D.A.R.E. to Know the Truth: The Ineffectiveness of DARE Due to an Inability in Addressing Context and Reality – Danielle Tuft

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.

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

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.
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The Truth About D.A.R.E.: Unsuccessful Application of Public Health Models Led To An Increase In Drug Use Among Adolescents – Nisha Bhinde

The Drug Abuse Resistance Education (DARE) program is an effort to provide children with the information and skills they need to live drug-free and violence-free lives. The program exists in nearly 80% of the school districts in the United States, in 54 countries around the world, and reaches approximately 36,000,000 students each year (1). Since the program’s inception in 1983, studies conducted by the U.S. General Accounting Office (GAO), the U.S. Department of Education, and many others concluded that DARE is ineffective in reducing the use of alcohol and drugs and is sometimes even counterproductive (2). Early DARE evaluations, from 1987-1989, were generally favorable, showing decreased alcohol, tobacco, and other drug use. The majority of the recent evaluations of DARE, however, show increased use of these substances (3, 4). These studies suggest that the DARE program has no significant long-term effect on preventing illicit drug use among adolescents.
According to GAO’s 2003 report, numerous studies found no significant differences in illicit drug use among students who received the DARE curriculum and those who did not. A few of the studies found that the DARE students showed stronger negative attitudes about using illicit drugs approximately one year after receiving the program. Unfortunately, these attitudes diminished over time and many students increased drug use after several years (5). In response to these results, the U.S. Department of Education now prohibits schools from spending federal money on DARE (6).
Nevertheless, DARE is still one of the largest education-based drug control programs taught in school districts nationwide. The program spends over $1 billion dollars annually to provide students with trained police officers, educational resources, and materials and supplies needed for the curriculum (7). Unfortunately, the benefits of the DARE program do not outweigh these costs. The DARE curriculum attempts to use the scare tactic to deter students away from drugs, yet the program’s supply of DARE paraphernalia actually increases students’ curiosity and experimentation. Additionally, presenting trained officers to teach the curriculum creates a disconnect between the instructor and the student because adults cannot easily relate to the adolescent world (8). DARE also focuses on completely refraining from drug use, which decreases many students’ level of self-efficacy and increases their likelihood of creating self-fulfilling prophecies. DARE’s approach to provide effective drug abuse resistance education has failed to impact its young audience through unsuccessful application of public health models.
DARE glamorizes and demonizes drugs at the same time
DARE attempted to convey the seriousness of drug use and violence by utilizing uniformed police officers and promotional paraphernalia, such as buttons, bumper stickers, t-shirts, and the program’s mascot, Daren the bear. Inadvertently, the students directed most of their focus on the police officers’ guns, seized drug vehicles, and all of the free DARE materials. The students were attracted to the glamour rather than the content of the presentations, illustrating the “forbidden fruit” syndrome (9,10). This effect refers to indulgence or pleasure in something that is tempting but dangerous (10).
Even though the DARE curriculum teaches students about how dangerous drugs are, curiosity tempts many students to try them anyway. This is not surprising because adolescence is a time when many choose to experiment. It is a time when teens start to listen to new music, try new sports and activities, read new books and magazines, and even try drugs and alcohol (11, 12). In fact, curiosity is accepted as the most common motive for initially trying drugs. Research indicates that many adolescents want to know how it feels to lack inhibitions; they believe it will help them to better understand who they are (13). Accordingly, the DARE officers were unsuccessful in preventing the students’ increased awareness and curiosity from being translated into illegal use. The evidence suggests that by exposing young impressionable children to drugs, the program was encouraging and nurturing drug use (14).
Aside from curiosity, the increased drug use among students may be a result of adolescents’ risk-taking characteristics. Studies show that the onset of puberty is related to an increase in risk-taking, sensation-seeking, and reckless behavior (15). Many youths feel the need to expose themselves to unsafe environments and new and exciting experiences (13). Often times, students discover these experiences through drug-resistant education programs such as DARE. The name DARE itself also encourages risk-taking behavior. The word “dare” often means a challenge to do a hard, dangerous, or rash thing, especially as a test of courage. Therefore, adolescents often dare to go against what they learn in classroom, which is “just say no” to drugs. The main lesson students learn is the concept of rejection, which they reinforce by challenging the entire DARE program (9).
The method used to teach the students about drugs involves the scare tactic. The strategy here is to induce fear into the students by telling horror stories of junkies, crackheads, and other drug users who spend a majority of their lives supporting habits that they cannot control (16). Additionally, DARE lumps all drugs together into one category: Marijuana, cocaine, heroin, LSD, PCP, ecstasy, and even cigarettes and alcohol are all equally dangerous (17). Such categorization demonizes all drugs and exaggerates the dangers of the less harmful substances. DARE believes this tactic will scare young people into refraining from drugs. Research suggests that scare tactics are not only ineffective, but they can be counterproductive. As young students mature, they realize the fallacy of the myths that were once presented to them as fact, which causes the officers to lose credibility (18).
Many other public health campaigns have also used this fear-arousal approach to attempt behavior change. Fear messages increase the severity of the perceived threat, which motivates the recipient to change his or her behavior to reduce that threat (19). However, if an individual doubts that the recommended behavior change will be effective, then he or she will focus on eliminating the fear through denial or reactance (19). Communication theory suggests that using tactics that induce fear have the opposite intended effect because they cause a complete denial of the message (20). Thus, students should not hear that all drugs taken in any amount will lead to the path of destruction. Once youths actually begin experimenting, their experiences differ from what they learned. As a result, the entire prevention message is lost and increased drug use results.
DARE officers cannot relate to students’ situations
Communication theory also states that in order to develop a persuasive message, the audience must see the messenger as a credible source of information. This means that the messenger must display honesty and similarity to the receiver (20). With time, the instructors begin to lose credibility when the students compare their experiences outside of the classroom to what they learned in school. Students observe their peers and older siblings to find that what they see is often less serious than the experiences of the police officers. Such discrepancies lead to a loss of trust in the authoritative figures because it appears as though the instructors are lying to the students.
In addition to falsified information, many of the police officers who advocate for restraint have themselves previously used or currently use tobacco, alcohol, and/or drugs. For example, an Iowa DARE officer who was caught stealing drugs, trafficking methamphetamine, and making pornography was returned to teach in the classroom (9). There have also been several other cases reporting DARE officers who take smoke breaks in plain view of the students (21). This leads students to perceive the instructors as hypocrites, and in turn rebel against what they are teaching. As with fear messages, studies suggest that if students have negative perceptions of influencing agents, in this case the police officers, they will do the opposite of what the influencing agent desires (22). This is a case of an unsuccessful application of the social learning theory.
Social learning theory states that people learn from one another through observation, imitation, and modeling, which then leads to behavior. Two of the necessary conditions for effective modeling include attention, or selectively concentrating on a specific stimulus, and motivation, or having a good reason to imitate (23). With the DARE program, the students attention shifts away from the intended stimulus, the drug information, toward another stimulus, the drug paraphernalia. In the case of the students and the hypocritical police officers, there also does not appear to be a good reason to imitate. In fact, the students seem to have good reasons to not imitate the officers because they lied. Therefore, DARE does not create an environment conducive to effective modeling.
While there is distrust of information received about drugs and alcohol, there is also a lack of information for those students who have previously tried drugs or alcohol. The DARE officers focus on completely refraining from use and tend to ignore the important distinction between use and abuse. They make the mistake of treating any use as abuse. Students are not offered information on how to distinguish the differences between various alcoholic beverages, on the importance of having something to eat when consuming alcohol, or on how to pace one’s self when drinking (18). Thus, the current approach of DARE stigmatizes drugs and scares youths into refraining from these substances, rather than providing them with information on how to reduce the risks of drug and alcohol use.
DARE decreases self-efficacy and increases self-fulfilling prophecies
By focusing on complete risk-elimination, meaning to prevent all of one’s risk of a bad health outcome from occurring, rather than risk-reduction, meaning to merely reduce a person’s risk, DARE’s message sets unrealistic goals for the students (24). According to the social cognitive theory, a person’s decision to engage in a particular behavior is influenced by the person’s perception that he or she can successfully complete the behavior and achieve the desired outcome. This perception is reflective of the individual’s level of self-efficacy (23). Thus, when students who have previously said yes to drugs or alcohol hear the message “just say no,” they lose confidence that they can overcome the obstacles that led them to say yes in the first place. DARE portrays a negative attitude toward those who have tried illegal substances, which discourages students and sets them up to fail. Essentially, DARE decreases the youths’ level of self-efficacy by insinuating that they can never be redeemed for their actions (23).
Social cognitive theory also suggests that changing a behavior is a function of individual characteristics, including their level of self-control (23). As previously mentioned, puberty is a peak stage for seeking out risk-taking behaviors, thus a student’s level of self-control is lower at this age. Additionally, recent brain science suggests that teens’ brains may in fact be partly to blame. Imaging studies have shown that brain development of the frontal lobe, which is the center for planning, understanding cause and effect, foreseeing consequences, and controlling impulses, is still occurring during adolescent years (25).
In addition to decreasing self-efficacy, DARE also increases students’ creation of self-fulfilling prophecies. A self-fulfilling prophecy is a prediction that directly or indirectly causes itself to become true (26). This concept is a feature of the labeling theory, which states that an individual’s behavior is influenced by how he or she is characterized by other people in his or her society and the ‘label’ he or she is given (27). In many societies, adolescents who have tried drugs or alcohol before are often labeled as “bad” or “tainted.” Thus, these youths have no other choice but to conform to the essential meaning of such judgments, fulfilling their own prophecies.
Labeling theory also incorporates the concept of stereotypes. People tend to generalize that if a person does one drug, they probably do other drugs, and they are labeled as “druggies.” This is parallel to the concept of the gateway theory, which holds that using one substance, such as alcohol or tobacco, leads to the use of other substances. However, years of government research have failed to produce any evidence that using one substance causes the use of another (17).
Conclusion
While the DARE program proved to be effective in reducing alcohol, tobacco, and other drug use in the short-run, its impact diminished as the recipients of the program grew older, unintentionally leading to increased drug use. DARE’s attempt to increase drug awareness in order to prevent youths from trying drugs resulted in increased curiosity and experimentation of different substances. Additionally, DARE’s implementation of the scare tactic and its attempt to utilize communication theory had a boomerang effect. DARE fails to address the idea that the audience must see the messenger as a credible source. The instructors teach lessons that differ from their own lifestyles as well as from what the students actually experience, thus the officers’ trust is lost. Finally, DARE decreases self-efficacy and increases self-fulfilling prophecies by focusing on temperance rather than risk-reduction. In order to make DARE more successful, the program must appropriately apply social and behavioral health models such as communication theory, social learning theory, social cognitive theory, and labeling theory.
REFERENCES
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"Above the Influence" Goes Down in Flames: Failure to Consider Their Target Audience Dooms Government's Anti-Marijuana Campaign -- Sarah Kenney

Between 1998 and 2004 the Office of National Drug Control Policy (ONDCP) poured over $1.2 billion into the National Youth Anti-Drug Media Campaign, yet a 2005 evaluation of the campaign found that it was not effective in reducing drug use among teenagers (1). In the same year the report was issued, the Anti-Drug Media Campaign launched “Above the Influence,” a series of print and television advertisements that advocate against marijuana use among teenagers. The “Above the Influence” campaign is proving to be another failed campaign developed by ONDCP. The lack of consideration given to the campaign’s target audience (teenage marijuana users) and the social conditions under which these teens live, contributed to this campaign‘s ineffectiveness. The "Above the Influence" campaign fails to affect changes in youth behavior for several reasons: 1.) they alienate their target audience by negatively
labeling them as "stoners", 2.) they do not provide positive models for adolescents to emulate, and 3.) they exaggerate the consequences of marijuana use, thus, their message does not resonate with the target audience.

Negatively label the target audience as "stoners"
Labeling theory is concerned with how the behavior of an individual is influenced by the way that individual is "labeled" or categorized by others in society (2). Labeling theory seeks to explain the long-term consequences of negative labels on a person's self-identity. When people are labeled negatively they begin to think of themselves negatively, and they then begin to act negatively and thus the label becomes a self-fulfilling prophecy.

The commercials in the "Above the Influence" campaign use descriptors such as "remarkably unmotivated" and a variety of other negative labels to describe adolescents who smoke marijuana (3).They show adolescents sitting on "Pete's couch" until they are 86 and a group of boys who let their non-stoner friend "live life for them" because they cannot make any decisions on their own (3). The ad spot titled "Whatever," even goes so far as to suggest that the boy who doesn't smoke weed is going to leave the other stoners behind when he goes off to college, thus suggesting that if you smoke weed you won't go to college. All these negative labels seem bound to affect the way adolescent pot smokers view themselves. If others in society think they are unmotivated and aren't going anywhere in life then maybe they will start to believe this and act accordingly.

When negative labels damage the adolescents’ self-image, they also damage their self-efficacy to stop using marijuana. The concept of self-efficacy is the focus of Albert Bandera's social cognitive theory, and it is the belief that one is capable of accomplishing a goal or performing a task (4). An important influence on a person's self-efficacy is social persuasion i.e. the encouragement or discouragement someone receives from others when trying to accomplish a goal. All the commercials in the "Above the Influence" campaign show unmotivated adolescents making bad life decisions. The messages discourage the audience's self-efficacy to stop smoking pot because if society feels stoners are unmotivated and unable even to get off Pete’s couch, then they certainly do not believe they are capable of stopping their marijuana use. Thus damaging the target audience’s self-efficacy to stop their marijuana use will not result in the desired behavior change.

There are no positive role models for adolescents to emulate
Modeling is a component of social learning theory, which emphasizes that most human behavior is learned through observing and then modeling the behavior of others (5). Social learning theory plays a large role in understanding adolescent behavior because peer influence and acceptance has such a high priority in that stage of development (6).The "Above the Influence" campaign has an abundance of adolescent stoners modeling negative behavior e.g. pot smoking, yet the ads are trying to get today's youth to stop smoking marijuana. What the campaign does not have is adolescents modeling positive behavior e.g. not smoking pot. The campaign is then telling adolescents what not to do--smoke marijuana--without offering them a positive alternative.

Young adolescents are particularly susceptible to peer influence, both good and bad (6). Thus, a more effective utilization of social learning theory would be to present the “don’t use drugs” message through a positive peer role model. Instead of wasting money on ineffective advertisements void of positive peer influence, the government could actually create more positive role models through peer mentoring programs.

Unrealistic consequences of marijuana use discredits message
When exaggerated dangers or false information are presented to teens, they tend to disbelieve the message and discredit the messenger especially if they have access to contrary information and experience (7, 8). The “Above the Influence” campaign presents a number of unrealistic consequences that an increasingly savvy adolescent population is just not going to buy into. One ad spot titled “Cocoon” (3), depicts a young boy in his room smoking weed, day in and day out, until he is suddenly encased in a cocoon. The boy then emerges as a balding, overweight, middle-aged man who is still living in his parent’s home and the TV screen reads, “what you choose today -- affects who you are tomorrow.” This advertisement is saying to the audience, if you smoke weed you will become unattractive and live with your parents for the rest of your life. However, most teenagers know plenty of young adults who smoke weed and still go to college or have jobs and live on their own and consequently this advertisement is unrealistic--almost laughable--and will not resonate with adolescent audiences because they have access to knowledge that is contrary to the message.

Conclusion
Evaluations of the ONDCP’s media campaign have been consistent in only one area: they are not an effective method for reducing drug use. “Above the Influence” demonstrates that when implementing media campaigns there needs to be more use of formative research with the target audience to ensure that the message is effective. Had the ONDCP considered their audience, they would not have misused labeling theory and thus would not have damaged their target’s self-efficacy with negative labels. Also, if ONDCP paid more attention to research in behavioral science, they would know that including positive role models in their ads would be a more effective means of changing behavior. Lastly, if they did their research, the campaign creators would be aware that exaggerating the consequences of marijuana use is not an effective means of changing behavior in adolescents.

References
1. United States Government Accountability Office. Contractor’s National
Evaluation Did Not Find That the Youth Anti-Drug Media Campaign Was Effective in Reducing Youth Drug Use. Washington, DC: GAO 06-818, 2006. http://www.gao.gov/highlights/d06818high.pdf.
2. Calhoun, C., Light, D., & Keller, S. (1989). Sociology (5th. ed.). Alfred A.
Knopf: New York. http://www.skidmore.edu/academics/english/courses/en205d/student7/labelling.html.
3. “Above the Influence.” The Ads. Washington, DC: National Youth Anti- Drug Media Campaign. http://www.abovetheinfluence.com/the-ads
4. Pajares, F. (2002). “Overview of social cognitive theory and of self-efficacy.” http://www.emory.edu/EDUCATION/mfp/eff.html.
5. Kearsley, G. (1994). “Social Learning Theory.” Theory Into Practice Database. http://tip.psychology.org/bandura.html.
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Needle Exchange Programs: An Unrealistic Approach to Decreasing Rates of HIV/AIDS – Elyssa Pesin

The HIV/AIDS Epidemic
Human Immunodeficiency Virus (HIV), the virus that causes AIDS, attacks the immune system, leaving the body vulnerable to a variety of life-threatening infections and cancers [1]. This devastating disease is the focus of many public health interventions in the United States, especially among intravenous drug users (IDUs), a recognized risk group. Nevertheless, current efforts are inadequate to address the complex risks associated with injection drug use, particularly among disadvantaged populations [2]. The nature of intravenous drug use, specifically the process of preparing and injecting drugs, is conducive to the spread of HIV. As the CDC reports, “many opportunities for contamination with and transmission of HIV or other blood-borne viruses” exist among IDUs, due to the mechanics of drug injection [3].

Introduction: A Public Health Intervention
Needle Exchange Programs (NEPs), in which IDUs exchange dirty needles for clean replacement needles, are intended to be a critical strategy for containing the spread of HIV and other blood-borne diseases within this population. However, issues relating to social and behavioral sciences, differences in socioeconomic stratum and sociopolitical issues contribute to the failure of implementation in the United States. Contrary to the 1980’s United States Drug Campaign known as the “war on drugs,” using the slogan “Just say no,” the NEPs’ ideology is based on “Just say yes,” as these programs prioritize HIV/AIDS prevention over reducing drug use.
In a social and behavioral context, the Health Belief Model (HBM) was developed to explain health-related behavior at the individual, decision-maker level. The focus of this model is preventative health behavior of individuals, assuming that human behavior is determined by an objective, logical thought process. HBM includes four concepts: “perceived susceptibility,” “perceived severity,” “perceived barriers to taking that action,” and “perceived benefits of an action” [4]. With regard to NEPs, the former three concepts are skewed and lead to NEP failures. First, instead of realizing that the perceived susceptibility of drug use is the chance IDUs will overdose, develop neurological problems, or acquire multiple chronic and acute illnesses, the perceived susceptibility is the realization that IDUs could only contract HIV/AIDS through dirty needles. Second, IDUs overlook the perceived severity, that is, how severe the effects of transmitted diseases might be, as they continue to use drugs and reject other ways blood borne diseases are transmitted - through sexual contact [5]. Lastly, the perceived barriers and costs of emotionally and financially supporting drug use are overlooked by NEP creators and supports. Interestingly, NEPs use an HBM limitation to their advantage – that is, if drug users have the intent to do a particular behavior, they will do it. Thus, NEPs are structured around the susceptibility to HIV/AIDS and the perceived benefits of preventing the transmission of the disease through shared needles.
By expecting drug-users to seek out these programs on their own using undersupplied and underprovided distribution methods and providing limited geographic locations, needle exchange programs fail to decrease HIV/AIDS through shared needles within the IDU population. More specifically, failures of NEPs can be seen in their inability to reach many drug users due to geographic disparities, broad target populations, and limited distribution strategies.

Reason for Failure #1 – Geographic Disparities
Failures of NEPs are attributed to several different models of social and behavioral science. First, the Stages-of-Change model applies to IDUs who utilize NEPs, who realize they engaged in drug use, who contemplated the risks of intravenous use, and who decided to address those risks by participating in a needle exchange program. Nevertheless, the “action” and “maintenance” stages of change in NEPs, where individuals begin to engage in a new behavior and attempt keep that pattern going or sustain the new behavior respectively, is flawed [6]. This relates to an IDUs use of NEPs, as research shows there are inconsistencies in location, equal distribution of supplies, and accessibility [7]. As a result, IDUs are not able to engage in and maintain this new behavior consistently. Herein lies the first problem: NEP geographic disparities.
Geographic disparities in access to NEPs present clear difficulties to program utilization. Indeed, NEP locations do not always correspond to a demand for such a program in the area. In 1999, a study reported the existence of NEPs in 81 cities and 31 states as well as the District of Columbia. The study concluded that many of these programs were heavily concentrated in four states: California, New York, Washington, and New Mexico. Yet, data suggest that New Jersey – a state with high demand for NEPs –disproportionately lacks in access to these programs [8]. As Barbara Tempalski reports, “injection drug use is the most frequent reported risk behavior among HIV-positive individuals” in New Jersey, and in Jersey City, Newark, and Bergen-Passaic have some of the highest rates of IDU related AIDS in the country [9].
Even within existing NEPs, inequalities in supplies inhibit the efficacy of these programs; twelve of the largest programs, for example, receive 62 percent of available syringes, leaving other NEPs without adequate supplies [10]. The unequal distribution of NEPs and NEP-related resources do not address disparities in HIV prevalence among socially disadvantaged groups or the geographical distribution of IDUs.
One last social and behavioral theory can be attributed to the first reason for NEP failure. The last several stages of the Diffusion of Innovations (DOI) theory are interrupted, as the NEP geographic and inventory shortages prohibit the success, wider implementation, and unrestrained use of this public health intervention. Within the DOI theory, the “adoption process,” is affected by insufficient locations, supplies, and geographic representation, prohibiting the “uptake” of the behavior by IDUs. According to this principle, “uptake” requires movement through knowledge of NEPs, persuasion or attitude development (about adopting behavior), decision (to adopt behavior), implementation, and confirmation, and none of these steps can occur, as NEPs fail to be equally accessible or sufficiently equipped [11].

Reason for Failure #2 – Broad Focus
Two additional social and behavioral principles can be applied to a second reason for NEP failure. On one hand, the success of NEPs relies largely on selecting a target population, where IDUs among different socioeconomic strata are the targets. The widespread use of the intervention relies on these social groups or networks to communicate the benefits of the program. On the other hand, failure to account for the “political economy,” which has an important bearing on why and how people do what they do, and consequently, how people change what they do, affects the efficacy of NEPs [12]. Both political economy and behavior are factors that must be addressed when assessing the inadequate and very broad focus of NEP interventions as it contributes to the crisis of HIV/AIDS in poor, urban communities. Because HIV/AIDS has such a disproportionate effect on poor, minority, and urban communities, NEPs are suffering because they frame HIV/AIDS as just a health problem, rather than the product of a larger set of social relationships, particularly relationships of socioeconomic structure, class, ethnicity, and gender [13]. Consequently, the NEP failure is rooted in its very broad focus, as they do not take into account the aforesaid larger set of social and political relationships.
Despite drug regulation, illegal drug use continues among the underserved and the needs of those who seek prevention or treatment have not been met. As Dr. Adewale Troutman states in his on-line tutorial Creating Health Equity Through Social Justice, “the existence of social injustice typified by the continued growth of the gap between the have and the have-nots, lack of access to services and care, preventive and curative is unethical and immoral” [14]. This inequality is ever-present among IDUs. According to Richard Hofricter, although overall life expectancy has increased and mortality rates have decreased in the twentieth century, “an increasing level of inequality in the health status and mortality of those with less material resources in relation to their social class, particularly in ‘communities of color’ persists” [15]. Moreover, disadvantaged groups do not benefit equally from advances in HIV and AIDS intervention, treatment and prevention.
While the HIV/AIDS epidemic has had a disproportionate impact on certain populations, particularly racial and gender minorities, NEPs do not effectively narrow their focus among these groups. Within the IDU population, disadvantaged groups are especially vulnerable to HIV infection. In certain racial and ethnic groups, half of the deaths due to HIV in both African American and Latino populations can be attributed to injections with contaminated needles. Furthermore, African American IDUs are 5 times as likely, and Latinos are 1.5 times as likely as white IDUs to develop AIDS [16]. These statistics highlight the limitations in the breadth of NEP, as programs do not have specific strategic plans to reach each group.
The African American experience portrays an obstacle that NEPs do not address or overcome with regard to ethnicity. African Americans are increasingly vulnerable to the transmission of HIV/AIDS. With this, another social and behavioral principle accounts for the larger HIV/AIDS cases in this group: the Social/Environmental Context, and more specifically within this context, the Historical Context. Historically, African American communities have greatly opposed NEPs as a consequence of their distrust of the government and medical trials in general. According to Stephen Thomas, African Americans’ adverse response to NEPs is connected to the “persistent neglect of the drug abuse epidemic, mistrust of public health authorities, and fear that the broader society may consider large segments of the black population expendable consumers of scarce human and economic resources” [17]. Many of these opponents worry that needle exchange programs will ultimately lead to Tuskegee-like abuse of research subjects [18]. Within many African American communities, NEP initiatives are held in high suspicion due to historic exploitation and discrimination [19]. With these factors, one can observe that throughout various segments of the American public, NEPs prove controversial. This Social/Environmental Context is relevant, as the Tuskegee-mentality is shared across this group, contributing to an African American experience made up of historical influence and personal experience interacting with the environment that inhibits this group from utilizing NEPs [20]. The failure of NEPs in this group is rooted in the history of the African American experience for which NEPs do not account.

Reason for Failure #3 – Methods of Distribution and Legal Implications
A third reason for the failure of NEPs lies in their distribution strategies, which are neither private nor anonymous. When using NEPs, IDUs must make themselves publicly available to the needle “exchanger” and must make behavioral changes through regular needle exchanges. For this reason, there is a great deal of social and personal responsibility, motivation and social and personal acceptance of help. The two primary methods of delivery are fixed NEPs located in pharmacies or health and community centers and NEP vans that drive through areas with known groups of IDUs [21][22]. Both of these methods of delivering exchange services require IDUs to seek out needle-exchange programs, which deter many from utilizing them. For this reason, drug-users typically refrain from using NEPs, consequently transmitting disease.
Many states have opted to utilize pharmacies in addition to local community centers to allow IDUs to obtain sterile syringes if businesses choose to participate. Nevertheless, while the pharmacy model has been shown to dramatically reduce the risk associated with IDU, not all geographic areas have benefited from these programs. For example, in New York, it is legal for pharmacies and other organizations to register and to provide up to ten syringes to individuals over the age of eighteen without prescriptions [23]. However, many pharmacists have refrained from participating in such services due to personal beliefs of fear that the presence of IDUs are detrimental to their businesses [24]. Moreover, the exchange of syringes in this model is not necessarily free, so many IDUs are unwilling or unable to participate [25]. For this reason, implementation of the pharmacy exchange model has been piecemeal and inadequate, contributing to the failure of NEPs in pharmacies.
Mobile exchange services are the second method of distribution which intend to reach more drug users. These mobile programs, which have predetermined van routes, are interventions for including hard-to-reach individuals and those who do not typically access mainstream services. For instance, an analysis of a 1997 Baltimore program revealed that mobile services attracted twice as many high-frequency injectors as pharmacy programs [26]. Furthermore, a study of the Vancouver program, which consisted of a variety of different facilities, reported that 65 percent of participants obtained some of their needles from the van and 17 percent used the van as their main needle source. Typically, users of this mobile exchange injected more frequently, were younger, more likely to engage in prostitution, and less likely to enroll in a drug treatment plan [27].
The mobile exchange model, whose intention is to reach those who are unable to access participating pharmacies, has several limitations [28]. First, the mobile programs offer fewer opportunities for counseling and other educational service, as the mobile programs do not afford lengthy time intervals during which the staff and clients can interact. Second, in the case of the San Diego, California NEP, IDUs refrained from visiting this site because legislation fails to protect IDUs from state laws prohibiting the transport of drug paraphernalia. In fact, reports confirm that law enforcement officers wait outside NEPs and arrest individuals suspected of carrying syringes [29]. Two social and behavioral theories, the Social Cognitive Theory and more specifically the Social/Environmental Context applies to the existing laws pertaining to drug paraphernalia in each state [30]. Drug paraphernalia laws, which exist in all states except Alaska, hinder the sale, distribution, purchase, and possession of syringes. In fact, 20 states have drug paraphernalia laws that are used against IDUs who possess a syringe [31]. Additionally, pharmacies may implement their own requirements and regulations that inhibit access [32]. The fear that this regulatory environment and existingpolicies instill in IDUs prevents them from accessing either method of distribution, even though the presence of these programs is acceptable. A third theory known as Political-Economic Space - a space that is governed by a specific political system, with regulations, values, and procedures –applies to the existing regulations and laws that affect health [33]. In this framework, many states, even those that support NEPs, continue to restrict the sale of syringes to pharmacies and require IDUs to have a prescription, provide valid identification, or disclose their reasons for purchasing the syringe [34]. This barrier to access is associated with the Political Economy, as NEPs encompass a wide range of theory and history about the links between politics and behavior, and their functions in society [35]. While NEPs focus on reducing disease transmission through sharing needles among IDUs, NEPs have failed to address the legal implications of the program such that the legal framework and Political Economy deter users for fear of identification and police harassment.
The lack of anonymity in these two methods of distribution makes IDUs vulnerable to the ever-present legal and regulatory barriers to access and to possess sterile syringes. Barriers include: drug paraphernalia laws, syringe prescription laws (both of which place restrictions on syringe exchange programs), pharmacy regulations and practice guidelines, fear of identification and police harassment - presenting obstacles to participation and decreased disease transmission. Further, the fear instilled in IDUs is largely derived from a Social Cognitive Theory known as Reciprocal Determinism, in which a person acts based on individual factors and social environment cues, receiving a response from that environment, and adjusting behavior accordingly [36]. In this fashion, IDUs act based on their personal responsibility and motivation to use NEPs, but ultimately react to the negative “cues,” that is regulation and punishment for attempting to use this intervention. Lastly, the concept of Self-Efficacy applies, as IDUs’ past experiences with NEPs will affect whether they are motivated to use this intervention. IDUs with low Self-Efficacy regarding NEP use may feel more hesitation, and when they actually use the program, may be reluctant to use it for fear of being punished. Once IDUs feel comfortable and confident in their chosen NEPs, this sense of Self-Efficacy may help the IDU continue this intervention and spread the word about NEPs in their networks [37].

Conclusion
NEP programs, meant to decrease HIV/AIDS transmission, are unsuccessful not only structurally, but also for reasons surrounding social and behavioral sciences, socioeconomic strata, and sociopolitical issues. More specifically, NEPs fail to address their geographic disparities, political patterns, and relationships of ethnicity that contribute to the efficacy of this intervention. This intervention fails to identify groups of IDUs on which to focus their strategies, as the target population is much too large to see positive results, that is, a decrease in HIV/AIDS transmission. After this assessment, it is clear that HIV/AIDS affects a wide-ranging population of potential NEP users who, in one form or another experience barriers to access.

References
1. Centers for Disease Control and Prevention. Prevention Among Injection Drug Users. US Department of Health and Human Services, January 2007. http://www.cdc.gov/idu/default.htm. Date accessed: 27 Mar 2008
2. Ibid.
3. Ibid.
4. Rosenstock, Irwin M. Ph.D. Historical Origins of the Health Belief Model. Health Education Monographs 2 (4): 328-335, 1974.
5. Centers for Disease Control. op.cit.
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8. Robert E. Fullilove and Mindy Thompson Fullilove. HIV/AIDS in the African American Community: The Legacy of Urban Abandonment.
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17. S.B. Thomas and S.C. Quinn. The Burdens of Race and History on Black Americans’ Attitudes toward Needle Exchange Policy to Prevent HIV Disease. Journal of Public Health Policy, 14(3):320–347, 1993.
18. Ibid., p337
19. Ibid., p343
20. Edberg, Mark, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, 52.
21. Institute of Medicine of the National Academies. Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence. The National Academies Press, 2006.
22. Riley E.D., M. Safaeian, S.A. Strathdee, M.A. Marx, S. Huettner, P. Beilenson, and D. Vlahov. Comparing New Participants of a Mobile Versus a Pharmacy-Based Needle Exchange Program. JAIDS Journal of Acquired Immune Deficiency Syndromes, 24(1):57–61, 2000.
23. Institute of Medicine of the National Academis. op.cit.
24. Institute of Medicine of the National Academis. op.cit.
25. Institute of Medicine of the National Academis. op.cit.
26. Riley, E.D. op.cit. p59.
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32. Ibid., p 6-9.
33. Edberg, Mark. op. cit. p52.
34. Ibid., p52.
35. Ibid., 72.
36. Bandura A. The Self System in Reciprocal Determinism. Am Psychol. 1978; 33:344-358.
37. Bandura A. Social Learning Theory. op. cit.

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

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

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

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

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

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

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