Challenging Dogma - Spring 2008

Limitations of Restaurant Nutrition Labeling in Promoting Healthier Choices and a Proposal for Increasing Its Effectiveness – Stacey Kokaram

2009-05-07T12:55:00.000-07:00

An increasing number of cities and towns across the US are requiring restaurants to provide nutrition information for their menu items (1, 2). Currently, the Nutrition Labeling and Education Act (NLEA) gives the Food and Drug Administration (FDA) the authority to require and regulate nutrition labeling for most food products regulated by the Agency (3). Over the past years, several pieces of legislation have been introduced in Congress to expand the FDA’s authority to also require nutrition labeling in restaurants (4). A recent observational study published in the American Journal of Public Health, showed that only 0.1% of patrons entering four popular fast-food restaurants referenced in-store available nutritional information (5). The study did not analyze whether the information had an effect on the food choices of these consumers. Nutrition labeling in restaurants would provide information for consumers to make healthier food choices but is only a small component of what is necessary to promote and support healthier eating among consumers.
This paper explores three key limitations that prohibit restaurant nutrition labeling from leading to healthy eating behavior. These limitations include: 1) the amount and accuracy of information posted; 2) the belief that intent to eat healthier will lead to healthy eating behavior; and 3) the lack of access to healthier food alternatives.

Nutrition Labeling Requirements & Accuracy
Many of the current restaurant nutrition labeling regulations require restaurants to post minimal nutritional information. The labeling requirements in King County, Washington require chain restaurants with 15 or more establishments to include total number of calories, grams of saturated fat, grams of carbohydrate, and milligrams of sodium for all standard menu items (2). This amount of information is not adequate in order to promote healthy dietary habits. Additionally, variability in nutritional content of foods requires that additional steps occur in order to make the available information useful to consumers.
The American Dietetic Association (ADA) convened the Task Force on Restaurant and Nutrition Labeling Research to analyze the effects of restaurant nutrition labeling using scientific principles tested through research and to identify gaps in the available research (6). The task force, comprised primarily of public health officials and registered dieticians, raised a key concern about the unintended consequences potentially caused by nutrition labeling. The concern is that by posting minimum caloric information, consumers will make choices based solely on calories and not on other nutritional values. Overall nutrition is particularly important for children and adolescents whose bodies need nutrients and who tend to eat at fast-food restaurants most frequently.
Another concern raised by the ADA’s task force is the accuracy of nutritional analysis programs. The task force reports that nutritional information can vary significantly in packaged foods, which are produced in tightly controlled environments, therefore the probability is high that even greater amounts of variability will occur in restaurant nutrition labeling. Steps should be taken to reduce this variability and this variability information should accompany any labeling initiatives to ensure that the information provided to consumers is accurate. Providing inaccurate information to consumers would counter the intentions of the restaurant nutrition labeling initiative.

Healthy Eating Intent vs. Behavior
Restaurant nutrition labeling initiatives follow the principles of the health belief model (7,8). The principle most affected by these initiatives is the consumer’s perception of the severity of eating unhealthy foods. These initiatives assume that most people know that high calorie foods are bad for them and will avoid eating foods they know are high in calories. Like the health belief model, restaurant nutrition labeling erroneously assumes that because a person intends to eat healthy foods, they will actually eat healthy foods.
The United States Department of Agriculture’s (USDA) Economic Research Service (ERS) conducted a study in which the researchers analyzed consumer food choices based on the consumer’s long-term health objectives and immediate visceral influences, such as hunger and stress (9). The analysis used behavioral economics to develop models to predict the effects of time pressures and hunger and compared these models to results from the 1994-96 Continuing Survey of Food Intake by Individuals and the Diet Health and Knowledge Survey. The results found that those under stress and those who had gone longer without eating were more likely to eat more calories per meal than those who were not under these influences when faced with immediate food choices. These results remained true even for those who had long-term health goals.
Another key limitation of using the health belief model for this initiative is the assumption that people will make rational food choices. Even if a person is presented with accurate nutritional information, knows the severity of eating unhealthy foods and is not under stress, there are still other factors that could lead the person to choose unhealthy foods over healthier options. A study challenging the notion that intention leads to behavior was published in the Journal of Marketing in 2003 (10). This study found that health claims and nutrition information generally had an effect on consumer’s attitudes towards food items but for many, this evaluation did not actually influence the consumer’s actual consumption behavior.
Consumer’s attitudes towards taste of healthy foods can play a significant factor in their decision to choose either the healthy item or the unhealthy item. A study conducted by Horgen and Brownell (11), suggests that consumers may associate the term healthier foods with bad taste. The study looked at the effects of price decreases, health messages and the combination of the two methods on consumer choice of targeted food items. Although the combination of price decreases and health messages produced an increase in sales of the healthy items, the results suggested that the perception of the taste of healthier foods attenuates the effect of price decreases alone in these healthier food choices.

Access to Healthier Alternatives
In a 2006 study of fast-food restaurant patrons, 87.2% indicated that price was an important factor in their food choice while only 57.9% indicated that nutrition was an important factor (12). While cost is a factor in food choices for most people, for some cost is THE deciding factor. Restaurant nutrition labeling may provide consumers with the information to make healthier food choices but the labeling initiative does not go far enough to ensure that those who want to make healthier choices have the resources to follow through with their intention. Even if these individuals know the nutritional information related to the food they’re purchasing, there may not be a cost-effective alternative available for them to purchase. Several studies have been conducted which show that diet-related health outcomes are worse in areas with less access to supermarkets and more access to convenience stores and fast-food restaurants than in areas with large supermarkets (13,14) The populations that live in the areas with less access to large supermarkets in general have a lower socioeconomic status than those who live in areas with accessible grocery stores (15).
An earlier study mentioned in this paper, showed that price decreases on food items had a more significant impact on the purchase of these items than did the inclusion of health messages promoting the items (11). If prices for healthier food options were decreased, this suggests that the likelihood of consumers purchasing these items would increase.
Finally, healthy food options available at restaurants need to increase in order to assure that people have choices in what they can eat. Glanz, et al (16) evaluated the major factors that influence restaurant chains to plan their menus. They found that growing sales and increasing profits were not surprisingly the most important consideration, with health and nutrition much less influential. Several respondents to the survey noted that healthier food options have been offered in order to prevent loss of business from certain health advocacy groups. The study suggested that consumer demand is likely the major factor that will influence major chains to include and keep healthier food options on their menus. Additionally, the researchers suggest that public health and government agencies should work towards increasing chain restaurant perceptions of consumer interest and also incentives for restaurants to offer healthier food options. The availability of healthier food options will help reduce a potential barrier consumer’s face while trying to adopt healthier eating habits.

Conclusion
Restaurant nutrition labeling initiatives have the potential to provide valuable information to some consumers who wish to improve their dietary health. These initiatives facilitate healthy eating among those who already perform healthy eating behaviors but do little to promote healthy eating behaviors among those who do not regularly make healthy food choices. Strategies to expand the benefits of restaurant nutrition labeling to wider audiences must include other components that affect food choice behavior and reduce barriers to healthier food choices.

Counter-Proposal for Intervention
The three limitations of the restaurant nutrition labeling program presented above can be remedied. The remainder of this paper will present a modification to the program which will address these three main limitations. The redesigned restaurant nutrition labeling program should be comprehensive and include multiple public health campaign components rather than simply providing information to the public. A committee at the Institute of Medicine “strongly suggests that interventions need to use multiple approaches (e.g. education, social support, laws, incentives, behavior change programs) and address multiple levels of influence simultaneously (i.e., individuals, families, communities, nations)”(17). The proposed campaign has three key components that improve upon the previous intervention. The first component is for restaurants to provide more complete and accurate nutrition information to the public using a system that allows consumers to easily identify healthier menu items. Secondly, the campaign would use social sciences theories to promote the use of the system to consumers so hey could make healthier food choices. Finally, the campaign would focus on making restaurants that used these labeling systems easier to access for those who would like to make healthy food choices.

Complete and Accurate Information System
The information that restaurants are required to post should take into account nutrients rather than just calorie count and fat content as some restaurants have done (1,2). By providing only calorie count and fat content, people may not be making the healthiest food choices. According to the ADA, posting of calorie and fat information without additional nutrient information could take the focus away from healthy eating and put the focus on calorie counting alone (6).
Comprehensive posting of nutritional information, however, may become burdensome for both the restaurant and the consumer if there are lots of items on a restaurant’s menu. An alternative strategy for condensing prominent displays of nutritional information while still providing complete nutritional information for patrons could be done using two components. The first should be a pamphlet with complete information on all products the restaurant serves. This gives the customer the option of seeking out specific amounts of various nutrients in foods if, for example, they are diabetic and need to watch their sugar intake or if they have high blood pressure and need to limit their sodium intake. The majority of consumers would use the second component which would be a nutritional posting similar to the “DDSMARTTM” menu used by Dunkin’ Donuts (18). This type of menu creates a visual way for consumers to more easily identify foods that are the healthiest on the restaurant’s menu. This menu would allow consumers to see which items are healthiest in the restaurant and would allow them to make smarter food choices without having to analyze the nutrition content of every item served by the restaurant. According to a study by Malhotra (19), consumers have finite ability to absorb and process information given a short amount of time. If given too much information in a short time, consumers can actually make poorer decisions than they would if they didn’t have as much information. This theory supports concise but accurate restaurant labeling which could serve as a compromise to promote healthier food choice and prevent restaurants from being overburdened by extensive menu labeling. Nutritional standards would have to be developed by agency enforcing the restaurant labeling regulation in order for foods to make it on to the “healthy options menu.”

Promoting the Labeling System
Once an acceptable system is established to identify the healthiest items on restaurant menus, the system needs to be marketed to consumers. If a consumer can easily identify a brand to mean healthier food, without having to process lots of information at the point of purchase, then they would be more likely to make a healthier food choice than if they had to process lists of nutritional information (19). Branding theory is based on analyzing a target audience to create a brand that has attributes with which the audience can identify (20). Once this identity and sense of shared attitude is established, consumers will recognize the brand and may become loyal to it (21). The association by consumers of healthier foods with bad taste suggested by the Horgen and Brownell (11) study could be combated by this branding campaign. This type of branding and brand loyalty would make it easier for consumers to choose items from the menu with which they were familiar. The branding would have to include a visually appealing and easily recognizable menu design that consumers could identify once in the restaurant. The simple act of being able to identify healthy choices without sorting through nutritional information will increase the likelihood that people who intend to eat healthy will eat healthy. The simplification of the choice reduces an irrational barrier that prevents people from following up their intent to eat healthy with the actual behavior (19).

Increase Availability of Restaurants With Labeling System
Finally, once the labeling system is in place in the restaurants and is made easily recognizable for consumers through the promotion process, policy makers should ensure that consumers have access to get to these restaurants. The labeling policies in both New York City (1) and King County (2) both had limitations on which type of restaurants had to comply with the labeling law. If an area does not have a high quantity of restaurants that must comply with the regulation, then the labeling system would be virtually useless to the consumers who lived in that area. Policy makers should ensure that the majority of restaurants must comply with the regulation or that the restaurants that do have healthier menus are more accessible within neighborhoods.

Conclusion
Although current restaurant nutrition labeling programs in various cities have good intentions, the programs do not go far enough to ensure that the labeling program itself is effective. By assuming that providing more information will lead consumers to make healthy behavior changes, policy-makers are erroneously designing interventions based on the Health Belief Model (7,8). While having more information may change consumer intentions, their behavior at the point of purchase in these restaurants is what should be addressed in order to truly promote healthier food choices.

References
1. Board of Health Vote to Require Chain Restaurants to Display Calorie Information in New York City. New York City Department of Health and Mental Hygiene Web site. Available at http://www.nyc.gov/html/doh/html/pr2008/pr008-08.shtml. Accessed on April 5, 2009.
2. Trans fat and nutrition labeling in King County. King County Public Health Web site.
Available at http://www.metrokc.gov/health/healthyeating/. Accessed on April 5, 2009.
3. Nutrition Labeling and Education Act. http://www.fda.gov/ora/inspect_ref/igs/nleatxt.html#GUIDE%20FOR%20REVIEW %20OF%20NUTRITION
4. HR. 1334
5. Roberto C, Agnew H, Brownell KD. An Observational Study of Consumer’s Accessing of Nutrition Information in Chain Restaurants. Am J Public Health, 2009;99:xxx-xxx.
6. American Dietetic Association. Task Force Report on Restaurant Nutrition Labeling Research. http://www.eatright.org/ada/files/RLR_Task_Force_Report_FINAL.pdf.
7. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones & Bartlett Publishers, 2007.
8. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN 39(3) 128-135: 1991.
9. United States Department of Agriculture. Is Dietary Knowledge Enough? Hunger, Stress and Other Roadblocks to Healthy Eating. ERR, 2008; 62.
10. Kozup JC, Creyer EH, Burton S. Making Healthful Food Choices: The Influence of Health Claims and Nutrition Information on Consumer Evaluations of Packaged Food Products and Restaurant Menu Items. J Marketing, 2003; 67:19-34.
11. Horgen KB, Brownell KD. Comparison of Price Change and Health Message Interventions in Promoting Health Food Choices. Health Psych, 2002;21(5):505-512.
12. O'Dougherty M, Harnack L, French S, Story M, Oakes J, Jeffery R. Nutrition labeling and value size pricing at fast-food restaurants: A consumer perspective. A J Health Promot. 2006;20:247-250.
13. Morland KB, Evenson KR. Obesity Prevalence and the local food environment. Health & Place. 2008;15:491-495.
14. Larson NI, Story MT, Nelson MC. Neighborhood Environments: Disparities in Access to Healthy Foods in the US. Am J Prev Med, 2009; 36(1):74-81.
15. Morland K, Wing S, Roux AD, Poole C. Neighborhood Characteristics Associated with the Location of Food Stores and Food Service Places. Am J Prev Med, 2002; 22(1):23-29.
16. Glanz K, Resnicow K, Seymour J, et al. How Major Restaurant Chains Plan Their Menus: The Role of Profit, Demand and Health. Am J Prev Med, 2007; 32 (5): 383-388.
17. Institute of Medicine. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academies Press, 2000.
18. DDSMART Nutrition Advisory Board. https://www.dunkindonuts.com/aboutus/BreakfastChoices/Nutrition_board.aspx .
19. Malhotra NK. Information Load and Consumer Decision Making. Journal of Consumer Research, 1982; 8 (4): 419-430.
20. Huhman M, Heitzler C, Wong F. The VERBTM Campaign Logic Model: A Tool for Planning and Evaluation. Preventing Chronic Disease: Public Health Research, Practice and Policy. 2004; 1(3): 1-6.
21. Evans WD, Wasserman J, Bertolotti E, Martino S. Branding behavior: the strategy behind the truth® campaign. Soc Marketing Q. 2002;8(3):17–29.

Why 5 A Day Fell Short And Alternative Solutions in the form of Community Supported Agriculture– Jacquelyn Murphy

2009-05-07T12:52:00.000-07:00

Fruits and vegetables are an important part of everyone’s diet. They provide vitamins, fiber, and few calories, which are all things anyone, especially most Americans, could benefit from. With these things in mind, the National Cancer Institute and the Produce for Better Health Foundation teamed up to found a nutrition program, entitled 5 A Day for Better Health, in 1991 (4). The 5 A Day program very simply encourages people to eat five servings of fruits and vegetables every day as part of a low-fat, high-fiber diet, marking packages of acceptable fruits and vegetables with the small trademark symbol (2). On the Center for Disease Control and Prevention Website, there are recipe ideas to incorporate servings of fruits and vegetables into meals as well as tips on how to reach the five servings, such as having fruit or vegetables for in-between meal snacks. In 1991, when the program first began, and in 1997 after six years of spreading the “5 A Day” message and pouring millions of tax dollars into raising awareness on this critical nutrition issue, there was no significant difference in fruit and vegetable consumption after researchers adjusted for demographic shifts (4). The 5 A Day program is flawed in that it is based on the Health Belief Model and thus the assumption that people act rationally, it lacks consideration for environmental factors, and it advertised poorly. These flaws could account for part, or all, of the lack of response after millions of dollars were spent on increasing awareness of the 5 A Day for Better Health program.
Based on assumptions of Health Belief Model.
The 5 A Day program is based entirely on the idea that if people are educated about what actions they should take to optimize their health, in this case eat at least five servings of fruits and vegetables daily, then they will do it. Like many public health interventions based on the Health Belief Model, it is limited in various ways and assumes a few different things. Many individual level models assume that people act rationally and plan their behavior. The Health Belief Model is no different. In general, the Health Belief Model is based on increasing perceived susceptibility or perceived severity, or both, of the consequences of performing or not performing a certain action (3). From here, people determine the perceived benefits of adhering to guidelines set by the intervention, as well as barriers preventing them from following the guidelines of the intervention outlined by the Health Belief Model. Finally, they come to a conclusion and determine their intention, which they then carry out through their behavior, which is both planned and rational (3).
Specifically, the limitations and assumptions of the Health Belief Model come into play in a few different ways in the 5 A Day nutrition campaign. First, this campaign gives people information about what they should be doing, eating five servings of fruits and vegetables per day. From there, it assumes they will change their behavior to eating five or more servings of fruits and vegetables just because they know it is beneficial to their overall health. The campaign does not take into consideration that people oftentimes do not care about their health, or care about it enough to give up their unhealthy, but perhaps tastier, habits, such as eating a cookie instead of an apple. People value their health as much as they do not want to be sick or feel poorly, but many people do not think about their actions’ impact on their long term health. They usually invest their thought in other things, such as appearing attractive or being well-liked, rather than spending their time thinking about their slightly increased chances of certain types of cancer years down the road due to poor nutritional choices.
Secondly, and somewhat deviating from the limitations of the Health Belief Model, this campaign does little to raise people’s perceived susceptibility or severity of the consequences of not eating five servings of fruits and vegetables, which is a trademark of interventions based on the Health Belief Model. If the campaign was more strictly based on the Health Belief Model, it would incorporate more information about the negative repercussions of their lack of eating at least five servings of fruits and vegetables in order to scare people into action. However, this campaign tries to get people to eat five servings of produce without the aspect of increasing people’s perceived susceptibility or severity of potential negative consequences.
Thirdly, since it assumes that people’s behavior is rational, it obviously does not capitalize on the ways in which the behavior of most people is irrational. There are three main facets to irrational behavior, as discussed in this lecture January 29, 2009. The first is that people have expectations of how things should be, and their experiences impact their expectations. The second is that people enjoy owning things and have an aversion to losing the things they own. The third aspect of irrational behavior is that people generally do not have as much self-control as they think they do. Rather, they are mostly lazy procrastinators. The 5 A Day campaign mostly disregards the second of the three features of irrationality in that it did not take into account the strength of people’s habits. They own their unhealthy eating habits, and they will only relinquish these unhealthy habits and practice self control, another feature of irrational behavior not taken into account by the 5 A Day campaign, if they think they will be rewarded with a result that they deem to be worthy of their sacrifice and effort to change their behavior.
Lacks consideration for environmental factors.
Another reason that there was such an insignificant change in the amount of fruits and vegetables people ate before and after the implementation of the 5 A Day nutrition campaign is the lack of consideration for environmental factors. Barriers to consuming the recommended five servings of fruits and vegetables, according to a survey of single mothers included cost, lack of availability, time and effort required to prepare produce, a preference for other foods instead and habit (6). Some of these environmental factors were discussed in the experiments performed during the first seminar meetings on January 22, 2009. Groups went to grocery stores in Roxbury and the South End, two different neighborhoods near the Boston University Medical Campus. The groups that went to the South End, the wealthier of the two neighborhoods, found plenty of full-sized grocery stores, such as Trader Joe’s and Whole Foods, which contained many varieties of fruits and vegetables, usually including a lot of organic produce as well. On the contrary, groups that went in search of produce in Roxbury could only find small and overpriced convenience stores in their designated neighborhood, which usually contained a very small selection of fruits and vegetables which did not look appetizing, especially relative to the produce from the South End grocery stores. Therefore, the residents of Roxbury and other similar neighborhoods had to put in a larger time and effort to get the same quality of food which residents of the South End and other comparable neighborhoods can get quickly and easily.
Aside from availability of produce in their neighborhoods, students in the seminar groups also pointed out the safety of the two different neighborhoods. Roxbury has a much higher crime rate than the South End, adding an element of danger to getting groceries at night after people get out of work, which is when most people have time to do so. Since produce spoils faster than less nutritious, packaged snacks, such as cookies or crackers, it requires more frequent trips to the store. The lack of safety of a neighborhood makes keeping fresh produce available in the house even more difficult than it would be if the grocery store were closer or the trip there less risky.
Finally, amongst a variety of other environmental factors that should have been taken into account by the 5 A Day campaign, financial cost was not considered. As is easily observed in any grocery store, the fresh produce that the 5 A Day campaign strongly encourages is much more expensive than other foods that are perhaps less nutritious but would fill stomachs when parents’ main concern is making sure their children are all able to have dinner. The campaign did not enlist the government to subsidize the cost of produce in any way or perhaps try to organize farmers to sell their produce directly to the customer at farmer’s markets, which would be beneficial to both the farmer and the customer in terms of cost.
In short, the 5 A Day campaign was set up as if people made their decisions in a vacuum, but they do not. They have to think about availability of produce, their own safety when they are en route to buy food for the family and how they will bear the financial costs, among many other environmental factors which are likely too numerous to list here.
Poor advertising methods and media.
Lastly, the methods of advertising employed by the 5 A Day campaign were another shortcoming of the national nutrition intervention. They did not utilize basic principles of communications theory or the idea of agenda setting within the theory. Agenda setting within Communications Theory notes that the target audience, in this case people who are buying food for their families or deciding what to eat when faced with different options, must view the information as important enough to really hear the message and act on it (1). Being bombarded on a daily basis with countless messages about what is best for a healthy lifestyle, it is difficult to distinguish the useful information from the useless. If people do not care, they will not spend the extra money on fresh produce or decide to eat that instead of tastier, less nutritious foods. Creating a message the person in the situation can relate to is the primary focus of agenda setting because the goal is to dramatize the issue and get the audience to care about the issue enough to act, since they view it as important (1). Advertising created with this in mind, and using basic principles of agenda-setting theory, such as dramatizing an issue to make it important to people, would be most effective.
However, the main method of advertising used by the 5 A Day campaign was to put a logo on the sides of packaging which contained acceptable servings of fruits and vegetables and to distribute informative pamphlets in the offices of primary care physicians. Not only is this foolish since most people already know what counts as a fruit or vegetable, but this medium, which the 5 A Day campaign chose to use, does not reach the target audience. People who are purchasing products with this logo on them are already attempting to reach their five servings, or at least already have enough information to know that fruits and vegetables are worth their money. The target audience for this message should include the large portion of the population who drastically fall short of the five servings per day mark, which tends to be adults with less education, lower income and uncertainty about whether or not they will consistently have food in the near future (6). This part of the population is either not at the grocery store for reasons mentioned before, or they are not in that aisle, examining the produce closely enough to see the small 5 A Day logo encouraging them to buy that product. They are likely deciding which foods to buy based on the amount of money they have and possibly also what will keep their family feeling satisfied longest. A second reason that this medium is ineffective is that it in no way dramatizes the issue, which would increase the likelihood that people would care enough to pay attention and change their behavior, which showed by a self-reported survey that most people do not get five servings of fruits and vegetables daily (5). It simply provides guidance to the products condoned by 5 A Day, should the person already have established that habit. There was a small improvement with the information in the doctor’s offices, since they actually provided reasons why the reader should try to incorporate more produce instead of simply putting a logo on a package and expecting a drastic improvement. The pamphlets and the information about this program on the Center for Disease Control and Prevention website provide information from studies that found five servings to be where they saw lowered rates of many chronic illnesses such as cancer and obesity, which is where this campaign incorporates tenants of the Health Belief Model, as outlined above.
In conclusion, the 5 A Day campaign tried to change the nutrition of a nation by raising awareness, but awareness does not change behavior. The first flaw of the 5 A Day campaign is assuming that people plan their behavior, which is always rational, and do what they intend to do. As extensively studied, behavior is oftentimes irrational, a fact disregarded by the 5 A Day for Better Health Program. Secondly, the 5 A Day campaign assumes that behavior takes place in a vacuum, and it does not consider various environmental factors that impact people’s food choices, such as the high relative cost of fresh fruits and vegetables, the lack of access people in neighborhoods with a low average socioeconomic status have to grocery stores, and the safety of these neighborhoods for them to get to the grocery store in the first place. Lastly, a lack of consideration for how to deliver the message, by picking ineffective media to deliver the message through, and a lack of dramatizing the issue of incorporating enough produce into a healthy diet have both lead the general public to be largely uninformed or unengaged – as uninformed or unengaged in 1997 after the intervention as they were in 1991.

Since the vast majority of the population falls short of the goal of five servings of fruits and vegetables every day, other groups had to develop ways, separate from the government’s 5 A Day for Better Health program, that those most in need could have access to produce. Four factors have been found to increase fruit and vegetable consumption, including point-of-purchase (POP) information; reduced prices and coupons; increased availability, variety, and convenience; and promotion and advertising (11). Instead of asking the government to subsidize the cost of fresh produce they were encouraging the citizens to eat, in turn further increasing many of the deficits at the state and federal level, Community Supported Agriculture was developed. Little known to many people, Community Supported Agriculture is a grassroots movement that puts produce within reach of people of all socioeconomic backgrounds. Community Supported Agriculture is an intervention that addresses the 5 A Day campaign’s poor advertising, lack of consideration for environmental factors and assumption that people hold their health as one of their core values. In addition, Community Supported Agriculture offers both a wide variety of produce and lower costs, two factors shown to directly increase fruit and vegetable consumption.
First, an explanation of Community Supported Agriculture is necessary, because despite them being quite widespread, not everyone has heard of, or is knowledgeable about, such programs. These farms can come about in a number of ways. Farmers sign up their farms with organizations, or they simply designate their farm as Community Supported Agriculture land without the organization (8). Another way is for a city or town to own land and a group of committed individuals take responsibility for the land each season. Either way, they sell shares, also known as subscriptions or memberships, to people who do not own a farm, known as the consumers. In exchange for a flat rate that consumers pay to cover the costs of growing materials and supplies on a per season basis, they receive a box of fresh, locally grown produce, usually vegetables. They can pay more or less depending on the size box and variety of produce within the box. Additionally, most Community Supported Agriculture farmers will accept food stamps if that is how the family would normally pay for produce, were they to purchase the food in a grocery store. Families may also choose to trade labor for food if they do not have food stamps or the money to pay up front, which is a problem for many families (9). Especially if they have been unemployed or are consistently living beyond their means even as they subsist in unpleasant living conditions, the “labor for food” option offers membership to those who are struggling most. Finally, these memberships are not for sale to those strictly adjacent to the farm. On the contrary, the farmers usually have several drop off locations to reach a wider customer base (8).
More effective advertising.
Community Supported Agriculture does not advertise or communicate with the public as a typical public health campaign is expected to. They do not have commercials on television or the radio, but they use what has been the most effective method of advertising for years: word of mouth. Before the growing season begins, farmers typically try to sign people up for memberships in order to get their cash flow jumpstarted, as they usually have been without a reliable income during the winter. Satisfied consumers will likely spread the word about where they got their produce, and encouragement from a trusted friend or family member is usually most successful in convincing someone that buying something, in this case a membership, or spending their time doing something, such as helping on the farm in exchange for produce, is worthwhile. Additionally, people in the Community Supported Agriculture would be looking for people to share the costs, monetary or labor, which would lead to them recruiting people they trust to follow through on either or both accounts.
The whole premise of Community Supported Agriculture is to keep costs down to everyone, so a mainstream, widespread advertising campaign would, in itself, be contradictory to the message of the Community Supported Agriculture. Instead of spending their time trying to convince people that they should be eating more fresh vegetables, they provide it for those that want it and are willing to buy or work for it. Also, due to hearing about the Community Supported Agriculture through friends, it makes sense that skepticism would be reduced, which is oftentimes high when people are asked to change something about their lifestyle by the government.
Availability of nutritious foods has been shown to have a positive association with their consumption, therefore Community Supported Agriculture makes this food truly available to consumers, unlike the small corner stores typical in supermarket desserts which contain a very small, very expensive produce selection (7).
If Community Supported Agriculture were to improve or expand upon this method of advertising, they should put their information where the largest amount of their target audience will be reached. Needless to say, this is not on the label of a package of produce, as the 5 A Day campaign is currently advertising. The point of such a campaign is to get the potential consumer to walk over to that section of the store and pick up the produce in the first place. Perhaps in community health clinics, which are the main, or only, source of medical care for those without health insurance, informational brochures could explain what Community Supported Agriculture is and the benefits it offers as well as and provide a phone number to call or person to contact if they were interested in getting a membership to that particular farm. Also, in community centers, such as the Boys and Girls Club, a large percentage of the attendees there would benefit from knowing of a Community Supported Agriculture farm, so more information could be distributed at similar places.
Consideration for peoples’ varying environments.
Community Supported Agriculture not only takes environmental factors into consideration, on the contrary it was seemingly founded on the principle of providing produce for those who have difficulty accessing it. Given the way environments are currently, with supermarket desserts, as witnessed in Roxbury, Massachusetts in the seminar exercise, not only is fresh produce expensive once people get to the grocery store, but for residents of neighborhoods similar to Roxbury, it is a huge time investment to take a trip to the grocery store. The drop off locations that many Community Supported Agriculture farms have organized still require the consumers to pick up the produce as they would in a grocery store, but the drastically reduced cost alleviates one of the major stressors people encounter when buying fresh produce. Of course, there are limitations to this idea, especially if the potential consumer is not located near the farm itself or near to a drop off location and does not have a car to get there. However, on the whole, the two major environmental factors which the 5 A Day campaign ignored were the monetary access and geographic proximity to a store with a decent selection of fresh produce. Additionally, the logistical limitations will always be difficult to get around, and the farmers and consumers must work together to set up the most convenient place for as many people as they are able.
As previously mentioned, for people who cannot pay for the vegetables up front, they can work in exchange for a membership to the Community Supported Agriculture. This is another level of alleviating the financial burden and offering inclusiveness, since it provides a way for people who are unemployed and underemployed to also have a membership and access to healthy food. For many, being unemployed usually means an absence of all nutritious or extra food except the bare minimum, in quantity and quality, families can afford.
Not based on Health Belief Model assumptions.
Unlike the 5 A Day for Better Health campaign, community supported agriculture is not based on the major assumption that people behave rationally. This idea does not try to convince people, as 5 A Day does, to eat five servings of fruits and vegetables because it is good for them and then they will be healthier and possibly have reduced cancer risk years from now. It simply offers the option of eating healthier at a lower cost.
Additionally, much like the sticktoit.com website discussed in lecture, it does involve an initial monetary payment to the farm, which people do not get back if they do not pick up their food every week. When people put their money on the line, they are more likely to follow through on their actions, and certainly they would be more motivated to go get food they have already paid for.
However, there would most likely be some people who are not paying for the produce, but rather working in exchange for the box of fruits and vegetables. These individuals are driven to stick with eating the produce because they have invested time into the health and growth of the vegetables. Often, they have worked very hard every week and feel bonded to their produce or they know how much work went into producing the vegetables so they are less likely to waste them by letting them go bad or not retrieving them from the drop off stations.
Additionally, children and young people can, and should, perhaps, get involved in the Community Supported Agriculture. Studies have shown that in regards to young people, they are most likely to consume healthier foods when they choose the foods instead of being told what to eat by their parents or guardians (10). If the children had been in charge of watering the same tomato plant or corn stalk each time the family went to the farm, they would obviously have a sense of pride when the vegetable was ripe and ready to eat. This finding is not surprising, given that one of the main core values children and adolescents hold in high regard, indeed much higher regard than their own health, is their independence, separation and growth from their parents, as seen in the Truth anti-smoking campaign.
In conclusion, Community Supported Agriculture did not begin initially as a cheaper option, but it has grown into a major alternative for those of lower socioeconomic status as it provides produce at lower costs and often closer to their homes. Geography and monetary cost often prohibit their access to the government-recommended five servings of fruits and vegetables every day, but when the 5 A Day for Better Health campaign made that recommendation, they should have researched what actually gets people to eat more fruits and vegetables. Unlike that campaign, Community Supported Agriculture is based on assumptions shown to hold true about people’s behavior, that they do not care about their health but other things such as money and independence, addresses environmental factors such as making produce geographically and cost available, and advertising itself through word of mouth of previous satisfied consumers. In all these ways, Community Supported Agriculture is a better intervention than the 5 A Day for Better Health campaign.

REFERENCES
1. Edberg, M. (pp. 35-47) In: Edberg, M., ed. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.
2. Heimendinger J, VanDuyn MA, Chapelsky D, Foerster S, Stables G. The National 5 A Day for Better Health Program: A Large-Scale Nutrition Intervention. Journal of Public Health Management and Practice 1996; 2 (2).
3. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
4. Stables G, Subar A, Patterson B, Dodd K, Heimendinger J, VanDuyn MA, Nebeling L. Changes in vegetable and fruit consumption and awareness among US adults: Results of the 1991 and 1997 5 A Day for Better Health Program surveys. Journal of the American Dietetic Association 2002; 102 (6): 809-816.
5. Thompson B, Demark-Wahnefried W, Taylor G, McClelland J, Stables G, Havas S, Feng, Z, Topor M, Heimendinger J, Reynolds K, Cohen N. Baseline fruit and vegetable intake among adults in seven 5 A Day study centers located in diverse geographic areas. Journal of the American Dietetic Association 1999; 99 (10): 1241-1248.
6. Quan T, Salomon J, Nitzke S, Reicks M. Behaviors of low-income mothers related to fruit and vegetable consumption. Journal of the American Dietetic Association 2000; 100 (5): 567-569.
7. Williams DR. Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports 2001; 116:404-416.
8. United States Department of Agriculture. Defining Community Supported Agriculture. http://www.nal.usda.gov/afsic/pubs/Community Supported Agriculture/Community Supported Agriculturedef.shtml
9. National Sustainable Agriculture Information Service. Community Supported Agriculture. http://attra.ncat.org/attra-pub/csa.html
10. Consumer Health Interactive : The Edible Schoolyard. http://www.yourhealthconnection.com/Imagebank/audio_flash/edibleschoolyard.html
11. Glanz K. Yaroch A. Strategies for increasing fruit and vegetable intake in grocery stores and communities: policy, pricing, and environmental change. Preventive Medicine 2004; 39 (2): 75-80.

Exercise is Medicine: A Poor Prescription for Physical Activity Promotion – Maureen Harris

2009-05-07T12:51:00.000-07:00

Regular physical activity is a critical component of a healthy lifestyle and has a strong role in health maintenance and promotion. Exercise has been shown to reduce the risk of chronic diseases such as cardiovascular disease, diabetes, and cancer; promote quality of life; aid in maintenance of a healthy weight; reduce symptoms of depression; and enhance functional health (1-2).
Despite the manifold benefits of being physically active and risks of being inactive, adherence to the recommended guidelines for activity is remarkably low. The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) recommend 30 minutes of moderate-intensity daily physical activity five days per week (3), and the 2008 Physical Activity Guidelines for Americans released by the Department of Health and Human Services (DHHS) calls for a minimum total accumulation of 150 minutes of moderate physical activity per week (4). Nearly two-thirds of adults in the United States do not meet these recommendations, and a quarter do not exercise at all (5). This has clear and severe public health implications.
The “Exercise is Medicine” Initiative
To address this burning issue, hundreds of small- and large-scale interventions have been developed, yet the problem persists. Many of these programs are based on faulty or tenuous theories or, worse yet, are not based on any framework at all. The Exercise is Medicine (EiM) initiative (6), sponsored by the American College of Sports Medicine (ACSM) and the American Medical Association (AMA) seeks to improve rates of physical activity through encouraging a dialogue about exercise between patients and health care providers. Despite the best intentions, this program, like the others, is fatally weakened by multiple flaws.
The program’s goal is to make physical activity a standard “vital sign.” EiM calls upon health care providers to assess patients’ activity levels at every office visit and to counsel patients on how to become more active. Providers are encouraged to “prescribe” exercise for disease treatment and prevention just as they would prescribe a pharmaceutical as well as to refer patients to fitness professionals just as they would refer to a medical specialist. Additionally, EiM instructs patients to ask their doctors about exercise. The program’s website provides reference materials for providers to facilitate dialogue with patients, and it offers “tool kits” and educational videos for patients to help them initiate an exercise routine. The initiative aims to link exercise with medical treatment and equate exercise with more traditional and familiar modes of treatment, such as pills. It promotes the long term physical health benefits of exercise while presenting limited information on other, more immediate benefits of exercise.
EiM appears to be based on the Health Belief Model (HBM; 7-8), which presents four factors central to an individual’s health behavior motivation: perceived susceptibility (assessment of the likelihood of acquiring disease/condition), perceived severity (assessment of the physical and emotional hardship that may be experienced if the disease/condition is acquired), perceived barriers (assessment of obstacles to perform health behavior, such as cost, access, embarrassment), and perceived benefits (belief that a given action will be efficacious in preventing a negative outcome or minimizing its severity). Each of these factors is considered during decision making and, if the pros of the behavior exceed the cons, the individual will form an intention to engage in the behavior. Intention is assumed to result in behavior. EiM, following the logic of the HBM, emphasizes the risks (i.e., severity) of not exercising, assuming that if people know that they should exercise then they will exercise. Despite its good intentions, EiM’s design is fraught with lack of foresight and faulty logic that severely hinders its potential to improve adherence with national physical activity guidelines. Three fundamental issues with EiM will be discussed: the definition of exercise as a medical treatment, the choice of doctor-patient interactions as the mode of message delivery, and the failure to anticipate barriers.
Definition of Exercise as a Medical Treatment
Defining exercise as medicine is potentially damaging and counterproductive. While the definition is intended to convey the importance of exercise and stress its role in health maintenance, it is more likely to reduce intrinsic motivation to engage in physical activities. Intrinsic motivation is considered to be a desire to participate in an activity for the inherent satisfaction of the activity whereas extrinsic motivation is desire to participate in an activity for a reward distinct from the activity (9). Cognitive evaluation theory (CET; 10-11) proposes that intrinsic motivation relies on social-contextual factors such as perceived choice, autonomy, and enjoyment. Supporting this concept, self-efficacy and perceived satisfaction were shown to predict maintenance of physical activity (13). Presenting exercise as a treatment and as a "doctor's order" implies a lack of choice on the part of the patient. Moreover, by suggesting that exercise is something the patient must do, rather than something the patient wants to do, it undermines inherent enjoyment of, and desire to participate in, the activity (12). Deci and Ryan propose a hierarchy of motivation, including amotivation (no motivation), extrinsic motivation, and intrinsic motivation (11, 14). Extrinsic motivation is broken into four categories which are differentiated by the ratio of external to internal locus of causality. The most external category, external regulation, is associated with compliance and external rewards, whereas the most internal, integrated regulation, is associated with overlap between personal values and the activity. An individual has greater enjoyment of, and greater likelihood of maintaining, an activity when the locus of causality is most internal (9). Thus, intrinsic motivation, or deeply internalized extrinsic motivation, is critical for maintaining a physically active lifestyle. Through its disregard for the components necessary for intrinsic motivation, EiM substantially weakens its ability to promote physical activity. Worse yet, it may even have the unintended effect of decreasing physical activity by reducing inherent enjoyment of active hobbies (e.g., dancing, playing soccer) by suggesting that the reason for engaging in the activity is because it is necessary or "the right thing to do," rather than simply an enjoyable activity.
An additional issue with defining exercise as medicine is that adherence to medically prescribed regimes is often low (15-21), especially for difficult, complicated, or long term treatments. Poor adherence to medical regimes is even present when the consequences of non-adherence are severe, such as in the case of medication for coronary heart disease (21). Committing to an exercise routine requires significant effort and dedication, putting exercise adherence at great risk for low adherence. Although adherence is a difficult construct to assess, a review of the literature (22) found estimates of adherence between 4% and 93%, with most rates falling between 29% and 59%. A second review (23) found estimates of poor compliance in 30-50% of all patients, regardless of diagnosis or setting. These discouraging rates of adherence, especially considering the time consuming and long term nature of exercise that increase likelihood of low adherence, suggests that EiM's strategy of defining exercise as a medical treatment is misplaced. Lack of trust in physicians (24) or perceived discrimination (25) can cause patients to disregard their provider’s exercise “prescription,” further damaging the chance that patients will adhere to providers’ EiM recommendations.
Choice of Doctor-Patient Interactions as the Mode of Message Delivery
EiM aims to relay messages about the importance of exercise through doctor-patient interactions, but this limited strategy is a poor choice. First, many people do not have access to, or choose not to seek, healthcare services. People do not access health services for a wide range of reasons, including lack of insurance (26), lack of time (27), lack of nearby health facilities (28), and lack of trust in healthcare professionals or medicine (24). Rates of healthcare utilization are also low among minority groups (5, 29) and non-English speakers (30). Low income families may not have access to healthcare even if they have insurance due to barriers such as distance from healthcare providers and high financial costs beyond what is covered by insurance (31). The low rates of healthcare access and utilization among the uninsured and the consequent low rates of doctor-patient interaction in this population represents a significant weakness of EiM, particularly because members of low SES groups (1, 5, 32-33) and low education (1) have higher rates of inactivity and, therefore, are at greater need for exercise interventions than member of high SES groups. Among the general population, a 2007 study (34) reported that 21 percent of Americans has an annual preventive physical exam. This indicates that a large percentage of the population will not see a doctor unless they perceive a health problem requiring treatment, suggesting that many sedentary, but otherwise healthy people will not receive EiM's message. A recent review of health insurance and access (26) reported that 67% of adults, including both insured and uninsured individuals, had no contact with a health professional in the past year, similarly indicating EiM’s lack of reach.
Assuming patients have access to and seek healthcare services regularly, a provider’s advice may not result in increased exercise behavior. As previously mentioned, distrust (24) and perceived discrimination (25) in healthcare settings can cause patients to disregard doctors’ recommendations. Additionally, even if patients have a good trust relationship with their doctor and accept the message that exercise is medicine, intentions to exercise may improve without a corresponding increase in rates of exercise. The doctor-issued recommendation puts the responsibility to be physically active in the hands of the patient without addressing larger scale and upstream factors. Moreover, EiM’s success lies on the Health Belief Model-based premise that increasing salience of health risks associated with inactivity will increase intention to exercise. However, this logic is flawed and, even if intentions to exercise improve, behavior will not necessarily follow. The Health Belief Model assumes rational behavior, but it is clear that people often act irrationally. Moreover, the relationship between intention and behavior cannot be assumed. Research has shown that many who intend to engage in a behavior fail to do so (35) and that habits may inhibit the influence of intention on behavior (36). In order to improve behavior, EiM must do more than improve intentions to exercise through doctor-issued guidance.
Failure to Anticipate Barriers
A major flaw of EiM is its failure to anticipate barriers to exercise and its subsequent failure to address these barriers. The physical, “built” environment plays a substantial role in one’s choice to be physically active or inactive. Subjective assessment of physical activity in adolescents (37) and adults (38) as well as objective (39) measurement of physical activity in adults using accelerometers has shown that proximity to physical activity-related facilities (e.g., schools, parks, dance studios, YMCAs, swimming pools, bicycle rentals) increase engagement in physical activity. Similarly, the more convenient it is to exercise and the less convenient it is to be sedentary, the more likely an individual is to choose active over sedentary activities (40). Thus, the lack of areas and facilities suitable for exercise make it inconvenient and less likely that individuals will exercise, even if they know they should. Physical activity-related facilities tend to be less common in low SES and minority areas (37, 41). This barrier for low SES areas is particularly concerning because, as mentioned previously, rates of physical activity are lower in these population (1, 5, 32-33). An environment characterized by barriers to exercise will likely counteract the effect of increases in exercise intention motivated by EiM.
An additional, but related, barrier is the easy availability and convenience of alternative sedentary behaviors. According to behavioral economics, individuals weigh alternative choices based on costs and benefits as well as the proximity and tangibility of the costs and benefits (42). Behaviors with high immediate benefits and low immediate costs are preferred, even if high costs will be experienced later (43). The immediate costs of exercise (e.g., inconvenience, hard work, time, physical discomfort) are high and salient whereas the benefits promoted by EiM are distal and uncertain. Though exercise may reduce the risk of chronic disease, it is not a guarantee. Subsequently, from a behavioral economics perspective, a sedentary lifestyle may be perceived as more rewarding and higher value than an active lifestyle. While EiM aims to inform patients of exercise’s future health benefits, it focuses little attention on exercise’s more immediate benefits and does little to anticipate and downplay immediate costs of exercising. Evidence has shown that, given the choice between sedentary activity and exercise, most will choose sedentary activities (44). If access to sedentary behavior is restricted such that exercise is more convenient, however, exercise behavior increases (40, 45) demonstrating the utility of behavioral economics in exercise promotion programs. EiM’s failure to incorporate the ideas of behavioral economics inhibits its efficacy. Its chance of success would be far greater if it anticipated the barrier of readily available and tempting sedentary activities and encouraged perceptions of exercise as being more accessible and rewarding than sedentary behavior.
Conclusion
While the Exercise is Medicine program is intended to increase exercise behavior, its design has fundamental flaws that reduce its efficacy and may even be counterproductive. It oversimplifies the problem and the solution, creates potentially damaging associations between exercise and medical treatment, makes faulty assumptions, is too limited in scope, puts too much responsibility on the shoulders of individuals, and ignores substantial barriers. A novel intervention that capitalizes on social and behavior sciences theory and research would have higher chance of success in increasing exercise behavior and helping Americans reach national physical activity guidelines.

Active Communities Today: A Social Science-based Physical Activity Intervention – Maureen Harris
The Exercise is Medicine (EiM) initiative aims to battle the alarming prevalence of sedentary lifestyle and encourage adults to meet the national recommended guidelines for physical activity. Despite its good intentions, the program’s ignorance of social and behavioral principles greatly inhibits its efficacy. A previous critique of this program highlighted several crippling flaws. Here, an alternative program is proposed.
The Active Communities Today (ACT) initiative is based heavily on social science research. As its names suggests, it has three primary objectives. First, to get people active and moving, without necessarily framing exercise in a health context. Second, to engage communities, foster social support, avoid blaming individuals, promote policy changes to encourage activity, and to campaign for improvements in the built environment that facilitate physical activity. Third, to emphasize that the time for change is now; exercise behavior, not exercise intentions, will lead to public health improvements. These objectives are targeted by three key strategies that specifically address EiM’s fundamental weaknesses.
Strategy 1: Foster Intrinsic Motivation and Adherence
The EiM program defines exercise as “medicine” and employs medical terminology (e.g., “prescription”) throughout its materials. This definition is not only ineffective, but potentially counterproductive. By limiting the factors known to support intrinsic and internalized motivation, EiM reduces the likelihood that people will voluntarily choose to be active. The importance of protecting intrinsic motivation is more than theoretical. Applied research has shown that promotion of the factors that enhance internalization of motivation is positively related to exercise behavior (13, 46-49). ACT, guided by cognitive evaluation theory (CET; 10-11) and motivation research (e.g., 9-11, 14), promotes perceived choice, autonomy, self-efficacy, and the inherent enjoyment of physical activity to foster intrinsic/internalized motivation.
The program empowers people to make their own decisions and avoids directives and orders, with its primary goal being to allow exercise to become a naturally reinforcing activity. Through program materials and outreach events, ACT proposes a wide variety of activities, including competitive (e.g., road races and sports leagues), cooperative (e.g., recreational sports leagues and walking groups), and individual (e.g., health club workouts and swimming sessions) options from which people can choose, allowing people with all personality types to select an activity that is most appealing to them. The program recommends experimenting with nontraditional exercises (e.g., boxing or dance classes) to maximize interest and maintain satisfaction. Importantly, though abundant choices are offered, guidelines are provided. To make a noticeable public health impact, people must achieve a certain volume and intensity of physical activity. ACT advises participation in at least one activity for at least 30 minutes most days of the week in order to see short term benefits, such as increased energy and improved mood. As Whitehead notes (12), freedom of choice can be maintained within guidelines.
To enhance exercise self-efficacy, ACT encourages simple activities (e.g., brisk walking) as well as offering community classes and online tools to provide tips and skills on more complicated activities. At outreach events, fitness experts offer free consultations to help people design appropriate workout routines. While educational, the primary emphasis will be to encourage confidence. This aspect of the program is critical as self-efficacy has been shown to predict exercise behavior (46, 48-49) and adherence (13, 47).
ACT markets exercise as fun, with the goal of helping adults reconnect with the enjoyment of playful activity of childhood and to incorporate daily activity into their lifestyle. Defining exercise as a positive and pleasurable activity portrays physical activity as a satisfying choice. Furthermore, the expectation that exercise will be enjoyable increases the likelihood that an individual will perceive exercise as enjoyable. Cognitive biases often cause us to see what we want to see or experience what we predict we will experience (50). Positive exercise expectancies have been associated with exercise behavior (51).
By facilitating the factors necessary for intrinsic/internalized motivation, ACT simultaneously addresses EiM’s likely problem with poor adherence. A smoking cessation intervention that supported autonomy and perceived competence increased long term adherence to tobacco abstinence (52). Similarly, it has been demonstrated that those who adopt exercise as a personal value are more likely to adhere to regular physical activity (9).
Strategy 2: Employ Widespread, Effective Communication
As noted, many people do not see their doctor for various reasons. Even among those that do see a healthcare provider, many lack trust in him or her, meaning that directives from a provider may be disregarded. In order to communicate the core program messages effectively, ACT employs a multifaceted communication strategy.
To maximize distribution, print, radio, and television ads are used to broadcast ACT’s key messages widely. Posters are placed in public buses and trains as well as high traffic centers such as libraries, schools, and outside of grocery stores and banks. Radio and television ads are aired several times a week. Local outreach events featuring ACT representatives bring key concepts directly to community members. A website offers confidential guidance, encouragement, and tools to get started. Visitors to the site will be encouraged to offer suggestions for site improvements to maximize its utility (53). A network of message boards hosted on the site will offer a forum for social support and exchange of questions and answers. Importantly, medical experts will moderate the boards to ensure the accuracy of answers provided by community members. The site will also feature a space for individuals to get involved in policy change by reporting concerns (e.g., crime levels render neighborhood unsafe for outdoor exercise) and requesting changes (e.g., construction of bike lanes on city streets). This space is intended to open a dialogue between community members and policy makers.
In addition to being well-distributed, it is equally important that ACT’s communications are interpreted positively. This involves appealing to values of the intended audience (54), as assessed by pilot focus groups and survey samples, rather than the values of ACT staff. As an example, the program promotes commuting by bike rather than car to be “green” and doing house/yard work on your own rather than hiring landscapers to be thrifty. ACT’s materials and events feature a wide range of regular people with whom the target population can relate, including members of various racial and cultural groups, young and old, male and female. Beyond facilitating social learning (55), this shows that exercise is truly for everyone and helps develop imagery of people having fun being active. The aim is for members of the target population to begin to imagine themselves in an active lifestyle and consider adoption of an active lifestyle as an achievable goal.
Strategy 3: Reduce Barriers and Market Immediate Benefits
ACT is firmly based on behavioral economic principles and recognizes that there are infinite sedentary activities competing with exercise to fill the limited number of hours in a day. To portray exercise as a valuable choice, the short term benefits must be emphasized while short term costs are minimized (42). The program’s goal is to sell the idea that exercise is a small investment with a large immediate reward.
ACT works to reduce immediate costs by making physical activity accessible and convenient. A major obstacle in the widespread adoption of active lifestyles is the lack of exercise-friendly environments. With unsafe streets, car-dependent communities, and neighborhoods lacking recreational centers, finding opportunities to be active can be difficult, even if an individual has an intention to be active. In order to make improvements in physical environments, ACT works closely with government officials, community developers, and business leaders. The program sponsors grassroots organizations to campaign for change at the town and city level while opening a parallel dialogue with state and federal leaders. As mentioned in the second section, ACT involves the community members in this dialogue. Short term projects include establishment of bike share programs in urban centers. The long term vision is for development of high-density, “walkable” communities with low crime rates, low pollution, and abundant physical activity-associated facilities (e.g., recreational centers, swimming pools, tennis courts). These attributes are associated with higher rates of physical activity (e.g., 56-58), and a recent case study reported that increased access to recreational resources raised physical activity levels (59).
In addition to reducing structural barriers, ACT reduces perceived immediate costs by showing that exercise can be just as easy and uncomplicated as sedentary behaviors. The program website and print materials offer suggestions on how to incorporate simple exercise and non-exercise physical activity (e.g., walking for transportation, vigorous housework) into a daily routine. Moreover, it suggests inexpensive activities that can be done without leaving the house (e.g., exercise videos, jumping rope, dancing), and reminds people that if they cannot tolerate high intensity exercise, they can still reap benefits from higher frequency, lower intensity workouts.
Keeping in line with behavioral economic principles, the immediate benefits of physical activity are advertised much more heavily than long term health benefits. Program materials highlight increased energy and vitality, improved mood, higher quality sleep, improved mental functioning, reduction in mild depression, increased self-esteem, and even higher sex satisfaction. Fun activities that are considered pleasurable rather than painful (playing tag with the kids, playing tennis with a friend or spouse) are highlighted. To help physical activity gain an extra edge over sedentary activities, behaviors such as television viewing and video game playing are marketed as having few benefits. Time spent TV viewing has been shown to be inversely related to leisure time physical activity in women (60), girls (61), and adolescent boys and girls (62), suggesting that reducing TV viewing may encourage activity.
Conclusion
ACT is a broad, multifaceted program. It works primarily above the individual level to create large scale changes in the culture, physical environment, and social environment. In parallel, it targets individual level behavior by reframing exercise with positive terms and promoting exercise’s inherently reinforcing properties.

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England’s Maternal Prenatal Smoking Cessation-Robbie Frank

2009-05-07T12:47:00.000-07:00

There are a number of successful smoking cessation interventions based on behavioral theories. Even though many smoking cessation interventions are deemed successful, none of the interventions are without flaws (12). In England, there is a smoking cessation intervention targeting pregnant women. This intervention is based on the theory of planned behavior (TPB). An intervention based on the TPB model is a fundamentally flawed approach to maternal prenatal smoking cessation because it is an individual level based intervention, it asserts that perceived behavioral control is a predictor of actual behavioral control, and assumes that human behavior is the output of rational, linear decision making process.
Intervention
The England Department of Health launched a smoking cessation ad campaign based on the TPB model targeting pregnant women (20). The ad shows an obviously pregnant woman smoking a cigarette. The campaign then goes on to provide information on how cigarette smoke “restricts the essential oxygen supply to an unborn baby, so that their tiny heart has to beat harder every time a pregnant woman smokes.” The campaign reinforces the message that cigarette smoking harms unborn babies, and that stopping smoking is the right thing to do (social norms say smoking when pregnant is bad). The ad also goes on to inform the reader that smoking cessation –no matter how far long the pregnancy is−will immediately benefit the woman and her baby (control belief—the belief in the ability to control the improvement of the health of mother and child will make it easier for the mother to participate in smoking cessation). It then offers information on how pregnant women can take the situation into their own hands and receive professional support to assist them in smoking cessation (perceived power). The offer of assistance in smoking cessation is meant to turn intentions into the desired behavior. This ad presents smoking cessation as a positive, desirable behavior that one can control.
Theoretical Framework of Intervention
To contextualize the flaws of the England smoking cessation intervention, it is important to understand the health behavior model upon which the intervention is fashioned. The TPB model was proposed by Icek Ajzen in 1985 as an extension of the theory of reasoned action (TRA). TRA is an individual level theory based on the concept that individuals go through complex cognitive assessments before making decisions on behavioral intentions. This is then followed by the rational movement from assessment to behavior (15). A person’s intent to perform (or to not perform) a behavior is viewed as the instant determinant of the action (13). TRA includes two determinants to intention: personal (attitude) and social (subjective norm). An attitude is described as a negative or positive evaluation of performing or not performing a desired behavior. Subjective norm indicates a person’s perception of the social pressure exerted by others who think that a given behavior should or should not be performed. This theory lacked because a person can go through the process of assessment and have a behavioral intention, but still not be able to do the behavior (13). To address this issue, a new element called perceived behavioral control was added to TRA. Perceived behavioral control refers to the degree to which someone believes they have control over whether they can take the action (control belief) and the strength of that belief (perceived power). This new element reformulated TRA to TPB. It attempts to explain the relationship between people’s attitudes and their behaviors, based on people’s perceived behavioral control and perceived power (13).
Flaws of Intervention
Individual Level Intervention

The ultimate goal of the ad intervention is to reach a broad target audience of maternal prenatal smokers and convince them to change to the desired health behavior of smoking cessation. This smoking cessation intervention is based on the TPB model. Due to such, this intervention has inherit flaws of the TPB model, one of which being that this intervention functions on the individual level. The ultimate goal of an individual level intervention is to change the knowledge, awareness, and skills of an individual. These types of campaigns focus on changing a specific aspect of an individual’s attitude, belief, and/ or cognition (27). This is a drawback in an attempting to change the health related behavior of a target audience because the enactment or non-enactment of the target audience’s behavior is likely a result of personal individual-level processes that precede the behavior. Because maternal prenatal smokers are not a homogenous group, different women will have different reasons for participating or not participating in the desired health behavior of smoking cessation. England’s individual level smoking cessation interventions does not take into account that being healthy and giving birth to a healthy baby is not a core value for all women. Due to such, a smoking cessation intervention must be able to find a common ground amongst pregnant women and impact those core values in order to effectively promote the behavior change of smoking cessation.
The individual level approach to maternal prenatal smoking cessation is unable to address the social factors that may influence the behavior of continued smoking. Research shows that tobacco use (or non-use) results from a complex mix of influences that range from factors that are directly tied to tobacco use (e.g., beliefs about the consequences of smoking) to those that appear to have little to do with tobacco use (e.g., parenting styles and school characteristics) (22). Thus, there are a number of social factors that attribute to why women continue to smoke during pregnancy. Some women have cited a socio-economic burden as a barrier to smoking cessation. These women are unable to fund smoking cessation aids such as cigarette modification products, thought changing products, and stop smoking educational products (22). In a study conducted by Greaves, research found that some women use cigarettes to “organize” their social interactions in order to build and bond pleasant social and work relationships (24). In other studies, pregnant women cited smoking as a tool of self definition. Continued smoking projected a personal image perceived by the smoker as cool, tough, defiant, adventurous, sexy, young, and slim. Smoking was also cited as a means through which pregnant women are able to suppress emotions or dissipate feelings of fear or pain in preference to expressing negative emotions openly. The behavior of continued maternal prenatal smoking was also influenced by the smoking habits of husbands, partners, family members, and friends. These factors can contribute to the difficulty of smoking cessation (2). An individual-level model is inappropriate in shaping a smoking cessation intervention for pregnant women because it neglects to acknowledge that the decision of smoking cessation is not necessarily made on and individual level and that there are a number of social factors that impact decisions related to health behaviors.
Perceived Behavioral Control is a predictor of Actual Behavioral Control
A fundamental defect of a maternal prenatal smoking cessation intervention based on the TPB is the assumption that perceived behavioral control is a predictor of actual behavioral control. It is postulated that perceived behavioral control serves as a proxy for actual behavioral control, therefore having a direct influence on both intention and the actual behavior (1). On the contrary, perceived behavioral control is fundamentally different from actual behavioral control. Perceived behavioral control is a strong predictor of the strength of a person’s intention to participate in a certain behavior (25), not a substitute or predictor for the actual behavioral control that a person possesses. Actual behavioral control refers to the extent to which a person has the skills, resources, and other prerequisites needed to perform a given behavior (19). Due to the conceptual difference between perceived behavioral control and actual behavioral control, it is inaccurate to assume that perceived behavioral control can predict or impact a person’s actual behavioral control. Whether or not a person perceives that he/she has full control over his/her ability to perform a behavior and also the strength to do so, does not necessarily lead to the person performing the desired behavior (25). The TPB model does not accurately predict how people move from intention to behavior because it inaccurately asserts that perceived behavioral control is a predictor of actual behavioral control.
In a study conducted on the influence of perceived behavioral control, research revealed that perceived behavioral control impacts behavior only through the prediction of a person’s behavioral intentions (8). Perceived behavioral control is a strong predictor of the intent to do a behavior, but not a predictor of the actual behavioral control a person possesses (25). The fulfillment of many health behaviors do not coincide with attitudes towards, or intentions regarding a specific behavior. The England’s maternal prenatal smoking cessation intervention possesses the ability to convince a pregnant woman to develop a strong belief that she has control and power over her ability to stop smoking. However, strong perceived power and control beliefs do not lead to actual behavioral control, which is necessary to act on the desired behavior intention. Strong perceived power and control beliefs lead to strong intentions to do the desired behavior. Strong intentions is not sufficient enough to illicit the execution of a desired behavior. Pregnant women must possess actual behavioral control in order to perform the intended behavior (19). The assertion that the belief of perceived behavioral control is linked to pregnant women’s ability to act on the intention to participate in smoking cessation is inaccurate. Actual behavioral control must be present in order for a person to act upon his/her perceived behavioral control. Without actual behavioral control, the pregnant woman does not possess the skills and resources necessary to enable her to exercise the intended behavior of maternal prenatal smoking cessation. It is therefore difficult to assess how the construct of perceived behavioral control impacts behavior modification without first understanding the role that actual behavioral control plays in the human decision making process.
Human Behavior is Rational and Linear
Due to the fact that this intervention is rooted in the TPB model, its design oversight assumes that behavior is the output of rational, linear cognitive decision making processes (15). Many behavioral theorists and social scientists argue that human behavior is complex and irrational, therefore difficult to predict (18). Irrationality is defined as the tendency that humans possess to behave, express emotions, and think in ways that are inflexible, unrealistic, absolutist and self- and social-defeating and destructive (16). In light of the irrational nature of human behavior, it cannot feasibly be asserted that decision making is a linear, planned process. Human behavior is affected by the broad social or cultural environment surrounding the behavior, the immediate social situation or context in which the behavior occurs, the characteristics or disposition of the person performing the behavior, the behavior itself and closely related behaviors, and the interaction of all these conditions (22). There are a number of factors that can cause a person not to carry out their planned behavior. In smoking cessation, the decision to use or not to use tobacco is linked with a range of factors, some of which have little or not relation with actual tobacco usage (22). The human decision making process is the result of a complex interplay between cognitive, emotional, social, personal, and environmental influences (16) that can often time lead to irrational, self defeating unplanned behavior.
Today, most pregnant women seem to be aware of the health risks associated with maternal prenatal smoking, however, awareness alone is not sufficient enough to prompt women to stop smoking (9.). Studies show that maternal prenatal smoking is not solely the result of a lack of knowledge of health risks associated with the behavior. It is instead the result of the human decision making process which is shaped by external factors that can persuade women to deviate from the planned, desired behavior of smoking cessation (7). The assumption that decision making is a linear process neglects to consider the extraneous factors that might influence the target audience’s behavior. In a study of women’s attitudes toward smoking, it was found that although most of the women in a focus group considered themselves addicted and dislike smoking itself, they liked the social, psycho-logic, and physical effects of the cigarettes (23). Some reasons given by women for maternal prenatal smoking included those related to an inability to cope with psychological issues (i.e., depression, anxiety, irritability, etc.) and their physical addiction to nicotine (the appearance of characteristic withdrawal symptoms when the use of nicotine is suddenly discontinued) (3). Other factors associated with smoking cessation for pregnant women are their level of education and their race. Research reveals that smoking cessation among pregnant women increases as their level of education increases (5.). In 1991, 45.4 percent (±10.5) of women with 16 or more years of education quit smoking during pregnancy. This finding is consistent with previously published studies (6, 11.). Studies also showed that the percentage of smokers who reported having quit smoking for at least one week during their pregnancy was higher among American Indian mothers (64 percent) than among white mothers (57 percent) or black mothers (49 percent) (26). The factors that impact the decision to participate in maternal prenatal smoking cessation are not all rational, nor are they part of a linear decision making process. The previously stated research helps to illustrate the fundamental flaw of a maternal prenatal smoking cessation intervention based on the TPB model because it demonstrates that the human decision making process is irrational and unplanned (10), thus completely contradicts the functioning of the TPB model.
Conclusion
Due to the inherent flaws and shortcomings of all health behavioral theories, there is no one theory able to adequately and accurately predict human behavior. Human behavior is complex and influenced by a number of intrinsic and extrinsic factors (12). When attempting to predict human behavior, it is important to examine behavior decisions in the context of the target audience’s needs, preferences, social and environmental networks, and core values. In regards to such, public health practitioners must design and utilize health behavior modification interventions based on appropriate health behavior models in order to continue to advocate for healthier behavior.
Introduction
In assignment #3, the fundamental flaws of a maternal prenatal smoking cessation intervention based on the theory of planned behavior (TPB) approach was highlighted. This paper addresses the fundamental flaws highlighted in assignment #3 by offering an alternative approach to the maternal prenatal smoking cessation intervention. To address the fundamental flaws of the TPB approach, the new approach is based on the framing theory. Framing theory asserts that an issue can be viewed from a number of different perspectives . These different vantage points can be interpreted as having implications for multiple deeply ingrained core values of a population. Framing refers to the process by which people develop a particular conceptualization of an issue or organize their opinions about an issue (30). Thus, framing theory redefines, repackages, repositions, and reframes behavior modification interventions in a way that addresses the fundamental core values and needs among the target audience (33). The framing theory approach improves upon the flaws of the TPB approach in assignment #3 because it functions on a community level, takes advantage of the fact that human behavior is irrational and decision making can be non-linear, and it understands that perceived behavioral control is not a predictor of actual behavior control because there are external factors that can impact whether or not a person performs a desired behavior.
Functions on Community Level
Unlike the TPB approach, the framing theory functions on a community level by addressing the wide-spread core values of the target audience. This theory does so by speaking to the packaging and positioning of a public health intervention to appeal to deeply ingrained, widely shared core values held by the target audience (33). A community level smoking cessation intervention must be able to address the common ground amongst pregnant women and impact those core values in order to effectively promote the behavior change of smoking cessation. Literature shows that health is generally important to individuals because it impacts their core values by garnering the fundamental need and desire to have a certain degree of personal freedom, independence, autonomy, and control over their lives (33). To market changes in health behavior, public health must redefine, repackage, reposition, and reframe the health behavior intervention in a way that satisfies an existing demand among the target audience (33). By redefining the problem, framing also suggest a new solution to the problem (35). Framing theory moves the maternal prenatal smoking cessation intervention from the individual level to the community level because this approach equips the intervention with the capacity to appeal to the core values of the general public (34).
While the underlying model in assignment #3 tries to change current health behaviors to fit with the suggested health behaviors, the framing theory recognizes that the target audience will only take action when they believe that the suggested behavior aligns with the core values of their community. Thus, the framing theory focuses on appealing to its audience’s widely accepted core values and not the health value of the public health practice (33). For example, if public health practitioners were trying to market a framing theory approach of smoking cessation to pregnant teenaged girls, the intervention should address the core values of this target audience. Research shows that continued smoking during pregnancy projects a personal image perceived by the smoker as cool, tough, defiant, adventurous, and sexy (29). The framing theory approach could use these core values to create an intervention that sends the message that not smoking during pregnancy is cool, tough, defiant, adventurous, and sexy. This repackaging and repositioning of teenaged maternal prenatal smoking cessation speaks to the core values of a large community of people, thus having appeal beyond the individual level.
Takes Advantage of Irrational Human Behavior and Non-Linear Decision Making

The framing theory takes advantage of the fact that human behavior is irrational and that decision making can be non-linear. This theory addresses the flaws from assignment #3 by using irrational human behavior and spontaneous decision making as means through which it can change the perception of a suggested behavior while ultimately changing the audience’s perception of self interest. It does so by altering the relationship between the perception of the behavior and the audience’s self interest. Framing theory does not assume the need to change its audience’s health behaviors to conform to the suggest health behavior. This model redefines the suggested behavior so that it is perceived as being in the audience’s self interest and addresses the audience’s core values (33). This will encourage the audience to participate in the suggested behavior. This is achieved by demonstrating that the intervention will help the audiences to fulfill its fundamental needs and desires.
For example, a maternal prenatal smoking cessation campaign based on the framing theory can use a group of core values; such as freedom, independence, and control, to frame an intervention. Instead of defining a smoking cessation intervention as a behavior that will improve a person’s health, it can be redefined to be perceived as a behavior that will offer smokers freedom from the tobacco industry’s manipulation, independence from the addiction of nicotine, and control over the fate of their lives. In this smoking cessation campaign, the solution to the problem of loss of freedom, independence, and personal control is smoking cessation. The irrational behavior and non-linear nature of human decision making enables the relationship between the perception of the audience’s behavior and the perception of the audience’s self interest to be altered by repackaging and repositioning a smoking cessation campaign to be about empowerment within the target community.
Perceived behavioral control is not a predictor of actual behavior control because there are external factors that can impact a person’s ability to perform a desired behavior

The framing theory accounts for the fact that perception of control over one’s ability to complete a behavior (perceived behavioral control) does not necessarily lead to actually having the power or control to practice that behavior (actual behavioral control). Perceived behavioral control does not lead to actual behavioral control because there are external factors that can limit a person’s ability to perform a behavior in which he/she might have perceived control over (13). Whether or not a person perceives that he/she has full control over his/her ability to perform a behavior and also the strength to do so, does not necessarily lead to the person performing the desired behavior (25). Research shows that tobacco use (or non-use) results from a complex mix of influences that range from factors that are directly tied to tobacco use (e.g., beliefs about the consequences of smoking) to those that appear to have little to do with tobacco use (e.g., parenting styles and school characteristics). Thus, there are a number of social factors that attribute to why women continue to smoke during pregnancy (22).
The TPB approach does not accurately predict how people move from intention to behavior because it inaccurately asserts that perceived behavioral control is a predictor of actual behavioral control. It does not consider the impact of external factors in a person’s ability to have actual behavioral control. The framing theory addresses this flaw by redefining, repackaging, repositioning, and reframing the health behavior intervention in a way that satisfies an existing demand or need within the lives of the target audience, thus, addressing the external needs and desires of the audience to enable them to participate in the desired behavior (33). For example, a group of pregnant women have the desire to stop smoking are offered an opportunity to participate in a free program that will assist them with smoking cessation (perceived behavioral control). Unfortunately, many of the women are unable to attend the weekly program due to transportation issues, lack of appropriate child care, work, etc. This means that these women do not possess actual behavior control to carry out their desired behavior of smoking cessation. A framing theory approach would restructure the health behavior intervention in ways that would satisfy the demands and needs within these women’s lives in order to give them actual behavior control to participate in smoking cessation.
Conclusion
Maternal prenatal smoking is a complex behavior that is influenced by a number of factors. The framing theory is able to addresses the different ways in which situational and personal factors influence a woman’s decision to participate in smoking cessation. The framing theory provides public health practitioners with a means through which they can define, position, and package a smoking cessation intervention in ways that address pregnant women’s core values and help to them to quit smoking.

Works Cited

References
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3.) Draper, E. and Haslam, C. A qualitative study of smoking during pregnancy.
Psychology Health & Medicine 2001; 6, 95−99.
4.) Dutta-Bergman, M. Theory and Practice in Health Communication Campaigns: A Critical Interrogation. Health Communication 2005; 18 (2); 103–122.
5.) Fingerhut, L.; Kleinman, J.; and Kendrick, J. Smoking before, during, and after
pregnancy. American Journal of Public Health 1990; 80 (5):541–4.
6.) Floyd, R et al. A review of smoking in pregnancy: effects on pregnancy outcomes and cessation efforts. Annual Review of Public Health 1993; 14:379–411.
7.) Gillies, P., Madeley, R., and Power, F. Why do pregnant women smoke? Public
Health Sept. 1989; 103 (5): 337-43.
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D.A.R.E. to Know the Truth: The Ineffectiveness of DARE Due to an Inability in Addressing Context and Reality – Danielle Tuft

2009-05-07T12:44:00.000-07:00

Adolescent drug use has been a continuous problem that the U.S has had to face and one which has yet to be controlled. In response to this, preventions focused on youth have become a larger focus with hopes that kids will learn to avoid negative peer pressure and recognize the damaging consequences of drug use. School-based drug use prevention programs have been a fundamental part of the US anti drug campaign since the 1970s (1). These programs allow for early prevention opportunities as well as include an already existing structured environment useful for the introduction of important and potentially unknown information.
Of the anti drug campaigns that have been used in the U.S., project DARE (Drug Abuse Resistance Education) has become the most widely disseminated school-based prevention program (2). DARE was created in 1983 as a product of a collaboration between the Los Angeles Police Department and the Los Angeles School District to teach drug use prevention curriculum primarily in elementary schools, though it grew to include middle schools and high schools. Its curriculum, taught by police officers, focuses on providing information about drugs, decision making skills, building self-esteem, and finding alternatives to drugs (1). According to the DARE website, the program benefits children in more than 300,000 classrooms and in all 50 states, as well as millions of children in other countries (3).
Over the past 25 years, many studies have found that the DARE program to be ineffective (1,4). A 5 year longitudinal evaluation of the effectiveness of DARE concluded in 1996 that “no statistically significant impacts of the intervention were observed with respect to the cigarette, alcohol, or marijuana use” (2). Beyond individual reports of the ineffectiveness of the DARE program, the federal government has also recognized this conclusion. The Department of Education prohibits schools from using federally allocated funds on the program as they have determined it ineffective and in 2001, the U.S. Surgeon General put DARE into the group of “ineffective programs”. It is estimated that DARE costs $1-1.3 billion dollars each year, yet it is still widely used regardless of the fact that many studies and organizations have found the program to be ineffective (5).
Failure to Recognize the Importance of Cultural Context
The curriculum of DARE is set up in such a way that it addresses large numbers of school children at one time. While there are some opportunities to focus on the individual, most of the curriculum is addressed to an entire class, or in some situations, an entire school. The program lacks the structure to allow for the exploration of individual students’ different social, economic, or cultural backgrounds and their behavior in response to those contexts.
It has been shown that students respond more favorably to drug prevention programs when the programs visibly incorporate their culture and allow students to be represented (6). It makes sense that a program which directly addresses cultural situations for a specific person or group of people would resonate more with that person. Many anti drug programs have failed to consider the importance of ethnicity and culture and instead have opted for a standardized curriculum assuming it to be effective for all (6). This is the case with DARE as it does not incorporate cultural situations into their curriculum but instead uses role playing focused on simple peer pressure situations, such as “What would you do if your friend offered you drugs?”. There is no exploration into the possibility that the reaction to this question may differ depending in what cultural situation it is asked. Even more, DARE is used throughout the country in cities with many different resources and demographics, yet the same classes and topics are taught with the same methods. It has been argued that standardized prevention messages can and do enforce “dominant cultural values that do not validate or utilize minority children’s cultural experiences” (6).
DARE does not account for the diversity found in many schools and the structured curriculum limits the program’s ability to use different communication techniques or introduce other possible cultural values when dealing with different students from different backgrounds. Minority youth may be underrepresented if prevention materials are constructed from middle class, white culture (6). One book, in discussing a student approved approach regarding the relationship between the officers and students, quoted a student who said that “They need to get to know the kids personally and find out why they’re using drugs or whatever. You need to know the kids and find out why they’re doing something before you can do anything about it” (7). It cannot be assumed that every person sees drug use in the same way, especially considering that many religions use alcohol in a positive manner during rituals or that a child with parents that smoke may perceive cigarettes different from a child who has grown up in a smoke free home. It may be much more difficult for a student to “just say no” when they live in a community where drug related issues are constant or where trafficking drugs is a prevalent option for youth. With this in mind, it is easy to argue that since DARE does not allow for cultural and ethnic differences, many children may feel that the program does not apply to them.
Incorrect Choice in Leaders
The Communications Theory is a widely used theory within public health and one which touches upon the importance of “who says what to whom in what channel with what effect” (8). This theory clearly points to the importance of recognizing the person who is conveying the message and what effects may be brought about by that choice.
Since its inception, DARE has relied upon police officers to be the “teachers” of anti drug information. DARE explains that there are multiple benefits to the use of police officers, such as the fact that it “humanizes” the officers and allows youth to relate to them as people or that it removes police from the enforcement role and allows students to see them in a different one (3). While to some effect, there may be a “hero” factor attributed to police by young people, the police officer’s authoritative position is still kept. They come dressed in uniform and as a special guest, separating themselves from the youth. Even more, in many situations the officers may lecture, thus once again putting themselves above the youth and in an authoritative position as the person who has the answers.
It is also very possible that the perceptions students have of officers may differ greatly. It is unlikely that a student who comes from a neighborhood with high crime rates and constant police action will be able to recognize a police officer as credible or to see them in a positive manner. DARE is a program that lasts about one hour a week for between 10 to 17 weeks. The officers with whom students are to bond with are not considered to be normal members of the educational community and it could be argued that their infrequent interaction with the youth make it difficult for the youth to cement positive relationships with them.
It has been found that peer led programs have been better at reducing substance abuse than programs without a peer component, yet DARE has continuously used police officers as the main person to disperse anti drug information (9). Children cannot relate to them and are even more likely to disregard the advice they may receive from them. Early adolescence is a period in which children shift from being primarily influenced by their parents to being primarily influenced by their peers (6). With this in mind, it does not make sense that DARE would choose adults, especially ones with no previous relationship with the youth, to attempt to influence the ideas and behaviors of early adolescents.
Unrealistic Goals and Failure to Look Past the Individual
The DARE program uses an abstinence approach, telling students that they should never do drugs at all rather than recognizing that many students at some point experiment. It has been hypothesized that this approach may actually be damaging to prevention efforts as it may provoke rebellious behavior from students already experimenting (10). It is unlikely that a student will never experiment, and in the case of alcohol, DARE does not provide methods in which to avoid actual alcohol abuse once a student reaches the legal age to drink. In the case of adolescents who have experience with substances, advocating no use may actually lead to an increase in drug use, as they may reject the intervention (10). DARE does not address students who are already experimenting and the curriculum gives them no reason to stop because the program no longer relates to them as they have not abstained from drug use. A person like this may feel that they have no place within the current program. Even youth who have not experimented may recognize the program to be unrealistic and view it as ineffective or not applicable to current youth.
It is clear to see the unrealistic expectations of the DARE program simply within its well known slogan of “Just Say No”. The simplistic nature of the statement seems to allude to a mistaken idea that turning down drugs is as easy as saying a couple words. DARE, like many other public health programs, focuses solely on the individual level, and fails to look at reasons beyond individual control for unhealthy behaviors. This approach focuses on providing individuals the tools they need, such as education and skills, to say no; however this clearly is not enough as approximately 6,000 youth try a cigarette per day (11). Similar to looking at cultural backgrounds as reasons for behavioral choices, it is necessary to look at the larger reasons beyond a person themselves as to why a student may say “yes” instead.
Conclusion
The U.S. has recognized for years that adolescent drug use is a huge problem and has encouraged the use of school based prevention programs to combat it. Although many of these programs have been created, none have been as prevalent as the DARE program. However, DARE’s ineffectiveness in reducing adolescent drug use behavior clearly contrasts its popularity and prevalence (1). Aspects of the program’s ineffectiveness could be attributed to its inability to account for certain ideas found within social theories.
In order for DARE to become more effective it must recognize the problems it currently has and reformat its curriculum. The program must look past the individual level and attempt to find reasons for unhealthy behavior within the cultural context of its students as well as welcome the different views and perceptions student have on drugs. DARE must also realize that while there may be some uses for police officers in the program, they cannot be the main distributor of information as many students may not see them in a positive light. Lastly, it is important that DARE adjust its goals and realize that it is unlikely to end all adolescent drug use but to instead focus on how to control it or how to offer other options to students who already are or have the potential of experimenting with drugs.
Introduction
Recognizing problems in the structure and implementation of the DARE program allows for an opportunity to address possible changes and a new intervention that uses different health behavior theories and correct those issues found in DARE. While a completely new intervention is not absolutely necessary, a revamp of the traditional DARE program is needed. Studies have continued to show DARE to be ineffective in the long term and a new anti-drug intervention which takes cultural theory, social network theory, and harm reduction into account must be put into action (1,4).
Intervention
The intervention would address the three main faults discussed in regards to the current DARE program, those being its failure to recognize cultural context, employing ineffective leaders, and putting forth unrealistic goals. The revamped program would be much more comprehensive and look at possible social and cultural contexts in regards to drug use. It would also be designed in a way so that it could be reworked to fit a particular geographic setting or demographic.
First, the program would make use of the Cultural Theory and recognize the need for different techniques for different groups of people based on their cultural background and understandings of health and addiction. The program would include discussions that are targeted and tailored to specific groups, particularly different ethnic groups, in an attempt to be more effective after recognizing the differences in drug use rates among different ethnicities and cultures. The intervention would also be created with the use of focus groups, employing a specific cultures view on alcohol use, smoking, and illicit drug use so as to use a group of people’s own views on drug use to influence their health behaviors.
Second, it would be a long-term program starting in elementary school and continuing through middle and high school, with discussions and seminars happening at least 50% of the weeks in an academic school year. The intervention would take into account the Social Network Theory and the importance of peers and their influence. The discussions would be led by older peer leaders who share commonalities beyond simply age with the targeted age group, such as middle school students leading discussions for elementary students and high school students leading for middle school students. This intervention would still use police officers but rather than lead discussions in an authoritative manner, they would join discussion groups as participants in order to allow for a more even relationship between themselves and the students. This would allow police officers to still form positive relationships with students without “scaring” students or exacerbating the negative impression some students may have of the police force. The program would also employ a buddy system between younger peers and responsible older peers with similar cultural and social backgrounds, in order to provide a positive role model and to show actual alternatives to drug use.
Lastly, the program would be designed in such a way to meet the changing attitudes and social contexts that come with growing up. This revamped intervention would take into account the changing attitudes of alcohol and marijuana within the American public, such as the increasing push to legalize marijuana. The program would integrate use reduction goals with harm reduction goals, in an attempt to include all students as well as to teach students how to be safe or how to handle situations such as a friend who is drunk and needs help. Harm reduction goals would also give a student the skills needed to be safe once they reach the legal age to drink alcohol or smoke cigarettes. The integration would move from a heavier focus on use reduction to a heavier focus on harm reduction as the students get older. For example, the elementary based program would be more focused on use reduction, though may find in certain communities that harm reduction is necessary while, the high school program would still promote abstinence while recognizing the growing need to rely more heavily on harm reduction.
Using the Cultural Theory and Recognizing the Cultural Context
When youth are able to see themselves in presented situations, they are more likely to relate to and support the prevention messages (6). The Cultural Theory recognizes that a behavior related to health is influenced by a person’s understanding about its meaning or is a result from a lifestyle built around meanings, symbols and values, as they are connected to a larger social structure (8). Through this theory, which asks questions such as “what does it mean to be healthy?” this new intervention is able to account for different students varying understandings of drug use (8). Its use in creating the discussions and program topics, allow the intervention to change methods depending on how one group may view alcohol in a larger context or the fact that students who live in neighborhoods with heavy drug use may see dealing or using as inevitable. The targeted nature of this intervention also allows for the opportunity to do this rather than approach a larger group with multiple backgrounds using only one view of drug use.
The use of the Cultural Theory would also allow for cultural tailoring, defined as the “process of creating culturally sensitive interventions” (12). As part of this intervention there would be a focus on both the surface structure and deep structure, two dimensions of cultural sensitivity. It is explained that surface structure looks to match intervention materials and methods to the observable characteristics of a population, such as music, food, preferred clothing, and language. Deep structure on the other hand involves incorporating outside forces, such as culture, history, and environment in an effort to influence behaviors (12). The employment of these methods would most likely be more effective in reducing drug use both because students would understand drug use in a context familiar to them and the influences that are more problematic to a specific group can be addressed rather than spending time on issues that one cultural group hold to be insignificant.
In order for the intervention to be effective, focus groups must be a major part of the development. Focus groups have been found to be effective in creating culturally sensitive intervention message (6,12). Youth from the targeted groups must be involved in order to understand the realities of the social and cultural context as well as in an attempt to avoid stereotyping.
The Social Network Theory and Choosing Effective Leaders
This revamped intervention pairs up younger students to older students who serve as positive role models and creates a support system that is outside the student’s normal environment or friend base. The intervention does so in accordance with Social Network Theory which recognizes that “relationships between and among individuals are important, as is how the nature of those relationships influences beliefs and behavior” and that these relationships play an important role as to whether a person partakes in risky health behavior or not (8). More specifically related to drug use, the Social Network Theory means that students are heavily influenced by the drug use habits of their family, community, or friends. With this in mind, it is important that young students are able to see positive role models and identify how responsible youth avoid drug use.
Unlike the traditional DARE program, this intervention uses peers to lead discussions and interactive activities and places police officers in a more even level with students. As addressed in the previous critique, it has been found that peer-led programs are more effective at drug use reduction than prevention programs that lack a peer component (9). Using youth that students can relate to is important in attempting to change behavioral norms. Peers are more effective as leaders in that they seem more credible to students, which encourages those students to actually support the anti-drug information discussed, and that norms created through use of a discussion group are more likely to continue outside of school (9). As part of this intervention, using middle school students to help lead discussions for elementary students, provides role models who do not partake in drugs and may impart to the youth that drinking and drug use is not a norm and that it is not necessary to be “cool”. Particularly, using youth who have avoided drug use in an area where it may be prevalent may show students that it is not inevitable and that there are people who they can go to that will help them keep healthy behaviors.
Integrating Harm Reduction Approach with Use Reduction Approach
There has been a growing movement in creating a framework for a harm reduction approach in public health intervention, which is rooted in the awareness of adolescent psychosocial development where curiosity and a willingness to experiment are prevalent (13). Today, youth are seeing states continued interest in legalizing marijuana for both medical and leisure or their parents drinking a glass of wine at dinner. Even more, students eventually reach an age where it is legal to consume alcohol or smoke cigarettes, yet the traditional DARE program disregards this and does not provide students with the skills needed to partake in alcohol use safely. It has been argued that “school based prevention programs cannot be effective because they are inconsistent with the messages that adolescents receive from the larger social environment” (13)
With this in mind, this new intervention includes a harm reduction approach, primarily aimed at older youth. The approach focuses on the principles of harm reduction and uses them pragmatically, offering information about drugs rather than solely against them (13). It is unrealistic to assume that youth will abstain completely from drugs and it is important to offer safe options and teach moderation skills. In addition to promoting safer use, this approach allows the program to reach out to students who may have already experimented or are currently use drugs.
Conclusion
This revamped intervention corrects the faults found in the traditional DARE program though the use of the Social Network Theory and the Cultural Theory. It provides a program that is better at dealing with growing multiculturalism and is accessible to many more students than the original program. It also moves away from the abstinence only approach and accepts the need to educate students on safe use. Overall, an intervention like this may be much more effective and positive to students.
References
1. Ennett, S, et al. How Effective is Drug Abuse Resistance Education? A Meta-Analysis of Project DARE Outcome Evaluations. American Journal of Public Health 1994; 84: 1394-1401.
2. Clayton RR, et al. The Effectiveness of Drug Abuse Resistance Education (Project DARE): 5-Year Follow-Up Results. Preventive Medicine 1996; 25: 307-318.
3. D.A.R.E. Drug Abuse Resistance Education. About D.A.R.E. Los Angeles: Drug Abuse Resistance Education. http://www.dare.com.
4. West S, O’Neal K. Project D.A.R.E Outcome Effectiveness Revisted. Research and Practice 2004; 94: 1027-1029.
5. Kalishman A. Drug Policy Alliance Network. D.A.R.E. Fact Sheet. New York: Drug Policy Network. http://www.drugpolicy.org.
6. Gosin M, Marsiglia F, Hecht M. keeping’ it R.E.A.L.: A Drug Resistance Curriculum Tailored to The Strengths and Needs of Pre-adolescents of the Southwest. J. Drug Education 2003; 33: 119-142.
7. Orcutt J, Rudy D. Drugs, Alcohol, and Social Problems. U.S: Rowman and Littlefield Publishers, 2003.
8. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
9. Valente TW, et. al. Peer Acceleration: Effects of a Social Network Tailored Substance Abuse Prevention Program Among High-risk Adolescents. Addiction 2007; 102: 1804-1815
10. Mash E, Barkley R. Treatment of Childhood Disorders. NY: Guilford Press, 2006.
11. Bergsma L. Center for Media Literacy. Media Literacy and Prevention: Going Beyond “Just Say No”. CA: Center for Media Literacy. http://www.medialit.com
12. Resnicow, Ken, et al. Cultural Sensitivity in Substance Use Prevention. Journal of Community Psychology 2000;28: 271-290.
13. Erickson, Patricia G. Reducing the Harm of Adolescent Substance Use. Canadian Medical Association 1997; 156: 1397-1399.

“Think. Don’t Smoke”: Why the Health Belief Model Makes the Campaign Ineffective- Simona Shuster

2009-05-07T12:41:00.000-07:00

"In order to motivate someone to quit, you have to provoke a strong emotional response," Jenna Mandel-Ricci, director of special projects for the Department of Health, told the Daily News. "If we run ads that people don't remember or that don't affect people, then people won't call for help (1).” This statement can be extrapolated to describe any situation, particularly anti-smoking. Many a campaign has been created to show the ravages of smoking on the psyche and body on youth and adults alike, but to no avail. About half of all smokers who keep smoking will end up dying from a smoking-related illness (2). If information and campaigns are so prevalent about the horrifying effects of smoking, why is youth still determined to smoke?
Most anti-smoking campaigns remain failures because their messages are unclear or weak. Millions of dollars have been wasted in efforts trying to make people quit, but much of the ads are only informational in nature. Ironically, it is more the colorful and fun pro-smoking campaigns and billboards that most people remember and not their antithesis. Philip Morris is notorious for making the Marlboro Man, the iconic rugged man on his horse, smoking his cigarette, because that is what real men do, and to which other men can only aspire. Thus, when Philip Morris set out the venture to dissuade youth from smoking, most were surprised, but admittedly pleased initially with the “Think. Don’t Smoke” campaign that resulted. However, what looks too good to be true often is and this campaign, with its official message of discouraging youth from smoking, brings out many subliminal messages, least of which is the adage that was intended.
As an anti-smoking campaign, “Think, Don’t Smoke” failed miserably because it based its advertisements on the Health Belief Model. Many facets of the Health Belief Model do not hold true when applied to this public health epidemic. Thus, the campaigns built upon them can only have limited success in their endeavor to keep adolescents off cigarettes. This essay will focus on the 3 most influential flaws of the “Think. Don’t Smoke” campaign committed by Philip Morris, based on the Health Belief Model.
The Health Belief Model is the oldest model and upon which much of public health campaigns still rely. Its main premise is that human beings are rational creatures and behave in predictable patterns. Therefore, once the intent is present, it will lead to behavior. However, several crucial components stem into the intention. Perceived susceptibility is the degree to which a person feels at risk for a health problem. If the susceptibility is high, the person will have increased chances of committing the behavior. Perceived severity focuses on the premise that the person may believe the consequences of the problem to be harsh. Perceived benefits are the positive outcomes a person believes will result from the action, whereas the perceived barriers are the exact opposite as the negative outcomes. Once a person has carefully accessed all of the pros and cons of the making that choice, and it is their intention to do it, they will go ahead and commence with that conclusion.
Flaw #1: Youth Act in a Predictable Manner
The first incorrect assumption is the most hindering to public health campaigns and entails the premise mentioned earlier that youth will act in a predictable manner. However, people are predictably irrational and youth make it their stance to be deliberately so. The research that Philip Morris used primarily failed to account for the rationale of youth and their rebellious nature and determination to seek full independence and maintain decision making authority. It is precisely their irrationality that makes the ads unrealistic and to which adolescents cannot relate. The children found the Philip Morris adverts to be the least effective of all in making them “stop and think” about not smoking. Some of the respondents said that the Philip Morris adverts sounded more like a parental lecture, and overall there was a feeling that they lacked substance and good reasons not to smoke (3). Studies have proven that the worst campaigns are those reflecting an authority figure telling the adolescents what to do. In one example, a young teen is going out with friends and upon leaving, her father reminds her not to drink or smoke. She replies that she knows and does not do so when someone tries to offer her a cigarette in her group. The ad is cleverly done because the girl is in a group of her peers and says no. However, if one pays attention to the subtleties of the advert, he will notice that she did not even glance at the person offering her a cigarette which means that she either does not know this person or does not hold him in high regard. If she did, she would have more likely accepted his offer of a cigarette.
The ads are also clever in that they only focus on teens as their current ages and do not extrapolate into the future. It is a well documented fact that young adults do not think about their health in the future. The focus is more short-term and during their teen years, adolescents have yet to acquire any diseases that could be attributed to smoking. Heart disease and lung cancer seems a long way away to a 16 year old girl starting to smoke because of peer pressure. Her attitude may be “anyway by the time I get to 40, they will have a cure(4).” There are also no perceived barriers to smoking during adolescence because the negative outcomes will be much later in life. The perceived severity is greatly reduced as teenagers feel, precisely as a result of their youth, that they will be able to quit whenever they want. That is very true in that they will quit and start up again. Nicotine, a drug found naturally in tobacco, is highly addictive -- as addictive as heroin or cocaine. Over time, a person becomes physically and emotionally addicted to (dependent on) nicotine. Studies have shown that smokers must deal with both the physical and psychological (mental) dependence to quit and stay quit (2).
Flaw #2: The Health Belief Model doesn’t Account for External Factors and Social Norms

The next flaw of the “Think. Don’t Smoke” campaign is that, because it is based on the Health Belief Model, it does not take into account external factors and social norms. A University of Georgia study found that youth will only respond to a campaign because of peer pressure; they assume that their friends are interested and will be listening. Otherwise, the ads appear to stimulate the rebellious and curious nature of youth, making them more interested in smoking (5). One advert that Philip Morris uses does have a group of teenagers sitting around the steps leading to a beach and discussing how different all of them are and that is what makes them unique (6). This is the reason they cite for not smoking. Some teenagers may react well to this ad, but if they think their friends will scoff at it or notice their peers making fun of it, then they will partake in this action. "Perception is sometimes more powerful than actual behavior, that it doesn't necessarily matter how your friends respond to the ads, but how you think your friends are responding (5).” While Phillip Morris tries to capture individuality or independence that adolescents crave during their teen years by showing all of the teenagers together, it still fails to make a big impact upon other teens in terms of anti-smoking, but does a great job of convincing them to pursue the bad behavior. Those who do not share the thoughts and feelings of the youths presented in the “Think. Don’t Smoke” campaign simply do not relate to the ad. This latter group, however, has greater potential to become future smokers and should therefore be the main focus of a tobacco counter-marketing campaign (7). The point is supposed to be to make the advertisements very pragmatic so that teens can realistically see themselves in those positions and being able to avoid succumbing to peer pressure.
Flaw #3: The Slogan Is a Failure
The final flaw in the “Think. Don’t Smoke” campaign is the actual failure of the slogan itself. Firstly, the slogan manifests itself in a derogatory and patronizing manner, which teenagers will immediately find offensive. When one is commanded to perform an action, it will immediately set off a rebellious attitude against the stated action, despite the perceived benefits of knowing that the consequences of performing that action would be positive. Furthermore, the authoritative and negative tone of the slogan draws teenagers to counteract out of spite. Philip Morris says it has spent more than $1 billion on its youth smoking prevention programs since 1998 and that it devised its current advertising campaign on the advice of experts who deem parental influence extremely important (8). Clearly their research is not very thorough because adolescents do not want to be told what to do, especially not by adults. Therefore, the slogan is stating if one thinks, then he is listening to what adults have to say, and he won’t smoke. Teenagers do not want to be associated with thinkers because they are the “not cool” crowd. The ad is counter-productive in the sense that it specifically draws out the disobedient nature of youth who will relish the thought of smoking just to avoid being mislabeled into the wrong crowd. This is again where societal norms take precedence over what the individual may think. Teenagers do not want to be different, and instead form cliques that then generate the label to all who “fit in.” The campaign has failed to take into account what adolescents hold in esteem and have created ads that are ridiculous in content and scope. Also, a very basic and obvious critique of the campaign is the tackiness of the ads. It gives one the impression that the Anti-Smoking campaign, albeit spending over $100 million dollars to create, couldn’t really care less about the anti-smoking message and that each campaign involved the most minimal of efforts on the part of the creators and writers. Youth seeing these adverts could disregard them based on these tenets alone, not even bothering to query about the message the campaign is trying to convey. The campaign did the least well among youths in greatest need of messages that discourage smoking (9).
The failure of the “Think. Don’t Smoke” campaign can be relegated to the fact that Philip Morris created these adverts. It would be prudent to remember that these people are in the market of promoting cigarette smoking and addiction because it keeps them in business. They would never create logical campaigns to promote anti-smoking because they would lose their revenue base. For each smoker who dies, the firm then taps into the youth markets and recruits more by using more of these campaigns. Oddly enough, the Philip Morris website itself indicates that they are actively promoting youth anti-smoking and that their product is intended for adults. These phrases will make the idea of the all mighty cigarette even more idealistic to young adults who see this as a toy that can only be played with once they are grown. They will do everything in their power to obtain this product to be able to brag that they are performing the action only meant for adults. This is a predictable behavior of human nature. One will always want what one “can’t have.” A new study by the American Legacy Foundation gives conclusive evidence that Philip Morris’ latest efforts to clean up its image by running advertisements purporting to discourage youth smoking are nothing more than a sham. Instead of reducing youth smoking, they insidiously encourage kids to use tobacco and become addicted Philip Morris customers (10).

Using Advertising and Marketing Theories in “Infect Truth” to Counteract the Health Belief Model and “Think. Don’t Smoke.”- Simona Shuster

Insofar as many anti-smoking campaigns have failed to live up to the promise of their campaigns, “Infect Truth” comes out with a stunning victory over other efforts as they base their campaigns on young adults’ and adolescents’ core values. The “Infect Truth” adverts are the exemplary counterpart to the “Think. Don’t Smoke” campaign launched by Philip Morris. The campaign features young adults revealing messages about tobacco companies- they are often campy and catchy, with sing-song phrases and musicals. It is the only national smoking prevention campaign not directed by the tobacco industry, which exposes the tactics of the tobacco industry, the truth about addiction, and the health effects and social consequences of smoking. It is a national peer-to-peer intervention that works (11). The messages are very cleverly designed because they criticize the tobacco slogans in a manner that is clearly understandable to the layman.
“Infect Truth” resulted from a victory of the state of Florida over the tobacco companies in 1998. The State took the $13 billion per year settlement and formed the Florida Tobacco Pilot Program in 1997. The program set out to drive a wedge between the tobacco industry's advertising and a youth audience. It not only assembled a team of advertising and public relations firms to develop the marketing portion of the campaign but also directly polled Florida's youth. From this, emerged “Infect the Truth” in 2000, the campaign concept of a youth movement against tobacco companies promoted through a youth-driven advertising campaign (12).
The campaign uses the social models of Advertising and Marketing Theories, based not on the individual but rather on society as a whole, to drive its point. Advertising and Marketing Theories are ubiquitous in the advertisements and show “Infect Truth” as a global brand that all young adults now recognize. Advertising theory posits that the way to have people behave is to make them a promise and provide support for that promise that will in turn help people behave in said manner. In this instance, the entire premise and promise of the “Infect Truth” campaign is if youth knows the truth about smoking and its effects and more importantly, can relate to the messages conveyed, they will be less likely to begin smoking or continue smoking if already started. Marketing Theory takes Advertising Theory one more level with the branding of the product- which in this case, is “infecting truth” about smoking. The campaign does an excellent job of correcting the three flaws that were prevalent in the “Think. Don’t Smoke” campaign.
Flaw #1: Youth Act in a Predictable Manner
The “Think. Don’t Smoke” advertisements focused on campaigns that had children listening to authority figures. “Infect Truth” advertisements feature edgy, and rebellious multi ethnic teens rejecting tobacco marketing efforts and revealing stark facts about the deadly nature of tobacco (13) “Truth” accounts for the rebelliousness of teenagers by showing them ridiculous adverts based on the real results of cigarette smoking. The adverts work because of their ludicrous nature- the whole scheme is that as the commercial is over, one shakes his head and says “wow, that was stupid” and that is exactly the point because it makes the person stop and focus exactly on the meaning and in turn grabs his attention to the inanity of smoking. The advert entitled the Sunny Side of Truth (14) shows two young males in front of a large corporate edifice, meant to portray the tobacco company, with a table filled with poisons outlining the chemicals found in cigarettes. One says to the other- “cigarette companies must really hate us.” To which the other replies, “or love us- it’s called tough love,” then they break into song and dance about how cigarette smoking maims and kills. The adage that comes to mind with this commercial is “tough love- whatever doesn’t kill you, will only make you stronger.” Ironically, cigarettes will kill, or make one significantly weaker. The adverts use both a white and black actor so as to not prejudice the commercial. Framing the adverts in such a manner encompasses and promotes the unity of all teenagers, indicating that youth smoking is a problem across ethnicities. There are no parental roles showcased in these adverts- solely teenagers making a mockery of the tobacco industry so that other teenagers can see this and relate.
Seventy-five percent of all teenagers between the ages of 12 and 17 state that they can accurately describe one or more of the Truth campaigns and that the adverts gave them good reasons not to smoke (15). The point is to have young children not smoke now so that they need not worry about their future health, as it relates to smoking. “The Truth” campaign provides a return on investment that would make the greediest corporate CEOs salivate and if the Truth campaign continues for another five years (2009-2014) with similar effectiveness, there will be up to 500,000 fewer youth smokers with savings of up to $9 billion in future medical costs (11).
Flaw #2: The Health Belief Model doesn’t Account for External Factors and Social Norms

The “Infect Truth” campaigns, as based on the Advertising and Marketing Theories, greatly focus on external factors and social norms. These adverts intentionally do not use the Health Belief Model because of its individual nature. The adverts’ foundation, the promise indicated in the commercials, is their ludicrous nature that amalgamates youths’ opinion. The commercials unify youth by exploiting the asininity of the messages. The very nature of the message is intended to have youth scoff at it, but simultaneously pay attention. Therefore, no alienation will occur amongst teenagers as they will think the same. The advert entitled Box of Poison (16) shows several teenagers walking into a shipment facility and asking if they can ship cyanide and poison. The workers are astounded and obviously say that these ingredients are hazardous material and therefore illegal to ship. The teenagers entirely agree, but also maintain their stance that they want to send the product, finally letting on that the product is a box of cigarettes. The commercial manifests itself in a sneaky, but witty manner, in that the contents are presented first, before the merchandise is revealed. Furthermore, the commercial imparts information without being obnoxious and alienating people. Teenagers find the commercial to be very relevant and significantly changed their attitudes towards tobacco. “The Truth” campaign is successful precisely because it takes into account [advertising theory] and develops its ads using the best scientific research about how young people make their decisions about whether to smoke and what is most likely to influence them not to smoke [which is social perceptions] (13).
Flaw #3: The Slogan is a Failure
“Infect Truth,” unlike “Think. Don’t Smoke.” is a very straightforward slogan. There is no mockery, no gimmicks being implied nor orders being inferred. It is the truth that the adverts are maintaining and therefore cannot be labeled anything else. There are no subliminal messages and the meaning, most importantly, is very clear. The slogans in every truth advert also feature “Knowledge is contagious.” This is a very pithy comment, and yet absolutely genius, because it resonates with people. It is human nature to share details of what one has learned or heard, regardless of whether groups are discussing gossip, local and national news or more trivial matters. People communicate constantly and will discuss these adverts. Therefore, knowledge really is contagious. Case in point is the advert featuring the crawling babies with orange shirts (17). It immediately grabs one’s attention because they are “crying babies,” but also because of the message written on the shirt, stating that babies avoid second hand smoking by learning to crawl away (17). One’s initial reaction is incredulity of the message and then the necessity to share it with others. Using the television medium empowers the efficacy of the commercial to reach millions of people. Once very small children are affected, the message is much more effective.
Infect Truth is written at the end of each advert and manifests the advertising theory very successfully in the way the phrase is actually written. The word infect is in white and truth in black dots that seem to diverge. The point is to infect, or spread the contagious truthful knowledge. The promise behind this campaign is again infecting truth and spreading knowledge such that the promise of keeping children from smoking is realized and executed. The fact that these scenes are filmed in public places where ordinary citizens are allowed, even subtly encouraged to participate is key to the slogan. These people are spreading the contagion of knowledge by reading the messages (in Baby Invasion) or listening to the teenagers (Box of Poison, Sunny Side of Truth) and their very reactions cause teenagers’ perceptions to shift even more so because they see on national television that others are appalled and/or disgusted by the newfound information. These adolescents would therefore be more inclined to pay attention to the adverts from these reactions as well.
“The Truth” adverts, as myriads of studies have attested, are the only ones that make a positive dramatic impact on the perceptions and attitudes of teenagers. It is imperative to keep the focus on decreasing the prevalence of youth smoking. Although the Truth campaign’s funding was officially cut in 2003 by the tobacco industry because the latter lost its 99.05% market share, new adverts have begun to play again. The Citizen’s Commission to “Protect the Truth”, the only independent national youth counter-marketing campaign with demonstrated results in keeping children and teens from smoking, is demanding that the tobacco firms resume payment because ending smoking by American children and teens is crucial to their health and cost of healthcare to our nation (11). Moreover, the adverts themselves, and the message implied, are very concise and factual. There is no attempt to mislead anyone, but only to “infect truth.”

REFERENCES:
1. New York Daily News. Australian Anti-Smoking Campaign draws howls as boy sobs for mommy. New York, New York. http://www.nydailynews.com/lifestyle/health/2009/04/04/2009-04 04_australian_antismoking_commercial_draws_-1.html.
2. American Cancer Society. Guide to Quitting Smoking. Oklahoma City, Oklahoma. Http://www.cancer.org/docroot/PED/content/PED_10_13X_Guide_for_Quitting_Smoking.asp
3. British Medical Journal. “Don’t Smoke,” Buy Marlboro. Washington DC: Public Medical Central. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1115680
4. Tate, Peter. The Health Belief Model Explained for Patients. EzineArticles.com.<http://ezinearticles.com/?The-Health-Belief-Model-Explained-for-Patients&id=411478>.
5. University of Georgia. Why Some Anti Smoking Ads Succeed and Others Backfire. ScienceDaily. 6. Phillip Morris. Think. Don’t Smoke Campaign. Http://www.youtube.com/watch?v=Bh8YMaO-wsQ.
7. American Legacy Foundation. Getting to the Truth: Assessing Youths’ Reactions to the “Truth” and “Think. Don’t Smoke” Tobacco Counter-marketing Campaigns. Washington DC: American Legacy Foundation. 2002. p.22
8. New York Times. When Don’t Smoke Means Do. Washington DC: The New York Times. http://www.nytimes.com/2006/11/27/opinion/27mon1.html.
9. American Legacy Foundation. Getting to the Truth: Assessing Youths’ Reactions to the “Truth” and “Think. Don’t Smoke” Tobacco Counter-marketing Campaigns. Washington DC: American Legacy Foundation. 2002. p.18
10. Spivak, Joel and Berman, Michael. “American Legacy Foundation Study shows Philip Morris Think. Don’t Smoke Campaign is a Sham.” Washington DC: Tobacco Free Kids. http:www.tobaccofreekids.org/Script/DisplayPressRelease.php3?Display=499&zoom_highlight=duplicity
11. Citizens’ Commission to Protect the Truth. Truth Campaign Can Save Half a Million Lives and Billions of Dollars. New York, New York. http://www.jointogether.org/news/yourturn/announcements/2009/truth-campaign-can-save-half.html.
12. Wikipedia Encyclopedia. The Truth Campaign.
http://en.wikipedia.org/wiki/TheTruth.com
13. Counsel for Amicus Curaie, National Campaign for Tobacco Free Kids. Columbia Expert Panel and the Florida “Truth” Campaign. Washington DC. http://www.lungcanceralliance.org/news/documents/ALFAmicusBrief2.pdf
14. The Truth Advertisement. Sunny Side of Truth. Infect Truth Anti-Smoking Campaign. New York, New York. http://www.thetruth.com/videos/
15. The Truth Campaign. New York, New York
http://www.protectthetruth.org/truthcampaign.htm
16. The Truth Advertisement. Box of Poison. Infect Truth Anti-Smoking Campaign. New York, New York. http://www.thetruth.com/videos/
17. The Truth Advertisement. Baby Invasion. Infect Truth Anti-Smoking Campaign. New York, New York. http://www.thetruth.com/videos/

The Gardasil Campaign: Merck, Take a Look at it from a Public Health Perspective – Maithili Jha

2009-05-07T12:39:00.000-07:00

In 2008, the American Cancer Society (ACS) estimated that 11,070 women in the United States were diagnosed with invasive cervical cancer, and 3,870 women died of cervical cancer (4). A leading cause of cervical cancer is human papillomavirus (HPV) that is passed sexually from one person to another (1). In response to both the rate of cervical cancer and the cause of cervical cancer, pharmaceutical companies have been racing to find a vaccine against HPV. One such pharmaceutical company, Merck claims that they have succeeded in finding a vaccine against HPV called Gardasil. Merck’s marketing approach to promote the drug was to lobby for mandatory vaccinations for 11 year-old girls in junior high, and infiltrate the media with the “One less” advertisement. The Food and Drug Administration and the Center for Disease Control have approved and recommended Gardasil, for women between the ages of 9 and 26. The FDA and the CDC also convey the message that women who are already infected with HPV will not be protected by the vaccine (5). While some may see the importance in vaccinating a female before potential exposure to HPV, others have seen Merck’s lobbying of mandatory vaccination of young girls in schools as a point of controversy and the “One Less” campaign as misleading. This paper will review and evaluate the means with which Merck has promoted the Gardasil vaccine, from a public health perspective.
The Premature Promotion of Gardasil, Merck could have used HBM
The FDA approved Gardasil for marketing and sale in 2006. Soon after, Merck began lobbying for mandated vaccinations in schools (14). The lobbying campaign ended in February 2007, but the opposition and views against compulsory vaccinations for a sexually transmitted virus still linger for two reasons. First, the vaccine was marketed and promoted before the entire public even knew what HPV was or that HPV may lead to cervical cancer. And, second, because representatives in at least 24 states and DC have initiated legislation to require vaccination in schools (9).
Rick Perry, the Governor of Texas, issued an executive order requiring Texan schoolgirls to be vaccinated against HPV. The conclusion that "the governor of Texas provided a solution to a problem before many were even aware of the problem. Educating the public after the fact is much harder” (11) remains even though three months after Rick Perry issued the order, he passed a bill undoing the mandate. Rather than using policy to market the vaccine, the promoters of Gardasil would have benefited from the use of traditional health behavior models such as the Health Belief Model. To an unaware public, education relaying the risks associated with HPV, marketing the benefits of preventing HPV, and addressing the perceived barriers to getting the vaccine may have muffled the backlash against expedited vaccinations.
In 2004, Holcomb, Bailey, Crawford and Ruffin conducted a study assessing adults’ knowledge of HPV. They concluded that adults seen in a physician’s office have a limited knowledge of HPV (7). In 2008, Gerend and Magloire conducted a similar study, and found that awareness of HPV was relatively high and increasing amongst sexually active individuals. They then went on to say that “With the release of Gardasil, Merck has since initiated its ‘One Less’ marketing campaign, which has received regular television airplay. High levels of awareness observed in the present study, coupled with the fact that television, radio, and magazines were cited as the most common sources of HPV information, provide some evidence for the effectiveness of these campaigns” (6). However, even though Gerend and Magloire’s study found that the awareness of HPV among sexually active individuals was relatively high, women who may have benefited the most from the vaccine, namely those who are not yet sexually active, were more likely to communicate the least interest in getting vaccinated (6). Had the campaign addressed the perceived risks of being sexually active and getting HPV, and the perceived benefits of being vaccinated, then maybe the parents or guardians of the eleven-year-old school girls and women who are not yet sexually active would be more receptive to the idea of endorsing and using Gardasil, and feel like they are at risk.
The perceived barriers associated with implementing mandatory vaccinations are multi-faceted. The monetary cost of Gardasil may be too high for some women, and calculating the return on the investment of being vaccinated may be difficult. The Gardasil vaccine costs $125 per dose, and $375 for the full series consisting of three vaccinations. While some health insurance companies may cover the costs being vaccinated, others may not (8). If a young girl is required to be vaccinated against the virus, and she does not have adequate health insurance then her parents or guardians would be forced to pay on their own. Once approached with a bill for a vaccine against a sexually transmitted virus, the parents and/or guardians may question why they should pay for a vaccine, if there is a chance their child may not get HPV. A parent’s acceptance of the idea of their child being sexually active is variable. As a writer for the National Health Federation states, “…many parents are opposed to making the vaccine mandatory, and in some states, like Massachusetts, the efforts have stalled. Some parents are opposed to mandatory vaccination on moral grounds, believing that vaccinating their daughters against a sexually transmitted disease sends the message that sexual activity at such a young age, or even prior to marriage, is acceptable. Others simply believe that the government has no right to usurp parental authority by mandating a vaccine for a disease that is not spread through casual contact” (2). Religious views, conservative values, education, and socio-economic status are all examples of what may affect how willing a parent is to consider the risks of their child being sexually active, even if their daughter will not be sexually active until she is older.
Mandatory vaccination of 11-year-old girls does not provide the parents and guardians with a sense of self-efficacy. Along with the vaccination, the lobbyists have not proposed a method for the parents to approach their daughters with the topic of sexual activity and consequences thereof. The mandate does not provide HPV education for the parents and children, leaving the parents and children to learn about the causes and effects of the virus on their own. Incorporating educational materials administered by the schools for the parents and children into the mandate may ease the transition into having children be vaccinated.
Social Cognitive Theory says, “Don’t just look at the 11 year-old, look at her environment too”
The Gardasil campaign failed to consider the individuals environment, when proposing mandatory vaccinations, and could have better incorporated how an individual responds to cues from the environment and visa versa, or reciprocal determinism into the campaign. In the 1960s, Albert Bandura proposed a behavioral theory that looked beyond the individual, and into the individual’s environment (3). He suggested that behavioral change is dependent on three constructs: individual characteristics, environmental factors, and reciprocal determinism (3).
Environmental factors like social norms, culture, and religion, affect an individual’s decisions. Before educating the public with the “One less” campaign or lobbying for mandatory vaccinations, the Gardasil campaign should have taken into account that the vaccine is to guard against the result of a behavior – sexual activity. In conservative groups, religious or political for example, the reception of learning about sexual behavior differs. A conservative Muslim woman may not be open to talking about her sexual behavior, or may not consider herself at risk for HPV, because of her conservative background and the understanding that she only has one partner. Yet, that Muslim woman is as much at risk of getting HPV as anyone else, simply because the virus is sexually transmitted. Merck should have borrowed from Bandura’s theory, evaluated the situations in which HPV occurs, and the perceptions of those situations within a social group by the individuals themselves (3).
Follow the Communications Theory, Avoid a False Sense of Security
As stated earlier, the Gardasil vaccine was the fasted drug to be approved and endorsed by the FDA and CDC. Because of this, the drug was prematurely marketed as a cervical cancer vaccine and not an HPV vaccine for certain strains. And, Merck’s marketing department and the lobbyists petitioning for mandatory vaccinations unsuccessfully communicated the vaccine’s purpose and benefits, while providing a false sense of security to the public (10). Previous public health campaigns had similar shortcomings until they started utilizing theories like the Communications Theory (CT). It is unknown as to whether Merck’s marketing department followed the CT when promoting Gardasil. But, it is apparent that when applying CT to the Gardasil campaign, weaknesses in Merck’s marketing approach begin to surface.
The Communications Theory states that one must consider the source of the message, the message itself, the channel by which the message is communicated, the receivers of the message, as well as feedback and understanding from the receiver (3). The Gardasil campaign is vulnerable to criticism, because it did not consider the message, the receiver, or whether there is feedback and understanding from the receiver.
Within the constructs of CT, the sources of the Gardasil campaign are Merck, lobbyists, and the policy makers in favor of mandatory vaccination. The message that Merck conveys in its “One less” campaign is that Gardasil is a vaccine against cervical cancer and that women should make the decision on their own, without the influence of policy to be vaccinated. The lobbyists say that schools should implement mandatory vaccinations. The lobbyists are sending a message that the vaccine will be effective if made mandatory by policy makers for grade schools, and this message is incongruent with Merck’s ad campaign highlighting personal initiative. Merck used media (television, print ads, news channels) and policy as the channels to convey their messages. In the “One less” campaign, the receivers of the message are the women receiving the vaccine, and the policy makers who could implement mandatory vaccinations. And, to the lobbyists, the receivers are the policy makers and other people able to influence whether the vaccine becomes a requirement for eleven-year-old school girls.
Either Merck should have enlisted the aid of public health organizations to formulate its message and educate the receivers that Gardasil is a vaccine against the strains of HPV that are the leading cause of cervical cancer, or they should have incorporated that education into their own advertisements. “One less,” that is, “one less woman with cervical cancer” does not relay why women should take Gardasil, a vaccine against HPV, resulting in a false sense of security against the cancer. The lobbyists and some policy makers have endorsed the idea of mandatory vaccinations of eleven year-old girls. Their proposals should include education plans for schools, physicians and parents about HPV, how it relates to cervical cancer, and behaviors leading HPV, instead of just proposing vaccinations.
Merck’s advertisements use young women and mothers as subjects. However, young women and mothers are not the only receivers in the campaign. On the one had, the lobbyists are saying that it is best to implement mandatory vaccinations for girls who are eleven and twelve years old before they are sexually active. And, on the other hand, Merck is not using eleven and twelve year olds as the subjects for their advertising, but young women making decisions on their own. Both the lobbyists and Merck’s advertising team are not taking into consideration other receivers of their message: the parents of eleven and twelve year old female students, those families and young women who cannot afford the vaccine for their children or themselves, the sexual partners of the women who are not infected with HPV yet, but could be in the future, religious and conservative groups, and physicians. Again, advertisements directed to parents of the children who would be vaccinated, as well as education programs for all the receivers of the message should be integrated into the campaign.
While it is difficult to gauge understanding of a concept, it is important for Merck and the lobbyists to continue market research on whether all the receivers know what HPV is, and what Gardasil does. Even if the eleven year olds do not fully understand why they are receiving the vaccine, the parents and guardians of the children should understand why they must vaccinate their children against a sexually transmitted virus.
Bridging Private and Public Domains
While this has not been a critique of Gardasil, the vaccine, but it has been a critique of Merck’s approach to promoting the vaccine. Public health is still developing and improving upon its models for influencing behavioral change, private companies such as Merck would benefit from utilizing established traditional and non-traditional health behavior models in their marketing campaigns, and promotions of therapeutics. By learning from the Gardasil campaign, one hopes that in the future private industry, and public health will be able to form a liaison and prevent the educational holes in the public’s awareness of pharmaceutical effectiveness.
Two-Step Marketing, a New Approach to Vaccine Promotion
When Merck used marketing techniques in combination with policy promotion for the Gardasil campaign, they had the potential to positively impact a wide population. However, Merck fell short of its potential. Instead of focusing on ways to limit controversy surrounding the nature of the virus, or barriers to receiving the vaccine, they rushed to have the vaccine approved and promoted by the FDA and the CDC, and lobbied for mandatory vaccinations of girls in grade school. This section will propose an alternative approach to promoting the vaccine, addressing the three previously stated arguments for why Merck’s Gardasil campaign failed, while staying within Merck’s constructs of coupling marketing and public policy. This new two-stage approach would allow Merck to use policy to influence its advertising schemes, and would allow policy to steer Merck’s advertising schemes as well, splitting the marketing efforts into two phases: education (Stage I), and product promotion (Stage II).
Premature Promotion of Gardasil Leading to an Uneducated Public : Stage I
Merck marketed the Gardasil vaccine using the “One Less” advertisement, before the entire public knew what HPV was or that it may lead to cervical cancer, resulting in the misconception that Gardasil prevents cervical cancer. To thwart this reaction, State and Federal lawmakers should propose legislation requiring the pharmaceutical company producing the vaccine to advertise their product in two stages. First, in Stage I they would need to use market research techniques to gauge the public’s knowledge about HPV and cervical cancer, and release a preliminary set of educational advertisements. Then, Stage II of advertising would be for the drug itself.
With a policy in place requiring pharmaceutical companies to assess the knowledge of the public about the product, Merck would need to find out how much people know about HPV, cervical cancer, and their relationships to sexual activity. Asking questions like: ‘Do you know what the vaccine guards against?’ ‘Do you know the causes of HPV?’ ‘Are you comfortable talking to your children who are under the age of twelve about sex, and the risks involved with sexual behavior?’ would provide insight as to whether the “One Less” campaign is informative or misleading. And, asking these questions would lead to the first stage of advertising involving education in HPV, not Gardasil. The ads may involve mothers and fathers talking to their daughters about HPV, or could be in the form of educational pamphlets and web-based seminars for health care providers
In return, Merck would not just lobby for mandatory vaccinations, but for vaccinations and HPV/vaccine education in grade schools. The education in the school systems would involve informing the parents and guardians of the children about the benefits of the vaccine, thereby minimizing the impact of addressing sexual behavior with children. Merck would be able to incorporate finding out when parents and guardians are comfortable with learning about HPV vaccinations into their market research efforts for Stage I. Thus, Merck would be able to determine how much time parents need to be educated in the subject, and lobby for the amount of parental education necessary.

Does one Ad Apply to Everyone, Everywhere? : Stage II
For Stage II, Merck would use all of the information gathered during the market research phase, and determine how answers to their questions may vary according to race, ethnicity, age, gender, culture, and socio-economic status amongst other variables. Currently, there are not many variations to the “One Less” advertisements. Merck, has not marketed to conservative groups, transgender individuals, immigrants, or partners of those getting the vaccine. By performing the necessary market research for Stage I, Merck’s marketing directors would understand the challenges faced with being from a conservative culture and bringing up the topic of sexual behavior with children, and the impact of a partner asking their loved one to be vaccinated.
In one example of a Gardasil commercial there are eight different women individually, in the form of a soliloquy saying they want to be “One Less.” And they are saying everything during the commercial in perfect English, and with “American” mannerisms. It is not until the last ten seconds of the ad do they show a group of young girls, jump roping, saying “O-N-E-L-E-S-S,” appealing to a group of people who collectively agree that one should be vaccinated with Gardasil. There is not a single example of a mother saying the importance of talking to their daughter(s) about HPV, a partner talking to another partner, be it a heterosexual or a homosexual relationship, about getting vaccinated, or an example of a religiously conservative person expressing the importance of the vaccine (12). By going through the steps of Stage I, Merck would have known that a Muslim mother still may not feel comfortable talking to their husband or boyfriend about being vaccinated or having their daughters vaccinated, after seeing the advertisement described above. And, Merck would understand that some cultures are more community oriented, and the opinions of others matter more than their own individual opinion. After doing the research, and learning about the different educational requirements for each culture, Merck might have benefited from including a group of ethnic women who do not speak perfect English, sitting together, discussing HPV in their ads.
Avoid a False Sense of Security, a Riled Up Crowd : Stage I & Stage II
On June 9, 2006, Gardasil was approved by the FDA. And, on November 23, 2006 Merck launched its print, online and television advertising campaign for the vaccine (13). By February of 2007, Merck had already started lobbying for mandatory vaccinations in schools. They had only been marketing the vaccine for two months with advertisements like the one involving eight women mentioned earlier. In that same ad, one woman says “Gardasil will not treat cervical cancer,” and the woman right after her says, “Ask your doctor about getting vaccinated with the only cervical cancer vaccine” (12). Merck prematurely marketed the vaccine as one that prevents cervical cancer to a public that, in two months of advertising, had not been educated in HPV, the causes of cervical cancer, the fact that HPV is not the only cause of cervical cancer, and that even if one is vaccinated they still might end up with the cancer. Once Merck started lobbying for mandatory vaccinations, the public knew two things: that Gardasil is a cervical cancer vaccine, and that HPV is related to sexual activity. Gardasil is not a cervical cancer vaccine, so the public was misinformed and had a false sense of security in the vaccine. And, even though HPV is caused by sexual activity, they were not ready to be introduced to a mandatory vaccine for a controversial topic: sexual activity.
Had Merck followed a two-stage process for promoting the vaccine, and included a broader educational portfolio into their marketing campaign, their lobbying attempts and advertisements may not have caused such a great sense of distrust in a FDA approved vaccine. Instead of releasing the Gardasil ads five months after approval, Merck could have waited, done the research for Stage I of advertising, and been more effective by gaining the trust of the public. The two-stage approach of educating and then promoting the vaccine would force Merck to fully inform the public in HPV, and then push for mandatory vaccinations. By the time the lobbying efforts would be known to the different communities, the individual people making up the communities would be more accepting to the idea of having their daughters vaccinated, and they would have understood the value in having mandatory vaccinations in schools.
Conclusion : Money was not Discussed, and it won’t be
The two-stage approach to promoting a vaccine discussed in this paper, does not take into consideration the monetary impact of having twice as many marketing campaigns. However, one would hope that for FDA approved vaccines, and products affecting a person’s health, pharmaceutical companies will be able to fabricate, and re-organize their Research and Development and Marketing budgets to allow for better education of the public, and find value in equating education and product promotion. And, one would hope that lawmakers would see the benefit in aiding pharmaceutical companies in providing more information on the vaccines and the viruses. Maybe, one day it will become common practice to conduct Stage I type activities while doing clinical trials for the vaccine or drug at the same time. But, until education and product promotion have equal weight in the public and private sectors, we will continue to have vaccines quickly marketed to an ignorant public, and public opposition to effective vaccines.
References
"Cervical Cancer Basic Information." Centers for Disease Control and
Prevention: Your Online Source for Credible Health Information. 22 Dec. 2008. Department of Health and Human Services. 27 Mar. 2009.
2."Efforts to Make Gardasil Mandatory Stall in Some States." The National Health Federation: A Not-For-Profit Health-Freedom Organization. 24 Apr. 2008. National Health Federation. 4 Apr. 2009.
Edberg, Mark. Essentials of Health Behavior: Social and Behavioral
Theory in Public Health. Boston: Jones and Bertlett, 2007
4. "Facts about Cervical Cancer." Michigan Cancer Consortium. Feb. 2009. Michigan Department of Community Health. 4 Apr. 2009.
5. "FDA Licenses New Vaccine for Prevention of Cervical Cancer and Other Diseases in Females Caused by Human Papillomavirus." U.S. Food and Drug Administration. 8 June 2006. U.S. Department of Health & Human Services. 27 Mar. 2009.
6. Gerend, Mary A., and Zita F. Magloire. "Awareness. Knowledge, and Beliefs about Human Papillomavirus in a Racially Diverse Sample of Young Adults." Journal of Adolescent Health 42 (2008): 237-42.
7. Halcomb, Bryan, Joanne M. Bailey, Kathleen Crawford, and Mack T. Ruffin IV. "Adults' KNowledge and Behaviors Related to Human Papillomavirus Infection." Journal of the American Board of Family Medicine 17 (2004): 26-31.
8. "HPV Vaccination Information for Young Women." Centers for Disease Control and Prevention. 26 June 2008. Department of Health and Human Services. 27 Mar. 2009.
9. "HPV Vaccine." National Conference of State Legislatures: The Forum for America's Ideas. Apr. 2009. 4 Apr. 2009.
10. Jones, Bethany. "Gardasil Marketing Campaign for Cervical Cancer Misses the Mark." Associated Content: Information from the Source. 10 Oct. 2007. 27 Mar. 2009.
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New Cervical Cancer Vaccine." Medical News Today. 23 Nov. 2006. 27
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BMI Reports Card and the Negative Impacts Caused by Traditional Approaches, Labeling and Social Frames - Maura Hackett

2009-05-07T12:33:00.000-07:00

The increasing epidemic of childhood obesity has necessitated the creation of solutions to combat this issue. One proposed solution is the Body Mass Index (BMI) Report Card, first passed by the Arkansas State Legislature in 2003 (1). This report calculates a student’s BMI, which is the ratio of weight to height squared, and reports it to the child’s parents. It is considered a simple and effective tool in the correlation of body fat and health. Parents receive report cards based on this information informing them if their child is at risk for obesity. According to the CDC, while the concept of a BMI monitoring program appears to be beneficial there are other issues which must be considered. Currently obesity treatments do not exist, research has not proven the efficacy of this type of initiative, and many communities do not have the available resources to combine the report card with suggestions and health promotion programs for at-risk children (2).
The proposed implementation of these programs is considered controversial by many critics; because of the stigma it attaches to the child and his/her weight. From a social and behavior perspective, the program’s approach and supporting theories are flawed and ineffective. First, it relies on the traditional models of behavior to inform and inspire change in the child. Second, report cards utilize labeling theory apart of the inspiration for change. Society’s labels associated with health and obesity have far reaching consequences with regard to self-esteem and the child’s feelings of self-worth. Third, the ranking and valuation of a child’s weight in the form of a report card employs Framing theory to influence the child’s behavior based on the frame of the social norms and biases concerning health and obesity.
The report cards are intended to inform the parents of the child’s health status and whether s/he is “at risk of becoming overweight or underweight” or is “overweight” (1). It does not provided suggestions and recommendations for a healthy lifestyle or changes to the current diet. The reports cards utilize the ideas of self-efficacy, the weighing of the risks and benefits of obesity, and intention to change for motivation to change the child’s risk of obesity, key components of traditional approaches to health.
Traditional Theories
Traditional behavior theories focus on individual level behavior and the individual’s decision to change a behavior after consideration of social norms, motivation, and consequences. The models are centered on the internal rationalization that an individual has for the costs and benefits of an action and the influences of society have on whether person feels s/he is capable of accomplishing an action. In this case, the parents and child would rationalize the costs and benefits of being obese in America with the social norms of popularity, bullying, the pressure to be thin, and the alienation of morbidly obese individuals, especially in school social cliques.
The Health Belief Model presents decisions as a combination of the rational decision process that involves the consideration of the perceived barriers and the severity of the action, and creates an individual’s intention, which is a direct antecedent of behavior. Susceptibility is the person’s belief that they are vulnerable to the action, and severity refers to the intensity of the possible consequences associated with the action (3).
In comparison, the Theory of Reasoned Action is also based on a personal weighing of the behavior prior to action. However the pre-contemplation is based on the perceived social norms and the intention to carry out the behavior. The decision can be quantified as a cost-benefit analysis of the positive and negative outcomes of the behavior. This theory, unlike the Health Belief Model, draws upon the outside influence of social norms on decisions (4). The social norms in this case are the image of the perfect body and biases against individuals who do not fit this mold.
The Theory of Planned behavior is based on the foundation of the Theory of Reason Action, but also includes the person belief of whether the individual feels that s/he can accomplish the action (5). The feeling of self-efficacy takes the social norms into consideration and translates them into a personal feeling of whether the action can be accomplished. The personal beliefs of efficacy consist of the moral norms and consequences of the premeditated action (3).
The Theory of Reasoned Action focuses on the social stereotypes associated with obese and thin individuals and reinforces this idea by creating a report card system of those who pass i.e. are thin and those who fail are obese. Creating feelings of insecurity and alienation within the child or the parents decreases feeling of self-efficacy, which are components of the larger social norms and attitudes regarding weight loss and the child’s decision to become healthy.
The traditional theories have a similar disadvantage, which is problematic with regard to the BMI Report Card initiative. The theories are based on the individual’s decision to changed and do not consider the larger society or the environment as key components of the decision/ behavior process. As previously stated, communities often do not have the financial resources to implement suggestions and health promotion programs for at-risk children congruent with the report cards. Although, the Theory of Reasoned Action does account for some irrationality, the theories do not recognize the prevalence and frequency of irrationality in everyday behavior, such as the consumption of fast food, even though it is known to be unhealthy. Additionally, they assume that each action is pre-meditated with the costs, benefits and consequences measured prior to action, and spontaneity is not considered. Spontaneity in this case may include drastic measures a child may employ to combat his/her weight such as eating disorders, diet pills and vomiting.
While the theories promote the benefits of a behavior, they do not provide for the possible longevity of a behavior and the difficulty a child or adolescent may encounter in stopping or changing the behavior. The theories discuss the direct link between an individual’s intention and its product or behavior based on a variety of internal and external influences, but they do not the way an individual acts as part of a larger collective.
Labeling Theory
The valuation of weight as part of a report card implies a hierarchy within the children who are analyzed, and defines obesity as deviant from the social norm. The children, who are considered healthy, pass the test while the children who are obese or have the potential for becoming obese fail. The application of labeling theory would explain that the stigmatization of the child’s weight will not inspire the child to lose weight, but perpetuates the trend of obesity within the child. The theory identifies the way society defines and creates deviant behavior. The social groups generate rules for the members to follow and label outsiders who do not conform to the rules and sanctions (6). A report by the US Department of Agriculture stated that 17% of children identified as overweight were in fact healthy and incorrectly labeled. Critics have argued that schools lacking full comprehension of the limitations of the BMI may erroneously identify children as at risk for obesity, causing extra stress and feelings of inadequacy in the children (1).
Whatever initially caused the deviant behavior is not as important as the societal reaction to the behavior and creates a cycle of processes and reactions to the behavior (7). In other words, labeling a child as obese and outside the norm will invariably create a cycle of unhealthy behavior and stigma against the lifestyle, which can perpetuate the obesity throughout childhood and into adulthood. The marginalization of an overweight child triggers a negative self-image, limits feelings of self-efficacy with regard to change, and creates further deviant behavior.
In general, children are not afraid of becoming overweight or obese because of the health implications, rather the negative stigma associated with obesity in society. Studies have shown that children as young as five years old internalize the social stigmas and biases against overweight individuals. Consequently, overweight children have a higher risk of developing depression, low self-esteem, and social isolation. The report cards do not reduce these feelings, but highlight and intensify these thoughts (1). Decreased self-esteem places children at higher risk for alcohol consumption, smoking and feelings of nervousness and loneliness (8).
The risks of decreased self-esteem, depression, and social isolation have direct impacts on the child’s performance in school, motivation, and social relationships. The middle school years are the formative years of self-esteem development and predict the child’s potential interactions in the future (8). Report cards may prove detrimental to the development of a child’s self-esteem at a time when it is critically important. Ignoring a child’s difficulty with weight is not a solution to creating a healthier lifestyle. However, labeling a child at the onset of adolescence without positive, constructive solutions will increase the likelihood of decreased self-esteem and increase the potential of hurtful experiences (1).
The report cards serve only to identify problem of an unhealthy lifestyle and the potential risk of obesity. It is not combined with a solution initiative or prevention program which is applicable to all children as a healthy lifestyle imitative. The reports place the burden for change on the individual child and his/her parents. Although the Arkansas initiative includes provisions for restricted access to vending machines, the development of physical activity standards, and community partnerships, the main onus for change falls to the child and parents (1). This may lead to pressure to succumb to the societal definition of the perfect body and foster disordered eating. Research has shown that adolescents in particular place more importance on body appearance than actual weight. A report card stating that a child is overweight serves as further proof to the child that s/he is imperfect. These feelings increase the body dissatisfaction, the possibility of eating disorders, such as bulimia, anorexia, or compulsive eating, and may increase feelings of suicide. The child may take extreme measures to decrease their body weight rapidly such a purging, diet pills or laxatives (1).
Framing Theory
Utilizing the aforementioned stigmas and pressure to succeed, the BMI report card frame health positively and negatively frame obesity and the health consequences associated with an unhealthy lifestyle. Associating obesity with a failing grade on a report card fames the weight of the child so as to influence the child and his/her parents to choose a healthier lifestyle and decrease the child’s BMI. Framing theory is based on the perceptions of an individual regarding the outcomes of a choice and whether the choice will be profitable (9). The report card frames obesity as a negative option with health and social acceptance as the reward outcomes. Social acceptance and inclusion, especially during adolescent and pre-adolescence is critical in the development of the self-image of a child. Healthy reports on the BMI report card, encourage children who are considered healthy and in the normal range with positive reinforcement and marginalizes children who “fail” attaching a negative stigma to their health and weight.
Although the imitative to decrease childhood obesity rates is important in public health, the BMI report card is understandably controversial. Rather than promoting healthy lifestyles integrated with school curriculums, community outreach and education, the report card places the burden of change on the child and parents. The individual children and his/her parents are expected to change the components of their lifestyle that led to the risk of obesity based on the report card BMI “grade.” The report card marginalizes the child, which can negatively impact self-esteem, social relationships, personal feeling of self-worth and motivation. Without supporting health initiatives, the child is forced to either loser weight or risk becoming labeled as obese and a social deviant. Labels can positively reinforce good behavior, but they can also create a cycle of negative behavior and deviance from the social norms. Children who are not inspired to lose weight or do not have enough knowledge about how to lose weight effectively, will become trapped in the negative spiral of obesity and social stigma.

Alternative Approaches
BMI report cards are intended to inform the parents of their child’s health status and whether s/he is “at risk of becoming overweight or underweight” or is “overweight” (1). The program does not provide suggestions and recommendations for a healthy lifestyle or changes to the current diet, nor does it connect the child’s health to outside factors such as physical activity, school lunch programs, or nutritional education. The reports cards utilize the ideas of self-efficacy, the weighing of the risks and benefits of obesity, and intention to change for motivation to change the child’s risk of obesity, key components of traditional approaches to health. The stigma the report cards attach to a child’s weight reinforces the flawed and ineffective nature of the program. Traditional models of behavior, labels, and the ranking and valuation of a child’s weight dictate the rationale behind the program. Society’s labels associated with health and obesity have far reaching consequences with regard to self-esteem and the child’s feelings of self-worth (7). Framing theory explains the influence over the child’s behavior based on the frame of the social norms and biases concerning health and obesity (9).
The alternative behavior models approach change at the group level with subtle suggestions for change based on aspirations and promises for a healthier life based on core values of beauty, wellness, and overall happiness reinforced with the help of visual images that further inspire a lifestyle. The traditional health behavior models are centered on the internal rationalization that an individual has for the costs and benefits of an action and the influences of society have on whether person feels s/he is capable of accomplishing an action. The Health Belief Model approach presents decisions as a combination of the rational decision process that involves the consideration of the perceived barriers and the severity of the action, and creates an individual’s intention, which is a direct antecedent of behavior. Susceptibility is the person’s belief that they are vulnerable to the action, and severity refers to the intensity of the possible consequences associated with the action (3). A Theory of Reasoned Action would focus on the social stereotypes associated with obesity; focusing on overweight individuals as opponents to the social norms and individuals who fit the BMI healthy rating as part of the larger collective majority (4). In 2003, a lawsuit was filed against McDonald’s accusing the company of making two girls obese. The case was thrown out of court based on a lack of substantial evidence. The judge asked “where should the line be drawn between an individual's own responsibility to take care of herself and society's responsibility to ensure others shield her?” (10) The blame was placed on the girls for becoming fat without regard for the larger social and environmental factors which may have contributed to the girls’ obesity. The logic behind this case and the BMI report cards assigns the blame and responsibility on the individual rather than explaining the obesity epidemic as a condition that must be combated not only on the individual level but at the larger, societal level.
The alternative approach to change would address behavior change at the group level rather than the individual level. This is one of its strengths compared to the traditional models. It also focuses on the multiple forms that influences can be presented to influence changes in behavior. The traditional models only address a few of the factors that influence action and not others such as spontaneity, society as an environmental context, and the frequency of irrationality in individuals, or a group mentality when addressing change. Groups of individuals with the inspiration for changes and images with which to aspire make the behavior appear more approachable so that individuals can overlook some of the hindrances that they may be prone to focus on with the other theories such as pre-meditation, costs, benefits and consequences. The alternative model further improves on the traditional theories through its approach and level of action. It considers the irrationally of individual and groups, by addressing the group mentality through the creation of a visual aspiration of a lifestyle and although the herd mentality can lead to irrational behavior, this attempts to steer the behavior by creating inspiration and promise of a lifestyle visually portrayed by models in commercial and print ads.
A combined approach to the presentation of a health lifestyle and nutritional foods, combined with physical activity would be an affective public health initiative when combating the influence of fast food industry and would lead to changes in school lunch programs and funding for physical education in schools. Therefore the changes will be based on the actions of the larger collective, which represents a distinct improvement on the traditional models of behavior which focus solely on the individual.
New Labels and Frames
The “Truth Campaign” focuses its message toward the youth by creating a rebellion again the large tobacco companies and their operation motives. The goal is to expose “an industry manipulating its products, facts, and advertising to secure replacement for the 1200 customers they ‘lose’ every day…To expose how the tobacco industry has been manipulating our generations and others before it.” (11) The campaign successfully frames the risks of smoking and tobacco so the industry is the guilty party and the American consumer, especially the youth, have the ability to change the way smoking is viewed and regulated. One of the advantages to the “Truth Campaign” is its use of the framing theory to show young consumers that “thinking smoking is rebellious is wrong and cigarettes are systematically marketed and sold a sign of rebellion.”(11) “Truth” illustrates the manipulative, misanthropic acts of the tobacco companies while emphasizing the power individuals and society have to combat tobacco companies’ influences.
A health initiative which framed unhealthy foods and the attempts of food manufactures and lobbyists to manipulate the consumer and appeal to children would change the ideology of weight and health in the US. Fast food, soda and candy companies market to children with colorful advertising and cartoon characters in order to sell their products while making a lasting impression on the children so they will become lifelong consumers. (12) Vending machines sponsored by candy and soda corporations in school combined with the elimination of physical education in schools are contributing to the obesity epidemic. Alternative approaches to behavior would not place the blame on the individual but incorporate weight in the context of the larger unhealthy lifestyle and culture of American society today, creating an effective initiative to combat the obesity epidemic in America. In Appleton, WI, the local school board contracted a natural food company to provide the school lunches and remove vending machine containing candy and soda, with a “a district-wide commitment to healthier eating and lifestyle in general.” (13) The results were healthier, more attentive and academically successful children (13).
Healthy Lifestyle Campaign
The campaign for healthier lifestyle and the fight against obesity is not without its challenges. The fast food industry and food special interest groups including the Corn Refiners Association are spending millions of dollars to convince the American public of the safety of their food while distracting the public form the unhealthy aspects of the foods they produce. The Corn Refiners of America sponsor the “Sweet Surprise” Campaign in which they promote the similar chemical composition to table sugar and state “sweeteners, such as high fructose corn syrup and sugar, make many nutritious foods taste even better, and can be part of a balanced diet.” (14) The manufactures downplay the negative health affects associated with high fructose corn syrup such as “an increased risk of diabetes, especially in children as well as an increased risk of obesity.” (15)
A healthy lifestyle imitative needs to appeal to the American consumer as much as the fast food industry does. Creating a revolution for health in which the fast food companies, lobbyists and manufactures were framed as the villains and deviants from the basic American values of health and happiness, the campaign would create a sensation for change in every generation. Framing the argument is the key to the determination of the perception of problems and will influence the shift in outcomes based on the definition of normal and deviant behavior. (9) An effective way to combat the millions spent in advertising would create a positive label for health and a negative stigma against the industry which bears some responsibility for the epidemic, while including not alienating those who are obese. (7)
The BMI report cards place a numerical value on health without supportive interventions for an overall lifestyle change for not only the child, but his/ her family and American society as a whole. Currently the report card implies a hierarchy within the children who are analyzed, and defines obesity as deviant from the social norm (7). The obsession with success creates a negative stigma in the report cards, children who are considered healthy, pass the test while the children who are obese or have the potential for becoming obese fail. Parents who are not educated about healthy food choices or the overall effects of unhealthy and/or obese lifestyles will not know how to address the BMI report card. Schools and communities need to create interactive programs that combine healthy eating habits, exercise, smart shopping tips, fast and healthy recipes, and an emphasis on physical activity in order to eliminate the stigma of the report cards.

REFERENCES
(1) Ikeda, Joanne P., Patricia B. Crawford, Gail Woodward-Lopez. 2006. “BMI Screenings in Schools: Helpful or Harmful.” Health Education Research Theory and Practice. 21, 6: 761-769.
(2) Centers for Disease Control and Prevention. “BMI Executive Summary.” Date Retrieved April 3, 2009. (http://www.cdc.gov/HealthyYouth/obesity/BMI/pdf/BMI_execsumm.pdf).
(3) Simsekoglu, Ozlem and Timo Lajunen. 2008 “Social Psychology of Seat belt Use: A Comparison of Planned Behavior and Health Belief Model.” Transportation research 11: 181-191.
(4) Ellis, Shmuel and Shaul Arieli. 1999. “Predicting Intentions to Repot Administrative and Disciplinary Infractions: Applying the Reasoned Action Model.” Human Relations 52: 947-967.
(5) Hagger, Martin S., Nikos L. D. Chatzisarantis, and Jemma Harris. 2006. “The Process By Which Relative Autonomous Motivation Affects Intentional Behavior: Comparing Effects across Dieting and Exercise Behaviors.” Motiv Emot 30: 307-321.
(6) Raybeck, Douglas. “Anthropology and Labeling Theory: A Constructive Critique.” Ethos. 16, 4: 371-397.
(7) Klein, Malcolm W. 1986. “Labeling Theory and Delinquency Policy: An Experimental Test.” Criminal Justice and Behavior. 13, 47: 48-79. Date Retrieve April 3, 2009. (http://www.jstor.org/stable/1685855).
(8) Strauss, Richard S. 2000. “Childhood Obesity and Self-Esteem.” Pediatrics. 105, 15. Date Retrieved April 3, 2009. (http://pediatrics.aappublications.org/cgi/content/full/105/1/e15).
(9) Tversky, Amos and Daniel Kahneman. 1981. “The Framing of Decisions and the Psychology of Choice.” Science, New Series. 211, 4481: 453-458. (http://www.jstor.org/stable/1685855).
(10) Wld, Johnathan. 2003. “McDonald's Obesity Suit Tossed U.S. Judge Says Complaint Fails to Prove Chain is Responsible for Kids' Weight Gain.” CNN. February 17. Retrieved April 24, 2009. (http://money.cnn.com/2003/01/22/news/companies/mcdonalds/).
(11) Truth Campaign. 2009.”About Us.” Retrieved April 24, 2009. (http://www.thetruth.com/aboutUs.cfm)
(12) Public Health Institute. 2006. “Junk Food Marketers Target Children, Survey Says.” Retrieved April 24, 2009. (http://www.phi.org/news_events/news-viewRelease.cfm?pressReleaseID=96&year=2006).
(13) Pure Facts. 2002. “A Different Kind of School Lunch.” Retrieved April 24, 2009. (http://school-lunch.org/wisconsin.html)
(14) Corn Refiners Assocaition.2009 “Sweet Surprise.” Retrieved April 24, 2009. (http://www.sweetsurprise.com/hfcs-and-your-family)
(15) Science Daily. 2007. “Soda Warning? High-fructose Corn Syrup Linked To Diabetes, New Study Suggests.” Retrieved April 24, 2009. (http://www.sciencedaily.com/releases/2007/08/070823094819.htm)

Anti-Smoking Campaign Amongst Youth in Nigeria: A critique of the Social Marketing Theory – ASHAYE AJIBADE OPEOLUWA

2008-04-25T03:34:00.000-07:00

INTRODUCTION
Over the last decade there has been a significant increase of youth smoking in Nigeria. According to the World Health Organization (WHO), there was a ten fold increase in smoking among young women between 1990 and 2001.1 A survey conducted by the WHO in the southern part of Nigeria revealed a smoking prevalence of 23.9 % among male youths, 17.0 % among female youth and an overall prevalence of 18.1%. 2 Smoking is harmful to nearly every organ of the body; causing many diseases and reducing the health of smokers in general.3 The adverse health effects from cigarette smoking account for an estimated 438,000 deaths, or nearly 1 of every 5 deaths, each year in the United States.4, 5 More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murder combined.4,6

Active smoking causes most leading causes of death worldwide: cancers, cardiovascular diseases, chronic respiratory diseases, and respiratory infections. Not surprisingly, smokers have a substantially reduced lifespan in comparison with never smokers. Tobacco smoking causes diminished health and several problems such as cataract and gingival disease. Smoking by women adversely affects nearly all aspects of reproduction. Even though the health effects of active smoking have been under investigation for decades, new adverse health effects are still being identified. As recently as 2002, the list of cancers caused by smoking was expanded to include cancers of the liver, stomach, and cervix, along with acute leukemia.7 Tighter controls need to be instituted in the control of tobacco so that the growing epidemic does not wipe out the working population of developing countries like Nigeria.

The issue of smoking and health is complicated by the fact that Governments of developing countries have been slow to arrest tobacco smoking because of the large government revenues derived from the manufacture and sale of tobacco products. Tobacco is grown commercially and is relied upon to bring in foreign exchange through export, or revenue for the government if sold on the home market. Consequently, in some nations the ministries of health and of agriculture are working at crossroads. Transnational tobacco companies take full advantage of the present lack of legislation in most African countries on the promotion and use of tobacco.

While countries in the western world are making attempts at reducing the levels of cigarette smoking, not much is being done in the developing countries. Thus, while there is a significant decline in smoking rate in the United States and Europe, in the developing world such as Nigeria, the smoking rate increases by at least 20% each year. There are social factors that help contribute to the increase in smoking in Nigeria.

The Federal Governments fight against Tobacco has largely been on the basis of the Social marketing theory which is a combination of theoretical perspectives and a set of marketing techniques. It is defined as the design, implementation, and control of programs seeking to increase the acceptability of a social idea or practice in a target group. While not trying to discredit its effort, the Nigerian Government needs to employ additional behavioral model changes in its Anti-tobacco control campaign in ways that will be acceptable to the youth.

SOCIAL MARKETING THEORY AND SMOKING

The Federal Ministry of Health in Nigeria adopts the Social marketing theory in its anti smoking campaigns. These campaign involves the use of Billboards are erected in several locations throughout the country bearing warning signs about the harmful effects of tobacco smoking. Most of these bills boards are not attractive and are not located in places where they can be easily seen by the youth. They are on major highways and in the health care centers, clinics and other health care delivery centers. It has however not been effective as evidenced by the growing prevalence of tobacco smoking amongst the youth population. The present billboards need to be overhauled and their content adjusted to messages that will appeal to the youth population. The messages appear coercive and judgmental thereby limiting its effectiveness. Also, youth do not like to be told what to do, they want to be able to make their own decisions and be responsible for it.

More appealing billboards and TV adverts need to be employed in the fight against tobacco smoking. Information is being given without the necessary skills to change behavior. It also assumes that behavioral change, is largely a result of changes in beliefs, and that people will perform behavior if they think they should perform it. However, according to Prochaska and DiClemente (1986), behavioral change occurs in five distinct stages, Pre-contemplation, contemplation, preparation, action and maintenance. The later (maintenance) is lacking in the anti-smoking campaign. They should be given skills necessary to effect changes in behavior and to maintain such changes.

SMOKING AS A GLAMOROUS HABIT
The issue of acceptance is paramount amongst youth; they want to be among, do not want to be the odd one amidst their group. Tobacco industries make the youth believe that smoking makes them look mature, independent and courageous. Most youths who want liberation quickly buy the entire ideas of tobacco companies. So as soon as thy get into their teenage years, they want to pick up habits that are seen to be for adults. With this declaration is made however subtly, that they have now become of age and can take decisions of their own as deemed appropriate. Instead of bunging correct information on relationship between cancer and tobacco smoking, the big tobacco companies buy over some reputed scientists to refute correct research about tobacco smoking and health. In most of the French-speaking West African countries, you see three of four youths sharing a stick of cigarette. They use it to express their love for each other. In mall, youths inter-viewed claim that cigarette makes them strong and gives them courage. Unfortunately it is a false courage.

The present antismoking campaign in Nigeria does little or nothing in portraying smoking as a harmful habit other than the billboards it erects and the health warnings it requires some cigarette companies to place on their packages. Youth learn more by modeling and not by being ordered or given rules. Rules may play a role but advertisements that depict acceptable social behavior by modeling will be more efficient. This can be in the form of peer modeling or modeling by adults or icons in the society. Youth tend to identify with this role models and their influence can be positively harnessed. Behavioral change in the youth could be maintained by ensuring that they belong to the right peer group, one that supports the promoted behavior (not smoking). In the past two decades social marketing campaigns have been conducted in developed countries as well, to bring about other kinds of behavior change: smoking cessation, diet, condom use, helmet use and other preventive health behaviors. There is a great deal of literature on some very successful programs in developing countries.8

SOCIAL ACCEPTABILITY AND SMOKING
Even though smoking is not socially acceptable in Nigeria, tobacco companies have made tremendous efforts in increasing the social acceptability of tobacco smoking in the youth population and in the country at large. They have employed Cultural sponsorship as a marketing strategy. They have done this by sponsoring youth programs like Sport competitions, Movie shows and talent hunts all to increase access to the youth. A good example is Benson and Hedges who now sponsors some festivals as a way of projecting and expanding its product and market. Their products are clearly displayed in such festival. In Schools, they sponsor inter-school cultural activities and inter-house sports competitions, giving the youth the impression that cigarette smoking gives them courage, equality with adults, and makes them feel like adults. An example is the British American Tobacco (BAT) which commands about 78% of the cigarette market in Nigeria. The tobacco firm took a number of blockbuster films, including the Matrix and Ocean's Eleven, around the country in a domed travelling theatre with 500 seats and a wide screen and called it the "Rothmans Experience It Cinema Tour". Posters for the films were overlaid with pictures of packets of Rothmans and free cigarettes were handed out to people buying tickets.

The anti-tobacco campaign has not demystified the various myths and legends associated with smoking. Smoking is widely thought to offer a number of benefits, as in other African markets, it is believed to aid/speed digestion and to prevent vomiting after eating. Smoking is also said to aid/speed excretion hence it is a common practice for smokers to have a stick when they go to the toilet. It is also believed to be a stimulant especially in cases of depression. This and many more beliefs that individuals hold drive their demand for tobacco smoking. The FGN and the Ministry of Health (MOH) will need to intensify its effort in disseminating appropriate health education messages. Wrong beliefs needs to be dispelled with appropriate health information as pertaining to tobacco smoking.

IMPLICATIONS OF SMOKING AMONGST NIGERIAN YOUTH
With annual cigarette import of the increase (20 million sticks in 1970 to 2.966 billion sticks in 2000) 9, it is imperative to create anti-tobacco campaigns that are effective in reducing the initiation of tobacco smoking especially amongst the youth and also to reduce tobacco consumption in the nation as a whole. Other control measures have been introduced without much effect. Such include the cigarette taxes and duties, enforcing anti- tobacco laws. This can be done by encouraging private companies’ participation in the fight against tobacco smoking encouraging them to sponsor anti-tobacco programs and also encouraging the numerous antismoking Non Governmental Organizations that are springing up in the country.

As seen with the Florida Youth Tobacco campaign, The Florida TRUTH anti-smoking campaign built a new product and branded it. The product/action was being cool by attacking adults who want to manipulate teens to smoke. The campaign reduced the price of the behavior (attacking adults) by selecting adults everyone agreed had been manipulating them. They created places where kids were found by means of a statewide train caravan and the founding of local "Truth chapters." And, of course, they used promotion - but promotion that went beyond the traditional media ads to having kids directly confront the tobacco industry and publicize this teen "terrorism" in the popular media. The Campaign routinely carried out surveys of its target audience that allowed the campaign to discover important micro-market segments (South Florida Hispanics) where impacts were lagging. The Truth campaign has been a dramatic success; it is now the model for the Legacy Foundation's national anti-smoking campaign. In just two years, from 1998 to 2000, the percent of Florida middle schoolers who smoked cigarettes in the past 30 days fell from 18.5 to 8.6 percent while the percentage for high schoolers went from 27.4 to 20.9. 10

The Present Anti- Tobacco campaign in Nigeria needs to employ the strategies used in the Florida Youth Tobacco Campaign (FYTC), merchandise like t-shirts, key holders, baseball caps, and other branded materials can be distributed via an official campaign van at teen functions; youth advocacy groups should be encouraged as they will serve as a peer groups that will positively reinforce the acceptable behavior of ‘not smoking’ and increase youth empowerment through community involvement. Facilities need to be put in place to reduce the availability of and youth access to tobacco products and reduce youth exposure to second- hand smoke. Unlike in South Africa, for instance, it is still legal and common in Nigeria for cigarettes to be sold individually which makes it easier for children to afford them. Stricter control measures need to be in place like it’s done in other parts of the world where one requires an ID to purchase tobacco products.

CONCLUSION
The antismoking campaign adopted by the Nigerian government will work effectively if other social marketing methods are used in the campaign. Community-based participatory research should be encouraged as this provides communities and researchers with opportunities to develop interventions that are effective as well as acceptable and culturally competent. Ads asked youth to directly confront the tobacco industry and publicize this teen activism in the popular media. There is still an opportunity to change the situation that exists in Africa especially NIGERIA by learning from the experiences of other public health interventions, such as those for the HIV epidemic. The interventions appear to have reduced the risk behaviors by utilizing the existing infrastructure such as antenatal clinic. Applying this model to the current situation, it may be possible to provide public health information on the risk of smoking and exposure to environmental tobacco smoke.

In many modern societies, smoking has been an acceptable norm. It used to be socially acceptable in Europe and the United States but is less so now. This is because large-scale tobacco control programs have been instituted in such countries with increasing effectiveness. The mass media provide effective tools for convincing youth not to smoke; because they can communicate prevention messages directly to young people and influence their knowledge, attitudes and behaviors (Hopkins et al, 2001). Mass media campaigns usually achieve long- term success but they must be framed in ways that are attractive to the target population especially the youth. Research has also shown consistently that tobacco counter – marketing campaigns are most successful when they are part of a broader, comprehensive tobacco control activity.

REFERENCES
1. Nigeria takes on big tobacco over campaigns that target the young
http://www.guardian.co.uk/world/2008/jan/15/smoking.britishamericantobaccobusiness
2. Smoking Prevalence. Adult (15 Years & Older), 1990. Southern Nigeria (survey year unknown); Okojie, O.H., Isah, E.C. and Okoro, E. (2000). www.who.int/tobacco/media/en/Nigeria.pdf
3. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004 [cited 2006 Dec 5]. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm.
4. Centers for Disease Control and Prevention. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 1997–2001. Morbidity and Mortality Weekly Report [serial online]. 2002;51(14):300–303 [cited 2006 Dec 5]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5114a2.htm.
5. Centers for Disease Control and Prevention. Health United States, 2003, With Chartbook on Trends in the Health of Americans. (PDF–225KB) Hyattsville, MD: CDC, National Center for Health Statistics; 2003 [cited 2006 Dec 5]. Available from: http://www.cdc.gov/nchs/data/hus/tables/2003/03hus031.pdf.
6. McGinnis J, Foege WH. Actual Causes of Death in the United States. Journal of the American Medical Association 1993;270: 2207–2212.
7. Tobacco Free Japan: Recommendations for Tobacco Control Policy, 2005. Health Risks of Smoking.
8. DeJong, W. Condom promotion: The need for a social marketing program in America's inner cities. Am J Health Promotion, 1989;3(4):5-10.

9. SMOKING PREVALENCE. Adult (15 Years & Older), 1990. Southern Nigeria (survey year unknown); Okojie, O.H., Isah, E.C. and Okoro, E. (2000). www.who.int/tobacco/media/en/Nigeria.pdf
10. Social Marketing Institute; Success Stories – Florida Youth Campaign. http://www.socialmarketing.org/success/cs-floridatruth.html

Failure Of The Healthy Futures Program-Grace Thiongo

2008-04-24T19:38:00.000-07:00

Introduction
Federal support for “abstinence-only” education programs has expanded rapidly. The federal government spends approximately $170 million on abstinence-only education programs. However, states are limited to spending the money on abstinence-education programs only. As a result abstinence-only education, which promotes abstinence from sexual activity without teaching basic facts about contraception, now reaches millions of children and adolescents each year in the United States. In contrast, comprehensive sex education encourages both abstinence and effective contraceptive use, which have been shown in many studies to delay sex, reduce the frequency of sex, and increase the use of condoms and other contraceptives. In addition, the abstinence-education programs, which promote sex after marriage, do not take the lesbians, gays, bisexuals and transgenders into account, who cannot get married in 49 of the 50 states. Massachusetts is among one of the states that promote the abstinence-only education curricula. Governor Mitt Romney announced in April 2006 that the state will funnel nearly $1 million in federal funds to a faith-based organization to teach abstinence to public middle school students in a dozen communities across the state [1]. This faith based organization is known as Healthy Futures.

A 2005 Youth Risk Behavior Survey [2] indicates that among Massachusetts high school students 45% ever had sexual intercourse, 34% had sexual intercourse during the past three months, 35% did not use a condom during their last sexual intercourse and 75% did not use birth control pills during their last sexual intercourse. CDC recommends better health education. A 2004 School Health Profiles indicated that among Massachusetts middle/junior and senior high schools that taught health education, 59% of them required students to take two or more health education courses, 94% taught abstinence as the most effective method to avoid STDs and 50% taught how to correctly use a condom and 40% taught the basic prevention methods of STDs.

Healthy Futures is a state- and federally-funded health program that bases its curricula on educating teens in the areas of sexuality, healthy relationships, and self-respect through arguably “medically-accurate” information and interactive skits and demonstrations. Further, it empowers teens to avoid the social, psychological and health consequences of early sexual activity and provides the skills necessary to attain abstinence before marriage [3]. Supporters of abstinence-only programs argue that they are an effective way of reducing pregnancies and reducing the spread of sexually transmitted diseases. The group, the largest of its kind in Massachusetts, was formed in September 2002 by A Woman's Concern, a pregnancy health services agency that lists its guiding principles on its website as the importance of the gospel, the sanctity of human life, and the soundness of sexual purity, marriage, and family [4]. The Healthy Futures program, a Boston-based agency, runs abstinence programs in several dozen schools across the state. The program, free to the school districts, is available to schools in 12 communities with high numbers of teen births, including Boston, Lawrence, Lowell, and Lynn [3].

Opponents of abstinence-only programs counter that teens are going to have sex anyway, and that such programs, by not teaching the merits of condoms and other contraception, increase the risk of pregnancy and disease.” The problem here is not the abstinence," said Angus McQuilken, director of public relations and governmental affairs for the Planned Parenthood League of Massachusetts, a leading provider of comprehensive sex education in the public schools [5]. ''We're doing them a disservice if we deny them medically accurate information about how to protect themselves" she says.

Healthy Futures And The Gay Community
Despite the nearly 15000 lesbian and gay teenagers in Massachusetts public high schools [6], and the growing visibility of gays and lesbians in the broader culture, few educators are willing to address homosexuality in the classroom. Advocates assert that including gay issues in sexuality education could help address heightened health risks faced by gays and lesbians due to misinformation and lack of information about safe-sex practices; emotional isolation that contributes to high suicide and dropout rates among gay teens; and widespread harassment of gay and lesbian students by their peers and teachers [7].

In a society that generally shuns from the idea of homosexual relationships and marriages, curricula that reject the idea of sexual intimacy among homosexuals ignore their need for critical information about protecting themselves from sexually transmitted diseases. The program’s objective of reducing the number of pregnancies and STDs among teens cannot be effective if a large number of teens who are vulnerable to these practices are excluded from the curricula. This ultimately undermines efforts to educate teens about protecting their health and also creates a hostile environment for gays and lesbian teens.

Stacy Weibley, a sexuality educator and public policy associate, states that teens face increased health risks, largely because of fear and ignorance [7]. In 1995, a study based on Minnesota teens published in the Journal of Adolescent Health found that lesbian and bisexual girls were more likely to become pregnant and more likely to have multiple pregnancies than heterosexual girls. In addition to the health risks, these teens can become suicidal as well. A 1995 report from the Centers for Disease Control and the Massachusetts Department of Education found that lesbian and gay youth are four times more likely than non-lesbian and gay teens to attempt suicide. And the U.S. Department of Health and Human Services has reported that gays and lesbians account for 30 percent of all teen suicides [7].

Including information about homosexuality, remains highly controversial among parents, school administrators and teachers. About 1 in 12 high school health teachers taught their classes that homosexuality is wrong in 1995, according to a survey of 211 U.S. school districts published in the Journal of School Health. LAMBDA reports that 77 percent of prospective teachers would not encourage a class discussion on homosexuality and 85 percent oppose integrating gay and lesbian themes into their existing curriculums [7].

Healthy Futures And Self-Efficacy
The curriculum teaches the adolescents and teens that abstinence from sexual activity until marriage is the expected social norm and the only manner in which to avoid sexually transmitted diseases and unwanted pregnancy. Healthy Futures plainly state in their curriculum that “sex is wonderful in the context of a faithful, lifelong relationship, which is marriage, but that there are physical and emotional risks outside of the context”. They also misrepresent the effectiveness of condoms in preventing sexually transmitted diseases and pregnancy. The curriculum teaches that the claim that condoms help prevent the spread of STDs, is not supported by the data; it also states that in heterosexual sex, condoms fail to prevent HIV approximately 31% of the time; and that a pregnancy occurs one out of every seven times that couples use condoms [3]. Abstinence-only program educators are not permitted to discuss the proper use of contraception, including condoms, as a way to reduce risk of contracting HIV or other sexually transmitted diseases.

The concept of self-efficacy based on Albert Bandura’s social cognitive theory assumes that human beings by means of self-esteem, exercise control over their thoughts, feelings and actions. This theory is rooted in a view that individuals are engaged in their own development and can make things happen by their actions [8]. Based on this ideology, the Healthy Futures curricula believe that teens and adolescents will not have sex before marriage because they are told that they should wait is being unrealistic. The virginity pledge program, strongly emphasized by Healthy Futures, encourages students to make a pledge to abstain from sex until marriage. However a study by Bearman et. al [9] found that while in limited circumstances virginity-pledgers may delay first intercourse, they still have sex before marriage and are less likely than non-pledgers to use contraceptives at first intercourse or even get tested for STDs when they do become sexually active.

Healthy Futures And Contraceptives
With only two-thirds of teens in the United States having had sexual intercourse by the time they are 18, it is vital to provide them with information to protect them [10]. Such discussions must include information on methods of reducing risks, including use of condoms and other birth control methods. While abstinence-only programs may delay sexual activity and reduce the number of sexual partners over a lifetime, abstinence-only education curricula that do not discuss contraceptive methods are placing the teens in danger of unwanted pregnancies and being infected with sexually transmitted diseases.

A study by Kirby [11] found that there is enough evidence to show that abstinence-education programs coupled with comprehensive sexual education, delay sex and reduce sexual risk among teens. It is disheartening that abstinence-only programs do not include comprehensive sex education in their curricula. According to Duberstein et. al [12] between 1995 and 2002, the proportion of adolescents who had received any formal instruction about methods of birth control declined substantially, and by 2002, one-third of adolescents had not received any advice on contraception.

Undoubtedly, the Healthy Futures abstinence-only education program presents information about pregnancy prevention and testing and treatment of STDs. However, they do so incompletely and inaccurately. For instance, a 2004 congressional report [13] concluded that many federally-funded abstinence-only curricula misrepresent the effectiveness of condoms in preventing STDs and pregnancies by exaggerating the failure rates. In particular, the Healthy Future program presents data on the effectiveness of latex condoms by using data from a 2000 workshop by the National Institutes of Health panel [14]. This program concludes that the NIH determined that there is insufficient evidence whether condoms can prevent STDs. However, looking at data from the NIH panel, they determined that the relative risk of acquiring STDs or getting pregnant decreases as condom usage increases from a relative risk of 0.006 of using a condom which then breaks, to using a condom with no break or leak at a relative risk of 0.0.

A vast majority of parents, teachers and health practitioners have been in recent years at a consensus that teens should receive complete and accurate information about abstinence and contraceptives. In a nationwide poll conducted by Kaiser Family Foundation, National Public Radio and Kennedy School of government [15], researchers found out that the majority of parents wish to a have comprehensive-based sex education curricula that cover topics such as condom use, sexual orientation and options such as abortion and adoption.

In addition, a national survey by Darroch et. al [16] that was carried out in 1999 among 7th-12th grade teachers found that 93.4% believed that sexuality education courses should cover birth control methods, 89% believed that curricula should cover factual information about abortion, 88.8% believed that the curricula should include where to go for birth control, 82% proposed that curricula should include correct ways to use a condom, and 77.8% believed that curricula should be geared towards other sexual orientations other than heterosexuals.

Conclusion
It is undoubtedly true that abstinence-only education programs aim to reduce the spread of STDs and unwanted pregnancies among teens. However, curricula need to further help them by giving them complete and accurate information about STDs and use of contraceptives effectively. In addition, lesbians and gays need to be taken into account as well, keeping in mind that they too are a vulnerable population and therefore their health needs to be protected as well. Lastly, the social cognitive theory only goes as far as a person’s will and strength takes them. Believing that teens will not engage in sexual practices until they are married is unrealistic particularly because of the influence of media and social networks as well.

REFERENCES
1. http://www.boston.com/news/local/massachusetts/articles/2006/04/21/state
_widens_teaching_of_abstinence/
2. http://www.cdc.gov/HealthyYouth/sexualbehaviors/state-facts.htm
3. http://www.healthy-futures.org/choose.htm
4. http://www.awomansconcern.org
5. http://www.plannedparenthood.org/ma/
6. http://www.boston.com/bostonglobe/magazine/articles/2007/11/11/easy_out/
7. http://www.womensenews.org/article.cfm/dyn/aid/811/context/cover/
8. Bandura, A. Self-efficacy: The exercise of control. New York. WH Freeman and Company. 2001.
9. Peter S. Bearman & Hannah Bruckner. Promising the Future: Virginity Pledges as they Affect Transition to First Intercourse 35 (2000); see also Hannah Bruckner & Peter Bearman, After the Promise: the STD Consequences of Adolescent Virginity Pledges, 36 J. Adolescent Health 271 (2005).
10. Hatcher RA et. al. Contraceptive technology, 18th rev. ed. New York: Ardent Media, 2004.
11. Douglas Kirby. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy 16 (2001)
12. Laura Duberstein et al., Changes in Formal Sex Education: 1995-2002, 38 Persp. Sex. & Reprod. Health 182, 184 (2006).
13. United States House of Representatives Committee on Government Reform – Minority Staff Special Investigations Division, The Content of Federally Funded Abstinence-Only Education Programs (2004) (hereinafter House Committee Report) Christopher Trenholm et al. Impacts of Four Title V, Section 510 Abstinence Education Programs (2007).
14. http://www3.niad.nih.gov/research/topics/STI/pdf/condomreport.pdf
15. National Public Radio et al., Sex Education in America, General Public/Parents Survey (2004), available at http://www.npr.org/programs/morning/features/2004/jan/kaiserpoll/publicfinal.pdf
16. Jacqueline E. Darroch et al. Changing Emphases in Sexuality Education in U.S. Public Secondary Schools,1988-1999, 32 Fam. Plan. Persp. 204, 206 (2000).

USDA Fails to Proactively Remove Dangerous “Downer Cows” from Human Food Source – Punit Patel

2008-04-24T14:42:00.000-07:00

The Committee chairwomen and Democratic Representative from Connecticut aggressively claimed that the United States Department of Agriculture (USDA) needs to take the issue of Mad Cow Disease seriously and take more stringent measures to ensure the safety of the American people. She pointed out that 5,000 Americans die each year due to insufficient inspection of food based on current regulations and compared their deaths to the 3,000 American lives lost in the World Trade Center attacks and vehemently stated, “This Nation went to war because of those deaths. We have 5,000 people every single year in this nation who die from food-borne illness. Do we not believe we should go to war against the system that allows that to happen?”(1) Of the 5,000 people accounted for about 250 die each year from Mad Cow Disease that was ingested from the processed meat of a “downer cow” on American soil(2). Downer Cows are sick and weak cows that are not able to stand on their own feet any longer and have a very high chance of having Mad Cow Disease.

Although the actual percentage of deaths from downer ingested meat is relatively low, it is important to note that symptoms from Mad Cow Disease appear years after meat ingestion has occurred. (3)The nature of such a prion disease is that it constantly is changing so it is difficult to contain and has the potential to incorporate itself into a part of the DNA passed down to the next generation.(4) Hence, we can only know of the past prevalence of the disease from how many people have currently died. However, epidemiologists predict a steady increase in deaths from downer ingested meat once the current infected population begins to show symptoms (5).

Since the USDA is the federal agency in charge of providing “leadership in food, agriculture, natural resources, and related issues based on a sound public policy, the best available science, and efficient management,”(6) the responsibility to make “sound public policy” lies in their hands and that is what is currently lacking. In March 2004 US legislation passed a law banning all downer cows from entering into slaughterhouses for the use of meat for human consumption. (7)In July 2007 the USDA removed this ban, and once again allowed USDA policy to include downer cows.(7) There was a stipulation to this ban lift stating that downer cows would be considered and included in the human food supply, only after the downer cow in question was re-inspected by a USDA certified veterinarian. (8) The USDA felt that a certified veterinarian would be qualified enough to understand the health implications of allowing a downer cow to pass USDA inspection. (8) The USDA’s policy allowing downer cows to be used as processed meat and re-enter the American food supply is irresponsible and unsafe taking into account the flawed foundation behind the policy, the lack of responsible and consistent implementation of it, and the dire consequences to the overall American Public Health.

Political Foundation
The political drive behind this policy is evident in that there are a series of obvious assumptions regarding the meat packers and convenient loopholes within the policy that allow the USDA to “look the other way” when certain regulations aren’t followed all the time. The USDA has two major responsibilities as an organization, one is to promote the agricultural industry via its Agricultural Marketing Service (AMS) and the other is to maintain the safety of food quality for the American public via its Food Safety and Inspection Service (FSIS).(6)

Though the intention of this paper is to critique the intervention or lack thereof via the policy and not the USDA or the federal organizational issues regarding overall food safety, it goes without saying that they go hand in hand as their is an inherent conflict of interest that cannot be overlooked. The USDA is expected to crack down on safety measures while maintaining the growth of the agricultural industry placing them in a political catch 22 situation.(2) Unfortunately, they choose not to enact seriously needed strict policies because they are influenced by the lobbyists from the meat industry and thus safety loses at the hands of marketing because of the meat industry’s strong political power over the USDA.(2)

Secondly, this policy is based on unreliable data and flawed laws from previous years which fall short of full proofing the food supply. For example, the 2006 USDA Inspector General Report stated that all annual inspections of Mad Cow Disease after the initial outbreak were voluntary and not random which misrepresented the actual sample size of potential cows with Mad Cow Disease. (11)This annual inspection is what the USDA uses when formulating the relative risk of the disease in the cow population of the United States which meets the 40,000 cows to be tested goal but ends up testing mainly healthy cows and not ambulatory downer cows.(9) This system works for the USDA as well as the meat industry since meatpackers who utilize a higher number of downer cows into their food source would not want to reveal themselves to the USDA and the USDA can fulfill their quota of testing without doing any serious damage to meat packers. Countries like England and Japan test all of its cows for Mad Cow Disease while the United States only tests .1% of its cows breeding a false sense of security from inadequate testing. (9)Though it might seem that there is no need for this, the Japanese originally had no cases of the disease but once they started testing they found 31 cases so the trend seems to be the more you test the more you find. (2) In the United States, testing isn’t even proportional to the number of cows slaughtered per state and in no way reflects the current risk in cattle.

The USDA relies heavily on the 1997 law stating the cattle feed cannot be fed to other cattle and spinal cord and brains of cows 30 months or older cannot be utilized as food but blood from cows can be incorporated in cattle feed.(7) The problem here is that prions can still travel via blood and what about the risk of a downer cow with Mad Cow Disease of 29 months?(8) Such laws with numerous loopholes cannot be considered the fundamental basis of safety from Mad Cow Disease in general or specifically from downer cows.

Finally, this new policy is a continuation of past mismanagement of food quality and safety as a result of basing the approach to safety solely on the Health Belief Model causing the responsibility and decision making to fall in the hands of the distributor of the processed meat and not the regulator, the USDA. (10)It is based on the idea that if the meat packers feel that a downer cow is susceptible to Mad Cow Disease and if they are informed of the seriousness of the disease, the industry will automatically choose the perceived benefit of public safety and accept the cost of the downer cow as lost revenue for the sake of the public’s health. It is also assumed that their intention of protecting the meat supply from disease will lead to responsible and safe behavior on the part of the meat packers. The assumptions this model makes are not only unrealistic but they are dangerous because they give so much power to an industry whose key incentive is profit and this one major fact automatically alters the outcome from this model. This is something the USDA has failed to realize allowing them to claim that according to their new policy, derived from this model, food safety is accounted for but the real question here is if the individual factories and their employees that makeup the industry are following through on that model?

Unsatisfactory Implementation of the Policy

The only way this policy would be able to successfully promote the interests of the meatpackers while still maintaining the safety of food quality from diseased downer cows is, if the state level implementation was carried out impeccably and if every single division and subdivision of this hierarchical ladder would honestly and carefully carry out his or her duties. Unfortunately, there are organizational deficiencies in staffing and training within the FSIS (the body that handles state-wide inspections and enforces regulations) as well the individual meat packing factories that have lead to a high level of inconsistencies confirming the risk of increased Mad Cow Disease prevalence in future years.

Training Issues

There is a serious lack of quality training being offered to both USDA officials and none is offered to the managers or their employees who are the ones assessing the on-site status of downer cows. A USDA Training and Development Consortium has been established “to provide coordination and consistency to the training function within USDA. The Consortium is authorized and empowered to direct mission areas and agencies to comply with its programs, procedures, and guidance” but one of the major goals as stated within their priorities is to “eliminate duplication of effort” so this is clearly training that is geared towards efficiency and conservative budgeting schemes than to genuinely train the employees for safe and tedious inspection of unsafe cattle. (6)

The FSIS deals mainly with managers of meat factories and rarely interacts with employees so no specific training is given to any employee by the government regarding state and federal regulations and that responsibility lies with the individual managers. (6) Though, it may seem fair and cost effective to not train private employees, there is no standard test or license or even certificate of completion or any document that states that the particular necessary training has been provided for the proper treatment and exclusion of downer cows. Every manager will train his or her employees and this is where the inconsistency occurs in quality of meat because though the policy requires a USDA certified veterinarian to inspect the downer cows for safety, before used as meat, the person making that decision is the ill trained employee whose expected to observe the downer cows on a federal standard of safety but works for a biased employer who would benefit from incorporating as much meat as possible. (2) Therefore, the employees may be “encouraged” to overlook certain regulations in an attempt to increase output causing the employees to not inform the USDA veterinarian and the potentially diseased downer cow ends up in the American food supply being distributed to various companies to be incorporated in hundreds of products.

The issue of inconsistency does not stop with the ill trained employees of the factories, but spills over into the main body enforcing the regulations, the FSIS. Staffing is limited requiring a higher level of “efficiency” which results in inconsistent implementations of policy. This allows for an ambiguous gray area where managers tend to use their own “discretion” and that is where the enactment of the policy fails.

Staffing Issues

There are 7,800 inspectors working for the USDA for 6,200 facilities, though this may seem adequate, each facility on average slaughters 500 cows which leaves approximately 1 inspector to every 400 cows for inspection per day. (6) Of that, there is an average vacancy of 500 inspectors which creates a 7%-21% lack of much needed inspectors within the districts. (6) The actual ratio should be of inspectors to number of cows within a facility since it clarifies the immense amount of responsibility for every inspector. Not only do they have to check the downer cows for injuries and disease, they also have to sample butchered meat for E. coli and various other bureaucratic tasks as well which leaves little time for actual thorough inspection.

Even if the inspectors manage to find regulations not being followed within factories, there seems to be an inherent inconsistency in the inspection process showing a dangerous level of leniency in some states. For example, the state of Pennsylvania has 139 meat plants but only 4 citations were written least year whereas in a more stringent and safer state like California there were 15 citations written where there are only 32 plants. (5) Though, it is a fair argument that the number of citations do not have to be proportional to the number of plants, there is a serious number of discrepancies in the above two states and the disheartening thing is that inspectors of both states receive the same federal and state level training. (6)

Finally, if inspectors do stay on there toes and actively issue citations when needed, there may be piles of citations before anything is done about the plant in terms of closing it down for violations or increasing on site inspections. There is no written rule of “x number of strikes and your out” so each violation amounts to a fine and tends to stop there. (7) For example, the Westland Meat Company in Chino, California was recently closed down and the largest meat recall in the history of the USDA was done amounting to 147 million pounds of meat after having received numerous violations from the USDA for the last 10 years. (2) This shows how long the meat company has been able to freely pass on dangerous meat into the food supply enhancing the argument of the increase in future deaths and current prevalence of Mad Cow Disease.

Consequences
Along with the medical dangers of this policy, there are a series of social consequences that prove to be detrimental to society psychologically, through the inhuman treatment of downer cows, and financially through the numerous recalls that occur in increasing numbers annually. The way in which the USDA has formulated this policy it seems that the only loophole to utilizing the maximum amount of downer cows is either to get the cows to stand by forceful means or injure the downer cows so that they may pass the inspection as “injured” rather than automatically excluded as “diseased.” (12) Though, downer cows are segregated for inspection separately, the sheer number of downers to inspect per day causes the quality of inspection to suffer. Here is where meat packers take advantage of the situation and through inhumane treatment inflict injury on the cows while trying to force them to stand.(12) And if an injury is found on a downer cow, the chances of it passing inspection as “injured” is much higher, taking advantage of the USDA’s Chairman, Ed Schafer’s argument that “injured downer cows are not a threat to the food supply and should be allowed.”(2) A key thing to remember here is that a downer cow with Mad Cow Disease can also get an injury and end up passing the test because of the nature of the disease. Veterinarians have trouble deciphering between the actual disease and an injury because the disease causes similar external symptoms of weakness as does an injury. (8)

Inhumane Treatment

Unfortunately, this policy harbors and instigates meat packers to employ inhuman methods of electrical prodding of downer cows, power hosing them, or simply pushing them with a fork lift until they stand up and walk into the slaughter house assembly line or get injured in the process and end up inspected and labeled as “injured” and then forced into the assembly line. (12) In fact, the Westland and Company factory was even cited for “too much electrical prodding” but was allowed to continue there slaughtering after a fine. (12) The Humane Society of the United States has clearly agreed that this policy is “dangerous and deplorable taking into account the large economic incentive the meat packers have to force downer cows into slaughter lines and the risk that even those cows with broken limbs and weak muscles are 49 to 58 times more likely to have Mad Cow Disease as the disease weakens muscles.”(12)

A major danger of this mistreatment is the greater impact on the industry as a whole as this creates a type of Meat Plant Culture of abuse and mistreatment of downer cows that is passed on as some sort of tradition to each new generation of employees. The entrance of a new employee into the meat factory and the training one receives as a result is based on the Social Learning Theory (10) where an employee will do what he sees his fellow workers doing and in this case it will be the illegal and inhumane attempts at trying the get downer cows to stand or pulling them with chains to the slaughter line. There is no question of any Reasoned Action () as the concept of self efficacy does not exist for most of these workers who are poor immigrants who are living pay check to pay check and are afraid of losing their job if they voice any sort of opposition to existing methods. As time goes on, the employee that initially entered the work force and learned this behavior of mistreatment through modeling has become a member of that very Social Network as in the Theory of Social Networking (10) and his or her behavior is a result of belonging to that Social Network which forms the “Plant Culture” of inhumane treatment and maintains this tradition through the Theory of Social Learning and a cyclical series of events occur over generations and the tradition of force and abuse continues as the next wave of employees arrive.

Recalls

In an effort to correct their wrongs of this policy, the USDA issues recalls whenever proof is presented of mistreatment of animals or risky entrance of un-inspected downer cows into the human food source as an attempt to protect the public from products containing the risky meat via the loopholes of this policy. (12) Unfortunately, recalls are a voluntary procedure and the USDA does not have the power to force any plant to comply and as the Consumer Federation of America’s Food Policy Institute points out “critical time can be lost in negotiating between the USDA and the company over the terms of the recall” prolonging the risk of Mad Cow Disease from the downer ingested meat. (13) Recalls cause the public to go under a scare and paranoia infiltrates members of society causing mistrust of food products and as a result the economy is effecting when United States quality of meat is questioned when other countries like France refuse American beef and revenue is lost. (1) Also, as was the case for 220 employees of the Westland and Company, hundreds of employees lose their jobs when a recall occurs as the loss of credibility leads distributors to pull out of their contracts with the plants. (2)

Finally, the meat from these factories which have recalls does not remain in a concentrated geographic area, but travels across the nation to millions of people as the meat is first sent to distributors and companies which process the meat for different products, 466 in the case of Westland and Company, so containing the potentially diseased meat is close to impossible. (2) In fact, the meat from the Westland and Company was distributed to the National School Lunch Program as well as to needy families with low income and that is a serious risk. (2) Most children who are approved to be a part of a school lunch program are required to be from medium to low income households and those very children’s parents might be ones receiving a part of the quota of meat distributed to needy families so that child is at risk two times more than the average person. (2) Children in general have lower immunity but coming from a low income household, whether child or adult, it is clear in the literature that healthcare options are limited if at all available. (12)

Conclusion
This policy is a threat in itself to the safety and well being of millions of Americans and needs to be changed immediately. The USDA is inherently not able to and lacks incentive to prevent downer cows from entering the human food supply and that needs to change. If nothing is done, we will have to watch an entire generation of beef consumers becoming infected with Mad Cow Disease and there will be nothing that can be done for them. One of public health’s main goals is prevention and we might have missed the current population but we can surely save the next one if action is taken now.

The ethical implications of allowing such a small group of people, in the industry, to control the health status and health outcome for millions of people is disturbing and unsafe. The fact that our world today is becoming smaller and smaller is a haunting fact when thinking of meat from downer cows and the increasing geographic area in which such meat is consumed. The factory owners in the industry weigh the chances of higher profits against the future sickness of the public and choose the immediate profit. One of the main reasons for this is that this is a decision for which the consequences will occur in the long run and by that time it will be nearly impossible to trace the meat to the original factory. Hence, the industry sees utilizing downer cows as a crime without a consequence and it is the current policy which gives them this security and causes such discomfort within the field of public health as well as the masses that may be at risk as of now.

REFERENCES
1. Lee, Christopher. Washington Post. USDA Rejects “Downer Cow Ban”. February 29, 2008.
2. http://www.pe.com/reports/2008/cattle/vitindex.html
3.http://www.usda.gov/wps/portal/usdahome
4. Zimmerman, Janet. United States Department of Agriculture Handbook of Laws. Washington, DC: Penguin Press, 2007 Edition
5.CJD deaths 'may have peaked'. BBC News (2001-11-23). Retrieved on 2008-04-08.
6."BSE: Disease control & eradication - Causes of BSE", Department for Environment, Food, and Rural Affairs, March 2007.
7."The BSE Inquiry", led by Lord Phillips of Worth Matravers, report published October 2000.
8. Harden, Blaine (2003-12-28). Supplements used in factory farming can spread disease. The Washington Post. Retrieved on 2008-04-08.
9.Bovine Spongiform Encephalopaphy: An Overview (PDF). Animal and Plant Health Inspection Service, United States Department of Agriculture (December 2006).
10. Association of Health Practitioners. List of Health Behavior Models. Washington, DC. Association of Health Practitioners. http://www.aph.org/health.
11. United States Department of Agriculture. 2006 USDA Inspector General Report. Washington, DC.
12. Humane Society of the United States. Westland and Co. Surveillance Report. New York, NY.

The SunSmart Skin Cancer Campaign: An Intervention That Fails To Recognize Social And Behavioral Components – Deep Patadia

2008-04-24T10:06:00.000-07:00

Over the last two decades, the rates of skin cancer have been increasing. As a result, over 90% of skin cancers are caused by sun exposure (1). One in five Americans and one in three Caucasians will develop skin cancer during the course of their lifetime (2). Moreover, research from the American Cancer Society suggests that more than twenty people die each from skin cancer (3).
There exist three types of skin cancers: squamous cell carcinoma, basal cell carcinoma, and melanoma. Non-melanoma (or squamous cell and basal cell carcinomas) is the most common; however melanoma skin cancer is the most lethal. In 2004, the total direct cost associated with the treatment of melanoma amounted $291 million, which included office visits, hospital inpatient and outpatient treatment, prescription drugs, and emergency room treatment. On the flip side, the cost of non-melanoma skin cancer during that year was much higher, totaling $1.5 billion (4).
In an attempt to raise awareness and practice safe habits with regards to excess exposure to the sun, The Cancer Council Victoria launched the SunSMART campaign in 1988. Their goals involve reducing the prevalence of skin cancer, decreasing the mortality rate, and assessing baseline levels of UV radiation awareness to the public with regards to all types of skin cancer. Multiple countries such as the United States, Great Britain, and Australia have taken part in this program. The program proposes a five-letter acronym: S.M.A.R.T.:
Spending time in the shade between 11am and 3pm
Making sure you never burn
Aiming to cover up with a t-shirt, hat, and sunglasses
Remembering to take extra care with children
Then using factor 15+ sunscreen (5)

This is not an effective acronym because it is not well thought out nor does it consider social and behavioral standards carried out in society. The SunSMART campaign lacks credibility as a practical public health intervention because it is too age-specific, violates the social expectations theory, and disregards occupational and nutritional consequences.
Age-Specificity
SunSMART proposes to take special care of children. The reason for this is that one sunburn in childhood more than doubles the chances of a person developing skin cancer later in their life (6). While it is important to target these issues towards younger individuals, it is also equally as necessary to include adults.
This program fails to direct any attention towards the adolescent and adult population, skewing their overall message. Skin cancer is a progressive disease and will develop later in life, where more than 90% of skin cancers cases are attributed to those over 40 years of age (7). Less than 0.1% of children acquire skin cancer, predominantly because skin cancer is a progressive disease (8). However, this program’s intention in preventing skin cancer in the long run is contradicted by the research that claims men and women born in 1970, now in their mid-30s, are being diagnosed with melanoma at the same rate as people who were born in 1930 and didn't develop melanoma until their 50s (9). Thus, the age of incidence of skin cancer is occurring much earlier than it has been in the past and protecting children is not sufficient enough.
Though the incidence of obtaining skin cancer decreases if one is protected from the sun as a child, it is not adequate considering that the skin cancer latency period is narrowing and that there should be more of an effort to target the older generation. If SunSMART were more comprehensive in their program’s protocol by expanding their age-window, it would raise awareness to individuals off all ages, fulfilling their ultimate aim to reduce the prevalence and mortalities associated with skin cancers.
History, Beaches, and Social Norms
Culturally, a skin tan is viewed as attractive, which dated back to the time of the end of World War II. During this time, the middle class citizen got more time and money to spend on leisurely activities due to the economic boom. As a result, vacationing became a standard practice, especially going to tropic areas. Thus a socioeconomic shift occurred, where dark and tanned skin (usually of a lower-economic status) labor worker transformed into a sign of a well-cultured and wealthy individual that enjoyed life at beaches, pools, barbeques, and exotic vacations, and dinner parties. It also became an indication of health and strength as the bodybuilding and fitness industries vastly promoted tanning to highlight muscle tone and definition (10).
Sun tanning is acquired through skin exposure to UV rays from the sun. The greatest exposure to UV rays for a majority of the population occurs on shores and beaches, where over 50% of people in these locations do not wear hats, large sunglasses, or sufficient clothing necessary to protect against sunlight (7). SunSMART urges individuals to make sure to stay covered up, which violates the Social Expectations Theory and Social Learning Theory. The Social Expectations Theory suggests that social norms affect an individual’s expectations while the Social Learning Theory states that individuals model what they see (11,12).
It is socially acceptable and expected for individual to go to a beach in order to relax and be minimally clothed to engage in sun bathing. However, it would be socially unfavorable for an individual to be in an environment, such as a beach, in which he or she is fully clothed. According to Miles’ study, 50.7% people feel a suntan makes them look more attractive and 66.3% feel a suntan makes them look healthier (7). According to the Social Expectations Theory and Social Learning Theory, if an individual is in an environment where the population wears minimal clothing, they will be inclined to behavior almost synonymously.
Violation of the Social Expectations Theory and Social Learning Theory could lead to various effects for the individual. One may feel ostracized, embarrassed, neglected, or simply out of place. This could lead to lead various psychological affects, such as neglect, loss of self-esteem, or in the extreme case, depression (9).
Thus, SunSMART does not take into account the violation of the Social Expectation Theory or Social Learning Theory with regards to beaches and other outdoor recreational areas, places where UV rays are most prevalent. Failure to address these social and cultural issues makes this intervention’s goals even more difficult to obtain, an angle at which SunSMART neglected to address.

Occupation, Race, and Vitamin D
It is well understood that sunlight is the most efficient way to absorb vitamin D. This vitamin D is an essential vitamin protects against osteoporosis, heart disease, cancers, diabetes, osteomalacia, and rickets (13). SunSMART stresses to avoid the sun as much as possible between the hours of 11am and 3pm. However, according to Michael Holick’s study, the greatest amount of vitamin D is absorbed between noon and 4pm (13). To avoid these particular times could be detrimental to an individual’s health in the long run because these are periods at which the greatest amount of vitamin D can be absorbed. The economic burden for the nation of chronic disease due to inadequate vitamin D is estimated at $25–36 billion- a significant amount of money spent on a deficiency that can be easily addressed (14).
In response to SunSMART’s lack of consideration for vitamin D, this campaign just recently suggested that people can supplement themselves with vitamin D by eating eggs, fatty fish, and liver oils (15). However, this diet is not pertinent to vegetarians, a large portion of the population. Various individuals and communities do not eat meat or eggs due to religious or ethical reasons. In a sense, SunSMART is asking to these people to go against their principles and morals to absorb vitamin D into their diets. As a result, most individuals would not eat eggs, fish, or liver oils to obtain adequate amount of vitamin D. Thus, rather than making the program more comprehensive, SunSMART can now only be attributed to non-vegetarians, failing to address eating habits of various communities.
The 11am to 3pm time restriction also affects the portion of individuals that work outdoors. Over 40% of the working class in the United States works outdoors, in which over 85% of these people work between 11am and 3pm, the time where SunSMART advises individuals to avoid (16). This restriction fails to address the issue to the majority of the outdoor working class. If put in this predicament, an individual will choose to work outdoors rather than be “at risk” for acquiring skin cancer. If one does not to work out doors, it could potentially mean a reduction in wages or getting fired by their employer. Most individuals will do what it takes to be financially stable, whether it means involves buying food to eat, supporting the family, or having heat under a roof. Most American’s would choose their job over not working long hours outdoors to prevent skin cancer because of the economic advantage. Thus, SunSMART does not take account for the occupational risks their program has on the outdoor working force.
In addition to the outdoor working class in America, 64% of workers are African-American (17). Those with darker skin are less likely to get skin cancer because they absorb less UV light than light-skinned people (13). Thus, darker-skinned individuals need to stay in the sun for a longer period of time to absorb more vitamin D. Limiting African Americans to less sun exposure outdoors will put them at risk for possibly losing their job and a lower concentration of vitamin D absorption, resulting in various health complications, such as osteoporosis, heart disease, cancers, diabetes, osteomalacia, and rickets. Thus, SunSMART should standardize their interventions based on different ethnicities and races with regards to their time restriction in the sun because it impacts the occupational, nutritional, and racial levels separately and together.
In summation, the SunSMART program should adopt new guidelines to allow it to be more age-specific, in addition to socially, behaviorally, nutritionally, racially, and occupationally acceptable standards. The SunSMART acronym is intended to be catchy and memorable; however the acronym is too weak to publicize a growing epidemic around the world. Its phrases are too long to memorize and intervention regulations do not attack the issue from all angles.
Since this campaign was launched, the rate of skin melanoma has increased by 107%, proving that their model is insufficient to prevent against skin cancer (18). This program should be framed to publicize the issue from a power-coercive and normative-re-educative standpoint rather than a rational-empirical. This way, there may be more persuasive techniques that could encourage individuals to change social norms and make it more acceptable. For example, a bill could be passed asking employers to have their employees wear more appropriate clothing to protect against the effects of skin cancer. Implementing this change could bring forth much more positive results from a occupational standpoint so they can get the same wage, a nutritional standpoint so they can absorb the appropriate amount of vitamin D, a physiological standpoint so that they would be at a lower risk for obtaining skin cancer, and an economic standpoint so they would keep the national costs low. In addition, opening up the age-window to all group and not specifically younger individuals could also bring about some more comprehensive solutions to the problem since the latency period is decreasing.
SunSMART’s intentions in preventing the rising epidemic of skin cancer were appropriate. However, the measures they took to carry out those objectives were not fully thought out from a cultural and social standpoint. Maybe with some changes to the program, we would see more positive results with regards to skin cancer prevalence and mortalities.

References
1- Fayid, Lisa. About Cancer- “Top 8 Shocking Facts About Cancer.
June21, 2007.
2 - Pfahlberg A, Kolmel KF, Gefeller O. Adult vs childhood susceptibility to melanoma. Is there a difference? Arch Dermatol, Sept 2002; 138: 1234-1235.
3 - American Cancer Society's 2007 Facts & Figures. American Cancer Society, Inc.
4 - SunSMART- Cost to Employeers. National Business Group on Health. Jul. 6, 2008. http://www.businessgrouphealth.org/healthtopics/sunsmartarticle.cfm>
5 - SunSMART. Cancer Council Victoria. 1988.
6 – Mayo Clinic Skin Cancer Facts 2006
7- A. Miles. SunSmart? Skin cancer knowledge and preventive behaviour in a British population representative sample. Health Education Research. 2005: 20(5), 579-585.
8- Hoey, S.E.H. Skin cancer trends in Northern Ireland and consequences for provision of dermatology services. British Journal of Dermatology. 2007: 156, 301-307
9- Medical News Today. Deadly Skin Cancer Set to Treble.

10 – Sikes, Ruth G. The History of Suntanning. A Love/Hate Affair. Journal of Aesthetic Science, 1998: I, 2: 6 -7
11 - Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, Massachusetts: Jones and Bartlett Publishers:2007.
12 - Bandura, A. Social Learning Theory. New York: General Learning Press: 1977.
13- Holick, Michael F. Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease and osteoporosis. American Journal of Clinical Nutrition. 2004: 79, 362-371.
14 - Grant WB, Garland CF, Holick MF. Comparisons of estimated economic burdens due to insufficient solar ultraviolet irradiance and vitamin D and excess solar UV irradiance for the United States. Photochem Photobiol. 2005 Nov-Dec;81(6):1276-86.
15- SunSMART. Vitamin D.

16- Green, Adele, et. al. Skin cancer in a subtropical Australian population: Incidence and Lack of Association with Occupation; American Journal of Epidemiology. 1996: 144(11), 1034-1041.
17 – US Bureau of Labor Statistics. United States Department of Labor. Employment status of the civilian population by race, sex, and age. Table A-2.Apr. 4, 2008.
18- Center for Disease Control and Prevention. Comparing Melanoma of the Skin by Race and Ethnicity. 2007.

: The Partnership for A Drug Free America– Examining Prevention Efforts In Prescription Drug Abuse - Matthew Kluge

2008-04-24T09:57:00.000-07:00

Founded in 1986, The Partnership for a Drug Free America (PDFA) is a non-profit organization which aims to reduce illicit drug use in America (1). Just as trends in specific drug abuse among America’s youth have changed throughout the organization’s 20 year history, so too have the PDFA’s approaches to dealing with these concerns. In 1986, they began what was originally a three-year program to “unsell” drugs in America. Fast forward to 2008: The PDFA now utilizes some of the largest media outlets in America, such as Super Bowl advertising, to unveil their new initiatives. These public service announcements (PSA’s), though well intended, often fall short of their goals due to an over-reliance on traditional health belief models. As the PDFA becomes open to a wider range of alternative models, they may improve the efficacy of their already commendable public health interventions.
In the mid 1980’s, the PDFA’s early strategy in their War on Drugs was to “demoralize” and “deglamorize” the use of narcotics, which had persisted since the 1960’s, while also increasing perceptions of risk (14). The most memorable ads of this era included the image of an egg frying to represent one’s brain on drugs, or likening the risk of a drug induced high to diving into an empty swimming pool (10). Such images of menace or melodrama were often accompanied by a message of strict chastisement through the slogan, “Just say No.”
The 1990’s saw PDFA’s ads narrow in specificity, tailoring each ad campaign to a particular type of drug abuse, even a specific demographic. Furthermore, by 1993, their mindset had changed noticeably, as PDFA campaign executives abandoned their old rhetoric of a War On Drugs, which suggested an obstacle that was short and winnable (10). In 1994, for example, a new campaign heeded research from inner city neighborhoods, which identified a sense of hopelessness, or a need to kill psychological pain, as reasons for drug abuse. Their campaign focused the message on individual empowerment, with images of hope, vision and strength (10). Other noteworthy PSA’s of the past include the Inhalant Campaign in 1997, the Heroin Campaign in 1998, the Check Yourself- Helping At risk teens campaign in 2004, and the Intervention & Treatment Campaign of 2005 (14).
Recent data from the University of Michigan suggests that overall teen drug use is in steady decline, yet more teens abuse prescription drugs than any other illicit drug except marijuana (1). In an effort to curb these alarming trends, the PDFA unveiled their most recent campaign in late January of 2008. The initiative involves a national public awareness campaign alerting parents to the dangers of prescription drug abuse. One parent-targeted ad portrays an indignant drug dealer, who attributes slow “business” to the ready availability of prescription drugs in the medicine cabinets of parents. He leaves parental viewers feeling guilty in the event that “something goes wrong with their kids;” holding them responsible for their son/daughter’s prescription drug abuse, even likening their role to that of a drug dealer. A second ad depicts a high school student cataloging his parent’s prescription medications, which presumably, he had taken from their medicine cabinet. The narrator closes by asking parents to, “Safeguard your kids against drugs” (1). One final noteworthy ad in this campaign attempts to heighten the perceived severity of prescription drug abuse by depicting a man in a morgue comparing the corpses of a teen who died from the use of illegal drugs and another who died from the use of prescription pain killers. He asks, ‘Which one is more dead?’ A narrator closes the PSA by warning parents to, “Talk to your kids about prescription drug use” (1).
To its credit, the PDFA has generally molded each of its ad campaign initiatives to the status of drug abuse in a particular region of the United States. Indeed, any quality advertising campaign should know and cater to its desired target “market.” However, since its inception in 1986, this program has often failed to utilize basic social science principles that could most effectively reach America’s youth. The PDFA’s Public Health initiative targeting prescription drug abuse among America’s youth ignores underlying social factors, overestimates the efficacy of their oversimplified message to parents, and targets a limited audience. In doing so, it has failed to realize its potential to reduce illicit drug use in America.

1. Media campaigns targeted towards parents fail to provide them with the proper tools; limiting specificity of instruction while at the same time enhancing perceptions of harm
In many PDFA ads employed between 1998 and 2003, the PDFA too broadly advised parents concerning intervention. Even in the most recent campaigns, parents are essentially informed to talk to their children about prescription drugs at, “teachable moments” but do little else to help parents with these “moments” depending on their teen’s specific choice of drug abuse and personal situation. According to the theory of reasoned action, an intervention will be most persuasive when the behavior is defined by its action, target, time, and context. Specific parenting should be addressed in the context of specific drug use (2). For example, a parent would most likely approach their studious son/daughter who has been abusing the common prescription medication Aderol for the purposes of a study aid differently than if they had been abusing a pain killer such as Oxycontin for recreational use on the weekends.
A study published in 2008 suggested a lack of communication entirely. They found that at least half of the respondents reported that their parents did not even provide them with information about drugs or drug abuse (5). Parents who feel ill equipped to talk to their children about drugs may avoid such conversations altogether.
Many of the PDFA advertisements utilize risk or fear as a tool to emphasize that a child’s drug use is serious or remind parents that their children are susceptible. The concept of Fear Appeal is defined by two important variables (in addition to the concept of Fear itself). First is the idea of perceived threat, which is defined by the familiar concepts of perceived severity and perceived susceptibility. Second is the idea of perceived efficacy, which has two components: Perceived self-efficacy and the concept of perceived response efficacy (one’s belief on the effectiveness of the recommended response) (16). Investigators involved in a 2000 meta analysis of public health campaigns which utilized fear appeal, showed that fear appeal can have persuasive effects, when accompanied by high-efficacy messages. If individuals believe they can effectively protect themselves from a given risk, than fear can be an effective impetus for behavioral change (16).
Early advertisements, which emphasized risk through drastic imagery, such as the memorable ad developed in 1986 which likened a fried egg to the condition of a drug user’s brain, tend to enhance perceptions of harm and risk. This technique is still implemented in current ads such as the PSA morgue ad mentioned earlier. Here, the fear appeal is pronounced, but how does this ad address the perceived efficacy – that “talking to one’s children about drugs” will ultimately keep them from prescription drug abuse? Unguided fear does little else than instill a culture of fear and paranoia. Thus, it is important to accompany risk messages with a message of efficacy to channel fear into an adaptive behavioral response (2). Underutilizing an efficacy message, though a common practice in Public Health, can severely deflate the overall utility of an ad campaign.
Finally, in the case of countless ads utilized since the PDFA’s inception, in which the use of drugs are framed as a stigmatized act of which parents and authorities do not approve, the overall effect may be to elicit rebellion amongst teens. Widely documented in the social science realm is the phenomenon of the “Boomerang Effect,” in which anti-drug messages may elicit the exact opposite response of the intended outcome. In his 2001 article, Julain De Meyrick warns against the dangers of a paternalistic approach, in which, “the experts speak and the citizens listen” (17). He reminds readers that adolescence is a time when children are struggling to achieve independence, and a paternalistic voice instructing them to avoid a particular behavior may have the opposite effect (17) In a 2002 study examining 30 PSA’s previously employed by the PDFA, the adolescents felt that they and their friends would actually be more likely to try drugs after viewing six of the 30 ads. (13). Indeed, the PDFA is commonly criticized for its reliance on the health belief. By establishing a mindset that, “Drugs Maim, Drugs Kill,” they are heightening the perceived severity of a social activity, thus, providing another outlet for a demographic of adolescents that are, by their very nature, seeking risky, rebellious behavior.

2. How does the most recent ad campaign address the larger confounding social factors that may influence a youth’s decision to use?
To merely address the question of how America’s youth is acquiring drugs, and not why, and under what circumstances, would do a great injustice to the potential potency of social science-based interventions. For example, in the current prescription drug campaign, an attempt to thwart individuals from illegally acquiring drugs that are legally distributed to hundreds of thousands of individuals on a daily basis seems like a fruitless endeavor. The distribution and abuse of prescription drugs is, and always will be, very difficult to police. My intent is not to devalue the PDFA’s efforts to reduce youth access to prescription in parent’s medicine cabinets, but rather to suggest that this is merely one minor source of a larger prescription drug abuse problem.
Rather than focusing on the physical mediums through which these medications are acquired, more influential interventions may be targeted towards the social environments of America’s youth. One advertisement from 1992 actually acknowledges the impact of societal problems, by criticizing the simplicity, the futility, even, of the, “Just Say No,” campaign in the face of larger social pressures. In this commercial, by Goodbye, Berlin & Silverstein in San Francisco, a boy takes a roundabout route to avoid drug dealers. He says: "My teacher tells us to just say no. Policeman said the same thing. They don't have to walk home through here" (10).
Changes need to be made much earlier in a youth’s life, before drugs are even available or socially apparent. According to the social networking theory, which states that one’s behavior is determined by the specific social network with which you associate, by prohibiting your son/daughter access to your medicine cabinet you will have little effect on the influence of their larger social network. Social networks are often formed based on similar interests, and interests are developed early on in one’s life. By creating a positive, activity filled environment in which a child can explore and identify positive interests at a young age, they may be more likely to engage in positive social networks in the future. Thus, the simple instructions, “talk to your kids about drugs,” may do very little to help parents develop anti-drug socialization.
Marketing research has also investigated how best to reach typical adolescents, who tend to display interdependent tendencies; those influenced by peer pressure. Researcher Jennifer Aaker holds that these individuals display an interdependent view of themselves, which is characterized by connectedness and social context (18). Thus, rather than utilizing scientific fact, the most effective campaigns portray “consensus” information that offers a type of social membership to drug free peer group. (18). Rather than stigmatizing the use of prescription drugs, perhaps these ads could be better served to tout the social benefits of a drug free community.
A conceptual framework of parent-child communication pertaining to anti-drug socialization to help inform parents and ultimately help socialize their children to make individually responsible decisions should be established early in a child’s life (5). Such socialization cannot be achieved quickly or simply. Social networks are very complex. A conventional, ‘social network’ often includes social or institutional influences in addition to individual learning.

3. The PDFA, in their latest campaign, underestimates or misunderstands their target audience resulting in campaigns that often miss their mark
The social marketing theory is based upon the notion that public health officials need a strong, research based understanding of their target audience –their needs, wants, etc, before they can adequately market to create change. The Parents, The Anti-Drug campaign ignores many important avenues for prescription drug acquisition. Furthermore, this ad campaign does little to target the individuals who are actually at risk - America’s youth.
Considering the wide range of viewers who tune in for the one of the biggest sporting events of the year, it seems misguided, and a foolish waste of money to market this Parents, The Anti-Drug campaign during the Super Bowl. If the PDFA wanted to specifically target parents, they should choose alternative timeslots, such as late night television shows or ten or eleven o’clock news broadcasts. To children, these ads function in few other ways than to reinforce the availability of prescription drugs in their household.
Not only should the age of the intended viewers be carefully considered, but the specific population finely focused and understood on multiple levels as well. In his article examining the effectiveness of anti-drug PSA’s, Dr. Martin Fishbein emphasizes the importance of recognizing that, “beliefs may be important determinants of attitudes, perceived norms, or self-efficacy in one population may be unimportant in another….for any behavioral change to be effective, it is first necessary to understand the factors underlying the behavior in the population in question” (13).
The PDFA has indeed fallen short in utilizing Social Marketing Theory to sell their ideas. Despite engaging in straightforward qualitative research to see if potential target audiences, “understand” or “like” a particular PSA, one study stated that of the 30 PDFA-developed PSA’s they reviewed, none were subjected to experimental evaluation before being broadcast (13). Not surprisingly, this study, which collected data from 3608 students, grades five through twelve showed, demonstrated great variability in the perceived effectiveness of 30 PSA’s developed by the PDFA. To prevent possible negative impacts of these PSAs, the authors stress the importance of critically evaluating effectiveness in addition to more traditional, empirical research (14).
Perspective can also be critical to identifying with a target audience. In a study published in 2006, investigators found that among current smokers who were subjected to anti-smoking campaigns, “denial, defensiveness, and rationalizations get in the way of sincere contemplation of a healthier lifestyle” (15). They highlight the weakness of a reliance on nonsmokers to develop their campaign, who may have difficulty creating resounding messages which truly understand the smokers’ perspective.
Finally, this ad campaign narrowly focuses on one means of acquiring prescription drugs, while largely ignoring other avenues, such as online sales, their own prescriptions, and the college network. The internet sale of prescription drugs, in particular, has risen sharply in recent years (12).

In Conclusion
The PDFA has a difficult task on their hands. They must stress to parents the importance of developing positive socialization in their child’s formative years which may lead to drug free social networks in adolescents. They must also effectively target their desired market, with specific instructions. Meanwhile, they must be careful to remain sensitive to the needs and wants of America’s youth as they mature in the complicated interdependent social networks which characterize the often fragile, and tumultuous adolescent years.
As the PDFA lessens their reliance on the health belief model, and looks toward alternative models, they may reach more individuals and help make positive change for America’s youth.

References

1) Parents. The Anti Drug. Rockville, MD. Natinoal Youth Anti-Drug Media Campaign. http://www.theantidrug.com/drug_info/prescription_tips.asp
2) Stephenson, Michael, Quick, Brian.Parent Ads in the National Youth Anti-Drug Media Campaign. Journal of Health Communication, 10:701-710, 2005
3) McCarthy, M. Prescription Drug Use Up Sharply in the USA. The Lancet. Volume 369 , Issue 9572 , Pages 1505 - 1506
4) Hornick, Robert. Yanovitzky, Itzhak. Using Theory to Design Evaluations of Communication Campaigns: The Case of the National Youth Anti-Drug Media Campaign. Communication Theory. Thirteen: Two May 2003 Pages 204-224.
5) Miller-Day, Michelle. Talking to Youth About Drugs: What Do Late Adolescents Say About Parental Strategies? Family Relations, 57 (January 2008), 1–12.
6) Hornick, Robert. Personal Influence and the Effects of the National Youth Anti-Drug Campaign. The ANNALS of the American Academy of Political and Social Science 2006; 608; 282.
7) Manchlkantl, Laxmalah. National Drug Control Policy and Prescription Drug Abuse: Facts and Fallacies. Pain Physician 2007; 10:399-424
8) Forman, Robert F., Marlowe, Douglas B., Mclellan, Thomas A. The Internet as a source of drugs of abuse. Current Psychiatry Reports Volume 8, Number 5 / October, 2006. 377-382.
9) National Youth Anti-Drug Media Campaign Home Page. Office of National Health Control. http://www.mediacampaign.org/
10) George Bush President Library and Museum. College Station, TX. Texas A & M University. http://bushlibrary.tamu.edu/
11) Morgan, Et al. Associations Between Message Features and subjective evaluations of the Sensation Value of Antidrug Public Service Announcments. Journal of Communication, v53 n3 p512-26 Sep 2003
12) Robert F. Forman, Douglas B. Marlowe and A. Thomas McLellan. The internet as a source of drugs of abuse. Current Psychiatry Reports. Volume; 377-382.
13) Fishbein, M, et al. Avoiding the boomerang: Testing the relative effectiveness of antidrug public service announcements before a national campaign AMERICAN JOURNAL OF PUBLIC HEALTH Volume: 92 Issue: 2 Pages: 238-245
14) Partnership for a drug free America. Advertising Educational Foundation. http://www.aef.com/exhibits/social_responsibility/pdfa/2420
15) Wolburg, Joyce M. College student’s responses to antismoking message: Denial, Defiance, and other boomerang effects. ,” Journal of Consumer Affairs, 40 (2), 293-323. 2006
16) Witte, Kim; Allen, M A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns.. Health Educ Behav 2000; 27; 591.
17) de Meyrick, Julian. Forget the ``blood and gore'': an alternative message strategy to help adolescents avoid cigarette smoking. Health Education
Volume 101 . Number 3 . 2001 . pp. 99±107
18) Aaker, J.L. et al. (1997), ``The effect of cultural orientation
on persuasion'', Journal of Consumer Research, Vol. 24, pp. 315-28

Breast Cancer Screening: Public Health Is Failing To Use Mammography To Reach All Women Equally – Alicia Agnoli

2008-04-24T06:04:00.000-07:00

A body of evidence indicates that a significant proportion of breast cancer deaths can be prevented through effective screening (1, 2). Under this rationale, breast cancer screening via mammography has become an important and widespread practice, and even an explicit public health policy (1). In fact, all major United States Medical organizations expressly recommend mammography screening for women of 40 years or older (3). However, despite both the proven efficacy and widespread endorsement of mammography, rates of screening continue to be substantially lower among minority women and women of low socioeconomic status (4, 5).

The significant disparities in rates of screening across certain demographic categories indicate that, in its current form, mammography-centered screening is not being optimally utilized by the field of public health. Public Health has failed to sufficiently employ the tool of mammography among all women because it does not account for key factors that directly affect the likelihood of participation among certain women. This critique will highlight three specific factors that the field of public health must consider in order to lessen the ethnic and socioeconomic disparities in rates of breast cancer screening.

Public Health has not adequately examined the psychological and psychosocial factors that influence an individual’s screening behavior.
Many psychological factors, including fear and anxiety, directly influence an individual’s decision to participate in breast cancer screening. However, these factors are not adequately incorporated in the current implementation of the public health approach. Stress and health awareness disparities associated with age, SES, marital status, and ethnicity need to be examined in correlation with screening behaviors. Doing so would allow the field to better understand specific causal factors underlying trends in individual health decisions and to most precisely identify areas and strategies for intervention. One study found that vast differences in styles of emotional regulation may exist across ethnic groups, which can have an important implication on screening behavior (2). Another study cited specifically Hispanic women and the plausible correlation between larger average tumor size, poor screening rates, and documented “fatalistic view of disease” (6). These studies both underscore the important and often culturally-specific connection between women’s emotional influences and mammography choices.

By failing to examine the multitude of psychological and psychosocial factors at play for women, the field of public health is missing a critical point of understanding why certain groups of women are more or less likely to participate in breast cancer screening. Effective interventions must incorporate an understanding of these factors, and particularly the ways in which they affect the health decisions of specific demographic groups.

Public Health has not sufficiently educated physicians in cultural competency so as to reduce the effects of disparities in practitioner screening recommendations.
Though breast cancer awareness is at a cultural high, evidence shows that women’s screening behaviors are most directly influenced by the advice of their healthcare providers. In fact, women who receive a recommendation for a breast cancer screening from a healthcare provider are far more likely than those who do not to undergo mammography (7). However, the research indicating this positive correlation also reveals distinct trends in physician recommendations for mammograms. Studies conducted by O’Malley et al revealed that identified “vulnerable women” (i.e. older, lower SES, lower educational attainment) received significantly fewer recommendations for mammography (8). In subsequent investigation, the group found that recognition of social stigmas was largely responsible for the low rate of recommendations given to vulnerable women, citing physician concerns about these groups’ inability to afford the services and a lack of confidence in their compliance (7).

The existing public health approach has failed to adequately scrutinize these patterns of physician recommendations regarding breast cancer prevention. In doing so, the field of public health has overlooked a pivotal causal factor in disparate rates of screening participation. With a better understanding of recommending practices, the field of public health would be able to better tailor practitioner-level interventions so as to overcome the disparities in the resultant screening behaviors of certain demographic groups. Public health has an obligation to educate physicians in cultural competency so as to overcome social stigmas and mitigate the inherent bias seen in the recommending practices towards vulnerable populations.

The field of public health has not made low-cost alternative screening options sufficiently available and well-publicized to the women who need them.
Despite the progress made to provide financially-sensitive screening alternatives (e.g.. free and subsidized mammography clinics, mobile screening vans) to women who need them, many barriers to access still prevent women from participating in breast cancer screening who otherwise would. Mammography alone can seem prohibitively costly and otherwise inaccessible for many women, especially among women who are uninsured or under-insured. The current public health approach does not sufficiently include efforts to overcome such perceived financial barriers. In light of abundant evidence indicating the negative correlation between low socioeconomic status and mammography participation (5, 7), the field must make a more comprehensive effort to overcome these apparent issues of access experienced by medically underserved women. In one study, researchers found that economic barriers were directly correlated with decreased mammography use. These barriers were associated with a perceived high cost of the screening technology and low awareness of accessible public services (5).

In addition to the lack of awareness of low-cost mammography options among the women who need them, public health has failed to adequately provide medically underserved women with alternatives to mammography. The current USPSTF recommendations for breast cancer screening did not include an explicit recommendation for routine breast self-examination (BSE), citing "insufficient evidence" (1). This practice should be incorporated into the options presented to those women at risk for not obtaining routine mammography. Low income women need to be adequately and consistently educated in how to do the BSE. Public health has a two-fold responsibility to vulnerable women to raise awareness about breast cancer screening options and to make these options more accessible.

Conclusion:
The issue with mammography-centered breast cancer screening does not lie in the efficacy of the tool; indeed, it is impressively successful in preventing breast cancer mortality and morbidity (3). The issue, rather, lies with the failure of public health to employ this tool to its fullest potential so as to screen all groups of women sufficiently. To do so, public health needs to thoroughly understand the reasons why certain groups of women—those of low SES and minority status—do not undergo mammography screening as often as other women. The key factors of psychosocial inhibitions, the differential recommending practices of physicians, and insufficient access to affordable screening options need to be better examined and incorporated into the strategies of breast cancer screening implementation.

REFERENCES
1. U.S. Preventive Services Task Force (USPSTF). Screening for Breast Cancer : Recommendations and Rationale. Available at: URL: http://www.ahrq.gov/clinic/3rduspstf/breastcancer/brcanrr.htm.
2. Consedine NS, Magai C, Krivoshekova YS, Ryzewicz LR, Neugut AI. 2003. Fear, Anxiety, Worry, and Breast Cancer Screening Behavior: A Critical Review. Cancer Epidemiology, Biomarkers & Prevention [Internet]. 2004 April; 13(4):501-510. Available from: URL: http://www.departments.dsu.edu/library/sctc303/cse.htm
3. Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for Breast Cancer. JAMA [Internet]. 2005 March 9; 293(10):1245-1256. Available from: URL: http://jama.ama-assn.org/cgi/content/full/293/10/1245.
4. Marbella AM, Layde PM. Racial Trends in Age-Specific Breast Cancer Mortality Rates in US Women. Am J Public Health [Internet]. 2001 January; 91(1):118-121. Available from: URL: http://www.ajph.org/cgi/reprint/91/1/118?ck=nck.
5. Coughlin SS, King J, Richards TB, Ekwueme DU Breast Cancer Screening and Socioeconomic Status --- 35 Metropolitan Areas, 2000 and 2002. MMRW [serial online] 2005 October 7; 54(39):981-985. Available from: URL: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5439a2.htm.
6. Hedeen AN, White E. Breast Cancer Size and Stage in Hispanic American Women, by Birthplace: 1992-1995. Am J Public Health [Internet]. 2001 January; 91(1):122-125. Available from: URL: http://www.ajph.org/cgi/reprint/91/1/122.pdf.
7. O’Malley MS, Earp JA, Hawley ST, Schell MJ, Mathews HF, Mitchell J. The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: Who gets the message about breast cancer screening? Am J Public Health [Internet]. 2001 January; 91(1):49-54. Available from: URL: http://www.ajph.org/cgi/content/abstract/91/1/49.
8. O’Malley MS, Earp JA, Harris RP. Race and Mammography Use in Two North Carolina Counties. Am J Publich Health [Internet]. 1997 May; 87(5):782-786. Available from: URL: http://www.ajph.org/cgi/reprint/87/5/782.
9. McCoy CB, Pereyra M, Metsch LR, Collado-Mesa F, Messiah SE, Sears S. A community-based breast cancer screening program for medically underserved women: Its effect on disease stage at diagnosis and on hazard of death. Rev Panam Salud Publica[Internet]. 2004;15(3):160-7. Available at: URL: http://journal.paho.org/?a_ID=483#aff_1.
10. Whitman S, Ansell D, Lacey L, Chen EH, Ebie N, Dell J, Phillips CW. Patterns of Breast and Cervical Cancer Screening at Three Public Health Centers in an Inner-City Urban Area. Am J Public Health [Internet]. 1991 December; 81(12): 1651–1653. Available from: URL: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1405273&blobtype=pdf.
11. Lostao L, Joiner TE, Pettit JW, Chorot P, Sandin B. Health beliefs and illness attitudes as predictors of breast cancer screening attendance. Euro J Public Health [Internet]. 2001; 11(3):274-279. Available from: URL: http://eurpub.oxfordjournals.org/cgi/reprint/11/3/274.

National School Lunch Program Doesn’t Make the Grade: Why America’s Children are Obese- Jayme Lerner

2008-04-23T17:16:00.000-07:00

Over the past decade, childhood obesity has increased significantly. Degree of obesity is commonly assessed through body mass index (BMI), a ratio of weight to height (1). A BMI of 25-29.9 is classified as overweight, 30 as obese with greater then 40 indicative of morbid obesity (1). According to the National Health and Nutrition Examination Survey (NHANES), in the 2003-2004 year, 17.1% of United States children and adolescents were overweight and 32.3% of adults were obese (2). Between 1999-2000 and 2003-2004, an increase in overweight children and adolescents rose from 13.8% to 16.0% in females and 14.0% to 18.2% in males (2). The more prevalent overweight and obesity occurs is in childhood and adolescent years, the higher risk of being overweight and obese is in adulthood.
In the past, health related complications of obesity were common only in adults, but now has been found in staggering numbers in children. Obesity is a multisystem disease, affecting psychological, neurological, pulmonary, cardiovascular, gastrointestinal, renal, musculoskeletal and endocrine systems (3, 4). The most prevalent complications include depression, sleep apnea, asthma, exercise intolerance, hypertension, atherosclerosis, dislipidemia, chronic inflammation, and type 2 diabetes mellitus (4). Each condition may have been avoided through weight loss, exercise and healthy eating (1).
The National School Lunch Program (NSLP) began in 1946 as part of the National School Lunch Act to ensure the health of children in the United States (5, 6). NSLP is a federally assisted meal program with the aim of providing nutritionally balanced, low-cost or free lunches to children in public, non-profit private schools and residential child care institutions. Individual school boards must apply to their state education agency to establish the program. Each district receives a cash subsidy and donated commodities from the United States Department of Agriculture for each meal served (5). In 1998, NSLP was expanded to include reimbursement for snacks served during after school educational programs (6). The number of participating children has grown from 7.1 million in 1946 to upwards of 30.1 million (5).
To combat the widespread epidemic of childhood obesity, Healthy People 2010 aims to decrease the proportion of youth who are overweight and obese (3). A specific objective is to increase the proportion of children and adolescents aged 6-19, whose intake of meals and snacks at school contributes proportionally to good overall dietary quality (7). The National School Lunch Program’s approach to resolving childhood malnutrition and obesity ignores pertinent aspects involved in combating this widespread epidemic. These faults are centered around includes low participation rates, competition, poor regulations, and deficient nutrition and physical education.
Low Participation Rates
The National School Lunch Program (NSLP) is available in all 50 states as well as the District of Columbia, Guam, Mariana Islands, Puerto Rico and Samoa (8).Even though the NSLP is available to all students, not all school districts partake in this program. Only 14,000 of 99,500 districts participated in 2006 (9, 10). Delaware, with a total of 34 school districts has only 19 participating. Nevada is one of the only states that have all 17 districts participating (9, 10). Participation is the highest in elementary schools at 67%, and lowest in high schools, 39% (12). Due to these low participation rates, the number of children and families taking advantage of the National School Lunch Program is extremely limited.
While a total of 30.1 million children participate in the National School Lunch Program, according to 2005-2006 school year data, there are strict eligibility requirements. Eligibility is contingent upon on household income levels and federal poverty lines (6). If a family currently receives Food Stamps, Temporary Assistance for Needy Families (TANF), participates in the Food Distribution Program on Indian Reservations (FDPIR) or if a child is homeless, runaway or migrant, they are automatically entitled to free meals (6). In these instances, the school works directly with the State to ensure families are aware that their children can receive free meals (6). A child whose family income falls below 130% of federal poverty level, $26,845 for a family of four, is eligible for free meals. In these situations, the school does not work in conjunction with the State to offer the program (11). Incomes higher then 185%, $38,203 for a family of four, must pay full price for meals (5, 6). Incomes falling between 130 and 185 % receive reduced fare lunches (5, 6). For those receiving free meals, participation reaches 80% while reduced priced meals and full price meals have lower rates of 69 and 48% respectively (12). Even though there are a high number of students receiving free lunches, there are low participation rates for the other meals. Coupled with the lack of participation throughout the United States, many students are no receiving the entitled meals, thus not improving the overall health status of children. In addition, some families feel that income and financial status is something that should be kept confidential, and because of this do not ask for help even though it is needed. The majority of families are left alone to determine their eligibility for NSLP. Since many may not be aware that such programs exist, or know how to start their children in the program, participation for reduced and full price meals is low.
There are potential additional reasons why children and adolescents who are eligible to receive meals are not participating in the program. According to public health theories, social norms and social networking theory have significant implications for people. Social norms are expected codes of behaviors set forth by and experienced by a group or culture (17). These codes are guidelines for how to behave, including the unspoken standards about what are “normal” and acceptable behaviors (17). Similarly, social networking theory assumes that depending on the social network someone belongs to, behaviors are influenced to conform to the group (17). If eating school provided meals is not something that is socially acceptable, NSLP participation rates will be low. Those who must pay the full price or reduced fares have the lowest participation rates compared to those receiving free meals. Students who can afford other foods may find it more socially acceptable to purchase foods from other sources. This may be the reason for why on a typical day only 17.7 million students are taking advantage even though 30.1 million are eligible (6).
Competitive Forces & the Lack of Regulation
The National School Lunch Program has narrow regulations on what foods can and cannot be served as lunches. The United States Department of Agriculture (USDA) sets the standards for nutrition guidelines found in school lunches. The target goal is for lunches to meet the recommendations of the Dietary Guidelines for Americas, with no more then 30% of calories from fat, and less than 10% from saturated fat. It is also suggested that lunches provide one third of the Recommended Dietary Allowances (RDA) for protein, vitamin A, vitamin C, iron, calcium, and total calories (5). In the 2004-2005 school years, around 15% of schools served lunches that did not meet the RDA standards, and 2/3 of schools served lunches that did not meet the standards for total fat and saturated fat (14). On average, lunches contained 34% of calories from fat and 11% of calories from saturated fat, missing the target goals (14). When evaluating elementary students’ nutrient intake composition, there was no difference between those who participate and those who do not, proving the ineffectiveness of the program (14). Even though each school must meet these requirements, they are at liberty to select the foods and preparation methods for each (5).
Although schools can select preparation methods, the USDA has some guidelines. It is required that schools follow one of two procedures. They must either offer five food items selected from four food types: fluid milk, meat or meat alternatives, at least one serving of grain, and two or more servings of fruit, vegetables or both, or determine foods based on weekly nutrient composition of meals (12). Requirements for fruits and vegetables are not specified. Similarly, there is no restriction for high calorie energy dense items such as cookies and cakes that are served with lunches (12). With these lax regulations, there is a wide variety of food types that can be served.
The National School Lunch Program has narrow restrictions on competitive foods found in and around schools. Competitive foods include a la carte foods and beverages, foods sold as fundraising efforts, vending machines, snacks in classrooms and those made available during after-school activities (12). Foods of low nutrient density that are high in calories are sold in competition to school meals through vending machines, school stores and off campus locations when students are allowed to leave school property (12). Fundraisers focused on food and beverage sales in 37% of elementary schools and 50 to 60% of middle and high schools included foods of minimal nutritional value (14). Although vending machines are sometimes located away from cafeterias, they are still are available in 17% of elementary schools, 82% of middle schools and 97% of high schools (14). In a study of 20 Minnesota schools, on average there were 11 vending machines in each school (12). Since there are no strict guidelines for hours of operation of competitive foods they are readily available.
With the high prevalence of competition, some states have enacted their own set of guidelines in addition to those set forth by the USDA. In Florida, competitive foods are not allowed in elementary schools, and are not available until one hour following the last lunch period in secondary schools. The sale of carbonated beverages is allowed at all times in high schools permitting there are 100% fruit juices available at each location (8). In Virginia, coffee and tea can not be sold to students regardless of the time of day (8). Even with these additional recommendations, foods of low quality are allowed for consumption and compete with school served lunches.
Additionally, the National School Lunch Program has no guidelines regarding portion sizes that are served to students. When there are no standards for portion control, even if a food is deemed to be “healthy”, in large quantities it may not be. Over the past 20 years, portion sizes for the majority of foods have increased significantly (15). This growing trend is one of the main reasons for the rise in obesity, since energy intake is exceeding energy expenditure (15). It would be virtually impossible to monitor each child’s eating behavior, but not having standard portions exacerbates the problem of obesity in children and adolescents.
Lack of Nutrition and Physical Education
While the National School Lunch Program aims to increase the proportion of healthy foods served at lunch to increase child and adolescent health, there is no simultaneous discussion of nutrition education. Food choices are influenced by the total environment, not just the availability of foods. Nutrition education is not something that is mandatory for each state. 69% of states require health education curricula to include nutrition and dietary behaviors (13). In a 2000 survey, 75% of health courses included lessons on nutritional and dietary behavior (12). On average, a total of 5 hours per academic year is spent on topics of nutrition and diet (12). In comparison to time spent on traditional subjects, these 5 hours are not enough to educate students on making the necessary changes. Additionally, many school districts do not require all grades to have health education classes. Some schools offer health education every other year. With the extreme lack of nutrition education, children are not learning about the c0responding health benefits of making these choices. The availability of healthy foods such as fruits and vegetables is not enough to prompt children to choose them especially when competition is available (12). For dietary changes to take place, it is essential to educate children and adolescents about the benefits of making dietary changes, and how to do so properly.
It is also vital that children participate in physical activity. Physical education (PE) is required by law, but there are no requirements on the nature and duration of classes (12). Physical education is mandated in 36 states for elementary school students, 33 states and 42 states for middle school and high school respectively (13). A 2000 School Health Policy and Programs Study (SHPPS) found that typical PE classes, lasted on average 45 minutes. Students spent an average of 15.3 minutes participating in games, sports or dance and 9.6 minutes on skill drills (13). In a typical 30 minute elementary school PE class, the average child was vigorously active for only two to three minutes of class time (13). In 2006, SHPPS found that 69% of elementary schools, 84% of middle schools, and 95% of high school required physical education. Students were exempt from gym if they participate in community service activities, community sport activities, band or chorus (16). At the same time, only 62% of states require physical activity and fitness education in health curriculums (13). In 2000, 69% of health courses addressed physical activity and fitness, averaging a total of 4 hours per year (12). With the lack of physical education students are not getting the activity necessary for optimal health.
The National School Lunch Program (NSLP) focuses only on what children consume for lunch in schools as a means of promoting good health. Since this program only focuses on school lunches, there is a large divide between what children and adolescents consume at school versus elsewhere. Parents and caregivers are often unaware their children are obese or at risk for obesity (13). When families are not aware of the risks of being overweight, the benefits of consuming nutritionally balanced meals and performing physical activity there are barriers to combating the obesity epidemic. If parents become aware of the consequences of poor health on their children, some may make the effort to increase healthful behaviors at home.
Associated with the lack of family education, NSLP lacks family involvement and encouragement which are vital components of children being healthy. Parents are the ones doing the food shopping, preparation or purchasing of meals, for the majority of children. It has been found that teens who eat meals with their families more frequently, or who assist in preparation of meals report higher intakes of fruits, vegetables, grains and essential nutrients (13). There are also lower intakes of sweetened soft drinks and dietary fat and are at lower risk for developing eating disorders (13). Even though 30% of meals are consumed outside the home, what children see and experience on a daily basis influences choices, as evident in these findings (1). Social learning theory explains the idea that people acquire behaviors through observation or vicarious learning (17). While people are not necessarily cognizant of this, the behaviors modeled are subconsciously acquired and put into practice. Parents and peers are two of the most prominent people modeled after. Children are picking up behaviors of their parents and caregivers. If a child is not exposed to healthy behaviors at a young age, when the majority of their time is spent with parents and caregivers, it is less likely that they will practice healthy behaviors on their own. This process occurs throughout life for both positive and negative behaviors, but it is up to parents to start the positive behaviors early, and to reinforce those acquired throughout their children’s lives.
Implications & Conclusion
A multifaceted program that involves healthy eating, physical activity and support systems is the optimal method to ensure overall health for children and adolescents 13). Due to the lack of these attributes, the National School Lunch Program fails in its mission to increase the overall health and nutritional status of students. Not all schools participate and those that do have relatively low participation. With low participation rates many of the eligible students are not receiving their entitled lunches. Additionally, the lack of regulatory action against competitive foods and portion sizes further complicates the issue of obesity. Targets for nutritional composition are not being reached. There is lack of support and encouragement from family members and potentially other students as seen through public health theories that are being overlooked. In order for this program to fulfill its mission of bettering the health status of students it is necessary to alter the approaches taken. Increasing participation rates, creating strict regulations, increasing health and physical education, and generating family education programs to increase involvement are necessary to make the National School Lunch Program efficient in promoting good overall health for students and decreasing the high rates of childhood obesity.
References
1. Mahan, L.K, Escott-Stump, S. Krause’s Food, Nutrition, & Diet Therapy. Philadelphia, PA: Elsevier, 2004
2. Ogden, C. et al, Prevalence of Overweight and Obesity in the United States, 1999-2004. Journal of American Medical Association, 2006; 295; 1549-1555.
3. Kreipe, R. Adolescent Health and Youth Development: Turning Social Policy into Public Health Practice. Journal of Public Health Management and Practice 2006; S4-S8
4. Ebbeling, C. Pawlak, D. Ludwig, D. Childhood Obesity: Public Health Crisis, Common Sense Cure. The Lancet 2002; 360: 473-482
5. Food and Nutrition Services. National School Lunch Program. United States Department of Agriculture
6. Food Research and Action Center. National School Lunch Program. Food and Research Action Center, 2008
7. United States Department of Agriculture. National School Lunch Program/School Breakfast Program: Foods of Minimal Nutritional Value. 2001. http://www.fns.usda.gov/cnd/lunch/CompetitiveFoods/fmnv.pdf
8. American Dietetic Association. Competitive Food Policies by State- A Report to Congress. Washington, D.C: American Dietetic Association. http://www.fns.usda.gov/cnd/lunch/
9. LaFaive, M.D. A School Privatization Primer. Michigan: Mackinac Center, 2006
10. Great Schools. List of School Districts. San Francisco, California: Great Schools http://www.greatschools.net
11. American Dietetic Association. Income Eligibility Requirements. Washington, D.C; American Dietetic Association. http://www.fns.usda.gov/cnd/governance/notices/iegs/iegs.htm
12. Koplan, J. Liverman, C. Kraak, V. Preventing Childhood Obesity: Health in the Balance. 2005.
13. Progress in Preventing Childhood Obesity: How Do We Measure Up?
Authors- Committee on Progress in Preventing Childhood Obesity
14. Food and Nutrition Service. School Nutrition Dietary Assessment Study- III, Summary of Findings. Washington, D.C; United States Department of Agriculture http://www.fns.usda.gov/oane/menu/Published/CNP/FILES/SNDAIII-SummaryofFindings.pdf
15. Smicikilas-Wright, H et al. Foods Commonly Eaten in the United States. 1989-1991 and 1994-1996: Are Portion Sizes Changing? Journal of the American Dietetic Association. 2003, 103:41-47
16. Centers for Disease Control. School Health Policies and Program Studies. Washington, DC Centers for Disease Control: http://www.cdc.gov/HealthyYouth/shpps/2006/factsheets/pdf/FS_PhysicalEducation_SHPPS2006.pdf
17. Edberg, M. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Sudbury, Massachusetts: Jones and Bartlett Publishers, 2007

Revising the Mpowerment Project: Critical Suggestions to Improve the Effectiveness of One of the Best HIV Prevention Programs- Nicholas Deputy

2008-04-23T17:14:00.000-07:00

Over half a million people have died from the acquired immunodeficiency syndrome (AIDS) in the United States since the epidemic began in the early 1980s (2). Homosexuals were often targeted as the cause of the disease, but were also the first activist groups to prevent the disease from spreading (1). The prevention programs that they created were aimed at educating and spreading awareness about the severity of the human immunodeficiency virus (HIV) that causes AIDS (1). These interventions grew to incorporate town and city centers where men who have sex with men (MSM) can go to get HIV testing and to join a support group. These centers also provided the standard information to promote a healthy lifestyle that incorporates safe sex. While these resources are essential to an effective intervention, real progress wasn’t made until the Mpowerment Project and other similar programs were put into place in the 1990s (9). This program has had a lot of success in reducing the numbers of new HIV cases diagnosed by using a diffusion of innovations model (22). Using this technique, the Mpowerment Project attempts to change social norms through social outreach events and education on HIV prevention (9). Informal outreach goals are also incorporated into this program, which include casual conversations about safe sex among friends and acquaintances in order to promote safe sex as a norm (8,9). Community centers were also established, as in traditional interventions, to form a community where young MSM can congregate for social, educational, and recreational events (9).
While the Mpowerment Project and other similar programs have had a lot of success, the incidence of HIV and AIDS has been increasing in the past several years (1,3). Between 2001 and 2005, there has been a 13% increase in new cases, which is thought to be due to unsafe sex practices in MSM (7). Many of these cases have been found to be in young MSM, which indicates a failure of the Mpowerment Program to create an effective prevention program (3,7). This failure revolves around the perceived threat of HIV and AIDS by young MSM, social considerations for the target population, and who is specifically apart of the target population.
Many young MSM currently do not feel an immediate threat from HIV or AIDS (5). These men have grown up in a time where HIV has had a treatment available, and so they are unaware of how severe the disease can be (5,6). The Mpowerment Project does educate about HIV, but it doesn’t put the risks in terms of what young men value most. Young MSM in present day are also faced with more social stigmas than older MSM have not had to face. Stigmas such as homophobia and family acceptance pressure young MSM to be accepted by the general population. The pressure that these stigmas place on young MSM can often cause them to ignore safer sex practices in order to maintain discretion (13). The Mpowerment Project works to create a small safe community for MSM, but doesn’t attempt to change the social stigma that is present outside of that community. The Mpowerment Project also does not include minoritiy MSM in its target population, who are thought to be those most at risk of having unsafe sex (7). Despite the initial strength of the Mpowerment Project, its several failures could be corrected by putting a more proximal frame on HIV, by addressing social stigmas outside of its own community, and by working to include minorities who are at most risk.

The Importance of a Frame
For any public health intervention, a frame is created regardless of whether public health officials consciously spent time creating one. A frame is described as a conceptual base that is used by the mind to help understand a notion (11). Anytime a word, image, event or anything else is perceived by the mind, it begins to create a frame so it can understand the perception and what it is referring to (17). In public health, framing is used to create context around an issue in order to make the intervention more appealing. For example, creating an underlying deception frame around smoking can make teenagers feel that smoking companies are deceiving them with advertisements. This underlying feeling will then cause teenagers to stop or not try smoking because they don’t want to be deceived (23). This kind of customized frame has been proven to make selling a product (public health, in this case) more effective (7,12).
AIDS in itself already has a frame associated with it, one that does not imply an immediate threat or convey the severity of the life threatening disease. The Mpowerment Project does not attempt to alter this frame or stress the threat associated with HIV. If the Mpowerment Project, in addition to attempting to normalize safe sex practices, adjusted the frame and made HIV seem more like a tangible threat, it would create a powerful message. This message would then discourage young MSM from engaging in unsafe sexual practices and make the Mpowerment Project more effective in reducing the incidence of HIV.
The impression that most young MSM have about HIV is that, while it is ultimately a deadly disease, most people are not affected by it (5,7). The advent of HAART, highly active antiretroviral dug treatment, has caused many young MSM to believe that HIV and AIDS is now a treatable disease (5, 6). Because of this misconception, they do not realize the importance of safe sex practices and sometimes decide to forego them (6,7). In order to counter this belief, the Mpowerment Project needs to reframe the issue in order to make it seem more relevant. Reframing issues are particularly effective when they involve an emotional aspect and such a frame could be created that depicts the harsh side effects of HIV/AIDS therapy (19). An example of this kind of frame could include images of young MSM having to take multiple medications a day, or the side effects of aggressive treatments. Another approach could include images of popular gay figures who have died from HIV and AIDS in order to remind young MSM that there is no cure for this virus. A new frame of this issue that incorporates the severe risks and images of popular loved ones who did not survive HIV and AIDS would discourage unsafe sexual activity. Including this new frame in the Mpowerment Project would make it a more effective intervention among young MSM.

The Impact of Social Stigma
The Mpowerment Project encourages the creation of a community within the program to create a sense of connection and belonging among young MSM(9). While this community is set up to provide a place that allows young MSM to be at ease with one another, the project does not address social factors that occur outside of this community. These social factors, which center around social stigmas, do not directly increase the risk of spreading HIV or AIDS, but cause young men at risk to not receive the intervention they need (14). Having to face these social stigmas is one of the largest challenges that MSM have to deal with, and this more distal, but equally important factor is not addressed by the Mpowerment Project (13). Several studies prove that the impact that social stigmas have on MSM hinder an individual’s participation in HIV/AIDS interventions, and thus increases their risk (13,14,15,20). Additionally, findings indicate dealing with stigma might lead to depression, poor self-esteem and in some cases cause a direct increase in risky behaviors (13). The Mpowerment Project does not address this issue, and thus does not address an important factor that contributes to an increase in HIV incidence.
Two of the most common stigmas that MSM must face are homophobia and family acceptance. Homophobia particularly affects MSM because an individual who knows that his community is afraid of him is in turn frightened of his community. Having a homophobic community can cause an individual to fear for his own safety and in order to any danger to himself from his community, he may hide the fact that he is a MSM. Hiding his sexuality makes it particularly difficult to then attend gay targeted outreach projects where the Mpowerment Project is working. This ultimately results in a MSM not receiving the intervention because of his community, and therefore puts him, and others in his situation at a higher risk of engaging in unsafe sexual practices. The family acceptance stigma is similar to that of homophobia. Most MSM believe that their family will not accept them if they admit to their sexual practices, and so they hide them. This prevents them from being able to be targeted by the Mpowerment Project, and therefore puts at higher chance of practicing unsafe sex.
In order to reduce the impact of these stigmas, the Mpowerment Project needs to not only target the homosexual community, but the whole community. Their campaign to raise awareness and normalize condom use should also attempt to encourage the acceptance of homosexuals. Once this is accomplished, individuals will be able to attend the interventions and begin changing their behavior. Through this addition to the Mpowerment Project, the program will increase its effectiveness and be able to decrease the incidence of HIV in young MSM.

Appropriate Targeting: Focusing on Minorities.
The Mpowerment Project has shown to have great success in all of the young MSM who were involved with it. Unfortunately, most of the participants involved were Caucasian (75% or more) and so minorities were not well represented (16). This disregard for minorities limits the Mpowerment Project’s ability to effectively change social norms in all young MSM. This neglect causes a large disparity between Caucasian young MSM and African American young MSM. In fact, it has been reported that approximately 3% of Caucasian young MSM are HIV positive, compared to approximately 14.1% of African Americans (14). This disparity could be treated if the Mpowerment Project targeted all young MSM, including minorities in its attempt to decrease HIV and AIDS incidence.
In order to effectively target these minority groups, considerations that affect non-minority MSM groups have to be considered, such as minority-specific stigmas, and different bar and club habits and locations. African American MSM have their own set of stigmas that impact their involvement. These stigmas are similar to those faced by the general majority, but are often more severe (20). Homophobia and sexual discussion in particular hold a stronger stigma in minority groups. As stated before, homophobia causes individuals to hide their sexuality, and therefore makes them unable to be apart of the Mpowerment Project. Because sexual discussion is also a strong stigma, there is even pressure in communities that are more accepting of homosexuality. In this kind of situation, no one talks about sexual activity, and so the major method of the Mpowerment Project is defeated because safe sex messages cannot spread.
In order to properly target minority groups, more research has to be done to investigate where minority MSM convene. These locations may not be similar to where majority MSM interventions can take place, such as in popular “main-stream” bars or clubs. When attempting to perform outreach in such a minority location, care has to be taken to not offend any of the different subculture. In order to make this transition easier, specifically recruiting minority persons could help to locate and understand potential minority outreach locations. By slowly accumulating minority MSM, attempts can be made to change the stigmas associated with being a MSM, as in the majority group. Doing this will make it easier for minority MSM, who are often the most in need of intervention, to participate in the Mpowerment Project and reduce the spread of HIV.

Conclusions
The goal of the Mpowerment Project is to reduce the transmission of HIV within the young MSM population by attempting to change social norms. This intervention has been very effective but has failed to consider changing trends in the MSM population that have begun to hinder the effectiveness of the program. Similar intervention programs have been criticized in the past for not altering techniques to accommodate new changes in culture (21). An intervention that does not recognize these changes and adapt to them slowly becomes ineffective. If the Mpowerment Project continues without adapting to these new trends it too will become ineffective and will not achieve its mission to decrease HIV incidence.
Adjusting current frames around HIV and AIDS, addressing stigmas, and beginning to target minority groups are all critiques that can be used to improve the Mpowerment Program. The use of framing theory has been proven to be effective in public health interventions as well as consumer marketing campaigns (11,18). Readjusting the frame around HIV will cause more young MSM to recognize the severity of HIV that was common during the beginning of the epidemic. Addressing stigmas will target a more distal cause of unsafe sex in the MSM community: it will allow MSM to feel comfortable with their sexuality and make them easier to target through the Mpowerment Project. Targeting minorities is also essential so that the subgroup most at risk will get the attention it needs to combat the high rates of unsafe sexual practices. Incorporating these suggested strategies will address the new concern about the increase in HIV incidence in young people. These new strategies provide a fresh look at the intervention that has been very successful so far, and will allow it to continue to be successful in the future.

Reference:
1.) Wolitski, et al. Evolution of HIV/AIDS Prevention Programs --- United States, 1981—2006. Morbidity and Mortality Weekly Report June 2, 2006 / 55(21);597-603
2.) Centers for Disease Control and Prevention. HIV AIDS Basic Statistics. Division of HIV/AIDS Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention http://www.cdc.gov/hiv/topics/surveillance/basic.htm
3.) No Author. “H.I.V. Rises Among Young Gay Men” The New York Times. Jan 14, 2007 http://www.nytimes.com/2008/01/14/opinion/14mon2.html?_r=2&oref=slogin&oref=slogin
4.) Crepaz, et al. Highly Active Antiretroviral Therapy and Sexual Risk Behavior. Journal of American Medical Association. 2004;292:224-236
5.) Chen, et al. Continuing Increases in Sexual Risk Behavior and Sexually Transmitted Diseases Among Men Who Have Sex with Men: San Francisco, Calif. 19990-2001. American Journal of Public Health. September 2002, Vol 92, No. 9. 1387-1388
6.) Katz, et al. Impact of Highly Active Antiretroviral Treatment on HIV Seroincidence Among Men Who Have Sex With Men: San Francisco. American Journal of Public Health. March 2002, Vol 92, No. 3. 388-394
7.) Jaffe H, et al. The Reemerging HIV/AIDS Epidemic in Men Who Have Sex With Men. Journal of American Medical Association. 2007; 298(20): 2412-2414
8.) Center for AIDS Prevention Studies, University of California, SanFranciscoThe Mpowerment Project. San Francisco, CA. http://www.mpowerment.org/
9.) Hays, et al. The Mpowerment Project: Community Building With Young Gay and Bisexual Men to Prevent HIV. American Journal of Community Psychology. June 2003, Vol 31, Nos 3/4
10.) Coppola, et al. Preventing without stigmatizing: The complex stakes of information on AIDS. Patient Education and Counseling. Volume 67, Issue 3, August 2007, Pages 255-260
11.) Chua, K. Introduction to Framing. American Medical Student Association Website. February 10, 2006. http://www.amsa.org/uhc/FramingIntro.pdf
12.) Bakker AB. Persuasive Communication About AIDS Prevention: Need for Cognition Determines the Impact of Message Format. AIDS Education Prevention. 1999 Apr;11(2):150-62.
13.) Preston DB et al. The Relationship of Stigma to the Sexual Risk Behavior of Rural MSM. AIDS Education Prevention. 2007 Jun;19(3):218-30
14.) Frost DM, et al. Stigma, Concealment, and Symptoms of Depression as Explanations for STI Among Gay Men. Journal of Health Psychology. 2007 Jul;12(4):636-40
15.) Harawa NT, et al. Perceptions Toward Condom Use, Sexual Activity and HIV Disclosure Among HIV Positive African American Men Who Have Sex With Men, Implications for Heterosexual Transmission. Journal of Urban Health. 2006 Jul;83(4):682-94
16.) Kegeles SM, et al. Mobilizing Young Gay and Bisexual Men for HIV Prevention- A Two Community Study. AIDS. 1999 Sep 10;13(13):1753-62
17.) Valleroy, et al. HIV Prevalence and Associated Risks in Young Men who Have Sex. Journal of American Medical Association. 2000;284:198-204.
18.) Dorfman, et al. More Than a Message: Framing Public Health Advocacy to Change Corporate Practices. Health Education and Behavior. June 2005; Vol. 32(3): 320-336
19.) Professor Siegel
20.) Choi, et al. HIV Prevention Among Asian and Pacific Islander aMerican Men Who have Sex with Men: A critical Review of Theoretical Models and Directions for Future Research. AIDS Education Prevention 1998, Supplement A, 19-30.
21.) Stall, R. How to Lose the Fight Against AIDS Among Men. BMJ 1994 Sep 17;309(6956):685-6
22.) Centers for Disease Control and Prevention. The Mpowerment Project: A Community-Level HIV Prevention Intervention for Young Gay Men. Division of HIV/AIDS Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
http://www.cdc.gov/hiv/topics/prev_prog/rep/packages/mpower.htm
23,) Tengs, TO et al. The Cost Effectiveness of Intensive National School Based Anti-Tobacco Education: Results from the Tobacco Policy Model. Preventative Medicine. 2001 Dec; 33(6): 558-570.

The Shortcomings of Public Health in Promoting Nutrition to Fight Cancer - Jean Kim

2008-04-23T17:13:00.000-07:00

Cancer is one of the leading causes of death in the United States. Its widespread nature has led to the development of numerous public health campaigns all aimed at its defeat. However, current campaigns place a great emphasis on clinical intervention, failing to shed light on primary prevention of cancer. Dietary habits are increasingly being recognized through research as an important contributing factor to the disease. Not having an optimal diet may contribute to as much as 35% of all cancer cases (1). Even as this knowledge emerges, though, it is often overshadowed by messages to the public advocating only clinical therapies. Due to the focus on cancer from a clinical perspective, there is limited awareness of the link between nutrition and cancer due to a lack of effective promotional activities.
The Relationship between Nutrition and Cancer
Despite successful efforts in bringing cancer to the forefront of public health, there are gaps in approaches to cancer that must be addressed. Nutrition is crucial in aspects of cancer prevention, treatment, and cures. An individual’s diet can help establish his or her risk of developing the disease. Thus, it is imperative that the public is aware of dietary guidelines, as well as the importance of detecting suboptimal nutritional statuses. Subsequent intervention for any nutritional problems can be a significant factor in the prevention of cancer, as well as other diseases. Issues such as malnutrition, weight loss, and muscle wasting prior to diagnosis will only be worsened with treatment if they are not addressed first (2).
Nutritional status is directly correlated with a cancer patient’s response to treatment. Malnutrition can play a major role in the deaths of as much as 20% of patients. Additionally, malnutrition is shown to significantly decrease quality of life and the effect of treatment (3). A patient will become more susceptible to infections and less responsive to chemotherapy (1). However, performing nutritional assessments and addressing symptoms from both a clinical and nutritional perspective can restore weight in 50% to 88% of undernourished cancer patients (2). Some experts recommend that nutritional support be started when the patient loses at least 5% of his or her body weight, but even less weight loss can be detrimental. Nutritional guidelines should be given early in the diagnosis so that patients can make the appropriate dietary changes. These guidelines are crucial because they lay the foundation for preventing harmful fat and muscle loss associated with the disease (1).
The nutritional needs of those fighting cancer can be different from the general public. Many patients are told to “eat whatever they want,” but nutritional professionals now realize that advocating foods that support the immune system and overall good health is more beneficial. The key point is allowing the body to have the greatest advantage in fighting cancer. A lot of patients respond to ill advice or total lack of guidance by adopting diets or taking supplements that might have negative effects unbeknownst to them. This indicates the need for increased awareness of nutritional support and the application of reliable guidelines that people can assuredly rely on (1).
Food components that have been shown to help fight carcinogens include selenium, folate, carotenoids, and dietary fiber. Folate affects the cell cycle, which can influence the growth and survival of cancer cells. Additionally, certain food components have been shown to be beneficial in fighting more specific cancers. For example, greater ability to fight the disease is associated with lycopene and prostate, lung and stomach cancers (3).
In addition to those looking to prevent cancer and patients who are undergoing treatment, nutrition is important for those who are in remission. The key concept is that adopting a healthy diet will improve overall health, protect the body against other diseases, and help prevent future malignancies (2). Epidemiologic results show that reducing intake of red meat, animal fat, excess calories and alcohol, while increasing intake of fruit, vegetables, and fiber can help prevent cancer (1). Not only will the risk of cancer be reduced, but the dietary changes could increase overall health to decrease risk of other diseases.
The American Institute for Cancer Research supports research related to preventing cancer with nutritional support. It has provided guidelines and reports announcing the link between fat and cancer, and a list of foods and their relationship with cancer, among numerous other findings. People can access their resources and learn more about nutritional guidelines (5). However, this type of research remains in the dark for many individuals. They are unaware not only of the findings, but also of the research’s very existence. This unawareness can be attributed to the failure of public health in placing nutrition and cancer on the agenda.
Public Health and Medical Professionals Fail to Emphasize Nutrition
In order to make proper nutritional interventions possible, the cooperation of doctors, nurses, registered dietitians, and other healthcare professionals is necessary (2). However, currently more focus is placed on clinical oncology, which approaches cancer with surgery, radiotherapy, and chemotherapy. A cancerous tumor itself can cause problems with absorption of nutrients and digestion of food. Additionally, the clinical therapies can cause fatigue, nausea, vomiting, pain, diarrhea, constipation, and changes in appetite, all which can affect adequate oral intake of foods. Thus the patient is unable to tolerate usual foods, which leads to weight and muscle loss. Although adverse reactions to the treatments can cause suboptimal nutritional statuses in patients, oftentimes the medical team lacks competence in nutrition and cancer (1).
Oncologists are generally unqualified or untrained in identifying patients at risk for malnutrition, and lack knowledge in appropriate nutritional interventions (4). Hospital surveys reveal that nutritional screenings and assessments are not carried out on a routine basis (6). However, the debilitative nature of cancer should make nutritional assessment of patients a priority. Nutritional status can help indicate the strength of a patient in responding to treatment, and his or her ability to recover. Health professionals may recognize the importance of nutrition, but mere recognition is not enough. There is no requirement in medical training for professionals to have a background in nutrition. Insufficient training prohibits them from advocating preventive nutritional counseling to patients, and assessing for malnutrition (4). These findings highlight the fact that nutritional education must be distinguished as a priority for professionals across a range of health fields.
The same concept should apply to public health promotion strategies. The primary motto of major cancer campaigns is that early screening saves lives. Supporting this motto is focus placed on funding research to develop drugs for decreasing the incidence of breast cancer (8). The campaigns are placing the major cause of cancer incidence on lack of screening, or lack of medical prevention of the disease. No social factors are incorporated into the campaigns. Little focus is placed on primary prevention techniques, especially the self-efficacy of individuals with respect to modifying their diets. Individuals are fully capable of changing their lifestyle and behaviors to improve their health and possible outcomes with cancer. Most cancer patients would be willing to change their diets if that would mean a more positive result. If they had known of dietary guidelines in preventing cancer prior to their diagnosis, most would respond by saying they would have adopted the modifications. However, without proper promotion of nutrition, the public cannot put their self-efficacy to use. Instead, the current campaigns force them to look at cancer through only the aspect of medical screenings and treatment.
People are urged to receive mammograms starting as early as age 25, but there is much less encouragement of maintaining lifelong health through dietary changes. One such campaign that narrowly supports mainly clinical action is the Pink Ribbon Campaign for breast cancer (8). While it has been effective in increasing awareness and setting the agenda, it is being framed in a way that prevents full progress in fighting cancer.
Example of Flaws in Framing the Issue
The Pink Ribbon Campaign is framed largely around the concept that “early detection is the best protection.” Its successes are complicated by the fact that it does not acknowledge the need for reframing the breast cancer issue. The campaign calls upon different models from the social and behavioral sciences, including the agenda setting theory and advertising theory. It directly targets people’s core values of hope, survivorship, and courage. The pink ribbon itself acts as a symbol of the breast cancer movement, having been first handed out to cancer survivors by the Susan G. Komen Breast Cancer Foundation in 1990. Contributing to the movement’s success was the involvement of corporations including cosmetics companies such as Estee Lauder. The ribbons were distributed in stores across the U.S. Profits from the pink ribbon are to be donated to charities such as the Breast Cancer Research Fund (7).
Now, more products promoting the pink ribbon are being sold, including caps, t-shirts, etc. Thousands of women participate in functions such as Race for the Cure and other walks. There is no doubt that the pink ribbon has put breast cancer on the map, dispelling many of the social stigmas surrounding it and thus allowing affected women to open up about the issue. However, a major problem exists in that the federal funding for breast cancer research, which in recent years has increased to over $55o million, is not directed towards preventive strategies. Instead, research for more clinical therapies and clinical preventive techniques is being done (7).
Advocating early detection leaves the public with the impression that the major contributing factor to cancer is failure to receive a mammogram. The pink ribbon is still representative of setting the agenda for breast cancer, but further action against the disease has been long overdue. Most of the public is well aware of the need for screening, self-administered exams, and the progression of good treatment options. What they are much less aware of is how they can prevent malignancies through changes including dietary modifications. The role of physicians here is critical, as they can provide more personal recommendations, but public health campaigns themselves must also shift gears. The public and even patients, if their medical team is also unaware, often do not know where to go for reliable information on “cancer nutrition.”
The pink ribbon campaign does not address this issue. Leading breast cancer organizations, such as the Komen Foundation, are still making preventive research a low priority. In addition, the research that is carried out on prevention is related to pills for breast cancer, which may pose safety issues. Even while many medical advances have been made, the treatment options available to patients 35 years ago still remain to be surgery, radiation therapy, and chemotherapy (9). On the contrary, research on nutrition has been rapidly expanding. New findings such as the relation of soy and breast cancer, the positive effects of milk, and trends in total fat intake and breast cancer have emerged. A diet low in fat was found to help decrease breast cancer risk (10). Studies have also indicated that the consumption of alcohol may increase risk (11). Many other findings exist, but the public is largely unaware of them because most campaigns do not consider them high priority. In order to effectively incorporate preventive strategies, campaigns such as the pink ribbon must be reframed to focus on them.
Current Approach to Cancer Lacks Integration
Although the pink ribbon is one of the more widely publicized campaigns, most anti-cancer campaigns are less widely known. This is considerably due to the absence of effective marketing techniques, including the advertising theory. Health promotion agencies such as the National Cancer Institute spend much less on advertising than large corporations such as McDonald’s (12).
With less advertising promoting cancer prevention, it is even more difficult to reach a wider audience. In this case, public health needs to increase awareness among children, adults, healthcare professionals, and just the general public. However, a major missing link in the campaigns is an appropriate way to reach children. The most effective would be to counsel parents on nutrition, which would in turn affect their children (13). It is essential to broaden awareness among all people and begin prevention at an early age, which will decrease cancer incidence. Current approaches are mainly targeted towards an older audience, leaving adolescents in the dark about changes they can make to improve their health and future (14).
Existing public health interventions target cancer with either a rational-empirical or normative-reeducative approach, but fail to integrate a power-coercive approach. A combination of the three is necessary. Education and persuasion can help increase awareness through patient counseling and informing health care professionals. However, because behavior is largely influenced by social norms and other cultural factors, it can be difficult to apply actual changes with just promotion campaigns. With consideration of current nutrition research, government policies could be enforced in future years. This is an area that has not been touched on by anti-cancer campaigns. Legislation could help shift the nation’s diet towards more healthful options, thus promoting more optimal nutritional status (15).
Conclusion
As medical advances are continuously made, nutrition knowledge is also expanding. There is already adequate research to provide the basis for preventive strategies against cancer. However, the current state of public health campaigns addressing this issue does not evolve around prevention. Rather, campaigns are focused on early detection and other clinical therapies. This failure to reframe the cancer topic and incorporate a multidisciplinary approach acts as a barrier in preventing cancer. The key is to involve teams of healthcare professionals and combine different social theories and approaches to increase awareness among a wider audience.
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7. Fernandez SM. Pretty in Pink. Think Before You Pink- Breast Cancer Action.
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8. Ehrenreich, B. Welcome to Cancerland: A Mammogram Leads to a Cult of Pink Kitsch.Breast Cancer Action 2007.
9. King S. Pink Ribbons, Inc. University of Minnesota Press, 2006.
10. Liaw Y, Chen H et al. An international epidemiologic study of breast cancer mortality and total fat intake in postmenopausal women. Nutrition Research 2005; 25:823-834.
11. Harvard School of Public Health Nutrition Source. Alcohol. President and Fellow of Harvard College. http://www.hsph.harvard.edu /nutritionsource/alcohol.html.
12. Nestle M, Jacobson M. Halting the obesity epidemic: a public health policy approach. Public Health Rep 2000; 115: 12–24.
13. World Health Organization Regional Office for Europe. Health and Health
Behaviour among Young People: Health Behaviour in School-aged Children.
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14. Temple NJ, Balay-Karperien AL. Nutrition in Cancer Prevention: An Integrated Approach. Journal of the American College of Nutrition 2002; 21: 79-83.
15. World Health Organization Regional Office for Europe. The Adelaide
Recommendations: Healthy Public Policy. Geneva: WHO, 1988.

An Evaluation of the Implementation of the Department of Health & Human Services’ Breast Feeding Campaign’s Lack of Effectiveness—Victoria María Klyce

2008-04-23T14:10:00.001-07:00

Introduction
It is well documented that babies who are breastfed have lower morbidity and mortality rates than babies who are bottle-fed (1). The protective properties of breastfeeding are well understood. Breast milk contains a wide range of many biologically active compounds including cytokines, hormones, and enzymes that function in the maturation of a child’s immune system (1, 2, 3). Breast milk also transfers immediate protection against microbes from mother to child through the specific immune response via activation of antibodies and the non-specific immune response via activation of proteins, glycoproteins, and lipids. In an effort to increase breast feeding rates among women, in June 2004 the United States Department of Health and Human Services (DHHS) launched a nationwide campaign to increase exclusive breastfeeding for at least 6 months to 50% (4). The need for a breastfeeding promotion campaign is clear. In 1995, 59.7% of mothers initialized breastfeeding, and only 21.6% of mothers were breastfeeding at 6 months (5). In a randomized experimental study published in the Journal of Nutrition, babies in the exclusive breastfeeding group crawled sooner and were more likely to be walking at 12 months than infants in the group where formula supplemented breastfeeding (6). The DHHS website lists many benefits to breastfeeding, including easier digestion for the baby, and the baby being at lower risk of SIDS (in the first year of life), and Diabetes type I and type II, lymphoma, leukemia, Hodgkin’s disease, overweight and obesity, high cholesterol and asthma (4). Studies have also shown that breastfeeding helps the mother lose the weight gained during pregnancy (4, 6), as well as lowering the mother’s risk for ovarian and breast cancer, and lessening postpartum uterine bleeding (4). The DHHS Breastfeeding campaign used radio, video, and print to with the goal of increasing the percent of mothers exclusively breastfeeding for six months. However, due to incorrect source, audience, message, and destination of the intervention this campaign was not successful.

DHHS National Breastfeeding Campaign
The DHHS Breastfeeding campaign includes two video commercials, two radio spots, and four print ads. The video ads show women doing reckless behavior while pregnant, both finishing with the statement: “You wouldn’t take risks before your baby is born, why start after?” Both radio commercials are narrated by men telling women to breastfeed exclusively for six months. The print ads show images of dandelions, ice cream scoops, and otoscopes simulating breasts, and the bold words “Babies were born to be breastfed”. The three print ads with images state in small letters: “Breastfeed for six months. Help reduce your child’s risk for _______”, with varying ailments which correspond to the picture (i.e. obesity with ice cream) (4).

The DHHS campaign to promote exclusive breastfeeding has not been successful. Firstly, the campaign’s focus is inappropriate, having “Babies were born to be breasted” as the take-away tag line is not constructive to promote exclusive breastfeeding for six months. Secondly, it applies only the Health Belief model and Social Cognitive Theory, assuming that the only barriers to mothers breastfeeding are that they are ignorant of the severity and susceptibility their child will have for disease if they do not breastfeed, and that they lack self-efficacy, which is promoted through guilt. Both these assumptions are incorrect. Lastly, the campaign lacks an effective frame. The campaign needs to employ social science and alternative modeling methods in order to be effective, including Social Market Theory, Framing Theory, Social Expectations Theory, Advertising Theory, and Stigma Theory.

Initialization of Breastfeeding is Not the Right Message
The DHHS Breastfeeding intervention’s message of demanding women to initialize breastfeeding is misguided. Seventy-four percent of mothers breastfeed their babies immediately after birth, while only 30% are breastfeeding at three months and 22.3% are breastfeeding at six months (7). The fact that 26% of mothers do not initiate breastfeeding could be for a variety of reasons, such as maternal infection with HIV/AIDS, adoption, inability to produce milk, or baby allergy. Therefore, an intervention aimed at achieving that these 74% of mothers who initiate breastfeeding continue to do so exclusively for six months will have the more significant benefit to society. Furthermore, the DHHS study’s self-identified goal is not to increase initiation of breastfeeding to 100%, but to increase exclusive breastfeeding for six months to 50% (4). An effective campaign requires a proper message, and the DHHS campaign to promote exclusive breastfeeding for six months does not provide one. The take away catch phrase—babies were born to be breastfed—promotes breastfeeding initiation, not exclusive breastfeeding for six months. The facts are clear on that there is not a great need for a campaign to increase the initiation of breastfeeding.

The campaign needs to focus instead on who is not continuing to breastfeed and why. There is great variation in breastfeeding rates amongst sociodemographic characteristics. Only 19.8% of African American infants were breastfed for three months, compared to the national average of 30%. Young mothers breastfed for three months at a rate of 16.8%, and mothers with a high school education (22.9%) or less (23.9%) were also far less likely to breastfeed for three months. Only 18.8% of unmarried mothers who initiated breastfeeding continued to do so at three months, and rural mothers and mothers who were poor each had breastfeeding rates of 23.9% (7). These mothers chose to initiate breastfeeding, so one can infer that they see the value in breastfeeding but met an obstacle that disallowed them from continuing.

The DHHS campaign, which aims to persuade these women to continue to breastfeed through its media campaign, will not only fail to achieve this goal, but could have additional harmful effects. Stigma Theory tells us that an individual will live up to a label placed on him or her, or the primary group he or she identifies with (8). In this case, a woman who chose to initiate breastfeeding but was unable to continue will see the DHHS ads equating not exclusively breastfeeding for six months with risky, reckless behavior and be labeled as a “bad mom”. This will have two major consequences. The first is that she will think of herself as a bad mom, and Stigma Theory tells us she will be more likely to live up to that label. Secondly, she will feel judged by the public health campaign, and this will foster distrust and animosity toward health campaigns in general. This mother will now be harder to reach regarding childhood immunizations, cigarette smoking, fruit and vegetable consumption, et cetera.

Instead of stigmatizing mothers who do not continue to breastfeed with the current implementation, DHHS should instead widen their view of why half of mothers begin to breastfeed and stop before six months. The current campaign applies only the Health Belief Model and Social Cognitive Theory, assuming that the only barriers that impede a mother breastfeeding for six months are that she is unaware of the risks of not doing so and that she lacks the necessary self-efficacy to achieve it. These models are not appropriate to be the primary tools implemented in this intervention because there exist other more fundamental causes for the low rates of breastfeeding, which should be addressed with Social Expectation Theory.

Social Norms and Legislation are Barriers to Breastfeeding
Currently 21 states have laws decriminalizing breastfeeding—which leaves 29 states where breastfeeding is considered a lewd act (9). The barrier is thus not lack of assertiveness or ignorance on the mother’s part, but the social norms, values, and expectations of society, which are reflected and reinforced by the legislature, or lack or legislature. Most states do not require employers to allow mothers to breastfeed or pump while at work. Even those that do have exceptions, such as “if it is busy in the office” (10). These issues are of special importance to mothers who are poor and cannot take time off, single working mothers, and mothers with less education who work in hourly paid jobs.

States that do not count breastfeeding as a lewd act still do not create a culture accepting of breastfeeding. Missouri, for example, states that mothers must breastfeed "with as much discretion as possible". Thus, the language frames breastfeed as a necessary evil, a shameful procedure that should be minimized. Furthermore, the ambiguity of the language gives individuals the power to approach a breastfeeding mother and accuse her of not being discrete enough, and thus committing a lewd act (9).

In states where laws exist protecting breastfeeding they are not always honored. There have been high profile cases in many states where mothers were told to leave public and private establishments where they legally had the right to breastfeed (10). In the last month alone there have been many instances in the news of discrimination against breastfeeding mothers. In Vermont a woman, her husband, and their baby were removed from a plane when the mother declined the flight attendants demand that she cover her baby’s head with a blanket while breastfeeding. After waiting on the plane for nearly three hours due to delay, she had begun to breastfeed her daughter, sitting at her window seat, with her husband sitting beside her. She told the flight attendant that she was exercising her right to breastfeed her child, but was still forced off the plane in tears (11, 12). A woman in Maryland was sentenced to a night in jail and a $150 fine when she asked to postpone jury duty in order to breastfeed her 12 week old baby (13). In Texas a mother was kicked out of a hair salon in the middle of her haircut because she attempted to breastfeed her infant (14). Clearly, without changing the public’s attitude toward breastfeeding the rates of breastfeeding cannot increase.

The DHHS campaign does attempt to use Agenda Setting Theory to create awareness of the necessity of breastfeeding, however, store owners who ask a mother to breastfeed in the bathroom, or legislators who demand breastfeeding be “discreet” do not need more information on the list of diseases that breastfeeding can avert. What they need is a change in the culture of the United States. They need to be more comfortable with the image and presence of a breastfeeding mother. Posters with dandelions about asthma will not make a restaurant owner allow a woman to breastfeed in his store. He needs to fell assured that a woman breastfeeding will not disturb or offend the other patrons. He needs to consider it “socially acceptable”. The DHHS breastfeeding campaign does nothing to achieve this.

Lack of Imagery of Mothers, Babies, and Breastfeeding
The frame that the DHHS attempts to employ is not continuous across media types, with the exception that each includes the catch-phrase: Babies were born to be breastfed. The video frame is that not breastfeeding is reckless and irresponsible; and not doing so means a mother is knowingly and willingly disregarding her baby’s well being, The radio commercials both attempt to be creative through comic music spoofs, but both consist of the leading man telling the female back-up singers that if they don’t breastfeed they are bad mothers. The print ads list diseases that a baby who is not breastfed for six months is at higher risk for. Not one of these ads in any of the three medias portrays a mother breastfeeding. The radio commercial is not a woman talking about the joy of breastfeeding and how happy she is to do it. Not one of the two forms of visual media shows an image of a mother breastfeeding: in fact, none of them show babies at all. An effective frame should go for the heart, not discuss rational decision-making.

An appropriate frame should portray a mother breastfeeding as a beautiful, harmonious image. These images should be both displayed on billboards around town in print ads and shown in the video commercials. This would create a unifying feeling throughout the campaign and improve the public’s image and comfort with breastfeeding. When people see a mother breastfeeding in a café they will not associate the exposed breast with a lewd act, but with the warm feeling they experienced when they saw the breastfeeding campaign ad. Likewise, a woman who is breastfeeding will not feel awkward and apologetic, she will feel beautiful and the center of the world, like the women in the breastfeeding ads. Especially in a nationwide intervention targeting a diverse population on many levels, the DHHS should think carefully about what the takeaway message of the campaign will be. According to ABC news, America’s very low breastfeeding rate (the lowest of any industrialized country) could be due to Americans’ discomfort with the image of a breastfeeding woman (15)

Conclusions
The DHHS breastfeeding intervention is thus inappropriate because it fails at a number of points. McGuire’s Communication Persuasion Matrix lists the five pieces necessary in changing behavior: source, audience, channel, message, and destination (16). When we apply this matrix to the DHHS Breastfeeding campaign we can quickly see that the campaign’s failures are comprehensive. The source of the message is an omnipresent voiceover in the videos, a critical man in the radio commercials, and an unclear government entity in the print ads. As for the audience, the ads are directed at mothers and future mothers: “You wouldn’t take risks before your baby is born, why start after?” This targeting of mothers places all the burden of breastfeeding on the mother. The intervention attempts to use guilt to persuade mothers to breastfeed in the current climate and social norms (which are not accepting of breastfeeding) instead of targeting society as a whole. In order to increase rates of breastfeeding the DHHS would need to properly determine what the barriers are to breastfeeding and address those barriers. The channel—video commercials, radio commercials, and print ads—is appropriate because they reach mass audiences. The message is flawed in more than one way. The tag line, “Babies were born to be breastfed” is offensive in its judgment—it implies that if a woman is unable to breastfeed her child she is failing to provide her baby with a basic and essential human right. The tag line is also inefficient due to incorrect focus on initialization of breastfeeding. The second part of the DHHS message, that your baby will be at high risk for obesity, asthma, diarrhea, SIDS, and infectious disease if not breastfed, simply ads more guilt and stress to mothers who are already anxious due to lack of protective legislature and social norms supporting a breastfeeding mother. Lastly, the problem with the destination—the intervention’s intended and desired result—is tied closely to the problem with the target audience. The intervention’s destination is for mothers to choose to breastfeed. However, in a country with social and legislative barriers, like those present in the United States, this destination is not appropriate.

The need for an intervention to promote breastfeeding for six months nationwide is apparent due to the low rates of breastfeeding and the benefits of breastfeeding to baby, mother, and society. However, the Department of Health and Human Services’ breastfeeding campaign is not the needed intervention. The study achieved an increase in the public’s perception of the susceptibility of babies who are not breastfed to disease and the severity of that disease. However, after one year of the intervention, fewer women felt “very comfortable” breastfeeding their own baby in public, and fewer women felt “very comfortable” seeing another woman breastfeed her baby in public (17). Thus, more people see not breastfeeding as dangerous, and fewer people feel comfortable breastfeeding or seeing others breastfeed. This targeting and blaming of mothers for low nationwide breastfeeding rates has the potential to cause distrust by mothers—not only for the breastfeeding intervention, but also for public health interventions at large. These mothers who feel attacked by public health, the source of the campaigns, will be less likely to embrace future public health interventions. The intervention could be implemented in a manner that is effective by utilizing social science principles and perspectives, such as Social Expectations Theory, Framing Theory, and Stigma Theory. Had focus groups been held with mothers the DHHS could have learned about the social and legislative barriers to breastfeeding for a mother in the United States and appropriately set the audience, message, and destination to battle the barriers to breastfeeding instead of battling the mothers.

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7. Flore, Marrecca. (2007). CDC: Almost 75 Percent of New Mothers Breastfeeding. Retrieved from Fox News: http://www.foxnews.com/printer_friendly_story/0,3566,291878,00.html
8. Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S., Phelan, J.C.. Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People With Mental Illnesses. Psychiatr Serv 52:1621-1626, December 2001
9. National Conference of State Legislators (updated 2008). 50 States Breast Feeding Laws: http://www.ncsl.org/programs/health/breast50.htm
10. La Leche League International. (2003). LLLI Center for Breastfeeding Information: US Breastfeeding Legislation, Sept. 15, 2003.
http://www.llli.org/llleaderweb/LV/LVJunJul05p51.html
11. Fox 28 (2008). Woman Discriminated for Breastfeeding. Retrieved from Fox News: http://www.fox28.com/News/index.php?ID=35278
12. Barsch, Sky. (2008) Panel finds breast-feeding discrimination. Retrieved from Burlington Free Press: http://www.burlingtonfreepress.com/apps/pbcs.dll/article?AID=/20080328/NEWS02/803280308/1007
13. ABC 7 News. (2008). Breastfeeding Mother Sentenced to Jail for Postponing Jury Duty. Retrieved from ABC News: http://www.wjla.com/news/stories/0308/506006.html
14. NBC5i. (2008). Breastfeeding Mom Claims Salon Kicked her out. Retrieved from NBC5i: http://www.nbc5i.com/news/15555280/detail.html
15. Vargas, E., Hoffman, L., and Varney, A. (2006). Is the Breast Better?: Ad Campaign Rattles Mothers on Breast-Feeding Controversy. Retrieved from ABC News: http://abcnews.go.com/2020/story?id=2188066
16. McGuire, W.J., Input and Output Variables Currently Promising for Constructing Persuasive Communications. In Rice, R. & Atkin, C. (Ed.)
17. Haynes, Suzanne. “National Breastfeeding Awareness Campaign Results-Babies were Born to be Breastfed: http://www.4women.gov/Breastfeeding/campaign_results.pdf

The Limited Impact of Violence Intervention and Prevention (VIP) Among Target Neighborhoods in the City of Boston - Yuanyu(Emily)Lo

2008-04-23T11:48:00.000-07:00

Introduction
Nationwide, we are seeing a surge in violence among the younger population, and youth violence has become a very important public health problem in recent years. Around the country, gang violence has spread to communities throughout the United States. At last count, there were more than 24,500 different youth gangs around the country, and more than 772,500 teens and young adults were members of gangs(1). From 1999 to 2000, youth-gang related homicides in Massachusetts rose more than 50 % (2), and the number of shootings started to climb: 268 in 2004 and 341 in 2005. Statistics show that Suffolk County Juvenile Courts handles approximately 2,275 cases annually for youths under 18 (3). According to the Massachusetts Youth Risk Behavior Survey, 2005: 10% of high school students were involved in a gang in 2004.

In 2007, Boston Mayor, Thomas Menino launched a Violence Intervention and Prevention (VIP) public health campaign in an effort to decrease the increasing violence in Boston neighboring communities. VIP used a canvassing approached and had volunteer go to four specific neighborhoods and knock on in order to distribute educational materials and survey the residents about violence concerns in their neighborhood. The volunteers worked in pairs knocking on residents’ doors and walked on the street in teams of six people per group. In addition the intervention put in place public safety officers (police and EMS) in each neighborhood to support the door-knocking team. Education materials were given in backpacks to each family filled with school supplies, giveaways for kids, and key information regarding city benefits and services such as educational flyers, youth service agencies and violence prevention agencies. When residents opened the door, VIP volunteers would ask the permission from the residents and spent 30 minute to an hour using the standardize survey to discuss about their concern in the neighborhoods. The goal of this campaign is to improve the safety of Boston residents living in high risk neighborhoods and to provide youths, and their families with the tools and strategies to address and resolve violence.

Failure of addressing social network issues
This campaign did not use social network to make it successful. According to the Greater Vancouver Street Gang Study, there are three types of gangs: criminal business organizations, street gangs and wannabe groups (4). These types of gangs must be distinguished in order to be able to tackle the major issues pertinent to the type of gang or gangs in these communities. Neighborhood implemented interventions need to understand this kind of range of gang difference in order to have a successful intervention. The VIP campaign had a good approach to visit residents in high risk neighborhoods between 4-8 pm however, most likely elderly and children would be home. The VIP intervention therefore needed to canvass the neighbourhoods and talk to community members that would know the difference between the kinds of gangs in their community to be able to get more information about what kinds of violence interventions the neighbourhood needs. Also, the educational materials did not offer the information that target different youth population, therefore, it may not deliverer the violence prevention message.

Most of the VIP volunteers were health educators and public health advocates, and most importantly members outside of the neighborhoods that were being canvassed. If we took social network perspective, neighborhood youth may think that talking to the volunteer is not “cool” since the volunteers do not belong to their peer group. Also, volunteers accompanied by EMT’s or the police. This may attract unwanted attention in the neighborhoods, and residents may feel intimidated talking to the volunteers because they don’t want to be associated with the police. According to social network theory, people’s behaviors are based on their social network. Using youth gang behaviors as an example, youth used violence to resolve conflict or seek revenge against their rivals. Failure to recognize the social network issue will lead to the inability to alter group behavior.

Failure to use “McGuire’s Communication Model”

Violence prevention interventions need to look at effective strategies that help people change behavior, like persuasive communication theory. Over the years, William J. McGuire has done extensive research in the area of attitude change and persuasive communication (5-8). He states when an individual is exposed to a message the information will be processed based on their individual personality and demographic (6,8). According to McGuire, there are several steps needed to alter the behavior including exposure, perception, comprehension, agreement, decision making, and action.

From the McGuire, it is critical to know who deliver the message. VIP campaign, messages were instituted by City Hall and delivered by public health advocates. Historically, young people tend to rebel against authority and do not like to be told what to do. They may rebel against their parents, teachers and public officials and do not want to listen to them. Who delivers the message and what messages are delivered are critical.

Even with exposure, attention is not guaranteed. The human brain can only process a small portion of the information it receives. When VIP volunteer handed over educational flyers and asking survey questions, it might overwhelm the residents with too many information which did not apply to them. It would be very helpful to select certain key messages to disseminate among the population with the hope that certain portions of the message will be retained. Personally, I think a backpack full of information will overwhelm residents. The backpacks would surely deliver the message, but it was not really a comprehensive means by which to do it. One thing to consider was that the residents might be less educated or limited in their English speaking skills. It might be hard for them to understand the message from the volunteers. Also, how they interpret the information might be very different from the message put forth by the campaign.

Self-efficacy issue
Self-efficacy is a person’s belief in his or her ability to succeed in a particular situation. Bandura described these beliefs as determinants of how people think, behave, and feel (9-12). Everyone can identify the goals and that which they wish to change to achieve these goal. However, young people who lack self-efficacy will believe that these tasks are too difficult or impossible to achieve. Therefore, they may just give up, or not follow through at all. Using adults showing up at their doors and telling youth the risk of street violence would not give them enough of a reason to change their behavior. Young people knew the risks of being in a gang and the amount of violence on the street. However, sometimes they believed that they had to join a gang to survive or to be part of the community. They had grown up in a gang culture, and it might be the only way of life that they knew. Gangs was a part of their lives and part of neighborhood culture. Failure to address these behaviors that were a direct result of their background would result in not being able to target the intended group.

Another obstacle young people might face is the inability to break away from the group or gang. Handing out surveys and fliers would not achieve the goal of preventing violence in the neighborhood. There needs to be tools and guidance to teach them how to break away or not join a street gang in the first place. Eventually, they will have to learn how to say “no” to the violence.

Conclusion
In order to have an effective public health campaign, we first have to identify and focus on our target population. One way to win over young people that we might consider is to use a previous gang member who could speaks their language. Other outreach methods that might influence young people are rap/pop concerts, basketball games or commercials to deliver the message rather than adults knocking on doors. For high risk neighborhoods, we should understand the culture of the communities and let youth know that there is another way to solve the problem besides violence. By understanding their background and the environment that they live in, we will be able to design a comprehensive plan to help residents and prevent future violence in the city.

REFERENCE
1. Howell, J.C. (1998). Youth Gangs: An Overview. Washington, D.C.: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention.
2. “Caught in the Crossfire: Arresting Gang Violence by Investing in Kids,” Fight Crime: Invest in Kids 9/14/04, available at http://www.fightcrime.org/reports/gangreport.pdf
3. Boston High-Risk Youth Network, “Needs Assessment of High-Risk Youth in Boston,” Sept. 2005.
4. Youth Justice in Canada Excerpt on “Youth Gangs”, 2003
5. McGuire, W. J. (1968). Personality and attitude change: An information-processing theory. In Greenwald, A.G., Brock, T.C., & Ostrom, T.M (Eds.), Psychological foundations of attitudes (pp.171-196). New York: Academic Press.
6. McGuire, W. J. (1976). Some internal psychological factors influencing consumer choice. Journal of Consumer Research, 2, 302-319.
7. McGuire, W. J. (1989). Theoretical foundations of campaigns. In Rice, R. E., & Atkin, C. K. (Eds.), Public Communication Campaigns (2nd ed.) (pp. 43-65). Newbury Park, CA: Sage Publications.
8. McGuire, W. J. (1999). Constructing social psychology: Creative and critical processes. Cambridge: Cambridge University Press.
9. Bandura, A. (1982). Self-efficacy mechanisms in human agency. American Psychology, 37, 122-147
10. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215.
11. Bandura, A. (1982). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
12. Bandura, A. (1997). Self-Efficacy: The exercise of control. New York, NY: W. H. Freeman.

The “WE CAN!” Campaign Has Missed The Target – Gayle Salomon

2008-04-23T11:27:00.000-07:00

The increasing prevalence of obesity in children is a significant and alarming public health problem. During the last 20 years there has been a dramatic increase of overweight and obesity in the United States. In 2006, according to the Centers for Disease Control and Prevention, only four states had a prevalence of obesity less than 20%, twenty-two states had a prevalence equal or greater than 25%; two of these states had a prevalence of obesity equal to or greater than 30% (1). In 1971, the National Health and Nutrition Examination Survey (NHANES) was started to document the growing prevalence of overweight and obesity across different age groups. Analysis of the 2003-2004 NHANES shows that an estimated 17.1% of children aged 2-19 years old in the United States were overweight (2). In comparison with the original NHANES data from 1971-1974 the 2003-2004 data showed a significant increase of prevalence across all age groups: 8.9% for ages 2-5 years, 14.8% for ages 6-11 years and 11.3% for ages 12-19 years (1,2). The consequences of childhood obesity are both short-term and long-term, differing in severity from mild to potentially life-threatening (3). In the short-term, health problems such as asthma, Type 2 Diabetes Mellitus, and sleep apnea (3-7) are directly associated with obesity. Additionally, there are social and psychological problems associated with childhood obesity. For example, teasing and isolation from the other children, low self-esteem, depression, loneliness, sadness, nervousness, and poor body image (4, 7, 8). In the long-term, children who were obese have a greater chance of becoming obese adults (5, 9, 10) and an increased risk of cardiovascular disease through increased risk of hypertension, high cholesterol, elevated triglycerides, and elevated fasting insulin levels. In addition, obese adults who were obese children have a lower self-efficacy to lose the weight that they have had all their lives (10-12). Long-term costs associated with obesity are also of concern for the individual and society in general (1). There is a need for public health interventions targeting children at a young age to help with both the short-term and the long-term problems associated with childhood obesity (7).
Prevention of childhood obesity is beginning to be addressed as an important public health policy in the United States. Intervention programs are being created to try and decrease the amount of children suffering from this epidemic. The Ways to Enhance Children’s Activity and Nutrition (We Can!) Campaign is an example of such a program. We Can! is a collaboration of the National Heart, Lung, and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Child Health and Human Development, and the National Cancer Institute (13). It is a national education program designed for parents and caregivers to help children ages 8-13 stay at a healthy weight (13). The campaign targets parents and families as a primary group for influencing the youth audience (13). The program focuses on three important behaviors: improved food choices, increased physical activity, and reduced screen time (13). The We Can! Campaign is a website that provides families and communities with helpful resources including practical tips and handouts. It also offers community groups and health professionals resources to implement programs and fun activities for parents and youth in communities around the country (13). The We Can! Campaign has significantly missed the target by attempting to influence the wrong population, neglecting to target all sources of influence on children, and by not properly creating awareness of their program.
We Can! Targets the Wrong Population to Achieve Their Goals
The We Can! program targets children aged 8-13. We Can! needs to expand their age range to include younger children. Feeding skills are closely linked to Piaget’s Theory of Child Psychology and Development (7). Jean Piaget’s theory states that children actively construct their understanding of the world and go through four stages of cognitive development: sensorimotor stage (birth – 2 years), preoperational stage (2-7 years), concrete operational stage (7-11 years), and formal operational stage (11 years and beyond) (7, 14). During the preoperational stage food is described by color, shape, and quantity, but the child has only a limited ability to classify food into groups (7). Foods tend to be categorized into “like” and “don’t like” as well as “good for you,” but the reasons they are “good for you” are unknown or mistaken (7). During the concrete operations stage, mealtimes take on a social significance to children and can influence their eating patterns (7). Unrealistic expectations for a child’s mealtime manners, arguments, and other emotional stress can have a negative effect (7). Moreover, meals that are rushed create a hectic atmosphere and reinforce the tendency to eat too fast (7). In the formal operations stage, the expanding environment around the child increases the opportunities for and the influences on food selection. Additionally, the conflicts in making food choices may be realized; that is, knowledge of the nutritious value of foods may conflict with preferences and non-nutritive influences (7). Therefore interventions aimed at children of all ages, including those younger than age 8, can try and influence children’s perception of healthy foods as something they like (7, 15). Aside from Piaget’s Theory of Child Psychology and Development, differences shown through data from NHANES support the idea that children are becoming obese at a younger age (16). Data compiled from NHANES 1971-1974 and 2004-2005 shows a larger increase in obesity among children aged 2-11 (23.7%) than children aged 12-19 (11.3%) (16). The overlap of the 8-13 age range within these categories should be expanded and started at a younger age.
Along with targeting the wrong population of children, We Can! sites are located and concentrated in the wrong places. Based on the U.S. Obesity trends from 1985-2006, in 2006 the most concentrated areas of obesity are in Mississippi and West Virginia followed by states such as Texas, Oklahoma, Louisiana and Arkansas (1). Mississippi and West Virginia had a prevalence of obesity equal to or greater than 30% (1). In general, the south has the highest concentrations of obesity in the country, however, We Can! sites are more concentrated in the northeast (1,13). West Virginia and Mississippi, the states that have the most concentrated obesity rates have the least amount of We Can! sites (13). West Virginia has two sites throughout the entire state and Mississippi has four (13). We Can! needs to refocus their efforts on the areas of the country that have the highest prevalence of obesity in order to make a larger impact.
The Primary Influence on Children Aged 8-13 is Not Their Parents, But Their Peers
As previously mentioned, the We Can! program targets children through their parents and communities (13). Although parents are a significant influence on children aged 8-13, they are not the primary influence (17). By not aiming their campaign at the children themselves, the We Can! program is missing out on many opportunities to influence the targeted population. For toddlers and preschool children the primary influence is the family (17-20). Children aged 8-13 spend more time in school, at after-school activities and with friends than they spend with their parents (7). The influence of peers and significant adults such as teachers, coaches, or sports idols increases throughout adolescents (7). Parents begin to have less of an impact on the food choices when the children begin to purchase and make their own decisions about food (7). These children are busier than those generations before them and have less time to eat. Therefore, they often choose fast foods, foods from vending machines, and skip breakfast (7, 16, 20). They also have less money for these purchases, which causes them to choose cheaper, usually less healthy, options (7). School aged children and adolescents strive to be accepted by their peers and do what their friends are doing as well as their parents, which is explained by Social Network Theory (7, 19-21). Social Network Theory states that inter- and intra-individual relationships, as well as the nature of those relationships, are important influences of beliefs and behavior (21). These networks can play an important role in whether someone acts in a way that is either risky or good for their health, what information someone is exposed to about health, and what kinds of social support a person has available to them (21). In a recent study, children were more likely to report more intense physical activity when in the company of peers or close friends than family (22). Overweight children reported greater physical activity when in the presence of peers, compared to family, than did lean children (22). Both these findings confirm the idea that peers are a great influence on overweight children and should be taken into consideration when formulating a public health campaign such as We Can!
The We Can! campaign does not directly aim their intervention at the children themselves. This is extremely shortsighted on their part because the children need motivation to make the changes to their lifestyle (7). The program assumes that Social Learning Theory, which states that children will do what they have seen modeled by their parents is the correct model to follow for their intervention, however they are wrong (21-23). The key principle to this theory is that children learn by observing and vicarious learning in their immediate environment, for example, their parents and family (23). As previously mentioned, the children are being influenced by their peers, teachers and coaches as well as their family (8). This can cause conflicting ideas of what is good and bad for their health if each influential person is stressing different behaviors. The Social Learning Theory assumption may hold true for parents who model good behavior, however many times parents are not perfect and they model behaviors that children should not be learning (24-26). The risk of becoming obese is greatest among children who have obese parents due possibly to parental modeling of both eating and exercise behaviors (27-30). Therefore, if the parents do not care about making a lifestyle change for themselves and send contradictory messages to their children than they are doing themselves, the modeling is null and void.
We Can! Uses the Wrong Approach to Creating Awareness and Change
We Can! runs their campaign through a website in which parents, community groups and professionals can go online and get handouts, tips, and resources for their children (13). It allows people to start their own We Can! sites throughout the country to try and combat obesity (13). However, this approach is ineffective because there is no way for people to find out about the program through media or advertising. Part of their plan is to decrease television screen time because studies have directly linked the amount of television screen with obesity risk (7, 13, 31-35). By not using television as a way of reaching out to children, they are missing a large portion of their target population. Television and magazines have a greater influence on children’s eating habits than any other form of mass media (7). Preschool and school-aged children watch between 23-27 hours of television per week (7, 35). According to the American Academy of Pediatrics (AAP), children in the United States see 40,000 commercials a year and half of them advertise food (7, 35). Although We Can! does not want to promote television screen time, these children are watching television and the best way to influence them is by commercials (7). By doing this, way can combat the commercials encouraging children to eat unhealthy empty-calorie foods (35).
Since We Can! does not market their program in any way, parents do not hear about the program. Unless someone in a community has already started a We Can! site, there is no way to learn about the program and get involved. There are great resources and tips on the website but there is no marketing campaign to let people know that they are there. Other public health campaigns use relevant messages disseminated through existing community networks such as, such as beauty parlors, health centers and public schools (36). The more ways that We Can! creates awareness of their program, the more successful it will become (36). Thus, without a marketing strategy, We Can! is not effective.
Conclusion
The rates of obesity in the United States are increasing exponentially and have no indication of slowing down anytime soon (1-3). The only way to try and stop this epidemic is to start targeting children at a younger age to instill in them the values and knowledge to be healthy (2, 3, 7, 13, 16). Obesity and overweight have many consequences for the individual and society in general (3). For the individual consequences can include health problems, psychological and social problems lasting from childhood throughout life (3-6). Society has a price to pay for obese individuals as well. Financially, more than $90 billion dollars are spent per year on obesity related medical costs and costs to employers for absenteeism, life insurance, retraining, and disability costs (1, 37).
The We Can! program has constructed a good base to start their intervention however, many changes need to be made in order for it to be a successful program. The population that We Can! targets is very narrow in scope and needs to be expanded, to target children younger than 8 years old. They need to recruit children that are good role models, perhaps a child celebrity, to help model the behaviors set forth by the program. More We Can! sites need to be opened in areas where there is a higher prevalence of obesity to help combat it. In addition, the marketing plan of We Can! needs to be rethought to include ways of actively creating traffic to their website. For example, they should use mass media such as television and magazines to spread awareness.
REFERENCES
1. Department of Health and Human Services: Centers for Disease Control and Prevention. U.S. Obesity Trends 1985-2006. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/
2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. Journal of the American Medical Association 2006;295:1549-1555.
3. Ogden CL, Flegal KM Carroll MD, Johnson CL. Prevalence and trends of overweight among US children and adolescents, 1999-2000. Journal of the American Medical Association 2002;288:1728-32.
4. Department of Health and Human Services: Centers for Disease Control and Prevention. Overweight and Obesity: Childhood Overweight. Atlanta, GA: Centers for Disease Control and Prevention.
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/index.htm
5. Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, Robinson TN, Scott BJ, Jeor SS, Williams CL. Overweight in Children and Adolescents: Pathophysiology, Consequences, Prevention and Treatment. Circulation 2005;111:1999-2012.
6. Aetna. Children’s Health: Health Consequences of Childhood Obesity. Hartford, Connecticut: Aetna. http://womenshealth.aetna.com/WH/ihtWH/r.WSIHW000/st.48408/t.48814.html
7. Mahan LK, Escott-Stump S. Krause’s Food, Nutrition and Diet Therapy 11th Edition. Elsevier:2004. 259-318.
8. Deckelbaum RJ, Williams CL. Childhood Obesity: The Health Issue. Obesity Research 2001; 9: 239-243.
9. Dietz WH. Health Consequences of Obesity in Youth: Childhood Predictors of Adult Disease. Pediatrics 1998;101:518-525.
10. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine 1997;37:869-873.
11. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Preventive Medicine 1993;22:167-177.
12. Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics 1999;103:1175-1182.
13. Department of Health and Human Services: National Institute of Health. Ways to Enhance Children’s Activity and Nutrition.
http://www.nhlni.nih.gov/health/public/heart/obesity/wecan/
14. Santrock, JW. CHILDREN 9th Edition. New York, New York: McGraw-Hill Companies, 2007.
15. Birch LL. Development of Food Preferences. Annual Review of Nutrition 1999;19:41-62.
16. Brown JE. Nutrition Through the Life Cycle 2nd Edition. California: Thomson Wadsworth:2005.
17. Patrick H. A Review of Family and Social Determinants of Children’s Eating Patterns and Diet Quality. Journal of the American College of Nutrition 2005;24:83-92.
18. National Dairy Council. Factors Influencing Eating Behaviors. Rosemont, Illinois: National Daity Council. http://www.nationaldairycouncil.org/NationalDairyCouncil/Health/Digest/dcd74-3Page4.htm
19. Johannsen DL, Johannsen NM, Specker BL. Influence of Parents’ Eating Behavior and Child Feeding Practices on Children’s Weight Status. Obesity 2006;14:431-439.
20. Cullen KW, Baranowski T, Rittenberry L, Cosart C, Hebert D, Moor C. Child-reported family and peer influences on fruit, juice and vegetable consumption: reliability and validity of measures. Health Education Research 2001;16:187-200.
21. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, Massachusetts: Jones and Bartlett Publishers:2007.
22. Salvy SJ, Bowker JW, Roemmich JN, Romero N, Kieffer E, Paluch R, Epstein L. Peer Influence on Children’s Physical Activity: An Experience Sampling Study. Journal of Pediatric Psychology 2008;33:39-49.
23. Bandura, A. Social Learning Theory. New York: General Learning Press:1977.
24. Tibbs T, Haire-Joshu D, Schechtman KB. The Relationship Between Parental Modeling, Eating Patterns, and Dietary Intake Among African-American Parents. Journal of the American Dietetics Association 2001;101:535-541.
25. Home Educator’s Family Times. Parental Modeling. Brunswick, Maine: Home Educator’s Family Times. http://www.homeeducator.com/FamilyTimes/articles/8-5article11.htm
26. Wrotniak BH, Epstein LH, Paluch RA, Roemmich JN. The Relationship Between Parent and Child Self-Reported Adherence and Weight Loss. Obesity Research 2005;13:1089-1096.
27. American Association of Colleges for Teacher Education. Defining Obesity in Children and Adolescents. Washington, DC: American Association of Colleges for Teacher Education. http://www.kidsource.com/kidsource/content2/obesity.html
28. Dietz, W. H. Childhood obesity: Susceptibility, cause, and management. Journal of Pediatrics 1983; 103(5), 676-686.
29. Wardle J, Guthrie C, Sanderson S, Birch L, Plomin R. Food and Activity Preferences in Children of Lean and Obese Parents. International Journal of Obesity 2001;25:971-977.
30. Yale-New Haven Children’s Hospital. Adolescent Rebellion: A Survival Guide for Living with a Teenager. New Haven, Connecticut: Yale-New Haven Children’s Hospital. http://www.ynhh.org/pediatrics/behavior/adolescent_rebellion.html
31. Bloomberg News. Limiting TV, Screen Time Curbs Childhood Obesity, Study Finds. Tuscan, Arizona: Bloomberg News. http://www.azstarnet.com/sn/health/227997
32. National Institute on Media and the Family. Study: Limiting Screen Time Lowers Risk of Childhood Obesity. Washington, DC: National Institute on Media and the Family. http://www.mediafamily.org/press/20070524.shtml
33. Lanningham-Foster L, Jensen TB, Foster RC, Redmond AB, Walker BA, Heinz D, Levine JA. Energy Expenditure of Sedentary Screen Time Compared With Active Screen Time for Children. Pediatrics 2006;118:1831-1835.
34. Allina Hospitals and Clinics. Downloading Obesity: Balancing Screen Time and Healthy Weight. Minneapolis, Minnesota: Allina Hospitals and Clinics. http://www.allina.com/ahs/aboutall.nsf/page/balancing_screen_time
35. Nemours Foundation Kids Health. How TV Affects Your Child. Nemours Foundation Kids Health. http://www.kidshealth.org/parent/positive/family/tv_affects_child.html
36. Department of Health and Human Services: Centers for Disease Control and Prevention. Health Marketing in Action. Atlanta, GA: Centers for Disease Control and Prevention.
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37. Finkelstein EA, Fiebelkorn IC, Wang G. National Medical Expenditures Attributable to Overweight and Obesity: How Much and Who’s Paying? Health Affairs (Web Exclusive);2003:W3-219-W3-226.

The Failure of Abstinence-Only Sexual Education in Schools in Reducing the Rates of STD’s and Pregnancy in the Adolescent Population – Katelyn Spada

2008-04-23T11:26:00.000-07:00

Abstinence-only sexual education has failed in reducing the rates of STD’s and pregnancy in teens because those implementing the program neglected to frame the issue to teens in a relatable manner. The main focus of this paper is to address the need for abstinence-only sexual education programs to incorporate the social and behavioral sciences, such as psychology and sociology, in order to reframe abstinence-only sexual education so that it appeals to teens. Current abstinence-only sexual education programs fail to incorporate concepts that play important roles in teenagers’ lives. These programs neglect to address the importance of the messages about sex that are displayed by the mass media and accepted by society. Also, many abstinence-only educators fail to realize that teens are in the process of establishing their own sense of autonomy and may not abstain in order to prove that they can make their own decisions about sex (1). Although many teens intend to abstain from sex until marriage, there are few who are able to maintain this commitment (2). Abstinence-only sexual education fails to inform teens about contraceptives and birth control that could protect them should they choose to have sex. By incorporating the social and behavioral sciences, these programs would be able to address these issues and be more effective in lowering the rates of pregnancy and STD’s in the adolescent population.
About Abstinence-Only Sexual Education
Abstinence-only sexual education exclusively promotes the importance of abstaining from sexual intercourse until marriage and typically includes no discussion of contraceptives, birth control, or abortion. The abstinence-only curriculum emphasizes that abstinence is the expected social standard for school-aged children and teaches children that pre-marital sex leads to STD’s, teen pregnancy, and social stigma (3).
The federal government largely funds abstinence-only sexual education in public schools through Title V of the 1996 Welfare Reform Act and through Community-Based Abstinence Education. Title V of the Welfare Reform Act allows the government to allocate grants to states whose public schools teach abstinence-only sexual education (3). The government outlines strict curriculum criteria that must be met in order for the state to receive federal funding. The programs funded by this act are able to discuss contraceptives, but are allowed only to give examples of their failures. These programs do not educate teens on the benefits of contraceptive use (4). A large amount of money has been allocated to fund abstinence-only education programs. From 1996-2006, the federal government has given over 1 billion dollars to state-run abstinence-only programs through Title V of the Welfare Reform Act. Abstinence-only sexual education programs also receive funding through Community-Based Abstinence Education (CBAE), which began in 2000. CBAE is the largest federal abstinence-only funding source, giving 115 million dollars in grants in 2006. These grants bypass state governments and are awarded directly to state and local organizations that teach abstinence-only sexual education. Many grantees are faith-based or small non-profit organizations that service local private and public schools and other organizations in their area (3).
The Importance of Recognizing Teen Autonomy
Current abstinence-only sexual education programs fail to engage teens and educate them about the dangers of promiscuity because the curriculum does not take into account the fact that teens are in the process of establishing their own sense of autonomy. Proponents of abstinence-only programs argue that teens must be taught abstinence in order to guide them away from promiscuity, but they fail to recognize that many teens are mature enough to know the difference between acceptable and unacceptable behavior. According to psychological theory, teens aim to be independent, self-governing individuals who make their own decisions and live by their own rules of morality (3). Programs aimed at educating teens about sexual behavior should incorporate this theory in order to help teens create their own set of morals without the values of others being forced upon them.
Studies have shown that sexuality is especially associated to freedom and control during adolescence. While parents and teachers should be involved in the surveillance and control of teen behaviors to ensure their safety, teens should be in charge of creating their own morals and making their own decisions. Battles over right and wrong behavior are often fought between adult and child, but the more important struggles are within the teens themselves (5). Sexual education programs should not emphasize the beliefs of those in charge of presenting the material, but should present information on all of the ways to practice safe sex.
The Impact of the Mass Media and Societal Norms
Society as a whole regards sex as normal and acceptable. This conflicts with the message that “sex is immoral and wrong” that is being presented by abstinence-only educators. Oftentimes, teens feel pressured to do what everyone else is doing in order to fit in with their peers (6). By not taking into account the role of social norms and the messages presented by the media, abstinence-only educators are setting their programs up for failure. Teens are exposed to the “sex sells” message sent out by the media on a daily basis. Media outlets, such as television, radio, and magazines, are constantly presenting teens with sexual images and lyrics that are contradictory to the message taught by abstinence-only programs (7).
Media sources are important life-lesson educators for teens and teens often use media sources to gain information about sexuality (7). Bandura’s Observational Learning Theory is based on the idea that learning results from observing the behavior of some other person or model (7). This theory can be applied to suggest that teens can learn the mechanics, motives, and consequences of sexuality from the media and store such knowledge for use in their own personal circumstances. Teens often use this information like a script that outlines what behaviors are expected of them in sexual situations (7). For example, many articles in teen magazines say that girls should not kiss their dates until they have had a second date with them to avoid giving off the wrong impression, and studies have shown that many girls take this advice (8). In this way, the media plays a crucial role in educating teens on the “right” way to act according to societal norms.
While parents and the community may have some influence on the decisions teens make, studies have shown that the mass media and peer influence have the most impact on teen decision-making processes (9). These studies have also shown that families have little to no influence on adolescents’ self-evaluation of sexuality when compared to the influence of the media and peers (9, 10). The information that teens gather about sexuality from the media and from their peers plays an important role in the development of their own sexual behavior (10).
Intent Does Not Always Lead to Behavior
Abstinence-only sexual education programs have failed in reducing the rate of pregnancy and the incidence of STD’s in the adolescent population because these programs have relied too heavily on the idea that if teens intend to abstain from sexual intercourse until marriage, they will uphold that commitment (2). In reality, intentions to abstain from sexual intercourse until marriage may not determine whether or not teens actually do abstain (2). Many external factors may interrupt the intention-behavior continuum.
A recent study presented at the 2003 annual meeting of the American Psychological Society found that over 60% of college students who had pledged virginity during their middle or high school years had broken their vow to remain abstinent until marriage (2). While many of these students may have intended to uphold their vows to abstain from sexual intercourse until marriage, their behavior did not follow their intentions.
There are many situations in which adolescents choose to have sexual intercourse even if they had previously intended to abstain. Teenage romance often evokes strong emotions. Studies have shown that when involved in a serious relationship, teenagers who may have intended to abstain from sexual intercourse before marriage choose to have sex for a number of reasons (11). Most commonly, teens who once intended to remain abstinent have had sex in order to make their relationship feel more adult and to feel more intimate with their partner (11).
Teens also choose to engage in sexual intercourse when under the influence of alcohol or drugs. An estimated 50% of American teenagers have experimented with alcohol and/or drugs at least once (12). Alcohol and drug use has been proven to cause individuals to engage in behaviors that they would not have engaged in otherwise (12). For this reason, intentions to abstain from sexual intercourse until marriage do not accurately predict one’s actual behavior.
Correcting Abstinence-Only Sexual Education Programs’ Failures
Today’s abstinence-only sexual education programs neglect many issues that affect how teens view sexuality. Those developing these programs must realize that social norms and peer pressure, in conjunction with a teen’s developing sense of autonomy, have a strong influence on sexual behaviors. It is also important for these programs to provide teens who choose not to abstain from sex with information on ways to protect themselves. In order to be more effective in reducing the rates of pregnancy and STD’s in America’s adolescent population, these ideas must be incorporated into abstinence-only education programs.
Social norms must be modified in order to make abstinence a more acceptable option in today’s society (13). Abstinence-only sexual education proponents must work with the media in order to incorporate more examples of behaviors that are in accordance with abstinence-only program values. By making abstinence a social norm, these programs will be more relatable, and therefore more successful, in increasing the number of teens who choose to abstain (13).
Abstinence-only sexual education programs need to be restructured in order to be effective in reducing the rates of pregnancy and STD’s in teens (14). While abstinence should remain the focus of these programs, information regarding contraceptives and birth control should also be included. Many proponents of abstinence-only education may be unwilling to accept the need for information about contraception and birth control in abstinence-only programs, but this information is important for those who choose to have sex to know in order to protect themselves from STD’s and to prevent unplanned pregnancies. Studies have shown that programs that focus on abstinence but include information regarding contraceptives have been the most successful in reducing pregnancy and STD’s in adolescents (14). Since abstinence-only sexual education is taught in many public schools and students do not have a choice to enroll in other sexual education programs, including information regarding safe sex is important for all students – especially those who do not agree with the abstinence-only sexual education programs’ goals.
Involving teens in the development and the presentation of the abstinence-only sexual education curriculum would also have a positive impact on abstinence-only programs. Peer influence plays a major role in decision-making processes during adolescence (6). By involving teens in the development and the delivery of the abstinence-only sexual education curriculum, these programs would be able to increase the social acceptance of abstinence among the adolescent population (13).
Conclusion
Current abstinence-only sexual education programs have failed to reduce the rate of pregnancy and incidence of STD’s in the adolescent population. This failure is a result of the fact that those implementing the programs have not framed the issue in a way that is relatable to teens. Abstinence-only sexual education program creators neglect to consider the fact that teens are in the process of establishing their own sense of autonomy and may rebel against the messages being taught to them by their instructors (1). They also fail to acknowledge that the messages about sex received by teens through the mass media and social norms conflict with the values being promoted by abstinence-only programs (7). Lastly, abstinence-only sexual education programs are based on the idea that intent directly governs behavior. This is not always true; there are many external factors that influence whether or not an individual’s behavior reflects their intentions (2).
Addressing the failure of current abstinence-only sexual education programs is an important public health matter because of the high rates of pregnancy and STD’s in the American adolescent population. In order for these programs to have an impact on teen sexuality, social norms must be altered to make abstinence more commonplace and information about contraceptives needs to be included in these programs.

REFERENCES
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