The Healthy Families Model as an Outdated Approach to Reducing Child Abuse and Neglect—Kira W. Taj

In 2007, approximately 800,000 children were abused or neglected in the United States and 1,760 children died because of maltreatment. Children from birth to one year of age were the most likely to be victimized (1). Although many interventions have focused on supporting parents who are at risk for abuse, a greater number of social scientists and practitioners are beginning to realize the impact of the social environment on the problem of child abuse and neglect (2,3). Long-standing programs such as Healthy Families America lack this broader, contextual approach and may need to reconsider the narrow theoretical bases on which they are built.

Healthy Families Background
Healthy Families America, founded in 1992 by the agency Prevent Child Abuse America, is a newborn home visiting program designed to prevent child abuse and neglect. It focuses on families with the highest risk factors for child abuse and neglect, including new parents, young parents, single mothers, and households with low incomes. Its intended outcomes include:
1) Reducing child maltreatment;
2) Ensuring healthy child development;
3) Encouraging school readiness;
4) Promoting family self-sufficiency; and
5) Demonstrating positive parenting (5).
Based originally on a pilot program in Hawaii, the program is now running in over 440 communities across the United States. It serves a mix of families in rural, semi-urban and urban locations (6).
Healthy Families Massachusetts has 27 sites across the state and focuses on serving first-time parents aged 20 years and younger. Home visitors, trained specifically for Healthy Families MA, provide prenatal and parenting education for families from pregnancy until the child turns three years old. All home visits and services are provided at no cost to the family. Home visitors work hard to establish a relationship of trust and mutual understanding. They attempt to engage all members of the family unit in learning about the child’s growth and development in the hopes of reducing child abuse, which is seen as the outcome of family stress and a misunderstanding of the child’s natural developmental processes.
Healthy Families home visitors are well trained in child development and social service work. They are able to connect families to supports in the community such as WIC, financial assistance, housing, and health care access. They develop Individualized Family Service Plans with each family to monitor progress and goals. They attempt to provide as much relevant information as possible, spanning all areas of child health, family planning, child safety, economic self-sufficiency and overall health. Healthy Families programs in Massachusetts all provide group activities and workshops so as to create an extended support system among these young parents.


The Healthy Families Theoretical Model
The Healthy Families approach is largely based on theories of child development, individual psychology, and principles of social work. Twelve "critical elements" taken from evidence-based research shape the program. These twelve elements address three main areas of service initiation, service content and staff characteristics. The program believes in the power of early initiation of services in a child’s life, as is supported broadly in early childhood literature. Services to families are offered voluntarily, based on family need and investment. Finally, the program attempts to achieve culturally competent services by matching language and social traits of home visitor and client (7). The Healthy Families approach sees home visiting as intrinsically more effective than clinic- or center-based services because the intervention happens in the family’s home context. The home visitor works as a bridge between the family and the outside world of service delivery and regulations. The success of the program lies in the relationship built between home visitor and client, and ultimately between parent and child.
The Healthy Families model sees the health of a single child as being influenced profoundly by his/her home environment. It attempts to educate parents on positive parenting and healthy discipline in order to influence belief systems surrounding how to raise a child. Home visitors care strongly about the families they serve. However, the Healthy Families model is based on three faulty premises. It remains an individual level model, it places a value judgment on “good” and “bad” parenting, and it fails to look at fundamental causes of child abuse and neglect.

Individual Level
The Healthy Families model reflects social learning theory, which emphasizes the human inclination to learn from others (8). The child is seen as prey to the interaction between his/her parent(s), the immediate social environment of the family, and the resultant behavior of the parent(s). Despite the focus on family context, the larger social environment plays no role. The ultimate emphasis is on the relationship between the home visitor and the parent(s), and between the parent(s) and the child. With the proper knowledge, tools and beliefs, the Healthy Families model believes that families can transcend their social situation and raise their child just as any other loving parent would. Fundamental attribution error therefore prevails.
The social context of the neighborhood, the educational system and the extended social reality that surrounds the family is completely neglected. If it is culturally accepted within a certain social circle to beat children, a family may find it more difficult to break from these social norms. Even if the immediate family treats a child with respect, a child care facility or school teacher may not. The program ultimately does little to change the larger environmental context of child rearing and community health. Some Healthy Families programs in Massachusetts serve families in as many as 13 neighborhoods, spread across large geographic regions and each having distinct social contexts. Because the program is not set up to consider the neighborhood context, each family is treated as an isolated unit. This diffusion of efforts inhibits any greater environmental or institutional changes in the communities where families live.
Additionally, the individualized focus adds a stigma to those enrolled in the program. Many families may not participate because the program is framed as a program that helps families who are at risk for abusing their children. To start from a deficit perspective may be limiting the families that can be served, as well as disempowering them on the basis of the initial assumption that they are somehow predisposed to abuse their child.

Based on Presumably Universal Norms
The Healthy Families model relies on the mostly Western idea of effective parenting. Anything deviant from what is considered good parenting, defined by dominant society, means abuse. This implicit neglect of differing social values means that low-income, minority parents are sometimes labeled more often as being abusive without the consideration of why they may choose certain types of disciplines because of their social environment (9).
In a study comparing communities with varying levels of defiant youth behavior, Ronald Simons’ research found that parental control decreases as the amount of deviant behavior in a community as a whole increases. Therefore, he argues, a particular parenting strategy that might be effective in a middle class neighborhood may prove ineffective in a lower-income community with differing social norms (10). Although the fundamental human right that underlies child protection is non-negotiable, the parenting strategies and techniques used may be more effectively tailored according to community-specific contexts. Healthy Families fails to challenge its basic assumption that there is one correct philosophy towards parenting.

Compartmentalized focus
Thirdly, the Healthy Families program focuses narrowly on the issue of child abuse and neglect during early child rearing, without showing how the intervention is sustained after a child turns three years old or how it interacts with broader issues such as poverty, mental illness, and health. The hope is that after 2 or 3 years of the intervention, parents have developed crucial bonds with their child and the health of the family unit is strong. Although early intervention is an important time to intervene in a child’s life, the social forces that pull on a parents and children after the age of 3 can be massive. The school and peer environment exert considerable influence on child behavior and the stressors facing parents of 10 or 15 year olds continue. Without a change in the larger neighborhood or social context of the family, the threat of child abuse remains. With so many related, multi-faceted social issues facing American families, it is time for interventions to reflect this multidimensional reality.

Outcomes
Although Healthy Families America has established 12 critical elements, its objectives and anticipated impacts are unclear. Is the intervention simply focused on lowering the rate of child abuse and neglect or will that be expected to lead to the increased overall health of children in the nation? What is the real cause of child abuse and neglect? The program has yet to clarify their focus in regards to these questions.
Existing research on the Healthy Families program remains inconclusive. One of the few randomized control trials done with Healthy Families New York reports results based solely on parent-reported assessments. There were no demonstrated changes in the incidence of child abuse and neglect as reported to Child Protection Services (11). The California Evidence-based Clearinghouse for Child Welfare has conducted a review of the Healthy Families America model and rated it “4 - Evidence Fails to Demonstrate Effect” on its scientific rating scale, 1 being the best and 5 being the worst (12). Indeed, even a recent evaluation of the Healthy Families Massachusetts program failed to produce measurable and reliable outcomes measurements (13).

Summary
Although Healthy Families has the potential to support families emotionally and to connect them to needed services, the program’s individual focus, cultural bias and narrow approach prevent the program from achieving meaningful impacts on a large scale. Its approach grows out of the individual level model of social learning theory and relies heavily on childhood development knowledge to change behavior. The program has found it difficult to demonstrate clear effectiveness because of the lack of broad social change and the challenge of measuring the impact of changes in family attitudes towards child rearing. There is much that contemporary social theory could improve with regard to the Healthy Families theoretical approach.

Alternative Intervention
In order to address the contextual issue surrounding child abuse and neglect, an intervention must be carried out at the community-level. The theoretical focus of the intervention should be on the societal factors influencing the general well-being of children (4). The Harlem Children’s Zone (HCZ) serves as a model program.
The Harlem Children’s Zone in New York City aims to provide comprehensive services to families and children in Harlem. It grew out of a truancy-prevention program started in 1970. Then the program expanded community centers and piloted a project that provided holistic services to one neighborhood block. It grew to a 24-block area and now to a 100-block area. The program aims to build a “pipeline” of services for children from birth to college. Its “Baby College” offers parent education classes to young parents and begins the trajectory for a child’s education. There is also an asthma initiative, an obesity initiative and community-building activities to address broader public health needs (15). The Harlem Children’s Zone does not run a specific program to combat child abuse and neglect, but it is designed to strengthen the social fabric of the community and change social norms—two things that directly impact child abuse and neglect (2,3).
The proposed program would not strive to provide comprehensive services to fight poverty as HCZ does, but would utilize the same theoretical principles. Project CENTER will target three communities in Massachusetts with the highest rates of reported child abuse and neglect. New, comprehensive and community-run social service centers will be built in each of the three target communities. Community Advisory Boards will identify key social services in the community related to families and children that should be physically moved to the social service centers, if possible, or that should be involved in the CENTER partnership. Agencies housed in the new community centers will receive with subsidized rent costs. Project CENTER will fund and staff bi-annual conferences for these identified agencies, with a focus on community capacity building and integration of services for children.
Each target community will implement free “Baby College” classes for all new parents, held at the community centers. Based on the Harlem Children’s Zone model, these classes will educate parents on child development theories and will serve as a support group for parents, to share their challenges and suggestions. Parent ambassadors from the community will be hired to recruit participants and begin the dialogue around child health in the context of their community. Four parent case managers will be hired to work with families for one year after the “Baby College” course ends in order to offer their support and to help families connect with appropriate community services. Participants who complete the program will receive discounts in local retail shops and will also receive subsidies to help pay for childcare.
Three approaches to Project CENTER contrast with the Healthy Families model. It is ultimately implemented at the group/community level, it is community driven and embedded, and it views child abuse within the larger context of community support for children in general.

Group level
The first premise of this intervention is that behavior is largely determined by the group. The program and HCZ model follow the Diffusion of Innovations Theory by attempting to create a “tipping point” in the community served (16). The idea is that once a critical mass of parents and families begin to focus on child education and positive outcomes, the social fabric of the neighborhood will tip towards a change. Fathers attending parenting classes will become the norm, instead of fathers dealing drugs or getting involved in violence. Children succeeding academically will become a societal expectation, not an exception. Mothers reading to their children every night will be more common than mothers leaving children alone to hang out with friends. By focusing on a definable neighborhood and social context, the program utilizes the power of imitation and social pressure to transform the environment that children live within.
Communities influence parental attitudes and behaviors in many ways. The social environment sets norms for how parents should act towards their children. Community supports either improve or diminish parental mental health, and children’s services aid a parent in continuing to raise his/her child outside of the home (2). Therefore, interventions aimed at reducing child abuse and neglect may not need to explicitly address the issue, rather they might attempt to provide services that increase the ability of parents to act responsibly toward their children and to influence other parents to do the same. In fact, the emphasis on community building helps to de-stigmatize the problem and to provide families with more relevant services.

Culturally Competent
Project CENTER and HCZ are community-specific and culturally competent. They are staffed and advised by community members themselves, instead of by those outside of the community imposing ideals of the model parent-child relationship. The programs realize that parents who yell at their two year old are not bad or simply ill-informed people. They have grown up in a culture in which certain styles of discipline were accepted. They are living in an environment with multiple stressors. Project CENTER mobilizes the community together to say, “It’s tough out there, so we’re going to learn together on how to make our lives better.” Parenting classes explore different theories of early childhood education, but emphasizes the important synthesis of ideas within the classroom, as families learn together. Instead of focusing on the individual home context, families in a community learn together and join to make their community better for children.
The Project CENTER program targets those communities with high levels of child abuse and neglect and/or high risk. Through piloting efforts in these communities, the intervention is focused on specific social contexts. The vast diffusion of services to individual families, as seen with the Healthy Families program, ignores the influence of the environment within which families live. If these pilot programs prove successful, they can serve as a model for other communities and can spread throughout the state based on need.

Complete picture; fundamental cause
HCZ realizes that to focus on one part of the puzzle—child abuse, substance abuse, violence, education—is to treat symptoms of the disease. As Bruce Link pointed out in 1995, interventions must target “fundamental causes” (17). The larger picture in many communities is one of poverty and a culture of failure rather than a culture of success. By focusing on lifting up the entire community and through focusing on educating children and families comprehensively, the social fabric is strengthened. Although Project CENTER does not specifically focus on the issue of child abuse and neglect, it implements a parenting education program within the context of existing services. It improves the service delivery infrastructure by connecting key community services physically and professionally. It hires and trains community members to act as “early adopters” and role model messengers for social change. Finally, it paves the way for larger community collaboration around children’s overall health.

Final Summary
The outcomes of HCZ’s work have already begun to show. Its clear program design and evaluation process reflect its strong theoretical basis. The appeal of the model has already spread. President Obama has announced the future funding of 20 “promise neighborhoods” to be built throughout the nation, based specifically on the HCZ model (18). On a smaller scale, the HCZ approach can be used to bolster community participation and organization, as Project CENTER does. The community-level focus, culturally relevant content, and the comprehensive scope make Project CENTER’s approach more effective than that of Healthy Families. Only when social norms begin to shift does the behavior of families change substantially. Programs focused on the specific family context may find themselves merely treading water.









REFERENCES

1. United States Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2007. Washington, DC: U.S. Government Printing Office, 2009. http://www.acf.hhs.gov/programs/cb/pubs/cm07/cm07.pdf.
2. Daro D, Dodge KA. Creating Community Responsibility for Child Protection: Possibilities and Challenges. The Future of Children 2009;19(2):67-93.
3. Slep AM, Heyman RE. Public health approaches to family maltreatment prevention: resetting family psychology's sights from the home to the community. Journal of Family Psychology 2008;22(4):518-28.
4. Greeley CS. The Future of Child Maltreatment Prevention. Pediatrics 2009;123(3):904-5.
5. Healthy Families America. Research Findings. Chicago, IL: Healthy Families America. http://www.healthyfamiliesamerica.org/research/index.shtml.
6. Healthy Families America. About Us. Chicago, IL: Healthy Families America. http://www.healthyfamiliesamerica.org/about_us/index.shtml.
7. Prevent Child Abuse America. Healthy Families Program Facts and Features. Chicago, IL: Healthy Families America. http://www.healthyfamiliesamerica.org/downloads/hfa_facts_features.pdf
8. Bandura A. Social Learning Theory. New York, NY: General Learning Press, 1977.
9. Baumrind D. The Social Context of Child Maltreatment. Family Relations 1994;43(4):360-68.
10. Simons R, Lin KH, Gordon LC, Brody G, Murry V, Conger R. Community Differences in the Association between Parenting: Practices and Child Conduct Problems. Journal of Marriage and Family 2002;64(2):331-45.
11. DuMont K, Mitchell-Herzfeld S, Greene R, Lee E, Lowenfels A, Rodriguez M, Dorabawila V. Healthy Families New York (HFNY) randomized trial: effects on early child abuse and neglect. Child Abuse & Neglect 2008;32(3):295-315.
12. The California Evidence-Based Clearinghouse for Child Welfare. Healthy Families America. San Diego, CA: The California Evidence-Based Clearinghouse for Child Welfare. http://www.cachildwelfareclearinghouse.org/program-healthy.
13. Tufts University. Healthy Families Massachusetts Final Evaluation Report. Medford, MA: Tufts University, 2005. http://ase.tufts.edu/mhfe/research/documents/Phase1-FinalReport.pdf.
14. Harlem Children’s Zone. 2008-2009 Biennial Report. New York, NY: Harlem Children’s Zone, 2009. http://www.hcz.org/images/stories/pdfs/2008-2009_biennial.pdf.
15. Harlem Children’s Zone. The Harlem Children’s Zone Project. New York, NY: Harlem Children’s Zone. http://www.hcz.org/programs/the-hcz-project.
16. Link BG, Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; 35(special no):80-94.
17. Aarons DI. President Envisions Anti-Poverty Efforts Like Harlem's 'Zone'. Education Weekly 2009;28(24):6. http://www.hcz.org/images/edweek_article.pdf.

“5- A – Day” Intervention Program Targeting Obesity in the African- African Population in the Southern states of USA-Asween Marco

“Eat 5 servings of fruits and vegetables a day”. This slogan was born out of a private- public nutrition education initiative partnership between the National Cancer Institute (NCI) and the Produce for Better Health Foundation in 1991 [1].The purpose of this partnership was to increase the consumption of fruits and vegetables in the people living in United States. The target of the organizers was that by 2010, 75% of Americans would eat at least 5 servings of fruit and vegetables in a day [2]. Studies have found an association between higher intakes of fruits and vegetables and lower risks of cardiovascular disease [3], reduced risks of many cancers [1], and reduced risk of obesity [4].
Obesity can be defined having a Body Mass Index (BMI) greater than 30.[5] Results from the 2005-2006 National Health and Nutrition Examination Survey (NHANES) indicate that an estimated 32.7 percent of U.S. population, 20 years and older is overweight, 34.3 percent is obese and 5.9 percent is extremely obese[5]. These growing numbers of obese individuals are also susceptible to a wide variety of diseases like hypertension and diabetes which are known to be greatly affected by dietary influences. The Southern states of USA have the maximum number of obese people. In 2000, the highest obesity levels for men were found in Texas (31%) and Mississippi (30%). For women, Texas (37%), Louisiana (37%), Mississippi (37%), District of Columbia (37%), Alabama (37%) and South Carolina (36%) led the pack [6].African Americans constituted 56% of these obese individuals in the Southern States [6].

CRITIQUE OF CURRENT CAMPAIGN:
ARGUMENT 1:
Lack of access to cheap fruits and vegetables:
It is an easier option on the pocket to pick up cheap, ready- to- eat foodstuffs rather than fresh fruits and vegetables. The CDC has been working in close association with supermarkets to increase the popularity of the campaign. However, a major factor which has not been addressed by the CDC is the availability and presence of cheap, wholesale supermarkets in lower SES areas [7]. Several studies investigating the association between socioeconomic status and fruit and vegetable intake reported higher consumption of fruit and vegetables among people of higher socioeconomic status [8-11] .These studies however only used individual level measures of socioeconomic status and thus may not have captured the potential influence of the area where the people live. Evidence also supports the fact the more the number of supermarkets in a neighborhood, the healthier is the diet of the residents.[12] However the number of supermarkets reported in higher income neighborhoods as compared to their availability in low-income neighborhoods is two – four times [13]. There are also studies done which clearly indicate a heavy concentration of fast food and other unhealthy food options in lower SES areas [14]. There is also a documented evidence of higher concentration of fast food restaurants in predominantly African-American neighborhoods. [15]

ARGUMENT 2:
Lack of knowledge about food labels:
The CDC has laid emphasis on eating at least 5 servings of fruits and vegetables in its campaign [1]. However, it includes canned food products also in this list in an effort to make people believe that five servings is not a difficult goal to achieve. Promotion of canned products without taking into account all the other harmful additives like preservatives, high sodium content, flavoring agents, coloring agents, defeats the whole purpose of the campaign. Without any knowledge about what could be the harmful implications of these additives, the whole point of the campaign is lost. Also, these food items have high calorific content and huge servings which tend to encourage their use as it seems to make them more economically viable.
It is generally believed that fresh food is better than the frozen food provided it has not been over cooked and has its nutrient content intact [16]. However, the general population would always prefer the canned option as that is quicker and more convenient. But canned foods contain higher percentage of added salts and sugars. In fact, most dietary salt or sodium is added to foods during processing or preparation with smaller amounts being added to food by the consumer.[17,18] Meanwhile, frozen foods require a lot of additives (for example: Emulsifiers and binders present in desserts) [16]. Also, food processed a year or more before being consumed cannot have the same nutritious value as fresh produce.
Each nutrition label on canned or processed foods provides a lot of factual information and variables which is difficult for a consumer to understand in a glance. Also lack of ability to do math and read the information aggravates the problem.
A specific phenomenon was demonstrated by Rothman et al [19] in his study. He divided education factors into two: Literacy and Numeracy. Literacy was a measure of the subjects’ ability to read while Numeracy was measure of his basic mathematical abilities.He found that sometimes even people who had a high level of education experienced problems doing basic mathematical calculations. Thus they were at a disadvantage of deciphering what the nutritional labels on processed foods said. He concluded by saying that currently the numeracy and literacy skills of the public are not adequate to understanding the labels due to a lack of education [19]. Even if emphasis was laid on policy and regulation, this would remain a big hindrance. Newer ways need to be developed for organizing such information.

ARGUMENT 3:
Campaign unable to address cultural differences in communities:
The 5 a day campaign is run on the “one-size fits all” theory. It does not take into account the social factors which could be the factor deciding the success or failure of this campaign. This could explain the lack of success of this campaign in specific communities. Some communities like Haitians focus on a high carbohydrate diet and there is no importance given to dietary intake of fruits and vegetables [20]. In the southern states, especially in Texas, the chief crop being grown is corn. Fruit and vegetable consumption here is not as high due to more emphasis being placed on a high carbohydrate diet. African American community-in the southern states as elsewhere, are known to have diets rich in fat content. Their staple diet, which is typical of African American culture is “soul-food” [21] which consists of combination of the following: grits, ham or bacon, homemade biscuits, country-smothered steak or pork-chops ,fresh milk and eggs, fried chicken A lot of emphasis is laid on fried foods even though their nutrition content is low. When low physical activity is combined with a diet of fried “soul food”, it results in a high rate of obesity especially in this ethnic group.
This data on communities and their link with individual eating habits proves the failure of the health belief model and the other individual level models like the transtheoretical model used to describe it [22]. Human behavior is not rational but predictable irrational [23].However, the five a day campaign goes against this basic principle. The health belief model[24] is an individual level model which works on the belief that once an individual knows what it is that is harmful or useful for them, they make informed choices based on that. Everyone knows fruits and green vegetables are good for health. It is drummed into us since we are kids by our mothers that eating that green leafy vegetables would make us big and strong. However, this message gets lost along the way someplace and does not remain a consideration when we are buying groceries. The CDC has been marketing the 5 a day campaign in a way that it believes in the individual role that knowledge and perceptions play in personal responsibility. They have taken for granted that once people are told that fruits and vegetables are good for them, they would definitely eat them .However, planned intention is not what always makes a person act the way they do. The primary focus of the CDC campaign has been promoting the belief in “health” which has been proven not to work in a community based program like the five a day program.

INTERVENTION:
In the 15 years of its existence, the “5 a day campaign” proved to be a failure. However, the incentives of eating fresh fruits and vegetables cannot be ignored. Community gardening is one of the effective ways of growing them in a convenient and economical way. According to the American Gardening Association, a Community Garden [25]can be defined as “Any piece of land gardened by a group of people”. It usually refers to growing of fruits and vegetables in urban settings and hence complements the aim of the 5 a day campaign. Mark Francis, a professor at the University of California at Davis (and past Board member of the ACGA) has done numerous studies [25] of the community benefits and perceptions of parks and gardens. He found that the gardens which are built and maintained by the community residents have “unique social and economic benefits.” He further elaborates in his statement by saying that “The spaces provide opportunities for neighborhood residents to develop and control part of their neighborhood, an advantage not afforded by traditional parks”. This he noted from a 1987 study of park and garden users in Sacramento, California.
Community gardening also helps us address the failure of 5 a day campaign with support of the social learning theory. SLT states that an individual’s behavior depends on his/her expectation of health outcomes and his/her perspective of self-efficacy. Growing fruits and vegetables in your own local community helps overcome the problem of self – efficacy.
Promotion of community gardening can also be supported by the advertising theory [33]. A campaign promising attractive body can be initiated along with 5 a day campaign. The advertising campaign can also work on the principle of “substitution”-that is substituting the heavier and unhealthy component of Soul food with a healthier food component. This is known to work better than disregarding their cultural tradition of cooking food and expect them to suddenly adopt a newer, different cooking habit. Also community gardening can provide financial independence to individuals in lower income group by selling extra fruits and vegetables in local farmers market [27].

Defense 1:
Lack of access to fresh food and vegetables is one of the key issues which made 5 – a day campaign a failure. A lot of changes in policy as well as marketing strategy need to be implemented to correct this problem. There can be incentives or subsidies like cheaper land or lesser tax given to supermarkets if they open their stores in low income neighborhoods. People can be informed of the existence of farmers produce markets which are close to their area of residence.
An innovative and simpler approach to tackle the problem of lack of access would be to promote community gardening. These community gardens are then a convenient source of fresh fruits and vegetable to local people at significantly lower cost.
These three ways can help in making cheaper fruits and vegetables accessible to a wider number of people.


Defense 2:
The campaign should not include canned foods. If they are being included, to prevent misinformation and canned foods being given precedence over the fresh variety, people need to be informed about how to balance the two. The community farming venture would be encouraging weekly lunches where people would get together to maintain the garden and meet each other. Over these weekly lunches, recipes could be exchanged. Competitions could be held and the tastiest recipe involving the maximum amount of fresh fruits and vegetables would win. The members of the community would be given information via pamphlets or printouts of what to avoid and how to read food labels more carefully before buying them. These pamphlets would also be distributed to nearby grocery stores, supermarkets and shopping areas. They can be put up in prominent areas for easy visibility. Other than providing basic information in these pamphlets, information can also be provided about online resources available which can make food labels easily comprehensible to the consumer. Based on the 2005 Dietary Guidelines [35] for Americans recommendations, the FDA has made available an easily downloadable “Nutrition Facts Label” brochure (PDF, 350Kb) on its website. The brochure is useful for both consumers and health professionals. For consumers, it provides a step –by –step guide on how to read the nutrition facts label and use it to shop and plan their meals each day. Health professionals can use it to counsel their patients on healthy eating. Thus, by making food labels easy to understand, consumers can make informed food choices which can contribute to life-long healthy eating habits. Supermarkets should be encouraged to stock lower calorific content and reasonable servings of food items in order to achieve a balance between calorific and nutritional content of food items.

Defense 3:
The 5 a day campaign needs to take into account cultural factors. No individual can take a decision alone without taking into account cultural factors like race along with individual factors. The five a day work could be a success if we implement group level models to make it work. Community gardening provides an opportunity for an individual to be in a group level setting where he is interacting with not just people of his own ethnicity or racial group but with a diverse population of different ethnicities. This encourages interaction between them when they are performing a task like gardening [25]. Using the concept of ‘herd behavior’, we are better able to appreciate how such an interaction can bring about desired behavioral change. [27]Community gardening would increase interaction between African Americans and the other communities in their neighborhood. Research by Jill Roper, a graduate student at Rutgers University, confirms the theory that community gardens improve the interaction between people in the neighborhood. As Charles Lewis says: “A community activity such as gardening can be used to break the isolation, creating a sense of neighborliness among residents. Until this happens, there is no community, but rather separate people who happen to live in the same place.” [31]It would allow them to learn and appreciate the differences in their diet and that of people around them. Sharing of recipes also would encourage them to appreciate the varied cultures and tastes. It would also allow them to appreciate that food can be tasty even without frying it.
Low physical exercise is also a factor compounding the problem of unhealthy diet in this community. This can also be tackled when we consider that gardening is a great form of exercise [31] while interacting with new people.

CONCLUSION:
The five – a – day campaign was a much hyped public health venture which has failed drastically. There are various reasons for it failure. They organizers not taking into account cultural and economic differences between various sections of the population is an important reason. Also, basing a community based intervention program on an individual level model like the Health Belief Model does not help the case either. Lack of information about ways to comprehend food labels further aggravates the problem. Till the time these factors are taken into account for designing an intervention program like community gardening, and basing the campaign on theories like the advertising theory, social learning theory and the social marketing theory can help in effectively tackling a problem like obesity .


REFERENCES:
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Improving Adult Immunization Rates through use of Social Network Theory

Introduction
Immunization is a great success story of preventive medicine. Regulatory mandates for schools and daycares have vastly improved childhood immunization rates; however, adult immunization rates are lagging behind. Although 90% of the children aged 19-35 months receive the recommended vaccines, only 66% of adults aged 65 or older received influenza vaccine and about 62% received pneumococcal vaccine in 2002 (Orenstein, Douglas, Rodewald, & Hinman, 2005) .
The Advisory Committee on Immunization Practices (ACIP) recommends immunizations against the following diseases/pathogens for adolescents and adults age 19 and older: tetanus, diphtheria, pertussis, pneumococcus, Herpes zoster, meningococcus, Human papillomavirus and Hepatitis A and B for certain high risk people (CDC, ). In January 2000, the Department of Health and Human Services launched a nationwide health promotion and disease prevention program called Healthy People 2010. It contains 467 objectives organized in 28 focus areas. One of the objectives is to improve Hepatitis A and B, and Influenza and Pneumococcal vaccinations among high risk adults (U.S Department of Health and Human Services, ). The goal for 2010 is 90% coverage for annual influenza vaccine for adults aged 65 and over and 90% coverage for one dose of pneumococcal vaccine (Poland et al., 2003).
Most of the current interventions for vaccine acceptance are based on the Health Belief Model (HBM) (DiClemente, Crosby, & Kegler, 2002)and on the assumption that mixing of individuals in society is homogeneous (Chen & Yuan, 2009). The current immunization strategies are designed based on these beliefs. However, the current strategies have not been effective as mentioned above. In recent years powerful computing has facilitated the study of social networks. Based on this tool the social network theory can help augment the immunization rates not only for endemic diseases but also help in epidemic and pandemic preparedness.
Traditional vaccination Strategies
The Health Belief Model (HBM) has been extensively utilized in health care programs including immunizations (DiClemente et al., 2002)(Painter, Borba, Hynes, Mays, & Glanz, 2008). The HBM was first proposed by Social Psychologists Hochbaum, Kegels and Rosenstock in the 1950?s to explain and predict preventive health behavior. Hochbaum initiated the research on HBM when the turnout for free chest x-rays for early detection of tuberculosis was low. The originators were concerned with the widespread failure of people to engage in preventive health behaviors. The HBM is an individual based theory which posits that a person?s health behavior depends on some key factors: perceived susceptibility to a condition, perceived seriousness of a condition, perceived benefits of taking action toward prevention and barriers to taking action. The perceived susceptibility provides the force to act, and the difference between benefits and barriers provide the path of action. An individual may also require an internal or external cue for action. Other theories also used for designing health interventions are the theory of reasoned action and the theory of planned behavior (Dutta-Bergman, 2005). The Boston Public Health Commission has well developed educational programs for Seasonal Influenza and H1N1 Flu in the form of posters in public places, brochures, videos, websites, Twitter, Facebook, podcasts, and Youtube (BPHC, ). There are some education and outreach programs for hepatitis. However, for other diseases mentioned in the ACIP recommendations, there are only fact sheets providing information about the disease, its symptoms, treatment, and immunization guidelines. The Centers for Disease Control and Prevention (CDC) also offers educational materials on their website and in the form of brochures for physicians? offices (CDC, ). All these immunization efforts are based on educating people about a disease, risks for acquiring it, and vaccine availability. The fact sheets are expected to lead to immunizations. However the immunization strategies based on these theories have certain shortcomings. One shortcoming is that the focus of the efforts is on the individual. It is assumed that individuals make decisions based on calculations of their susceptibility and risks. It is also assumed that people make rational decisions. Another shortcoming of the traditional strategies is the assumption that individuals have homogeneous mixing in society and every person has the same risk of infection. I propose that immunization strategies should be based on social network theory to help overcome these issues.
1. Individual level, Susceptibility and risk based:
As noted above, various agencies have put forth fact sheets that provide information about diseases and immunization guidelines. The assumption is that if people are educated about a disease and about the availability of the vaccine to protect them against the disease, they will take advantage of it and get immunized. The efforts for immunization are focused on individuals because of the flawed logic of the theories on which these programs based. The programs do not take into account special influences, cultural factors, socioeconomic factors and previous experiences. Dutta-Bergman performed a critical review of HBM in health communications. He stated that one of the limitations was Individualistic bias which means that the focus is on the individual. However, the individual is part of a collective and the outcome of a particular behavior and barriers to action are located in the society. Health behaviors occur within the context of the complex social fabric. The social norms are very important. Another reason cited by Dutta-Bergman was Minimizing Context. This means that the theory does not take into account the social context in which a behavior is occurring (Dutta-Bergman, 2005). Immunization programs are based on the HBM and they rely on individual action without any attention to the social norms.
Another limitation of the traditional immunization programs is that it they are deeply rooted in an individual?s perceived risk for developing a condition. It is assumed that fact sheets about a disease will educate people about their risk of acquiring the disease and that will lead to immunization. However, a person?s perception of risk may not be accurate. People may have an unrealistic optimism causing them to perceive their personal outcome to be more positive than that of others? in a similar situation. Several studies exemplify the fact that risk perception is not accurate. Ann Bostrom, in her essay ?Future risk Communication? discusses that risk appears factual when communicated in terms of magnitude and probability of harm. However, risk is not a fact. It is a composite of values, specific context and future events. This is why some people feel that vaccine-preventable diseases are less risky than other diseases. (Bostrom, 2003).
The HBM was developed in the 1950?s and despite its limitations, it continues to be widely used and advocated in designing preventive services. However, with the advances in the field of psychology, it is clear that the individual level theories based on susceptibility and risk perception do not accurately depict human behavior. Hence the programs based on these theories have had limited success (Painter et al., 2008).
2. Behavior is rational:
The traditional vaccination strategies assume that human behavior is rational and therefore the individual is responsible for making rational decisions about his or her health (DiClemente et al., 2002). This too is a result of immunization programs being based on the HBM. Dutta-Bergman described a limitation of the HBM which he called Cognitive Orientation. This means that the HBM assumes that individuals are rational beings and conduct a cost-benefit analysis taking into account the susceptibility, severity, benefits and barriers to a health behavior before enacting that behavior. Decisions made at the spur of the moment or habitual choices are not taken into account (Dutta-Bergman, 2005). Traditional immunization strategies are based on the assumption that after people have been educated about a disease through fact sheets, they will perform a mental arithmetic of the benefits and barriers and reach a rational decision. This rational decision will result in appropriate behavior of receiving immunization. Any cultural factors, fears, or rumors about the vaccine or access issues are not taken into consideration.
Human behavior is not always rational. Emotions are powerful navigators of behavior. Chapman and Coups evaluated the role of emotions (worry about getting the flu, regret about not getting flu vaccine and perceived risk about getting flu) in influenza vaccination among 428 university employees. Their study showed that the emotions (worry and regret) are the ?more immediate precursors of decisions than are calculations of the risk probability and severity?. They feel that these results can also be applied to other preventive health behaviors and not just influenza vaccination (Chapman & Coups, 2006).
3. Uniform and homogenous mixing of population:
About 100 years ago, researchers started studying dynamics of infectious diseases. Early models assumed uniform mixing of people and ignored spatial patterning (Hartvigsen, Dresch, Zielinski, Macula, & Leary, 2007)(Eubank et al., 2004). The immunization guidelines are based only on the age and existing medical conditions of individuals. Social networks and patterns of clustering of people in society are not taken into consideration. Guidelines assume homogeneous mixing of people or that every individual has equal probability of contracting a particular disease. However, this is not accurate. Due to social networks, individuals have varying degrees of risk in acquiring an infection. Bascompte states that traditional models in epidemiology were developed in a homogeneous setting (where all individuals have the same number of interactions and the same probability of infecting each other). The concept of homogeneous population led to the belief that it is not necessary to vaccinate all individuals in a community. It has been assumed that after a certain fraction of the population is immunized, an eradication threshold is reached and the disease disappears. The fact is that the social networks are complex and heterogeneous. This means that the bulk of the nodes (individuals in a network) have a small number of connections, but a few nodes have a large number of connections, more than can be expected by chance. In addition, the probability is higher that new nodes will connect with the existing nodes with greater number of links. In these complex networks with heterogeneous distributions of links per node, there are always a few nodes that maintain the disease and therefore the disease never disappears (Bascompte, 2007). This means that a disease outbreak can occur even with a high immunization rate because the immunizations have been spread homogeneously in a heterogeneous population. Dallaire et al. reported a recent measles outbreak in Canada despite an immunity level estimated at 95%. The cases belonged to several unrelated networks of unvaccinated individuals. This outbreak underscores the fact that social networks are very important. Even a small change in the aggregation of individuals can lead to transmission of infection in unvaccinated individuals (Dallaire, De Serres, Tremblay, Markowski, & Tipples, 2009). Perisic et al. also noted that voluntary vaccination was able to contain the infection in models of small neighborhoods, but after a certain neighborhood size, voluntary vaccination failed to contain the epidemic despite a large number of people who were vaccinated. This occurs because in heterogeneous networks, disease is not localized anymore (Perisic & Bauch, 2009).
Summary of Critique
The rational cost-benefit Health Belief Model dominated the field of public health and psychology for several decades and led to the development public health interventions including immunization programs. As the field of psychology has matured, it has led to the development of conceptual models which take into account the contextual factors that lead to behaviors. The focus of theories has shifted from the individual to larger social networks including family, community and even global systems. In order to address the health issues of people in modern society, one must understand the lifestyle patterns and social context in which people live. It is imperative for new health programs to shift the focus from the individual to groups and take into account the contemporary way of life (Coreil, 2008). Newer computational models offer greater information about social networks and insight into spread of infectious agents within these networks. If we are to make improvements in adult immunization rates, cognitive theories need to be supplanted by group based theories which acknowledge that human behavior does not occur in isolation, nor is it planned and rational. Strategies should take into account the effects of heterogeneous societal structure and modern technology on individuals. Social network theory fulfils these criteria and can be utilized for developing new public health interventions.
What is Social network Theory?
There has been tremendous interest to develop novel models that address immunizations through use of social network theory. According to Dunn, social network theory is a set of assumptions and guidelines for ?development and appraisal of particular theories of knowledge creation, diffusion and utilization?. Social network theory makes four basic assumptions: (1) knowledge structures are constituted by relations among people or events or actions and not by attributes of individuals, (2) relations are structured, (3) structured relations have overt behavioral properties (such as frequency of direct contact) and cognitive properties (such as congruence of beliefs), and (4) behavioral and cognitive properties emerge from structured relationships (Dunn, 1983).

History and definition of networks
May has provided a historical account of networks. In the earliest model, introduced by Erdos-Renyi, n nodes (or vertices) are connected by links or edges. Nodes represent the individuals in the network. Degree distribution is the number of links per nodes. In the Erdos-Renyi model, the degree distribution is governed by a Poisson distribution where m is the average number of links. A uniform network is one where each node is linked to exactly m others (May, 2006). In 1967 Stanley Milgram, a Harvard professor, discussed the idea of real-world networks. His goal was to find the ?distance? between any two people in the United States. He found that the median number of intermediate persons was 5.5. This led to the famous concept of ?six degrees of separation? (Barabási, 2002), (May, 2006). This was followed by the work of Watts and Strogatz on ?small world? networks. These networks combine local clusters and occasional ?long hops? (May, 2006). Lastly, there are ?scale-free? networks (SF) which obey the power-law distribution where there is no specific number of links per node; a small number of nodes have a large number of links and a large number of nodes have a small number of links. Two important characteristics of networks are network ?diameter? and ?clustering coefficient?. Diameter is found by calculating the shortest path between each pair of nodes. The largest of these shortest paths is the diameter. Clustering coefficient is the average probability that two neighbors of a node are also neighbors of each other (May, 2006). Network dynamics are being used to study infectious diseases, epidemic preparedness, and immunization strategies. Networks can be interpersonal or web based.
Immunization strategies based on social network theory addresses the three limitations discussed previously. These interventions are group based, they do not assume rational behavior, and they address heterogeneous mixing of people.
1. Group based:
Social network based immunization strategies will target the entire network of people and not just individuals. Individuals in a network behave as a unit and exhibit health behaviors simultaneously. Introduction of appropriate immunization related information in the networks has the potential of affecting individual acceptance through establishing social norms and social acceptance. Interventions can be developed to target interpersonal networks or may be Internet-based. People are more likely to adopt certain behaviors through word of mouth in a trusted social group and if they see people in their social group adopting these behaviors.
The Internet is an example of an SF network. Social networking on the Internet leads to formation of virtual communities and to changes in behavior of groups instead of individuals. Social networks are rapidly emerging on the Internet. Khan et al. call them ?digital town squares? where people with common interests can interact (Khan & Shaikh, 2008). The current Web 2.0 offers a plethora of social networking technologies and software to connect healthcare organizations, clinicians, and laypeople. KamelBoulos and Wheelert feel that the educational potential of Web 2.0 applications, such as ?wikis, blogs and podcasts are just the tip of the social software iceberg?. Online interactions between users create a sense of community, promote learning through feedback and result in ?collective intelligence?. These social networking services may be used for linking people based on a medical issue (KamelBoulos & Wheeler, 2007). A number of disease-based blogs and websites provide a forum for individuals with these conditions to interact and share ideas. Example of such a websites and blogs are http://www.patientslikeme.com and http://diabetes.wikia.com/wiki/Diabetes_Wiki. Introduction of health behaviors in such networks has the potential for spreading through diffusion of innovations.
Gary Bennett, a professor at the Harvard School of Public Health, found that about 75% of adult Americans are regular Internet users and many access health related information. Bennett states that the Internet provides a high reach. Internet-based interventions are efficacious and offer an advantage because they allow the users to participate at their own convenience and allow anonymity (Bennett, ).
Interventions for boosting immunizations should be designed to reach the target social groups so that the dissemination of information can occur in a viral fashion. Future efforts to improve immunization rates should be focused on development of interactive Internet programs and development of programs to reach interpersonal groups of people in the society. This would provide greater impact in terms of behavior change in the target social groups.
2. Behavior is irrational:
Contrary to traditional belief, people do not always behave in a rational manner. Social norms, peer pressure, and herd mentality are important determinants of behavior. Individuals are embedded in their social networks and adoption of behaviors is not dependent on rational thinking. Various authors have suggested ways that behaviors can spread through social networks like contagions. The diffusion of innovations can spread desirable behaviors in social networks. These networks can be utilized to increase vaccine acceptance. Spread of behavior in this manner does not assume or expect rational behavior of people.
Numerous researchers have studied the spread of behaviors in various types of networks. It has been generally seen that new behaviors spread faster if clusters of people are linked by bridges. Granovetter calls this phenomenon the strength of weak ties. Weak ties are the links between acquaintances, and they bridge the connection between two close knit groups (Granovetter, 1983). Immunization interventions should be developed to target the networks and weak ties in a strategic manner. Computer modeling can assist in locating clusters and bridges of these clusters in social networks.
Other studies also favor the idea of bridges or weak ties between clusters. Choi et al. studied the diffusion of innovation in computational network models. They found that diffusion patterns are dependent on the number of initial adopters. The larger the number of initial adopters, the faster is the diffusion. As the group centrality increases (a large number of bridges and lower degree of cliquish sub-networks) diffusion is faster but is more likely to fail. When the number of bridges is low and the level of cliquish sub-networks is high, the diffusion is slower but has greater penetration. Diffusion of innovation is successful in cliquish networks with few bridges. Too many bridges lead to a rapid early stage but then the diffusion fails because it does not gain enough momentum to go forward due to insufficient build up of benefits (Choi, Kim, & Lee, ).
An individual is more likely to engage in a behavior if a large number of people in the network are already engaging in that behavior. One?s adoption of a new collective behavior depends on the behavior of the group (Valente, 1996). All these studies show that ideas spread in social networks based on network structure and irrational human behavior. Immunization programs should take advantage of this phenomenon and strategize the efforts to weak ties and early adopters.
3. Heterogeneous mixing:
As noted in the previous section, the traditional models have assumed that the population is homogeneous and has uniform mixing. However, the population is quite diverse and heterogeneous. It can be divided into subpopulations based on disease related factors or other factors that are social, cultural, economic, demographic or geographic. Population can also be subdivided based on spatial factors such as schools, neighborhoods, cities, states etc. Modeling based on Social networks takes into account that people move around and do not have homogeneous mixing. New immunization interventions should take into account this heterogeneous nature of population and develop heterogeneous strategies that superimpose the network. This would provide a more optimal coverage of immunizations. As noted previously, even high immunization rates in a community were unable to contain an epidemic because they were based on the assumption of homogeneous mixing. The epidemiological information about a disease and the topology of social networks should guide immunization strategies because social networks are complex structures and different people have different probability of getting infected. A study performed by Eubank et al. shows that infectious disease outbreaks can be contained by targeted vaccinations instead of mass vaccinations. They suggest that vaccinating people who visit a popular and most visited location would yield a better outcome than vaccinating the most gregarious people who meet the same group of people regularly (Eubank et al., 2004).
Hartvigsen et al. discuss strategies to improve influenza immunization through utilization of network structures. Increased computational capability had led to development of spatial models that better represent social networks. These networks mimic the spread of some infectious agents in a community. They evaluated various vaccination strategies in the network models and vaccination rates ranging from 0% to 90% for spread of an epidemic. They found that vaccinating people at the hubs of the networks or people with the highest degree (largest number of neighbor contacts e.g. health care providers) provided the greatest protection. The hub strategy also led to the shortest epidemic duration. Even vaccinating low clustering coefficient models and models with longest distance between nodes were better than random vaccinations. Vaccinating people with a high clustering coefficient (the proportion of the host?s neighbors that are connected to each other relative to the number of possible connections i.e. individuals whose contacts know each other e.g. residents of group homes or members of the same family) showed the lowest amount of protection and longest epidemic duration (Hartvigsen et al., 2007). Such information on network based targeted immunization can have significant bearing on routine vaccines and epidemic preparedness.
Miller et al. compared the effects of various vaccination strategies in preventing the spread of infectious diseases in realistic social networks. They found that PageRank (network with complete information, also the algorithm behind Google web ranking) outperformed all other models, namely Degree vaccination (vaccinates nodes by descending degree), Degree vaccination with Dynamic Reranking (recalculates the degree and vaccinates the node with most unvaccinated neighbors), Acquaintance vaccination (selects a node randomly and vaccinates one of its neighbors) and Random vaccination (vaccinates a fraction of the population randomly). However, obtaining complete information about a social network is not practical. Therefore the authors suggest vaccinating people who visit the most locations because this is easier to ascertain and yielded comparable results to Acquaintance vaccination and better results than Random vaccination in their study. They noted that vaccination efficacy was low on vaccinating individuals whose contacts also had many contacts. Essentially, strategy based vaccination was found to be better than random vaccination (Miller & Hyman, 2007).
Various researchers have proposed different strategies based on network topologies, and they have all yielded better results than current random strategies. Chen and Yuan propose a novel immunization strategy on scale-free networks. It is called the random walk immunization strategy. They performed a theoretical analysis and found this model to be very effective when compared to other strategies (Chen & Yuan, 2009). Guo et al. propose a targeted immunization strategy called Local region immunization using a novel Euclidean Distance Preferred (EDP) model. They generated EDP models in a small world network and found that there exists a critical immunization radius for a susceptible-infective pair of nodes to effectively suppress the epidemic prevalence (Guo, Li, & Wang, 2007). Khan et al. propose algebraic computation for immunization of social contacts of a person who has contracted an illness (Khan & Shaikh, 2008). Kretzschmar also recommends mathematical modeling for effective vaccination strategies in public health. These models will help determine best ages for various vaccines, target groups and other strategies for eliminating infectious diseases (Kretzschmar, 2008). All these studies highlight the fact that strategic heterogeneous immunization of population based on topology of networks is likely to provide improved control of diseases and therefore should be incorporated in future programs.
In conclusion, the adult immunization rates have improved over the past few years, however, there is still work needed to minimize the incidence of vaccine-preventable morbidity and mortality. We need to address this problem with strategies that provide widespread reach to people, especially in high risk categories. The strategies should conform to the modern societal structure and lifestyles. This will require a multi-prong approach and social network theory appears to offer a promising potential.

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Abstinence, Sex And The Illusion Of Self-efficacy: Criticisms Of The Texas Power2Wait Program – Carrina A. Burke

The latest data on teen and unplanned pregnancy published in 2005 states that the national teen pregnancy rate is 40.5 percent (1). Among the fifty states and the District of Columbia, Texas has the third highest teen pregnancy rate at 61.6 percent, behind only New Mexico and the District of Columbia (1). Despite this, Texas receives almost $17 million annually in government funding that is specifically allocated to abstinence education in the state’s public school systems (2). Abstinence education, by definition “teaches abstinence from sexual activity outside marriage as the expected standard for all school age children and stresses the social, psychological, and health benefits of abstinence” (3). There are many abstinence programs supported by the Texas Department of State Health Services, one of the largest being the website Power2Wait.com. Abstinence programs like Power2Wait.com are less successful at preventing teen pregnancy than comprehensive sexual education programs because the programs focus the intervention at the individual level, do not provide strategies for the individuals to refuse sex if they are in “the heat of the moment,” and do not consider the multiple facets of sexuality while ignoring comprehensive sexual education.

Texas Power2Wait Program
According to the Texas Department of State Health Services, the Power2Wait program is “an abstinence-centered education program designed to offer guidance to school districts, communities, and parents to reduce the need for future family planning services for unwed minors” (4). The program offers kits, pamphlets and CD-ROMs to school districts that are specifically tailored to grades 4 through 12. The main goals of the program are to decrease teen pregnancy, teen STIs, teen abortion rates, teen dropout rates and teen “interest in future orientation” (4). In addition to targeting teens, the program targets parents, offering strategies on how to talk to teens about waiting until marriage to have sex with their sister websites Power2Talk.org and Poderdehablar.org (Spanish).
The Power2Wait program uses four intervention strategies to reach its target population. The first strategy is to provide education resources through the websites Power2Wait, Power2Talk and Poderdehablar, and through publicity tool kits provided to schools and community groups (4). The kits include interactive video games and card games. The second strategy is to provide assistance to local teen pregnancy prevention consortiums whose goals are to create community infrastructures and apply for funding opportunities to address teen pregnancy (4). The third intervention strategy is to “coordinate the Texas Youth Leadership Clubs by providing training and guidance for youth leadership clubs including the use of curricula, communication via a bi-monthly news letter, Texas Youth Leadership Club member T-shirts, and an annual Youth Leadership Summit” (4). The fourth strategy is to continue programming for abstinence education activities, including workshops and awareness presentations available through Education Service Centers around the state of Texas (4).
The main marketing tool of the Power2Wait program is the Power2Wait.com website. The website is composed of six sections: Stories, Media, Love.Sex.You, Things 2 Do, Games and Resources. The “Stories” section provides seven testimonials from teenage men and women about why they are waiting to have sex. The “Media” section offers a free MP3 download of an abstinence-themed hip-hop song and a short music video. In the “Love.Sex.You.” section, there is information about relationships, pregnancy, sex, and self-esteem issues commonly faced by teens. The “Things 2 Do” section offers alternative activities to do instead of having sex. Finally, the “Resources” section provides a list of websites addressing the topics of abstinence, STIs and HIV, teen pregnancy and relationship abuse.

CRITIQUE OF POWER2WAIT
The Flaw of Individual Responsibility
The main message of the Powe2Wait.com website is that “you” (the individual) must be in control of when you decide to have sex. The website says, “Only you choose what’s right for you. Your parents can love you. Your teachers can advise you. Your friends can give their opinion. But you are ultimately responsible for you” (5). The intervention was created using individual-level theories of behavior, specifically echoing the Health Belief Model and the Theory of Reasoned Action.
The Health Belief Model and the Theory of Reasoned Action were developed to explain health-related behavior at the individual level (6). According to the Health Belief model, before an individual performs a behavior, she weighs the perceived benefits and the perceived barriers of the behavior. Within the perceived benefits, there are perceived susceptibility and perceived severity of the behavior. In the case of the abstinence message of Power2Wait, the behavior is sex before marriage and the perceived susceptibility is the probability of becoming pregnant (if female) or impregnating someone (if male). The Health Belief Model only considers the individual’s perception of the behavior. The Theory of Reasoned Action goes a step further and accounts for social norms (6). The individual weighs the outcome expectancies and the beliefs of others about the behavior before performing the behavior. The outcome expectancies are determined by the individual’s attitude toward the expected outcome and the importance of the outcome to them. The beliefs of others are weighted by who is expressing the belief and how important to the individual is that person’s or group’s opinion.
The two main problems with using individual-level theories of behavior when teaching abstinence to prevent teen pregnancy are that the theories assume rational behavior and do not consider context. The entire basis of the Power2Wait internet campaign is that with self-esteem and good morals, abstinence can be achieved (5). The intervention assumes the fundamental attribution error, which attributes all behaviors performed to character and does not consider context into the equation (7). Teens know that unprotected sex leads to pregnancy while surfing the internet and listening to a lecture in class, but in the context of an intimate setting, the behavior may be performed anyway.

In the Heat of the Moment
The Power2Wait program emphasizes that self-esteem is the key to maintain abstinence throughout adolescence (5). The website provides broad, albeit vague advice on how to build self-esteem. However, the self-esteem building is not related directly to waiting to have sex. The website offers advice like, “Practice being assertive in everyday situations. If your order is wrong at a restaurant, ask to have it fixed. If someone calls you by the wrong name, correct it” (5). Similar advice is offered for dealing with peer pressure, with adages like: “Keep working on your confidence and practice speaking up for yourself. Maybe even come up with a few excuses, ways to get out of things that make you feel uncomfortable” (5). The major problem with this method of maintaining abstinence is that the program does not provide effective, concrete strategies on how to say “no” to sex once in a sexually charged situation. Without methods to diffuse a sexual encounter, maintaining abstinence relies solely on self-efficacy.
Another individual-level behavioral theory, the Theory of Planned Behavior includes self-efficacy into the model. The Theory of Panned Behavior, like the Theory of Reasoned Action, assumes behavioral intention is the most important determinant of behavior (8). In addition to the components of the Theory of Reasoned Action, the Theory of Planned Behavior includes perceived behavioral control, which is an individual’s perception of how much control she has over a behavior. The self-esteem level of a person is directly related to that person’s belief that she can control her behavior in certain situations. The problem with this theory is that, as with the Health Belief Model and the Theory of Reasoned Action, it assumes rational behavior. It also assumes that an individual has self-control and that all behaviors are planned. The Power2Wait website even mentions this flaw when addressing experiencing sex for the first time: “A lot of teens that have sex explain their decision by saying, ‘It just sort of happened’” (5). The admission that the initial sexual act was not planned undermines the entire intervention strategy of bolstering self-efficacy because it does not provide self-efficacy strategies for when sex happens “in the heat of the moment.”

Beyond Babies
The ethical debate regarding abstinence-only education programs is rooted in the individual right to health information. The Power2Wait program is supposed to be implemented in addition to the current sexual education curriculums in the school system. However, depending on the county and district, there may not be any additional comprehensive sexual education. The Power2Wait website does not offer any comprehensive information of sexually transmitted diseases or contraceptives. The website has an “STI Library,” where is provides definitions of the most common STIs, in addition to teen pregnancy statistics. It also provides a link to the Center for Disease Control website and the phone number for the STD and AIDS hotline under the “Resources” section.
In a survey of non-married, heterosexual adolescents ages 15-19, the sexual health risks were compared between participants who received comprehensive sex education and those participants that received abstinence-only or no sex education, those who received comprehensive education were significantly less likely to report teen pregnancy (9). Furthermore, comprehensive sexual education was not associated with increased sexual risk or STD reports (9). By not providing information on contraceptive use, the intervention assumes: 1) the individuals receiving the intervention have self-control, and 2) the individuals perceive the susceptibility and severity of the behavior outcome (pregnancy, HIV) as too high to rationally perform the behavior. In a meta analysis of four abstinence education programs, there was no significant difference between program groups and control groups on the rate of unprotected sex (10). This aspect of the intervention, in addition to the individual-level focus and the failure to provide “say no” strategies and to account for context, is also based on the tenets of the Health Belief Model, the Theory of Reasoned Action, and the Theory of Planned Behavior.

PROPOSED CHANGES TO POWER2WAIT
Moving From “I” to “We”
As discussed previously, there are many limitations to creating an intervention that takes place at the individual level. If an abstinence intervention could be focused on a group level, it would be more successful at conveying the message. In economics, there is evidence to suggest that people exhibit “herd” behaviors when it comes to investment recommendations and portfolio management (11). Reputational herding in economics is said to take place “when an agent chooses to ignore his or her private information and mimic the action of another who has acted previously” (11). It is commonly accepted among most teens that everyone is having sex in adolescence. However, according to a recent poll, in reality 87 percent of 13-16 year olds are abstaining from sex (12). By shifting the focus of the internet campaign from the individual to the 87 percent majority, it would make teens more aware that everyone is, in fact, not having sex. In addition to focusing on the majority of teens not having sex, creating a formidable brand will further strengthen the message. Advertising theory states that there are three constructs to advertising: the promise, the support, and the core values (13). The Power2Wait website already has all three components. The promise is that if you abstain from sex you will not become pregnant, and you will be able to achieve your dreams. The website supports the promise with the stories of abstinence teens. The core value of the Power2Wait program is independence.
Another change that can be implemented to move from the individual to the group is by involving a larger demographic. A main message of abstinence education (by law) is to abstain from sex before marriage. Evidence suggests that this has a potentially negative effect on teens who are gay, lesbian, bisexual, transgendered or questioning (14). Many states have implemented laws outright banning same sex marriages, and the alternative of a lifetime of abstinence is extremely unrealistic. By changing the message from abstinence until marriage to a more general message, it will reach a larger demographic of teens.

Effectively Saying “No”
Another problem with Power2Wait is the deficit of strategies advising teens on how to stop sexual advances when in a sexually charged situation. The Power2Wait website offers suggestions on how to get out of uncomfortable situations, but it quite vague as to what are those situations. It is also vague as to whom which the advice applies. A better approach would be to offer gender-specific advice on how to diffuse sexually vulnerable situations by applying the Theory of Gender and Power. The Theory of Gender and Power focuses on women’s risk and states that there are three major structures that characterize the gendered relationships between men and women: the sexual division of labor, the sexual division of power, and the structure of cathexis (14). According to theory, women who are younger than 18 years of age, having limited access to STD/HIV education, experience an individualistic family dynamic, and have conservative cultural norms have higher risks of STD and HIV infection (14). By applying the three structures of the theory, Power2Wait can compose a set of strong messages for young women who want to abstain from having sex during adolescence.

Abstinent, But Why?
It was previously discussed that studies have found that comprehensive sex education does not lead to an increase in sexually risky behavior or in STD incidence (9, 14). Therefore, inclusion of comprehensive sexual education to support the current emphasis of abstinence would be beneficial to the intervention. However, the Section 510 of the 1996 Social Security Act states that abstinence education is defined as a program which “has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity”(14). Despite this, the Power2Wait program can still convey a successful message of abstinence if it utilizes a comprehensive approach to the sexuality of its target population.
An approach to integrate multiple facets of sexuality into abstinence education is to follow the Sexual Health Model. The Sexual Health Model is composed of three tenets: 1) key characteristics of an established sexological approach to comprehensive sexuality education, 2) literature-based recommendations for culturally specific, relevant, normative models of sexual health derived from the target community’s experience, and 3) qualitative and quantitative research on the sexual attitudes, practices, and risk factors of various populations, as well as their context for safer-sex decision making (16). By considering the background of the target population of Power2Wait (i.e. Texas teenagers), the program can focus the abstinence message instead of the current vague messages and testimonials currently emphasized. The Sexual Health Model addresses ten issues relating to the sexuality of a population. Though all of them will not be discussed here, there are four that are relevant to the message of abstinence: 1) culture and sexual identity, 2) positive sexuality, 3) intimacy and relationships, and 4) spirituality (16). Power2Wait can address these issues that are specifically relevant to teens who abstain from sex, and therefore, can create a stronger message as to why to abstain, and more importantly, how to abstain under varying amounts of social pressures and in different environments.

Waiting For Change
The Texas Power2Wait Program is an individual-focused intervention promoting abstinence to prevent teen pregnancy. It states that abstinence is achieved through building self-esteem and maintaining self-control. However, it does not provide concrete advice on how to maintain abstinence in actually sexual situations, and does not take into account the contextual nuances and different environments of their target population. The Powe2Wait program can be improved by focusing the intervention at the group level, by offering advice based on gender and relationship theory to diffuse sexually charged situations, and by creating intervention strategies that integrate specific sexuality issues relating to the teen population.

REFERENCES
1. The National Campaign to Prevent Teen and Unplanned Pregnancy. Teen Pregnancy and Birth Rates in the United States December 2007. Washington D.C. http://www.thenationalcampaign.org/national-data/pdf/STBYST07.pdf.
2. Biel L. Abstinence Education Faces an Uncertain Future. The New York Times. July 18, 2007. http://www.nytimes.com/2007/07/18/education/18abstain.html.
3. Kim,C & Rector, R. Abstinence Education: Assessing the Evidence. The Heritage Foundation. April 22, 2008.
4. Texas Department of State Health Services. Texas Power2Wait Program. Austin, TX: Texas Department of State Health Services. http://www.dshs.state.tx.us/abstain/default.shtm.
5. Power2Wait.com. You. http://www.power2wait.com/#/love_sex_you/.
6. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. American Association of Occupational Health Nurses 1991; 39:128-135.
7. SB721 Class Notes. Types of Irrationality. September 17, 2009.
8. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp 9-21.
9. Kohler PK, Manhart LE, & Lafferty WE. Abstinence-only and Comprehensive Sex Education and the Initiation of Sexual Activity and Teen Pregnancy. Journal of Adolescent Health 2008; 42:344-351.
10. Trenholm C, Devaney B, Fortson K, Clark M, Quay L, & Wheeler J. Impacts of Abstinence Education on Teen Sexual Activity, Risk of Pregnancy, and Risk of Sexually Transmitted Diseases. Journal of Policy Analysis and Management 2008; 27: 255-276.
11. Sornette D. Why Stock Markets Crash: Critical Events in Complex Financial Systems. Princeton, NJ: Princeton University Press, 2003, pp 91-114.
12. MSNBC. Nearly 3 in 10 young teens ‘sexually active’. January 31, 2005. http://www.msnbc.msn.com/id/6839072/.\
13. SB721 Class Notes. Alternative Models: Advertising Theory. October 15, 2009.
14. Santelli J, Ott MA, 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.
15. Wingood GM, DiClemente RJ. The Theory of Gender and Power: A Social Structural Theory for Guiding Public Health Interventions. Emerging Theories in Health Promotion Practice and Research:Strategies for Improving Public Health. San Francisco, CA: Jon Wiley & Sons, Inc., 2002, pp. 313-346.
16. Robinson BE, Bockting WO, Rosser BRS, Miner M, Coleman E. The Sexual Health Model: Application of a Sexological approach to HIV Prevention. Health education Research 2002; 17:43-57.

A Critical Analysis of Failed Nutrition Interventions – Leigh Simons

Increased fruit and vegetable consumption has been show to reduce the risk of stroke, various types of cancer, and type 2 diabetes and may result in weight loss (1). As a means to reverse, or even just to slow, physically and financially costly public health problems, many federal and state agencies have launched campaigns to promote healthy eating.
One such campaign was the “5 A Day” campaign which was launched in 1991 and implored the public to eat at least five servings of fruits and vegetables a day. It was replaced in 2007 by the “Fruits & Veggies: More Matters” campaign when the USDA guidelines for fruit and vegetable consumption were tailored to individuals and the units of measure changed from servings to cups (2). “Fruits & Veggies: More Matters” introduced a web site with health eating tips, tips for spreading your fruit and vegetable budget, and resources for health educators to teach kids healthy eating.
Despite the extended use of the “5 A Day” and “Fruits & Veggies: More Matter” campaigns and $4.5 million spent on communication in 2004 alone, the percentage of the population that eats 5 or more fruits a day decreased from 52% to 26% between1988 and 2006 (3,4). In fact, average consumption across the country, adjusting for changes in demographics, increased only from 3.8 fruits and vegetables a day to 3.9 vegetables a day between 1991 and 1997 (5). Not only did the population adhering to healthy eating guidelines decrease, but the marketing campaign was not particularly effective in informing the public about fruit and vegetable recommendations: in a 2002 survey by the Department of Health and Human Services, more than 50% of men did not know the “5 A Day” recommendations for fruit and vegetable consumption (6).
This summer, the New York Department of Health and Mental Hygiene launched a campaign aimed at reducing consumption of sodas, juice, and sports drinks. “Are You Pouring on the Pounds?” depicts a hand pouring either soda, juice, or a sports drinks into a glass overflowing with human fat (7). A health bulletin from the campaign includes the images from the ads and also includes various statistics, including the amount of sugar in the targeted drinks (8).
Typical nutritional interventions rest on the Health Belief Model and consequently fail to account for the ways that environmental factors affect accessibility and the ways social networks affect behavior. Nutritional interventions also use marketing campaigns resting on faulty assumptions about the public’s desires. An intervention that addresses these inadequacies must be developed using alternative health models.

I. Failures of Nutrition Campaigns
Interventions to improve the diets of Americans, including the “5 A Day,” “Fruits & Veggies: More Matters,” and “Are you pouring on the Pounds?” campaigns, have not substantially changed behavior because they fail to address three critical issues. First, as these campaigns are based primary on the Health Belief Model, they do not address environmental factors associated with poverty and location and how these factors influence the ability to pay for produce and the accessibility of produce. Second, diet campaigns do not take into account how social networks affect food decisions as these campaigns operate at the individual level. Finally, nutrition campaigns do not effectively use marketing theory, so the messages they employ do not resonate with their intended audience.

A. Nutrition Campaigns Fail to Address Environmental Factors
The “5 A Day” and “Fruits & Veggies: More Matters” state and national campaigns use the Health Belief Model to influence human behavior. The use of the Health Belief Model, however, fails to address how the environmental factors of poverty and location influence consumption of produce.
The Health Belief Model theorizes that an individual’s perceived susceptibility and perceived severity of a condition or disease will lead to a perceived benefit of taking a specific action to combat the condition. These perceived benefits are weighed against perceived barriers to the action. The outcome of weighing perceived benefits against perceived barriers is an individual’s intent. Intention leads, finally, to the individual performing the specific behavior (9).
The “5 A Day” and “Fruits & Veggies: More Matters” campaigns provide information to consumers so they can make rational decision about their food choices based on the Health Belief Model. One element of the “5 A Day” campaign, “California Children’s 5 a Day-Power Play! Campaign: Fruits and Vegetables,” aims to influence the perceived benefits of eating nutritiously by teaching children how to read nutrition labels and interpret the food pyramid and aims to reduce their long term risk of chronic diseases (10, 11).
The “5 A Day” campaign, however, does not adequately address the environmental factors associated with complying with fruit and vegetable consumption recommendations: fruits and vegetables in certain areas are either too expensive or not accessible, or both for some populations, and thus no amount of intent to purchase make it a feasible action. According to a United States Department of Agriculture (USDA) study, about 19 percent of low-income households did not purchase any fruits or vegetables in a given week, 10 percentage points higher than households with higher income (12). Several studies across the country have shown that there are fewer chain supermarkets in inner-cities and minority neighborhoods than in wealthier and white neighborhoods; the food outlets in inner-city and minority neighborhoods tend to be convenience stores and small grocery stores (13, 14). These smaller grocery stores are more expensive and carry far fewer products, including vegetables and produce (13). Further exacerbating the environmental factors that restrict access to more affordable produce is that fewer residents of poor and African American neighborhoods have access to private transportation, so it is much less feasible for residents of these neighborhoods to access chain supermarkets outside of their neighborhoods (14).
Publications like “30 Ways in 30 Days to Stretch Your Fruit & Vegetable Budget” from the “Fruits & Veggies: More Matters” campaign aim to reduce affordability barriers by providing tips to consumers such as buying store-brand forms of fruits and vegetables (15). Such a recommendation is likely not feasible for a consumer who only has access to food from a convenience store or small grocery store which do not have generic products like chain supermarkets do. There is evidence that the availability of fruits and vegetables increases consumption, even in children, as found in an intervention of British school children that provided students a free piece of fruit or vegetable in their first and second years of schools. Average consumption during the program increased by .5 servings a day, but when student were no longer eligible for the program, fruit and vegetable consumption returned to baseline consumption rates (16). It is access to produce that must be addressed, especially after considering evidence that when income increases among the lower-income population, they are less likely than high-income households to increase spending on fruits and vegetables (17). This research suggests there are strong environmental factors at work beyond the barrier of price.
The “5 A Day” and “Fruits & Veggies: More Matters” campaigns encourage the public to eat more fruits and vegetables by informing them about their nutritional value and how consumption can prevent disease. Attempts to address barriers like price fail to consider environmental factors that make compliance impossible.

B. Nutrition Campaigns Fail to Address Social Networks
As nutrition campaigns tend to be based on the Health Belief Model, they try to change an individual’s behavior. These campaigns fail to take into account how social relationships shape behavior.
Social Networks Theory says that people are influenced by others in their social network and those that are closest to them in their network (friends, spouse, friends of friends, etc) have more influence than people farther from them in the network. The actions of the people in a person’s network affects what that person will do and they are influenced by the social support, social norms, social engagement, and access to resources of the others in the group (18). Efforts to change behavior in a social network must be aimed at the entire group and not at individuals.
Obesity studies have shown that the likelihood of obesity increases if someone in your social network is obese. In the Framingham Heart Study, chances of becoming obese increased by 57% if the person had an obese friend, 40% if the person had an obese sibling, and 37% if the person had an obese spouse (19). The same study showed that geographical distance was less likely to affect obesity than distance in a social network, suggesting that the behaviors and decision of people you are close to affect obesity more than neighbors, coworkers, etc.
The “5 A Day,” “Fruits & Veggies: More Matters” and “Are You Pouring on the Pounds?” campaigns simply inform individuals of recommendations and fail to address entire networks. “T.A.S.T.E Tips and Information for Moms,” a publication from the “Fruits & Veggies: More Matters” campaign, is aimed at mothers as individuals because they are the likely food purchaser in the family. The publication offers ideas like bringing your kids to a farmer’s market or making meals as a family as a means to influence a mother’s, and consequently her family’s, behavior (20). While such a behavior change would likely alter a family’s behavior, the mom herself is unlikely to initiate such activities on her own. The publication fails to address the mother’s social network as a group, which likely consists of siblings, other moms that are friends, etc., who would have more of a collaborative influence on her purchasing and eating behavior, and consequently that of her family’s because of social support and engagement provided by networks.
Social norms in a network shape how people in the social network behave. The biggest changed in dining social norms in the last twenty years is the propensity of Americans to eat dinner outside of the house (17). This on-the-go eating behavior has a significant effect on produce consumption, according to the USDA. About one third of the average American’s daily caloric intake is from food that is not made in the home, but that portion of the American diet accounts only for 1 ¼ servings of vegetables and less than ½ a serving of fruit (17). These are dismal numbers for a dining option that has become a norm in American life.
Another norm of American food consumption is the propensity toward convenient, inexpensive food. Americans in 2002 spent only 10.1 percent of their disposable personal income on food, less than half as much as 1950 when Americans spent 20.5 percent of their income on food (17). It is not just a few people, but America as a population that has fundamentally changed how we eat.
“Are You Pouring on the Pounds?” tries to address the change in food patterns with an illustration in their health bulletin about how soda consumption has increased. Two graphics in the publication, however, only serve to reinforce what the social norms of the American public are. One graphic in the bulletin explains how many more calories a day Americans consume than they did 30 years ago, thus associating those extra calories to normal contemporary behavior. Another graphic shows how soda sizes have changed from what used to be a normal bottle at 6.5 ounce bottles. “Today,” the graphic explains, “12-ounce cans are considered ‘small’…and 20-ounce bottles are typical.” Consequently, the illustration validates the consumption of 20-ounce bottles, all the way down to the use of the word “typical.”
None of the campaigns take advantage of interactions within social networks as a means to influence behavior change. In order for a campaign to be effective, it must change the social norms within a social network. Individual behavior will not change without the support of others in the network as well as group interaction focused on new norms.

C. Nutrition Campaigns Fail to Adequately Use Marketing Theory
Nutrition campaigns use advertisement and marketing material to communicate their interventions, but these campaigns fail to resonate with the public because they do not adhere to the principles of marketing theory.
Marketing theory contends that formative research should be conducted in order to determine what the public wants. The product being sold should be packaged based on this research so that it appeals to the public’s desires using a promise that is constructed to demonstrate that the product fulfills these desires. The marketing must have imagery to illustrate how the product fulfills the public’s core desires and there must be support that the product will fulfill its promise (20).
In the context of marketing for public health, it is important to understand that individuals are most likely to act in their own self-interest, and are more likely to act in their own interest if “the individual can discern immediate self-interest in the behavior.” A behavior that has no perceived benefit is less likely to occur than one that does (22). In the short term, an individual might see immediate benefits by satiating their appetite with unhealthy foods; the long term benefits of eating fruits and vegetables, like reduced obesity and other improved health factors, are remote and less satisfying. Consequently, the value of health is not a strong enough core value for nutritional marketing to rest on and it must be redefined as fulfilling another interest (21).
Nutritional marketing campaigns fail at the most basic level of marketing theory: it encourages a change in behavior by emphasizing better health when “it is not really health itself that people value most. Rather, it is the freedom, independence, autonomy, and control over their lives that come with being healthy for which people have the most fundamental need and desire” (21). The actual slogan from the campaign “Fruits & Veggies: More Matters,” is meant to market eating more fruits and vegetable by appealing toward the public’s desire for good health. Its website explains that fruits and vegetables provide a “better future” by “reducing your risk of certain chronic disease” (23). But while some people value health more than others, health is not a compelling enough reason for most people to alter their behavior. One study shows that increases in the percentage of adults who consume at least five fruits and vegetables a day were more prominent among people who were initially consuming larger amounts of produce than people who consumed less produce, suggesting that the “5 A Day” campaign had more of an effect on people who were already on the upper end of produce consumption (24). An increase in this group indicates they valued better health and the campaign consequently was less successful in modifying the behavior of those who likely did not hold health as a main desire.
While the imagery of human fat in a glass in the “Are You Pouring on the Pounds?” advertisements is eye-catching and visually disturbing, it is not framed in a way that appeals to human desires of freedom, independence, autonomy, and control. It suggests that an individual who consumes sugary beverages is destined to a predetermined fat future instead of using the campaign as an opportunity to provide an individual with choices so that they can assert their desires for independence and control. The imagery in this aspect of the campaign is compelling, but since it is based on the flawed assumption that the public desires better health, it misses the opportunity to truly resonate with the public.
While the bulletin for the “Are You Pouring on the Pounds?” campaign is also based on the public’s desire for better health, it is made even less compelling by the use of statistics as the support for its health claims. The bulletin informs that, “Teens who consume sugary beverages drink an average of 360 calories per day. Someone would have to walk about 70 city blocks to burn that many calories” (8). This type of support feels arbitrary and statistics are not particularly relatable, especially since the increase in calories does not necessarily have an immediate negative effect. The consequent lack of resonance will not likely alter behavior, especially if a person determines it is more in their self-interest to have a drink they enjoy than a remote future possibility of obesity. Similarly, the “5 A Day” campaign’s suggestion that schools help students learn about food choices by posting “fun facts” on bulletin boards is not compelling and does not appeal to any desires beyond good health (25).
None of the nutritional campaigns package good nutrition as a means to achieve freedom, independence, autonomy, or control and since health is not often perceived to be an immediate self-interest, none of the marketing campaigns will effectively alter behavior.

II. Crunch
In order to address poor nutrition, a new campaign must be devised that accounts for environmental factors affecting affordability and accessibility, utilizes social networks to alter behavior, and bases its marketing on human desires for freedom and control. In order to address environmental factors, government policy will be changed on the basis of Ecological Theory. A campaign called “Crunch,” the noise many fresh fruits and vegetables make when you eat them, would be used to encourage fruit and vegetable consumption among social groups using Social Networks Theory. The use of Marketing Theory would be used to design the campaign so that the “product” of increased fruit and vegetable intake appeals to the desires of the public.

A. Addressing Environmental Factors
The first aspect of the intervention uses the Ecological Theory to address environmental factors of affordability and location that inhibit the consumption of fruits and vegetables in lower-income neighborhoods.
Ecological Theory, developed by Urie Bronfenbrenner, says that a person is at the center of a series of environmental systems stacked on top of each “like a set of Russian dolls.” At the center is the individual, whose immediate surroundings are defined as the microsystem, typically the home, school, work, etc. The mesosystem is the second layer and is defined by the relationship between the environments in the microsystem. Next is the exosystem which consists of external, indirect environments and how they affect an individual: for example, how the workplace of one spouse affects the life of the other spouse. Finally, the outer level is called the macrosystem, which is the overarching environment that involves the culture and government of the society (26).
As addressed in the first critique, large supermarkets offer store brand fruits and vegetables that are more affordable but they tend not to be located in inner-cities or minority neighborhoods. Instead, these communities typically have small grocery stores and convenience stores that are less likely to offer produce, and especially produce at affordable prices (13, 14). To increase the amount of affordable produce options in these areas, an intervention at the macrosystem level is needed to bring fruits and vegetables into the community. Government regulation would give supermarket chains tax breaks for the stores that they open in low-income neighborhoods, these tax breaks would encourage the chains to enter a market they currently do not serve and would provide lower-income residents a place where they can purchase produce at a more affordable price. State governments would also provide schools with funding to hold farmer’s markets on a couple of weeknights and on the weekends. Holding the markets at schools would reduce transportation issues and the varied times for the markets would allow for variances in work schedules.
The lack of affordable produce options in lower income neighborhoods makes it difficult for residents to increase their fruit and vegetable consumption even if they have a desire to do so. Since large, consumer friendly supermarket chains do not exist in these neighborhoods, government intervention is needed.

B. Using Social Networks to Influence Behavior Change
The campaign “Crunch,” would be designed around Social Networks Theory in order to increase the intake of fruits and vegetables among social groups.
Social Networks Theory says that people are influenced most by those in their network and that they are influenced by their social support, social norms, and social engagements (18). To encourage a new social norm of increased fruit and vegetable consumption within social networks, an online community called “Crunching Together” would be developed where friends could connect with each other, mark the progress they make maintaining healthy eating patterns, tell others the methods that work for them, create a platform to share struggles they have in reaching their goals, and provide support for others who are struggling. The site would also post “crunch reminders” that suggest different social activities like meeting at a healthy restaurant, hosting a cooking party, a group outing to a farm or farmer’s market, or another healthy event that the group would be interested in. These “crunch reminders” would provide a link so anyone who wanted to organize such an event could send an invitation to those in their social network on the site. Each individual in the group would have an individual page where they could enter their vegetable and fruit consumption, time they spent exercising, playing sports, or doing other types of physical activity, and other health goals. The site would measure progress individually in “crunch points” and would also measure the progress of the group as a whole, encouraging support and engagement among group members.
“Crunching Together” creates a place where people in a social network can come together to change their social norms by providing each other support and a means to engage with other members of the network.

C. Using Marketing Theory to Promote Change
A marketing campaign would be created to encourage use of the “Crunching Together” site as well as overall good nutrition.
According to Marketing Theory, effective marketing of a product must be based on formative research about what the public wants (21). Good health is generally not one of the public’s main self-interests, so the campaign would instead appeal to two interests the public does hold: control and freedom (22, 21). To do so, a series of advertisements would be created that emphasized taking control over your life by eating fruits and vegetables and breaking free of restrictive food choices by doing the same.
The first advertisement shows a woman weighed down by junk food and soda attached to her body. She holds an apple and with every bite she takes, there is an audible “crunch” and a piece or two of junk food fly off her body. As the ad progresses, she becomes visibly lighter and walks markedly faster until the background scene drops out and she looks triumphant over an unappealing pile of junk food. The advertisement ends with one of the two slogans of the campaign: “Taking Control, One Crunch at a Time.”
The other, similar, slogan: “Freedom, One Crunch at a Time,” is based on a Hot Pockets ad campaign called “EatFreely” that sells itself as a rebellion against the constraints of eating at a table. The ads show people “rebelling” by eating Hot Pockets in a variety of different places: on a tennis court, in a limo, while walking, etc. The “Freedom, One Crunch at a Time” advertisements use similar rebellious images of physically fit people eating carrots one loud crunch at a time at various places like on the top of a mountain, on a bike, or in a library and contrasts these healthy images with images of people eating stereotypically unhealthy foods like pizza and hamburgers while chained to their desk or kitchen table. To tie in with the advertising campaign, the social web site would use the slogans as graphics and also would encourage people to share with their network how they were taking control of their lives and gaining freedom by eating fruits and vegetables.
These ads promise the viewer that eating fruits and vegetables will give them control and freedom over their life. The promise of control is further supported by the images of vanquished junk food at the end of the first commercial. In the second commercial, the promise of freedom is supported by images of the people who are eating fruits and vegetables doing exciting activities compared to the bored and constrained images of people eating the unhealthy food.
Control and freedom are big promises offered in return for eating fruits and vegetables, but it is necessary to frame the product of good nutrition in a manner that convinces people that changing their behavior is in their self-interest.

III. Conclusion
Nutrition campaigns as they are frequently designed fail to address how environment shapes the affordability and accessibility of food choices, especially in lower-income neighborhoods. Use of the Health Belief Model directs these interventions toward individuals and fails to take into account that social networks and social norms affect how a person will behave. Finally, the failure to package nutrition in a way that appeals to the public’s desires results in marketing that does not resonate and will not affect nutritional behavior.
In order for a substantial change in nutritional behavior to occur, government regulation must be used to increase accessibility, social networks must be mobilized to change group behavior, and formative research must be used to create marketing campaigns that appeal to a base desire for control and freedom.

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