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

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

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

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

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

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

References

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

But What About The Binge Drinkers? How The Social Norms Campaigns Fail To Change Binge Drinking Behaviors On College Campuses. –Jackie Harvey

Binge drinking on college campuses is a matter of national concern (1). Despite many traditional public health attempts to change college student binge drinking behavior (2-3), the problem persists (4-5). Colleges began to adopt social norms campaigns to curb binge drinking en mass after research by Perkins and Berkowitz showed that students’ perceptions of alcohol consumption on campus presumed a higher level of consumption and higher rates of permissive attitudes towards substance abuse (6). The researchers suggested that correcting these misperceptions might reduce heavy drinking. The social norms campaign incorporates the social sciences and mass media to ensure that students have an accurate perception of the presence of alcohol consumption on campus. The theory behind the campaign is “the revelation of accurate information about the environmental context—in the form of group or population norms—to reduce individual problem behavior and enhance protective behavior (7).”
Colleges that adopt the social norms campaign are attracted to the very low cost-to-results ratio (8). In most programs, on-campus advertising is by far the largest expense (6). Research demonstrates the high efficacy of a mass-marketing campaign in changing students’ misconceptions of the rate of alcohol consumption on campus (9). In fact, there is little opposition to the findings that show a change in the students’ perception of alcohol consumption. Rather, the oversight with this intervention lies in the reduction of actual binge drinking on campus.
Changing Perception Does Not Change Behavior
The campaign incorrectly assumes that a change in binge drinking behavior is directly related to a corrected perception of the level of binge-drinking on campus. Additionally, research has indicated that students, specifically those in large universities (where the social norms campaign is touted as most effective), are not influenced by the behavior of the entire campus, but rather, their own smaller peer group (10). Furthermore, a campaign that seeks to reeducate students by showing that the rate of alcohol consumption on campus is actually lower than initially perceived runs the risk of normalizing underage alcohol consumption within the target population. Proponents of the social norms campaign are excited by the low-cost, high-results promise of correcting student perceptions, but colleges fail to realize that the campaign must be part of a larger, comprehensive program—not simply used to pacify parents worried about increasing binge drinking statistics on campus. While the social norms campaign succeeds in providing the truth about alcohol consumption on campus, it fails to significantly change the behavior of the target population- binge drinkers-on campus.
The goal of the social norms campaign is to use mass media efforts to correct the misperceptions of the level of alcohol consumption on campus. In theory, by correcting the perceived level of consumption, the students then would be less likely to feel supported in their binge drinking habits and/or would refrain from using their peers as a justification for increased alcohol consumption. However, an analysis of this behavioral model quickly shows that the correction of perceptions does not always directly link directly to a correction of behavior. The theory of reason action (11) shows perceived social norms and attitudes towards behavior directly affecting one’s intentions which, in turn, directly affect behavior. However, a main criticism of the very traditional theory of reasoned action is that intentions do not directly lead to behaviors (12-13).
Applied to a college setting, a student may be fully aware that the average number of drinks consumed per weekend night is actually only four drinks thanks to the social norms campaign advertising. She may therefore decide that she will not consume more than four drinks herself while getting ready to go out with friends on a Friday night. That is, of course, until there is a cute boy at a party who offers her a fourth…and then a fifth drink, which she gladly accepts. In this student’s case, behavior was not entirely reasonable- she did not need to consume the drink in order to gain the boy’s attention, but decisions are not always well reasoned! Another example of the disconnect between intention and behavior is the social cultures on college campuses. Despite an intention to remain sober on a weekend night, it is very likely that much of the social scene revolves around parties that have a lot of alcohol and other students drinking. Rather than stay in on the weekend, a student may find his or herself out with friends that insist on going out to parties on the weekend. Again, the student intended to remain sober, but the behavior was the result of a poorly reasoned belief that s/he must drink to maintain certain friendships, resulting in a weekend of binge drinking. There is significant research to support the lack of a connection between intent and behavior in young adults (13)
Not All Students Misperceive Consumption Levels
On many campuses, there is no misperception of the level of alcohol consumption on campus (14). In fact, campuses with more accurate perceptions of alcohol consumption had more drinking than campuses with less accurate perceptions (15). In these cases, according to the Social Norms institute, “if the needs assessment indicates that a campus has very few binge drinkers and/or those students do not misperceive the campus norm,” then the social norms approach would not be effective. Despite these statistics, the social norms marketing campaign is by far the most popular anti-drinking campaign on college campuses. Even in schools where the students are fully aware of the drinking habits of their peers, administrators fall back on the campaign.
Few Schools Succeed with Social Norms Alone
The National Social Norms Institute cites only six institutes of higher education in which there has been a change in alcohol consumption after the implementation of the social norms campaign. In several of these schools, the behavior change may be attributed to other programs used in conjunction with the mass media approach implemented by the social norms campaigns. Many schools that tout the social norms marketing on campus do not have any data to support its efficacy on campus. After investigating their elaborate social norms website, I contacted Southern Methodist University (SMU) in the hopes that they would have some insight into the success of their extensive campaign (16). The administration commented that there was no data available at the time, and, that there was no evidence that the levels of drinking have decreased on campus during the time of the program.
The failure rate of the social norms campaign in schools is unknown, since many schools, such as SMU do not perform follow-up evaluations of the program. Many articles have explored reasons for failures at particular schools, citing poor implementation of the program (17). A major study in 2003 sought to perform a national evaluation of the social norms marketing programs but did not detect a decrease in alcohol consumption (10).
Individual Peer Groups Are Most Valued
I challenge that the program is not suitable for the vast majority of schools in reducing the level of binge drinking. Young adults are not affected by what their peer group as a whole does in college. Why would one student out of 15,000 care what the average student consumes during one weekend? The first response would be “surely those numbers don’t refer to me and my friends.” Students are influenced by their own, smaller peer group (sports teams, sororities, organizations) far more than statistics about the school as a larger entity. Peer group influence over behavior is evidenced in the social networking theory, which explains that the most important predictor of behavior is what is happening in your own social network.
Research into the effect of the social norms campaign on specific campus groups shows that the reductions of the level of drinking in Greek members is very slight (18). Not only do Greeks have a reputation for high levels of alcohol consumption, but on many college campuses, Greek organizations have a huge impact on the social lives of the students.
By targeting the Greek organizations themselves, college campuses could be much more successful in changing student attitudes about drinking. Not only are Greek organizations powerful campus figures, they are also upperclassmen. Targeting older peer leaders to serve as role models would be significantly more effective. A 2003 study by Campo et. al found that drinking behavior was related to perception of friends drinking, but not to the campus norms. The research indicates that drinking behavior is “positively related to perceptions of friends' drinking as suggested by the theory of planned behavior, which emphasizes subjective as opposed to social norms” (19). The social network theory provides an explanation for the usefulness of targeting Greek upperclassmen in order to reduce the level of drinking. The social network theory also predicts behavior, not intention— a model that can predict a behavior of sobriety is far more effective than a model that can predict intention but not behaviors.
Reliable Sources are Key
In addition to believing that statistics refer to those outside of their own peer group, communication theory explains that the target population (college students) must be able to trust and have confidence in the source of the information. The social norms campaigns survey students in class in order to ensure participant in the study (6). However, what are the odds that students that have been drinking heavily are up in time for class the next day, much less willing to fill out a survey? Are students able to trust information that comes from the school administration? If the students do not believe that the information is reliable, their perceptions will not change.
Unintended Concequences
Similar to peers, students are affected by marketing. The social norms campaign is founded on the theory that mass media can change students’ perceptions of drinking on campus. However, what other perceptions are the media blitz changing? Social marketing can normalize underage drinking by advertising what most students are doing, not what they should do. Messages posted around campus advertise that having a ‘few’ drinks is normal, but five drinks is not. This type of advertising would be like putting up posters in a middle school saying that “most of your friends smoke three cigarettes per day, not twelve, like you think!”
In “A Social Norms Approach to Preventing Binge Drinking at Colleges and Universities,” a major limitation listed is that the social influence methods “may be ineffective or have minimal impact” (18). In fact, the guide shows that promoting a non-normative behavior such as drinking alcohol on a college campus, regardless of the legal status, may be “counterproductive and unintentionally reinforce the actual drinking norm.”
Even more telling is that the alcohol industry, including Anheuser-Busch, is a large financial backer of the social norms campaign on college campuses. The social norms campaign provides an easy venue for the alcohol industry to downplay the seriousness of the campus alcohol problems while continuing to provide an image of concern towards underage drinking. The campaign is not implying that students should stop drinking—simply that their peers may not drink quite as heavily as once thought.
Another aspect of the oversights of the social norms campaign involving the link between intention and behavior is the accessibility of alcohol on college campuses. An awareness that fewer of their peers binge drink than one originally perceived does not change the students’ access to the alcohol. One suggestion to preventing binge drinking is to implement a physical barrier between the students and the alcohol, such as an increase in monitoring liquor store sales, or preventing marketing campaigns from targeting college students.
More rigorous research is needed to put social norms marketing to the test, but the evidence to date has been encouraging. The social norms campaign should be commended for its new approach to solving public health problems. The campaign went beyond simply restating problem behaviors or positing what are believed to be good prevention practices, to documenting effective prevention results. Finally, social marketing campaigns need to be viewed in context, as part of a comprehensive approach to prevention (20). Campus and community officials have other means of clarifying for students that underage drinking is against the law. One approach would be stricter enforcement: undercover operations to catch retailers who sell to minors; parental notification when students break the rules; prosecution for using fake IDs or purchasing alcohol for minors. In essence, a social norms campaign, by making clear that students don’t have to drink heavily to fit in, can serve to decrease normative pressure to break the law against underage drinking.
REFERENCES
Wechsler H, Davenport A, Dowdall G, Moeykens B, Castillo S. Health and behavioral consequences of binge drinking in college: A national survey of students at 140 campuses. Journal of the American Medical Association 1994; 272:1672–1677.
A matter of degree: The national effort to reduce high-risk drinking among college students. Robert Wood Johnson Foundation; 1996. Available at: http://www.rwjf.org/app/rw_about_our_grantees/rw_gra_main_set.html. Accessed March 24th 2008.
Hansen, W. B. School-Based Alcohol Prevention Programs. Alcohol Health and Research World 1993; 17: 54–60.
Wechsler H, Lee J, Kuo M, Lee H. College binge drinking in the 1990s: A continuing problem. Results of the Harvard School of Public Health 1999 College Alcohol Study. Journal of American College Health 2000; 48:199–210.
Wechsler H, Dowdall GW, Maenner G, Gledhill-Hoyt J, Lee H. Changes in binge drinking and related problems among American college students between 1993 and 1997. Journal of American College Health 1998;47:57–68.
Perkins, H. W., & Berkowitz, A. D.. Perceiving the community norms of alcohol use among students: Some research implications for campus alcohol education programming. International Journal of the Addictions 1986; 21, 961–976.
Perkins, H. W. The Social Norms Approach to Preventing School and College Age Substance Abuse. Josey-Bass, New York, NY: 2003.
Langford, L. and Gomberg, L. Frequently Asked Questions Topic: Social Norms and Social Marketing. Available at http://www.higheredcenter.org/ta/faq/social.html#q7. Accessed April 2nd 2008.
Perkins, H. W., & Wechsler, H. Variation in perceived college drinking norms and its impact on alcohol abuse: A nationwide survey. Journal of Drug Issues 1996: 26, 961–974.
Wechsler H, Nelson TF, Lee JE, Seibring M, Lewis C, Keeling RP. Perception and Reality: A National Evaluation of Social Norms Marketing Interventions to Reduce College Students' Heavy Alcohol Use. Journal of Studies on Alcohol 2003; 64: 484-494.
Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135
Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology 2003; 22:424-428.
Sheeran, P. Intention. Behavior Relations: A Conceptual and Empirical ReviewEuropean Review of Social Psychology, 2002.
Richard P. Bagozzi. The Self-Regulation of Attitudes, Intentions, and Behavior. Social Psychology Quarterly 2002; 55: 178-204
Licciardone, JC. Perceptions of Drinking and Related Findings from the Nationwide Campuses Study. Journal of American College Health, 2003; 51: 238-245.
http://www.smu.edu/healthcenter/alcoholeducation/adp_socialnorms.asp)
Thombs,D. Dotterer,S. Olds, R.S., Sharp, K., Raub, C. A Close Look at Why One Social Norms Campaign Did Not Reduce Student Drinking. Journal of American College Health 2004; 53: 61-68.
Haines, M. “A Social Norms Approach to Preventing Binge Drinking at Colleges and Universities.” The Higher Education Center for Alcohol and Other Drug Prevention. Newton, MA. 1996.
Campo, S. Brossanrd, D., Frazer, MS, Marchess, T, Lewis D & Talbor J et al. Are Social Norms Campaigns Really Magic Bullets? Assessing the Effects of Student misperceptions on Drinking Behavior. Health Communication 2003; 15: 481-497.
The Social Norms Approach: Theory, Research and Annotated Bibliography http://www.higheredcenter.org/socialnorms/theory/correction.html. Accessed April 1st 2008.

Know Stigma: Why the “Know Your Status” Campaign in Lesotho was bound for failure – Sonali Padhi

Currently, about one in four people in Lesotho has HIV or AIDS and by 2021 that figure is expected to rise to one in three (1). This epidemic has taken a devastating toll on the country that now has an average life expectancy of 39 years for men and 44 years for women (1). Without the HIV/AIDS burden the average life expectancy would be 70 years (1). This alarming discrepancy has forced the government of Lesotho to take action against the epidemic. The latest program is the “Know Your Status” campaign, which started in 2005. The campaign employed community-based workers to go door-to-door offering voluntary, confidential HIV/AIDS testing. The “Know Your Status” campaign in Lesotho claimed that by 2007, all Basotho would know their HIV status, but it did not achieve this goal because it failed to address the issues of stigma, confidentiality, treatment adherence, and the root cause of the problem.
Stigma Theory
There is a stigma associated with HIV and AIDS in Lesotho for several reasons. To begin, HIV and AIDS are relatively new concepts in Lesotho. The first documented AIDS case in Lesotho was in 1986, but the government did not initiate an AIDS program until ten years later (2). Accurate surveillance techniques on HIV prevalence and incidence rates were not in place until 2000 and government–sponsored condom distribution did not start until 2001 (2). And the first antiretroviral therapy program was not started until 2001 (2). Due to these factors, HIV and AIDS were not extensively discussed in Lesotho until the year 2000. The discussion started mostly in the capital city and slowly disseminated to the districts and then the rural areas. In the meantime, rumors, myths, and misinformation spread more quickly on what the disease was, how it was contracted, and how the disease progressed. Even now, people do not die of AIDS. They die from a “cough”, a “cold”, maybe tuberculosis. Even though, Basotho people attend funerals every Saturday, no one talks about the real killer, AIDS. This is due to the social stigma. Once someone is known to have the disease, he or she can be shunned from his or her community or even from his or her family (3). Sometimes the whole family is shunned. The Basotho are terrified of being tested because being labeled as HIV positive, in their eyes, is a death sentence, socially, even if not physically. When I was living in Lesotho, I asked my Sesotho language tutor why she had not been tested and she said, “If I get tested and I am positive everyone will know. People will be afraid to eat the food I serve, they will not come to my house anymore, I will be ostracized and I cannot afford to live like that. I would rather not know and just die.”
One reason the “Know Your Status” campaign failed is that it did not address this issue of social stigma in its design. Lesotho is a small country of about 1.8 million people (4). About 70% of the people live in the rural mountainous areas, in villages (5). These villages are very tight-knit and families are in close contact with one another. Even in the capital city, Maseru, where about 500,000 Basotho live, the community is quite close and news can travel very fast (5). Due to this dynamic, confidentiality is a hard concept to enforce. The campaign employed people from the villages to conduct door-to-door testing. This means that your neighbor that you may go to church with every Sunday would know your HIV status. Moreover, the villages are not very private as the housing, rondovals, are often very close to each other. Therefore, the community-based worker may be overheard by neighbors. Lastly, health centers, clinics, and hospitals are often one per village area and the HIV treatment facilities are separate from the rest of the medical services. Therefore, if you go to receive HIV treatment or to be tested, it is likely that you will run in to your neighbors and they may be able to determine what treatment you are seeking by what area you enter. The campaign did not address the fact that confidentiality is not present in Lesotho and community members fear the stigma associated with being HIV positive.
Social stigma is a large issue in Lesotho, as it is in most cultures. Scrambler’s Hidden Distress Model postulates that people with stigmatized conditions fear social isolation and discrimination and may conceal their status to avoid these consequences (6). HIV is absolutely a stigmatized condition in Lesotho and this model states that HIV-positive people in Lesotho may pretend to be HIV-negative to avoid the social consequences. If the Basotho felt they could conceal their status once they were tested for HIV, they may still be tested and then hide their results. However, because they feel that confidentiality is not present they may avoid testing all together to appear as a non-stigmatized member of the community (3). The campaign sent workers directly to people’s doors to be tested without discussing the stigma issues that people have around HIV testing. This method not only avoided the stigma issue, but actually may have intensified fears of discrimination and social isolation.
Intention is not linked to behavior
Another shortcoming of the campaign is that it rested on the Health Belief Model. It assumed that if individuals knew about the perceived severity and susceptibility of HIV/AIDS they would want to know their status. However, it is clear that intention is not linked to behavior (7). People act based on emotions, fears, and non-rational thought (8). The Basotho people are bombarded with messages via billboards, street signs, and graffiti about the risks of HIV, the importance of knowing your status, and statistics about treatment and death related to HIV/AIDS. They know that HIV/AIDS is a serious, deathly disease and the sooner they know their status, the better their chances are for survival. They know that one in four Basotho have HIV and that they are very susceptible to the disease depending on their lifestyle. This knowledge should lead a person to be tested, but emotions get in the way. The Basotho are intending to know their status, but it is a large leap from intention to behavior. The campaign assumed that people knew the risks of HIV; therefore, they would want to be tested. The campaign assumed, as the Health Belief Model postulates, that intention is directly linked to behavior. But the campaign needed to create that link from intention to behavior.
Furthermore, the campaign assumed that once people knew their status they would seek treatment and maintain treatment. The campaign did not provide treatment adherence protocols or assure that HIV positive people sought treatment. The Transtheoretical Model states that an individual can move backwards through the stages of change (9). For example, a HIV positive person can move from action (receiving treatment) all the way back to pre-contemplation (should I be taking treatment) before they move to maintenance (continuing treatment). Once again, intention is not linked to behavior. Once the HIV positive person knows their status they may intend to seek treatment, but that link needs to be made. The “Know Your Status” campaign could have created that link by providing treatment counselors or creating a check-in process for HIV-positive people.
Root Cause of HIV/AIDS was not addressed
Lastly, the campaign rested on a false assumption of the HIV/AIDS issue. The campaign was formed based on the assumption that the root of the HIV/AIDS issue was that people did not have the resources or access to be tested. However, the root problem is actually lack of prevention and risky behavior. The campaign did nothing to include prevention activities such as condom use, sexual education, and encouraging a change in risky behaviors such as having sex with multiple partners or having unprotected sex. Studies have demonstrated that treatment and prevention must go hand in hand for a campaign to be effective (10). If the campaign had included prevention strategies in addition to the door-to-door testing, it may have been more successful. Instead, the campaign focused on providing access to HIV testing, which most Basotho already have (11). While it may be a far trip to the local health center, the distance is not the discouraging factor. Basotho are used to walking for days to access health care facilities and most of their daily needs, if they live in the mountains. Creating proximity or ease of testing will not solve the epidemic. To combat the epidemic the campaign needs to incorporate prevention into its testing strategies.
A Better Approach is Possible
The campaign could have addressed these issues of social stigma, confidentiality, treatment adherence, and the root cause of the problem through a variety of tactics. The social stigma issue could have been addressed by offering formalized pre-testing counseling. This pre-testing counseling could have educated the people on what it means to live with HIV/AIDS, transmission methods, treatment options, and dispel some of the myths and rumors they may have heard. The confidentiality issue could have been addressed by embracing a more realistic concept of shared confidentiality. The Prime Minister of Lesotho has publicly stated, “The notion of shared confidentiality is more suitable to the HIV and AIDS context in Lesotho, where as more and more Basotho know their status, they will be more able to care for and support one another, as well as protect themselves and their partners, and thereby break down the walls of secrecy and denial, which feed the social stigma and discrimination (12).” The campaign could have incorporated support groups or treatment counselors into the treatment process to ensure treatment adherence. If an individual tested positive, they could meet with a support group or their treatment counselor to discuss the reality of treatment and provide a check-in process to ensure that the individual maintains the treatment protocol. The root cause of the problem is a difficult issue, but one that needs to be addressed. The campaign should have included a dialog on changes in risky behavior. Until Basotho start talking about the dangers of multiple partners, unprotected sex, and sex at a young age, these behaviors will not change.
In conclusion, the “Know Your Status” campaign failed because it did not take into account the issues of social stigma, confidentiality, treatment adherence, and the root cause of the problem. The campaign could have been more successful if it had incorporated pre-testing counseling to alleviate issues of stigma, embraced a more realistic concept of shared confidentiality, provided treatment support groups or counselor to assure adherence, and included prevention strategies to address the behavior changes needed to combat the HIV/AIDS epidemic. The people of Lesotho should know their status, but that knowledge is not enough.
References
UNAIDS 2007 AIDS Epidemic Update December 2007.
Avert. HIV and AIDS in Lesotho. United Kingdom: http://www.avert.org/aids-lesotho.htm
The International Community of Women Living with HIV/AIDS. Positive women's workshops in Swaziland and Lesotho. United Kingdom: http://www.icw.org/node/129.
Population Reference Bureau. Lesotho Statistics. United States: http://www.prb.org/Countries/Lesotho.aspx
Rural Poverty Portal. Rural Poverty in Lesotho. United Kingdom: http://www.ruralpovertyportal.org/english/regions/africa/lso/index.htm
Alonzoa AA and Reynolds NR. Stigma, HIV and AIDS: An exploration and elaboration of a stigma trajectory. Social Science & Medicine 1995; 41:303-315.
Marks DF. Healthy psychology in context. Journal of Health Psychology 1996; 1:7-21.
Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology 2003: 22:424-428.
Prochaska JO, Redding CA, Harlow LL, Rossi JS. The Transtheoretical Model of Change and HIV Prevention: A Review. Health Education & Behavior 1994; 21:471-486.
Russel S. Gates calls for emphasis on HIV prevention. San Francisco Chronicle, August 2006 (http://www.sfgate.com)
H. Marseille E, Hofmann P, Kahn J. HIV prevention before HAART in sub-Saharan Africa. The Lancet 2002; 359:1851-1856.
World Health Organization. WHO applauds Lesotho Prime Minister for leading universal voluntary HIV testing drive. Switzerland: http://www.who.int/3by5/newsitem6/en/

Loving Support Might not be Enough: A Critique of a Breastfeeding Promotion Campaign Marketed Through the Theory Of Planned Behavior – Reagan Kane

Low breastfeeding rates persist in certain populations despite the obvious benefits to both the child and the mother. Breast-fed infants develop an enhanced immune system and have a decreased risk of childhood obesity and several chronic diseases (1). Breastfeeding positively impacts the mother by facilitating uterine recovery and in developing a bond with the newborn, among many other benefits (1). Evidence shows that 59.7% of women with higher incomes breastfed in the hospital and 21.6% continued to breastfeed at six months. Compare this to women of lower incomes, where 46.6% breastfed in the hospital and a mere 12.6% breastfed at six months (2-3). There is an obvious need to increase these rates among women of low income.
Despite the scientific knowledge of the benefits of breastfeeding, there are many other factors that will influence a woman’s decision. These include social, cultural, and psychological factors. As a health behavior, breastfeeding is guided not necessarily by empirical evidence from years of research, but by underlying attitudes, skills, beliefs, and perceptions of what others think (4). Many people close to the mother will have strong opinions of breastfeeding. Equally as important as a strong opinion in the decision to breastfeed is a neutral attitude among physicians and nurses (4).
The Supplemental Nutrition Program for Women, Infants, and Children (WIC) uses the “Loving Support Makes Breastfeeding Work” (LSMBW) campaign to encourage women of low income to breastfeed their infants. While it is national in scope, it is implemented through state agencies. The campaign goals are well laid out and include: encourage WIC participants to initiate and continue breastfeeding; increase referrals to WIC for breastfeeding support; increase general public acceptance and support of breastfeeding; and provide technical assistance to WIC State and local agency professionals in the promotion of breastfeeding (2).
The way health care professionals attempt to achieve these goals is not effective. A series of videos are shown and pamphlets are given out, each tailored to a specific goal (2). But how can breastfeeding in this population increase simply by watching a video and reading a pamphlet? The campaign borrows on many ideas of the Theory of Planned Behavior, and falls short in empowering women of low income to initiate breastfeeding in the hospital and continue past discharge and in to the real world.
Health Care System and Self Efficacy
Self efficacy is the expectancy related to an individuals belief that he or she can execute the actions necessary to achieve a goal (in this case, breastfeeding) (5). If self efficacy does not exist regarding a certain behavior, no motivation to do the behavior will be allocated to it. Whatever health behavior that is being targeted by the intervention will not change if the predicted self efficacy toward the behavior in a population is miscalculated. Self efficacy is malleable, and can be positively influenced. In the case of breastfeeding initiation and continuation, it can be influenced by supportive, knowledgeable, and encouraging health care providers (5).
At the individual level, LSMBW assumes that self-efficacy will result from being counseled on the benefits of breastfeeding during prenatal visits and at the hospital with the use of the campaign’s materials. This, of course, can not happen unless health care providers feel comfortable and confident to dispense breastfeeding promotion information and support. Unfortunately, many health care providers do not feel confident with their knowledge of breastfeeding, or fail to even mention it as an important issue (6). One of the main reasons mothers of lower income status will not be able to achieve self efficacy (as is one of the program’s assumptions) is the lack of follow-up and support from the medical field.
Many women enrolled in WIC report that lack of support or even a neutral attitude about breastfeeding by a health care provider greatly influenced their decision to not breastfeed (6). One study found that one third of physicians and nurses did not encourage their patients to breastfeed, or missed key opportunities to support and follow-up with patients (1).
The LSMBW campaign attempts to remedy this situation by distributing a Breastfeeding Resource Guide to providers, publishing articles describing the program in state professional newsletters, and implementing a training program called “How to Support a Breastfeeding Mother” that hospitals and clinics can participate in. These steps seem rather short-sighted; if, in fact, the goal is to give women confidence to breastfeed, education must start in medical or nursing school on the importance of breastfeeding education and support.
The Social Network and Perceived Norms
Social networks have always played an important role in determining what constitutes appropriate behavior. These social beliefs can determine whether breastfeeding is perceived as good or bad, and how long is appropriate. Social norms can be particularly important to a first time mother who is more likely to ask for advice and consider other’s opinions (4). The Theory of Planned Behavior explicitly defines social norms as the perceived social pressure to perform or not perform a behavior (5). In regards to breastfeeding, and especially in low income women, those most important in influencing social norms are the woman’s mother, grandmother, and significant other (4).
Therefore, family support is critical in the role of breastfeeding. The perceived norms in low income families are actually to not breastfeed. It is seen as embarrassing, inconvenient, and discouraging to the father’s involvement with the child (7). Also at the social network level is the woman’s occupation and the professional support given. Two thirds of working mother’s of low income return to work within six months post-delivery. They are also more likely to have a job that makes breastfeeding rather difficult, whether it is because of the type of job or the fact that there is no on-site child care (1).
LSMBW focuses mainly on the mother and changing her perceived norms (although not very successfully). However, one of their key messages is “the involvement of family and friends to make breastfeeding a success” (2). Much like the material given to the new mother, the campaign attempts to educate fathers and other family members via a two page informational pamphlet. If the LSMBW campaign wants to change an entire social network’s beliefs about breastfeeding in order to help the mother, it almost certainly will take more than an informational pamphlet for this to happen.
Among the WIC women who do initiate breastfeeding, one of the major barriers for the continuation of breastfeeding is their occupation and the lack of professional support. Studies have shown that women who return to are at a higher risk of discontinuing breastfeeding than those who do not return to work (2,7). Women of low income are more likely to need to return to work within three to six months post-partum compared to their higher income counterparts. The campaign put together a presentation, in the form of a CD, that they can distribute to employers entitled “Creating a Breastfeeding Friendly Workplace: Loving Support Makes Breastfeeding Work” (8). There is no literature that supports this presentation as having the ability to change the perceived norms and attitudes of the workplace or employers, thus, low income women are left to advocate for themselves.
Shortcomings of the Theory of Planned Behavior
LSMBW based partially upon the Theory of Planned Behavior does not consider many variables which affect breastfeeding initiation and continuation. Mother’s health, lifestyle, and education, as well as previous breastfeeding experience should be considered but are not a part of the intervention model. All of these variables could certainly affect breastfeeding initiation outside the hospital, and need to be taken into account when designing a program.
Among the most predictive lifestyle factors that influence breastfeeding are education, age at first birth, and marital status. WIC participants are, on average, less educated, younger at first birth, and less likely to be married or have the father living in the home (9). The interaction between lifestyle factors most associated with WIC participants and health behavior is a controversial and much debated issue. There have been somewhat inconsistent results as to what can best predict health behaviors (9). Still, it has been considered that these factors can contribute to the decision to not breastfeed (1). One survey found that these factors made WIC certified women half as likely to initiate breastfeeding (8).
Although strengths of these results can vary, lifestyle factors and health behaviors are all extremely important to consider. Breastfeeding promotion might need to start even before pregnancy, to focus on these issues so that future mothers are more likely to breastfeed their infants. Unfortunately, room for these issues, and others like them, have been left out of LSMBW and many other health behavior intervention programs.
There are so many obvious benefits to breastfeeding, and very few (and rare) drawbacks. Rates are far from the Healthy People 2010 goal of 75% of women initiating breastfeeding, especially for low income women (10). The field of Public Health has attempted to increase these rates, as evidenced through the LSMBW campaign. However, the designers of these campaigns are not focusing on the beliefs and attitudes that need to change in order to accomplish the programs goals. Moreover, the campaigns do not always focus on the correct people, including the father of the child and the woman’s mother and family. There is room for improvement in the health care system if women are supposed to feel confident to breastfeed. In addition, assumptions made on the social network and the society levels need to be examined in a new and creative way to allow for a breastfeeding-friendly community. Until then, a large amount of low income women and their children will not have the benefits breastfeeding brings.
REFERENCES
1. Khoury A, Moazzem S, Jarjoura C, Carothers C, Hinton A. Breastfeeding Initiation in Low Income Women: Role of Attitude, Support, and Perceived Control. Women’s Health Issues. 2005. 15: 64-72.
2. WIC Learning Center. 2007. Available at http://www.nal.usda.gov/wicworks/Learning_Center/support_goals.html. Accessed February 21, 2008.
3. USDA National Breastfeeding Promotion Campaign: Loving Support Makes Breastfeeding Work. 2005. Available at http://www.fns.usda.gov/wic/Breastfeeding/lovingsupport.HTM.
Accessed February 21, 2008.
4. Swanson V, Power K. Initiation and Continuation of Breastfeeding: Theory of Planned Behavior. Journal of Advanced Nursing. 2005. 50(3): 272-282.
5. Vancouver J, More K, Yoder R. Self Efficacy and Resource Allocation: Support for a Nonmotonic, Discontinuous Model. Journal of Applied Psychology. 2008. 93(1): 35-47.
6. Mitra K, Khoury A, Carothers C, Foretich C. The Loving Support Breastfeeding Campaign: Awareness and Practices of Health Care Providers in Mississippi. Journal of Obstetrics, Gynecologic and Neonatal Nursing. 2003. 32(6): 753-7
7. Racine E, Frick K, Guthrie J. Individual Net-Benefit Maximization: A Model for Understanding Breastfeeding Cessation among Low-Income Women. Maternal and Child Health Journal. 2008. Online but not yet published.
8. Smith, C. Multimedia Review: Creating a Breastfeeding Friendly Workplace: Loving Support Makes Breastfeeding Work. Journal of Human Lactation. 2006. 22: 459-461.
9. Lantz M, House JS, Lepkowski JM, Williams DR, Mero RP, Cheng J. Socioeconomic Factors, Health Behaviors, and Mortality: Results from a Nationally Representative Prospective Study of US Adults. Journal of the American Medical Association. 1998. 279(21): 1703-1708.
10. Wolf J. Low Breastfeeding Rates and Public Health in the US. American Journal of Public Health. 2003. 93(12):2000-2010.

The SmallStep Kids Campaign: How a Missed Target Prevents Success of an Innovative Public Health Promotion – Patricia Walsh

Childhood obesity is continuing to be a predominant issue within public health. The National Health and Nutrition Examination Survey (NHANES) estimated 17.1% of US children (aged 2-19 years) were overweight in 2003-2004 (1). The prevalence of pediatric obesity and overweight has been steadily and significantly increasing in recent time periods (2). In an effort to address this issue, public health campaigns which target the youth audience have emerged. One of the most recent and largest of these campaigns is SmallStep Kids.
The SmallStep Kids campaign is a sub-campaign of the HealthierUS initiative of the U.S. Department of Health and Human Services which was launched in April of 2007. It encourages children ages 6 to 11 to eat healthier, portraying food as fuel for play, and incorporates NFL players, other athletes, and cartoon characters to persuade children to get out and “play 60” or “be a player” everyday. This campaign integrates many traditional models of health behavior, and attempts to address some non-traditional models, such as framing and social marketing theories. However, the campaign does not address many issues which are crucial to understanding and mitigating the childhood obesity epidemic.
The SmallStep Kids campaign fails to address many factors in the lives of children who most need obesity intervention. Poorer, urban areas tend to have the highest concentration of obese children, and are also areas which lack access to affordable fresh fruits and vegetables and safe play spaces (3). It also misses in an attempt to establish social norms with the use of prominent athletic and entertainment figures as role models for healthy living. This campaign also makes the false assumption that children have a large degree of control over their meal choices and schedules, and will be able to integrate healthier choices into their lives.
Missing a Crucial Target
SmallStep Kids ignores the socioeconomic and racial/ethnic disparities within the obesity epidemic. While childhood obesity is a problem across all races in the United States, it is most prevalent among minority groups. According to NHANES data, 35.9% of non-Hispanic black children and 39.3% of Mexican-American children ages 6-11 are overweight or at risk, with a body mass index at the 85th percentile or higher. 19.5% of black children and 23.7% of Mexican-American children in this age group have BMIs in the 95th percentile or higher (1). Studies have linked deprived neighborhoods with increased prevalence of obesity, particularly in childhood and adolescence (4).
The SmallStep Kids campaign assumes that children at risk for obesity will have access to healthy foods, places to play, and technology such as television and the internet. The campaign reaches out through television commercials and an interactive website. It assumes, via the Health Belief model, that children can be influenced to make healthier food choices and engage in more physical activity as a means to avoid obesity (5). However, urban, impoverished areas tend to be those most hard hit by the childhood obesity epidemic; children in these areas are less likely to have access to the resources required for the SmallStep Kids campaign to work. Children in these areas are less likely to have consistent access to affordable fresh fruits and vegetables, due to a lack of nearby grocery stores, no means of reliable transportation, or economic issues (3). The potential threat of neighborhood violence limits time and space available for outdoor play, as does the lack of open areas in an urban neighborhood. Also, the extension of school days, particularly in urban areas, may make it nearly impossible for this demographic of children to “play 60” on a regular basis (6).
By not approaching the obesity epidemic from a standpoint which integrates more lifestyle factors, the Department of Health and Human Services is unable to reach the groups in most need of intervention. They ignore modern theoretical constructs such as Link and Phelan’s proximal and distal causes of disease, and instead approach this public health problem with traditional models of health behavior change, such as the health belief model (7). Within the health belief model, the primary motivation for a change in health behavior is a perceived threat of disease, while the primary resource for change is self-efficacy (5). The SmallStep Kids campaign works on this platform, encouraging children to make healthier choices as a means to avoid obesity. This requires children to both recognize their risk, and have the ability and means to make better food and activity choices.
Establishment of Shaky Social Norms
The SmallStep Kids campaign utilizes advertisements to establish a social norm of healthy diet and regular exercise, hoping that this will influence children to conform. It integrates athletes and entertainment figures into its television and internet advertisements, assuming that children will recognize and want to emulate them. The advertisements tend to show these figures playing outdoors with groups of children, while a catchy jingle plays. Advertisements advocating healthy eating have children eating fruit or sandwiches made with whole wheat bread, and a voiceover explains how the nutrients in these foods can fuel play.
Behavioral interventions based on the theory of social norms focus on peer influences, which are held to have a greater impact on individual behavior than biological, personality, familial, religious, cultural and other influences (8). Extensive research has documented the importance of peer influences and normative beliefs on health behaviors of youth (9). SmallStep Kids attempts to influence children via social norms theory by portraying healthy activities being enjoyed by children with each other, as well as with some familiar and famous faces.
The major figures of the campaign are NFL players, LPGA golfers, and characters from DreamWorks Shrek movies. The choice of these figures as role models or peers is troublesome in that they may not actually be the best influence on children. While many NFL players are exemplary athletes and citizens, recent news stories have covered the crimes and debauchery committed by high profile players. Shrek is an accessible figure for many children, but not necessarily the best picture of good health or hygiene. It is also questionable if the LPGA is popular with a large cohort of children ages 6 to 11 at all, and if any will recognize the women in the commercials.
According to DeFleur and Ball-Rokeach, the mass media establishes impressions upon its audiences that common cultural norms concerning emphasized topics are structured in a specific way (8). This is the basis of social norms theory, which is followed by the Department of Health and Human Services in this campaign. They utilize mass media to create an idea that children are supposed to go outside and play (with interaction by adults) and should happily eat fruits, vegetables, and whole grains. However, this social norm may backfire, as all children may not have access to these foods, outdoor play space, or adults who are willing to play with them. While the advertisements produced by SmallStep Kids have a positive message, they highlight a fatal flaw of this campaign—it does not reach out to underprivileged children who are most at risk for obesity.
This campaign also ignores the theory that children and adolescents are often inclined to “rebel” or deviate from social norms established by adults and other authority figures (9, 10, 11). The use of adults such as athletes to establish the idea of healthy behaviors may backfire, as children may associate these adults with those who exercise control over their daily lives.
Control Issues
A major failing of this campaign is that it assumes children are able to exercise enough control over their schedules and food choices to change them. Children in the target age group of 6 to 11 do not control their school schedule, means of transportation, or what food is readily available to them. This control is in the hands of parents or guardians, school districts, and local government. By assuming that children in the target age group will be able to make the choice to change health behaviors, the campaign sets itself up for failure.
In its adherence to the health belief model, this campaign ignores that social networks exist around these children and that problem could be better addressed by targeting the entire family, neighborhood, or school system. Social networks provide long term influence over health behaviors, unlike the short-lived influence which may be created by this campaign. Recent research from the Harvard School of Public Health has stated, “Network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. These findings have implications for clinical and public health interventions” (12).
Rather than addressing the issue of childhood obesity and overweight by influencing children through a commercial campaign, the Department of Health and Human Services may have been able to be more effective by reaching out to the social and ethnic communities who are suffering the most from this epidemic. Encouraging access to healthy foods and outdoor space through programs and subsidies, as well as though community health education, could provide a lasting benefit for those at highest risk. The organization of healthy activities for children by community members can also lead to decreased obesity, as was shown by Weintraub, et al. in their randomized study of overweight and obese children in a low-income community (13). Studies have also found that prolonged parental and familial involvement in juvenile weight-loss programs is necessary for continued success (14).
Conclusion
The SmallStep Kids campaign is not all bad. Its utilization of both television and the internet in a way that is friendly to children is commendable, at is its use of time limits on internet games. The portrayal of healthy foods as fuel for play may be a message which is attainable for many children who do have access to these foods and the time and space to play, but have chosen not to. However, it has missed a few major aspects of the nature of childhood in the United States which may prevent its positive messages turning into changes in behavior. This campaign does not approach the childhood obesity epidemic from a social science or social epidemiology standpoint, but instead follows more traditional models of health behavior. This leads it to miss many important aspects of this epidemic, particularly how socioeconomic status plays into the development of obesity. By ignoring modern theories such as the proximal and distal causes of disease, the SmallStep Kids campaign does not address a child’s social situation and how this may impact their availability of healthy food and their ability to go outside to play.
REFERENCES
1. Department of Health and Human Services: Centers for Disease Control and Prevention. Overweight and Obesity: Childhood Overweight. Atlanta, GA: Centers for Disease Control and Prevention.
2. Ogden CL, Flegal KM Carroll MD, Johnson CL. Prevalence and trends of overweight among US children and adolescents, 1999-2000. JAMA 2002; 288:1728-32.
3. Perez-Lizaur et al. Environmental and personal correlates of fruit and vegetable consumption in low income, urban Mexican children. Journal of Human Nutrition and Diet 2007; 21: 63-71.
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/index.htm
4. Dragano N et al. Neighbourhood socioeconomic status and cadiovascular risk factors: a multilevel analysis of nine cities in the Czech Republic and Germany. BMC Public Health 2007; 7: 255.
5. Baranowski, et al. Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obesity Research, Vol. 11 Supplement. October 2003.
6. Massachusetts 2020. Expanded Learning Time (ELT) Schools. Boston, MA: http://www.mass2020.org/elt.html
7. Link BG, Phelan J. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior 1995; Extra Issue: 80-94.
8. DeFleur M, Ball-Rokeach S. Socialization and theories of indirect influence (pp. 203-227). In: Theories of Mass Communication, 5th Edition. White Plains, NY: Longman, Inc., 1989.
9. Berkowitz, AD. Responding to the Critics: Answers to Common Questions and Concerns About the Social Norms Approach. The Report on Social Norms: Working Paper #7. 2002. Little Falls, NJ: PaperClip Communications.
10. Allen JP, Porter MR, McFarland FC, Marsh P, McElhaney KB. The Two Faces of Adolescents’ Success With Peers: Adolescent Popularity, Social Adaptation, and Deviant Behavior. Child Development. 2005; 76:747-60.
11. Martin CA, Kelly TH, Rayens MK, Brogli BR, Brenzel A, Smith WJ, Omar HA. Sensation seeking, puberty and nicotine, alcohol and marijuana use in adolescence. Journal of the American Academy of Child Adolescent Psychiatry. 2002; 41:1495-502
12. Moffitt T. Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychology Review. 1993; 100:674-701.
13. Christakis NA and Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine 2007; 357(4):404-407.
14. Weintraub D et al. Team sports for overweight children: the Stanford sports to prevent obesity randomized trial (SPORT). Archives of Pediatrics & Adolescent Medicine 2008; 162(3): 232-237.
15. Stewart L et al. Parents’ journey through treatment for their child’s obesity: a qualitative study. Archives of Disease in Childhood 2008; 93(1): 35-39.
16. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006; 295:1549-1555.
17. McCombs M, Shaw DL. The agenda-setting function of the mass media. Public Opinion Quarterly 1972;36:176-185.
18. Salazar MK. Comparison of four behavioral models. AAOHN 1991;39:128-135.
19. Stubbs CO, Lee AJ. The obesity epidemic: both energy intake and physical activity contribute. Med J Aust2004;181:498-91.
20. Krieger N. Theories for social epidemiology in the 21st century: and ecological perspective. International Journal of Epidemiology 2001; 30:668-677.
21. McLeroy K et al. An Ecological Perspective on Health Promotion Programs. Health Education and Behavior 1988; 15: 351-377.
22. Thomas LW. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing 1995; 11:246-252.
23. Shishebor M et al. Association of neighborhood socioeconomic status with physical fitness in healthy young adults: the CARDIA study. American Heart Journal 2007; 155: 699-705
24. Goodman E et al. The public health impact of socioeconomic status on adolescent depression and obesity. Adolescent Health 2003; 93: 1844-1850.
25. Wang Y et al. Obesity and related risk factors among low socio-economic status minority students in Chicago. Public Health Nutrition 2007; 9: 927-938.
26. Wang Y, Zhang Q. Are American children and adolescents of low socioeconomic status at increased risk of obesity? Changes in the association between overweight and family income between 1971 and 2002. American Journal of Clinical Nutrition 2006; 4: 707-716.
27. Wang Y. Cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socioeconomic status. International Journal of Epidemiology 2001; 30: 1129-1136.
28. Wills W et al. The influence of the secondary school setting on the food practices of young teenagers from disadvantaged backgrounds in Scotland. Health Education Research 2004;20(4):458-465.
29. Lewis E. Children’s views on non-broadcast food and drink advertising, Report for the Office of the Children’s Commissioner. UK National Children’s Bureau, Office of the Children’s Commissioner. September 2006;1-20.
30. Freedman D et al. Racial and ethnic differences in secular trends for childhood BMI, weight, and height. Obesity 2006; 14: 301-308.
31. U.S. Department of Health and Human Services. SmallStep Kids. Washington, D.C.: http://www.smallstep.gov/kids/flash/index.html

Click It Or Ticket: Failing America While Trying To Protect It – Pat Brooks

In 1993, North Carolina became the first state to enact a campaign in which neglecting seat belt use in a motor vehicle would be grounds for law enforcement pulling over drivers. Since then many other states have adopted this program. The National Highway Traffic Administration brags that the campaign “is the most successful seat belt enforcement campaign ever, helping create the highest national seat belt usage rate of 82 percent” (7). The campaign’s name and its message are simple: “Click it or Ticket.” Click it or Ticket is a failure to American citizens because the message of this campaign ignores the issue of social norms, rational empirical and normative re-educative approaches (skipping to coercion without educating the public), and the causes of accidents (wrongly assuming that wearing seat belts prevents accidents).
Social Norms
This campaign is a failure to Americans because it ignores the issue of social norms. Two studies were conducted in the United States and Sweden to examine relationships among several behaviors. The studies examined the interrelationships among a variety of self-reported perceptual and behavior measures predicting driving behavior. Part of the study focused on seat belt usage. Results show that emphasizing factors such “as comfort and social norms [is] an efficient way of increasing seat-belt usage” (8). The article goes on to articulate the need for creating the social norm, “giving the feeling that other drivers are using seat belts, and that it is alright to do so” (8). Because Click it or Ticket has previously increased seat belt use rates nationwide, it should be using the idea that it is socially acceptable and normal to buckle up in order to persuade the citizens who are not complying with the law to join the majority of Americans. By not appealing to this aspect of influence, it fails Americans.
The findings of another study show that using a social norms-based intervention can provide people with more accurate perceptions about health behaviors (5). This change in perceptions would in turn lead to a modification in their behavior (5). A study published in the Oxford University Press designed a model for health behaviors. Their model relied heavily upon social norms, showing that an intervention which does not account for social norms cannot be a success (6). Even advertisers have caught onto this idea and realized its potential for impact. In 2005, the American Academy of Advertisers looked at current public health interventions aimed at reducing college binge drinking. It concluded that “behavior is influenced by others' behavior - as well as our sometimes inaccurate perceptions of their behavior” (1).
Coercion
The message of this campaign ignores rational empirical and normative re-educative approaches, skipping to coercion without attempting to educate the public. A study was done testing the hypothesis that giving children rewards for buckling up could increase their use of seat belts (10). During the reward phase at twenty five schools, children’s safety belt use increased from 4% to 66% and 5% to 70% in the United States and Sweden respectively. This study suggests that for children, a more effective approach than coercion is a system of positive reinforcement. The current Click it or Ticket campaign is a threat to drivers and does not attempt to offer any sort of reward system. Additionally, the menace of being ticketed by a law enforcement officer does not even reach children, since none of them can receive such tickets. If 100% of children under 5 years of age had used safety belts in the year 2000 alone, “an estimated 458 lives could have been saved” (4).
Another subgroup of individuals not being reached by the Click it or Ticket campaign and consequently with low probability of buckling up is the college age male (1). In 1985, researchers introduced a method, Flash for Life, that “increased belt use among 22% of unbuckled drivers” (3). In 2007, this intervention was revived and applied at a large university campus. In a study aimed at this particular age group, college students at a large university who were not buckled up were targeted by other students flashing signs that read “Please Buckle Up, I Care” (3). The university selected had already high seat belt use. The hypothesis of the study was that this positive reinforcement would be more effective than the current threat of Click it or Ticket for college aged drivers. The results of the study showed that “of 427 unbuckled drivers observed, 30% of these complied with the prompt” (3). Interestingly, the unbuckled male drivers were significantly more likely to buckle up when the student holding the sign was female. Another impact found in this study is an industrial one. It suggests that “a simple behavioral prompt could be used at most industrial complexes to increase safety belt use among vehicle occupants who are not buckled-up” (3). Programs such as Flash for Life are examples of better approaches to the issue of seat belt usage. By ignoring appeals that are targeted at specific subgroups of the population, Click it or Ticket is failing Americans.
Both of these studies showed alternatives to menacing intimidation, or coercion, which utilize positive reinforcement with compliance. The first steps to changing a behavior are rational empirical and normative re-educative approaches. These should be included in any intervention whose aim is to protect the public. The American Academy of Advertising has said that “fear-based appeals have been the dominant strategy over the years,” but that new evidence shows that marketing strategies from the normative and rational perspectives could be applied to some public health areas to make a greater impact than those fear-based approaches (1). “Behavior analysis has shown that [standard coercive practices] do not work” (11). Coercion lacks durability because it is “in the long run self-defeating” (11). It usually turns out that using punishment as a motivator will be counterproductive in the long run.
True Causes
The message of this campaign ignores the causes of traffic crashes, wrongly assuming that wearing seat belts prevents accidents. Seat belts may protect vehicle occupants when traffic crashes occur, but an effective intervention would target prevention of the crashes in the first place. Speeding, aggressive, drowsy, distracted or impaired drivers, and vehicle malfunctions all can be major contributors to traffic accidents.
In 1975 the National Highway Traffic Safety Association (NHTSA) created the Fatality Analysis Reporting System (FARS). FARS uses census data from all 50 states, Puerto Rico, and Washington D.C. Using FARS data, it is easy to see that there has been no significant decrease in the number of crashes since Click it or Ticket has been around. In 2005, twelve years after Click it or Ticket was enacted in the first state, “more than 6.1 million police-reported motor vehicle crashes occurred in the United States” (4). In 1994 there were 36,254 traffic fatalities compared with 38,588 in 2006. It is obvious and logical that a campaign solely trying to increase seat belt use has made no impact on the number of crashes in the United States.
Furthermore, alcohol is involved in 39% of fatal crashes and has a fatality rate of 75% in crashes between midnight and 3.m. (4) A successful campaign would target this major cause of traffic collisions. It would use prevention as its primary focus.
The total number of road deaths in the United States has either risen or stayed the same since Click it or Ticket. The table below outlines the trend of motor vehicle crashes in the United States over a 13 year period. (4)
Fatal Motor Vehicle Traffic Crashes
Year
1994
1995
1996
1997
1998
1999
Fatalities
36,254
37,241
37,494
37,324
37,107
37,140

2000
2001
2002
2003
20004
2005
2006
37,526
3,862
38,491
38,477
38,444
39,252
38,588

Click it or Ticket does not aim to reduce the number of traffic crashes or fatalities. It is like treating the symptoms without considering the disease. The campaign is a failure because the message ignores the causes of traffic crashes, wrongly assuming that wearing seat belts prevents accidents. A truly successful campaign would incorporate accident prevention as part of its message.
Conclusion
In conclusion, Click it or Ticket is a failure to Americans because the message of this campaign ignores the issue of social norms, rational empirical and normative re-educative approaches, skipping to coercion without educating the public, and the causes of accidents, wrongly assuming that wearing seat belts prevents accidents. If this campaign continues to be a failure, it could miss the opportunity to save countless lives. This failing campaign does not protect drivers or passengers from being involved in automobile crashes. Its focus on coercion and punishment will not provide the positive reinforcement that children and other subgroups of the population require. Its ignorance about the true causes of crashes will do nothing to prevent them. Continuing a failing program will continue to kill.
REFERENCES
Cressey, Peter H. Alternatives to Fear Appeals: New Strategies for Social Behavior Campaigns. American Academy of Advertising 2005; 22(4): 10-28.
Colgrove, James. The Legacy of Jacobson v Massachusetts. American Journal of Public Health 2005; 95(4): 571-576.
Farrell, Leah V. Prompting safety-belt use in the context of a belt-use law. Journal of Safety Research 2007; 38(4):407-411.
Fatality Analysis Reporting System. Encyclopedia: http://www-fars.nhtsa.dot.gov.
Hagman, Brett T. Social Norms Theory-Based Interventions: Testing the Feasibility of a Purported Mechanism of Action. Journal of American College Health 2007; 56(3): 293-298.
Jo, Heuisug. Structural Relationship of Factors Affecting Health Promotion Behaviors. Health Promotion International 2003; 18(3): 229-236.
National Highway Traffic Safety Association. Click It Or Ticket: http://www.nhtsa.gov.
Ola, Svenson. Perceived driving safety and seatbelt usage. Accident Analysis and Prevention 1985; 17(2): 119-133.
Ouimet M.C. Perceived Risk and Other Predictors and Correlates of Teenagers’ Safety Belt Use During the First Year of Licensure. Traffic Injury Prevention 2008; 9(1): 1-10.
Roberts, Michael C. Rewarding Elementary Schoolchildren for their Use of Safety Belts. Health Psychology 1986; 5(3): 185-196.
Sidman, Murray. Coercion and its Fallout. Boston, MA: Authors Cooperative, 1989.

A Critique of the Federal HIV/AIDS Web-based Prevention Programs – Michaela F. George

Since HIV/AIDS was first diagnosed in the United States in the early 1980s, it has grown from an isolated outbreak to a global pandemic. The country’s overall HIV estimated prevalence in 2003 was 1,039,000-1,185,000. Of these, 417,000 persons were living with HIV, 415,000 were living with AIDS, and 252,000-312,000 (24-27%) were undiagnosed (1). Although HIV/AIDS has become even more prevalent in this country since 2003, it remains a preventable disease. Scientists and epidemiologists have been able to identify biological risk factors and health behaviors that increase HIV transmission on an individual level (2). Still, prevention methods promoted by the federal government are inadequate. In this paper, I critique specific programs promoted and supported by the federal government and contrast them with more effective state-sponsored programs. Moreover, I identify the specific flaws that make the federal programs fail, using basic social science theories to support the analysis.
This critique focuses on web-based prevention programs sponsored by the federal government. As of February 2004, nearly 204.3 million Americans had internet access (3). Given this ubiquity of availability and use, the internet is an appropriate medium for reaching a wide audience. Furthermore, the internet can be accessed in privacy; thus, accessing sensitive medical information remains private. HIV/AIDS remains a highly stigmatized disease, and therefore, being able to access accurate information without exposing one’s condition is critically important to reaching the at-risk audience. Thus, an understanding and appreciation of the ways in which individuals use the information posted on the internet is critical when designing and planning these programs and interventions (4-5). While I will not critique the accuracy or overall quality of the information posted on federally-sponsored websites (which are generally good), the manner in which this information is presented makes it less likely to impact behavior of the targeted audiences. The poor manner of presentation and insensitivity to motivation in the target audiences are among the primary reasons that federally-sponsored websites are largely ineffective in HIV/AIDS prevention.
Many of the interventions supported by the federal government attempt to prevent HIV at the individual level, but they often fail to take account of the social influences affecting an individual’s health behavior choices. Moreover, the programs the federal government supports are not culturally sensitive or informed enough to communicate effectively to their target audiences. An example is the Tips for Teens campaign (6), (discussed below). Similarly, as explained in this essay, federal websites specifically targeted to bisexual men lack proper social sensitivity. In addition to lacking credibility through social insensitivity, the federal government’s overarching theme of prevention relies on informing and promoting the intention to change, with inadequate attention to translation of the intent to actual changes in behavior. As described herein, the program titled How to Protect Yourself from AIDS is a great example of this shortcoming (7).
In the context of this essay, the term “effective” connotes a subjective measure of how well these programs reach the goal of successful prevention. The purpose of these programs is to reduce the incidence of AIDS/HIV in the United States. Therefore, measures of effectiveness must go beyond whether and how well these web-based programs deliver information and strategies for protecting HIV-negative individuals from contracting the disease. To be effective, the programs must change health behaviors—arguably a much more daunting and complex task than information dissemination. I will look at a handful of these programs to offer specific examples which illustrate why federal web-based programs are ineffective. Understanding and explaining inadequacies may be a useful step toward re-conceiving, re-designing or even dropping these programs to promote effectiveness.
Argument 1: Failing the Adolescents
The first critique of the federal government’s HIV prevention programs is that they tend to focus on the intellectual side of decision making rather than evoke an emotional response from their audience. By using strategies from the discipline of social science to frame the context, an intervention can influence individual behavior by framing the desired behavior positively (or the risky behavior negatively) to evoke emotional, not just intellectual, responses (8-9). As successful advertising conclusively demonstrates, using cultural metaphors and drawing on meaningful analogies or ideals are more successful in influencing behaviors than bombarding target audiences with “mere” facts.
The program, Tips for Teens, is an example of a program’s blatant disregard for what the sociologists call framing. This website and the official website of the CDC aimed at youth focus their prevention efforts on conveying facts and figures about HIV/AIDS. They provide statistics and graphs to prove the point that HIV/AIDS prevention practices are available and effective in preventing the spread of HIV/AIDS; that is, they convey an intellectually compelling message supporting the wisdom of protective behavior. But that is exactly the cause of their ineffectiveness. Appealing to the intellect of teenagers is precisely the wrong way to influence their behavior (10). Rebellion, disobedience, insubordination and risk-taking are the behavioral pillars of this age cohort. If a prevention program wants to be successful, then it must take account of those qualities and appeal to emotion as well as intellect. Throwing numbers and lists of reasons why abstaining from risky behaviors would be the better choice just might encourage the opposite behavior (11). Notwithstanding the risk of political fall-out, the federal government needs to change its strategy toward HIV/AIDS prevention among youth if these programs are to become effective.
Argument 2: Failing the Non-mainstream (divergent, atypical and unconventional)
The second main critique of the federal government’s HIV prevention programs is that these programs lack authenticity and a “hearable voice” when speaking directly to specific at-risk groups. For example, the CDC has a program that directly targets a specific type of individual engaging in risky sexual behavior: men who have sex with men but participate in that behavior in secret (12). The website makes generalizations about these individuals and speaks to them from a foreign/outsider standpoint. The CDC provides an objective, clinical exposition of the facts and remaining questions regarding men “on the down low”. At no point does the reader get a sense of compassion or understanding for the unbalance, confusion, and stigma that would be associated with that group of individuals. Admittedly, the concept of “on the DL” is tricky and sensitive. However, because the CDC website lacks even a hint of identification with the target group, it is unlikely to be effective in affecting behavior among the target audience. While the clinical approach avoids acceptance (which would be politically unacceptable to many) and condescension (which would be counter-productive in the DL community), the website fails the effectiveness test because sociological agnosticism lacks the power to influence.
Individuals who are associated with stigmatized behavior are more likely to take on the characteristics of that social group, even when those characteristics are negative (13). A person’s primary social network is also the primary source for learned behavior. Thus, a successful intervention must address the issues that affect the stigmatized group in order to be effective (14-15). The intervention needs to speak directly to the group in a tone/language that is accessible, understandable and sociologically acceptable.
The CDC’s attempt to influence the behavior of the “down low” population doesn’t work. First, the website defines the group: “the term is often used to describe the behavior of men who have sex with other men as well as women and who do not identify as gay or bisexual.”(12). This language suggests an outsider forcing a definition, much as a taxonomist places organisms in hierarchy based on objective attributes that emphasize differences, not commonality. To be effective, all definitions of a group used in HIV prevention should arise internally and, thus, be consistent with the target’s self identity. The CDC’s clinical approach defines these men as “on the down low” and thereby fails to motivate behavioral changes—the very thing necessary to prevent the spread of AIDS.
Second, even if we overlook that this definition is not self-proposed, the method used to reach a “covert” population is futile. By their own definition, this population chooses to resist acknowledging membership in the group in the first place. If we were to follow this line of thinking, these men define themselves as heterosexual but engage in homosexual activities. Wouldn’t the program be more successful if the CDC targeted the group with which these men choose to associate? If the CDC re-structured the campaign to speak to sexually active men, giving both heterosexual and homosexual safe-sex advice, then these “down low” men would get the information they need while maintaining their social distance from the homosexual definition. They would be able to avoid the stigma associated with homosexual behaviors, but still obtain the necessary health/prevention information. Of course, that only addresses the information side of prevention and still ignores the emotional motivation for behavior modification.
Argument 3: Misusing the Health Belief Model
The third, and perhaps most important, criticism of the federal government’s HIV/AIDS prevention campaigns is that they complacently rely on the Health Belief Model as their main intervention strategy (16). The Health Belief Model assumes a rational decision making process. The intellectual balancing of cost and benefits of decision making is fundamental to this model. Moreover, this model hinges on the assumption that an individual’s intention to do a certain action will lead to the realization of that behavior. Even the combination of more complicated and more socially integrated theories assume rational decision making process (17-18). This is obviously not the model that applies to every individual during every decision. Sure, when making a decision about which college to attend or which job offer to accept, this rational model predominates. However, when thinking about the decisions concerning health behaviors, especially sexual behavior, the assumption of rational decision making practices is not realistic. Decisions about sexual behavior are often made under the influence of temporary pressures (alcohol or social situation, for example) and in response to emotional, not rational, influences.
For example, the Department of Human and Health Services has a website (accompanied by an optional pdf brochure), entitled How to Protect Yourself from AIDS, that outlines all the components necessary for making a rational decision (7). The website is bare of any pictures, graphics, or personal touches. There is an outline consisting of subtitles and bullet points, such as “How to use a Condom.” While this is an important aspect of HIV prevention to understand, the manner in which the information is presented implies that prevention can be reduced to using a condom correctly. The real story is much more complicated than that. If the AIDS pandemic could be avoided by just knowing the facts and relying on rational judgment, then we would not be in this dire health emergency. The decision to have sex with or without a condom is seldom a rational one. Thus, the federal government’s cautious resort to a health behavior model that assumes rational decision making is doomed to fail.
Conclusion: Hope in Successful Programs
There are several very successful, government-sponsored, web-based programs aimed at prevention of HIV/AIDS; take, for example, the Massachusetts and California state programs. These programs successfully integrate social science theories and used “trusted intermediaries” to influence the behaviors of the targeted audiences and, therefore, have the potential to actually reduce HIV transmission rates within the target group(19). Furthermore, these web-based programs successfully use the internet to reach their audiences with both authority and authenticity.
The Massachusetts Department of Public Health has instituted a training program for primary care health workers to encourage techniques of prevention on the individual level (20). These prevention programs are aimed at physicians and health care workers to offer “training [which] involve[s] concepts and procedures (standards of care) related to the prevention, diagnosis, treatment, management and patient counseling for STD and for prevention of HIV infection.” Making HIV care the “standard of care” allows individually tailored care. The information presented on this website relies on a rational decision, but that is appropriate in this circumstance. This is aimed at professionals who are making a decision about how to offer care on a clinically oriented basis. Therefore, relying on the link between intention and behavior is appropriate and effective. Put another way, the Massachusetts website provides accurate, actionable prevention strategies and empowers trained health care professionals to transfer the information to their clients, employing the communication techniques which “package” the information in the way most likely to impact the professional behavior of these clinicians.
Another example of successful prevention programs is the California campaign of web-supported peer-prevention networks that focuses on safe needle exchange for IV drug users (21). Peer education and prevention programs have authenticity. Hearing someone else’s personal experience and learning from that because you can see yourself in a similar circumstance are much more effective than governmental “preaching”. Shared experience, in this example, allows current IDUs to realize their own self-efficacy (22). These IDUs can see that change is possible, and protecting themselves against HIV/AIDS is reasonable and achievable.
The existence of these successful programs makes the lack of success of federal programs even more unacceptable. There are current and successful models for HIV/AIDS prevention programs and campaigns. However, the federal government continues to ignore these lessons learned. That is unacceptable. There are models out there that work. There are only reasons of “political correctness” to defend these ineffective programs. Unfortunately, in AIDS prevention it is not just what we don’t know that can hurt us, it is also that which we cannot listen to that dooms us to ineffectiveness.
REFERENCES
1. Glynn M, et al. Estimated HIV prevalence in the United States at the end of 2003. National HIV Prevention Conference; June 12–15, 2005; Atlanta. Abstract T1-B1101
2. Since the beginning of the HIV/AIDS epidemic, there have been certain populations that have been associated with the disease. For example, men who have sex with men, intravenous drug users, sex workers were among the first groups diagnosed with HIV/AIDS. Therefore, those social stigmas associated with those groups became synonymous with the disease. This association has been an enormous barrier in the fight against AIDS. While this is not an element of my central critique, it is an important context that I want the reader to understand.
3. Nielsen//NetRatings, March 2004: www.nielsen-netratings.com
4. Reeves PM. How individuals coping with AIDS use the Internet. Health Education and Research, Theory and Practice 2001; 16:709-719.
5. Ferguson T. Health online: how to find health information, support groups and self-help communities in cyberspace. Reading, MA: Addison-Wesley, 1996.
6. Tips for Teens: http://ncadi.samhsa.gov/govpubs/PHD725/
How to protect yourself from AIDS: http://www.fda.gov/opacom/lowlit/aids.html
8. McQuail, D. McQuail’s Mass Communitcation Theory. London, England: Sage Publishing, 2000.
9. Brown JD, Steele JR, Walsh-Childers K. Sexual Teens, Sexual Media: Investigating media’s influence on adolescent sexuality. Mahwah, NJ: Lawrence Erlbaum, 2002.
10. McKenna J, Gutierrez, J, McCall K. Strategies for an effective youth counter-marketing program: recommendations from commercial marketing experts. Journal of Public Health Management and Practice 2000; 6:7-13.
Clee MA, Wicklund RA. Consumer behavior and psychological reactance. Journal of Consumer Research 1980; 6: 389-405.
On the down low: http://www.cdc.gov/hiv/topics/aa/resources/qa/downlow.htm
Akers RL, Krohn MD, Lanza-Kaduce L, Radosevich. Social Learning Ans Deviant Behavior: A Specific Test of a General Theory. American Sociological Review 1979; 44: 636-655.
14. Siegel, M Doner, L. Marketing Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2004.
15. Devine PG, Plant EA, Harrison K. The Problem of “Us” versus “Them” and AIDS Stigma. American Behavioral Scientist 1999; 42:1212-1228.
16. Becker MH. The Health Belief Model and Personal Health Behavior. Thorofare, NJ: C. B. Slack, 1974.
17. Fishbein M, Guinan M. Behavioral Science and Public Health: A necessary partnership for HIV Prevention. Public Health Reports 1996; 111:5-10.
18. Fishbein M, Yzer M. Using Theory to Design Effective Health Behavior Interventions. Communication Theory 2003; 13:164-183
19. The comparison of effectiveness of the federal versus state programs is a difficult one to support. There are no research to support a causal relationship between accessing state level intervention programs and effectively staying HIV negative. However, with my background in social science research the potential effectiveness of these state programs are far beyond the potential effectiveness of the federal programs. Both because of the suitable methods used to target appropriate audiences and the use of valuable intermediaries, these state programs are designed to succeed.
20. Primary Care Prevention: http://www.mass.gov/dph/cdc/stdtcmai/stdtcmai.htm
21. Peer Education: www.satelliteexchange.org/docs/Poster_IHRA_Conf.doc
Strecher VJ, DeVellis BM, Becker MH, Rosenstock IM. The Role of Self-Efficacy in Achieving Health Behavior Change. Health Education & Behavior 1986; 13:73-92.