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

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

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

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

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

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

SOCIAL MARKETING THEORY AND SMOKING

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

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

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

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

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

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

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

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

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

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

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

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

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

Failure Of The Healthy Futures Program-Grace Thiongo

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Unsatisfactory Implementation of the Policy

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

Training Issues

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

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

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

Staffing Issues

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

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

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

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

Inhumane Treatment

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

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

Recalls

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


REFERENCE
1. Parker, L. 2001. Breast-feeding and cancer prevention. European Journal of Cancer. 37:155-158.
2. Lightfoot, T.J. 2005. Aetiology of Childhood Leukemia. Bioelectromagnetics Supplement. 7:5-11.
3. Lightfoot, T.J. and Roman, E. 2004. Causes of childhood leukemia and lymphoma. Toxicology and Applied Pharmacology. 199:104-117.
4. U.S. Department of Health & Human Services. (2005). National Breastfeeding Awareness Campaign—Babies were Born to be Breastfed: http://www.4women.gov/Breastfeeding/index.cfm?page=Campaign
5. Ryan, A.S. 1997. The Resurgence of Breastfeeding in the United States. Pediatrics. 99:12-19
6. Dewey, K. G., Cohen, R.J., Brown, K. H., Rivera, L.L. Journal of Nutrition 131: 262–267, 2001. http://jn.nutrition.org/
7. Flore, Marrecca. (2007). CDC: Almost 75 Percent of New Mothers Breastfeeding. Retrieved from Fox News: http://www.foxnews.com/printer_friendly_story/0,3566,291878,00.html
8. Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S., Phelan, J.C.. Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People With Mental Illnesses. Psychiatr Serv 52:1621-1626, December 2001
9. National Conference of State Legislators (updated 2008). 50 States Breast Feeding Laws: http://www.ncsl.org/programs/health/breast50.htm
10. La Leche League International. (2003). LLLI Center for Breastfeeding Information: US Breastfeeding Legislation, Sept. 15, 2003.
http://www.llli.org/llleaderweb/LV/LVJunJul05p51.html
11. Fox 28 (2008). Woman Discriminated for Breastfeeding. Retrieved from Fox News: http://www.fox28.com/News/index.php?ID=35278
12. Barsch, Sky. (2008) Panel finds breast-feeding discrimination. Retrieved from Burlington Free Press: http://www.burlingtonfreepress.com/apps/pbcs.dll/article?AID=/20080328/NEWS02/803280308/1007
13. ABC 7 News. (2008). Breastfeeding Mother Sentenced to Jail for Postponing Jury Duty. Retrieved from ABC News: http://www.wjla.com/news/stories/0308/506006.html
14. NBC5i. (2008). Breastfeeding Mom Claims Salon Kicked her out. Retrieved from NBC5i: http://www.nbc5i.com/news/15555280/detail.html
15. Vargas, E., Hoffman, L., and Varney, A. (2006). Is the Breast Better?: Ad Campaign Rattles Mothers on Breast-Feeding Controversy. Retrieved from ABC News: http://abcnews.go.com/2020/story?id=2188066
16. McGuire, W.J., Input and Output Variables Currently Promising for Constructing Persuasive Communications. In Rice, R. & Atkin, C. (Ed.)
17. Haynes, Suzanne. “National Breastfeeding Awareness Campaign Results-Babies were Born to be Breastfed: http://www.4women.gov/Breastfeeding/campaign_results.pdf

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

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

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

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

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

Failure to use “McGuire’s Communication Model”

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

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

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

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

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

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

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

Walking In The Wrong Direction: A Critique Of The Smallstep Anti-Obesity Campaign – Brad Karalius

Introduction
The obesity epidemic is bad and getting worse. The prevalence of overweight and obese Americans, ages 20-74, increased from 47% (1976-1980 survey results) to a recent level of 65% (1999-2002 survey results) according to the CDC’s National Health and Nutrition Examination Survey (NHANES). Obesity has risen from 15% to 31% for that same time period. In adults, the CDC defines overweight as a Body Mass Index (BMI), calculated as weight in kg divided by height in meters squared, of 25.0 – 29.9 and obese as BMI ≥ 30.0. Interestingly, the CDC recently adopted a different set of classifiers for children and established that those with BMI between the 85th and 95th percentile of the CDC Growth Chart are deemed “at risk of becoming overweight” with overweight children listed as ≥ 95th percentile of the growth chart. The statistics for children and adolescents are at least if not more alarming than for adults. Currently, there are over 9 million overweight children and teens ages 6-19 or a 16% proportion of the population and triple what it was in 1980 (1). Even preschoolers are getting fatter with overweight prevalence among children ages 2 through 5 increasing from 7.2% to 13.9% since 1990 (2). The CDC NHANES data has also shown that minorities are disproportionally affected with 21% of non-Hispanic black adolescents listed as overweight and 23% of Mexican-American adolescents while their white counterparts are 14% overweight. Similar data exists for children ages 6-11(1).

There is an increased risk for a myriad of deleterious conditions that comes with being overweight or obese including hypertension, osteoarthritis (degeneration of cartilage), high cholesterol and triglyercides, Type 2 diabetes, coronary heart disease, stroke, gallbladder disease, sleep apnea, respiratory problems, and even some cancers such as breast and colon cancer (3). In 2001, the Surgeon General’s Call to Action noted that not only do unhealthy diet and sedentary lifestyle together account for approximately 300,000 deaths each year but that the epidemic is also a burden to health care costs (4). In fact, in 2003, the total price tag of obesity that Americans pay was estimated at $75 billion (6). With the Medicaid population’s prevalence of obesity 50% higher than the privately insured population and obese adults incurring medical expenditures 40% higher than a normal BMI adult on average, the problem affects all tax-paying Americans (2,4,5).

In November of 2005, the US Department of Health and Human Services mounted an anti-obesity media campaign called Smallstep. The campaign has both adult/teen and kids components, each with their own website and set of media advertisements. The campaign’s goal is reducing overweight and obesity prevalence by offering information and tools in the form of small steps that the busy American can take to improve their health (7,8). While nobly preaching the integration of healthier eating and a more active lifestyle into the typical American’s life, the campaign doesn’t always do this in a compelling or effective manner.

The deteriorating obesity situation America is facing requires a multi-factorial, multi-contextual approach due to how deeply the underlying causes of obesity are embedded within society. The obesity quagmire is not unlike a rotten onion. Moving from the center out are the causes of obesity: the individual’s behavior, the individual’s family environment, local geographic and social environment, SES, free market conditions, agricultural infrastructure, and US policy. Americans value portion size and cheap prices. Readily available fast food providers and chain restaurants satiate such desires and conventional farming, in turn, provides the food service industry with cheap, energy-dense, low-in-nutrition food products. Government subsidies further encourage the production of high energy foods while failing to equally support produce growers. The US Department of Health and Human Services’ Smallstep campaign falls far short of what is needed to fix the obesity/health situation in America. The effort fails by only considering individual behavioral factors, and doing so insufficiently, while totally neglecting community, environmental, and political causes.

The Smallstep Media Campaign Doesn’t Send a Powerful and Effective Message
Smallstep Adult/Teen
The Smallstep media based campaign, like so many other public health initiatives, is based on the Health Belief Model; a model that states that the individual will weight perceived susceptibility, severity, and barriers to taking action against perceived benefits of taking that action to decide on an intention that directly leads to behavior (9). The adult/teen component of the campaign features a variety of television, print and radio ads produced by the Ad Council. The television ads typically feature people stumbling upon a mass of flesh identified as lost love handles, double chin, thunder thighs, etc. and conjecturing that it was lost while performing one of the diet or physical activity small steps the campaign advocates. The print ads take a similar approach showing concentric, dashed lines carving out excess body mass on susceptible body parts with a different small step connected to each dashed line. The final dashed line expresses a goal such as wearing a bikini or changing one’s name to “buff-daddy” (7). These ads aren’t designed to resonate deeply with the overweight and obese population. Just showing mounds of flesh scattered about the earth and relating it to a small step results in a very distal relationship between being a healthier, happier person and taking these small steps. In fact, the people who were changed by these small steps aren’t even featured in the TV ads. With the print ads, not only is the font often vertical but it is also very small. If these were billboards on a highway, no one would possibly be able to observe anything other than a picture of an overweight person. Advertising Theory argues that you design your ads around deep core values and use effective images to sell the promise and the product (10). One would be hard-pressed to admit that losing love handles is a deep core value and randomly dispersed mounds of flesh are effective images. As for the print ads, although wearing a bikini might represent a stronger core value, most of the other goals are humorous instead of deep: for example, “fights urge to run on the soccer field and play forward,” in the Soccer Mom print ad. Both the TV and print ads are humorous but they fall short of hitting home with their message. An effective ad using advertising theory might look more like a once overweight woman finally being able to complete that 5k charity race to benefit her mother who suffers from a disease for which finding a cure is the aim of that race.

Smallstep Kids
The Smallstep campaign for kids features television ads and a web page fully loaded with cool games and pointers on becoming healthier through improved diet and increased activity. The campaign includes six television spots, some of which are actually quite well written along with others that aren’t (8). The campaign is correct in its concern about children’s sedentary lifestyles. One study found that children ages 2-7 watched an average of 2.5 hours of TV per day and children 8-13 watched an average of 4.5 hours of TV per day. It should be noted that this study did not consider time spent playing video games or using the computer (11). Also, according to the US Surgeon General reports, 25% of young people ages 12 to 21 reported no vigorous physical activity and 14% reported no recent light or moderate physical activity (2). The Smallstep website is informative but is somewhat counterintuitive by featuring online games children can spend time playing (8). A few of the Smallstep Kids television ads aren’t particularly attention grabbers either. “Birds,” “Bull’s eye,” and “Grandpa” discuss nutrition using a monotone narrator, but do incorporate some humor. More effective are the “Shrek” and “NFL Play 60” ads that include characters from Shrek and professional football players, respectively. The kids in these ads are playing in parks or basketball courts with the Shrek characters or football players and they all appear to be having great fun doing so. The “Shrek” ad even features a catchy song. However, the park featured in the “Shrek” TV spot that the kids are playing in is conveniently very nicely equipped. The fields of the park are well maintained and expansive and the playground is enormous. Such an outlet is not realistically available to all demographics of children, particularly those in urban areas or of lower socioeconomic status (11,12). The NFL Play 60 ad is based in a basketball/tennis court though, which is more readily available to most children, regardless of their socioeconomic or geographic situation.

The nutritional information provided to children by the Smallstep campaign is ineffective because children are largely at the mercy of their environments. It is their parents or guardians who do the grocery shopping, pack their lunches and prepare or purchase their dinners and it is the school environment that provides children with lunches and vending machine snacks. To ask children to have a significant impact on their diet is misguided. Social Learning Theory explains that people perform actions because they see others doing it and Social Expectations Theory infers that people’s behavior is dictated by established social norms (9,10). Children learn diet and how to behave largely through observing their parents in daily life (13,14). Parental lifestyle has been found to be significantly associated with their children’s BMI. Specifically, obese parents were more likely to have obese sons and daughters (15). A related study found that parents have significant influence over child-feeding behaviors. Left to make their own food choices, children tended to opt for foods high in added sugar. But, when the parents imposed restrictions, the effect was exacerbated and the risk of weight gain increased. The study concluded that parental dictation of food availability was more likely the appropriate solution (16). Furthermore, it is not just parents that have direct influence over a child’s risk but also their friends. In one study on the spread of obesity, both parents and friends, particularly mutual friendships, were found to have significant impact on one’s risk of obesity. In fact, even friends of friends were found to have significant impact on risk (17). Ultimately, a Social Network Theory, Social Expectations Theory or Social Learning Theory approach would have proven more efficacious for the Smallstep campaign in addressing the proximal causes on children’s diets.

Smallstep Does Not Take Socioeconomic and Race Factors into Consideration
A significant flaw of the Smallstep campaign was that it did not target especially susceptible populations such as minorities and people of lower SES. As stated previously, the social environment, including parents and friends, has been shown to have an effect on one’s risk for obesity (14-17). SES has influence over one’s social environment and race is interlinked with SES (18). From 1971 through 2004, the level of poverty has consistently been associated with a higher prevalence of obesity. The difference has been diminishing, however. Between 1971 and 1974 the prevalence of obesity in the population below 100% of the poverty level was 21% compared to 12.5% for the population ≥ 200% poverty level. The 2001-2004 results revealed that while the prevalence of obesity in the population below 100% poverty level had increased to 35%, the prevalence among the population ≥ 200% poverty level was now at 31%. The difference in obesity prevalence among men of different ethnicity wasn’t nearly as significant as the difference seen in women: 31% for white women, 40% for Mexican women, and 52% for African American women. The race and weight gain disparity was also seen in children (2,11). Logically following from these data, regional differences in obesity prevalence were also observed within the US. In 1998, CDC data showed 17.1% prevalence in the southern states compared to 10.8% prevalence in the western states. Some southern states like Mississippi and Alabama had prevalences over 25% in 2002 (11). These findings are not surprising when considering that the southern US geographic area touts both a higher minority population and lower average per capita income than the western states (19,20). In Starr Country, Texas, where 59% of the children live below poverty level, 24% are overweight or obese by the age of four, 28% by kindergarten, and 50% of boys and 35% of girls by elementary school. Also, almost half of the adults in this community have Type-2 diabetes (6). Rationally, an increased risk of disease would follow from an increased risk of obesity and indeed, a lower SES was significantly linked to an increased risk for Type-2 diabetes in the Alameda County Study (21). Additionally, one study found an association between education level and income with risk of cardiovascular disease events (22).

The obesity imbalance between subpopulations results from the economic and food/build environment resource disparity between different SES tiers. Fast food, soft drinks, and other foods high in sugar, fat, and calories are cheap, largely as a result of the high fructose corn syrup and hydrogenated fats used to prepare such foods. High fructose corn syrup, America’s favorite sweetener, is also the cheapest and it keeps excellently (2,23,24). Hydrogenated fats, made from soybeans, are also cheap and very prevalent in inexpensive and fast foods (2,24). To really put this into context, from 1983 through 2005, the price of fresh fruits and vegetables increased almost 200% while the cost of fats and oils increased 65% and the cost of carbonated drinks increased only 30% (2). The bottom line is that it is expensive to eat healthy. A more effective approach by Smallstep would have included subsidizing fruits and vegetables rather than just telling people to eat more of them.

There also exist barriers to accessing health food for those of lower SES. Supermarket availability is less in low-income neighborhoods. With larger food stores and chain supermarkets being more likely to stock healthful foods than smaller stores and nonchain supermarkets, and there existing a correlation between supermarket availability and BMI, especially in African-Americans, the role of resource availability becomes clear in this battle against obesity (25). A study was conducted in East Harlem, New York to look at racial disparity with food store availability. The researchers found zero supermarkets or grocery stores in predominantly African-American neighborhoods compared to reference mixed race neighborhoods that contained many (26). Additionally, a study based in Queensland, Australia found that the cost of healthy foods increased with remoteness of location. Availability of food items was also inversely associated with rural areas. The researchers felt that these results had interesting implications for disadvantaged socioeconomic groups, particularly indigenous peoples, who were more likely to reside in remote locations (27). Dr. Risa Lavizzo-Mourey, president and CEO of The Robert Wood Johnson Foundation, an institution dedicated to fighting obesity, offered the following summary of the situation: “Obesity rates are the highest in communities afflicted by poverty. Families in these communities simply don’t have the same opportunities to make healthy choices as families in other neighborhoods. They don’t have grocery stores that stock affordable fresh fruits and vegetables” (6).

Lower SES groups are also at a disadvantage when it comes to the availability of physical activity facilities. Both the World Health Organization and The National Academy of Sciences has recognized this particular aspect of the build environment as key in the fight against obesity, but the Smallstep campaign never sought to address it (11,28). A recent study from the Journal of Pediatrics found that low-SES and minority geographically occupied areas were significantly associated with having less facilities than higher-SES occupied areas. The researchers also found that a greater number of facilities per area was associated with a decrease in overweight prevalence (12). With lower SES groups and minorities having lower availability of both healthy food and physical fitness resources, the Smallstep campaign could have benefited from targeting these highly susceptible subgroups.

Smallstep Does Not Address American Food Culture, Food Industry Infrastructure, and Politics
The true root of obesity lies in Americans’ values, culture, food industry, and the government’s influence over agriculture. These are the final, overarching causes of obesity and were never addressed by the government’s Smallstep campaign. It is not uncommon in American culture today for both parents to work full-time. Adolescents of full-time working mothers have been shown to be more affected by food store availability than their counterparts (25). The results are sensible because less time to prepare meals translates to making due with your immediate resources which entails eating whatever is ready to eat in your surrounding environment’s food stores and restaurants. Less eating in and more eating out impedes ones ability to dictate nutritional value and portion size of the meals they are consuming (2). Americans also desire value; they want large portions for affordable prices. Restaurants accommodate our desires to maximize business. Ruby Tuesday’s has the 1,677 calorie Ultimate Colossal Burger (2.5 lbs. beef on a triple-decker bun with cheese), Denny’s has the 1,128 calorie Grand Slam Slugger Average, Hardee’s has the 1,410 calorie Monster Thickburger, and Burger King now has the BK Stacker with 4 beef patties. Consistent with those offerings is the reality that portion sizes have dramatically increased in the past 20 years simply because larger portions sell better. The average serving size for a bagel went from a 3-in. diameter to 6-in., French fries from 2.4 oz. to 6.9 oz., soda from 6.5 oz. to 20 oz., and popcorn from 5 cups to 11 (2,29). When Ruby Tuesday’s tried to reduce its portion sizes, they actually lost customers. They then quickly made adjustments and added back to their portion sizes, even increasing them beyond what they were originally (2). Understandably, pricing has an effect on food choice. One study looked at how reducing the cost of healthy foods such as carrots by 10%, 20%, and 50% would affect sales. It did indeed with sales increasing 9%, 39%, and 93%, respectively (29). Price was shown to be particularly important when purchasing food among the Hispanic culture (30). This evidence further emphasizes how the Smallstep campaign was incomplete for ignoring the psychology of pricing and value with food choice.

Our schools aren’t helping much either. In fact, they may be downright hurting the anti-obesity efforts. School lunches average 40-120 kCal more than home prepped lunches. In 2000, 43% of elementary schools, 89% of middle schools, and 98% of high schools had vending machines where junk food could be purchased (2). These junk foods are known as competitive foods. They are not part of the federal school meal programs and thus are very minimally regulated on a federal level and inconsistently regulated by states (11). Amazingly, Taco Bell products are now being sold in over 4500 school cafeterias and Pizza Hut, Dominos, and McDonalds are even sold in some school cafes. Pizza Hut also sponsors the Book-It program where kids are rewarded with a free personal pan pizza for reading enough books (23). The physical education side of the situation is equally as bleak. Daily high school enrollment in PE dropped from 42% in 1991 to 28% in 2003 (2). The percentage of high schools requiring PE according to a 2000 survey for grades 9 through 12 were about 20%, 10%, 5%, and 5%, respectively (11). Increasing pressure for schools to perform academically lest they face fines is the cause for some of the cuts in school PE programs because the cuts allow for more time to be allotted to academic studies (2). Yet, the Smallstep campaign still asks kids to make healthy choices even though kids have little to no control over school food options and programs.

Child culture has changed at home too; particularly in regards to free-time activity choices. With the availability of video games, hundreds of television channels, DVD players, and computers in today’s culture, kids are faced with a number of seductive opportunities to be sedentary. Sedentary activities have been linked to obesity in a number of studies (31-33). 17% of children watch more than five hours of TV per day, 16% watch three to five hours, 31% watch one to three hours, and only 36% watch less than an hour of TV per day. These numbers also differ by race in the 8th, 10th, and 12th grade brackets with 42-58% of African-Americans watching four hours or more of TV per day compared to 16-23% of whites (2). During Saturday morning television, 56.5% of commercials were for food and the primary foods advertised were cereals, snacks, candy, and soft drinks (11). Subsequently, snacking, primarily on unhealthy foods, has been linked with the act of watching TV (2,11). One study randomized children to an intervention or control group with the intervention group having children reduce their television viewing time and computer usage by 50%. This intervention significantly lowered energy intake (34). Although the Smallstep campaign is airing ads that are competing against high energy, nutritionally bereft foods, the task is certainly formidable. Their relatively small budget must compete against the $1 billion allotted by the food industry for television commercials targeting kids (5).

Unhealthy, readily available foods such as fast food are cheap and abundant in America. As mentioned previously, much of it contains high fructose corn syrup and hydrogenated fats from soybeans. The United States is the number one producer corn and soybeans in the world. Such large production levels are encouraged by government subsidies for the two crops. The government also offers subsidies to wheat and rice farmers, crops often used to create less healthful, refined grains. Together with soybeans and corn, these crops account for 90% of all government subsidies. The subsidies were originally created to spur the agricultural industry to meet the nutritional demands of a growing nation back in the depression era but these subsidies are no longer as relevant as they once were (2,5). Corn is in fact so cheap and plentiful that it is even used to feed animals not normally meant to diet on the crop, like cows and chickens (5,24). Corn-fed cows are less healthy than their grass-eating counterparts because their meat is fattier and less dense in omega-3 fatty acids. Concentrated Animal Feeding Operations (CAFOs) are notorious for doing this (24). With conventional farming, operations are segregated. For example, corn or soybeans would be the only crops grown on a particular plot of land and the nutrient depleted soil, due to lack of proper crop rotation, would be supplemented with industrial fertilizer. Organic farming, typically a small farmer operation, offers an alternative to this. Cows are fed a mixed diet of legume crops & grass grown on the plot and then produce nitrogen-rich manure that is in turn used to fertilize subsequent heavy nitrogen-consuming crops like corn (35). The shift away from the conventional large agrochemical farming industries and their disproportionate growing of corn has been hampered by the lobbying power of these companies along with the effects of the government’s subsidy legislation (5). ConAgra, one such company, was even able to orchestrate state tax breaks due to its pull through the amount of jobs it created in that state. Since Richard Nixon took office, the fast food industry has had its allies in Congress and this has helped their efforts to oppose food safety laws. Fast food has also been effective at getting their slice of the subsidy pie as they benefit, as well, from a wide variety of government subsidies (23). The US government first set the pieces in motion that led us to this obesity epidemic, and kept with the legislation regardless of how times changed. It is ironic that the same government is now attempting to solve the problem by ignoring its own real role and instead placing the onus on its people with the Smallstep campaign.

Conclusion
The Smallstep campaign against obesity meant well but put forth an almost entirely futile effort towards ameliorating the obesity epidemic in the United States. The focus on individual behavior and action through the Health Belief Model is inappropriate for such a complex problem that’s causes are associated with family, social networks, socioeconomic status, race, culture, American values, industry, and policy. More complex theories such as Social Network Theory, Social Expectations Theory, and Advertising Theory would have been better suited for implementation but even that would provide just part of the solution. The World Health Organization and The National Academy of Sciences has advocated for a multi-factorial approach that includes providing more healthful foods and portion sizes through restaurant and fast food channels, increasing supermarket and healthy food store availability, improving the build environment to accommodate for more physical activity and less use of motorized transportation, community support programs, school support programs including PE and improved nutritious food options, recognition of especially afflicted subpopulations, increased preventative action by health care providers, and supporting legislation (11,28). Innovation has been lacking in solving this problem. Shining examples of these needed innovations are the Nintendo Wii and arcade games like Dance Revolution. Although not originally intended as public health initiatives, they are effectively serving as such. These video games and video game system involve moderate to high levels of physical activity, thus dispelling the norm that video games are sedentary activities. Involving schools in local farm programs for food access and education is another example of a thoughtful and effective measure to promote healthful eating and information on the concept. Organic products are also increasingly finding the favor of consumers and this demand must be met by higher levels of supplies. There are highly effective solutions to this obesity epidemic, just not the solutions that the Smallstep campaign had to offer.

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