Too Many Flaws in “After Too Many” Binge Drinking Intervention – Daniel Amante

I. Introduction

Despite an increase in intervention campaigns, the prevalence of binge drinking among college students has continued to increase over the past few years (1). While various studies have found that some interventions yield positive results, several campaigns have failed to connect with students effectively (2-5). Although the appropriate research studies needed to support my claim have yet to be conducted, I believe the After Too Many anti-binge drinking campaign is not only failing to appropriately connect with its targeted audience, but may actually be doing more harm than good.

The After Too Many campaign was started in 2006 in Northern California by the Youth Leadership Institute. It attempts to influence students to stop binge drinking by highlighting embarrassing things students do when intoxicated. It does so through various media advertisements such as posters, videos, and an interactive website. All three of these methods will most likely end up as failed attempts for reasons that will be discussed over the next several paragraphs.

II. Critique of the After Too Many anti-binge drinking campaign

This section is dedicated to explaining why the After Too Many campaign will ultimately result in failure. First, the campaign fails to deliver a realistic message that makes students think about the actual benefits and risks of not binge drinking. Secondly, the campaign not only fails to de-emphasize the prevalence of binge drinking among college students, I believe it makes students believe that binge drinking is even more common than it really is. Lastly, the campaign fails to make an appropriate promise that is necessary to produce a change in behavior. In order to accurately explain the deficiencies of this campaign, a description of each type of advertisement is required.

After Too Many created five different posters which have been displayed around 12 universities in California. All of the posters have the same general layout and attempt to deliver the same message. The message portrayed is that a student’s “Beer” tells the drinker to do embarrassing things. The five posters read; My Beer Told Me To Puke On My Girlfriend, My Beer Told Me To Drive Into a Tree, My Beer Told Me to Punch My Best Friend, My Beer Told Me To Piss My Pants, and My Beer Told Me to Blow the Football Team.

The two videos that the campaign created are of similar nature to the posters in that they talk about poor decisions that will be made after consuming too much alcohol. Both of the videos, which can be found online and have been aired on TV, feature two friends talking about their plans to go to a party. The first video features two girls talking in the bathroom about a party one of them plans on attending. Both girls are attractive, happy, and excited about the party. The party is described as the one that “all the cute boys go to.” The girl who is attending the party says that she will probably mess around with a few of the players. She then says, while laughing, that she is going to sleep with the whole team. The last thing she says is, “Yeah, I bet I’m going to get pregnant.” The commercial ends with the other girl shrugging off the “getting pregnant” comment with a nonchalant, “Eh, what can you do?”

The second video features two athletic looking guys walking down the street. They are talking about a party at their friend’s parents’ house that is described as being “so cool.” Similar to the first video, one of the guys is talking about his plans for the night. He says that he can’t wait to mess up the house, kick his foot through his friend’s big screen TV and “piss” all over the favorite rug of his friend’s mother. They then talk about a pretty girl who is attending the party. The ad finishes with the guy saying that he is going to rape the pretty girl and that it is going to be “so much fun.” Both videos end with the phrase “AFTER TOO MANY DRINKS THIS ISN’T JUST TALK.”

The website is called “Unhappy Hour” and upon entering, four options are displayed on the backdrop of a run-down, abandoned house. The first option, Binge 101, gives a description of what binge drinking is. The second option, Under the Label, presents facts about alcohol consumption as you scroll over various empty bottles. The third option, The Hard Stuff, is where you can find the posters and the videos described above. The last option, Crashing the Party, gives instructions to students, parents, teachers, and researchers about how they can help reduce binge drinking (although the researchers section has yet to be completed).

Criticism A. Failure to Deliver a Realistic Message that Discourages Behavior

The most obvious fault of the campaign is that all three types of advertisements fail to deliver a realistic message that would discourage students from engaging in binge drinking. College-aged students are known to participate and even seek out risky behaviors (6-8). The messages found in the posters about puking, pissing, getting into fights, hitting a tree, or hooking up with people while intoxicated are intended to deter students from binge drinking. The problem is that these “negative” activities are often the most important part of the many stories told by students after a drunken weekend of binge drinking. In many cases, these stories are even exaggerated and glorified by the guilty party in attempt to impress peers. The fact that their beer “told” them to do such foolish acts makes the posters more comical than effective, as students are fully aware that a beer is unable to talk.

Similar to the posters, the majority of each video highlights the risky behaviors that many students pursue. Unlike the posters, the videos go from fairly normal risky behaviors immediately followed by incredibly serious situations, such as intending to get pregnant or raping a girl. While both pregnancies and sexual assault have been highly associated with alcohol use (9,10), to portray either of these events as being desirable due to consumption of alcohol comes across as ridiculous and unrealistic. It is extremely unlikely that students would ever plan on making such terrible decisions before drinking. While the intent of the ad is to emphasize poor decision-making when under the influence of alcohol, the message is lost as they attempt to make light of such unfortunate and horrific situations. Further more, especially considering the particular target audience, there will be a fair amount of optimistic bias associated with events of such magnitude (11,12). Optimistic bias occurs when a person believes that an undesirable outcome is less likely to happen to them than to others (12).

The website also fails to connect to students in a realistic manner. The backdrop image of a rundown, abandoned house with eerie sound effects in the background suggests that the purpose of the website is to scare students away from drinking. Creating the website to look depressing and scary is a type of fear tactic intended to make the students associate drinking with falling on rough times. In reality, however, the majority of college students cannot relate to such a morose scene. A better way to get the message across to students is to frame it in a way that will elicit a desired response from the student. Framing is the process of packaging a program or policy so that it reinforces the public’s core values (13). An example of a better way to frame an anti-binge drinking intervention would be to address a core value such as the ability to make one’s own choices. This could be done by having the different choices on the website be depicted as roads on a map, emphasizing that the student can “choose” which direction they wish to go.

Criticism B. Failure to De-Emphasize the Prevalence of Binge Drinking

Another point of failure in this campaign is that it neglects to de-emphasize the prevalence of binge drinking. While binge drinking is obviously a topic of serious concern, several studies show that students will consistently overestimate the amount of students that are actually binge drinking (14). Instead of presenting facts to students about the true numbers of students who binge drink, the campaign focuses only on presenting information about those students who do drink excessively. When students hear friends talking about embarrassing stories of when they were drunk and then see posters with beer telling them to do embarrassing things, it will increase the perception that everyone else in their social network is already drinking.

The same effect will occur after watching the videos presented by the campaign. In both videos, young and attractive students are talking about their plans to drink that night. Both of the parties that the students are planning on attending are described as being “cool” places where attractive people are going to be partying. A vulnerable, young person watching these videos will most likely see how happy and excited the actors are. This will influence those students who are already participating in binge drinking to continue such behavior and intrigue those students who previously chose not to drink excessively. By the time the video delivers its final message, which in this case deals with either getting pregnant or raping a girl, the students are unlikely to relate to it as much as they are able to relate to the previous risky behaviors that aren’t nearly as serious in nature. The message that students will take away from the videos is that drinking at parties and acting irresponsible is cool and fun. Since they would never go to a party with the intention of raping or getting pregnant, it is highly unlikely that those situations would have a large effect on the students.

The website also fails to take advantage of an opportunity to educate students about the true prevalence of binge drinking. In the “Under the Label” section, which presents facts about alcohol and student drinking, the website focuses exclusively on negative statistics about alcohol. Examples of some of the facts presented are; Each year college students spend 5.5 billion dollars on alcohol, Binge drinking has increased 125% at women’s colleges since 1993, Alcohol is the #1 choice of drug among our nation’s youth, 60% of students begin binge drinking in 9th grade, On college campuses, 70% or more of the students binge drink, and Two-thirds of 12th graders report having been drunk. All of these statistics are intended to stress the severity of the alcohol problem our society is facing. The point students will take away from all these statistics, however, is that it is normal to binge drink and that if they don’t then they are in the minority of college students out there. According to the Social Norms Marketing Theory, the better way to present data regarding binge drinking is to show students that drinking isn’t as prevalent as they may think (14).

Criticism C. Failure to Make a Significant Promise

A major problem of the campaign is that it focuses solely on the allegedly negative aspects of binge drinking and makes no attempt to focus on any positive features associated with choosing NOT to drink. A key to Social Advertising Theory is to make a promise that is significant enough that it will be able to alter the target audience’s behavior. Generally speaking, the greater a promise is, the greater potential for behavioral change (16). In this campaign, there is no reference to any direct benefits the students will enjoy if they abstain from binge drinking. It is thus important to step back and consider the benefits and barriers students will consider after seeing the advertisements of this campaign.

Let’s first consider the perceived benefits and barriers of binge drinking that would come to mind after viewing this campaign’s advertisements. As mentioned before, students will naturally overestimate the amount of students who actually binge drink. This implies that by binge drinking, they believe they are performing “normal” behavior. This belief would enable them to feel like they fit in with the rest of their peers. Binge drinking may also appear as an opportunity to socialize, to release great amounts of stress, and to enable them to participate in risky behaviors that they normally might not be inclined to do. The barriers presented in the advertisements consist of embarrassing themselves in front of peers, engaging in risky sexual behavior, becoming violent and abusive, raping an individual and getting pregnant.

Now let’s consider what students will think the perceived barriers and benefits of NOT participating in binge drinking are upon seeing these advertisements. The barriers may include isolating themselves from the majority of their peers, not attending “cool” parties where “cute” members of the opposite sex will be and not engaging in desirable risky behaviors, including risky sexual behaviors. The perceived benefits of not binge drinking would consist of not embarrassing themselves, not raping an individual and not getting pregnant.

When considering these perceived benefits and barriers through one of the most basic theories of individual health behavior, the Health Belief Model (HBM), it is likely that students would continue to binge drink, as well as begin to binge drink if they hadn’t done so in the past. The HBM weighs perceived barriers against perceived benefits in order to determine a resulting intention that will lead to behavior. Critical to the HBM is that the perceived benefits of a behavior are influenced by both perceived susceptibility and perceived severity of the problems the behavior will prevent (17). When considering the behavior of choosing to binge drink, the perceived severity of becoming isolated from one’s peers by not participating in “normal” behavior is incredibly high for students. The perceived susceptibility of this occurring if they don’t participate in the common behavior is also very high. Both of these factors will increase the effect of the perceived benefits, which greatly outweigh the perceived barriers in this case and will result in the students deciding to binge drink.

When considering the effects of the campaign’s advertisements, the opposite effect would be seen when looking at the behavior of not participating in binge drinking. While the perceived severity of raping a girl or getting pregnant is very high, the perceived susceptibility that these problems will actually occur is very low. This will cause the influence of the two to cancel each other out to some degree. Meanwhile, the perceived susceptibility of embarrassing yourself among friends who are also drinking is very high but the perceived severity of this problem is very low, because such behavior while drinking has become tolerated, expected, and often glorified. Therefore, neither of these situations will significantly influence the perceived benefits of not drinking, which were already greatly outweighed by the perceived barriers mentioned above. Since the campaign never makes a promise of a significant benefit, there is little to no incentive for students to decide not to binge drink.

III. A Proposal For Effective Intervention Against College Binge Drinking

In order to create an effective campaign intended to reduce college binge drinking, several important elements must be present, and therefore must require a multi-faceted approach. The very first thing that must occur is that the intervention must be able to relate to the target audience in a way that is realistic yet influential. Secondly, the intervention must abolish false presumptions by educating the audience about the realities of binge drinking. And lastly, a powerful promise that abstaining from binge drinking will result in meaningful benefits must be made and well supported.

Proposal A. Relating To The Audience

Excessive consumption of alcohol has long been established as being a significant part of the college experience. Denying such a fact would instantly alienate the target audience. In order to successfully relate to students, we must take a step back and focus on other established aspects of college life that students value more than binge drinking. By focusing on important core values tailored specifically for college students such as sex, independence, control, health, athletics, happiness or academic success, we can design an approach that will not only grab the attention of students but also force them into a “hot state” as they take how much they actually value binge drinking into consideration.

This use of one’s core values in order to prevent binge drinking is a good way to eliminate restraint bias. The idea of restraint bias is that people will tend to overestimate their ability of self-control (15). Often, when a targeted audience sees an ad that is trying to influence a certain behavioral change, they may believe that they have the ability to resist the impulse associated with that behavior. Ultimately, this leads to people overexposing themselves to temptation, which leads to giving in and performing the behavior, resulting in a failed intervention (15). By introducing core values that are very important to the student, it will put them into a “hot state” and enable them to look past the restraint bias associated with binge drinking. By doing so, they may be more open to the message that an intervention is trying to get across.

Proposal B. Exposing The Truth

Many interventions, like After Too Many, ultimately fail because they choose to focus solely on the negative consequences that may result from a risky behavior. The problem with this technique is that in most cases students are already aware of the associated risks and possibly even further attracted to the behavior because of them (2). This is especially true if they believe pursuing a risky behavior is normal, expected, and valued among their peers. A critical aspect of my proposed intervention is to expose the truth about binge drinking prevalence to students. Several studies have shown that students often greatly overestimate the degree to which their peers are binge drinking (14). This leads to a false perception of binge drinking being the norm and a perceived increase of social pressures to perform the behavior.

As the Theory of Reasoned Action suggests, people will adhere to a particular behavior if they believe they should be performing it (17). Whether they believe they should perform the behavior is a function of two things. The first thing is their personal beliefs towards the action. The second is their perception of social pressures to perform the behavior. If we can successfully alter the student’s beliefs about binge drinking by contrasting it against their core values, and if we are simultaneously able to change their perception of the social pressures associated with binge drinking, then according to the TRA, there is a good chance we will be able to reduce the amount of people who binge drink.

Proposal C. Delivering a Powerful Promise

Although the TRA would suggest we have done enough to change behavior, a flaw of the model is that it assumes rational behavior of the audience. When addressing the issue of college students and binge drinking, we face a problem in that people, and students in particular, often act irrationally. Furthermore, we are dealing with a certain behavior, binge drinking, which promotes irrational behavior in itself. That being said, it is important that we deliver a promise that is so powerful, even the most irrational of people will want to change their behavior in order to obtain it.

David Ogilvy, in the book Confessions of an Advertising Man, references a comment made by Dr. Samuel Johnson hundreds of years ago. He said, “Promise, large promise is the soul of an advertisement” (16). The promise that is to be made must be more than just good. The promise must be so great that it is able to excite the students. In order to do so, one must incorporate the core values talked about previously into the promise. The bigger the promise is, the more influential the ad will be in altering the behavior. In order for the promise to be successful, however, it must be supported with effective imagery and factual information (13).

Conclusion – The Final Product

When developing the final product of the proposed intervention, several additional things should be taken into consideration. Such things consist of what types of advertisements will be used, their appearance, and how they will be delivered to the students. The use of poster advertisements around college campuses is a very effective way to deliver an intervention method. The posters should be placed in areas where students spend most of their time, such as campus centers, cafeterias, and dormitories. An interactive website is also a very effective way of relaying messages to students. The appearance of the website, however, should resemble something that students are familiar with and can relate to, such as a dormitory hallway. It should also be framed in such a manner that it evokes a positive association. It should contain all of our advertisements, as well as several facts that will educate students about the true extent of binge drinking that goes on.

When considering the design of the posters, we must be sure that our previously defined goals are met. This means that the poster must be able to relate to students by referring to their core values, expose the truth about false presumptions, and deliver a powerful promise. To do so, we can incorporate a core value into the promise so that there is a direct, negative relationship between that value and binge drinking. This will be our primary message we are trying to get across. We should then reinforce our promise with facts and strong imagery in order to increase excitement about the promise. Finally, we should include facts that de-emphasize the prevalence of drinking so that it makes the decision of choosing not to binge drink easier for the student.

In conclusion, I believe if we take our promise that by not binge drinking a core value will benefit, support that promise with hard facts, surround it with effective imagery and supplement it with information that alters the student’s perceptions of social norms, the proposed intervention will be able to successfully modify behavior and reduce binge drinking across college campuses.

References

1.Mitka M. College binge drinking still on the rise. JAMA 2009; 302(8):836-837.
2.DeJong W. The role of mass media campaigns in reducing the high-risk drinking among college students. J Stud Alcohol 2002; 14: 182-192.
3.Toomey TL, Wagenaar AC. Environmental policies to reduce college drinking: options and research findings. J Stud Alcohol 2002; 14:193-205.
4.Hingson RW, Howland J. Comprehensive community interventions to promote health: implications for college-age drinking problems. J Stud Alcohol 2002; 14:226-240.
5.Wolburg JM. The “risky business” of binge drinking among college students: using Risk Models for PSAs and anti-drinking campaigns. Journal of Advertising 2001;30 (4):23-39.
6.Parent EC, Newman DL. The role of sensation-seeking in alcohol use and risk-taking behavior among college women. Journal of Alcohol and Drug Education 1999; 44:12-28.
7.Rolison MR, Scherman A. College student risk-taking from three perspectives. Adolescence 2003;38: 689-704.
8.Martin CA, Kelly TH, Rayens MK, Brogli BR, Brenzel A, Smith WJ, Omar HA. Sensation seeking, puberty and nicotine, alcohol and marijuana use in adolescence. Journal of the American Academy of Child Adolescent Psychiatry. 2002; 41:1495-502.
9.Ingersoll K, Ceperich S, Nettleman M, Karanda K, Brocksen S, Johnson B. Reducing alcohol-exposed pregnancy risk in college women: Initial outcomes of a clinical trial of a motivational intervention. Journal of Substance Abuse Treatment 2005; 29: 173-80.
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Banning Trans Fats – Mary Bonds

Over the past thirty years obesity has emerged as a serious public health problem in the United States. According to the Center for Disease Control, in 2008 all but one state (Colorado) had a prevalence of obesity >20% (1). Thirty-two states had obesity prevalence greater than 25% in 2008 (1). And 6 states (Alabama, Mississippi, Oklahoma, South Carolina, Tennessee, and West Virginia) had the highest prevalence of obesity in the country at 30% or higher (1). These high rates of obesity are especially concerning since obesity is a major risk factor for several other serious diseases including cardiovascular disease, stroke, type II diabetes, high blood pressure, high cholesterol, and certain types of cancer.

The costs in human life, quality of life and medical care expense associated with obesity and these other diseases are significant. The CDC estimates that cardiovascular disease is the leading cause of death in the country (2). Diabetes can lead to serious health impairments such as limb amputation and blindness. Obesity has also been linked to depression and low self-esteem. The CDC estimates that in 2008 annual medical care costs associated with obesity reached $147 billion, for diabetes $116 billion, and for cardiovascular disease and stroke a whopping $448 billion (2).

The obesity epidemic is not restricted to adults. According to the CDC the prevalence of obesity among children aged 2-19 has tripled over the past 30 years (1). Obese children are experiencing the same serious illnesses associated with obesity in adulthood. For example, rates of type II diabetes, hypertension and high cholesterol are rising among children aged 2-19 as well. Obese children have been found to experience lower self-esteem, depression, and reduced capacity for learning in school more than average-weight children (6).

The rates of obesity are highest among lower income populations within the U.S. The states with the highest rates of obesity are also those with the poorest economies (3). With the current unstable U.S. economy, characterized by a growing unemployment rate, experts project that low income families will likely continue to find the costs of healthier foods prohibitively expensive (3). There is concern that rates of obesity will continually increase in lower income populations.

Given such negative health outcomes associated with obesity and in light of the potential for steadily rising obesity rates, many public health advocates and lawmakers have turned toward policy-making to prevent obesity on the population level. One population level approach to reducing obesity has been to pass laws banning the use of trans fats. In the period from 2006 through 2009 several cities and states have proposed, and are adopting, bills that will restrict trans fats to 0.5mg per serving or ban them altogether in restaurant, grocery stores, cafeterias, etc.(4).

The approach of banning trans fats is based on the belief that removing them from the American diet we will reduce risks for cardiovascular health and obesity. Trans fats, typically found in oils and shortenings used in restaurant food preparation and in many pre-packaged snack foods, have a greater negative impact on cholesterol levels than naturally occurring fats (5). Unlike saturated fat, that only increases LDL (bad cholesterol), trans fats both increase LDL and also decrease HDL (good cholesterol,) thus greatly increasing the risk of coronary artery disease (5). Given the evidence, the USDA recommends reducing trans fats intake to as low a level as possible (5).

The ban on trans fats is premised on the belief that reducing the dietary intake of trans fats, alone will yield the beneficial health outcomes of reduced cardiovascular disease and obesity. Reliance upon the ban of trans fats alone to reduce obesity assumes that people will not be subject to the risk of becoming obese or developing cardiovascular disease by other means such as consuming other high caloric, low nutritious foods or continuing a sedentary lifestyle. It also assumes that people will not substitute other harmful oils such as palm or coconut oil which are also very harmful to health due to their high levels of saturated fats. A ban on trans fats does nothing to promote healthier fats such as the monounsaturated and polyunsaturated fats or to promote consumption of healthier fresh fruits and vegetables.

Prior to banning trans fats fast foods were especially high in trans fats. Just as an example, a McDonald large fries contained 8 grams of trans fats, Kentucky Fried Chicken’s chicken pot pie contained 14 grams of trans fats, and even KFC combo meal contained as many as 15 grams of trans fats. Given their potential for such serious cardiovascular health risk, it is great that these trans fats for most menu items of these corporations are reduced to zero. However, I do not believe that reliance upon the ban alone is going to be adequate to reduce obesity and cardiovascular health. I believe that banning trans fats as an approach to preventing obesity is a step toward the right direction but it is flawed in several important ways. Therefore, reliance upon it alone will fail to achieve the public health goal of reducing obesity.

Argument 1: A ban on trans fats still does not prevent over-eating in general or eating equally fattening foods also known to contribute to obesity.

Obesity is a complex condition with multiple contributing factors (8). A program aimed at effectively preventing obesity must address as many contributing factors as possible. Most agree, though, that the main cause of obesity is a combination of an inbalance in calories consumed and energy expended. Over-eating is complex and not well understood.

The Trans fat ban fails to address over-eating. Even after the ban is in effect, restaurants can still serve portion sizes much larger than the USDA recommended portion size, thus allowing diners opportunities to consume more food than required to maintain a healthy weight. People can also still continue to cook and eat unnecessarily large portions of food at home, school and/or work. For example, while Pillsbury pre-made holiday cookies only contain 0.5g of trans fats per serving, a person could eat multiple servings and exceed the restricted 0.5 per serving size. The ban also does not address compulsive over-eating. For obese individuals who engage in overeating (out of boredom or stress) and have a set diet and sedentary lifestyle, the ban of trans fats does nothing to motivate a change in their pattern of over eating.

Also, although trans fats have been reduced to zero on most menu items, many of the remaining food items still contain high levels of other fats, sugars and other unhealthy ingredients likely to cause weight gain. Just one example is the seemingly healthy Crispy Chicken Caesar Salad without dressing on KFC’s menu that contains 19 grams of total fat (6 grams of saturated fat) (7).
Banning trans fats also does not prevent or reduce the use of other unhealthy ingredients in food products available to the public. Many restaurants and food manufacturers can substitute other oils that are high in saturated fats for trans fats in food preparation. Products high in saturated fats and sugar and low in vitamins and whole grains are still available to consumers and at much lower prices than healthier foods like fresh fruits and vegetables. So, banning trans fats does nothing to mitigate other sources of over-consumption of unhealthy foods and it does nothing to educate the public about appropriate portion size and selection of healthier foods for their diet. In this way, banning trans fats alone is unlikely to have the anticipated impact of reducing obesity.

Argument 2: The ban on trans fats targets only the nutritional aspects of obesity while not addressing the need to increase physical activity to fight obesity.

In terms of weight loss, evidence suggests that successful programs should combine nutritional changes as well as engagement in increased physical activity (8, 9). Banning trans fats as a means to reduce the prevalence of obesity is flawed in that it only addresses the first objective, modifying the diet. A sedentary lifestyle is also a major contributing factor to the obesity epidemic and a program that targets only one aspect of the diet will not be as effective in reducing obesity.

Katz (2009) reviewed programs aimed at weight control in children and concludes the research shows that children benefit most from school-based programs than those implemented outside school (9). The article also notes gender differences in terms of success of programs aimed at increasing physical activity: girls appeared to benefit more from programs based upon social learning theory, whereas boys benefited more from environmental reforms (9). The ban of trans fats fails to acknowledge the need for reforming activity levels at all and this I a major flaw in the trans fat ban as well.

Argument 3: The ban of trans fats makes no attempt to engage the population targeted for the program to persuade them to eat healthier and exercise more.

Applying the Community Coalition Action Theory in addressing other public health problems has shown some success. Preventing obesity is a public health problem to which this theory is well-suited to be applied as well. The ban of trans fats approach fails to do this in that the major cities targeted for the bans are not those with the highest rates of obesity. This is another major flaw to that approach.

The Community Coalition Action Theory holds that by getting community leaders to adopt the mission of bringing about the change in public health behavior first and then to motivate members of the community to work on bringing about the change as well. In terms of applying this to obesity, it would be important to get important leaders in communities most affected by poverty since obesity seems to be more prevalent among the poor. Such leaders could be those in churches, schools, local businesses.

Proposed Intervention

An alternative approach to the ban of trans fats that might be more effective in reducing obesity would be to form a group of members who share the common goal of reducing obesity. It would be important to gather a diverse group of members (ie., both professional, business owners, residents, school teachers, students, parents, grassroots). The group would be responsible for setting a specific goal(s) to achieve the result of reducing obesity. For example, the group could set as its first goal to lobby city planners to create “safe routes” for children to be able to ride their bikes or walk to school and to locate more grocery stores in areas where there are currently none available. The group could also lobby law makers to pass laws that provide an incentive to supermarkets to locate in under-served populations. Another example might be for members of the group to speak at different organizations to spread the message of the importance of healthy diet and exercise. There are limitless goals the group could set really. These are some great examples the Center for Disease Control suggests (1). Once a group achieves the first goal, they could move onto the next one so that they have momentum and are continually working toward the overall goal of reducing obesity.

This intervention would be an improvement over the ban of trans fats in several ways. First, the formation of a community coalition group whose goal it is to reduce obesity engages the population being impacted who therefore have more motivation to achieve the goal. This group of motivated individual can take organized action to improve the health of their community.

Second, the community group would set agenda items that would address both the nutritional aspects of obesity as well as the physical activity aspects of obesity. This is where the ban on trans fats failed as an approach because it only addressed one nutritional aspect of the American diet. Using a community coalition group will ensure that both the nutritional and physical activity aspects of obesity are addressed.

Finally, the community coalition group’s interaction with various groups in the community could address issues motivating over-eating. For example, community coalition members could partner with local Weight Watchers programs to learn more about what motivates over-eating and to bring these topics back to the coalition group in order to design programs that would encourage healthier diet and exercise habits in those who over eat.

Conclusion

The reasons why people are obese are complex and an approach to preventing obesity needs to take this into account and address both nutritional aspects as well as physical activity aspects of the condition. The ban of trans fats is a helpful first step but it alone cannot address obesity. The formation of community coalitions who set out to improve the health of their own communities and set goals toward achieving improved public health is an alternate approach I suggest would be superior to the use of only the ban of trans fats in fighting obesity. The community coalistin will be a successful alternative approach because it offers the ability for the group to attack multiple factors which could be leading to obesity: nutrition as well as physical activity as well as many other factors contributing to obesity such as availability of supermarkets in the neighborhood.

References

1. Center for Disease Control. Percent of Obese (BMI ≥30) in US Adults. Atlanta, GA: Center for Disease Control. http://www.cdc.gov/obesity/data/trends.html#County.
2. Center for Disease Control. Heart Disease Statistics. Atlanta, GA: Center for Disease Control. http://www.cdc.gov/heartDisease/statistics.htm
3. Trust for America’s Health. How Obesity Policies are Failing America. Washington, DC: Trust for America’s Health. http://healthyamericans.org/reports/obesity2009/
4. The National Conference of State Legislatures. Trans Fat and Menu Labeling Legislation. Washington, D.C.: The National Conference of Stat Legislatures. http://www.ncsl.org/default.aspx?tabid=14362
5. The Campaign to Ban Partially Hydrogenated Oils. Ban Trans Fats http://www.bantransfats.com/
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7. Kentucky Fried Chicken Menu. http://www.yum.com/nutrition/documents/kfc_nutrition.pdf
8. Anderson, PM, Butcher, KE. Childhood Obesity: trends and potential causes. Future Child 2006; 16:19-45
9. Katz, D.L. School-Based Interventions for Health Promotion and Weight Control: Not Just Waiting on the World to Change. Annual Reviews of Public Health. 2009. 30:253-272.
10. Butterfoss, F., Kegler, M. Community Coalition Action Theory. 2002.
11. http://healthyamericans.org/assets/files/TFAHHamburgtestimony.pdf

Help Stop Childhood Obesity: A Critique and Reformulation of the “Change4life” Campaign of U.K Government -Yang Wang

Section 1: Introduction

Prevalence of overweight and obesity has been increasing over last several decades. In 2005-2006, 67% of the adults in United States were overweight or obese; out of these 34% were obese (1). 15% of children aged 6 to 11 and 18% of adolescents aged 12 to 19 were overweight, respectively. Similarly, data from Health Survey for England (HSE) shows that in 2007, 60.8% of adults aged 16 or over in England were overweight or obese; of these, 24% were obese. In 2007, 28.6% of children aged 2 to 10 in England were overweight or obese; of these, 15.4% were obese (2).

The increasing prevalence of obesity in children is a result of high-calorie diet, decrease of exercise and increase of sedentary lifestyle (3). Consumption of fast-food has been a preeminent dietary pattern in the United States and United Kingdom today (3, 4) . Several factors of fast-food such as massive portion size, high calorie density, high density of saturated acid and trans fat and low content of fiber have all contributed to obesity of children(3). In addition, low levels of physical activity have also been shown to contribute to children obesity and consequent circulatory problems. Data from the CDC report shows that high students’ participation in physical education has declined by 30% in the past decade (5). Marketing campaigns and pervasive advertisements of fast-fast also drive adults and children to consume fast-food (3). Studies shows that children spend an average of 5.5 hours per day averagely using various media and are exposed to an 40,000 television commercials annually(6). Most of these commercials are for candy, fast-food and high sugar cereal (6, 7). Furthermore, parents report that they prefer that their children watch TV at home rather than play outside unattended because parents then can complete some chores while keeping an eye on their children(8).

On January 3 2009, the UK Government started a “Change4life” campaign. The ambition of this campaign is “to be the first major nation to reverse the rising tide of obesity and overweight in the population by ensuring that everyone is able to achieve and maintain a healthy weight”(9). The initiative of the Change4life campaign targets families with children under 12 years old. Its goal is to reduce the proportion of overweight and obese children to the 2000 level by 2020 (9). Change4life campaign launches television advertisements, billboards to build awareness of what families can do to live healthy lifestyles and prevent childhood obesity (9). The first advertisement, which is available on YouTube, starts with a stone-age family in the shape of cartoon-like dough figures hunting a mammoth and hitting a dinosaur with clubs. The picture moves on to a modern-day family eating pizza and playing electronic games. One day the child finds that there is too much fat in his body, so the modern-day family decides to change their lifestyle. The slogan of the Change4life campaign is “Eat well, move more, live longer” (9). Subsequently, the Change4life campaign focuses on“8 changes of lifestyles” including “sugar swaps, 5 a day, meal time, snack check, Me size meal, cut back fat, 60 active minutes, up and about”(9).

This paper focuses on the UK “Change4life”campain. It presents three critiques of the“Change4life”campain and then proposes and supports an alternative intervention to address the three flaws of the“Change4life” campaign.

Section 2: Critiques of the “Change4life” campaign

This section presents three flaws of the “Change4life” campaign. First, it assumes that food consumption and physical activity behavior is rational. Second, it does not incorporate some important environmental and social factors into the campaign. Third, it does not apply advertising and marketing theory appropriately.

The “Change4life” campaign assumes food consumption and physical activity behavior are rational

The “Change4life” campaign makes a assumption that when parents and children are told that unhealthy diet and lack of exercise can cause obesity and consequent heart disease, type 2 diabetes and cancer, parents and children will weigh the pros and cons of changing unhealthy food consumption and physical inactive behavior and the outcome of weighing will lead people to choose a healthy lifestyle.

This assumption is based on the Health Belief Model (HBM), in which an individual would balance the perceived benefits of taking an action against the perceived barriers of taking that action (10). In the “Change4life” campaign, the benefits refer to helping children avoid obesity and live longer. Perceived benefits result from the perceived susceptibility to the specific health outcomes and perceived severity of the health outcomes (10). The result of balancing benefits and barriers decides the intention of taking an action, and this intention finally dictates behavior changing (10).

However, “Change4life” ignores the fact that some irrational factors may affect the perceived benefits and perceived barriers.

One fact is unrealistic optimism: people tend to think their risk of experiencing negative events is lower than others. This unrealistic optimism may affect their perceived susceptibility and perceived severity of obesity (11). The likelihood of belief that their own chances of a negative event are lower than average increases when the event is more undesirable and when people perceive it is controllable (11). The undesirability of obesity and its consequent health problems and the belief that people can control their own food consumption and physical activity behavior would increase the optimism bias. Parents and children may be unrealistically optimistic that they will not be obese if they choose unhealthy diet or exercise little.

Second, time preference of behavior may affect the perceived benefits. That is, people give less preference to delayed outcomes compared to immediate outcomes (12). The benefits of healthy food and taking physical activities occur so far away in the future that they may seem little value to the individual relative to the immediate costs (12). People give greater weight to current costs of having healthy food or doing physical activities, such as less desirable taste of healthy food, exhausted feeling after exercise than future benefits of improved health (13). This phenomenon of behavior especially affects the perceived benefits among young children. Young children are concerned their realistic day-to-day lives rather than their future health conditions and the benefits of choosing fast-food, such as good tastes, lower prices or opportunity to make friends concern them more than being obese and developing heart disease, type 2 diabetes and cancer.

Also, time preference of behavior affects the perceived barriers because the current costs of having healthy food are tangible and immediate (10,13). Studies showed that children found that taste and the presentation of products such as sweets, chocolate, fizzy drinks and fast food hugely appealing. Many children think the temptation of fast food and drink is “too hard to resist” (14). In addition, for parents, prices, tastes and convenience of food are important when they choose food (15). Therefore, choosing healthy food means higher prices, less appealing taste and less convenience. These tangible and immediate costs of choosing healthy food may place inappropriate weight on perceived barriers, which will affect the intention of changing behaviors.

Another two bias- status quo and default biases which mean that “individuals are highly prone to keeping with customary (status quo) and default options even when superior alternative are available”(13) also contribute to an increase of perceived barriers. According to status quo and default biases, people are likely to adhere to what they have done in the past or what is automatic (13). This helps explain the lack of success of many interventions that attempt to change people’s behavior by simply informing them of the risks of bad behaviors or convincing them of the benefits of good behaviors (13).

Even though people have the intention to change unhealthy behaviors, there are many other environmental factors such as the unavailability of healthy food in dining halls of schools and social factors such as influence of organization structure of school (16), exposure to heavily marketed and branded food products (14) that will influence the conduct of behavior. We will discuss about the influence of environmental and social factors influencing children’s behavior in the next section.

In summary, “Change4life” campaign is flawed because it assumes that people will make a rational decision to change the unhealthy modern lifestyle when they are presented with the perceived benefits of choosing healthy lifestyle by simplistic advertisements. In reality, intervention to reduce children obesity requires consideration of irrational factors that affect behavior.

The “Change4life” campaign fails to consider some important environmental and social influences on behaviors

“Change4life” campaign calls for support and action from health and education professionals, charities, government agencies, the media and stakeholders in the private sector(9) to convey the message of “Eat well, move more, live longer”. However, the “Change4life”fails to incorporate some important environmental and social factors which can influence behaviors of children or parents (17).

First, the “Change4life” campaign fails to incorporate the school environment. Children who are 6-11 years old spend about half of their time every day at schools. The organizational structure in schools affects a child’s food choices and physical activities. A study shows that if there are lengthy queues at the school lunch room, children will opt to buy their lunch at local shops, choosing fast food outlets that have the shortest or fastest moving queues in order to eat quickly and resume other non-food activities (16). Even if children bring healthy lunches which their parents prepare for them, they will also probably neglect their homemade lunches just because their friends choose to go to a fast food restaurant and they do not want to lose the opportunities to be with friends. Also, children in schools spend less time in physical education classes (18). Schools are forced to reduce or eliminate time for recess and physical education classes in an attempt to meet the expectations of state and federal pressure to improve performance on state proficiency tests (18). As a result, only 21% of school children attend weekly physical education classes (18).

Second, the “Change4life” campaign ignores the influence of food marketing. Food advertising campaigns link fast-food, soft drink and candy products with enticing features such as movies, cartoon characters, toys, video games, branded kid clubs and educational materials(19, 20). Such advertising is especially influential among children younger than 8 years (18). In schools, fast-food vendors and other types of food-related advertising in school computer screen savers, yearbook pages, school media channels, and textbook covers are increasing (18). Children are exposed to these food advertisements every day and their food consumption are influenced greatly by these advertisements. US General Accounting Office report shows that soft drink and sport drink consumption has increased by 500% in the past 50 years (21). Ridiculously, the “Change4life” campaign has decided to allow sponsorship by commercial companies including PepsiCo and Kelloggs—the makers of the very products that contribute to obesity (22).
In summary, the “Change4life” campaign fails to incorporate the environment of school and food marketing into the intervention which may influence children’s behavior very largely. It makes a fundamental attribution error (23) that attributes behavior to individual characteristics rather than the context in which the behavior is conducted.

The “Change4life” campaign fails to apply advertising and marketing theory appropriately

The “Change4life” campaign realizes that “to be successful it has to appeal to everyone” (9) and has launched television advertisements, billboards, and posters by using social marketing principles. Unfortunately, the “Change4life” does not apply advertising and marketing theory appropriately. It provides an inappropriate promise to target audience and use poor images to support the promise it makes.

The benefit that the “Change4life” campaign offers to its target audience is health. However, because of unrealistic optimism and time preference, people do not take health but price, taste or convenience as the primary consideration when choosing food. Moreover, health itself is not the thing people value most (24). Rather, the independence, freedom, control and autonomy that comes with being healthy are what people really need and desire (24). The “Change4life” campaign provides a promise that if you eat too much or do not take exercise, you will have fat deposits in your body and become obese. This promise does not fulfill the deep aspirations of the target audience, but instead frustrates people and gives them no hope.

Exchange is one of the important components of social marketing (25). If you ask someone to give up, or modify, an old behavior or accept a new one, you must offer that person something very appealing in return because people have feeling of ownership to the behaviors they are making now (26). In commercial marketing, many fast-food advertisings master this important component to make their products successful. For example, by drinking Pepsi, consumers feel they receive everything that goes with the image of brand which includes control over life, freedom and attractiveness (25). But the “Change4life” campaign does not research the target audience well enough to understand what will motivate them to make changes in their lives.

While the advertisements of the “Change4life” campaign make an attempt to fulfill the principle of social marketing theory by creating a symbolic image to support the promise, the use of cartoon-like dough figures portrays an entirely unrealistic situation. Furthermore, the ads use many exaggerated and preposterous behaviors to support how unhealthy food and sedentary lifestyles affect our health. In one ad, the child opens a slide fastener on his belly to let his parents see how much fat is deposited in his intestinal tract. And in another ad, parents feed the child dishes with a truck: they load sausages and other unhealthy food on a truck and pour them onto their child’s dining plate. These unrealistic images and exaggerated, preposterous behaviors undermine people’s willingness to change behaviors. They also fail to increase parents’ understanding of unhealthy lifestyles because they convey information that only when you feed your child with dishes as large as a truck load does your family experience unhealthy lifestyles and your child become obese.

Failing to apply advertising and marketing theory appropriately undermines the effectiveness of the “Change4life” campaign in changing unhealthy lifestyles of families.

Section 3: A Reformulation of the “Change4life” campaign

This section proposes an intervention which addresses the three flaws of the “Change4life” campaign. The proposed intervention acknowledges that people do not behave rationally and are influenced by many environmental and social factors. It uses two techniques: asymmetrical paternalism (13) and marketing theory (24) to modify the three flaws we mentioned in the previous sections.

Asymmetric paternalism is asymmetric in the sense that it helps individuals who are prone to behaving irrationally without affecting those individuals who are making informed, rational decisions (13). It changes behavior without limiting individuals’ freedom of choice (13). Asymmetric paternalism is paternalistic in the sense that it helps people to achieve their own goals(13).

First, the proposed intervention uses asymmetrical paternalism to address different biases which make behavior irrational.

To address the status quo and default options biases, the proposed intervention would replace the soft drink with a bottle of water as a default, with soda serviced only on request. With soda as a default drink in most chain restaurants currently, people usually choose soda because of status quo and default options. Replacing soda with a bottle of water will preserve the freedom of choice while potentially make a change in beverage consumption behavior(13).

To address time preference, the proposed intervention would position soft drink vending machines in obscure places and serve healthy food in convenient containers that could be obtained and consumed quickly in schools(13, 27). To place soft drink vending machines in obscure places will help to address time preference because people will not constantly have to choose whether or not consume them(13), which requires and depletes the will power of choosing healthier alternatives. Also, to serve healthy food in convenient containers that could be obtained and consumed quickly in schools would allow children to choose healthier food in a more convenient way and leave them free time for other desired activities. It changes short-term incentives rather than requiring them to make decisions based on consideration of a long-term best interest (13).

Second, the proposed intervention uses asymmetric paternalism in several ways to address the flaw of the “Change4life” campaign of failing to incorporate some important environment and social influences into the campaign.

Price is an important factor which can influence people’s food consumption (15). The proposed intervention has recognized the influence of prices on behavior and would increase the prices of unhealthy food while decrease the prices of healthy food. This method uses asymmetric paternalism to increase the opportunities for healthy food to be chosen without depriving people’s freedom of choice.

The proposed intervention also realizes that school environment and food marketing are two important factors which can influence children’s behavior. Children will give up having their lunch at schools if the queues at the school lunch room are too long and will opt to choose fast food in order to have free time to resume other activities (16). Therefore, the proposed intervention would serve healthy food in convenient containers which will shorten the queues at the school lunch rooms and nudge children into making healthier decisions (28). Also, the proposed intervention provides a nudge towards making healthier decisions by limiting advertising of fast-food in children’s programs and decreasing fast-food advertising in school computer screen savers, yearbook pages, school media channels, and textbook covers. Instead, it would play more advertisements of healthy food in children’s programs and advertise more healthy food in the school environment. In addition, the proposed intervention would cooperate with supermarkets to place unhealthy products in obscure or inconvenient places and put healthy products in the middle of shelves which they are easier to see and more convenient to reach. When people go shopping in supermarkets, many people hurry to take what they need and then check out. People do not have enough time to go around the whole supermarket. Most time, people would choose what are arranged in the middle of shelves. Actually, this method takes advantage of default options and time preference biases because people would take the products on middle of shelves as their default options and weigh more on current time-savings.

The proposed intervention would build a walking school bus system (27) to allow children who live within 30 minutes walking distance to schools have opportunities to walk more.This optional project supplies to children who would like to walk an opportunity to make their own decisions and do not harm other children’s freedom of choice.

The asymmetrically paternalistic intervention may meet with resistance from fast-food companies whose revenue will be undermined. Therefore, we need to consider whether legally mandating is necessary to implement this intervention. Given that the “Change4life” is a national public health campaign which incorporates the efforts of government, the government should work out a practical and effective strategy to ensure the implementation of the proposed intervention.

Another component of the proposed intervention is appropriate application of advertising and marketing theory. The proposed intervention recognizes that health is not the most important thing to most people(24), therefore, it would use core values such as control, freedom and physical attractiveness rather than health, as the promises to fulfill people’s deep aspiration and motivate people to make changes in their lifestyles(24,29). In addition, the proposed intervention would abandon cartoon-like dough figures to support the promise and stop playing the set of advertisements using cartoon-like dough figures. Instead, it supports the promises it makes to people through both attractive images and real stories which will make people believe in the promises and finally convince people to change their behavior.

The advertisements of proposed intervention consist of two subthemes: “being yourself” and “joining us”. Two sets of advertisements provide different promises to different target audience. The advertisements of “being yourself” part will use physical attractive, beautiful images to advertise or invite parents who themselves or their children had got the benefits of control, freedom and physical attractiveness by choosing healthy food and doing exercise in their real lives to tell their stories. It promises to parents that by choosing healthier lifestyles, their family will become physical attractive, free and can control their own lives. In addition, the advertisements of “joining us” suggest that fast-food companies are manipulating our lives by duplicity. They cover up the facts about high calories, sodium and fat in their products in their commercial ads and deprive people of control and freedom of their lives. This set of advertisements focuses on young children for whom independence and rebellion are important (30). This set of advertisements conveys the promise that choosing healthy food (joining us) actually is rebelling to the duplicity and manipulation of the fast-food companies and getting control over our lives again. Images of young people who are fighting with fast-food companies and controlling their own lives would be used to support the promise.

The real stories of people who suffered from being obese and subsequent health problems are also given by the advertisements of proposed intervention. It would help to address the unrealistic optimism bias. Parents will decrease the unrealistic optimism and realize their family’s equal opportunities to become obese through deeply impressed by real stories and images.

The proposed intervention realizes that we can not take away people’s ownership of old behavior without giving them an alternative option (25,26). Control over life, freedom, attractiveness, independence and rebellion are provided by the proposed intervention to exchange people’s old behavior.

Conclusion

The “Change4life” campaign assumes food consumption and physical activity behavior are rational, fails to consider some important environmental and social influences on behaviors and fails to apply advertising and marketing theory appropriately. Therefore, it is unlikely to realize its objective and change people’s unhealthy lifestyles as it expects. With modification in several aspects, including using asymmetrical paternalism to address the irrational behaviors of population, incorporating important environmental and social influences and nudge people into making healthier decisions as well as applying advertising and marketing theory appropriately, “Change4life” can take some effects to change families’ unhealthy lifestyles but still needs to find out more effective strategies to reach its goal.

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Drug Abuse Resistance and Education (D.A.R.E.): A Failed Health Intervention – Pierre Cornell

Introduction

The iconic slogan, “D.A.R.E. to resist drugs and violence,” is printed across black t-shirts and mugs across the United States. The campaign D.A.R.E., or Drug Abuse Resistance Education, is a police officer-led series of lessons taught to children in classroom-based settings [1]. The lessons are taught to children anywhere from kindergarten all the way up to the twelfth grade [1]. The lessons work to prevent children from using illegal drugs, joining gangs, and participating in other violent activities. There are four facets to the curriculum: providing knowledge about drug and alcohol use, teaching effective decision-making skills, offering alternatives to substance use, and teaching children how to deal with overt and subtle peer pressures [1]. Currently, 75% of the United States school districts and numerous other countries around the world have adopted the program [1].

The program began as a national non-profit organization that was founded in 1983 by Los Angeles Police chief Darryl Gates and Glenn Levant [1]. One of the main problems faced by the LA Police Department at the time was narcotics-related crime. Chief Gates believed that uniformed police officers had the training, the experience, and the background needed to teach school-aged children the adverse effects of drugs and violence [1]. Today, D.A.R.E. continues to be run by a national board of executives in California.

Although D.A.R.E. is found throughout the United States and programs have been instituted internationally, studies have consistently shown that the curriculum is ineffective in reducing the use of illegal drugs in children and adolescents. A study that was conducted by a North Caroline research firm, The Research Triangle Institute (RTI), and funded by the federal Bureau of Justice Assistance, found that D.A.R.E. significantly failed to reduce drug use among students that had participated in the curriculum [2]. Emphasis was placed on the idea that D.A.R.E. was taking the place of a potentially more effective intervention. A randomized longitudinal field study conducted at the University of Illinois at Chicago, found that there was statistically no difference in children that had participated in the program from those that had not participated in the program, in terms of recent and lifetime use of drugs and alcohol [3]. A third study conducted at the University of Kentucky analyzing 10-year follow-up on students that had participated in the D.A.R.E. program, found that in none of the cases was there any improvement in actual drug use, drug attitude, or self-esteem improvement in any of the study subjects [4]. None of the studies addressed the influence of D.A.R.E. on violence as an outcome measure. Numerous other studies in the literature have shown that D.A.R.E. does not effectively prevent drug abuse, the attitudes of drug use, or alcohol consumption in children and adolescents. D.A.R.E. remains to be a controversially utilized intervention.

The program was implemented in the early 80’s when no other program addressed drug use and violence in youth. More money was allocated to the program’s growth until the program grew in recognition and became institutionalized within the school system. Parental and community support came without any evidence for efficacy for lack of an alternative.

Three main areas of interest arise in an investigation behind why the D.A.R.E. program fails to be successful. The arguments are mainly based on the social implications that affect adolescent substance abuse. The first argument draws upon the notion that the program does not take into account peer norms and how they influence the behavior of adolescents. The second argument places the importance of preventing adolescent drug abuse on parental influences. D.A.R.E.’s curriculum leaves no room for parental interaction. Therefore, the program fails to address a highly significant factor that affects adolescent drug use. The third argument presented here, discusses that the program does not take into account the core values of children and adolescents. In fact, D.A.R.E. might go against the core values of youth thus, pushing youth away from the desired message of the intervention. The acceptance of an ineffective drug program into the school system prohibits effective programs from being instituted and has grave implications for the health outcomes of future generations.

Critique Argument 1

One of the main social factors that D.A.R.E. fails to address is the perception of peer use of illegal substances. A study conducted at Weill Cornell Medical College found that perceived friends’ drug use, perceived peer smoking norms, siblings’ smoking, and refusal assertiveness were most directly related to substance abuse in inner city adolescents [5]. The study suggests that if youth have the perception that their peers are using illegal substances and drug use is a norm among that age group, then they are more likely to use illegal substances. Statistics from the CDC show that only 20% of high school students had reported smoking a cigarette in the past 30 days [6]. Fewer than 20% of adolescents have reported ever using any illicit drug [6]. Therefore, the majority of America’s youth are not participating in smoking and drug use. Throughout the multiple-lesson curriculum, the D.A.R.E. program conveys the idea that there is a substantial problem of drug use among adolescents. Constantly conveying the message that drug use is high among peers suggests to them that drug use among peers is a norm. This in turn, would cause more drug use among those adolescents that are going through the D.A.R.E. curriculum. For D.A.R.E. to be more effective in preventing drug use, a different approach should be used in which peers are shown not to be using drugs or participating in violence.

An increase in perception that drug use among peers is a norm could have grave implications for peer pressure. The D.A.R.E. program teaches methods to avoid peer pressure, but if adolescents perceive that drug use is common among peers, they will be more likely to engage in undesirable activities. Furthermore, the didactic method of learning how to deal with peer pressure in the classroom does not reflect what occurs in the heat of actual situations. Although, D.A.R.E. works to teach youth how to deal with peer pressure, the program fails to address other social factors that could affect how and when adolescents succumb to such peer pressure. Perceived social norms could encourage adolescents to act irrationally, even when lessons are aimed at teaching youth how to act rationally in given situations.

Critique Argument 2

A second social factor that fails to be addressed by the D.A.R.E program is the influence that parents have on their children with regards to drug abuse. Numerous studies have shown that parental smoking and parental attitudes toward smoking are associated with smoking initiation among children [7]. Reasons that have been attributed to the elevated risk of adolescent smoking among adolescents whom have parents that smoke include, increased availability of cigarettes for adolescents to access, increased curiosity to try smoking, and premature nicotine dependence from elevated exposures to second-hand smoke [8]. Increasing the awareness of parents to the detrimental effects of their smoking habits on their children’s health could help to reduce some of the factors that contribute to the elevated risks of drug use among these parents. D.A.R.E. police officers have no contact with parental figures at any time within the curriculum. Although, the curriculum teaches conventional methods of resisting peer pressure from friends and community members, D.A.R.E. fails to address pressures that could arise from the lack of parental support. There is less likely to be a change in parental behavior due to D.A.R.E. when in fact, parental behavior is directly related to the behavior of their children. An intervention that increases parental awareness of drug abuse among their children would help to decrease drug use among youth.

Numerous other factors that affect the ability of parents to support the prevention of drug abuse among children include socioeconomic factors, availability of drugs within schools, neighborhood safety, institutional racism, and discrimination. D.A.R.E. fails to address any of the secondary factors that might decrease the ability of parents to support a drug free existence for their children.

Critique Argument 3

The ideology of D.A.R.E. that uses police officials to teach drug and violence resistance goes against the core values of America’s youth. Advertising theory suggests that incorporation of the audiences’ core values into the promise of the intervention is essential for success. The didactic method of teaching youth about drug use has had the potential to result in the complete opposite outcome intended by the intervention.

“Youth involvement” was one of the main aspects of designing Florida’s “Truth” campaign that made it highly successful. The team that was assembled by Florida’s Department of Health to confront tobacco use in Florida’s youth began development of the program by convening a 500 person youth summit to gain insight into the core values of America’s youth and to learn what would be the most effective methods of reaching out to children and adolescents. With regards to gathering information, one of the team members writes, “Interviewers used bad language and, without really trying, were seen as peers. Trust was built in the information gathering stage that went well beyond any interaction in a focus group. Trust led to real answers.” (11) From the research of youth core values, the team found that having control of one’s life, rebellion, and making independent decisions was of utmost important. The team member writes, “…Youth told us that they did not want to be told what to do. They wanted ‘the facts’ and then to be left to make their own educated decision. If we were to be successful, ‘truth’ could not preach. ‘Truth’ needed a message other than ‘don’t’ (11).” Designing interventions around the core values of the target population is critical for the success of the intervention.

Unlike the ‘truth’ campaign, D.A.R.E. failed to take into account the core values of America’s youth. Adolescents have to constantly deal with peer pressure for drug use. Having an authoritative figure preaching “don’t” with regards to drug use, goes against the core value that the research behind the ‘truth’ campaign found to be most important. According to advertising theory, the core values of the audience are vital when giving the promise of an intervention. One facet of the D.A.R.E. curriculum that goes against the ideas behind advertising theory consists of students signing a pledge against using drugs [1]. The mandatory pledge communicates a restriction to youth, whereby going against the core values of independent decision making and revolting against authority. Furthermore, D.A.R.E.’s slogan “Just Say No” is a direct order toward changing behavior. A direct order for behavior change does not work with children and adolescents. The boomerang effect of drug use during a time when D.A.R.E. was the most highly used drug intervention for children in that age group is attributable to deviations from advertising theory. The structure of D.A.R.E. unknowingly branded itself as an intervention to tell youth how to act and how to behave with unsuccessful outcomes.

Proposed Intervention

A more successful alternative intervention to D.A.R.E. would take into account key aspects from the Social Science Theories. The intervention would have to address peer pressures, family influences, and youth core values. The issues would be addressed by increasing youth understanding that the majority of peers are not engaging in drug use, by increasing youth awareness that drug use would interfere with preferred lifestyles of the youth, by increasing parental awareness of their children through program involvement, and increasing community involvement within the implementation of the program.

The proposed intervention allocates interaction time between younger and older students to discuss matters that need to be addressed by the program. Instead of having a 10-week curriculum like D.A.R.E. where an official police officer teaches lessons, the alternative intervention would allocate one or two months where high school students could interact with middle school students and college students could be brought in to interact with high school students. For example, two college students and two high school students could work with a class of middle school students. The four students would come back to the same class weekly, to discuss and interact with the younger students. The idea being that older students would act as mentors to the younger students, with the emphasis of drug use. Multiple visits over a designated period of time would help to build a rapport between the students and the mentors. The mentors would go through similar training that D.A.R.E. officers go through, so that similar messages are given within the interactions.

Teachers, parents, and community members would facilitate the interactions between students. Although, these members would be included to facilitate the interactions, emphasis would be placed on the students organizing the discussions and the activities that occur during the interactions. Teachers, parents, and community members could also be involved in selecting the older students that would come to talk with the younger students through the program. The facilitators could help to design the activities that the older students utilize with the younger students to work towards the prevention of drug use. Also, the facilitators act as chaperones to lend support to all of the participants within the program.

All of the interactions would have the central theme of having the older students discuss drug use with the younger students. The interactions could begin in the classroom with discussions between the mentors and the students. Activities could be designed to have the older students teach the younger students how to react in certain situations where peer pressure could arise. Interventions could also be designed where older students and younger students can interact outside of the classroom. For example, a meeting could be scheduled to allow free ice-skating at a local ice-skating rink with older and younger students. The older students could then discuss alternatives to drug use with the younger students. Ultimately, the way the interactions are set up would depend on the mentors that are chosen to participate in the program and the kinds of things they would want to instill on the younger students. The interactions would also depend on the community and the involvement of the community. For example, a program committee meeting could be designed in communities to allow for community members to help support youth. Mentors can come to committee meetings and work to design activities for the youth.

Students could also receive benefits for being mentors within the program. The program could serve as a good volunteer program similar to The Big Brother program. Otherwise, college credit might be given if short curriculums are designed and implemented by the student. The benefits associated with instilling proper behavior with regards to drug use and gaining experience working and educating young children would be incentive enough to participate as a mentor in the program.

Defense of Intervention Section 1

The proposed alternative intervention would address the issue of perceived social norms among adolescents. Students would be able to see older mentors that live drug free and hear mentors discuss that drug abuse is low among their friends. Open discussions of drug use would allow perceptions of drug use among peers to be more transparent. Emphasis can be placed on conveying the fact that only a small percentage of youth actually engage in activities that involve drugs.

Students working with other students in the prevention of drug abuse would boost confidence levels among the younger students. If younger students can be taught techniques of avoiding succumbing to peer pressure from older students, then the younger students would be better able to handle hot situations where there is peer pressure among peers their own age. The interactive nature of student mentors teaching younger students allows for a more realistic environment for younger students to learn how to deal with peer pressure situations. Having a police officer teach younger students how to act in peer pressure situations is not relatable and would be less effective, than if lessons were coming from student mentors.

Defense of Intervention Section 2

Family involvement is a key aspect to the prevention of drug abuse in youth. Using family members as facilitators would help to increase parental awareness of drug abuse among their children and the ill effects that their smoking has on the health of their children. Although, increasing awareness does not necessarily mean smoking cessation, but increased awareness might work to reduce the leaving cigarettes around for their children to find for example. Increasing parental awareness would also help to engage parents in activities that children are participating in at school. Supporting the prevention of drug abuse at home is as important as preventing drug abuse among peers.

Community committee meetings would also work to increase involvement and dissemination of information produced by the program. One of the strengths of D.A.R.E. is the program’s popularity, political support, and wide availability. Community committee meetings would be a good way to gain community support for the program and increase awareness of drug abuse occurring within the community. Similar to Neighborhood Crime Watches, increased community involvement in the prevention of drug abuse could help to lower rates of drug use within that community.

Defense of Intervention Section 3

The alternative intervention refrains from using a didactic method of teaching youth as found in the D.A.R.E. program. Rather, an interactive method between youth is used to convey the message that smoking and drugs are not commonly used among students. A comparison of D.A.R.E. with a more interactive drug abuse program, All Star, found that students were more committed in the program outcome and showed a greater potential for influencing targeted problem behaviors [10]. The program All Star used classroom teachers to discuss drug abuse. The idea that an open discussion with someone more familiar, as a teacher or community member might be more beneficial than speaking with a police official, as done in D.A.R.E.

The interactions that occur between students in the proposed alternative models also bring into account the core values of America’s youth. While D.A.R.E.’s curriculum is designed by a board of executives and implemented by police officials, the alternative model allows for the core values of youth to be expressed by the mentors. The mentors are able to design lessons and portray the message that they think is most beneficial to those taking part in the program. The mentors within the program are closer in age or generation of those that they are teaching. Therefore, many of their core values will coincide. The positive message of resisting drug abuse and violence can be conveyed, while maintaining the core values that youth find the most important. If younger students see older students not using drugs, they will get the impression that that is the norm. Therefore, the younger students will be more likely to adopt the behavior of the mentors. Also, the student mentors can emphasize the importance and desirability of participating in other activities for example, school sports and clubs. Shared core values between the mentor those being taught would increase the commitment to the program and influence behavior in a positive way towards the prevention of drug abuse.

Conclusion

D.A.R.E. is one of the most widely accepted youth drug programs in America. Although, numerous studies have shown that the program is ineffective in reducing drug use among youth, the program is still institutionalized into our nation’s school system. The failure of D.A.R.E. results from the exclusion of incorporating social factors into the curriculum and the failure to understand youth core values. If an intervention can be designed in which the resistance of drug use is portrayed as a peer norm and family awareness can contribute to the prevention of substance abuse, than better outcomes would ensue. Furthermore, community involvement would help to address the larger societal influences that could affect adolescent drug use. New, effective, evidence-based programs that address social issues need to take over the role that D.A.R.E. has had in American over the past 20 years.

References

1. About D.A.R.E.: New D.A.R.E.. (n.d.). http://www.dare.org/home/about_dare.asp Accessed December 4, 2009
2. Ringwalt CL, Greene JM, Ennett ST, Iachan R, Clayton RR, Leukefeld CG. Past and Future Directions of the D.A.R.E. Program: An Evaluation Review. Research Triangle Institute. September 1994. National Institute of Justice, Office of Justice Programs, U.S. Department of Justice.
3. Rosenbaum DP, and Hanson GS. Assessing the effects of school-bsed drug education: A six-year multi-level analysis of project D.A.R.E.. Department of Criminal Justice and Center for Research in Law and Justice 
University of Illinois at Chicago 
April 6, 1998
4. Lynam DR, Milich R, Zimmerman R, Novak SP, Logan TK, Leukefeld MC, and Richard C. Project DARE: No Effects at 10-Year Follow-Up. Journal of Consulting and Clinical Psychology. 1999, Vol. 67, No. 4, 590-593
5. Epstein JA, Bang H, Botvin GJ. Which psychosocial factors moderate or directly affect substance use among inner-city adolescents. Addict Behav. 2007 Apr; 32(4): 700-713
6. National Center for Health Statistics. Health, United States, 2008. Hyattsville, MD, 2009
7. Winlinson AV., Shete S, Prokhorov AV.. The moderating role of parental smoking on their children’s attitudes toward smoking among a predominantly minority sample: a cross-sectional analysis. Substance Abuse Treatment, Prevention, and Policy. 2008, 3:18
8. Gilman SE, Rende R, Boergers J, Abrams DB, Buka SL, Clark MA, Colby SM, Hitsman B, Kazura AN, Lipsitt LP, Lloyd-Richardson EE, Rogers ML, Stanton CA, Stroud LR, Niaura RS. Parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control. 2009 Feb;123(2):e274-81.
9. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control. 2001; 10:3-5
10. Harrington N, Hoyle R, Giles SM, Hansen WB . The All Stars Prevention Program. http://www.tanglewood.net/projects/teachertraining/Book_of_Readings/Harrington.pdf. 121-129

The Tip Of The Iceberg. Screening for Breast Cancer- New Recommendations- A Failed Intervention. - Taiwo Obembe.

Introduction- Breast Cancer and the USPSTF

Breast cancer is the most common cause of cancer in women and the second most common cause of cancer death in women in the U.S (1) While the majority of new breast cancers are diagnosed as a result of an abnormality seen on a mammogram, a lump or change in consistency of the breast tissue can also be a warning sign of the disease (1). Approximately 31 out of every 100,000 African American women die from the disease each year compared to 27 out of every 100,000 White women.(2) Breast cancer is the number-one killer of American women age 40 to 55, with a disproportionate disease burden borne by African American women.(3). In 2005, 186,467 women and 1,764 men were diagnosed with breast cancer while 41,116 women and 375 men died from breast cancer. (4) As devastating as the consequences of breast cancer can be when not handled aggressively, the trend of incidence and mortality has been declining for the past 7 years with about a range of 1.5%-2.5% in African American women and Hispanic Women while it has remained the same in Asian/Pacific and American Indian /Alaska Native women.(5)

USPSTF (U.S. Preventive Services Task Force)

The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, is a leading independent panel of nationally recognized non-federal experts in prevention and evidence-based medicine. USPSTF is made up of an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. The USPSTF is charged with making evidence-based recommendations on a wide range of preventive services. Task Force recommendations are intended to improve clinical practice and promote the public health. The Task Force's scope is specific: its recommendations address primary or secondary preventive services targeting conditions that represent a substantial burden in the United States and that are provided in primary care settings or available through primary care referral.(6). The USPSTF objectively weighs the risks and benefits of prevention, screening, and treatment, within and between a range of ages, while incorporating socioeconomic status and family history. Ideally an objective approach should lead to objective conclusions that should be accepted by the public. The USPSTF is therefore similar to a role model that should command a lot of trust, support and cooperation whenever they set recommendations for clinical and preventive services not only by Federal partner organizations (i.e. CDC-centre for disease control and prevention , US FDA –Food and Drug Administration and others) but also by the primary partner organizations (i.e. American Academy of Family Physicians (AAFP), American Academy of Nurse Practitioners (AANP), American Academy of Pediatrics (AAP), and others) and the population at large.

However, USPSTF just released a new set of breast cancer screening recommendations that have not been generally accepted by the parties that are all required to be in full support of its recommendations. It has only succeeded in arousing a major controversy that has led to a lot of organizations and people questioning its motives and rules of operation. Adversely, the response to the new recommendations for mammographic screening for breast cancer clearly demonstrates that the recommendations have not been well received. Today’s literature is filled with compelling arguments that current approaches towards research, programmatic evaluations, and published guidelines include social determinants of health as fundamental factors.(7)

In the previous guidelines for breast cancer (2002), the U.S. Preventive Services Task Force (USPSTF) recommended screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older. The new Guidelines (2009) released by the USPSTF recommend biennial screening mammography for women aged 50 to 74 years recommending against routine screening mammography in women aged 40 to 49 years.(8)
One fact is very certain - the rate of outcry and levels of disagreement and discordance amongst breast cancer organizations and the populace completely eliminates the possibility of unawareness to the advantages of early screening of breast cancer. On the contrary there is increased knowledge and willingness on the part of women to more likely wish for earlier and frequent screening opportunities. The strategy employed by the USPSTF for the dissemination of these guidelines is very deficient. If strategy is well planned and applied properly, its main consequence should lead to an adoption of the proposed innovation. However, a number of themes come into play in its implementation that are very important and that should be put into consideration including communication style and the social context. Proper framing is also important in a bid to an appropriate response especially with the glaring and disastrous consequences of a late detection of breast cancer.

Argument 1- Communication problems

While the recommendations of the USPSTF are considered to be the "gold standard" for clinical preventive services, the typical receipt of information conveyed by public authority is not well accepted.(9) The lack of emphasis on key variables such as family history and genetics, as part of their assessment was a major problem with the framework. Despite the evidence based and objective research behind the message, the information was not effectively communicated to the general public. Consequently, the media was able to step in and capitalize on the lapses fulfilling their own agenda. Programs for cancer control measures must be properly diffused and disseminated in order to effectively reach full potential. The lack of insight by the USPSTF to incorporate the current and heated debates on health care reform as part of the framework in which the new guidelines for breast cancer were made public did not enhance the chances of public acceptance for the new recommendations for breast cancer screening. The receipt of the new breast cancer screening guidelines was not only completely rejected, but it raised issues in the eyes of the public leaving many confused. Americans were left to wonder whether this was coming from the American Medical Association, or American medical consumerism. (10) In a news analysis article, published in the New York Times just days after the screening recommendations were released, a Republican Senator reflected the confusion well when she stated, “One life out of 1,904 to be saved, but the choice is not going to be yours. It’s going to be someone else that has never met you that does not know family history.”(11). The fact that major decisions pertaining to issues as important as mammography screening for breast cancer being dictated by USPSTF was clearly uncomfortable and unacceptable by her standards. The Reaction of the Senator and a greater percentage of the public can be best explained by the ‘Psychological Reactance Theory’. According to the theory, there are 4 components: Perceived Freedom, Threat to freedom, Reactance (usually emotional) and a restoration to freedom. There was an initial freedom to screen by age of 40, then suddenly with the pronouncement of the new guidelines, a lot of people felt that they were about to be deprived of this privilege and freedom leading to the clamor and the reactions. It is also evident that most people have decided that they will ignore the new recommendations and go ahead with the old.

The ability to draw the conclusions between the guidelines and the truth behind the political debates on health care was not the intention. However, a necessary link between the two was missing. The publication containing the new guidelines enforced the fact that the task force did not discount benefits or include costs in their analysis, although the average number of mammograms per woman (and false-positive results) provides some proxy of resource consumption.”(12) The framework had to provide the link to the politics and that did not occur. Nowhere was it clear that the House and Senate have agreed that when passed, the bill would establish commission to research the effectiveness of medical tests and procedures but WOULD NOT mandate that those findings be translated into clinical practice. (11) (In other words, the health care reform would actually provide flexibility for the patient’s doctor to practice as he/she saw fit.

A second contributor to the public rejection of the new breast cancer screening guidelines was the role of the media in worsening the communication problem. The poor communication with the public created an open door through which the media was able to capitalize on- seizing the communication lapse to sell news. The agenda of the media is to sell news. They cannot publish blatant lies; however, they do leave room for a lot of questions. The media was provided with the opportunity to take advantage of and exploit the present controversy in order to achieve benefits by way of financial gain and increased ratings.

In 1997, a study was conducted to explore the effect of mass media on women who had been diagnosed with cancer. The researchers concluded that there were some advantages as well as a number of disadvantages of mass media in spreading health information. Subjects concluded that mass media sources were able to portray the disease as frightening and depressing, contributing to the idea of the disease as negative and sensationalized to the public. (13)
Another public view resulting from mass media is one where the disease and screening guidelines are under the influence of government. The reaction is based upon the portrayal by the media that science is influenced by politics. A perfect representation of the confusion about policies around a disease provided through mass media is a recent quote from by a Republican Senator in response to the announcement of the guidelines. According to the article, he was quoted as stating, “This was based mainly on cost.” The truth is, he was actually completely wrong, but the media never mentioned he was the only veterinarian in the senate and may not have been the best representative of the senate to be responding to the confusion that had been created by the media in the American public. Had the public known the details, perhaps the statement would not have been so compelling. (14).

Argument 2- Lack of Involvement and Collaboration with Opinion Leaders

Diffusion of innovation is enhanced through community organization by opinion leaders. The diffusion of innovation model describes the way an idea or product enters a social system and is "adopted” by groups of people within that system. (15). Considering the recent announcement of the new breast cancer screening guidelines, not only were the guidelines lacking the framework for proper dispersion, there was another issue hindering the public’s acceptance. There are some key players in the field of cancer research and cancer organization that publicly announced their lack of support of the new guidelines. The combination of the sudden introduction of the new guidelines with the general disapproval of most cancer organizations and physicians (the “opinion leaders” in this case) leaves no room for anything other than more confusion in the public eye. The news reports that came out on the following day only added to the confusion showing a clear division between many key players.

On one hand, The American Cancer Society and the American College of Radiology both said they were maintaining their current guidelines which advise annual mammograms starting at age 40. Then The National Cancer Institute was on the fence stating, “It was re-evaluating its guidelines in light of the task force’s report”. On the other end of the spectrum, the president of the National Breast Cancer Coalition believes that, “This is our opportunity to look beyond emotions. The task force is an independent body of experts that took an objective look at the data.” Other advocacy groups, like the National Breast Cancer Coalition, Breast Cancer Action, and the National Women’s Health Network, welcomed the new guidelines as well. (16) The challenge of persuading patients and doctors to accept such standards requires a transformational shift in thinking, particularly when the disease involved is as prevalent as cancer. The support of the new guidelines by ALL of breast cancer organizations, associations, and subgroups is imperative. These groups are a source of support and information for individuals; they tie between task force and communities, and ultimately individuals together. If the organizations do not publicly support the USPSTF, the public is only going to wonder why they should.

The practical effects of the task force recommendation, under the health care reform bill, might be to increase the number of insurance policies that require a co-payment for those early tests unless a woman’s doctor intervened to say that they were needed. Unfortunately, lack of a solid framework including key topics and links to particular factors, had to be established and concisely conveyed. The fact that the task force was unable to do this left the public without a solid groundwork upon which to rapidly accept these proposed changes.

Argument 3 Loss of focus and strategy- Social, biological and cultural factors ignored

The task force neglected to address the fact that breast cancer is part of complex ecological social environment. (17) The USPSTF recommendations focused largely on non-medical and non-scientific aspects- ignoring the social and biological context associated with the disease. The main reasons of the task force’s new recommendations according to a New York Times release were the risks caused by over diagnosis anxiety; false positives test results and excess biopsies. (18). These were the major issues put into consideration during the review for the newly released guidelines.

Breast cancer is a disease with many risk factors ranging from biological to social factors. These include –
• Family history in first degree relatives,
• Age: (increased risk with age),
• Personal history of breast cancer:
• Certain breast changes (Having certain types of abnormal cells (atypical hyperplasia and lobular carcinoma in situ [LCIS]) increases the risk of breast cancer.)
• Gene changes: Changes in certain genes increase the risk of breast cancer. These genes include BRCA1, BRCA2, and others.
• Reproductive and menstrual history:
o Woman’s age at first delivery, early menarche (age<12),>55years), women on menopausal hormonal therapy with estrogen are all associated with increased risk.
• Race: Breast cancer is diagnosed more often in white women than Latina, Asian, or African American women.
• Radiation therapy to the chest: Women who had radiation therapy to the chest (including breasts) before age 30 are at an increased risk of breast cancer. This includes women treated with radiation for Hodgkin's lymphoma.
• Breast density:
• Taking DES (diethylstilbestrol): Women who took DES during pregnancy may have a slightly increased risk of breast cancer.
• Being overweight or obese after menopause: The chance of getting breast cancer after menopause is higher in women who are overweight or obese.
• Lack of physical activity: Women who are physically inactive throughout life may have an increased risk of breast cancer.
• Drinking alcohol: Studies suggest that the more alcohol a woman drinks, the greater her risk of breast cancer. (19).

Considering the myriad of risk factors associated with the development of Breast cancer compared with the factors considered by the USPSTF, it is evident that the social , biological and cultural context surrounding the recommendation of the new guidelines was completely omitted and not given due consideration. The reasons for the new guidelines were not solid as most studies found that women who had a false-positive mammogram were just as likely to undergo subsequent mammography screening as women who did not have a false-positive mammogram. Overall, these studies found that false-positive mammograms were associated with a small increase in generalized anxiety and depression during the evaluation period, which resolved quickly after the evaluation, was completed.

Over diagnosis occurs when screening identifies cancer that would not have become clinically evident during a patient’s lifetime. Small cross-sectional studies suggest that women diagnosed with DCIS experience some emotional duress such as sleeplessness and anxiety, but how long these symptoms persist or their effect on overall quality of life is not known. (20) So, why should a reputable and federally appointed advisory panel –backer of science driven medicine base new recommendations on factors that are equivocal rather than well proven scientific facts?
The manner in which the new recommendation was introduced was very brusque with no diplomacy or strategy involved in its dissemination. The Advertising theory for instance emphasizes that people are generally influenced by large promises. The promises involving 2 main components: The product and the benefits (which should be supported with appropriate and relevant images, symbols and stories. (21). The USPSTF obviously did not employ any strategy with the release of the new recommendations.

PRAGMATIC INTERVENTION

Considering the discussed flaws in the approach above, I would like to propose a community organization approach for dissemination of new breast cancer screening recommendations. The new guidelines proposed by USPSTF for breast cancer screening were not entirely wrong. However, the manner in which they presented the issue was very questionable. I would like to use the community organization approach re-address the flaws that were highlighted above. The community organization theory is a process through which community groups are helped to identify common problems, mobilize resources and develop strategies to reach collective goals. Strict definitions of community organizing assume that the community itself identifies the problems to address (not an outside agent). Community organizing projects start with the community’s priorities, rather than an externally imposed agenda and are therefore more likely to succeed.

Community organizing is consistent with an ecological perspective in that it recognizes multiple levels of a health problem. It can be integrated with Social Cognitive Theory (SCT) based strategies that take into account the dynamic between personal factors and human behavior.

The Community Organizing theory involves three models, which may overlap or be combined.
1. Locality development-(or community development) is a process oriented. With the aim of developing group identity and, it focuses on building consensus and capacity.
2. Social Planning- is task-oriented. It stresses problem solving and usually relies heavily on expert practitioners.
3. Social Action- is both process and task oriented. Its goals are to increase the community’s capacity to solve problems and to achieve concrete changes that redress social injustices.

These different approaches broadly classified as community organizing share in common several concepts that are key to achieving and measuring change. They include;
• Empowerment- that describes a social action process through which individuals and organizations, or communities gain confidence and skills to improve their quality of life.
• Community capacity that refers to characteristics of a community that allow it to identify social problems and address them(e.g. trusting neighbors, civic engagements, corporate organizations and the medical personnel)
• Participation in the organizing process that helps community members to gain leadership and problem-solving skills.
• Relevance involves activating participants to address issues that are important to them.
• Issue selection entails pulling apart a web of interrelated problems into distinct, immediate, solvable pieces.
• Critical consciousness emphasizes helping community members to identify the root causes of social problems.(22)

A. How the Intervention can be used to address the Communication problem.

The intervention can be used to address the problem of miscommunication if USPSTF started off by developing a group that shares a common identity either in the form of beliefs or personal experiences. The group would comprise of people who believe strongly that the recommendation to start breast cancer screening by age 50 carry a greater percentage of the unit. USPSTF may go further to incorporate women who have had slightly negative experiences resulting from early and unneeded mammographic screening. The members of the group with these bad experiences would help to re-in force more effectively by the time the general public are allowed to see vivid examples of people who have suffered from the adverse effects of early screening for breast cancer. The general belief and acceptance that screening after the age of 50 can only then be gradually but effectively changed as people are allowed to share the views amongst each other. The concept of ‘’community development ‘’here in tackling the communication problem experienced by USPSTF can be further re-addressed with media advocacy. Media advocacy is an essential tactic in community organizing. It involves using the mass media strategically to advance public policies. The media help to set an agenda for the public and policy makers.(23) Hence by involving the media directly, the chances left for the media to manipulate information in such a way as to best suit themselves would be reduced drastically.

B. How the intervention addresses the involvement of opinion leaders


The opinion leader is the agent who is an active media user and who interprets the meaning of media messages or content for lower-end media users. Typically the opinion leader is held in high esteem by those that accept his or her opinions. Opinion leadership tends to be subject specific, that is, a person that is an opinion leader in one field may be a follower in another field. Individual whose ideas and behavior serve as a model to others. Key opinion leaders (KOLs) are physicians who influence their peers' medical practice, including but not limited to prescribing behavior. Pharmaceutical companies generally engage key opinion leaders early in the drug development process to provide advocacy activity and key marketing feedback. Key opinion leaders generally belong to a specific area of expertise, such as oncology, cardiology, diabetes, or sometimes do specialized work in very important therapeutic areas such as Colorectal Cancer (CRC), Non Small Cell Lung Cancer (NSCLC). (22) Hence the USPSTF needed to have incorporated the involvement of some opinion leaders into the group to disseminate the message of the new breast cancer guidelines.

The doctor for instance is the first person any confused patient would probably turn to for answers regarding any breast changes and if the doctor has been incorporated into the cancer awareness group, the confusion and the rate of opposition wouldn’t have been as significant and as controversial as it is presently. Some members from the various cancer organizations i.e. American Academy of Family Physicians (AAFP), American Academy of Nurse Practitioners (AANP) American Cancer Association (ACA) and other primary partner organizations should be involved as Key opinion leaders. This would enhance some degree of uniformity and acceptance to the new guidelines after its release rather than the haphazard nature in which the primary partners responded to the present release - some emphasizing their dis-approval while others pledged their support to the new guidelines. The uniformity in agreement that was denied by the USPSTF approach would have done a better job in allaying the fears and anxiety of the public.
The opinion leaders (physicians) Key opinion leaders (i.e. ACA, AAFP etc) through a series of debates and deliberations and research would have been able to constructively reach a decisive and a more plausible outcome.

C. How the intervention may be used to address the Loss of Focus and strategy - Social, Biological and Cultural Factors.

The involvement of Physicians as opinion leaders and the involvement of Primary Partner Organizations as Key Opinion Leaders would have generally through a lot of debates, social planning and social action help to address and highlight the importance of scientific risk factors mentioned above as the key issues for consideration in setting new recommendations rather that anxiety, false positives, pain and increase biopsies. Highlighting the biological, genetic(BRCA1, BRCA2) , social( i.e. diet), familial risk factors as reasons for the new recommendations would also be very relevant as to convincing the public of the awareness to the scientific basis underlying development and predisposition to breast cancer. Incorporating a good, appropriate advertising program would help to further re-in force and drive home the intended messages of change.

Conclusion

Breast cancer is a disease that has adversely affected the lives of women in the USA and around the world. There is an increased need to control and check the incidence and mortality associated with the late detection of breast cancer. However it is also important to weigh the benefits of early detection with the risks of over-diagnosis, and radiation. The USPSTF has been very systematic and conscientious in carrying out its duties. The approach however in which some of its decisions are implemented would require following appropriate and applicable interventions i.e. community organizing approach in order that their decisions may be well accepted by the groups/parties involved.

References

1. MedicineNet.com available at http://www.medicinenet.com/breast_cancer/article.htm#tocb
2. World Health Organization, 2009Accessed at http:// World Health Organization. Screening for Breast Cancer. Geneva: www.who.int/cancer/detection/breastcancer/en/index.html on 8 September 2009.
3. Women's health fact sheet. Some Things Only a Woman Can Do: A National Campaign to Educate Women about Medical Research 2006 [cited; Available from: http://www.womancando.org/conditions/conditions.htm]
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