Challenging Dogma - Fall 2007

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

Monday, December 10, 2007

Fetal Alcohol Syndrome Media Awareness Campaign: Flawed due to Adherence to the Health Belief Model—Sebastian Tong

Fetal Alcohol Syndrome (FAS) is caused by the consumption of alcohol during pregnancy by the mother and constitutes a serious public health problem. FAS affects a child’s physical growth, brain development and structure, and facial features (1-2). Throughout childhood and young adulthood, those with FAS remain short and their heads have abnormally small circumferences (3-4). Facial disfigurements, while prevalent during childhood for those with FAS, disappear as the individual grows up. In terms of brain developmental problems, prenatal brain damage results in cognitive impairment, poor attention and concentration skills, and behavioral problems (3). As adults, few persons with FAS can live independently or be employed (5). Despite these negative consequences of alcohol consumption during pregnancy on the child, 12.3% of women continue to drink alcohol during pregnancy (6). Statistics also show that African Americans are a high risk population. They drink twice as much as Caucasians during pregnancy (6). In general, FAS affects 0.3-1.5 cases per 1,000 live born births (7). African Americans and Native Americans have the highest rates of FAS among ethnic groups, with 3-4 per 1,000 live born infants born with FAS (7).
A targeted media campaign was developed in St. Louis, Missouri that was run between October 2002 and March 2004 and aimed to decrease FAS by increasing knowledge of FAS among African Americans. In an effort to appeal to African Americans, the campaign consulted fifteen leaders representing diverse parts of the African American community while developing the marketing campaign. The media campaign included visual, audio, and print advertisements; direct marketing in the community; public relations and media interviews; displays at community events; and educational videos for high school students. Four main prevention messages were presented in the campaign: “no safe time,” “no same level,” “no drinking if not using reliable forms of birth control,” and “if drinking and can’t stop, see a physician.” These messages reiterated that effects occur early in pregnancy, that any level of alcohol can affect the child, that sexually active women should not drink if they could become pregnant and that pregnant women who feel their alcohol use could endanger their child should see a physician for assessment. Pre and post intervention knowledge of these factors were measured using a random telephone survey. The results of the survey showed that knowledge levels were the same before and after the campaign and that there were no significant difference on FAS levels (8). This media awareness campaign in Saint Louis, Missouri was unsuccessful in promoting abstinence from alcohol in women who are pregnant or at risk of becoming pregnant because its design relied too heavily on the Health Belief Model.
The Health Belief Model
The Health Belief Model was developed in the 1950s, in part, to promote the work and practice of social psychologists (9). The model is based on four constructs: perceived susceptibility, perceived severity, perceived benefits and perceived barriers. Perceived susceptibility refers to an individual’s opinion about contracting a given health problem. Perceived severity is the person’s belief in the seriousness of the given health problem. Perceived benefits refer to the positive outcomes of taking a given behavior as seen by an individual. Perceived barriers refer to the negative outcomes of performing a given behavior as seen by an individual (10). The perceived susceptibility, severity and benefits are weighed against the perceived barriers rationally by an individual. The resulting behavior is a product of the intention of the individual based on this rational decision-making process.
Failure to consider social level factors
The targeted media campaign in St. Louis, Missouri relied on changing the constructs of perceived susceptibility, perceived severity and perceived benefits. These three factors all focus on the individual and ignore societal influences. In addition, the media campaign made no effort to decrease perceived barriers, many of which are social barriers. As a result, by focusing solely on these individual factors, the media campaign ignored some of the key causes of alcohol consumption in pregnant women and in those who are at risk of becoming pregnant.
Each of the four messages portrayed in the media campaign focused on something that the woman should do to stop drinking. However, other than the message to see a physician, there were no means to empower women to stop drinking when pregnant or at risk of becoming pregnant. Pre-intervention surveys of knowledge levels showed that many individuals in St. Louis were already aware of the “no safe level” and “no safe time” messages. Based on a series of questions about FAS, the survey suggested that African Americans were already well educated on FAS and its implications. Post-intervention tests actually showed that knowledge levels decreased instead of increasing. Furthermore, in the areas that African Americans were originally less educated on, “no drinking if not using reliable forms of birth control” and “if drinking and can’t stop, see a physician,” awareness levels remained low at 0.7% and 1.5% respectively. The project was unable to increase knowledge in any area because knowledge levels were already high at the beginning. This shows that the knowledge of the negative consequences of alcohol on the fetus does not necessarily translate into healthy behavior while pregnant. Studies show that educational advertisements that promote knowledge are not sufficient to induce change in behavior. Despite high levels of exposure to advertising, women often remain unclear about the actual consequences of FAS, the risk of consuming alcohol or the value of reducing or stopping alcohol consumption during pregnancy (11). Specific guidelines and the means to accomplish the goal must also be provided so that women who are pregnant or at risk of becoming pregnant can consider changing their behaviors.
Women can only be empowered to stop drinking while pregnant or when at risk for being pregnant if they are provided with the means to do so. Racial inequalities divide access to many key health resources (12). Often, African Americans lack social support systems, health insurance, and access to health care workers and physicians. The 2005 US Census showed that 19.6% of blacks lacked basic health insurance compared to only 11.2% in whites (13). As such, African Americans in St. Louis may often not even have access to physicians. Access to health personnel is important as observed by a study of Danish women, which showed that women were more likely to stop drinking during pregnancy from the advice of a health care worker than from mass media or from relatives and friends (14). Furthermore, lack of access to a physician renders the fourth message to seek a physician defunct because even if a pregnant woman felt she were unable to stop drinking, she would not have the means to see a physician for advice.
There are also cultural reasons why African Americans choose to drink that are not addressed by the media campaign. Studies show that in certain cultures it is more accepted than in others for pregnant women to drink or even to binge drink (15). If there were more social stigma within the African community against women who drank, then they would be more pressured to stop. Ultimately, the campaign fails to address social reasons that affect a woman’s decision to drink and, instead, focus on individual factors that women often do not have control over.
Reliance on rational decision making ignores addictive behaviors
The Health Behavior Model relies heavily on the fact that women are able to rationally weigh the four constructs of perceived benefits, barriers, susceptibility and severity when deciding on whether or not to drink during pregnancy or when engaging in sexual activity that might lead to pregnancy (16). However, this is often not the case since the use of alcohol during pregnancy may signify an alcohol dependence or addiction that supersedes the rationality of an individual. Furthermore, alcohol dependence can often be co-morbid with other drug addictions, some of which may be illicit. In a study completed of support systems for pregnant women who used cocaine, heroin or alcohol, 16% used both cocaine and alcohol and 19% used cocaine, heroin and alcohol. Eighty-five percentage of the women, who were randomly selected among drug-abusing pregnant women to be treated, were also of African-American descent, showing that African Americans have a higher ratio of drug abuse problems as compared with the general population (17). With alcohol dependence high amongst pregnant African American women, many may not be able to make rational decisions that are required for the Health Belief Model to be successful.
The underlying problem of alcohol addiction in pregnant women is not considered by this media campaign intervention. Since alcoholism has historically been considered a primarily male problem, most treatment programs are targeted toward men (18). In addition, women who suffer from alcohol problems are often stigmatized in society, which results in denial and refusal to seek treatment (18). Systems in place are often unable to help women in the time frame of 9 months and wait lists often result in lack of treatment in the first few months of pregnancy, the most critical months for FAS development. As a result, women are often unable to overcome alcohol addictions while pregnant because societal systems that are in place are not created to treat pregnant women. If pregnant women are unable to overcome their addictions, they will be unable to rationally make decisions regarding their child.
Since the intervention in the targeted media campaign in St. Louis focused on individual factors and ignored problems associated with alcohol addiction, this campaign ultimately failed. The intervention relied on the Health Belief Model, which does not explain health problems influenced by social factors. Research completed clearly showed that exposure to advertisements and campaigns regarding fetal alcohol syndrome were already high; women were merely unable to apply their knowledge into the action of abstinence from alcohol. For a successful intervention, a socially-based intervention is needed that changes the social view of drinking among African American women and provides concrete ways for those who drink to stop drinking through health care access and addiction services. Without these social interventions, fetal alcohol syndrome will continue to remain a serious public health problem that creates a burden on our health care system and has implications on the physical and mental well-being of new born children.
1. Hoyme, HE, May, PA, Kalberg, WO, et al. A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: clarification of the 1996 institute of medicine criteria. Pediatrics 2005; 115:39.
2. American Academy of Pediatrics, Committee on Substance Abuse and Committee on Children With Disabilities. Fetal alcohol syndrome and alcohol-related neurodevelopmental disorders. Pediatrics 2000; 106:358.
3. Streissguth, AP, Aase, JM, Clarren, SK, et al. Fetal alcohol syndrome in adolescents and adults. JAMA 1991; 265:1961.
4. Spohr, HL Willms, J, Steinhausen, HC. Prenatal alcohol exposure and long-term developmental consequences. Lancet 1993;341:907.
5. Spohr, HL, Willms, J, Steinhausen, HC. Fetal alcohol spectrum disorders in young adulthood. J Pediatr 2007; 150:175.
6. Sidhu, J, Floyd, R. Alcohol use among women of childbearing age—United States, 1991-1999. MMWR. 2002; 51(13): 273-276.
7. Fetal alcohol syndrome--Alaska, Arizona, Colorado, and New York, 1995-1997. MMWR Morb Mortal Wkly Rep 2002; 51:433.
8. Mengel, MB, Ulione, M, Wedding, D, Jones, ET, Shurn, D. Increasing FASD knowledge by a targeted media campaign: Outcome determined by message frequency. JFAS Int 2005; 3: e13
9. Wikipedia. Health Belief Model. 15 Nov 07. 2 Dec 07.
10. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
11. Kaskutas, L A. Understanding drinking during pregnancy among urban American Indians and African Americans: Health Messages, Risk Beliefs and How We Measure Consumption. Alcoholism Clinical and Experimental Research 2000; 24:1241-1250.
­12. Marks, David F. Health Psychology in Context. Journal of Health Psychology 1996; 1(1): 7-21.
13. DeNavas-Walt Carmen, Bernadette D. Proctor and Cheryl Hill Lee. “Income, Poverty and Health Insurance Coverage in the United States: 2005.” U. S. Government Printing Office, 2006.
[1]4. Kesmodel, Ulrik and Pia Schioler Kesmodel. Drinking during pregnancy: attitudes and knowledge among pregnant Danish women, 1998. Alcoholism: Clinical and Experimental Research 2002; 26: 1553-1560.
[1]5. Gladstone, J, Levy, M, Nulman, I, Koren, G. Characteristics of pregnant women who engage in binge alcohol consumption. Canadian Medical Association Journal, 1997; 156: 789-794.
[1]6. Rosenstock, M Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
17. Jansson, Lauren M, Dace Svikis, Jana Lee, Patricia Paluzzi, Peter Rutigliano and Florence Hackerman. Pregnancy and Addiction: A Comprehensive Care Model. Journal of Substance Abuse Treatment 1996; 13:321-329.
18. Finkelstein, Norma. Treatment issues for alcohol- and drug-dependent pregnant and parenting women. Health and Social Work 1997; 19:7-15.

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