Challenging Dogma - Fall 2007

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

Monday, December 10, 2007 A Public Health Failure to Appeal – Deric Topp

Boston Public Health Commission’s campaign is a public health intervention aimed at Boston residential teenagers to improve healthy decision-making, including mental health choices. A BPHC press release describes the campaign’s goal “to reduce the stigma with mental health issues by encouraging teens and parents to talk about the importance of emotional health. It will also emphasize the importance of understanding adolescent development and recognizing the signs of stress.” (1). The front-page header for the website reads: “Talk. You’ve got to start somewhere” and “If you’re feeling lonely, frustrated, depressed, tell someone. Anyone. If you’re a friend, a parent or a teacher, just sit down and listen. And if you can’t solve it together, contact a professional.” (2) The website, the campaign’s primary intervention, is a text-based educational resource for teenagers and parents that provides a lot of essential health information for teenagers to live a healthy life in an urban environment on a number of issues that a teenager may face in their life, such as peer pressure, drug and alcohol abuse or violence. Yet the website, as a public health intervention, fails. While using an Internet-based intervention could be an effective method to change adolescent health attitudes and behaviors,’s campaign fails to properly consider its target population and therefore fails to inspire healthy decision-making and lifestyle.
The website is deeply rooted in the classic health belief model and the rational empirical approach. The health belief model states that a person’s intention to change behavior is motivated by considering four factors: perceived susceptibility to risk, perceived severity, perceived benefits of an action and perceived barriers to that action (3). The rational empirical approach uses education through information as its method of changing behavior (3). Combining the two, this website goal is to give teenagers knowledge and influence behavior change; it tries to provide positive information about negative health risks, hoping that teenagers will be able to weight the cost and benefits and make a rational decision for a positive health outcome. has incorporated technology in a practical approach to increase knowledge about negative health behavior outcomes and provide resources to teenagers. However, this model vastly oversimplifies the Boston teenager and doesn’t consider that the website must initially appeal to the teenager before it can educate them through its health resources.

Generally, a person will use the Internet for three reasons – information (learning about a topic), entertainment (music, movies, You Tube) and/or social networks (email, instant messaging, websites such as My Space or Facebook) (4). is based on the information-use model and the belief that teenagers will seek out information to solve a problem. This is an individual level behavior and generally requires a pro-active approach. For, this would require a teenager to be aware of a problem, know about the web site, go to the website and then hold interest for long enough to result in a behavior change, if possible. This process is essentially a series of conditional assumptions where each one must be accomplished for the next to occur. is made for teenagers that will both seek information and, possibly, help for their problem. The intervention works on two assumptions: one that teenagers are aware of their problem and two that they are ready/able to change their behavior. In this paper, I will criticize the intervention as an effective media campaign to capture Boston teenagers’ attention and eventually change behavior.
Target Population: Boston Teenagers
The target population, as noted, is the Boston residential teenager, probably around the high school age, somewhere in the range of 13-18. The city of Boston is a relatively diverse population. The Boston Youth Survey states: “Boston youths are a diverse and heterogeneous group, with no racial or ethnic group representing as much as one-quarter of the student population in this sample of youth in the 9th through 12th grades (5) According to the 2000 census, the city is 54.5% non-Hispanic white, 25.3% African-American, 14.4% Hispanic/Latino, 7.5% Asian. 12.9% of the cities 589, 141 residents are aged 10-18 years. (6) Roughly 40% of families have a combined income of less than $34, 999. Roughly 25.5% of families make more than $75,000. The median family income is $44, 151 (7). While the census data is somewhat dated, it gives a basic idea that this is a diverse group of teenagers from varying economic backgrounds who may or may not access this website.

Web-Based Public Health Interventions for Teenagers: A Few Examples
Web-based public health interventions have reported to be both successful and unsuccessful among teenagers. Yet the relationship, regardless of success, is complex. For example, a randomized web-based intervention of high school students in Michigan showed an increase in positive attitudes toward organ donation (8). However, evidence of whether improved attitudes lead to actual increased organ donation is, at best, inconclusive. Another example of web-based interventions focusing on smoking behaviors demonstrated an association with increased smoking cessation although it was successful only in a role that enhanced the pre- existing Not on Tobacco program and not necessarily as a primary intervention (9). In a seemingly successful web-based smoking cessation, randomized groups were either placed in a clinical or web-based intervention study, the results indicated that the clinical-based intervention was more successful in increasing smoking cessation, compared to the web-based intervention (10). The authors reported that on the third week of the intervention less than 33% of participants used the website. In the city of Boston, according to the Boston Youth Survey, only 3% of teenagers surveyed have used the Internet as a resource if stressed or upset in the past and only 4% said they would use it in the future if stressed or upset (5). So while some successful precedents for web-based interventions exists and the internet can be a successful gateway to changed behavior, the inconclusiveness of the effectiveness of web-based interventions targeting Boston teenagers should give web-based intervention developers, like the Boston Public Health Commission, to look at ways to make these interventions better.

The Appeal Problem: Getting Teenagers Attention works from the assumption that the website will get kids attention. As previously noted, research has shown that it is difficult to maintain kids attention through web-based interventions (8,9,10). The logic behind this is simple – the websites did not interest them because it did not appeal to basic core values. Teenagers’ core values, as outlined in the Boston Youth Survey, include intimate friendships, outside-of-school activities, independence, social relationships and the future (5)

Gladwell and The Stickiness Factor: A Strategy to Appeal
Malcolm Gladwell, in his book The Tipping Point, discusses about a marketing strategy he calls The Stickiness Factor. He believes that this concept is one of three laws to convey marketing messages effectively (11). He describes the process of ‘stickiness’ as making something “memorable” to a specific, targeted group but that the act of doing so requires a certain understanding of that targeted group. Exploring this idea further, he writes:

Stickiness sounds as if it’s straightforward. When most of us want to make sure what we say is remembered, we speak with emphasis. We talk loudly, and we repeat what we have to say over and over again. Marketers feel the same way…But it’s not all that useful for say, a group of people trying to spark a literacy epidemic with a small budget and one hour of programming on public television. Are there smaller, subtler, easier ways to make something stick?

Gladwell answers this question by using examples of successful usage of the ‘stickiness factor.’ He discovers that context relative to a target population is everything and using that context to “package” a message will make all the difference in whether or not that message “sticks.” One of the examples Gladwell uses is the Columbia House Record Club back when it was still a mail order club and used both television advertisements and magazine advertisements to persuade people to join the club and purchase records from them. Gladwell describes how Columbia House Record Club marketing strategies included two methods, a television and mail media campaign. The television campaign focused on increasing the frequency of getting the companies brand name to the public, and the mail media included advertising in magazines, AND getting their consumers to participate in the “gold box” activity. This activity consisted of a typical Columbia House magazine ad that also small gold box in the upper corner of the ad in which a consumer could write in the name of any records they could get for free (previous ads also allowed free records, just not with this approach). The accompanying television advertisements were not the typical “awareness” ads but ones that challenged consumers to go on a “treasure hunt” and look for the “secrets of the gold box.” The campaign’s director, Lester Wunderman, explained that the ads together “made the reader/viewer part of an interactive advertising system. Viewers were not just an audience but had become participants. It was like playing a game.” Response for the gold box campaign outnumbered the “awareness” campaign 80% to 19.5%. (11). Wunderman knew that consumers valued interaction with a product and saw that as an opportunity to repackage something old to look entirely new.
The Stickiness Factor and TalkListen.Org: A Lesson to Be Learned
Gladwell’s theory should be used by public health web-based interventions to make them more interesting and appealing to a diverse group of teenagers, an important first step in ultimately changing behavior. As Dr. David B. Nash has noted, “the Stickiness Factor urges us to pay attention to the structure and format of a message to dramatically enhance its stickiness – its ability to implement a change in behavior.” An essential part of that structure or format is taking into account the intended audience of the message. (12) In the Columbia Record Club example, that audience was the general consumer who buys records on a regular basis.’s target audience is the modern, residential Boston teenager, roughly those at the high school age and the message is in the format of a website.
BPHC and, interprets how a teenager uses the Internet to be involve primarily searching for information to answer questions and solve problems. Essentially, they believe that Internet, due its popularity among teenagers, is itself the “gold box” that will spark a social epidemic and establish a successful public health campaign. This is not true. Education and information, as it is presented in this intervention, is more likely to be identified with school than the Internet a teenager uses in their free time. As we saw earlier in the Boston Youth Survey, only 3% of Boston teenagers used to internet to deal with stress (5) Teenagers are more likely to use the internet for social networks and entertainment purposes and this is what will initially appeal to them in an intervention based website and hold their attention for longer than reading.
As such, Boston Public Health Commission should take into account the core values of this population and apply them in a way that would ‘stick.’ This could be using anonymous message forums where teens can write and read about issues with each other or health workers, which would consider the values teens put on social relationships while also maintaining privacy. With the improved technology and popularity of YouTube and streaming video, it might be appropriate to put compelling yet effective short films that could express to teens the basic principles of the website text but without be being boring and didactic.

This is not to say that is completely missing the point with its audience. The text is generally easy to read, mostly concise and the links are appropriate. However, with careful consideration of the target population, high school age teenagers, it is apparent that this website will not win any competition for attention. A “gold box” is necessary, and requires further examination by the public health community as to how teenagers in Boston use the Internet and what would be a successful presentation of the necessary information.

Web-based Interventions and Effectiveness of Behavior Change: Ignoring The Way Teens See the Internet overlooks the attitudes teenagers have toward the Internet as a behavior itself. Among social scientists that study the Internet as a social phenomenon, there is a theory called the Internet Paradox where the use of the Internet can result in a decline in psychological well-being and a withdrawal in social activity despite having some social aspects to it. A study by Kraut et al. showed that greater use of the Internet as measured by time online resulted in a decline in household communication, sizes of social circles and increased in feelings of depression and isolation (13). This idea runs contrary to the intentions of – to improve mental well-being and to improve healthy decision-making. As a strictly information based website, this asks the question does the isolated act of reading about health information, specifically among teenagers, result in better social interaction and improved confidence for teenager who has is facing a problem like drug abuse or domestic violence. Could this website, by way of the activity, result in no change in behavior or instead magnify the feelings of isolation and declining mental health?

Attempting to answer this question, sociologist Michael Eastin (4) defines outcome expectancies as the perceived likely consequences of engaging in a behavior. He argues that Internet use among teenagers is highly linked to outcome expectancies and attitudes towards the Internet as a link to positive or negative outcomes. As a result, some teenagers have positive attitude toward the Internet and believe that they can get valuable information from it while others have negative attitudes. He further argues that these attitudes are shaped by social influences. To test this hypothesis, Eastin performs a study of 236 Southwestern and Midwestern high school students deriving correlations between social factors and different Internet use models – information, social and entertainment. In both the information and entertainment models, peer influences were positively correlated with positive outcome expectancy and negatively correlation with negative outcome expectancy; the information model failed to show a meaningful correlation. used the Health Belief Model and therefore, ignored social factors and influences. For example, students with mental health problems seeking help from could have issues with peer acceptance or other social influences. Without acknowledging those issues, teenagers will less likely change their behaviors because they may not approach the material with the necessary attitude that BPHC is assuming all teens to have.

Internet-based Intervention and Self-Efficacy assumes that by reading the information on the website, a teenager will have the confidence to talk about this problem with others. For this intervention to properly work, the information has to instill self-efficacy – a teenager needs to believe they can do the intended behavior (3). However, the link between reading a collection of information about a topic and possibly going to the necessary linked health resources to being more open to discussing problems with others or making better decisions seems dubious. It does not seem that the information alone will directly lead to self-efficacy; there has to be some other element to the intervention. Referring back to a study mentioned earlier, the web-based smoking intervention was better used as enhancement to a previous, established public health intervention.

A Hypothetical Example
Suppose a teenager in Boston is struggling with addiction to drugs and/or alcohol, hears about from one of their radio advertisements and goes to website. After clicking on the option for “What can I do support myself?” There is a sidebar of a number of options including Drugs and Alcohol. The Drugs and Alcohol page is all text, such as “A person who is abusing drugs or alcohol is preoccupied with thinking about and using drugs despite the harmful consequences to his or her health, personal responsibilities, legal and financial status, family, work, or school.” This type of text is dry and not unlike that found in the textbook of a high school textbook. The “What helps” section states:

There are places in and around Boston that offer treatment for substance abuse. The goal of a treatment program is to provide people with the tools that will help them avoid using drugs or alcohol. Before choosing a treatment, you should talk with a doctor or a professional counselor. A person who is abusing a substance may also suffer from depression or anxiety, and may need a treatment that deals with this additional problem.

Again, this is boring and uninspiring and ignores what a teenager values in terms of what they find interesting on the internet and what would inspire a social epidemic of using this type of information to change a behavior. The BPHC should instead consider the lessons of the Gladwell’s Stickiness Factor and consider to repackaging the ‘same old’ information into something new as Wunderman did with the Columbia House advertising campaign. Perhaps it would be useful to shift from a primarily information-use Internet model to something that also uses the social networks and entertainment Internet models. If teenagers have core values of independence, social relationships and their future, it is likely that these values would need to be incorporated into the website to make the message stick and use increase. For instance, it might be possible that a teen who values independence might not feel that the institutionalized resources, such as, are very appealing.

Secondly, considering the points made by Eastin, a teenager using drugs and alcohol may not have a positive attitude toward using to help change behavior. The social influence, such as a negative peer network or withdrawal from social norms, that may have influenced the teen to experiment with drugs undermines any expectancies about using the internet to find help because that social influence has shaped the way that individual views the consequences or even on a more basic level, information about the negative impacts on drug abuse. The views shaped by the many environmental influences are much stronger than a few lines about drugs and alcohol or any other health issue. The modeling used to make this intervention intended to instill confidence about behavior must look beyond information alone.

Lastly, the content of the website needs to establish self-efficacy in the teen. The link for drugs and alcohol provides brief pieces of information on four topics: abusing drugs and alcohol, what helps, what’s detox, and will I recover. Initially, the website’s message is to encourage and change behavior in terms of getting teens to talk about their problems. By providing brief information on how to get help on an issue such as drugs and alcohol, maybe a teen will be influenced positively and, in the right circumstance, might seek to talk to somebody about the treatment or seek treatment independently. However, there appears to be little about the content that would inspire a teenager to believe they can get treatment. For example, the what helps section begins, “The good news is that alcohol and drug abuse is preventable and treatable. You can seek treatment for drug use even if your use is moderate—and this can prevent you from becoming addicted.” Further down the page, the what’s detox is comprised completely of the following two sentences:

"Detox" is medical detoxification, usually the first step in treating severe addiction. If you try to quit cold turkey by yourself, you may experience painful withdrawal symptoms and possibly even a medical emergency. In detox, the drug's toxins are removed from the body in a controlled process.

First assuming the teenager stuck around long enough to read through the website to get to this and then had the necessary influence and attitude to believe this would help, he or she reading this would then have to translate information such as the excerpt above into not only an intended behavior but also believing they can do the action whether it be talk about drug treatment or try to get drug treatment. For some teenagers, objective, direct information could be helpful and may influence them into weighing costs and benefits and make a decision. But to many, this is, again, making a large assumption.

Conclusion appears to be a solid resource for teenagers to get important health information. The role of the information is not only to influence healthy decisions, but also to remove isolation by inspiring confidence in the teenager, using the proven concept of knowledge is power. Yet it fails as an intervention to change behavior based on three dangerous assumptions: teenagers would be interested in the website, teenagers view the website positively and teenagers will use the information to change behavior.

The website is grounded in the Health Belief Model. The intervention essentially suggests that by going to this website, a teenager who needs help will be influenced positively by the information to seek help by assisting them in weighing the costs and benefits. This relies on the assumption that the Internet will be successful at influencing these perceived costs and benefits. It also assumes that once at the website, it will appeal to teens and the messages will “stick.” It then further assumes that teens will also have the right attitudes in approaching the content. If peers or other social factors have an influence over outcome expectancies or the way that a behavior will end up, it would make sense that an information based website is not likely to change that outcome in many circumstances. In fact, the model does not consider the divide between Internet uses among different populations at all. This could even be extended to socioeconomic disparities or something as simple as family views on Internet usage. Considering the racial, ethnic and economic diversity in Boston, this view is not unlikely. And finally, it assumes that based on the intervention and its information the teen will have self-efficacy and believe they can change their behavior; this assumption is much too large based on the quality of the website’s content. By not addressing these assumptions, will not impact teenagers in Boston as it intends to.
1; Mayor Menino, coalition of 75 groups join together to improve emotional well-being of Boston teenagers. Boston, MAN: Boston Public Health Commission.
2 Boston Public Health Commission
3 Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007
4 Eastin, M. Teen Internet Use: Relating Social Perceptions and Cognitive Models to Behavior. CyberPsychology and Behavior 2005; 8:62-73.
5 Boston Youth Survey. City of Boston and Harvard School of Public Health, 2004.
6 Boston City, Massachusetts DP-1. Profile of General Demographic Characteristics: 2000 United State Census Bureau (2000)
7 Boston City, Massachusetts DP-1. Profile of Selected Economic Characteristics: 2000 United State Census Bureau (2000)
8 Vinokur AD et al. Education web-based intervention for high school students to increase knowledge and promote positive attitudes toward organ donation. Health Education and Behavior 2006; 33:773-86.
9 Mermelstein R et al. Web-based support as an adjunct to group-based smoking cessation for adolescents. Nicotine and Tobacco Research 2006; 8 Suppl: S69-76.
10 Patten C et al. Randomized clinical trial of an Internet-based versus brief office intervention for adolescent smoking cessation. Patient Education and Counseling 2006; 64: 249-258.
11 Gladwell, Malcolm. The Tipping Point: How Little Things Can Make a Big Difference. Boston, MA Little Brown, 2000.
12 Nash D. A Health Care Tipping Point? Health Policy Newsletter. Health Policy Newsletter 2001; 14: Article 1.
13 Kraut et al. Internet paradox. A social technology that reduces social environment and psychological well-being? American Psychologist 1998; 53: 1017-31.

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