Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Tuesday, April 22, 2008

Why Blaming Parents Fails to Prevent Rx and OTC Drug Abuse Among Teens: An Analysis Of Downfalls In Using Upstream Framing – Valerie Kong

For years, public health campaigns have used billboards, television and print advertisements to reach out to a wide range of audiences. Recently, public health outreach campaigns began fighting with more and more pharmaceuticals for primetime spots to drive their sales on national television (1). Newly approved medications are now advertised on television and other media outlets to promote products directly to consumers (2). A recent national survey reveals an emerging trend of prescription (Rx) and over-the-counter (OTC) medication abuse becoming more prevalent than illicit drugs among teenagers (3). The study concluded with two major findings that were alarming outcomes to public health. Study data indicates there is a common misconception regarding the use of prescription drugs. Two in five teens believe that Rx medicines are “much safer” than using illegal drugs (4). In addition, only a third of parents speak to their teenagers about the risks of abusing prescription drugs (5). Partnership for a Drug-Free America (PDFA), a New York-based non-profit group, launched a new campaign to warn parents that their teenagers may be misusing medications (5). This campaign includes broadcasting ads on multiple expensive TV spots, as well as web content providing information on how to communicate the risks of abusing Rx and OTC drugs to teens.
The framing of public health campaigns can be classified in two categories: upstream frame and downstream frame. An upstream frame refers to campaigns that target the causes preceding the issue as a preventive approach, while a downstream frame aims to implement a resolution to rectify the issue (6). This paper will analyze the pitfalls of using an upstream approach to prevent teens from abusing prescription drugs.
Choosing the best frame or model is crucial when developing a public health campaign in order to achieve maximum effectiveness with increase in desired behavior changes. As a result of downfalls in campaign message, design and direction, the new PDFA campaign targeting parental influence with an upstream frame fails to prevent teens from abusing prescription and over-the-counter drugs.

Evaluating Teens’ Intention
Traditionally, many public health interventions use the Health Belief Model (HBM) based on the belief that knowing different health risks and benefits will lead to an intention to modify behavior (7). This model fundamentally supports programs and campaigns to rid these bad habits through educating risks and consequences of undesired behaviors (8). The PDFA campaign encourages parents to “educate, communicate and safeguard” their teenagers against abusing prescription and OTC drugs (5). The main message of PDFA campaign fails because it relies too heavily on the Health Belief Model and its constructs: perceived susceptibility and perceived severity. However, many teenagers capable of learning about different effects of Rx and OTC drugs through the internet already know of the potential side effects of medications (9). In this case, increasing the perception of how likely one is to result in the negative consequences from medication overdose may not be effective in preventing abuse.
The campaign’s attempt to raise awareness of this new trend of substance abuse focuses entirely on perceived susceptibility and severity using an authoritative stance. Previous abuse-prevention programs involving parents with an instructional approach experienced low parental participation, diminishing effect of behavior change on teens (10). Teenagers often view their parents as authority figures who understand little about what it means to be an adolescent (11); hence, targeting this sensitive issue with such a harsh tone impairs its receptivity.
This campaign draws attention to Rx and OTC medications made accessible to teens by their parents. But little emphasis is placed on the key element of adjusting the parents’ personal perspectives towards this abusive trend (12). Social norms, including parental attitudes on prescription drugs, influence how teenagers perceive the dangers of drug abuse (11). A study done by Slone Epidemiology Unit at Boston University School of Public Health found that “in any given week, the large majority of US adults take at least 1 prescription of OTC medication, and substantial numbers take multiple products.”(13, p. 344) Yet this campaign to reduce the rate of abuse among neglects the blatant factor of addressing the how adults exercise behaviors of self-medication casually. Without further investigation to understand causes of misuse in teens’ adult counterpart, this public health problem is likely to grow rapidly among both age groups. A campaign to educate teens about the dangers of abuse without attempting to reform the practice of frequent buying and taking Rx and OTC drugs among parents proves an incomprehensive solution.

Rethinking Teenage Decision-making
Many public health campaigns utilize models that are based entirely on a rational thought process (14). The Health Belief Model makes multiple assumptions that a person’s intention has a direct effect on behavior. Perceived severity and susceptibility may influence a person’s intentions, based on thoughtful weighing of cost and benefit. However, the strong desire to use prescription pain killers, similar to other substance abuse, may supercede the rational thinking. The design of this PDFA campaign fails due to an excessive reliance on rational decision-making.
In American society, consumers are given the right to choose from shelves of pills at their local pharmacies or convenience stores. In 2002, a poll of 1011 adult Americans found that many do not recognize the potential risks of taking OTC medicines incorrectly, stating that one in three adults -- over 64 million consumers, say they have taken more than the recommended dose of a nonprescription medicine (15). Humans tend to act readily on immediate feelings rather than use logical reasoning when engaging in health behaviors (16). Rational decision-making can fall short in cases such as substance abuse where instant gratification overcomes healthy intentions. Thus, following the cognitive model imposed by the HBM can be detrimental to the design of a successful campaign against abusive behaviors driven by irrational decisions.
As for teenagers, many of them are exposed to pharmaceutical advertising and information on the web about numerous categories of chemicals that react with the body differently such as stimulants and anti-depressants (9). The HBM does not account for these luring factors affecting teenagers to abuse who are well aware of harmful effects by taking prescription drugs without a doctor’s advice. There is a weak relationship between intention and action when impulse drives behavior among teens (17). Overlooking this flaw in the HBM makes this campaign less effective in preventing teenagers from becoming caught in the helpless spiral of abuse.

Fighting for Independence
As mentioned earlier, the PDFA campaign uses an upstream frame of targeting parents as the direct cause for Rx and OTC abuse among teens. The media ads created for this campaign point to parents as guilty offenders for bringing prescription and OTC medication into their homes, making it accessible to teens easily. In addition, the message of “educate, communicate and safeguard” encourages learning about the risks of abusive behaviors and promoting the concept of modeling behavior of teenagers after their parents (18). However, this depressing and negative emotion directed towards the parental figure opposes the idea of building a constructive relationship between parents and their teenagers set forth by the campaign’s main message. The direction of this campaign fails because it relies too heavily on parental modeling.
Developmental psychology studies suggest defiant behavior among adolescents is a common stage of teens’ desire to gain independence from their parents (18). During the teen years, the uptake of substance abuse as an act of rebellion is highly prevalent (19). Using parental modeling neglects the issue of rebellion that plays a big role in predicting teenagers’ behaviors. Teens receive pressures from school, peers, and family members to act and behave a certain way, and many lack the capacity to face each issue with maturity (20). Due to the rebellious nature of this younger population, the focus on parental modeling results in a futile attempt to influence behavior.
Besides the desire to oppose authority, teenagers tend to search for scapegoats and blame external factors for their actions (21). Buying into the campaign’s portrayal of parents guilty of making Rx and OTC drugs accessible permits teens to blame parents for their abusive behavior. Shifting accountability towards parents perpetuates risky behaviors by lowering self-efficacy among teenagers. This shift in responsibility leads teens into believing that parents are the primary cause for their abuse and lacks the ability to influence their own behavior. Not only does this aspect of the campaign fail to empower teenagers to take control of their own fates, but also generates a scapegoat for their risky behavior.

Looking Ahead and Asking Harder Questions
In analyzing approaches to improve the main message, design, and direction of this PDFA campaign, the following areas that require improvement should be addressed after reviewing the pitfalls.
Re-examining the gap between theory and reality can change how public health campaigns are developed. Involving models other than HBM to account for preventing impulsive behavior can make campaigns more relevant to lowering rates of prescription drug abuse among teens. Instead of choosing from traditional cognitive models of reasoned actions, PDFA should build messages to change attitudes of Rx abuse in both parents and teens. Public health messages need to bring in emotional attachment rather than intellectual lessons to influence the audience’s feelings towards the targeted behavior.
Reprogramming how formative research is conducted prior to developing the campaign can reveal how teenagers and parents begin to develop the practice of self-medicating and explore ways to change behavior in both groups (22). Understanding the motives and what drives teens to use Rx and OTC drugs provides deeper insight to external factors that impacts their behavior at a contextual level (22). Before accusing parents for neglecting their teens’ behaviors, detailed analyses are warranted to explore deeper motives which drive teens to abuse Rx and OTC drugs (20), which aids in determining the root causes behind this new trend of abuse.
After reviewing the pitfalls of this PDFA campaign, this analysis provides evidence that using an upstream approach to prevent Rx and OTC drug abuse among teens remains an ineffective approach. The growing teen population abusing Rx and OTC drugs calls for critical attention to provide resources for social scientists to innovate better models to predict health behaviors. Public health officials must consider these implications when developing policies that can have great impact on trends in Rx/OTC drugs misuse and abuse.

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