Youth Violence on the Rise: Society Glorifying Violence Hinders Public Health Prevention Campaigns- Sheila Jeudy

Public health methods are essential to violence prevention. Current public health anti-violence programs often limit their scope and resources to victims of domestic violence and abused children. Public health has applied its analytical expertise to enhance the understanding of risk factors for youth violence, allowing for a broader vision in the planning and development of preventative approaches. Public health practice is both systematic and concerned with the root cause of youth violence (1). Public health preventions remain ineffective when combating against the media’s portrayal of violence geared toward the youth. Public health has failed to utilize the media successfully to implement and promote anti-violence campaigns because their focus has been on identifying high risk individuals, risk factors that contribute to violent behavior and media outlets geared toward youth that glorify violence and violent behavior. Although identifying the risk factors that lead to violence is the first step in resolving youth violence, public health has failed to successfully implement and enforce new policies and procedures that would address the rise in youth violence. Public health has made attempts to create new technology and policies to educate parents and children about the repercussions of violent behavior but these interventions fail to provide the necessary means to enforce such policies and implement procedures outside of the public domain. They have yet to devise a plan that will enforce prevention policies within the home.

Public Health Approach to Youth Violence

Public health perspective on media violence considers the effects of violent imagery on the child within the broader context of child welfare, families and communities. The behavior of parents monitoring the use of televisions and computers and knowingly or unknowingly allowing access to violent imagery is considered in addition to the habits and behavior of the child or adolescent viewer. There has been an attempt to integrate theoretical approaches into a general aggression model in relation to the effects of media violence. This model is based on the principles of cognitive behavioral theory, which explains interactions between an individual and their environment. The model claims that an individual’s response to violent behavior is established by their perception of violence and their level of interaction.

Violence preventions are categorized into various levels. Primary preventions address the broadest level of the general public to reduce the level of violence that is shown on television. This would be an effort directed toward dealing with public values and attitudes that may promote or encourage the use of violence. Primary prevention instruments tend to be those providing information and education on the problem of violence through the popular media. At the primary level, efforts have been made on enhancing public awareness of risk factors and the true characteristics of violent actions. Secondary preventions identify subgroups or circumstances that are at high risk of being involved in or causing violence. Secondary prevention efforts might focus on urban poor and adolescents who are at particularly high risk of engaging in or being victimized by violence and educating them in nonviolent methods of resolving disputes. At the secondary level, public health has been involved in the development of educational interventions specifically focused on behavior modification of high risk individuals. Tertiary prevention is a response to a violent event and not a preventive measure. Its focus is on trying to reduce the negative consequences of a particular event after it has occurred; trying to find ways to use the event to reduce the likelihood of similar incidents from reoccurring in the future (2).

The World Health Organization (WHO) has emphasized the necessity of adopting a public health approach for prevention of violence. WHO’s World Report on Violence and Health does not specifically address violence in the media, however it does discuss the effect of media messages on health promotion. The report emphasizes the need for health services to be associated with the prevention of violence through family and community interventions in order to successfully address youth violence prevention. Instead of focusing on the individual who is at risk for, or who engages in violence, the public health approach considers the individual’s relationship to his or her surroundings (3). The ecological model recognizes that each person functions within a complex network of individual, family, community and environmental contexts that affect their capacity of avoidance. The ecological framework is based on public health perspective for reducing risks and preventing violence (4-6).

Public Health and the Media

Media campaigns and public service announcements offer a means of increasing public awareness. Public health has utilized the media to advertise violence prevention campaigns through the National Crime Prevention Council (NCPC) by distributing action kits, Partner With the Media To Build Safer Communities, containing reproducible materials that communities can use to reach the public with their anti-crime and anti-violence messages. NCPC has partnered with the media in a Turn Off the Violence Campaign, where the community engaged the help of local print and electronic media to convince residents that violence is an unacceptable way to resolve conflicts. The campaign also encourages the media to reevaluate their own violent entertaining programming (7).

Public health approaches have generated several contributions to the understanding and prevention of violence; professionals have applied traditional public health strategies to violence prevention. Public health brings an analytical approach that identifies risk factors and important causes that could become the focus of preventive interventions. Public health preventions should utilize the media to initiate public education campaigns addressing various social problems, provide educational information, and identify risk factors and high risk individuals. Public health informative campaigns should make effective use of innovative media efforts, such as new dissemination techniques and outreach materials to convey the causes of youth violence and the effective strategies for violence prevention.

The Telecommunications Act of 1996 is an example of a public health attempt to take advantage of the media to advertise violence prevention. The act was intended to assist parents in reducing children’s exposure to violent media. The act mandated the inclusion of V-chips in all new televisions and for the development of a rating system to enable parents to assess the violent content of specific shows. The prevention itself was unsuccessful in that it provided a means to resolve the amount of violence exposure in the media but it did not provide a means for enforcing the implementation of such devices or educating parents on the importance of implementing policies within the home.

With the unsuccessful intervention of the v-chip installation, the FCC Commissioner Tristani sent a letter to major broadcast networks asking them to recommit themselves to educating parents about the V-chip in 2000. Tristani recognized that many parents didn’t know that the chip existed even though they had been installed in television sets since 1999. Networks such as Fox and NBC have not aired public service announcements regarding the V-chip installation into television sets (8). Public health should enforce networks to broadcast public service announcements more frequently and publish electronic print informing parents of the need to monitor TV ratings of programs viewed by their children.

The V-chip inserted into all televisions sold since 1999 was an attempt to address the amount of violence in the media. The chip being no more than an electronic selection and category system, suffered the same limitations as film classifications, in that it can easily be overridden or ignored by technology-savvy children. This violence prevention attempt failed due to the limitations of the device. Public health’s use of media provided public awareness and some education but couldn’t enforce implementation (9).

Public Health Fails to Apply the Social Learning Theory to Preventions

As youth violence has increased, the media has expanded national and local coverage of the problem, often using images that build upon community fear. The media frequently overlook the more complicated messages about the causes of violence and approaches to redress the problem. Recent surveys depict the abundance of media in U.S. homes and the extensive presence of violence within the media. They also show that the proliferation of new media has expanded the opportunities for children to be exposed to media violence at home. The social learning theory provides an explanation for how violent media may influence childhood aggression. Social learning theory states that a child learns how to act and forms his or her attitudes from observing important role models in his or her life. Characters portrayed in the media may become role models for children whether they positively or negatively influence them. With constant exposure to violence, children may learn to see violence as a part of everyday life and an acceptable way to solve interpersonal problems. Because violence in the media is presented without negative consequences, youth fail to accurately assess or even understand the real life consequences of violent actions against others.

Prolonged exposure to violence in the media by children has been shown to contribute to aggressive behavior and desensitization to violence. The media contributes to the perception of violence as a normative behavior, reinforcing and sensationalizing violence as an appropriate and justifiable problem solving strategy. Public health fails to properly address this issue and their preventions focus on providing education and identifying risk factors and high risk individuals. Research indicates that media violence increases aggressive attitudes and emotions, which are theoretically linked to aggressive and violent behavior. Public health approaches fail to enforce policies that provide actions toward curbing the amount of exposure to media violence by youth. Public health should encourage the media to prevent youth violence by minimizing the sensationalist aspects of coverage of violent behavior, reinforce anti-violence messages and ideas provided by schools and communities. Violence prevention campaigns would be more successful if they could convince the media to portray the consequences of violence realistically, promote and participate in community coalitions for the prevention of youth violence and promote and publicize anti-violence programs and policies (10).

Violence in the Media

The National Television Violence Survey report notes that many television programs fail to depict the harmful consequences of violence. Specifically, it finds that of all violent behavioral interactions on television, 58% depicts no pain, 47% depict no harm, and 40% depict harm unrealistically. Of all violent scenes on television, 86% percent feature no blood or gore. Only 16% of violent programs feature long term, realistic consequences of violence. Violence in movies, television and video games has become pervasive in our society and studies have shown that media violence can lead to aggressive behavior in children. Additionally, media violence often fails to show the consequences of violence. This is especially true of cartoons, toy commercials and music videos. As a result, children learn that there are few, if any, repercussions for committing violent acts (11).

Public health preventions address media violence but haven’t addressed other media outlets such as music lyrics and videos which also have been shown to have passive effects on youth. The evidence shows that violent video games are related to later aggressive behavior and delinquency in older children and teenagers. For both passive viewing (television and film) and interactive viewing (video and computer games), there seems to be consistent evidence of an association between younger children watching media violence and showing more aggressive play and behavior. Public health approaches have identified the correlation between the two but fail to provide effective preventions.

Contributing Risk Factors

Public health has addressed the fact that multiple risk factors contribute to the likelihood that an individual will engage in violent acts or aggressive behaviors. Most risk factors for violence are not strong predictors by themselves; it is the combination of risk factors that tend to be associated with violence. Media violence may have a very strong impact on some children and no apparent impact on others. The bottom line is that there are many factors-at home, at school, and in the community, which can increase or decrease the likelihood that a youth will become violent and media violence is one of them (12).

Preventions have failed to address the fact that there are several contributing factors that lead to violent behavior. Factors that appear to influence the effects of media violence on violent behavior include characteristics of the viewer such as age, intelligence, aggressiveness, and whether the child perceives the media as realistic. Social environment (parental influences), as well as aspects of media content including characteristics of perpetrators, degree of realism and justification for violence, and depiction of consequences of violence also contribute to violent behavior (13). Research on youth violence has primarily focused on the risk factors concerning the individual and family levels. These risk factors highlight the importance of the macro influences such as poverty at the neighborhood level, gun availability and social norms. Socioeconomic status has been constantly found to be an important contributing factor to violence in many studies. The public health approach to violence prevention targets high-risk communities including low-income neighborhoods, areas with gangs, high levels of neighborhood crime, drugs, or broken homes (divorce). Children from these high-risk communities are more likely to experience significant exposure to violence and become witnesses, victims, or perpetrators of violence.

Public Health Fails to Collaborate With Other Agencies

Successful prevention effectively promotes health and reduces the risk of violent behavior. The social, environment, individual, and behavioral factors would incorporate specific health related factors as well as educational factors (i.e. increased knowledge of media). The challenge is to automate such preventions by way of collaborations between health, educational, and social institutions (14).

Recent public health approaches identify risk factors (media), they suggest how to positively utilize identified risk factors and how to address the negative effects of media violence on youth. Risk factors do no operate in isolation, the more risk factors a child is exposed to, the greater the likelihood that he or she will become violent. Risk factors can be buffered by protective factors. An adolescent with an intolerant attitude toward violence is unlikely to engage in violence, even if he or she is associating with delinquent peers. Risk factors increase the likelihood that a young person will become violent, but they may not actually cause a young person to become violent (13).

Public health fails to implement successful preventions with other agencies because it lacks a collaborative approach. The public health approach is traditionally viewed as promoting the well being of and individual and community (15). Regardless of government and other interested groups’ attempts to limit the amount of violence reaching homes, families themselves play a critical role in guiding what reaches their children. Public health succeeds in providing education to parents regarding supervision but does little to enforce the policies and preventions. Whether by adopting V-chip technology for home television programming, by using internet violence screening, or simply by monitoring closely children’s use of televisions, computers, and video games, parents can limit and shape their children’s selection of, interaction with, and response to media violence (13).

Public health interventions should be directed toward reducing the extent and effect of violence in the media for the whole population (universal interventions) and high risk individuals (targeted interventions), respectively. Research on vulnerable groups has shown that some children and adolescents are more susceptible to media influence than others. The UNESCO review of research findings suggest that everyone is negatively affected in some way by media violence, but that these effects depend on an individual’s cognitive appraisal, physical and social environment (4).

REFERENCES

1. Castro G. et al. Code Red: A Public Health Approach to School Gun Violence. A Case Study in Assessment and Policy Development Mid America Regional Public Health Leadership Institute Year 12 Fellows

2. Prothrow-Stith D. Strengthening the Collaboration between Public Health and Criminal Justice to Prevent Violence. The Journal of Law, Medicine & Ethics, April 2004.

3. WHO: Milestones of a Global Campaign for Violence Prevention 2005: Changing the Face of Violence Prevention. Geneva, Switzerland: WHO; 2005: 1-42.

4. Dahlberg LL and Krug EG. Violence- a global public health problem. In Krug E et al. World Report on Violence and Health. Geneva, Switzerland: World Health Organization; 2002: 1-56.

5. A Public Health Approach to Violence Prevention. The Social-Ecological Model: A Framework for Prevention. Atlanta, GA: Center for Disease Control and Prevention, 2008.

6. The Social-Ecological Model: A Framework for Prevention. http://www.cdc.gov/ncipc/dvp/Social-Ecological-Model_DVP.htm

7. Implement an Aggressive Public Outreach Campaign on Effective Strategies To Combat Juvenile Violence. http://ojjdp.ncjrs.org/action/sec8.htm

8. Press Release: FCC Commissioner Gloria Tristani, April 2000.

9. Browne K. The influence of violent media on children and adolescents: a public health approach. Birmingham, UK: Centre for Forensic and Family Psychology, 2005.

10. Knox L. Connecting the Dots to Prevent Youth Violence: A Training and Outreach Guide for Physicians and Other Health Professionals. American Medical Association June 2002.

11. Brown M. The Portrayal of Violence in the Media: Impacts and Implications for Policy. Trends & Issues 1996;55:1-6.

12. Zuckerman D. What is to Blame for Youth Violence?: The Media, Guns, Parenting, Poverty, Bad Programs, Or…Youth Today, November 2004.

13. Satcher D. “Youth Violence: A Report of the Surgeon General,” January 2001.

14. Jenkins R. The public health model for violence prevention: A partnership in medicine and education. Journal of Negro Education 1996; 1-10.

15. Skybo T. and Polivka B. Health promotion model for childhood violence prevention and exposure. Journal of Clinical Nursing 2007; 16:38-45.

HealthierUS Campaign Offers a Tradeoff of Education for the Choice to Live Better Lives - Meghan Schneider

Although the HealthierUS government initiative has the intention to promote healthy lifestyles through education on daily exercise to ultimately reduce and prevent disease, the flaws that make up the foundation of this strategy contribute the program’s demise. The purpose of this paper is to formulate evidenced-based criticism as to why this public health campaign has failed to produce positive health outcomes and to offer comparisons to other qualitatively different, more successful initiatives of which the US could potentially take advantage.

The HealthierUS government initiative is a national public health effort that began in 2002 designed to promote community health and wellness through education[1]. The four key elements to the initiative instruct individuals to “be physically active everyday,” “eat a nutritious diet,” “get preventative screenings” and to “make healthy choices.” Those four goals are conveyed via the HealthierUS.gov website where credible, accurate information is offered in order to help individuals “choose to live a healthier life.” Additional media pathways used to disseminate information to the U.S. regarding the overarching agenda of reducing costs of disease include presidential news releases, community-based programs, volunteer committees, government councils, and school based interventions.

Due to recent disturbing trends of the increased incidence and prevalence rates of potentially preventable diseases like obesity and diabetes (especially among children) and the subsequent costs of those diseases, the government has attempted to implement change by addressing individual behaviors. Two recent demonstrations of the program include the “President’s Challenge” where individuals can log on to a website and track their individual physical fitness progress, and “Steps to a HealthierUS” where funding is allocated to communities, cities and states to address risky behaviors like physical inactivity, poor nutrition and tobacco use. Despite these well warranted efforts to influence an individual’s choice to change their current lifestyle, the trajectory of obesity trends in the U.S. remain on the rise. This begs the question then, are children choosing to be obese or inactive? Are adults choosing to contract deathly diseases like coronary heart disease and diabetes? This paper argues against such a fallacy by illustrating the major flaws of the initiative that depend on this type of logic.

Argument 1: Limited Use of Behavior Change Models Yield Limited Results

Similar to many other public health interventions, HealthierUS relies on models like the Health Belief Model (HBM) and Social Learning Theory (SLT) devised by psychologists in order to predict individual behavior[2]. The basic premise behind the HBM assumes that a person’s engagement in a specific behavior is contingent upon a ‘perceived susceptibility’ to a particular health outcome, a ‘perceived severity’ of its significance and a weighted analysis of the potential costs and benefits that the action may incur. SLT provides a ‘self-efficacy’ component that incorporates the element of confidence that each individual has in themselves to take action[3]. This logical analysis has a direct correlation to the intent of the individual which theoretically predicts behavior. For example, HealthierUS campaign is laden with statistics about obesity, chronic heart disease and cancer aimed at influencing the perceived severity of inactivity. Additional ‘easy’ tips that advise on the type of activity implemented into a daily routine like walking the dog, gardening or riding a bike focus on the self-efficacy component. Individual confidence is built upon messages like “you can do it!” and “you’ve already made a good start.” Even the benefits are explicitly written in terms of reducing the risk for cancer, diabetes, high blood pressure and osteoporosis. Since the HealthierUS initiative is a prime amalgam of both the HBM and SLT, why have the rates of obesity increased from 25% among adults in 2002[4] to 34% in 2006[5]?

Unfortunately, the HBM fails to address major social, economic, and psychological experiences across different environments that are pertinent to predicting behavior. For example, suggesting specific activities like walking the dog make assumptions that everyone has safe places or sidewalks available. Moreover, how many individuals own gardens in New York City, and how many of those people live in low-income housing[6]? Addressing some of the barriers to achieving daily exercise like lack of accessibility, time or social networks help to delve into the contextual predictors of behavior change[7]. In doing so, this initiative could begin to tap into greater sub populations that have been largely ignored up to this point as illustrated in the previous 5-a-day campaign failure.

The “5-a-day for Better Health” campaign, which began in 2000 and then evaluated in 2004, is a prime learning source for illustrating the fate of a program that ignores basic individual social and economic differences. The basic goal behind the promotion was to influence the American people to increase their consumption of fruits and vegetables to five per day. Yet after evaluation, it was determined that there was little or no change in the amount of fruits and vegetables that people reported eating[8]. Access to fresh fruits and vegetables from specialty stores, farmer’s markets, and supermarkets like ‘Whole Foods’ is quite disparate for those living in low-income neighborhoods[9]. Similar to this correlation between the availability of supermarkets and healthier diets[10], a correlation also exists between accessibility to gyms, gardens, parks, or sidewalks and increased physical activity[11].

Other morbid statistics concerning widespread patterns of inconsistent safe sex practice among the gay men community also help to exploit the need for the recognition of contextual social factors within public health programs[12]. HIV and other deadly sexually transmitted disease prevention efforts have been primarily based on the assumption that raising levels of education surrounding safe sex practices will help to initiate change. Data does not support this assumption; rather, Ron Stall suggests that interventions must address the actual context with which risky sex behaviors occur. Similarly, educating the American public about healthy eating habits or physical exercise does not address the circumstances, like type of neighborhood or family structure that may influence actual food consumption and exercise practices.

Moreover, some argue that the amount of acknowledgement and understanding that policies lack is a motivating factor to having unprotected sex for gay males[13]. In a sense, the potential health outcome of unprotected sex is seemingly less destructive that the guilty, shameful, anxious or depressed feelings that are felt by some throughout their daily lives. So the actual messages that are being portrayed are in direct conflict to the core values of the target audience! In parallel, the method with which African Americans internalize racism and discrimination throughout their daily experiences could be influencing overeating and underactive behaviors. Or as some literature suggests, being large in the African American female community is a value that signifies empowerment or attractiveness to black men; education that focuses on being fit and thin also acts in contention with their own embedded beliefs[14]. Prevention programs like these that are formulated from the HBM or SLT are dangerously lacking the attention to major psycho-social variables essential for successful results.

Argument 2: Generational Gaps Expose Gaps in Results

Another argument as to why the HealthierUS campaign has failed to show significant results is in part due to the method of how the message is conveyed. To the website’s advantage, it incorporates attractive sites and links that are geared towards distinct age sub groups like children, pre-teens, adolescents and adults. Children can view a 30 second TV ad of their favorite Shrek characters who talk to them about exercise, healthy facts are integrated into contests and online games for pre-teens to enter, and famous NFL players like Reggie Bush speak directly to teens about the importance of sport and play as images of football, four-square, and freeze-tag are demonstrated throughout the video. This purposeful design illustrates both the Theory of Reasoned Action and SLT where changes in attitudes about exercise are influenced from external socially acceptable ‘characters’ who are held in such high esteem; the expectation is that these behaviors are then modeled. But there is a profound flaw with enticing very developmentally different age groups using the same tactic.

The success of the TRUTH campaign in Florida speaks volumes about how teenagers mentally synthesize the external world, which is qualitatively different from how kids or adults process their surroundings. In order to ‘sell’ the smoking prevention or cessation idea to teenagers, Florida’s Department of Health incorporated several new techniques which had previously been untapped resources in Public Health. This two-year program was funded from a $200 million dollar settlement allocated by the tobacco companies which helped create an unconventional branding method[15]. TRUTH began with actual youth pilot data that was translated into a marketing strategy that still maintained a humorous tone without manipulation. From 1998 to 2000, an evaluative study found that the percentage of youths using tobacco within the previous 30 days had declined by 7.4% in middle schools and 4.8% in high schools[16]. Again, the success among teens was related to unexpected images where they didn’t feel “they were being told what to do.”

Unfortunately, HealthierUS has not adopted any of the useful methods that are correlated to the TRUTH’s triumph over the tobacco industry. Instead, messages overtly implore teens in an officious manner to “be active everyday” and “eat better.” Given the extensive and well-documented data that mark the adolescent years as a time of rebelliousness and asserting independence, it would be counteractive to demand teens to change specific behaviors and expect results. Arguably, in doing just that could instigate even less participation by this sub-group.

One final salient point is that adolescence is also a primary time where individuals take on different identities and formulate tight cliques with those exhibiting similar interests. How teenagers act within these cliques directly relates to the Social Network Theory (SNT) which supposes that people behave differently as a group than they would as individuals. For example, the President’s Challenge campaign within HealthierUS is designed to set school standards that relate to five main assessments including a one mile run (endurance), sit-ups and pull-ups (strength), ‘sit and reach’ stretch (flexibility) and a shuttle run (agility). The program is designed to offer individuals the opportunity to compete against all others in their age group where they are measured against a percentile. The focus of this program offers the majority of the rewards to those that are already athletic, or the ‘jocks’ in the school, and does not attempt to interest those that are not currently active. A study exemplifying this phenomenon showed increased exercise involvement within a community based intervention only among those of whom reported engaging in at least some exercise prior to the intervention[17]. Perhaps if the President’s Challenge were ‘branded’ to cut across these social cliques, participation and success might mirror that of the TRUTH campaign.

Argument 3: Selling the Right ‘Products’ Sells Successful Results

The final contention with the HealthierUS initiative is its failure to use well-known marketing strategies that actually empower the U.S. audience. As previously mentioned, the tone of the four goals represented throughout the website and its implemented programs across the states implore individuals to outright change their behavior. And although the underlying message is a positive one with a motivational intent, previously cited rates of obesity from 2002 to present are a much greater indicator of a foundational error that precedes the actual type of conveyed message.

The idea of reducing obesity and disease rates without selling exercise, healthy eating habits, and regular health screenings may seem counterintuitive, but some of the greatest businesses across the globe have encountered enormous successes in not selling their product, but in selling something else. Multi-billion dollar industries like Miller, Volkswagen, Marlborough, and Louis Vuitton are just a few name brands that use this marketing strategy for their own capital advantage. These companies do not sell beer, cars, cigarettes, clothes or handbags; they sell better relationships, higher quality of life, autonomy, independence, strength, beauty, and youth. These are the precise messages that are too often lacking within public health initiatives like HealthierUS.

A few key concepts highlighted in successful marketing strategies of fortune 500 companies involve ‘defining the product’[18]. For example, customers interested in buying software will actually be sold increased productivity, efficiency and savings. In turn, HealthierUS ‘customers’ should not buy vegetables like broccoli, they should purchase sex or happiness. Another tactic cited was to ‘know the competition.’ In stark contrast, public health campaigns actually team up with their competition demonstrated by the sponsorship of initiatives from fast food chains like Burger King and McDonalds. Campaigns like HealthierUS must begin to adopt some more multi-dimensional marketing approaches in order to reap the benefits that so many other prosperous companies have effectively executed.

The marketing tools used throughout some of the most well-known product in the world have adopted the ‘4-Ps’, product, place, promotion, and price which takes into consideration the social perspectives of the audience[19]. How the product is branded, the mediums throughout the environment where the product is advertised, and the tone of the promotion follow mass societal views. Likewise, normative re-educative approaches to changing behavior involve similar non-cognitive and perhaps much less logically rational determinants like values, attitudes, personal emotions, and social norms[20]. Some of the underlying assumptions to this theory is that people live in social environments and generally adhere or ‘go with the flow’ with social standards. Because culture is a defining characteristic to this model, selling physical exercise should take into consideration some of the distinct culturally based American values intertwined with exercise[21].

Provided that there are many models and theories to choose from, selecting the most appropriate intervention is paramount. There is no specific formula for public health scientists, researchers and activists to apply that yield a 100% success rate. Some considerations include recognizing the desired degree of change and the subsequent resistance to change that may exist. Various dependent variables also take into account population size, time frame, available expertise and the stakes of the situation which can call upon very different model applications to obtain optimum results. The VERB campaign is one final example that illustrates the use of an appropriate strategy with victorious results.

Successful strategy

The underlying mission of the VERB campaign was to increase and maintain physical activity among pre-teens, or ‘tweens’ ages 9-12. This national, multicultural initiative which ran from 2001-2006 by the Center of Disease Control and Prevention used commercial marketing strategies to heighten awareness about the various options and opportunities tweens have surrounding physical activity[22]. Additional audiences included parents, teachers, youth leaders, pediatricians and coaches all targeted as a medium to spread the slogan, “it’s what you do.” Over 350 million federally funded dollars allowed for copious quirky ads throughout major television networks like MTV and Nickelodeon encouraging kids to find their own “verb” that reinforced their present core values of spending time with friends, playing, and having fun. Tweens began to gain ownership over general verbs like ‘run’, ‘jump’ and ‘swim’ and integrated them into their own personal actions or games that appealed to them. It did not take long for this innovative program to spread to communities and elementary schools across the nation where research evaluations quickly validated its success.

Just after year one of the program, over 3100 tweens completed a survey which found that 74% were aware of the VERB campaign, and those 9-10 year olds that were aware engaged in 34% more physical activity per week than those who were unaware[23]. These findings were also illustrated in an incremental fashion where the highest awareness correlated with the greatest amount of exercise in comparison to moderate and least aware subgroups. Another study after two years illustrated the same dose- response effect after 2250 parent-child dyads were surveyed[24]. Yet despite such positive results, the end of the VERB mirrored that of the TRUTH initiative when the Bush administration eradicated the federal funding so essential to its success[25].

The uncontested value of the VERB campaign lies within its framework to reach its target audience and illustrate positive behavior change. Using a brand name like VERB, coupled with sophisticated commercial marketing strategy, across every type of communication medium, made possible from great funding, is a prime example of an appropriate model application. The recipe for future public health campaigns directed towards all types of health outcomes can be this successful when the consideration of various ingredients of methods and models and properly executed.

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25. Krisberg, K. Successful CDC verb campaign in danger of losing funding: budget cuts likely. Nations Health: American Public Health Association 2005; 35(8).

AIDS Intervention Strategies in India: A Socio-Political Approach Explaining Why They Are Ineffective – Nandini Ravishankar

India, a country with a population of one billion, is experiencing a rapid and extensive spread of AIDS. When HIV infection was discovered in India in 1986, the health authorities set up the National Aids Control Organization (NACO), which was primarily funded by the World Bank and technically supported by the World Health Organization (WHO) (9).

The current AIDS estimate suggests that the national adult HIV prevalence in India is 0.36 percent, amounting to between 2.5 and 3 million people. This number has seen a drop of nearly 50 % from the previous estimate of 5.2 million people living with HIV/AIDS (9). However despite a decrease in the overall number of people afflicted with AIDS, the current numbers are considerably high with most of the affected population losing out on the productive years of their lives. The prevalence rate for men is 0.43% while for women it is 0.29%. Prevalence is also high in the 15-49 age group (88.7% of all infections) indicating that AIDS still threatens the cream of society, those in the prime of their working life (20,23).

However, despite the work being done to tackle the crisis, there are some hurdles that may hamper the progress of the current interventions. Disparities still exist in the effectiveness and applicability of the interventions to vulnerable populations. The strategies adopted by the National AIDS Control Organization (NACO) to mitigate AIDS in India have been ineffective because social and political pressures prevent the right groups from being targeted.

1. Adolescents are not provided with adequate education about HIV/AIDS

Social Learning Theory is based on the tenet that people do not learn behaviors in a vacuum, isolated from external interactions (1). The theory stressed that a large contribution to adopting behaviors stems from observing and then emulating the actions of others within an individual’s community. In Indian society, there is a high level of taboo associated with talking about sex. Much of the information is communicated through a non-verbal channel and there are estimates that about two-thirds of meaning is communicated nonverbally (13). When adolescents see their parents and other elders hesitating to talk about sex, it leads them to believe that sex is something to be embarrassed about and something that is negative in nature. Adolescents may also experience confusion as the message projected in the interventions may not be in line with their core values, the core values being ‘sex is not something to be discussed’. They are less likely to accept interventions that are against their core values and may thus dismiss the information and education provided.

As mentioned earlier, in India it is taboo to talk about sex and it is an even greater taboo for parents to talk about sex with their children. There have been many barriers that have been identified which impede parents from communicating with their children about sex and sexually transmitted diseases (STDs). Studies report that parents often feel inadequately informed, embarrassed and ineffective and have difficulty finding the right place and time for communication (12). Thus parents often do not talk about sex and the adolescent is reprimanded for asking questions about sex. Parental education allows the adolescent to incorporate the idea of sex in a way that is in line with their core values. This would enable the adolescent to be better informed and better adjusted to the concept of sex and sexually transmitted diseases. Parents can also tailor the presentation of information to the life circumstances and social and familial context of the adolescent (12).

In the absence of parental communication, adolescents often turn to other sources to get more information. Recent work has supported the position that peers are often responsible for the onset of risk behaviors in adolescents (25). This work implies that although teens acquire information regarding risk behaviors from parents, teachers and the media, peers may also play a crucial role in a child’s development by shaping his/her normative beliefs and interpretation of information regarding risk activities (24). Becoming a member of a peer group is one of the primary developmental tasks of adolescence (4). Peer groups influence adolescent socialization and identity by allowing young individuals to explore individual interests and uncertainties while retaining a sense of belonging and continuity within a group of friends (8). Although a key aspect of normal adolescent development, there may be costs associated with becoming a member of a group of people. Some have considered peer pressure the ‘price of group membership’ (3), which research has linked to a variety of potential problems including substance abuse, risk-taking behavior and delinquency as well as dating attitudes and sexual behavior. For many young persons, substance use, risk-taking behavior and sexual activity may represent efforts to ‘conform to the norms of the group and to demonstrate commitment and loyalty to other group members’ (15).

Another frequent source of information for adolescents is the media, which influences how adolescents think and is likely to have a great impact on their behavior. The modeling theory is particularly relevant to the study of mass communications because the portrayal or description of social life is a frequent subject in the media. The actors who portray real people in visual, auditory or print media often serve as role models for others to imitate (6). As seen with other behavioral influences, the negative consequences of risk-taking behavior are rarely mentioned in the media in a way that would provide adolescents with important information. In the current scenario, the message that adolescents get is that it is acceptable to indulge in risky sexual behavior without experiencing any negative consequences. This contributes to an increase in sexual risk taking behavior among adolescents as they believe in the ‘feel good’ message being projected without considering the reality of the situation (8).

2. Social Stigma attached to HIV/AIDS

In many Asian countries including India, homosexuality is still a taboo. The social ostracism is also evident from the fact that homosexuality is considered a crime by the Judicial System in India. The statute does not directly state the ban on homosexuality but follows a law that was set by the ruling British Government in 1860. The Indian Penal Code (Section 377) states that: “Whoever voluntarily has carnal intercourse against the order of nature with any man, woman or animal, shall be punished with imprisonment for life, or with imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine”. The punishment for this crime ranges from 10 years to life imprisonment. The word ‘carnal intercourse’ being vague, it has often been used against homosexuality (21). To bring about change in the current status of the HIV/AIDS epidemic in India, drastic changes need to be brought about not only at the societal level but also at the judicial level.

Goffman (1963) defined stigma as any condition, attribute, trait of behavior that symbolically marked off the bearer as ‘culturally unacceptable’ or inferior with consequent feelings of shame, guilt and disgrace (10). There is a high level of stigma that is associated with HIV/AIDS and very often, people do not confess that they have the illness which explains why the heterosexual partner, in most cases the woman is afflicted with the virus as well. The spread of HIV in India has been at its peak in the Western and Southern part of the country (19). Stigma associated with HIV-AIDS negatively impacts people’s decision regarding whether and when to be tested for the virus (26). Stigma therefore is a crucial aspect that needs to be understood in the management of people with HIV/AIDS. Stigma not only exists in the general community but also exists within the homosexual community itself. Results of a study indicated that many HIV-positive gay men perceived a division within the gay community related to HIV/AIDS. Their perceptions that HIV-negative men held stigmatizing attitudes toward HIV-positive men included feelings of sexual rejection and discrimination (5).

Social stigma and ostracism against homosexuality are held not only by society, but by the families as well. Homosexual men often are faced with the difficulty of dealing with the cultural expectations of their parents. They experience parental pressure to get married, have children, carry on the family name and traditions and not bring shame to the family by individual behavior choices and nonconformity (2). As a result of these expectations, many homosexual men choose not to come out of the closet. This prevents them from obtaining and having access to the right preventive information regarding HIV/AIDS. The perceived failure of meeting parental expectations associated with the role of the son, as well as the shameful stigma associated with homosexuality often leads the gay son to hold negative emotions like guilt, shame, low self-esteem, social inhibitions and insecurities (2). Very often, homosexual relations are maintained in secret without the knowledge of the family and in such situations, safe sex and the use of condoms take a backseat as keeping the relationship secret becomes the first priority. Choi et al. (1998) also conducted another study where they found that family obligations and homophobia in the community, along with negative sterotyping, marginalization contributed to low self-esteem and in turn resulted in risk-taking and lapses to unsafe sex (2).

The law criminalizing homosexuality has led to interventions that are designed to tackle HIV/AIDS but have not taken into account the needs of the gay community. Few published research studies have delved into the lives, the minds and the hearts of gay men to understand their feelings, attitudes, experiences and values. As a result, the public health interventions have failed because they have not targeted the core values of one of their target audiences: the gay community (18). One example of a shortcoming evident in the HIV/AIDS intervention programs that stems from a lack of insight into the lives, feelings and experiences of gay men is the virtual disregard for risk reduction as opposed to risk elimination strategies and the reluctance to candidly discuss, rather than merely dismiss as deviant, unsafe sex. As a consequence of the failure of the interventions, a sense of hopelessness and complete lack of control has arisen among gay men (18). Because they do not really believe that they will use a condom each time, many men assume that they are destined to become infected and therefore see no point in using condoms at all (11). This is an important issue to consider when initiating HIV/AIDS interventions. The needs, feelings and attitudes of the gay community must also be included. Thus, to tackle the HIV/AIDS crisis in India, interventions must not only focus on the heterosexual population and youth but must also address the fears and concerns of the gay community.

While it is important to address the individual behavioral factors that contribute to HIV/AIDS, it is also important to contextualize the risk factors, that is, attempt to understand how people come to be exposed to the individually based risk factors to design more effective interventions. By this, interventionsists must use an interpretive framework to understand why people come to be exposed to risk factors and the circumstances that shapes their exposure to the risk factors (14). For example, it is important in the framing of interventions to contextualize the risk factors for HIV/AIDS which would give a better understanding of why some people cannot avoid the risk. In a patriarchal society like India, it is important to understand the reasons why commercial sex workers are unable to get the men to practice safe sex which consequently may lead to an increase in the levels of HIV/AIDS in the sex workers.

3. Political factors impede HIV/AIDS Interventions

In a developing country like India with a population of one billion, there are structural inequalities that come with the treatment of HIV/AIDS. There are often other diseases and illnesses which take precedence over AIDS and the social taboos often play a role in influencing political agenda as well (16). Parker (2002) reported that a range of structural inequalities intersect and combine to shape the HIV/AIDS epidemic. There is an increasing gap between the rich and poor states with regard to public resources available for health, with resultant disparities in health outcomes (16). A major political concern that interventions need to consider and address is the reduction in the role of the central government in health care delivery. With decentralization and privatization being the answer to fill the gap in health care delivery, safety nets for the poor, especially those in the rural areas are being threatened. According to the WHO, India continues to bear the burden of the highest number of tuberculosis patients (7). With TB being an overwhelming burden and the leading cause of death in the country, there is less emphasis and priority given to HIV/AIDS. NACO programs are also supplemented by state level agencies, with great variabilty in terms of emphasis given by each state to the HIV/AIDS crisis. Many states are still in denial about the spread of HIV/AIDS within the state and thus are unwilling to provide money to tackle the crisis (7). Thus in order to address these concerns, more HIV/AIDS interventions need to be conducted at the state level to ensure that all citizens of the country have access to the same level of services and state governments must be required to co-ordinate activities in accordance with NACO. The partisan views of the various political parties must be addressed and modified for any effective change to occur in HIV/AIDS interventions at the political level.

Framing according to Tversky and Kahneman (1981) is ‘focusing the attention of people within a field of meaning’. Framing theory suggests that how something is presented (‘the frame’) influences the choices people make. The agenda setting theory is also closely related to the Framing theory (22). This theory states that agenda setting not only tells individuals what to think of an issue but also how to think about that issue. The agenda setting theory states that in order to get people to pay attention to the information, they have to view it as important and relevant (27). Thus, the moral, core values and principles of the current ruling political party determine how the crisis of AIDS will be tackled. The framing and agenda setting theory explain why conservative political parties would be more likely to promote the thinking that commercial sex workers are the most high risk populations as this is in line with social thinking and is likely to garner them more election votes. Thus by projecting AIDS as an issue among heterosexual individuals, the conservative political parties ignore the presence of AIDS among the homosexual population.

The Health Belief Model (HBM) was developed to explain health-related behavior at the level of the individual decision maker. The Health Belief Model (HBM) proposes that individual health beliefs associated with a disease or medical condition (i.e. perceived vulnerability to HIV/AIDS) determines their likelihood of engaging in preventive health actions (eg: use of condoms to prevent exposure) (17). The interventions developed by NACO also operate on the same rationale. It is believed that as long as individuals are provided with the interventions, they will utilize it based on their health beliefs. However the model and the consequent interventions fail to take into account socio-cultural factors. According to Choi et al., HBM has limited utility in addressing environmental factors affecting HIV risk because they ignore the wider social context within which the individual must circulate such as the family, and any communities of which an individual may be a member (2). Furthermore, the model assumes that all behavior is the result of a cost/benefit analysis, of calculated rational thought following the principle of self-interest. The Health Belief Model views the individual as devoid of emotion even though interacting with the wider social environment may entail situational and emotional difficulties for the individuals that consequently affect HIV risk (2). As seen with the model, there is a tendency for those in power to operate with an ‘inside the box’ rationale and an unwillingness to explore new avenues for progress. Combined with the bureaucratic and political pressure, there is an increased likelihood of interventions being built on top of earlier interventions with few modifications. While this may work for a certain period of time, it is important to acknowledge that interventions need to change with the changing times.

Implications for Future Interventions and Policy Decisions

In the light of the above mentioned factors, future interventions undertaken by NACO must therefore take into account socio-political factors. The crisis of AIDS can be successfully addressed only when all individuals who are at risk of contracting AIDS are targeted to receive the interventions. By excluding a particular group or ignoring important factors that may impact the prevalence of AIDS, the current interventions exhibit a lack of informed implementation. Despite being the largest democracy in the world, India still faces political hurdles that diminish the effectiveness and applicability of public health interventions. With the AIDS epidemic being a threat to the population of the country, more steps need to be taken to tackle the concerns at the grass root levels. While the current interventions have been shown to be marginally effective, it becomes more imperative to develop interventions that don’t just follow what has been done before but which incorporate the concerns of the diverse at-risk populations. Changes must originate at the grass roots level and must address individuals in the rural and urban areas. Changes need to be brought about at the societal and the judicial level for the gay community to feel accepted and acknowledged. Only when interventions addressing all populations and all concerns are developed will the battle on HIV/AIDS be successful.

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