Parents: The Anti-Drug – A Critique and Rethinking of Parent-focused Anti-Drug Campaigns

– Kevin Delaney

Introduction

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.

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.

Peers Have More Influence Than Parents – Social Expectations Theory

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.

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.

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)

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).

Marketing the Anti-Drug Message to Parents Subverts Teenager Autonomy

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).

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.

The Campaign Communicates the Wrong Message of Who Controls Drug Use

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.

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.

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:

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.

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)

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.

The Proposed Intervention

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.”

Utilize Social Norms and Roles To Propagate Anti-Drug Message

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.

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.

Create a Movement that Emphasizes Freedom and Autonomy

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.

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.

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.

Create a Feeling of Control of the Anti-Drug Message by Teenagers

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.

Conclusion

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.

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.

References

(1) National Public Radio. (2007 2-April). Timeline: America's War on Drugs. http://www.npr.org/templates/story/story.php?storyId=9252490

(2) United States General Accounting Office. Youth Illicit Drug Use Prevention: DARE Long-Term Evaluations and Federal Efforts to Identify Effective Programs. Washington, DC, 2003.

(3) Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the national youth anti-drug media campaign on youths. American Journal of Public Health 2008; 98:2229-2236.

(4) Drug Abuse Resistance Education. About D.A.R.E. http://www.dare.com/home/about_dare.asp

(5) Parents: The Anti-Drug. About Us. Washington, DC: The Office of National Drug Control Policy. http://www.theantidrug.com/about.asp

(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. Pediatrics 2001; 107:1363-1368.

(7) DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5^th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.

(8) Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.

(9) Grube, J; Morgan, M. Attitude-Social Support Interactions: Contingent Consistency Effects in the Prediction of Adolescent Smoking, Drinking, and Drug Use. Social Psychology Quarterly December 1990; 53: 329-339.

(10) Parents: The Anti-Drug. Pressures on Teens. Washington, DC: The Office of National Drug Control Policy. http://www.theantidrug.com/advice/teens-today/navigating-the-teen-years/pressures-on-teens.aspx

(11) 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 (2^ndedition). Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 45-71.

(12) Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.

(13) Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975; 32:311-328.

(14) National Youth Anti-Drug Media Campaign. Resources. Washington, DC: The Office of National Drug Control Policy. http://www.mediacampaign.org/resources.html

(15) Above the Influence. Above the Influence. Washington, DC: The Office of National Drug Control Policy. http://www.abovetheinfluence.com/

(16) Above the Influence. About Us. Washington, DC: The Office of National Drug Control Policy. http://www.abovetheinfluence.com/

(17) Rosenstock IM. Historical origins of the health belief model. Health Education Monographs1974; 2:328-335.

(18) Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. New England Journal of Medicine 2008; 358:2249-2258.

Parents Can’t Do 'We Can!': A Critique and Redesign of 'We Can!' Program

– Siyang Liu

Introduction

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).

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).

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^st 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 (We Can!). 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.

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.

Critique of NHLBI’s We Can! Program

This section argues that the effectiveness of We Can! program is weakened by three main reasons. First, it overestimates the role 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.

I. We Can! Program Overestimates the Role of Parents and Community in Shaping Children’s Healthy Lifestyle.

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.

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). 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.

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.

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).

II. We Can! Program Assumes Parents’ Behavior is Rational and Controllable by Themselves.

We Can! program is based on the Health Believe Model (HBM). 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.

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.

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.

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.

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.

III. We Can! Program Does Not Incorporate Basic Principles of Advertising and Marketing Theory

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! 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).

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.

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?”

Possible Improvements for We Can! Program

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.

I. The Proposed Intervention

Social norms theory states that much of people’s behavior is influenced by their perception of how other members of their social group behave. 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.

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.

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.

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.

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.

II. Support For the Proposed Intervention

1. The Proposed Intervention Stresses the Role of Kids in Shaping Their Own Healthy Lifestyle

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.

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.

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.

2. The Proposed Program Avoids Many Decision Making Processes thus Decrease the Influence of Irrational Behavior

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.

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.

3. The Proposed Program Applies Advertising and Marketing Theory to Help Build Social Norms Among Kids

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.

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).

Conclusion

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.

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.

REFERENCES:

1. Centers for Disease Control and Prevention. Prevalence of Overweight among Children and Adolescents: United States, 2003-2004. Hyattsville, MD: National Center for Health Statistics, 2006.

2. National Heart Lung and Blood Institute. We Can! Background. http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/about-wecan/background.htm

3. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. The Lancet 2002; 360: 473-482.

4. 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. JAMA 1998; 279: 938–42.

5. Brehm SS, Brehm, JW. Psychological Reactance: A Theory of Freedom and Control. New York: Academic Press, 1981.

6. Swadi H. Individual risk factors for adolescent substance use. Drug and Alcohol Dependence 1999; 55:209-24.

7. Kandel D, Kessler R, Margulies R. Antecedents of adolescent initiation into stages of drug use: a developmental analysis (pp. 73-99). In: Kandel D, ed. Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues. Washington, DC: Hemisphere, 1978.

8. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.

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10. Edberg M. Individual health behavior theories (pp. 129-143). In: Edberg M, ed. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones & Bartlett, 2007.

11. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39(3): 128-135.

12. Weinstein, ND. Unrealistic optimism about future life events. J Pers Soc Psychol 1980; 39:806-820.

13. Centers for Disease Control and Prevention. Health, United States, 2008. Hyattsville, MD: CDC National Center for Health Statistics, 2009.

14. National Heart Lung and Blood Institute. We Can! Factsheet. http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/downloads/factsheet.pdf

15. 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.

16. Aarts H, Dijksterhuis A. The silence of the library: Environment, situational norm, and social behavior. Journal of Personality and Social Psychology 2003; 84:18–28.

17. Schultz PW, Nolan JM, Cialdini RB, Goldstein NJ, Griskevicius V. The constructive, destructive, and reconstructive power of social norms. Psychological Science 2007; 18(5):429-434.

18. Hamblin TJ. Fake! British Medical Journal 1981; 283:1671-1674.

More African Americans Dying from Cancer: A Critique and Modification of the Approach to Cancer Prevention in the African American Community

—Brandi Vaughan

Introduction

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).

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). 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). 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).

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.

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).

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.

A Critique on the Approach to Cancer Prevention in African Americans

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.

Previous Interventions heavily rely on the Health Belief Model.

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. 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.

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. 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).

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. 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.

Previous interventions have not paid substantial attention to the social, cultural and environmental factors that exclusively affect the African American community.

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.

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). 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. They accounted for educational differences by producing reading material from less than 6^th grade to 8^th 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).

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). 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).

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.

Previous interventions were discontinued after exposure to information and education.

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.

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.

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) 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). 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. 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.

“Yes We Can”: the introduction of social sciences to cancer prevention in African Americans

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.

The Proposed Approach

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.

The proposed approach will implement a community effort to increase the incidence of screening tests with the help of community institutions across the nation. 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.

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). 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.

Support for the Proposed Approach

The Proposed Approach assumes that others’ opinions can affect human behavior.

The proposed approach does not rely on the Health Belief Model which assumes that human behavior is rational and dependent on the individual. 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.

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.

The Proposed Approach uses the Advertising Theory to reinforce core values

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.

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.

The Proposed Approach accounts for environmental, social and cultural factors that have affected cancer mortality in the African American population.

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.

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.

Conclusion

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.

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