Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Wednesday, March 19, 2008

Preventing Medical Errors: Piercing the Shroud of Secrecy Surrounding the Issue is the Key to Success

While most new parents enjoy a time of celebration and wonder following the birth of their children, actor Dennis Quaid and his wife suffered the scare of their lives. In November 2007, their newborn twins nearly died after receiving a massive overdose of heparin, a blood-thinning drug.

According to an ABC News article: "the hospital released a statement that confirmed that three of its patients had received 1,000 times the prescribed Heparin. Instead of 10 units per millimeter, the patients received 10,000 units. ... a pharmacy technician mistakenly stocked the 10 unit vials and 10,000 unit vials in the same drawer. Protocol at the hospital is to keep the different units separated. 'This was a preventable error, involving a failure to follow our standard policies and procedures,' the hospital said. 'Although it appears at this point that there was no harm to any patient, we take this situation very seriously.'"

Not all patients, however, are lucky enough to survive severe medical errors. According to the Institute of Medicine, between 44,000 and 98,000 patients in the United States die each year due to medical errors occurring in the hospital. There are at least 1.5 million annual injuries due to preventable medication errors alone.

Upon first thought, one might believe that a strong litigation initiative - punishing health care providers and holding them responsible for errors - might be the way to amerliorate this serious problem. However, upon closer inspection, I believe that quite the opposite is true.

Perhaps the critical problem that has been holding up progress in reducing medical errors is secrecy about the issue - lack of reporting and lack of communication - due specifically to the threat of litigation.

According to a Food and Drug Administration (FDA) report: "Neonatologist Margaret Donahue, M.D., says the fear of being sued suppresses discussions about medical errors. 'Even if a procedure is done with the best intention and skill, and it doesn't turn out the way it was supposed to, the doctor often still ends up having to pay the patient a huge settlement. It's that culture--the feeling they're going to lose no matter what they do--that keeps physicians closed among themselves.'"

"Historically, people have looked for someone to blame when medical accidents happen, according to FDA's Woodcock [Janet Woodcock, M.D. is the head of FDA's Center for Drug Evaluation and Research]. For victims and their relatives, she says, there may be some satisfaction in that. But from the perspective of fixing the problem, the secrecy that results keeps the medical community from learning what happened and how to correct the problem."

The key, therefore, to unveiling the cloak of secrecy that surrounds health care providers and institutions and which shields patients from the information they need and deserve is to somehow address the litigation threat that is responsible for the veil of secrecy in the first place.

Perhaps this threat is most problematic when it interferes with the direct communication of the occurrence of medical errors to the patient and the patient's family. Even an apology or expression of sympathy for the consequences of a medical error could be construed as an admission of guilt, and health care providers may avoid such communications solely out of fear of litigation.

Another critical component of any successful intervention to reduce medical errors is to treat the problem from a systems level and not merely from the perspective of individual mistakes. Most errors, even when blame can be attributed to individuals, stem from more fundamental causes, often involving systems, policies, or social and environmental conditions.

But the most important component of a successful strategy to deal with medical errors is to bring these errors out into the open. We cannot fix a problem if the problem is not reported. We cannot expect accountability if hospitals are not accountable.

A bill (S1277) currently before the Massachusetts legislature, entitled "An Act Promoting Healthcare Transparency and Consumer/Provider Partnerships," goes a long way toward providing a strategy based on the above principles. The bill would require hospital reporting of serious adverse, preventable medical errors and hospital-acquired infections, require that health care providers inform patients when these errors occur, and allow providers to apologize or express sympathy to patients regarding errors without fear that the apology would constitute an admission of guilt under the law.

The bill states: "In an action for malpractice, negligence, error, omission, mistake, or the unauthorized rendering of professional services against a provider of health care, statements or writings by such provider of health care expressing apology or sympathy relating to the pain, suffering or death of a person which is not the result of intentional misconduct by such provider of health care and made to such person or to the family of such person shall be inadmissible as evidence of an admission of liability."

This would go a long way towards unraveling the veil of secrecy that enshrouds the issue of medical errors. It would open up doors of communication between providers and patients.

Ultimately, it is the partnership between the patient and the provider which determines the success or failure of medical treatment. Senate Bill 1277 aims to create such a partnership.

The battle against medical errors is not going to be won or lost by physicians and health care providers alone. The key to victory is empowering consumers and providers to work together to overcome the 8th leading cause of death among Americans.

Friday, December 14, 2007

REP Adult Secondary HIV Prevention Interventions: Their Failure to Address Sexual Risk Taking Among HIV- Infected Population- Jessica Ripton

Approximately 33% of HIV-infected individuals from diverse populations across the U.S. continue to engage in unprotected sexual intercourse (1). Nationally, unprotected sexual intercourse with an infected partner continues to be the leading transmission category among men who have sex with men (MSM) at 67% and unprotected heterosexual contact accounts for 80% of all infections among women (2). In response to continued sexual risk taking, HIV prevention strategies have expanded to include secondary prevention interventions, which are prevention interventions aimed at reducing transmission risk behavior among HIV positive individuals. Researchers, local health providers and government agencies recognize the need to quickly implement interventions that have shown effectiveness in reducing transmission risk behavior in randomized controlled trials. Such interventions are commonly referred to as evidence-based. The goal of the Center for Disease Control (CDC) Replicating Effective Programs (REP) is to package evidence-based behavioral interventions in an accessible language and format to be used to guide prevention providers in replicating effective risk-reduction programs in their own settings and communities (3). Three of the thirteen evidence-based behavioral interventions currently included in the CDC’s REP focus on reducing sexual risk behavior among HIV-infected populations. Two of the interventions focus on adult populations, while the third focuses on HIV-infected youth. This paper will concentrate on the REP behavioral intervention designed for HIV-infected adults, as the issues specific to HIV-infected youth merit a separate investigation.

The secondary prevention behavioral interventions included in REP for adults have contributed significantly to the field of HIV prevention; however, several limitations will impact the effective replication of these interventions in HIV-positive communities throughout the nation. Both interventions focus on either providing individuals with information on how to reduce sexual risk taking or building skills and strategies to reduce sexual risk taking. Yet neither intervention attempts to uncover the complex reasons why the sexual risk taking continues. This paper will address the following fundamental limitations of the REP secondary prevention interventions: 1) Social Cognitive Theory’s emphasis on skill and education-based behavior change doesn’t address the root cause(s) of continued sexual risk; 2) the interventions fail to assess how multiple psychosocial issues such as limited access to care, lack of stable housing and lack of social support impact sexual risk taking and; 3) despite strong evidence that HIV infected population experience high level of psychological distress, neither intervention addresses underlying mental health issues which may have initially put these individuals at greater risk of HIV infection and will likely continue to impact their sexual risk behavior.

REP & Evidence-Based Secondary Prevention Interventions

The CDC’s Division of HIV/AIDS Prevention (DHAP) has been working to make research–based HIV/AIDS prevention interventions available to communities since 1996 through technical assistance programs such as REP (4). Briefly, REP works in partnership with two other technology transfer projects in DHAP: Prevention Research Synthesis (PRS) and Diffusion of Effective Behavioral Interventions (DEBI). The programs work to identify evidence based interventions and prepare packages of materials for dissemination to HIV prevention agencies and providers (4). As noted previously, two of the thirteen REP programs focus on HIV-infected adults: Healthy Relationships and Partnership for Health. The following section will briefly describe the initial intervention studies where efficacy was determined.

Healthy Relationships is a behavioral intervention grounded in Social Cognitive Theory designed to assist people living with HIV to reduce HIV- transmission risk behavior through group sessions emphasizing the importance of building behavioral skills, enhancing self-efficacy for practicing risk reduction behaviors, promoting intentions to change risk behaviors, and developing strategies for behavior change. This study involved a randomized clinical trial design with a study population that included 230 HIV-positive men and 98 HIV-positive women from diverse backgrounds recruited from AIDS services and Infection Disease Clinics in Atlanta, Georgia. The study found significantly less unprotected intercourse and greater condom use at 6 month follow-up for the intervention arm (5).

In contrast, Partnership for Health is a behavioral intervention based on a social cognitive model that used brief provider-delivered counseling using either a gain-framed message (emphasizing the positive consequences) or a loss-framed message (emphasizing the negative consequences) on issues to reduce sexual risk taking among females and males at six large HIV clinics in California (6). The randomized controlled evaluation study found that at follow-up (up to 7 months after the intervention) the patients who reported two or more partners at baseline unprotected anal and vaginal intercourse (UAV) was reduced by 38% for those patients who received the loss-framed message counseling, but no significant changes were seen in those who received the gain-framed messages (6).

Limitations of Social Cognitive Theory
Both interventions are based on Social Cognitive Theory (SCT). SCT is rooted in an earlier theory of Albert Bandura’s called Social Learning Theory, which was based in behaviorism and was focused on how individuals learn through experience (7). SCT evolved when Bandura began to shift his focus to the concept of self efficacy and the role it plays in the process of behavior change. In addition to individual characteristics like self-efficacy, SCT also proposes that behavior change is a function of environmental factors and the interactive process between an individual’s behavior based on internal and external cues and the response the behavior elicits from society (7). While SCT clearly considers the individual’s interaction with environmental factors, it remains largely focused on the individual’s capacity to enact behavior change through self-efficacy. SCT, however, arguably does not expressly consider how self-efficacy can be limited by environmental factors, such as lack of affordable housing, access to care, ability to pay for medication, and other socioeconomic factors. Moreover, SCT seems to lend itself to interventions that are designed to provide individuals with information and skills or strategies to enact behavior change without addressing underlying issues that impact individual’s ability to negotiate sexual risk reduction. In their article on HIV prevention among Asian Pacific Islander (API) MSM, Choi et al. (8) argue that existing social cognitive theories have limited use in addressing the larger environmental factors affecting HIV risk because they are individual-focused models that ignore the individual’s wider social context. Choi et al. referenced how API MSM’s negative experience with cultural expectations, parent and family silence about sex, stigmatization and racism make it harder to practice safe sex (8). These issues could be considered “fundamental causes” of unsafe sexual behavior much in the way Link and Phelan (9) attributed social conditions as fundamental causes of major diseases. Link and Phelan argued that in order to understand risk factors we must contextualize the risk and examine how individuals come to be exposed to the risk (9). HIV prevention programs that fail to contextualize risk factors, assess the wider social environment, and identify the fundamental causes of sexual risk taking may be largely ineffective in the long term.

SCT in the context of both Healthy Relationships and Partnership for Health, leads to a reliance on individual based behavior change strategies. In Healthy Relationships, the intervention focused on increasing self-efficacy through targeted skill-building around issues of serostatus disclosure and negotiating sexual risk reductions. The intervention was administered in small groups and relied heavily on skill-based behavioral change (5). The brief provider messages used in the intervention for Partnership for Health were based on information regarding the health benefits of safer sex or health disadvantages of continued sexual risk taking. The brief provider messages were delivered at all visits except those that dealt with acute illness (6). Both interventions were successful at decreasing transmission risk behavior, but it can’t be determined if that decrease will be sustained. Information and skill-building interventions among HIV-infected populations undoubtedly impact behavior, but that impact is only as great as the individual’s ability to use the information or skill. An individual’s ability to use the information or the skill is not solely based on self-efficacy and secondary behavioral interventions need to do a better job identifying the fundamental causes of continued sexual risk taking.

Lack of Assessment of Multiple Psychosocial Issues
This paper uses the term psychosocial issues to broadly define a variety of psychological, social and economic issues impacting HIV-infected individuals such as mental health concern, socioeconomic concerns and lack of social support. In their article, Reif et al (10) state that HIV infected populations often experience multiple psychosocial needs and stressors, but often these needs are not met and HIV-infected individual are without the needed financial assistance, psychiatric care and social support (10). In multivariate logistic regression analyses, the author found that unmet needs in terms of benefits (Social Security, health insurance and prescription drug plan) and social support were associated with being less likely to be taking any HIV medication (10). The article suggests that those HIV infected individuals with unmet psychosocial needs may have worse health outcomes than those whose psychosocial needs are met. While there is no mention of a connection between unmet psychosocial needs and increased HIV transmission risk behavior, it may be that a similar relationship exists between numerous unmet psychosocial needs and increased transmission risk behavior. Using multivariate logistic regression models, Stall et al (11) found that a greater number of psychosocial health problems among MSM (polydrug use, depression, childhood sexual abuse (CSA), partner violence) were significantly and positively associated with high-risk sexual behavior and HIV infection indicating HIV prevention program need to address broader health concerns. The research of both Reif et al and Stall et al strongly suggest that reliance on traditional intervention models that focus solely on sexual risk may be unable to fully explain and address continued sexual risk taking in HIV-infected individuals.

There is little direct research on how psychosocial issues may impact transmission risk behavior among HIV-infected population; however, there is certainly evidence to suggest that such a connection is possible and merits investigation. Secondary prevention interventions like Healthy Relationships and Partnership for Health tend to be so focused on sexual risk taking that they de-emphasis other issues that are important to HIV-infected populations. Both interventions would benefit from taking a more holistic approach to sexual risk taking. A holistic approach would provide information and skill-building, as in Healthy Relationships and Partnership for Health, but would also include a thorough assessment of barriers to using the information or the skills.

Lack of Assessment of Underlying Mental Health Issues
Numerous studies have examined posttraumatic stress disorder (PTSD) and depression rates among HIV-infected populations and found them to be higher than rates among the general population and higher than individuals suffering from other chronic diseases (12; 13; 14). Within HIV infected sub-groups, MSM and minority women are at increased risk for PTSD (13), which may be attributable to both higher rates of stressful life events and childhood sexual abuse in these groups (14). Despite the strong evidence to support interventions aimed at assessing and treating mental health issues within HIV-infected populations, neither Health Relationships or Partnership for Health incorporated mental health assessment and referrals into the intervention. Given what is known about the prevalence of mental health disorders in HIV infected populations, this omission seems almost unbelievable. Prevention information and skill-building may have little impact on the sexual risk behavior of an HIV infected individual suffering from untreated anxiety disorder. It could be argued that the assessment of mental health status should be the first step in all secondary prevention programs. HIV-infected individuals with untreated mental health disorders may not be able to fully use the brief provider messages on risk reduction or the skill-building on risk reduction to enact sustained behavior change. An intervention that focuses solely on transmission risk behavior dismisses the important and complex role mental health disorders play in sexual risk taking and overall HIV disease progression.

Incorporating Mental Health Assessment in Interventions
In Healthy Relationships, the intervention would have benefited from having some individual counseling where the patient could discuss issues specific to their experience. Prior to the individual counseling session, patients could be asked to complete a brief mental health screening assessment. The counselor could use the results of the mental health screening assessment to inform the individual counseling sessions and when appropriate provide referrals for follow-up mental health services. Partnership for Health included brief provider message at all non-acute medical visits. However, it may have been more effective for providers to use some of the visits to address other issues that may impact the lives of their HIV-infected patients. Several of the brief interventions could have focused on assessing unmet mental health needs and developing a plan to access appropriate treatment services. By making small adjustments to overall interventions, both Healthy Relationships and Partnership for Health could address the mental health concerns of the patients, which may decrease their sexual risk taking and improve their overall health outcomes.

The critique of the REP behavioral interventions is not intended to be dismissive of their innovation or importance; rather, the intention is to illuminate areas that require further research. As the quest for a biomedical intervention (i.e. microbicides, vaccine, and post-exposure prophylaxis) suffers considerable set backs in clinical trials, the need for effective, targeted and diverse behavioral interventions is urgent. Moreover, these needed interventions must make an impact on the sexual risk taking in those groups most impacted by the epidemic. To accomplish this within high risk HIV-infected sub-groups (i.e. communities of color and MSM), research must tailor behavioral interventions to address major factors impacting continued transmission risk behavior. Interventions that fail to consider the complex social realities of HIV-infected populations will fail to develop holistic approaches and may run the risk of dismissing important issues that impact overall health. It may be that HIV prevention within infected populations requires multiple interventions to address the root causes of continued sexual risk taking. Researchers have begun to call for a more diverse array of prevention intervention within an integrated approach that considers and equally emphasizes social, psychological, medical and economic realities of HIV-infected individuals.

In their article assessing secondary HIV prevention interventions, Gordon et al note that the vast majority of the interventions have been limited to variants SCT, which typically highlight cognitive behavioral skill-building without incorporating contextual factors (15). Further, the authors argue that interventions should target multiple levels of prevention and calls for researchers to shift secondary HIV prevention towards a more complex social-ecological model (15). The ecological model of health promotion offers three advantages over the individualistically-orientated behavior change models as summarized by Choi et al: 1) deemphasizes the importance of the individual on behavior change, 2) examines both individual and environmental influences for unhealthy behavior, and 3) promotes the use of environmental approaches in prevention programs (8). The ecological model would involve the assessment of risk on multiple levels and would be better equipped to determine the fundamental causes of continued sexual risk taking.

HIV continues to disproportionably impact communities of color and MSM (3). Research must be committed to determining how and why HIV impacts those communities and exploring how HIV prevention programs may address multiple levels of risk. This critique of the REP secondary prevention interventions suggests that risk is impacted by a variety of individual and environmental factors that are not adequately addressed by interventions based on SCT. Examining those communities most affected by HIV forces us to confront how poverty, racism and homophobia contribute to increased HIV risk and will likely continue to impact transmission risk behavior. By replicating evidence-based interventions in MSM or communities of color that fail to account for poverty, racism and homophobia, researchers will find it difficult to initiate and sustain healthy behavior change. To better combat the transmission of HIV, research must focus on a new generation of secondary prevention interventions largely based on the ecological model.

1. Kalichman SC, Rompa D, Cage M. Sexually transmitted infections among HIV seropositive men and women. Sex Transm Infect. 2000 Oct;76(5):350-4.
2. CDC. CDC HIV/AIDS fact sheet: A glance at HIV/AIDS among men who have sex with men. November, 2007. Available at:
3. CDC, Replicating Effective Programs Plus. Atlanta, GA: US Department of Health and Human Services. Accessed November, 2007. Available at:
4. Eke AN, Neumann MS, Wilkes AL, Jones PL. Preparing effective behavioral interventions to be used by prevention providers: the role of researchers during HIV Prevention Research Trials. AIDS Educ Prev. 2006 Aug;18(4 Suppl A):44-58.
5. Kalichman, S.C., Rompa, D., Cage, M., DiFonzo, K., Simpson, D., Austin, J., Luke, W., Buckles, J., Kyomugisha, F., Benotsch, E., Pinkerton, S., and Graham, J. (2001). Effectiveness of an intervention to reduce HIV transmission risks in HIV-positive people. American Journal of Preventive Medicine 21(2), 84-92.
6. Richardson J.L., Milam J., McCutchan A., Stoyanoff S., Bolan R., Weiss J., Kemper C., Larsen R.A., Hollander H., Weismuller P., Chou C.P., and Marks G. Effect of brief provider safer-sex counseling of HIV-1 seropositive patients: A multi-clinic assessment. AIDS 2004;18:1179-1186.
7. Mark Edberg. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
8. Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10(Supplement A):19-30.
9. Link BG, Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; 35(extra issue):80-94.
10. Reif S, Whetten K, Lowe K, Ostermann J. Association of unmet needs for support services with medication use and adherence among HIV-infected individuals in the southeastern United States. AIDS Care. 2006 May;18(4):277-83.
11. Stall R, Mills TC, Williamson J, Hart T, Greenwood G, Paul J, Pollack L, Binson D, Osmond D, Catania JA. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003 Jun;93(6):939-42.
12. Koopman C, Gore-Felton C, Azimi N, O'Shea K, Ashton E, Power R, De Maria S, Israelski D, Spiegel D. Acute stress reactions to recent life events among women and men living with HIV/AIDS. Int J Psychiatry Med. 2002;32(4):361-78.
13. Kelly B, Raphael B, Judd F, Perdices M, Kernutt G, Burnett P, Dunne M, Burrows G. Posttraumatic stress disorder in response to HIV infection. Gen Hosp Psychiatry. 1998 Nov;20(6):345-52.
14. Kimerling R, Calhoun KS, Forehand R, Armistead L, Morse E, Morse P, Clark R, Clark L. Traumatic stress in HIV-infected women. AIDS Educ Prev. 1999 Aug;11(4):321-30.
15. Gordon CM, Forsyth AD, Stall R, Cheever LW. Prevention interventions with persons living with HIV/AIDS: state of the science and future directions. AIDS Educ Prev. 2005 Feb;17(1 Suppl A):6-20.

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Thursday, December 13, 2007

Roll Back Malaria Campaign—How its Ineffectiveness is Increasing Malaria Throughout Sub-Saharan Africa- Kamila Przytula

The Roll Back Malaria Campaign was initiated in 1998 by the World Health Organization, in collaboration with UNICEF, UNDP, and the World Bank to help fight the preventable and curable disease in such regions as Africa, Haiti, the Indian subcontinent, and Central America. Its vision as stated on the official website is to have accomplished the UN’s Millennium Development Goals by 2015, which include the elimination of Malaria as a major cause of death and a hindrance to social and economic development (1.) That is a confident and detailed goal for a campaign to achieve, especially worldwide. Unfortunately regardless of how optimistic the campaign’s goals may be on the issue of Malaria, it is not succeeding in halving Malaria deaths due to the following factors. First, supporting nations and organizations are unwilling to increase the budget set up for fighting Malaria with the proper drug-treatment because artimisin-based treatment is 10-15 times more expensive than chloroquine. (2) Refusal to adopt the new drug treatment universally is leading to the development of resistant strains, which are harder and much more expensive to treat. Third, is the campaign’s inability to distribute proper bed nets to all those living within high-risk areas. It has been proven that if 80% of a village uses bed nets, a protective barrier is created repelling the mosquitoes and protecting even those without bed nets. However, if only a few individuals use the bed nets in the community then the infected mosquitoes will just move next door. (3)
Introducing the issue
Malaria is a parasitic infection that is spread primarily through mosquito bites, but can also spread through two other ways, a transfusion, or the sharing of a needle with an infected person. It is endemic in tropical climate regions, such as Africa. There are four different parasites that cause malaria, the Plasmodium falciparum being the most dangerous (4); the African region is affected by the most fatal out of the four parasites causing Malaria to be a tougher epidemic to deal with (5). Once the parasite enters the blood stream it goes into the liver, multiplies exponentially and goes back into the blood stream, where it disrupts the flow of blood into major organs by clogging blood vessels and rupturing red blood cells (6). Fever is the major symptom associated with Malaria, and if untreated Malaria can cause permanent damage to the spleen, brain, and/or lead to death (7). Over 1 million people die yearly due to Malaria, regardless of the fact that it is considered a preventable and curable disease; most of these fatalities are young children living in Sub-Saharan Africa (8). Many well-accredited organizations have stated that the 2 major tools for malaria control are artimisin-based drugs and bed nets that have been sprayed with insecticides (9). Even the World Health Organization, the main founder of this campaign, states that artimisin-based drugs and not chloriquine treatment is the most effective (10). This shift in drug of choice for Malaria treatment was said to be approved by the US, who provides 1/3 of the budget for fighting Malaria, but then data in 2003 showed that most of the money was still being spent on chloroquine drugs instead of artimisin (11).
Failure to Increase Financial Support
The Roll Back Malaria Campaign claims its mission is to “…enable sustained delivery and use of the most effective prevention and treatment for those affected most by Malaria (12).” It has been reiterated several times by different sources that only through an increase in the budget will this campaign be able to become successful. Regardless of all the data presented to the health community, there is still insufficient funding for proper Malaria treatment. Private investors feel as though putting money into further Malaria research would be unrewarding in the long run. Also, many contributors to the campaign lack the will to promote an increase in the budget because “…eradicating the disease over such a large land mass [such as Africa] involves very high costs, and subsequent maintenance” that the world community is uncomfortable with accepting (13). According to the Red Cross, the international community needs to increase funding for intervention programs to significantly impact the fight against HIV/AIDS, Malaria, and other diseases in high-risk areas (14). Reiterating the need for more funds does not seem to be resulting in any action; recent data shows that $1 billion a year would pay for artimisin treatment for 60% of those who need it. But in the year 2000, the budget for the campaign was a mere $100 million, of which only a small percentage of it was used to buy the necessary drugs (15). An increased budget would also provide the opportunity to expand scientific research in the hopes of finding a vaccine for Malaria, but major vaccine producing companies, such as Merck, do not see a market for malaria. If a vaccine were to be developed, it would have to be distributed to countries at high risk at a low cost, if any; therefore private investors along with pharmaceutical companies are unwilling to participate (16).
The necessary changes that need to occur in the financial sector of the Roll Back Malaria Campaign could be easily understood using the social marketing theory. Social marketing theory depends on the 4 p’s: product, price, place, and promotion. This theory refers to how a campaign must take into consideration the benefits of adopting the best technology or treatment, and the overall cost, not just financial, of adopting this new treatment (17). The cost of increasing the budget for malaria would put a small dent in the pocket of major contributors such as the US, but its impact would save the lives of thousands.
One of the UN Millennium Development Goals is to “halt and begin to reverse [the] incidence of malaria and other major diseases by 2015 (18).” With high resistance developing throughout the Sub-Saharan African region this will be a more complex task to accomplish than initially expected. The emergence of drug resistance strains is also influenced by patients’ inability to adhere to the treatment suggested because of the campaign’s failure to consider the low levels of self-efficacy found among these poverty-stricken regions (19). Within the last 15 years, mortality due to Malaria has been rising primarily because of the development of drug resistance and the inability to speed up the rollout of new, more effective drugs because of the immense costs (20). Further studies show that from “…1999-2003, the number of deaths worldwide from Malaria was higher than in 1998, when the campaign was launched (21).” The parasite’s ability to develop a resistance to the drugs used in treatment hinders the campaign’s success, and maintains fatalities at a steady rate of one child every 30 seconds (22).
Self Efficacy & Treatment
Patients’ inability to stick to the treatment necessary to cure Malaria is aiding the spread of resistance throughout the region. A lot of the medical cases are located in devastating poverty-stricken regions where the nearest clinic might be located several walking hours away. Therefore, if a person has to choose between working, or finding food for the family, and walking to a clinic for a check-up or treatment, he/she will choose what benefits the family overall. The concept of self-efficacy has to be included in how the treatments are carried out by the Roll Back Malaria Campaign. The majority of Africans are struggling to feed themselves; they do not believe that they have the ability “…to take an action [and stick with it] and overcome the obstacles to taking this action;” The action referring to the ability to stick to the medical treatment necessary to recuperate from Malaria (23). Many individuals are less likely to even seek treatment if they know they are not going to be able to follow through with it. Others might begin treatment but due to other priorities they may stop seeking continuous medical attention. The idea of prioritizing one’s tasks and goals is part of the community mobilization theory, which needs to be incorporated in the Roll Back Malaria Campaign. The major concept of this theory is to understand and define the community that the campaign wants to target, and take into consideration whether or not Malaria is a top issue for this given community (24). The campaign needs to be more understanding of those living in these high-risk areas as they may have a hard time accessing a clinic and its facilities. They are living from day to day, trying to keep themselves and their family members alive with the limited resources they have. But it is “…necessary to improve public awareness of the importance of seeking appropriate treatment and complying with [the] recommended regimen” so the issue of Malaria becomes a prioritized issue that all have to deal with (25).
Failure in Bed Net Distribution
Along with the use of drugs to eradicate the Malaria epidemic, the distribution and use of insecticide-sprayed bed nets is the 2nd most important tool needed (26). The theory of diffusion of innovations incorporates the idea of introducing a new technology, such as insecticide-sprayed bed nets and seeing how effectively it is adopted by the community (27). The two main parts of this theory relating to the proper distribution of bed nets in the Roll Back Malaria Campaign are the adoption and implementation initiatives (28). The adoption portion is getting the community to incorporate the bed nets as part of the necessary preventative action. The implementation portion refers to getting the community using these bed nets continuously. Bed nets are very effective in reducing and preventing childhood mortality from Malaria. However, they are only effective if they are available to high-risk communities. Only 1 in 7 children sleep under a bed net in Africa, and out of this percentage only 2% use a net that has been sprayed with insecticides (29). A village elder living in the Sub-Saharan region said that “our people are poor, very few could afford to buy a mosquito net for 50 shillings [equivalent to 75 cents]. But she says that now they are all very happy since their village has received free bed nets for all (30). The only way to get bed nets to all the people that need them is to give them out for free. This type of distribution needs to happen worldwide. Many times, for a health change to be properly instilled, there must be a change in the community as a whole (31). Therefore providing bed nets for everyone, free of charge, would be the best way for people to implement using them at all times. A study has shown the benefit of having the majoring of a community using bed nets: “…insecticide-filled nets when used by 80% or more of a village, create a barrier that kills or drives off mosquitoes in the area, and protects even those few without nets (32).” But currently, the method in which most bed nets are distributed is not appropriate in order to achieve the campaign’s desired goal, along with the UN Millennium Development Goals, by 2015 (33).
Finding Success in the Future of the Campaign
The Roll Back Malaria Campaign, since its establishment in 1998, has only led to an increase in Malaria-related deaths throughout Sub-Saharan Africa (34). In order for the campaign to be effective it has to properly adapt to many factors that play a major role in its success such as individual self-efficacy, community mobilization, need for an increased budget, proper treatment with artimisin drugs, and effective distribution of insecticide-bathed bed nets. In 2002, 4 years after the start of the campaign, Malaria was still one of the major causes of death in children living in developing countries (35). Such statistics further support the lack of any drastic changes occurring in the worldwide fight against Malaria. In order for the high-set goals to be met by 2015, a deep renovation has to be made in the campaign and further international economic involvement is crucial. Without the necessary international investment in Malaria programs such as this one, Malaria will remain one of the leading causes of death in Africa and other high-risk countries.


1. "Roll Back Malaria Campaign." Roll Back Malaria Partnership. 4 Oct. 2007 .

2. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

3. "Roll Back Malaria Campaign." Roll Back Malaria Partnership. 4 Oct. 2007 .
4. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007

5. Kyama, Reuben, and Donald G. McNeil Jr. "Distribution of Nets Splits Malaria Fighters." The New York Times. 9 Oct. 2007. 13 Nov. 2007 .

6. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

7. Nchinda, Thomas C. "Malaria: a Reemerging Disease in Africa." Emerging Infectious Diseases os 4 (1998). Boston. 31 Nov. 2007 .
8. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

9. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .

10. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

11. Nchinda, Thomas C. "Malaria: a Reemerging Disease in Africa." Emerging Infectious Diseases os 4 (1998). Boston. 31 Nov. 2007 .
13. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .

14. "Vector Control: Malaria." Centers for Disease Control and Prevention. 15 Aug. 2006. 6 Oct. 2007 .

15. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

16. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .

17. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007

18. "Roll Back Malaria Campaign." Roll Back Malaria Partnership. 4 Oct. 2007 .

19. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

20. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

21. "African Red Cross & Red Crescent Health Initiative 2001." Red Cross Crescent-African Red Cross & Red Crescent Health Initiative. 13 Jan. 2001. International Federation of Red Cross and Red Crescent Societies. 23 Oct. 2007 .

22. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

23. Sachs, Jeffrey. "Helping the World's Poorest." 13 Aug. 2007. Harvard University. 8 Nov. 2007 .

24. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. 51-64.

25. Africa and the Millennium Development Goals: 2007 Update. United Nations. UN Department of Public Information, 2007. 1-4. 6 Nov. 2007 .

26. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

27. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

28. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007 .

29. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

30. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007 .

31. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p.53.

32. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p.69.

33. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

34. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .

35. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p 58.

36. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p 59.

37. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

38. Kyama, Reuben, and Donald G. McNeil Jr. "Distribution of Nets Splits Malaria Fighters." The New York Times. 9 Oct. 2007. 13 Nov. 2007 .

39. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p. 69.

40. Kyama, Reuben, and Donald G. McNeil Jr. "Distribution of Nets Splits Malaria Fighters." The New York Times. 9 Oct. 2007. 13 Nov. 2007 .

41. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

42. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

43. "Vector Control: Malaria." Centers for Disease Control and Prevention. 15 Aug. 2006. 6 Oct. 2007 .

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A Distorted Paradigm: Helmet Legislation Among Youth Detracts from a Comprehensive Attitude Towards Safety -- Anna Graves

Common wisdom within bicycle campaigns suggests that the finding of strong positive correlation between helmet legislation and head injuries supports the adoption of legislation for certain age groups (1,2). In 2005, there were 784 fatalities and an additional 45,000 injuries sustained in traffic crashes. Nearly one-fifth (18%) of the fatalities involved cyclists aged 10-20 years old; a number disproportionate to the population size (3). As such the issue of bicycle safety, especially among youth, is one that merits a concerned and thorough public health discussion. However, campaigns have failed to employ comprehensive interventions that successfully target this at-risk group.
As H. L. Mencken would say, for every complex problem, there is a solution that is simple, neat, and wrong. This paper contends that helmet legislation as the primary thrust and cornerstone of bicycle safety campaigns among youth is a cookie cutter solution for three primary reasons. First, it misplaces the focus of campaigns and detracts from other safety behaviors. Second, it is an individual-level intervention that ignores a range of societal and structural factors that increase bicycle safety. Finally, it fails to take into account the importance of youth attitudes and social dynamics as important behavioral determinants. The overall effect is a myopic paradigm with which bicycle safety is approached, and this has harmful consequences for the overall aim of campaigns.
Misplaced Focus
Legislation misplaces the focus of bicycle safety campaigns by putting helmets at the helm of the issue. Compliance with helmet laws is hailed as the primary safety behavior whilst the notion of a comprehensive attitude of safety is set on the back burner. Even non-legislative interventions such as research into helmet safety and aesthetic design, helmet giveaways, and educational programs for proper fit are spin-offs of the centrality of helmet usage. The implications of this tunnel vision are significant. The chance of an accident decreases significantly when cyclists use hand signals, are equipped with a safe bicycle and appropriate lighting equipment, travel at safe cycling speeds, and are unimpaired in their judgment by poor visibility or intoxication (4). Unfortunately, there has been a lack of emphasis upon such aspects of behavior in bicycle safety campaigns.
There is significant debate polarized around the misplaced center of helmet legislation. Opponents of legislation often argue that it constitutes unwarranted infringement of civil liberties of cyclists, and turns a pleasant leisure activity into ‘medicalized behavior (4,5).’ As a retort, proponents often portray wielders of such arguments as being unwilling to adopt relatively minor behavioral changes for the sake of safety, and dismiss them as being unreasonable (6). Such debates have tied up bicycle safety campaigns in judicial and policy-making circles, and because of the emphasis on the primacy of legislation, have precluded the widespread implementation of other measures. In addition, the political presumption that legislation is a primary solution to the problem of safety has crept into the public health domain. The issue has been defined, assessed, intervened upon and evaluated through the lens of helmet usage. In particular, evaluative studies often either control for or mention in passing a range of safety behaviors deemed confounding to the true object of study-- the efficacy of helmet legislation (1). This generates a cycle of less than optimal interventions and evaluations.
The focus on legislation may be an impediment to those who lack the self-efficacy to wear a helmet. These cyclists automatically assume themselves more prone to accidents and fail to adopt other behaviors that would greatly increase safety, even if helmets are not worn. This introduces a compounding phenomenon where the choice to not wear a helmet actually becomes a risk factor for not adopting other safety behaviors. In other words, the very population that campaigns hope to target is the same population that may feel marginalized and begin to characterize themselves as being ‘unsafe cyclists.’ This may preclude them from adopting a holistic attitude towards safety. Studies in support of this theory have shown that those who do not wear helmets are also less likely to “ride in... bicycle paths than city streets, obey traffic laws, wear fluorescent clothing and use lights at night (8).” This may be the most dangerous impact of all. While a helmet may serve as protection in the event of an accident, a behavior such as using a bicycle light may prevent an accident altogether (9). The chance of an accident relates directly to the visibility of the cyclist to motorists and pedestrians. Based on this principle, French law omits legislation pertaining to helmets, but mandates instead that retailers equip bicycles with lights and gives police the authority to stop cyclists for non-compliance with light laws (10).
Individual-Level Intervention
Helmet legislation places the responsibility for accident prevention squarely on the shoulders of the cyclist. It is an individual-level intervention that fails to highlight a range of societal and structural factors that increase bicycle safety. To begin with, the behavior of motorists is crucial to overall road safety. Significant injuries to a cyclist are 3-5 times more likely in collisions with motor vehicles as compared to bike only crashes. In most cases, both parties are at fault. Unfortunately, blame often falls on the cyclist, thanks in part to the societal expectations that they be the ones to exhibit safe behavior. The National Highway Traffic Safety Administration reinforces the importance of mutual responsibility and respect so that each party knows they are responsible for safety (4).
The speed at which vehicles are traveling greatly impacts safety. Trial zones in which 20mph limits were enforced had significantly lower incidence of injuries and fatalities than their control counterparts (11). Injury criteria to the head (79%), chest (30%), and pelvis (16%) were reduced with a 6 mph decrease in speed (12). In this particular intervention, legislation may be a powerful tool to increase road safety.
Structural factors also play an important role in reducing the chance of collision. The 2006 NHSTA Bicycle Report shows that 66% of fatalities occur in urban areas between the hours of 5 and 9 p.m, the busiest hours of traffic. It recommends the addition of additional bike paths and lanes in urban environments that limit the co-mingling of traffic and bikes. As a stark example of the successes of bicycle-specific road constructs, there were 225 bicyclist fatalities In New York City between 1996 and 2005, but only one of these occurred when a bicyclist was in a marked bicycle lane (13). Other important structural contributors to safety are “Share the Road” signs and up kept roads.
One of the most serious accusations leveled at helmet legislation is that it decreases the number of cyclists on the road and thereby increases risk per remaining cyclist—whether or not they are compliant with the enforced laws. The Safety in Numbers theory proposes that the incidence of fatalities and injuries does not increase linearly with the number of cyclists. Instead, it follows a power curve whereby the risk of collision decreases by roughly -0.6 the power of the number of people cycling. Thus a two-fold increase in numbers of cyclists would cause collisions to only disproportionately increase by a 32% and summarily benefit everyone (14). In societies where a larger proportion of society actively participates in cycling, motorist are more likely to be cyclists themselves and be more aware of other cyclists, hence avoiding more accidents (9).
Youth Culture and Attitudes
Youth, especially those who deliberately engage in dangerous cycling activities, are inevitably bound to the youth culture. As such, interventions need to be developed in a culturally sensitive and competent manner (15). This is particularly true given that youth between the ages of 11 and 20 years have the lowest helmet usage rates (16). Among youth, attitude is a particularly strong behavioral determinant. The Truth campaign, a highly successful anti-smoking intervention directed at Florida youth, was based on the premise that adolescents want to be told the facts and then left to make their own educated decisions (17). Safety helmet legislation may come across as being restrictive and dogmatic, inciting some youth to respond negatively and potentially participate in more dangerous behaviors as a means of resisting authority.
Rebellious attitudes aside, many youth have logical and practical reasons for their choice to not wear helmets. Research on college-aged youth has showed that they think helmets are uncomfortable (20%), restrict the natural feeling one gets from riding a bike (23%), make them look silly (36%) or are a nuisance to store between rides (33%) (11). Some of these perceptions may seem trivial but are apparently significant barriers to helmet use. While it must be conceded that legislation may be the positive tipping-point factor in the decision to wear a helmet, the manner in which youth reach the decision is crucial. It will inevitably effect how they frame the issue in their discussions with peers and how they will behave in the absence of enforcement or once they reach an age that excludes them from jurisdiction. Importantly, a choice that is self-initiated is more likely to be maintained. A detailed report comparing pre- and post-legislation counts concluded that youth were particularly resistant to changes not self-enforced. In the year following helmet legislation, teenagers registered a 44% drop in helmet usage compared to a 29% drop in adults (18). It is therefore crucial that youth be viewed in the context of their own youth culture, and that they be viewed as rational individuals. Interventions that take these considerations into account will lead to safe behavior being internally motivated rather than a forced.
Social Dynamics
Social dynamics also play crucial roles in decisions youth make about their behavior. A recent study based on social psychological models showed the subjective norm to be the strongest predictor of the intention to use a bicycle helmet (18). Only one in four students would not mind wearing a bicycle helmet even if friends did not wear them, leaving the other three to depend on the opinions and decisions of their friends (19). Instead of viewing this trend as an impediment to the encouragement of safety behaviors, campaign project researchers should embrace a community-based approach that positively incorporates social dynamics. Change should be instituted at a grassroots level instead of using the legislative thrust. A highly successful campaign at the University of Southern Carolina coupled this approach with social marketing. The student-initiated campaign developed the slogan “The Grateful Head” and succeeded in raising the helmet use across campus from a baseline mean of 27.6% to a mean of 49.3% by the last weak of intervention (20).
Another useful social theory is the Diffusion of Innovations Theory. It offers the concept of “early adopters”-- individuals who pick up on the benefits of a certain innovation and through social contacts, ideally spread the acquisition of the innovation. Using this model as a critique of current campaigns, it may be said that potentially beneficial sources of social influence are seldom incorporated. For instance, some bicycle interest groups appeal to youth and their subcultures but do not explicitly endorse helmet usage among their following. They often organize and compete in local competitions wherein incentives for the most popular bikers to speak up for bicycle safety could have widespread ripple effects. Bicycle retail shops are also often rider run, and because they already have a profit-driven motive to sell safety equipment, they are potentially an important voice for pushing bicycle safety. As a final note, campaigns should more actively employ the arm of media advocacy. Hip cycling or extreme sport personalities could be portrayed as early adopters of safe behaviors and encourage their following to do likewise. Therefore, a consideration of social dynamics among youth may open up a potential goldmine of interventions that could replace the lagging benefits of legislation.
The health benefits and environmental friendliness of cycling are undeniable. Bicycle safety campaigns strive to decrease in mortality and rate of injury while simultaneously increasing access to the cycling-- a task particularly challenging with regard to the younger generation. This paper suggests that the use of helmet legislation as a primary thrust of bicycle safety campaigns has been deleterious to their overall aims.
Instead, a bicycle safety needs to be approached with a much more comprehensive attitude. This will reduce the skew of interventions towards helmet usage and place greater emphasis on the societal and structural factors that factor into safety. In addition, such an attitude will demand a revision of the approach towards understanding the target audience of youth. This may involve the soliciting of youth specialists, the extensive use of sociological models, and the observation of youth trends and cultural shifts. Campaigns should be assured that such efforts will not go unrewarded as positive decisions internally motivated are likely to carry on into adulthood and so confer long-lasting impact. To reach this aim, significant reforms need to be made to the paradigm through which bicycle safety is viewed.
1. Macpherson AK, To TM, Macarthur C, Chipman ML, Wright JG, Parkin PC. Impact of mandatory helmet legislation on bicycle-related head injuries in children: A population-based study. Pediatrics 2002; 110:e60.
2. Attewell RG, Glase K, McFadden, M. Bicycle helmet efficacy: a meta-analysis. Accid. Anal. Prev. 2001; 33:345-352.
3. NHTSA’s National Center for Statistics and Analysis. Bicyclists and other cyclists. Traffic Safety Facts 2005, DOT HS 810 617,
4. London Cycling Campaign. Cycle helmets. London: LCC, 1999.
5. Skrabenek P. The death of human medicine and the rise of coercive healthism. London: Social Affairs Unit, 1994.
6. Sheikh A, Cook A, Ashcroft R. Making cycle helmets compulsory: ethical arguments for legislation. J R Soc Med 2004; 97:262-265.
7. Cook A, Sheikh A. Trends in serious head injuries among cyclists in England: analysis of routinely collected data. BMJ 2004; 321:1055.
8. Lajunen T, and Rasanen M. Can social psychological models be used to promote bicycle helmet use among teenagers? A comparison of the Health Belief Model, Theory of Planned Behavior and the Locus of Control. Journal of Safety Research 2004; 35:115-123.
9. Williams J, and Boyd H. Howard Boyd on: In training England’s cyclist. Interview of Howard Boyd, Bicycle Forum 1982; 8:24-31.
10. Osberg JS, Stiles SC, Asare OK. Bicycle safety behavior in Paris and Boston. Accid Anal. and Prev. 1998; 30: 5:679-687.
11. Geffen R. Portsmouth, Newcastle and Southwark to become 20mph zones. Cycle Digest 2006; 48:4.
12. Robinson DL. Reasons for trends in cyclist injury data. Injury Prevention 2004;10:126-127.
13. New York Department of Health and Mental Hygiene, 2005. Bicyclist Fatalities and Serious Injuries in New York City.
14. Jacobson PL. Safety in numbers: more walkers and bicyclists, safer walking and bicycling. Injury Prevention 2003; 9:205-209.
15. Rosenfeld SL, Fox DJ, Keenan PM, Melchiono MW, Samples CL, Woods ER. Primary care experiences and preferences of urban youth. Journal of Pediatric Health Care 1996; 10:4:151-160.
16. Rodgers GB. Bicycle helmet use patterns in the United States: A description and analysis of national survey data. Accid. Anal. and Prev. 1995; 27:1:43-56.
17. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
18. Hagel BE, Pless B. A critical examination of arguments against bicycle helmet use and legislation. Accid. Anal. Prev. 2006; 38:2:277-278.
19. Everett A, Price JH, Bergin DA, Groves BW. Personal goals as motivators: predicting bicycle helmet use in university students. Journal of Safety Research 1996; 27:1:43-53.
20. Ludwig TD, Buchholz C, Clarke SW. Using social marketing to increase the use of helmets among bicyclists. Journal of American College Health 2005; 54:1:51-58.

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Healthy People 2010: Failing to Obtain Targets for Infectious Disease- Due to a Flawed Plan of Action- Elena Quattrone

The Development of the Healthy People 2010 Campaign
Over the past thirty years there has been an increasing interest from United States public health officials to promote wellness among the population. Since 1979, initiatives to combat specific health issues with obtainable goals were pursued to promote health and prevent disease. Similarly, at the turn of the century the newest public health initiative to promote health and to prevent illness, disability, and premature death launched as the Healthy People 2010 campaign sponsored by the U.S. Department of Health and Humans Services. The Healthy People Consortium developed a campaign which consisted of an alliance of over 350 national organizations and 250 state public health agencies. The campaign addressed 226 health objectives in 28 categories to achieve over 10 years, with the key mission of increasing quality and years of healthy life, and eliminating health disparities (1-2). The issues targeted range from access to health care, to environmental health issues, to physical fitness activity, substance abuse and others. To date, the Healthy People 2010 campaign has seen much success. However, it is under the Immunization and Infectious Disease Category objective 14.8 that targets Lyme disease where the Healthy People 2010 campaign failed in developing and executing a plan of action to effectively lower rates of Lyme disease throughout the country.
The Healthy People 2010 consortium’s only strategy to combat Lyme disease was based on the availability of the LYMErix vaccine. The vaccine was developed by SmithKline Beecham Pharmaceuticals and was the only Food and Drug Administration (FDA) approved Lyme disease vaccination at the launch of the campaign. However, the vaccine was taken off the market by the manufacturer in 2002 due to poor sales and reported unspecified adverse effects (4). Since 2002, as incidence of Lyme disease has increased steadily there has been no additional public health intervention to combat incidence (5). Such negligence poses an unwavering obstacle for the Healthy People 2010 target to be reached. Therefore, the Healthy People 2010 initiative to combat the incidence of Lyme disease is a failed intervention due to its reliance on a vaccination as the primary means of control absent from necessary media involvement and educational support.
Lyme Disease: An Emerging Epidemic
Lyme disease is the most commonly diagnosed vector-borne disease in the U.S. The disease is prevalent in 48 states, especially in endemic areas such as the Northeast, Wisconsin, Minnesota, and Northern California (2). Contraction is caused by exposure to areas infected by Borrella burgdorferi-infected ticks and is categorized by a variable incubation period. Lyme disease is a multi-system disease described as having early and late stages. Persons of every age, race, and demographic are at risk for contracting the disease, with elevated rates occurring in children 2 to 15 years old, and adults 30 to 55 (3). Because the disease targets such a wide scope of the population, Lyme disease is a high-risk public health concern. However, despite the persistence of the disease, Lyme disease is controllable by individually targeted mechanisms.
The Healthy People Consortium confirmed that their plan of action to control incidence of Lyme disease was encouraging at-risk populations to receive the LYMErix vaccination. At the launch of the campaign there were a reported 17.4 new cases per 100,000 population. The Healthy People 2010 goal was to reduce this rate to 9.7 new cases per 100,000 population; a 44% decline (4). Since setting the target, cases of reported Lyme disease have more than tripled. To date, 32.5 new cases per 100,000 population in endemic regions have been reported annually (5).
Raising Public Awareness
The first step in targeting a public health problem is raising awareness that a problem exists. An effective way to increase awareness about any growing issue or epidemic is involving the media. The Agenda-Setting Theory, introduced by Maxwell McCombs and Donald Shaw in 1973, states that the mass media has the ability to convey to the public, information about issues of concern, thus influencing the public’s agenda (6-7). Involving the media in Lyme disease prevention at the launch of the Healthy People 2010 initiative would have been most beneficial in increasing awareness about the precautions at-risk populations may take to prevent contraction of disease.
As previously noted, the LYMErix vaccination was taken off the market in 2002 largely in part to poor sales (4). If the Healthy People 2010 Committee on Immunization and Infectious Disease had engaged the media to follow an agenda which promoted protection from Lyme disease, at-risk populations would have been more aware of Lyme disease as an impending epidemic. This increased awareness would have developed a desire for the public to obtain protection from contraction, resulting in an increased demand for the vaccination. Such an increase in demand would have boosted sales and prevented the vaccine from going off the market.
The existence of a vaccine to control the prevalence of Lyme disease is simply not enough to combat the epidemic. The Healthy People Campaign could have taken a much more productive approach by involving the media, also advertising the necessity of the vaccine. Similarly, the media could have educated the public on simple behaviors that at-risk populations could take, such as avoiding grassy areas, or knowing how to recognize ticks (7). Even though raised public concern would have not guarantee the at-risks populations becoming vaccinated, if the issue were brought to the public’s attention the media would have at least instigated public thought about the issue (6-7). Press intervention in the case of the Lyme disease epidemic could have controlled the increasing rates of incidence by bringing the issue of Lyme disease to the public’s attention.
Framing an Issue for Successful Intervention
Increased attention from the media regarding the dangers of Lyme disease and fear of contraction would have only been effective if the issues were framed correctly. Supplemental to agenda-setting theory which focuses on which issues are portrayed to the public, framing focuses on how issues are portrayed by the media to the public (6-8). Agenda-Setting Theory and Framing Theory work hand in hand, and incorporating both is crucial when attempting to influence a population’s behavior.
The Healthy People 2010 campaign never utilized the media effectively in targeting incidence of disease especially in how the issue was framed. Published articles reporting the possible failures of the LYMErix vaccine have run rampant in newspaper and magazines, “framing” the issue of vaccination as a dangerous means of prevention. Other articles reported the ineffectiveness of the vaccine (8). Reports also suggested that recipients of the vaccination were at risk for developing Lyme arthritis and other chronic arthritic disorders (8). Though such potential effects may be considered unwanted, the unspecified adverse effects of a vaccination seem miniscule compared to the definite effects of Lyme disease. Included in such effects are flu-like symptoms, fever, fatigue, muscular pain, secondary skin lesions, and facial paralysis occurring in the initial stages of the disease. Long-term untreated effects include distinctive arthritic, neurologic and cardiac problems (7).
However, if the media framed Lyme disease as a controllable epidemic that could be prevented with effective care and proper precautions, rates of incidence would not persist. Instead, the media raised awareness to the failure of the Healthy People 2010 campaign by publishing articles which did not support vaccination control (8). A national public health problem, such as Lyme disease, targets a wide scope in the political arena. Proper framing of the issue was necessary for any intervention to succeed. Unfortunately, Healthy People 2010 failed not only in engagement of the media, but in positively framing the LYMErix vaccination as a step towards prevention.
Failing to Provide Educational Support
In conjunction with the lack of Agenda-Setting and appropriate framing of Lyme disease, the Healthy People 2010 campaign to target incidence of Lyme disease also lacked a necessary education component. As reflected by the Rational-Empirical approach, education for at-risk populations about an issue is critical when influencing the adoption of a behavior (9). The goal behind the theory is to influence behavior without fear or persuasion. By providing persons with rational and logical information, at-risk persons will adopt a behavior if the behavior can be justified as beneficial (10-23). In 1999 before the launch of the campaign, the FDA, Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH) all agreed that education was the most important step to prevent Lyme disease contraction (7). By just relying on a vaccine-based strategy to combat incidence, the Healthy People 2010 campaign failed to utilize the necessary educational component.
Educational support could have benefited the Healthy People 2010 initiatives on Lyme disease. As previously mentioned, in line with the Healthy People 2010 plan of action, using agenda-setting and appropriate framing to educate the public about the LYMErix vaccine would have been effective. Education regarding disease management and general information about disease etiology would have been beneficial for at-risk populations. If accurate information is supplied to an individual, then a person can decide for him or herself the course of action that best addresses his or her needs (9). Perhaps vaccination was not the best approach for everyone. However, vaccination was the best choice for some, and education about the vaccination would have resulted in additional protection for those at risk.
Is Future Progress a Possibility?
In 2007, seven years after the launch of the Healthy People 2010 campaign, the Immunization and Infectious Disease Committee faulted the removal of the LYMErix vaccine as their main obstacle in lowering the incidence of Lyme disease. They discussed new approaches to the issue, strategizing about educational approaches they may take to promote safety by targeting school-aged children. They also discussed environmental steps that can be taken to promote practices that will reduce tick habitats near homes, suburban and residential areas (5). Unfortunately, the Healthy People 2010 committee on Immunization and Infectious Disease is still ignoring the fundamental causes that contributed to the campaign’s failure in the first place, which is supporting an intervention absent from media engagement and education about the disease for at-risk populations.
The way in which the media presented the issue of Lyme disease to the public highly influenced perceptions and actions towards vaccination. The lack of integration between media influences and education for the population is the reason behind the failed public health intervention of advocating the use of a vaccine to prevent contraction. When analyzing the campaign, it is apparent that the initiative never fully advocated the use of the vaccine. A remedy for a problem is useless unless vulnerable populations are aware that an effective remedy exists. The Healthy People 2010 Consortium failed to achieve the proper engagement to make the necessity of the vaccination known. Unless public health officials are willing to incorporate different social behavior models into one intervention, hope is slim that incidence of Lyme disease will decrease in time to reach the Healthy People 2010 target.
1. U.S. Department of Health and Human Services. Healthy People 2010 Understanding and Improving Health. Washington, DC: U.S. Dept. HHS, 2000.
2. Brody J. Fighting Lyme Disease, With a Pinhead as the Enemy. The New York Times, 2003. .
3. LYMErix Lyme Disease Vaccination. SmithKline Beecham Biologicals. Philadelphia: SmithKline Beecham, 1998. .
4. Groch J. Lyme Disease Worsens in Endemic States. Medpage Today, 2007. .
5. U.S. Department of Health and Human Services. Healthy People 2010: Progress Review Immunization and Infectious Diseases. Washington, DC: Office of Disease Prevention and Health Promotion, 2007.
6. McCombs, M., Shaw, D., and Weaver, D. Communication and Democracy. Mahwah: Lawrence Erlbaum Associate, 1997.
7. Lewis C. New Vaccine Targets Lyme Disease. FDA Consumer Magazine 1999.
8. Kliger C. Is the Lyme Disease Vaccine a Lemon? WebMd Medical News. Washington, DC, 2001. .
9. Siegel M. Education and persuasion versus coercion as public health approaches. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 4, 2006.
10. Chin R, Benne KD. General strategies for effective change in human systems. In Bennis W et al. (eds.): The Planning of Change (3rd edition), pp. 22-45. New York: Holt, Rinehart and Winston, 1976.

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The National Anti-Drug Media Campaign against marijuana use: Poor Understanding of Adolescents leads to Campaign Failure –Marsha Kocherla

1n 1998 The Office of National Drug Control Policy (ONDCP) launched the National Youth Anti-Drug Media Campaign in response to an upsurge of recreational drug use among adolescents. Drug use had been declining since the late 1970’s but rose sharply in the 1990’s from 10 percent in 1991 to 22 percent in 1998. The ONDCP proposed the 5-year campaign to Congress in 1997 and received $1 billion in federal support. This is the largest financial commitment that the federal government has ever made to an anti-drug media campaign (1).
Following the lead of other programs designed to promote youth health, the ONDCP relied on The Social Cognitive Theory of behavior to design the National Youth Anti-Drug Media Campaign. Social Cognitive Theory emphasizes the dynamic interaction of social-environmental factors, behavioral factors and personal factors in determining human behavior. Social-environmental factors are aspects of the environment that promote, permit, or discourage engagement in a particular behavior. These factors include influential role models (peers, teachers, etc.), situational contexts, social norms for behavior, and social support from friends and family. Behavioral factors are preexisting factors that affect behavior directly; these include extant behavior patterns, behavioral intentions, behavioral abilities, and coping skills. Personal factors are individual dispositions and cognitions that influence the likelihood of a person’s engagement in a particular behavior. These factors include level of knowledge about the behavior, personal attitudes towards the behavior, values, beliefs, and self-efficacy, or the belief in one’s own ability to carry out a certain behavior (2). Personal factors also include such complex abilities as the ability to determine the underlying meanings of behavior, the ability to foresee the outcomes of behavior, the ability to learn by observing others, the ability to self-regulate and self-determine behavior, and the ability to reflect on and analyze behavior (1). Social Cognitive Theory, by addressing the influence of multiple factors on behavior, recognizes the multi-dimensionality of behavior. The National Youth Anti-Drug Campaign however failed to understand the complexity of adolescents, and thus was unable to impact its target audience in any significant way.
The campaign relies on appeals to emotion rather than to reason
One of the main objectives of the National Youth Anti-Drug Media Campaign is to enhance perceptions that using certain drugs will lead to negative social consequences. The campaign takes the stance that smoking marijuana makes someone more likely to disappoint peers and family (1). The “Swim Meet” advertisement exemplifies an attempt to convey this message. The piece begins at a swim meet with the sound of a whistle being blown. We see three lanes (5, 4, and 3 from left to right) and three women’s swim teams. An announcer on a megaphone introduces the event: “JV Women’s 200 meter medley relay.” The teams in lanes 3 and 5 each have a swimmer on the diving board and three swimmers lined up behind her. There are only three members in lane 4, however, and they are standing around the diving board, scanning anxiously for the starting swimmer, who is conspicuously absent. The announcer notices and asks over the megaphone, “Do we have a swimmer for lane 4?” There is no answer, only the sound of a cough from the audience and people shifting in their seats. The announcer repeats the question, a brief silence follows, and the narrator begins the message of the ad: “Just tell your teammates you missed the race because you were getting stoned…” The announcer calls, “swimmers take your marks,” and the swimmers in lanes 5 and 3 poise themselves to dive into the water; the swimmers in lane 4 stand helplessly. “They’ll understand,” the narrator finishes. The viewer hears the starting horn as the words, “Responsibility; your anti-drug” flash across the screen (3).
This advertisement is ineffective because the behavior being negatively portrayed is not marijuana smoking but irresponsibility, which is assumed to be a result of marijuana smoking. The teammates’ disappointment at being unable to participate in the swim meet is the major appeal to pathos in this advertisement. The viewer is supposed to feel sympathy for the swimmers and he does. But the advertisement seems to expect that this sympathy for the swimmers will somehow translate into disapproval of marijuana smoking. Marijuana smoking is not the only behavior that could result in the situation portrayed by the advertisement and the viewers know that. Youth are not blindly led and are not easily persuaded; they demonstrate a complex capability to filter, interpret, and if necessary, reject messages presented by the media, and are very capable of separating emotional appeals from persuasive fact. While viewers may have an emotional response to the immediate stimulus of the advertisement, this will not translate into a long-term change in perception about drug-use (4).

The campaign fails to understand its target demographic

The members of the National Youth Anti Drug Campaign’s target demographic fall into one of two categories: late childhood, the period from age 9 to 12, or adolescence, the period from age 13 to 18. These periods of development are marked by dramatic cognitive changes, which include the development of the ability to reason logically (ages 7 to 11) and the ability to reason abstractly (ages 12 to 18). In addition, during these periods thought is becoming less egocentric and children are beginning to place more and more importance on developing close social relationships (5, 6). It is important for a media campaign targeting youth to understand the importance of social relationships in the lives of adolescents.
The swimmers in the advertisement, being normal adolescents, would probably not be as quick to judge or to excommunicate their missing teammate as the advertisement suggests. They would also be unlikely to place a swim meet as being more important than their teammate, and their love of swimming or enjoyment of the team would probably not be diminished by the day’s experience. Reaping the benefits of youth sports does not require intense competition or especial athletic prowess; it only requires participation. The major benefit of participating in youth sports is the social acceptance and self-esteem gained by being a member of a team (7). Excellence and victory are smaller components of organized sports that can only be reached once mutual respect, affability, and positivity exist within the team (8).
The outcome of drug use as portrayed by the campaign is not perceived as negative
“Supermarket,” another Anti-Drug advertisement, begins with an older teenager standing in a darkened super-market parking lot, shifting his weight and trying to keep warm, while inviting the stares of passers-by. He is obviously waiting for someone, a younger teenager, named Anthony, who appears from the supermarket after saying goodnight to the manager. Upon seeing Anthony, the older teen crosses the parking lot and calls his name. Anthony looks pleasantly surprised and asks the older teen what he is doing there. The older teen says that he is waiting for Anthony and Anthony asks, “What’s up?” The older teen hesitates, clearly uncertain of how to begin. The narrator speaks. “It takes a lot of guts to talk to your friends about their problems with drugs or drinking but it could make all the difference.” The screen fades and the message of the ad is displayed: “Courage: the anti-drug” (9).
This advertisement does not seem to be aimed at the drug-user but at the friends of drug-users, whom the advertisement encourages to dissuade their friends from using drugs. The advertisement is based on several assumptions, many of which are unfounded, and some of which are contrary to research findings. The advertisement assumes that there is a significant faction of teenagers in existence who have strong views against marijuana, but this is not the case. Social disapproval of marijuana smoking has decreased since the 1970’s, along with the perception of marijuana’s risk to health (10). The focus on marijuana in the media, rather than deterring marijuana use, has sent the message that marijuana use is common and widespread (11).
The advertisement also expects that the viewer will side with the older teenager, but by failing to develop the character, does not give the viewer a valid reason to do so. All that the viewer sees about the older teenager is that he is lurking in a darkened parking lot, visiting his friend at work, unannounced, and bringing up a subject that may cause conflict in the friendship. The soundness of the older teenager’s argument against drugs and proof of his courageous character are not presented, and this lack of evidence confers the older teenager no advantage in winning the viewer’s sympathy (3). Anthony, the drug-user in this piece, on the contrary, presents quite a positive image.
By being gainfully employed, Anthony is not only enriching his own life, but is contributing to the economy and to the community (12). Working late nights at a supermarket, Anthony seems disciplined, and his affability with the manager suggests that he is a good worker. Moreover, Anthony, although tired from a day of work, is still polite enough to spare time for a friend who wants to talk. The viewer sees no negative effects of drug use on Anthony’s life; rather, Anthony seems financially stable and socially adept, which gives the viewer little reason to think him in distress or in need of an intervention. Anthony’s array of competencies makes him more likely to be regarded as popular, a distinction that would give him greater influence over peers than the average teenager (13).


In conclusion, the campaign fails primarily because it misunderstands its target audience. The ONDCP fails to appreciate the complexity of adolescent thinking; by focusing on evoking emotion from the viewer rather than persuading him with facts, the campaign fails to induce a long term change in perception. Furthermore, the campaign overlooks monumental importance of peer relationships in the adolescent life. Finally, messages based on assumptions that are often contradictory to research undermine message credibility and dilute the efficacy of the campaign.
The National Youth Anti-Drug Campaign is unprecedented in breadth and in the financial support it garnered. However, due to ineffective strategies, the campaign proved disappointing (14). This not only implies a waste of resources but also the unchecked exacerbation of the drug problem in America.


1. Kedler, S.l. Planning and Initiation of the ONDCP National Youth Anti-Drug Media Campaign. Journal of Public Health Management Practice. 2000; 6:14-26.
2. Edberg, M. Essentials of Health Behavior. Sudsbury, MA: Jones and Bartlett Publishers,2007.
3. “Swimmeet” Anti-Drug Ads. Washington, DC: National Youth Anti-Drug Media Campaign.
4. Katovich, M. Media Technologies, Images of Drugs, and an Evocative Telepresence. Qualitative Sociology. 1998; 21:277-297.
5. Dasen, P. Cross Cultural Piagetian Research: A Summary. Journal of Cross-Cultural Psychology. 1972; 3:23-40.
6. Erikson, E. Childhood and Society. New York, NY: Norton, 1950.
7. Seefeldt, V. Youth Sports in America: An Overview. PCPFS Research Digest. 11: 2-20.
8. Schewe, A. Find the right sports program for your kids. CNN, 2005
9. “Supermarket” Anti-Drug Ads. Washington, DC: National Youth Anti-Drug Media Campaign.
10. Bachman, J. et al. Explaining Recent Increases in Students’ Marijuana Use: Impacts of Perceived Risks and Disapproval, 1976 through 1996. American Journal of Public Health 1998; 88: 887-892.
11. Leinwand, D. Anti-drug advertising campaign a failure, GAO report says. USA Today. 29 Aug. 2006; 3 Dec. 2007.
12. International Labour Office. Youth Employment: A Global Goal, a National Challenge. Geneva, Switzerland: International Labour Office, 2005.
13. Newcomb, AF. Children’s peer relations: a meta-analytic review of popular, rejected, neglected, controversial, and average sociometric status. Psychological Bulletin. 1993; 113: 99-128.
14. National Institute on Drug Abuse. Evaluation of the Office on National Drug Control Policy (ONDCP) National Youth Anti-Drug Media Campaign. Washington, DC: National Institute on Drug Abuse, 2004.

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Failure to Bridge the Health Gap Due to Neglect of Social Factors– Stephanie Chau

The United States takes great pride in being a nation well known for equality, opportunity, and diversity. According to the U.S. Census Bureau, one-third of the national population is comprised of minorities, which include African Americans, Hispanics, Asians, American Indians/Alaskan Natives, Native Hawaiians/Pacific Islanders, and individuals of multiracial origins (1). However, these minorities experience significant disparities in health, including healthcare access and quality, when compared to White, non-Hispanic Americans (2). For example, out of 22 core measures for quality of care, African Americans received poorer quality of care for 16 or 73% of the measures (2). Also, the death rates from HIV/AIDS and homicide were more than 200% higher for the Hispanic population when compared to non-Hispanic Whites (3). There have been significant improvements regarding quality and access to care for certain groups, including Asians/Pacific Islander and American Indians/Alaska Natives (2). However, disparities are still prevalent and worsening for other minorities, particularly for Hispanics, who are experiencing an increased rate of pediatric asthma hospitalizations and worse measures of access to care (2). The issue of healthcare disparities by race is a major public health issue, and Healthy People 2010 has identified the elimination of health disparities as an overarching goal (4).
In order to address the pressing concerns regarding health disparities, government health officials have developed various programs and interventions. An example is “Closing the Health Gap,” an educational campaign that aims to improve the health of racial and ethnic minority populations. Developed by the Office of Minority Health in the U.S. Department of Health and Human Services, this national program contains three key elements: Celebra La Vida Con Salud (Celebrate a Healthy Life), Take a Loved One for a Checkup Day, and Know What to Do for Life. The campaign utilizes public media outlets, community health fairs, and local partnerships to inform minority communities about healthier lifestyles and encourage greater healthcare access (3). However, “Closing the Health Gap” is an ineffective public health approach because it is overly centered on the individual and disregards the important social factors comprising Social Cognitive Theory, Social Marketing Theory, and Framing Theory.
Barriers in the Environment and Social Cognitive Theory
One of the primary reasons that make “Closing the Health Gap” an ineffective program is its reliance on incorrect assumptions regarding access to healthcare services and community support. These assumptions neglect geographic and economic barriers that disproportionately affect minority populations. At least 50% of African Americans, Hispanics, and Native Americans/Alaskan Natives have incomes less than 200% of the poverty level, compared to only 12% of Whites (5). A number of research studies have demonstrated a strong link between socioeconomic status and health status (6-9). Therefore, racial and ethnic minorities are more likely to be impoverished and experience decreased access and quality to healthcare services.
The social environment is an important factor in health disparities because it has a strong influence upon health behavior. Social Cognitive Theory uses modeling and self-efficacy to describe the interactions between social factors and health. In the modeling process, the behavior of certain prominent individuals serves as a guide for others to imitate (10, 11). Modeling is closely linked to mass communication, which uses visual and auditory media to publicize certain portrayals of behavior that observing audiences may try to adopt (10). Therefore, exposure to modeling in media portrayals, especially films and television, is an important part of the modeling process. Self-efficacy is another key to change because it involves a person’s confidence that they can do a behavior while overcoming various obstacles (11). The infrastructure and social support present in a community are critical in determining a person’s self-efficacy and the likelihood of modeling. Besides exposure to appealing models, successful modeling requires the ability to actually reproduce the behavior portrayed by the model as well as positive reinforcement (10). However, in communities that lack the appropriate healthcare infrastructure to serve the needs of minority groups, self-efficacy is reduced because community members may not believe that the behavior will result in the desired outcome. Without the belief in successful imitation and the necessary resources to reproduce positive health behaviors, modeling cannot occur. For instance, in areas characterized by racial residential segregation, differences in purchasing power and economic deprivation have impeded positive modeling and healthy behaviors (9).
Celebra Con La Vida Salud attempts to promote preventative health measures and address health concerns specific to the Hispanic minority population. Its central feature involves a 12-city tour of health festivals in areas densely populated with Latinos that provide free health screenings for cholesterol, HIV, and diabetes (3). The cities on the tour include communities in southern California, Texas, and Florida, but completely neglects other cities with significant Hispanic populations, including Philadelphia and Las Vegas (3). The campaign does not attempt to address this geographic barrier with alternative provisions to these other areas. Recognition of the media’s importance in modeling could offset the failure to attend to geographic difficulties. However, Celebra Con La Vida Salud, as well as other parts of “Closing the Health Gap,” completely ignores collaboration with major media outlets, such as Hispanic telenovelas, that specifically target minority groups. Therefore, the campaign leaves opportunities to facilitate modeling unrealized since mass communication is not effectively employed.
Take a Loved One for a Checkup Day encourages individuals to visit a health care provider regularly and participate in health screenings. It focuses its efforts on a single day of the year and broadcasts health messages and tips on public radio. The campaign assumes that individuals will have the opportunity and resources to seek health services. However, the day that the campaign selected was Tuesday, September 18, 2007 (3). Most people work on weekdays, and their jobs may not include benefits such as vacation or time off to allow them to see a doctor. The main message is to get a check-up, but there is little information or resources to assist individuals about where or how they may be able to accomplish that action. Therefore, in minority communities where convenient points of healthcare access are unavailable, many individuals lack the self-efficacy and ability to see a physician. The “Closing the Health Gap” campaign does not take into account situations and circumstances in which the needed resources are unavailable. As a result, it is difficult for either modeling or self-efficacy to occur.
Cultural Values and Social Marketing Theory
Aside from its connection to modeling, mass communications is significant for its deep impact on social institutions and culture (10). As a consequence, successful health reforms require careful planning and formative research in order to employ appropriate communication channels and themes (12, 13). Social Marketing Theory recognizes the importance of the specific needs and desires of the target audience. Public health officials must identify the wants of the particular group and proceed to present the information and health services in a salient way. A proven example of Social Marketing is the success of the Florida Pilot Program on Tobacco Control, which utilized targeted youth marketing of the “truth” campaign to decrease youth tobacco use (14, 15). In contrast, “Closing the Health Gap” fails to adequately address specific concerns and appeal to cultural values of ethnic and racial minorities.
The first step in Social Marketing Theory is to understand the social environment and identify social norms, which are the conventional beliefs and codes of behavior for a group or culture (11). Shared racial perceptions may influence health behaviors such as blood pressure control and medication adherence (16). By encouraging families to attend health fairs together, Celebra La Vida Con Salud recognizes the Hispanic population’s strong family values. However, it fails to address other important values, particularly religion and spiritual beliefs in traditional folk healing, which appear to have significant roles in the healthcare for Latino groups (17, 18). These beliefs may also affect their behavior in seeing a doctor for a checkup, which is the focus of Take a Loved One for a Checkup Day. Instead of simply promoting regular health screenings, Marketing Theory would emphasize cultural values and increase cultural competency for providers so that patients would feel more inclined to access regular healthcare.
In addition to social norms, Social Marketing involves four main principles that address issues about product, price, place, and promotion (13). Although “Closing the Health Gap” uses radio messages, the Internet, and celebrities like Grammy nominee Nicole Mullen (3), it does not promote modeling or use effective communication. It fails to utilize pertinent media outlets such as Black Entertainment Television (BET). Nor does it take into account the price and place of the health behaviors it endorses. For Take a Loved One for a Checkup Day, it does not adequately consider the costs or necessary steps involved with seeking health services. Again, resource availability in underserved areas may also be an issue that the campaign fails to address. For example, Know What to Do for Life, the third part of “Closing the Health Gap,” is an educational campaign that aims to reduce infant mortality among African Americans because rates are nearly 2.5 times higher than for Whites (3). However, the program fails to recognize the social conditions that have a strong influence on individual health behaviors. The campaign urges African American pregnant women to pursue prenatal care, but issues of access and availability may prevent this health behavior despite the efforts and knowledge of the mother herself.
Framing Theory Requires More Than Education for the Individual
Although individual behavior influences health outcomes, studies have shown that individual behaviors are only one factor, and that social and physical factors may even have a larger role (6-9). Various aspects of the socio-physical environment may have strong effects on the correlation between low socioeconomic status and mortality that are unrelated to individual behaviors (7). Therefore, this evidence indicates that public health approaches must consider aspects of the social environment rather than only focusing on individual-level factors. Reliance on individual-level approaches such as the Health Belief Model has limited the scope of health interventions (19). Instead, Framing Theory provides alternative paradigms that encompass environmental factors and suggests different sociological strategies to effect change.
Framing Theory analyzes the relationship between beliefs and the production of meaning by media frames within economics, politics, and social movements (20). It suggests that the portrayal of a public health problem in the media strongly affects beliefs and behavior. The focus of frames can be either on the proximal factor (usually the individual affected by consequences of the central problem or behavior) or the more distal entity (usually a social institution related to the cause of the problem). Focusing on the individual is a downstream frame, while the latter is an upstream frame because it attempts to direct attention toward likely fundamental causes. “Closing the Health Gap” utilizes media messages primarily targeted at educating individuals. As a result, it develops a downstream frame that places a lot of responsibility on the individual and fails to account for social influences such as misconceptions and discrimination. The goals of the campaign are to increase awareness through publicity, free health fairs, and education. However, as noted before, individual behaviors and intentions are only a few components that determine actual health outcomes and affect disparities in health. To address the substantial social barriers that often confront underserved minority populations afflicted with health disparities, framing theory demands a shift toward an upstream frame that recognizes the role of socio-physical conditions on health behavior.
An upstream approach requires different strategies to effect change. The three major categories of sociological change strategies include rational-empirical, which emphasizes knowledge and education; normative-re-educative, which utilizes counseling and social norms; and power-coercive, strategies that involve policies and institutional change (21). “Closing the Health Gap” falls under the first category and heavily relies on mass communications and diffusion of ideas and innovations. However, these alone are insufficient. A multilevel approach that incorporates the normative-re-educative and power-coercive strategies would be most effective by implementing change on the community level, in addition to increasing awareness on the individual level.
“Closing the Health Gap” and other similar public health campaigns have paid little attention to the contextual background for health behavior and outcomes. This context includes aspects of cultural, economic, and sociopolitical conditions (22). In order to maximize the effectiveness of health programs, public health must develop more broadly based interventions, which are better alternatives to individual-level solutions that focus on intermediate, or proximal, causes (23). Therefore, the successful application of social and behavioral principles to a campaign such as “Closing the Health Gap,” entails multidisciplinary efforts within an upstream perspective. These efforts would complement education-focused strategies by identifying social and cultural norms and barriers. When additional strategies that involve persuasive counseling and institutional change address these norms and obstacles, there will be a subsequent effect on self-efficacy and individual behaviors.
Increasing the utilization of social and behavioral sciences in public health would have important implications for future health interventions. The effective use of formative research to identify core values and target social norms is essential in developing a successful public health campaign (12, 14). As society continues to become increasingly more technological, mass communications through various public media will become more important. Since the necessary resources involved in mass communications remain expensive and involve competition with private corporations and industries, the importance of formative research will only increase. At the same time, increased awareness and individually-based strategies have proven insufficient since they comprise only one part of the bigger picture surrounding health outcomes and disparities. Therefore, campaigns must employ ecological approaches that account for interactions between individuals and the social factors of the surrounding environment.
The inadequacy of “Closing the Health Gap” as an effective public health intervention illustrates the importance of applying social and behavioral theories to public health. By neglecting socio-physical barriers and failing to consider significant cultural norms that influence the behaviors and health outcomes of minorities, “Closing the Health Gap” reduces its effectiveness. Also, its downstream frame burdens individuals with the major responsibility of preventing health conditions such as preterm birth and diabetes that disproportionately affect these minority populations. However, studies have proven that health disparities endure independent of individual level factors. Therefore, both the failures of past individual-level interventions and the successes of the few campaigns based on formative research and social factors warrant the use of social theories such as Social Cognitive Theory, Social Marketing, and Framing Theory to improve the elements of “Closing the Health Gap” and help shape future public health interventions.
1. U.S. Census Bureau. Table 3: Annual Estimates of the Population by Sex, Race, and Hispanic or Latino Origin for the United States: April 1, 2000 to July 1, 2006 (NC-EST2006-03). Washington, DC: Population Division, 2007.
2. U.S. Department of Health and Human Services. Keys Themes and Highlights From the National Healthcare Disparities Report. Washington, DC: Agency for Healthcare Research and Quality, 2007.
3. U.S. Department of Health and Human Services. Closing the Health Gap.
4. U.S. Department of Health and Human Services. Healthy People 2010. Washington, DC.
5. James C. Race, Ethnicity, and Health Care.
6. Lantz P M, Lynch J W, & House J S, et al. Socioeconomic disparities in health change in a longitudinal study of U.S. adults: the role of health-risk behaviors. Social Science & Medicine 2001; 53:29-40.
7. Haan M, Kaplan G A, & Camacho T. Poverty and Health: Prospective Evidence From the Alameda County Study. American Journal of Epidemiology 1987; 125:989-998.
8. Lu N, Samuels M E, & Wilson R. Socioeconomic Differences in Health: How Much Do Health Behaviors and Health Insurance Coverage Account For? Journal of Health Care for the Poor and Underserved 2004; 15:618-630.
9. Williams D R & Collins C. Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health. Public Health Reports 2001; 116:404-416.
10. DeFleur M L & Ball-Rokeach S J. Socialization and Theories of Indirect Influence (pp. 202-227). In: DeFleur M L & Ball-Rokeach S J Theories of Mass Communication. White Plains, NY: Longman, 1989.
11. Edberg M. Social, Cultural, and Environmental Theories (Part I) (pp. 51-62). In Edberg M Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett, 2007.
12. Seigel M & Doner L. The Importance of Formative Research in Public Health Campaigns: An Example from the Area of HIV Prevention among Gay Men (pp. 66-69). In Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett, 2004.
13. Edberg M & Abroms L. Application of Theory: Communications Campaigns (pp. 115-122). In Edberg M Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett, 2007.
14. Hicks J J. The strategy behind Florida’s “truth” campaign. Tobacco Contol 2001; 10:3-5.
15. Bauer U E, Johnson T M, & Hopkins R S et al. Changes in Youth Cigarette Use and Intentions Following Implementation of a Tobacco Control Program: Findings From the Florida Youth Tobacco Survey, 1998-2000. Journal of American Medical Association 2000; 284:723-728.
16Bosworth H B, Dudley T, & Olsen M K et al. Racial Differences in Blood Pressure Control: Potential Explanatory Factors. The American Journal of Medicine 2006; 199:70.e9-70.e15.
17. Southwest Borderlands. Latino Culture & Health. Phoenix Arizona: Arizona State University.
18. Castro F G, Furth P, & Karlow H. The health beliefs of Mexican, Mexican-American, and Anglo-American women. Hispanic Journal of Behavioral Sciences 1984; 6:365-383.
19. Thomas L W. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing 1995; 11:246-252.
20. Snow D A & Benford R D. Clarifying the relationship between framing and ideology in the study of social movements: a comment on Oliver and Johnston. Mobilization 2000; 5:37-54.
21. Bennis W G, Benne K D, & Chin R et al. General Strategies for Effecting Changes in Human Systems (pp. 22-45). In Bennis W G, Benne K D, & Chin R et al. The Planning of Change. New York, NY: Holt, Rinehart, and Winston, 1976.
22. Marks D F. Health Psychology in Context. Journal of Health Psychology 1996; 1:7-21.
23. Link B G & Phelan J. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior 1995; Extra Issue:80-94.

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