a large contribution to adopting behaviors stems from observing and then emulating the actions of others within an individual’s community. Since parents’ instructions may have some limitations due to reactance of children, it might be better to exemplify it rather than to tell their kids what they should do. However, if it is so simple for adults to change their life style, there won’t be an epidemic of obesity any more. A recent study collected data from 1988 to 2006 and tried to find trend of adherence to healthy life style habits in US adults. The results are disappointing. They find that over the 18 years, the percent of adults aged 40-74 years with physical activity 12 times a month or more has decreased from 53% to 43%; and eating 5 or more fruits and vegetables a day has decreased from 42% to 26%. Both of the results are statistically significant (9). <o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>II. We Can! Program Assumes Parents’ Behavior is Rational and Controllable by Themselves.<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">We Can! program is based on the Health Believe Model (HBM).<span style=""> </span>HBM is the oldest of the individual behavioral theories used in public health and have been proved having some limitations in changing health behaviors (10, 11). It indicates that human behavior is mainly determined by the balance between person’s perceived benefits and perceived barriers of taking an action (here, helping foster children’s healthy lifestyle). Perceived benefit is a function of two other variables – perceived susceptibility and perceived severity of the undesirable problems that taking the action could prevent (10). In this case, they are the risk of becoming obese and having other complications in children’s life and severity of those diseases, respectively. <o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">However, the variables in the model may be distorted by some irrational factors. For instance, perceived susceptibility might be largely underestimated by parents due to optimistic bias – the phenomenon that people believe negative events are less likely to happen to them than to others (12). This is particularly true when their children’s BMI is among normal range. Parents tend to disregard the fact that much more people become overweight or obese when they are getting older without having a healthy lifestyle established during childhood. In 2008, 67 percent of U.S. adults are overweight, and 34 percent of them are obese (13). These numbers are strikingly higher than the ones of children. Moreover, optimistic bias may be augmented due to person’s belief that the event (i.e. his/her children will become overweight) is controllable (12). As parents are likely to believe that it is easy for them to change children’s behavior after they become overweight by simply not buying them snacks and forcing them to exercise, they may be reluctant to put much effort in prevention.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Admittedly, the major achievement of We Can! program that makes it stand out among many other anti-obese programs is it realizes that even assuming people do form an intention to take an action, they may still fail to do so because of lack of self-efficacy. Therefore, the program not only informs parents the harmfulness of childhood obesity but also focuses on providing tools and skills to help parents build their self-efficacy. It teaches parents basic knowledge such as what is normal body weight range of children and how to calculate BMI, and it offers tips on how to shop food smartly and how to keep their children physically active. In general, the program resembles an instruction book that contains everything you need to know to maintain healthy weight of your children.</span><span style="font-family:宋体;"><o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Nevertheless, the program is less likely to have a significant impact because it still based on a flawed assumption that people’s behavior is rational and controllable by themselves: if they want and are capable to do it, they will do it. It asserts that people’s behavior is taken in a vacuum thus fails to consider other external social and environmental factors that may influence people’s decision. For example, parents living in poorer community or suburban area may be willing to let their children have healthy diet and adequate physical activity and they have already known how to do it from We Can! program, but they still feel hard to achieve the goal since they lack accessibility to sport facilities, can’t afford fresh organic fruits and vegetables, or have irregular shift of their job.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Unlike the assumption made by We Can! program, which largely depends on the HBM, human behavior, especially health behavior, is irrational and sometimes uncontrollable by each individual. It is unrealistic to expect parents could change their children’s life style by simply providing them with information and skills.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>III. We Can! Program Does Not Incorporate Basic Principles of Advertising and Marketing Theory<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">To disseminate We Can! messages and convince more people and family join this movement, the program builds partnership with local communities, NGOs and corporations. With the resources and influence of the four NIH institutes, We Can! program undoubtedly have made a huge success in expanding its exposure. More than 900 local community sites in 50 states and 11 other countries have committed to using We Can!<b> </b></span><span style="font-family:Georgia;">Over thirty national organizations and corporations are program partners, including Fortune 500 corporations and a number of government agencies. With this network, We Can! messages have reached nearly 700 million people (14).<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">However, knowing the messages is far from following the suggestions in the handbook or on the website. The messages marketed are not eye-catching or motivating at all. They contain merely information and depend solely on the flawed assumption that people’s behavior is rational and if they know too much calorie or little exercise is bad for their kids’ health they will take immediate action to prevent it from happening.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Additionally, the program does not incorporate basic principles of advertising and marketing theory. First, the core value this program tried to promote is health, which has been proved not one of the widely-held core values (15). Second, the whole program does not provide any convincing and desirable promises. In the center of their official poster, which shows four pictures of kids eating fruit and other healthy food or playing outdoor games with their parents, there is a slogan “ who can make it happen? We Can!” Although it sounds like a promise, it is actually an encouragement, because it doesn’t answer the question “what desirable thing will happen if we achieve the goal of eating healthy and exercising more?”</span><span style="font-family:Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>Possible Improvements for We Can! Program<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Taking the three critiques into account, this section proposes some possible improvements for the current We Can! program. Part I of this section describes the new proposed interventions based on social norms theory, and Part II provides support on how the new interventions can solve the problems discussed above.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>I. The Proposed Intervention<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Social norms theory states that much of people’s behavior is influenced by their perception of how other members of their social group behave. </span><span style="font-family:Georgia;">Research has established that social norms not only spur but also guide action in direct and meaningful ways (16,17). Most previous interventions guided by social norms theory focus on conveying actual and misperceived norms to community. However, the real norm of healthy diet and physical activity is unclear and probably truly disappointing. Aimed to use social norms to affect children’s behavior, we intend to build a new norm in the refined program.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">To apply social norms theory, first we want to retain the existing We Can! program. Their well-established network of partnership with community, corporation and NGOs may serve as a helpful infrastructure to build and defuse the new norm and the tools and tips on their website may provide parents valuable information to let them help children achieve the goal. In addition to the original We Can! program, a multi-faceted approach will be applied.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">In the modified program, children’s role has to be emphasized since they are the ultimate target of behavioral change. To build the new norm, the program first tries to change the surroundings of children through collaboration of parents, school and community. The major purpose of it is to increase of exposure of healthy behavior (i.e. eating healthy diet, having more physical activity) while reducing the unhealthy one’s. For example, in terms of eating diet, schools and parents could replace sugary soda and high calorie snacks with low fat milk, juice and fruits in their meals and fridges. Schools may also add required after-school sports hours in their policy to send the normative message that sport is for every afternoon rather than TV and video games. Special attention should be put on the timing of those changes. All the changes, particularly school policy change, should take place gradually to avoid reactance of the students.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Furthermore, advertising and marketing theory might be an effective tool to disseminate normative messages. Children’s core value is quite simple compared with those of adults. They just want to be smart and cool in front of others. So in the program’s promotional campaign, advertisements and posters may send promises such as eating fruits and doing sports will make you popular and look better. Besides, one powerful way to build norms among 8-13 years children is to incorporate marketing and advertising theory into their favorite cartoons and comics, even through an unconscious way. For example, if the popular princesses or superheroes eat healthy in their every meal and only the evil or ugly guys drink soda and gorge burgers and fries, it’s easy to imagine which way the children will choose to follow.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Finally, the program also has several new interventions to help parents overcome external barriers and facilitate the formation of the social norms. The program may try to lobby policy makers to collect extra tax on sugary beverage and other high calorie food, especially those foods targeting kids. Participating corporations may distribute fresh fruits and vegetables to employees as a gift for every holiday. Communities and local government of poor or suburban area should appropriate more money on building more sport facilities.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>II. Support For the Proposed Intervention<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>1. The Proposed Intervention Stresses the Role of Kids in Shaping Their Own Healthy Lifestyle<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">As mentioned above, the major change of We Can! program is to focus on interventions implemented directly on kids. One reason of doing so is social norms can be established more easily among kids since they have fewer deeply rooted pre-existing ones than adults, and presumably those social norms of healthy lifestyle will have influence in a longer term.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Another advantage of the improved program is it reduces children’s reactance. They perceived the normative information themselves from the surroundings, rather than from adult authorities. For those newly admitted kids, they can’t even notice the change in the school and will accept the new norms naturally. Additionally, the norm will defuse much faster among friends and peers and even beyond school and neighborhood. <o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">In the new program, parents only play an auxiliary role in delivering the normative message and shaping kids’ healthy lifestyle. It releases parents since they don’t to take all the responsibility for their children’s behavior formation and don’t have to change their own bad habit in advance. That may somehow increase the impact of the program because it lowers barrier for parents to participate.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>2. The Proposed Program Avoids Many Decision Making Processes thus Decrease the Influence of Irrational Behavior<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">Irrational behavior is coded in human’s instinct thus is very difficult to change. One effective way to reduce its influence is to avoid individual decision making processes and only let them respond spontaneously to external change. That is why tobacco taxes for reducing adolescent smoking and seatbelt law are two of the most successful public health interventions on health behavior so far. In the proposed program, parents don’t have to weigh the benefit of tasty high calorie food against risk of obesity of their family in the future anymore. They just purchase less of those products due to higher tax. The function of tax could also be explained in another way as it counteracts the misjudgment of the future susceptibility of obesity, therefore help parents make the right decision.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">The proposed program also acknowledges the external social and environmental factors that may affect behavior. For example, distributing fruits and vegetables as holiday gift by employer and building sports facilities by local government all increase accessibility to healthy lifestyle around those underserved area.</span><span style="font-family:宋体;"><o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>3.<span style=""> </span>The Proposed Program Applies Advertising and Marketing Theory to Help Build Social Norms Among Kids</b></span><span style="font-family:宋体;"><b><o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">The proposed program realizes that health is not a wide-held core value, especially for the kids. It identifies the core value that children cherish the most is looking smart, cool or beautiful in front of their friends. Based on this core value, it makes a promise in their promotional campaign that if you eat healthy and exercise more, you would looks better and become popular among your peers. Consequently, school children are more likely to be affected by such a promise.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">The idea of incorporate marketing and advertising theory in the most popular cartoons and comics may have great influence on building social norms. This strategy, called embedded marketing, has been adopted long time ago by commercial marketing, and is very popular in recent decade. Actually, this measure of marketing “diet” has been proved effective back in early 20th century. Popeye the sailor is a famous fictional hero in cosmic strips and animated films. His most memorable feature is he will gain superhuman strength right after swallow a can of spinach. In 1930s, when Popeye first became very popular in the US, the spinach consumption raised 33% from 1931 to 1936. Ironically, the appearance of spinach was not for public health purpose at that time, but attributed to a misprint of decimal point of a research result, which gave spinach ten times its actual iron content (18).<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; line-height: 200%;"><span style="font-family:Georgia;"><b>Conclusion<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">NHLBI’s We Can! program may have limited effect in promoting healthy eating, frequent exercise and less screen time among 8-13 years old children. This is because it overestimates the role of parents in transforming their kids’ behavior. Parents may fail to serve this purpose because their children may psychological reactance to their order, they are unable to change their own behavior thus fail to become a role model, and their behavior might be affected by irrational and uncontrollable factors. Additionally, the program fails to convince more family to actually take action because it doesn’t incorporate advertising and marketing theory.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify; text-indent: 28.35pt; line-height: 200%;"><span style="font-family:Georgia;">After several improvements, the program shifts the focus from parents to children and the main goal is to build new social norms among them. It also applies advertising and marketing theory in an innovative way to help achieve this goal. Therefore, the new program is more likely to win bigger and more lasting victory in the battle against childhood obesity.<o:p></o:p></span></p> <p class="MsoNormal" style="text-align: justify;"><span style="font-family:Georgia;"><b>REFERENCES:<o:p></o:p></b></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">1.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Centers for Disease Control and Prevention. <i>Prevalence of Overweight among Children and Adolescents: United States, 2003-2004. </i></span><span style="font-family:Georgia;">Hyattsville, MD: National Center for Health Statistics, 2006.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">2.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">National Heart Lung and Blood Institute. <i>We Can! Background.</i></span><span style="font-family:Georgia;"> <a href="http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/about-wecan/background.htm">http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/about-wecan/background.htm</a><i><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">3.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. <i>The Lancet</i></span><span style="font-family:Georgia;"> 2002; 360: 473-482.<i><o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">4.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Andersen RE, Crespo CJ, Bartlett SJ, Cheskin LJ, Pratt M. Relationship of physical activity and television watching with body weight and level of fatness among children: results from the Third National Health and Nutrition Examination Survey. <i>JAMA </i></span><span style="font-family:Georgia;">1998; 279<b>: </b></span><span style="font-family:Georgia;">938–42. <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">5.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Brehm SS, Brehm, JW. <i>Psychological Reactance: A Theory of Freedom and Control</i></span><span style="font-family:Georgia;">. New York: Academic Press, 1981.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">6.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Swadi H. Individual risk factors for adolescent substance use.<span style=""> </span><i>Drug and Alcohol Dependence</i></span><span style="font-family:Georgia;"> 1999; 55:209-24.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">7.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Kandel D, Kessler R, Margulies R.<span style=""> </span>Antecedents of adolescent initiation into stages of drug use: a developmental analysis (pp. 73-99).<span style=""> </span>In: Kandel D, ed. <i>Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues.</i></span><span style="font-family:Georgia;"><span style=""> </span>Washington, DC: Hemisphere, 1978.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">8.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. <i>Basic and Applied Social Psychology</i></span><span style="font-family:Georgia;"> 2005; 27:277-284.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">9.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">King DE, Mainous AG, Carnemolla M, Everett CJ. Adherence to healthy lifestyle habits in US adults, 1988-2006. <i>American Journal of Medicine</i></span><span style="font-family:Georgia;"> 2009; 122:528-534.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">10.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Edberg M. Individual health behavior theories (pp. 129-143). In: Edberg M, ed. <i>Essentials of Health Behavior: Social and Behavioral Theory in Public Health</i></span><span style="font-family:Georgia;">. Sudbury, MA: Jones & Bartlett, 2007.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">11.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Salazar MK. Comparison of four behavioral theories. <i>AAOHN Journal</i></span><span style="font-family:Georgia;"> 1991; 39(3): 128-135.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">12.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Weinstein, ND. Unrealistic optimism about future life events. <i>J Pers Soc Psychol</i></span><span style="font-family:Georgia;"> 1980; 39:806-820.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">13.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Centers for Disease Control and Prevention. <i>Health, United States, 2008</i></span><span style="font-family:Georgia;">. Hyattsville, MD: CDC National Center for Health Statistics, 2009.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">14.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">National Heart Lung and Blood Institute. <i>We Can! Factsheet. </i></span><span style="font-family:Georgia;"><a href="http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/factsheet.pdf">http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/factsheet.pdf</a><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">15.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Siegel M, Lotenberg LD. Marketing public health—An opportunity for the health practitioner. In: Siegel M, Lotenberg LD, eds. <i>Marketing Public Health: Strategies to Promote Social Change. </i></span><span style="font-family:Georgia;">Sudbury, MA: Jones & Bartlett, 2007.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">16.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Aarts H, Dijksterhuis A. The silence of the library: Environment, situational norm, and social behavior. <i>Journal of Personality and Social Psychology</i></span><span style="font-family:Georgia;"> 2003; 84:18–28.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">17.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Schultz PW, Nolan JM, Cialdini RB, Goldstein NJ, Griskevicius V. The constructive, destructive, and reconstructive power of social norms. <i>Psychological Science</i></span><span style="font-family:Georgia;"> 2007; 18(5):429-434.<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-align: justify; text-indent: -0.25in;"><!--[if !supportLists]--><span style="font-family:Georgia;">18.<span style=";font-family:";font-size:7pt;" > </span></span><!--[endif]--><span style="font-family:Georgia;">Hamblin TJ. Fake! <i>British Medical Journal</i></span><span style="font-family:Georgia;"> 1981; 283:1671-1674.<o:p></o:p></span></p> <!--EndFragment-->Evahttp://www.blogger.com/profile/02501334564882777513noreply@blogger.com0tag:blogger.com,1999:blog-8980458958375309252.post-3478055305399892542009-12-21T18:26:00.000-08:002009-12-21T18:40:40.907-08:00More African Americans Dying from Cancer: A Critique and Modification of the Approach to Cancer Prevention in the African American Community<span style="font-size: 12pt; font-family: Georgia;"><b>—Brandi Vaughan<o:p></o:p></b></span> <p class="ListParagraph" style="margin-left: 0in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><u>Introduction<o:p></o:p></u></b></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">Cancer is one of the top ten leading causes of death in the United States and has been for a number of years (4). Many technological advances have been made to assist with early diagnosis for cancer by screening patients in order to detect cancer, prevent further stage progression of the disease and to prolong life. These advances include the mammogram which is used to detect breast cancer, the colonoscopy and fecal occult blood test to detect colorectal cancer, and the PSA test to detect prostate cancer. Even with the uncertainty of the accuracy of the PSA test because of high false-positive rates, all of these screening tests have been successful in reducing the prevalence of cancer cases in this country (4,5). Interestingly enough, these cancers, as well as lung cancer, are the top leading causes of cancer deaths in both African American men and women (4).<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">The incidence of all sites of cancer in African Americans had substantially increased during the 1990s and significantly decreased between the years of 2000 and 2006 (5,6).<span style=""> </span>This has significantly narrowed the gap between the incidence of cancer in Whites and African Americans. However, the major concern regarding African Americans is based on the mortality and survival rates of this ethnic group compared to Whites. According to the American Cancer Society, the survival rate of African Americans compared to whites in the four cancer types at all stages respectively are: 77% vs. 90% for female breast, 55% vs. 65% for colon and rectum, 12% vs. 16% for lung and bronchus, and 95% vs. 100% for prostate cancers(5,6).<span style=""> </span>The mortality rate of African American men and women with cancer is 313.0 and 186.7 per 100,000 respectively, which is higher compared to those of their white counterparts which is 230.7 and 159.2 per 100,000(5,6). <o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">Some studies indicate that the reason for the high mortality rate in African Americans is due to the lack of taking preventive measures by getting the appropriate screening tests on a regular basis when prompted by their physicians(3,7). In this case, the disease is detected later when the cancer is no longer local and has progressed in stage. This has a direct effect on how responsive a patient will be to treatment, and how likely they are to survive. As a result, interventions were designed to reduce the incidence of cancer in the African American community. These interventions had two main focuses, exposure to information and education.<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">By using the Health Belief Model in conjunction with other models, they exposed African Americans to information about the mammogram, PSA and colonoscopy tests in hopes of increasing the number of those that understood the importance of these tests.(1,2) For example, The Targeting Cancer in Blacks (TCiB) intervention, conducted as early as 1994 to 1996 in Georgia and Tennessee, intervened by means of Historically Black College and University medical schools (Morehouse School of Medicine and Meharry Medical College) , churches and other institutions. These community institutions were used to spread the message of the importance of regular screenings and living a healthy lifestyle (1). Another intervention that was done from 2001 to 2003 was the randomized prostate cancer intervention conducted by Georgetown University. It was done in conjunction with the National Cancer Institute on the effects of print and video exposure to information on the PSA test to African Americans (2). Both interventions had the same approach which would allow African Americans to take the information and independently decide whether they should get screened regularly in the future (2).<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">Based on the data provided by the Surveillance Epidemiology End Results (SEER) and the American Cancer Society, the cancer mortality rate and survival rate of the African American population are a cause for concern. These rates not only magnify the problem, but they also reflect the effectiveness of the overall approach to the problem. This paper will critique the approach to cancer prevention in the African American population. It will present the existing problems in the interventions of the past and what changes can be made to future interventions of the approach to eliminate racial disparity of cancer mortality and survival with regards to the African American community. <o:p></o:p></span></p> <p class="ListParagraph" style="margin-left: 0in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><u>A Critique on the Approach to Cancer Prevention in African Americans<o:p></o:p></u></b></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">There are three main setbacks to the previous interventions designed to promote cancer prevention in the African American population that will be discussed. The first one is that these interventions have relied on the Health Belief Model to assure that people will get screened. Secondly, the previous interventions do not significantly take social, cultural and environmental factors with regards to the African American community into account. Lastly, these interventions have not intervened past education nor do they allow the community institutions to get involved past education on the screening tests.<b><i><o:p></o:p></i></b></span></p> <p class="ListParagraph" style="margin-left: 0in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><i>Previous Interventions heavily rely on the Health Belief Model.</i></b></span><span style="font-size: 12pt; font-family: Georgia;"><i><o:p></o:p></i></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">The previous interventions that have been designed to reduce the incidence of cancer in African Americans are flawed because they have consciously used the Health Belief Model which implies that human behavior is rational. Furthermore, it assumes that if information is provided to people, they will automatically weigh the perceived benefits and barriers which will prompt them to act accordingly to prevent disease.<span style=""> </span>The TCiB intervention purposely used this model with the assumption that it would help to promote unity and a community effort by promoting self efficacy and developing “cues of action” (1). This was attempted by displaying messages that would cause unity such as, “Get a pap smear once a year” and “Don’t wait too late, check the prostate”(1). This would then prompt intention which would lead to everyone acting as the intervention expected.<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">When weighing the perceived benefits, The Health Belief Model also takes the perceived susceptibility and perceived severity into account. This indicates that a person will consider how likely they are to get a disease (susceptibility) and how bad it would be if they got the disease (severity) which leads a person to act. Evidently, this model assumes that individuals are able to make a knowledgeable decision to act in order to prevent themselves from getting a disease. This is suggested in the prostate cancer screening intervention.<span style=""> </span>In this intervention African Americans were randomly assigned into three groups (2). Two of the groups were given information about prostate cancer and the PSA test in two forms, one in print and the other as a video. The third group was on a waiting list to set a control (2) The measure of the exposure types was tested based on how many people reported knowing of the information (2).<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">The complete disregard to test if the exposure had an effect on the number of people that would get screened regularly leads to the assumption that the decision to get screened is dependent on the individual. This interaction is flawed because it only measures the exposure, not the effectiveness of the exposure on the subjects (1,2). Providing people with information suggests that they will weigh the benefits, followed by intention and then acting on preventing disease by getting screened (1,2). However, this will not necessarily cue them to act as expected because it depends on how they perceive their susceptibility to getting prostate cancer and how severe it would be for them.<span style=""> </span>In addition, there are many factors that could have an effect on a person’s action and prevent them from getting screened such as fear of the screening test or potential diagnosis.<span style=""> </span><o:p></o:p></span></p> <p class="ListParagraph" style="margin-left: 0in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><i>Previous interventions have not paid substantial attention to the social, cultural and environmental factors that exclusively affect the African American community. </i></b></span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">The main aspect that is observed when studying different cultural groups is the difference between them and their white counterparts. Clearly there is a difference between these groups in terms of their environment, as well as social and cultural standards which are taken into consideration when intervening with other ethnic groups. Earlier interventions that target cancer prevention in African Americans have completely overlooked these differences which have affected their overall approach and have proven why they are flawed. <o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">When intervening with African Americans, previous interventions recognized that there is a necessity for cultural sensitivity (1) and that community involvement has a positive effect on administering information to this ethnic group (1).<span style=""> </span>However, these interventions fail to discuss in detail what other differences exist between African Americans and Whites and how to overcome those differences to intervene effectively in the future.<span style=""> </span>They accounted for educational differences by producing reading material from less than 6<sup>th</sup> grade to 8<sup>th</sup> grade levels (1) assuming that some African Americans aren’t on the same educational level as their white counterparts. They also understood the importance of getting community institutions involved and presented visual and culturally accurate print and video material in attempt to gain acceptance of the intervention’s message (2).<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">The incidence of cancer in African Americans was at its highest in 1993 at 567.6 per 100,000 people compared to 496.6 per 100,000 in Whites (6).<span style=""> </span>During this period, an insufficient amount of attention was paid to social, cultural and environmental factors when promoting screening tests to African Americans. It is only recently, particularly in the past couple of months that researchers are beginning to acknowledge these other factors that have affected the incidence and mortality rate of African Americans with cancer (3,7).<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">Recent studies have shown that there are social, cultural and environmental factors that have affected the mortality rate of African Americans. One study reveals that there are cultural factors that affect the prevalence of colorectal screening among the African American population such as medical mistrust, perception of group susceptibility and strong traditional cultural orientation (7). Another study that focuses on African American women with breast cancer suggests that there are external social factors that exist such as lack of access to high quality care and the opportunity to participate in clinical trials (3). Other factors include inadequate mammography screening and difference in tumor characteristics in African American women due to late detection of the disease (3). Presently, it is evident that there are strides being taken to tackle these environmental and external social factors, however, the mortality and survival rates of African Americans with cancer proves that there is still progress to be made.<o:p></o:p></span></p> <p class="ListParagraph" style="margin-left: 0in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><i>Previous interventions were discontinued after exposure to information and education.</i></b></span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">Since it is noted that recent studies have discussed that social, environmental and cultural factors should be considered when studying the mortality rates of African Americans with cancer, it can be predicted that future interventions will be extensive. However, previous interventions were not extensive in nature. These interventions were implemented with the preconceived notion that education and exposure to information were sufficient to increase incidence of appropriate screening in the African American population. <o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><span style=""> </span>As previously stated, the interventions of the past focused on educating African Americans about the importance of regular screening. They incorporated community institutions to educate them on the importance of getting screened, and they introduced print materials such as flyers, posters and brochures (1), as well as video material (2). Educational lectures and workshops took place at different community events, public health clinics, small businesses and churches (1). The measurement point of exposure to the information by means of educational workshops and different media materials marked the end of these interventions.<o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><span style=""> </span>Studies suggest that they were unable to determine the effects of education and the community outreach on the mortality rate of African Americans with cancer because their interventions only involved a cross-sectional survey (1,2,3,7)<span style=""> </span>This type of study examines the relationship between the disease of interest and other existing variables that have affected a population at a specific point in time (10).<span style=""> </span>In this case, previous interventions conducted by cross-sectional survey provided substantial information on different exposures which measured knowledge of the screening tests. However, it prevents follow up with subjects over a course of time (10). This did not permit the interventions to study how their efforts affected the African American population because they did not track the incidence over a given time period.<span style=""> </span>Therefore, the approach to this problem is flawed and more appropriate measures need to be taken to assure that the efforts of the intervention are measurable.<o:p></o:p></span></p> <p class="ListParagraph" style="margin-left: 0in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><u>“Yes We Can”: the introduction of social sciences to cancer prevention in African Americans<o:p></o:p></u></b></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">Given the fact that the majority of previous interventions conducted to prevent cancer in African Americans are based on individual health models, the proposed approach will be unique due to implementation of social sciences models. This approach will be explained and will show how the introduction of social science models can positively affect the cancer mortality and survival rates in the African American population.<o:p></o:p></span></p> <p class="ListParagraph" style="margin-left: -0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><i><span style=""> </span><span style=""> </span>The Proposed Approach</i></b></span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">This approach will maintain the promotion of regular screening and will continue to inform African American men and women of the benefits of getting mammograms, PSA tests and colonoscopies on a regular basis. It is important that screening continues and increases in the African American population in order to decrease the mortality rate (3,7). In addition to the screening promotion, this approach will continue to use community institutions as channels to emit the message (1). Lastly, this approach will implement the advertising theory as well as the psychological reactance theory to motivate people to live a healthy lifestyle by getting screened.<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">The proposed approach will implement a community effort to increase the incidence of screening tests with the help of community institutions across the nation.<span style=""> </span>Churches, black-owned businesses, hospitals, clinics and Historically Black Colleges and Universities (HBCUs) will be the institutions that will collaborate in order to host weekly community events. These events will provide educational workshops on the four cancers that are the main causes of cancer death in the African American population: breast, prostate, colorectal and lung cancers. They can also provide free screening tests, informational and Q&A sessions with African American physicians who would discuss the issues surrounding the cancer mortality rate among African Americans.<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">This approach will also implement the psychological reactance theory by including prominent figures in the African American community who can help in the efforts to eliminate the racial disparity. This theory suggests that messages are more accepted when they are given from someone of high similarity (11).<span style=""> </span>The community events present the opportunity for African American politicians, physicians, nutritionists, nurses, community organizers, and Greek social organizations to get involved in the efforts. This would also mark the inclusion of African American celebrities, Colin Powell, Richard Roundtree, Ruby Dee and Marsha Hunt who survived cancer by means of participating in the community events and the advertising theory. In this case, the advertisement will not be selling health. Instead it will sell the core values that are associated with a happy and healthy life such as family, unity and freedom.<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="ListParagraph" style="margin-left: 0in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><i>Support for the Proposed Approach</i></b></span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="ListParagraph" style="margin-left: 0in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b>The Proposed Approach assumes that others’ opinions can affect human behavior.</b></span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">The proposed approach does not rely on the Health Belief Model which assumes that human behavior is rational and dependent on the individual.<span style=""> </span>This approach utilizes the psychological reactance theory to demonstrate how a group of people can be motivated to act in response to a message that causes a threat to one’s freedom (11). It administers the message by means of the communicator. The presence of the communicator will determine how the group will act based on similarities between the communicators and the members of the group (11). This assumes that human behavior is irrational and is dependent on other factors.<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">In this approach, the communicators are the prominent figures of the African American community which include cancer survivors. The male survivors include the former Secretary of the State, Colin Powell, who was treated for prostate cancer in 2003, and the actor Richard Roundtree who was diagnosed with breast cancer in 1993 (8,9). The female survivors include the actress Ruby Dee who was diagnosed with breast cancer in 1974 and former singer Marsha Hunt who was diagnosed with breast cancer in 2004 (8,9) Under the psychological reactance theory, these communicators would be able to present a strong threatening message such as, “you will die unless you get screened”. This threatens the groups’ freedom and self control in which people are either prompted to behave in compliance or to not conform (11). However, since the communicators have physical and cultural similarities with the group, they are more likely to comply to the expected action and get screened regularly.<o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b>The Proposed Approach uses the Advertising Theory to<span style=""> </span>reinforce core values</b></span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">American core values are very important to the people of this country because they are one of the factors that separate the US from the rest of the world. Many of these core values such as love, family, unity, hope, and freedom are universal across the nation. The advertising theory is regularly used to persuade people to like a product or it used to change their attitude about a product in order to make them purchase it.(12) The proposed approach would use this model to persuade African Americans to get screening on a regular basis by showing images that represent these values. This is done through means of printed advertisements and television commercials.<o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><span style=""> </span>The phrase “Yes We Can” was borrowed from the Barack Obama campaign for the proposed approach for this purpose. The inauguration of the first African American president in this country and the pride that was felt among the African American community was immense. President Obama has been in office since January, and there are still people, including African Americans that continue to proudly wear the “Yes We Can” apparel. If African Americans were shown a commercial that showed the accomplishments that African Americans made in this country that ranged from freedom to President Obama’s inauguration, making a connection to screening methods would persuade African Americans to get screening because they are connected to that experience and screening would be connected to a sense of pride in making a positive difference in the community.<span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b>The Proposed Approach accounts for environmental, social and cultural factors that have affected cancer mortality in the African American population.<o:p></o:p></b></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">Aside from the theories and models that are used, the main aspect that separates this approach from the previous approach to reduce cancer mortality in the African American population is the consideration for environmental, social and cultural factors. This approach has accounted for these factors by implementing community efforts by introducing education, access to services and strong clinical and community leaders in the African American community. <o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">This approach takes a few steps ahead of the previous interventions which discontinued after education. In addition, by involving African American celebrities who survived the disease and are currently in remission, it is evident to the community that the disease does not discriminate and it is possible to obtain. However, with getting the proper screening and following up with treatment if diagnosed with the disease, it is possible to live a healthy life and to live longer than anticipated.<o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><u><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></u></b></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><u>Conclusion<o:p></o:p></u></b></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;">The mortality rate in African Americans with cancer is likely to continue to rise if the lack of attention to the different external factors that affect access and quality of care in this population are not taken into account. While I initially found interventions that only focused only on the education factor, it appears that there are upcoming interventions that will begin to take these factors into account. This provides a very promising future for the African American community, and hopefully future interventions will reduce and eventually eliminate the racial disparity that exists.<o:p></o:p></span></p> <p class="MsoNormal" style="line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><b><span style=""> </span>REFERENCES</b></span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">1.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">Blumenthal, Daniel S., Jane G. Fort, Nasar U. Ahmed, Kofi A. Semenya, George B. Schreiber, Shelley Perry, and Joyce Guillory. "Impact of a two-city community cancer prevention intervention on African Americans." <i>Impact of a two-city community cancer prevention intervention on African Americans.</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;"> 97.11 (2005): 1479-488. <i>PubMed Central</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;">. Journal of National Medical Association. Web.</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">2.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia;">Kathryn L. Taylor, Jackson L. Davis III, Ralph O. Turner, Lenora Johnson, Marc<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: Georgia;"><span style=""> </span>D. Schwartz, Jon F. Kerner, and Chikarlo Leak<o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: Georgia;">Educating African American Men about the Prostate Cancer Screening Dilemma: A Randomized Intervention <o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; line-height: normal;"><span style="font-size: 12pt; font-family: Georgia;"><i>Cancer Epidemiol Biomarkers Prev November 2006 15:2179-2188; doi:10.1158/1055-9965.EPI-05-0417<o:p></o:p></i></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">3.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">Gabram, Sheryl G. A., Mary Jo B. Lund, Jessica Gardner, Nadjo Hatchett, Harvey L. Bumpers, Joel Okoli, Monica Rizzo, Barbara J. Johnson, Gina B. Kirkpatrick, and Otis W. Brawley. "Effects of an outreach and internal navigation program on breast cancer diagnosis in an urban cancer center with a large African-American population." <i>Cancer</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;"> 113.3 (2008): 602-07. <i>Wiely InterScience</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;">. Cancer. Web.</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">4.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">ACS :: Statistics for 2009." <i>American Cancer Society :: Information and Resources for Cancer: Breast, Colon, Prostate, Lung and Other Forms</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;">. Web. 10 Dec. 2009. <http://www.cancer.org/docroot/stt/stt_0.asp?from=fast>.</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">5.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">"Browse the SEER Cancer Statistics Review 1975-2006." <i>SEER Web Site</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;">. Web. 10 Dec. 2009. <http://seer.cancer.gov/csr/1975_2006/browse_csr.php?section=2&page=sect_02_zfig.04.htm>.</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">6.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">"SEER Stat Fact Sheets - Cancer of All Sites." <i>SEER Web Site</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;">. Web. 10 Dec. 2009. <http://seer.cancer.gov/statfacts/html/all.html>.</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">7.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">Purnell, Jason Q., Mira L. Katz, Barbara L. Andersen, Oxana Palesh, Colmar Figueroa-Moseley, Pascal Jean-Pierre, and Nancy Bennett. "Social and cultural factors are related to perceived colorectal cancer screening benefits and intentions in African Americans." <i>Journal of Behavioral Medicine</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;"> (2009). <i>SpringerLink</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;">. Web.</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">8.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">"Touched by Breast Cancer - AOL Black Voices." <i>Black Entertainment and Sports, African American News, Culture, and Community - AOL Black Voices</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;">. Web. 10 Dec. 2009. <http://www.blackvoices.com/life-style/black-health/touched-by-breast-cancer>.</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">9.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">"Celebrities With Cancer." <i>About Cancer</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;">. Web. 10 Dec. 2009. <http://cancer.about.com/od/glossary/ss/celebscancer.htm>.</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">10.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">Aschengrau, Ann, and George R. <i>Essentials of Epidemiology in Public Health</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;">. New York: Jones & Bartlett, 2003. Print.</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">11.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">Brehm, Jack W. "PSYCHOLOGICAL REACTANCE: THEORY AND APPLICATIONS." <i>Advances in Consumer Research</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;"> 16 (1989): 72-75. <i>Association for Consumer Research</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;">. Web</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in; line-height: normal;"><!--[if !supportLists]--><span style="font-size: 12pt; font-family: Georgia;">12.<span style="font-family: "Times New Roman"; font-style: normal; font-variant: normal; font-weight: normal; font-size: 7pt; line-height: normal; font-size-adjust: none; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-size: 12pt; font-family: Georgia; color: black;">"Advertising theory: How to get people to think, feel and take action." <i>Creative advertising ideas, techniques, example ads and workshops.</i></span><span style="font-size: 12pt; font-family: Georgia; color: black;"> Web. 10 Dec. 2009. <http://www.adcracker.com/theory/index.htm>.</span><span style="font-size: 12pt; font-family: Georgia;"><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.5in; text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><span style=""> </span><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="margin-left: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.25in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><!--[if !supportEmptyParas]--> <!--[endif]--><o:p></o:p></span></p> <p class="MsoNormal" style="text-indent: 0.5in; line-height: 200%;"><span style="font-size: 12pt; font-family: Georgia;"><span style=""> </span><o:p></o:p></span></p> <!--EndFragment-->Evahttp://www.blogger.com/profile/02501334564882777513noreply@blogger.com0