England’s Maternal Prenatal Smoking Cessation-Robbie Frank

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

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

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

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





Works Cited

References
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2.) Brosky, G. Why do pregnant women smoke and can we help them quit? Canadian Medical Association Journal Jan. 15, 1995; 152(2): 163–166.
3.) Draper, E. and Haslam, C. A qualitative study of smoking during pregnancy.
Psychology Health & Medicine 2001; 6, 95−99.
4.) Dutta-Bergman, M. Theory and Practice in Health Communication Campaigns: A Critical Interrogation. Health Communication 2005; 18 (2); 103–122.
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pregnancy. American Journal of Public Health 1990; 80 (5):541–4.
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Health Sept. 1989; 103 (5): 337-43.
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The Gardasil Campaign: Merck, Take a Look at it from a Public Health Perspective – Maithili Jha

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

Does one Ad Apply to Everyone, Everywhere? : Stage II
For Stage II, Merck would use all of the information gathered during the market research phase, and determine how answers to their questions may vary according to race, ethnicity, age, gender, culture, and socio-economic status amongst other variables. Currently, there are not many variations to the “One Less” advertisements. Merck, has not marketed to conservative groups, transgender individuals, immigrants, or partners of those getting the vaccine. By performing the necessary market research for Stage I, Merck’s marketing directors would understand the challenges faced with being from a conservative culture and bringing up the topic of sexual behavior with children, and the impact of a partner asking their loved one to be vaccinated.
In one example of a Gardasil commercial there are eight different women individually, in the form of a soliloquy saying they want to be “One Less.” And they are saying everything during the commercial in perfect English, and with “American” mannerisms. It is not until the last ten seconds of the ad do they show a group of young girls, jump roping, saying “O-N-E-L-E-S-S,” appealing to a group of people who collectively agree that one should be vaccinated with Gardasil. There is not a single example of a mother saying the importance of talking to their daughter(s) about HPV, a partner talking to another partner, be it a heterosexual or a homosexual relationship, about getting vaccinated, or an example of a religiously conservative person expressing the importance of the vaccine (12). By going through the steps of Stage I, Merck would have known that a Muslim mother still may not feel comfortable talking to their husband or boyfriend about being vaccinated or having their daughters vaccinated, after seeing the advertisement described above. And, Merck would understand that some cultures are more community oriented, and the opinions of others matter more than their own individual opinion. After doing the research, and learning about the different educational requirements for each culture, Merck might have benefited from including a group of ethnic women who do not speak perfect English, sitting together, discussing HPV in their ads.
Avoid a False Sense of Security, a Riled Up Crowd : Stage I & Stage II
On June 9, 2006, Gardasil was approved by the FDA. And, on November 23, 2006 Merck launched its print, online and television advertising campaign for the vaccine (13). By February of 2007, Merck had already started lobbying for mandatory vaccinations in schools. They had only been marketing the vaccine for two months with advertisements like the one involving eight women mentioned earlier. In that same ad, one woman says “Gardasil will not treat cervical cancer,” and the woman right after her says, “Ask your doctor about getting vaccinated with the only cervical cancer vaccine” (12). Merck prematurely marketed the vaccine as one that prevents cervical cancer to a public that, in two months of advertising, had not been educated in HPV, the causes of cervical cancer, the fact that HPV is not the only cause of cervical cancer, and that even if one is vaccinated they still might end up with the cancer. Once Merck started lobbying for mandatory vaccinations, the public knew two things: that Gardasil is a cervical cancer vaccine, and that HPV is related to sexual activity. Gardasil is not a cervical cancer vaccine, so the public was misinformed and had a false sense of security in the vaccine. And, even though HPV is caused by sexual activity, they were not ready to be introduced to a mandatory vaccine for a controversial topic: sexual activity.
Had Merck followed a two-stage process for promoting the vaccine, and included a broader educational portfolio into their marketing campaign, their lobbying attempts and advertisements may not have caused such a great sense of distrust in a FDA approved vaccine. Instead of releasing the Gardasil ads five months after approval, Merck could have waited, done the research for Stage I of advertising, and been more effective by gaining the trust of the public. The two-stage approach of educating and then promoting the vaccine would force Merck to fully inform the public in HPV, and then push for mandatory vaccinations. By the time the lobbying efforts would be known to the different communities, the individual people making up the communities would be more accepting to the idea of having their daughters vaccinated, and they would have understood the value in having mandatory vaccinations in schools.
Conclusion : Money was not Discussed, and it won’t be
The two-stage approach to promoting a vaccine discussed in this paper, does not take into consideration the monetary impact of having twice as many marketing campaigns. However, one would hope that for FDA approved vaccines, and products affecting a person’s health, pharmaceutical companies will be able to fabricate, and re-organize their Research and Development and Marketing budgets to allow for better education of the public, and find value in equating education and product promotion. And, one would hope that lawmakers would see the benefit in aiding pharmaceutical companies in providing more information on the vaccines and the viruses. Maybe, one day it will become common practice to conduct Stage I type activities while doing clinical trials for the vaccine or drug at the same time. But, until education and product promotion have equal weight in the public and private sectors, we will continue to have vaccines quickly marketed to an ignorant public, and public opposition to effective vaccines.
References
"Cervical Cancer Basic Information." Centers for Disease Control and
Prevention: Your Online Source for Credible Health Information. 22 Dec. 2008. Department of Health and Human Services. 27 Mar. 2009.
2."Efforts to Make Gardasil Mandatory Stall in Some States." The National Health Federation: A Not-For-Profit Health-Freedom Organization. 24 Apr. 2008. National Health Federation. 4 Apr. 2009.
Edberg, Mark. Essentials of Health Behavior: Social and Behavioral
Theory in Public Health. Boston: Jones and Bertlett, 2007
4. "Facts about Cervical Cancer." Michigan Cancer Consortium. Feb. 2009. Michigan Department of Community Health. 4 Apr. 2009.
5. "FDA Licenses New Vaccine for Prevention of Cervical Cancer and Other Diseases in Females Caused by Human Papillomavirus." U.S. Food and Drug Administration. 8 June 2006. U.S. Department of Health & Human Services. 27 Mar. 2009.
6. Gerend, Mary A., and Zita F. Magloire. "Awareness. Knowledge, and Beliefs about Human Papillomavirus in a Racially Diverse Sample of Young Adults." Journal of Adolescent Health 42 (2008): 237-42.
7. Halcomb, Bryan, Joanne M. Bailey, Kathleen Crawford, and Mack T. Ruffin IV. "Adults' KNowledge and Behaviors Related to Human Papillomavirus Infection." Journal of the American Board of Family Medicine 17 (2004): 26-31.
8. "HPV Vaccination Information for Young Women." Centers for Disease Control and Prevention. 26 June 2008. Department of Health and Human Services. 27 Mar. 2009.
9. "HPV Vaccine." National Conference of State Legislatures: The Forum for America's Ideas. Apr. 2009. 4 Apr. 2009.
10. Jones, Bethany. "Gardasil Marketing Campaign for Cervical Cancer Misses the Mark." Associated Content: Information from the Source. 10 Oct. 2007. 27 Mar. 2009.
11. "Mandatory Vaccination with Merck's Gardasil Raises Eyebrows." Seeking
Alpha. 7 Feb. 2009. 23 Mar. 2009.
12. Merck. "Gardasil Commercial." YouTube. Nov. 2006. .
13. "Merck Launches National Advertising Campaign For GARDASIL, Merck's
New Cervical Cancer Vaccine." Medical News Today. 23 Nov. 2006. 27
Apr. 2009 .
14. "Merck lobbying States to mandate Gardasil for school girls." News-Medical.Net-Medical and Health News Headlines. 30 Jan. 2007. 4 Apr. 2009.

Failure Of The Healthy Futures Program-Grace Thiongo

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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