Challenging Dogma - Fall 2007

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

2008-03-19T12:47:00.000-07:00

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.

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

2007-12-14T09:02:00.000-08:00

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.

Conclusion
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.

References
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: http://www.cdc.gov/hiv/resources/factsheets/PDF/MSM_Glance.pdf
3. CDC, Replicating Effective Programs Plus. Atlanta, GA: US Department of Health and Human Services. Accessed November, 2007. Available at: http://www.cdc.gov/hiv/topics/prev_prog/rep/index.htm
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.

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

2007-12-13T18:01:00.000-08:00

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.

References

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 .

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

2007-12-13T17:55:00.000-08:00

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.
Conclusion
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.
REFERENCES
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, http://www-nrd.nhtsa.dot.gov/Pubs/810617.PDF.
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. www.nyc.gov/html/dot/downloads/pdf/bicyclefatalities.pdf.
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.

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

2007-12-13T17:49:00.000-08:00

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.
REFERENCES
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. http://www.fda.gov/fdac/features/1999/399_lyme.html.
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. http://tobaccoanalysis.blogspot.com/2006/05/in-my-view-education-and-persuasion.html.
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.

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

2007-12-13T17:35:00.000-08:00

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).

Conclusion

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.

REFERENCES
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. http://www.whatsyourantidrug.com/ads.asp#
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
http://www.cnn.com/2005/EDUCATION/09/28/youth.sports/index.html
9. “Supermarket” Anti-Drug Ads. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.whatsyourantidrug.com/ads.asp#
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.
http://www.usatoday.com/news/washington/2006-08-28-anti-drug-ads_x.htm
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.

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

2007-12-13T17:30:00.000-08:00

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.
Implications
“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.
Conclusion
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.
REFERENCES
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. http://www.omhrc.gov/healthgap/
4. U.S. Department of Health and Human Services. Healthy People 2010. Washington, DC. http://www.healthypeople.gov/default.htm
5. James C. Race, Ethnicity, and Health Care. http://www.kaiseredu.org/tutorials/REHealthcare/player.html
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. http://www.public.asu.edu/~cbaldwi1/swborderlands/lch.htm
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.

Unite for Children, Unite for AIDS: Campaign Fails by Same Mistakes as Previous Campaigns-Trudy Ann Spencer

2007-12-13T17:27:00.000-08:00

Everyday, thousands of public health professionals come up with interventions to solve health issues that affect the public. These issues range from chronic diseases to infectious diseases. Among these maladies is AIDS, a fatal disease that has a significant impact on the public. In the United States alone 15,000 infants were infected with HIV through mother-to-child transmission between 1978 and 1994 (1). According to UNAIDS (The Joint United Nations Programme on HIV/AIDS) worldwide statistics, an estimated 2.5 million children under 15 were living with HIV/AIDS at the end of 2003. Approximately 500,000 children under 15 had died from the virus or associated causes in that year alone (2). The US Bureau of the Census estimated that by the end of 2000, 15.6 million children around the world would have lost a mother or both parents to AIDS. By 2010, the number of orphaned children is estimated to rise to 44 million (3). Not only do children have to deal with the infection, many of them are forced to deal with the stigma and discrimination associated with the disease. These two factors contribute heavily to the emotional toll of AIDS because society usually keeps its distance from victims for fear of infection (4). The harsh environment in which these children victims live in has led UNICEF to initiate the launching of the worldwide campaign “Unite for Children, Unite for AIDS” (5).
Unite for Children, Unite for AIDS, a project of the United Nations Children’s Fund is a 5 year campaign. Overall, the project is geared towards making the global community aware about the pandemic and how it affects children, as well as stimulate political support towards addressing the problem(6). In attempting to make a real difference in the lives and life chances of children affected by HIV/AIDS, the campaign set up a child-focused framework around the “Four Ps”: preventing mother-to-child HIV transmission by providing antiretroviral drugs to HIV positive mothers, making testing more widely available, encouraging voluntary testing, and providing counseling for children and mothers. In addition, the campaign seeks to prevent infection among adolescents by increasing access and encouraging the use of gender sensitive prevention information and services. The campaign also provides pediatric treatment, protect an support children affected by HIV/AIDS. Furthermore, the campaign sets the stage for child-focused advocacy on global AIDS issues, and places children affected by AIDS at the center of the HIV/AIDS agenda. These goals set by the UNICEF campaign are both noble and noteworthy, yet lack the ability to fully cater to the intended beneficiaries. Despite the campaign’s efforts, Unite for Children, Unite for AIDS fails to take into account the sociocultural and economic factors that affect the HIV/AIDS victims.
Campaign Underestimates The Stigma Associated With HIV/AIDS Victims
“In 1999, nearly 1 in 5 American adults surveyed, said they “feared” persons with AIDS. One in 6 admitted to feelings of “disgust” related to persons with AIDS” (7). HIV/AIDS patients are aware that other individuals within the community harbor repulsive feelings toward them and their condition, and are emotionally affected by this stigma. Most victims fear losing ties with their family, friends, and loved ones. As a result, individuals suffering from the disease are willing to avoid diagnosis and treatment in order to keep their family ties intact. For example, the campaign makes antiretroviral drugs available to the HIV infected mothers. The effort does not however, account for the stigma, and infected mothers are likely to be humiliated by their situation and shy away from treatment altogether. Since these mothers are not willing to receive treatment and the campaign does not create other initiatives, simply providing the antiretroviral drugs is insufficient.
The campaign does not take into account that individuals act on impulses that are shaped by their surroundings. In other words, an HIV/AIDS patient’s social environment (peers), and perception of the environment has a great effect on his/her behavior. This idea is supported by the social cognitive theory, which focuses on the interaction between individuals and their immediate environment. The theory explains that people choose to carry out a certain behavior because of the influence of their environment. Social cognitive theory has two basic factors namely, the internal and external. The internal factor focuses on the individual’s self efficacy, behavioral capabilities, expectations, and emotional coping ability (8). On the other hand the external factor constitutes the social and physical that surrounds and influences the individual (9). In accordance with this theory, mother-to-child HIV transmissions will continue to prevail in affected societies, as long as the campaign continues to underestimate the stigma that plagues the victims.

Campaign Assumes That Intention Leads To Behavior
The campaign focuses on providing basic sex education courses to adolescents. However, simply trying to educate teens is not the most effective way to decrease HIV incidence. When faced with the decision to engage in sexual activity, teens may not adhere to information they learned during sex education. Moreover, teens are also vulnerable to peer pressure, and are likely to be influenced into making unwise decisions despite education efforts. While sitting in a sex education class, it is easier for adolescents to imagine themselves using protection during sexual activity. However statistics show that this intention does not always lead to. In a study maintained by Congress, teenagers who were sexually active reported having had sex for the first time when they were 15 years old. More than one-third of both groups had two or more sexual partners, the study found. Twenty-three percent of both groups reported having had sex and always using a condom; 17% of both groups reported having had sex and only sometimes using a condom; and 4% of the students in both groups reported having had sex and never using a condom, according to the report” (10). While the campaign provides the basic education it fails to consider the sexual reality most teens face, and that sex education can only do so much for the youth.
The health belief model states that there are four main components that influence behavior. The model states that the individual will weigh the perceived susceptibility and severity versus the perceived cost of an action. If the perceived susceptibility and severity out weighs the cost, the individual will have the intention to act, and the intention will fuel the action. However, the aforementioned statistics disproves this theory because intentions do not always lead to action. Adolescents may intend to practice safer sex, but may not always do so due to external factors such as peer pressure from their partner. The argument that a link between intention and action exists is invalid, and the campaign needs to be aware of that.

Campaign Does Not Provide Free Antiretroviral Drugs
Unite for Children, Unite for AIDS provides pediatric treatment to children affected by HIV/AIDS. This treatment, however, is at an “affordable” cost and is not free to the victims (11). The majority of the AIDS/ HIV victims live in poverty-stricken regions where they can barely afford the drugs, even at a low affordable cost. In her article The Scandals of Poor People’s Diseases, Tina Rosenberg affirms that poor people and poor countries have no hope of buying them [antiretroviral drugs] (12). The campaign needs to realize that an affordable drug is not sufficient to help these individuals in poor communities, and needs to determine new ways of providing these important drugs for free.
It is hard to imagine how a Rwandan woman with AIDS might be considered lucky, but in a way, she is…Poor countries like Rwanda are scrambling to provide free treatment to all who need it. ” (13) The Medecins Sans Frontieres, also known as Doctors Without Borders were able to successfully treat underprivileged and low income individuals with AIDS through their Triple Therapy Program. A key component of their program was to offer free anonymous treatment to patients (14). Undoubtedly, having individuals seek medical care anonymously and free of charge is a better solution that Unite for Children, Unite for AIDS should adopt over their current program.

Conclusion
The Unite for Children, Unite for AIDS campaign may have great intentions. However, they fall short of realizing how stigma has a behavioral affect on HIV/AIDS victims. In order for the campaign to reduce the incidence of HIV, it is vital that they understand what a profound effect stigma can have on an individual and his behavior. A stigma associated with HIV/AIDS alone can cause an individual to refrain from receiving treatment. The campaign also fails to learn from the mistakes of the health belief model by ignoring the notion that intentions do not always leads to behavior. In addition, Unite for Children, Unite for AIDS is unaware of the importance of free antiretroviral drugs. Providing free antiretroviral drugs to patients will dissolve the economic boundary that causes individuals to not seek treatment.
An ideal intervention would take the sociocultural and economic factors into account. It would direct its focus and resources into ensuring that society does not condemn and fear HIV/AIDS patients. Addressing this issue would make it easier for mothers to seek treatment so as to prevent mother-to-child transmission of the disease. Furthermore, the campaign should create programs that would make the patient comfortable when visiting the health facility without having to worry about any stigmas. Clients are more likely to seek and follow through with HIV testing services if the perception is that it is non-threatening, nonjudgmental, and responsive to their individual needs and circumstances (15). If Unite for Children, Unite for Aids adopted the above initiatives, the campaign will be more successful in preventing new incidence of HIV/AIDS in children.

References
1.Vazquez E. Disturbing HIV stats for young men. Posit Aware. 1996 Jan-Feb;7(1):9
http://www.ncbi.nlm.nih.gov/sites/entrez
2. National Insitute of Allergy and Infectious Diseases. National Insitute of Health. U.S. Department of Health and Human Services. HIV Infection in Infants and Children 2004. http://www.niaid.nih.gov/factsheets/hivchildren.htm
3.Gilborn, Laelia Zoe. Beyond our Borders: The effects of HIV infection and AIDS on children in Africa. West J med. 2002 January; 176(1): 12-14
4. Gilborn, Laelia Zoe. Beyond our Borders: The effects of HIV infection and AIDS on children in Africa. West J med. 2002 January; 176(1): 12-14
5. UNICEF- Unite for Chrildren, Unite for Aids, www.unicef.org
6. UNICEF- Unite for Chrildren, Unite for Aids, www.unicef.org
7. Freking, Kevin. Sex-ed approach is faulted in study Abstinence classes don’t stop youths. Associated Press, April 14, 2007
8. UNICEF- Unite for Chrildren, Unite for Aids, www.unicef.org
9. Freking, Kevin. Sex-ed approach is faulted in study Abstinence classes don’t stop youths. Associated Press, April 14, 2007
10. Freking, Kevin. Sex-ed approach is faulted in study Abstinence classes don’t stop youths. Associated Press, April 14, 2007
11. Rosenberg, Tina, The Scandal of ‘Poor People’s Diseases’. New York Times, March 29, 2006.
12. Rosenberg, Tina, The Scandal of ‘Poor People’s Diseases’. New York Times, March 29, 2006
13. Rosenberg, Tina, The Scandal of ‘Poor People’s Diseases’. New York Times, March 29, 2006
14. Doctor’s Without Borders. Triple Threat Campaign .
http://www.doctorswithoutborders.org/publications/reports/2001/malawi_12-2001.cfm
15. Gilborn, Laelia Zoe. Beyond our Borders: The effects of HIV infection and AIDS on children in Africa. West J med. 2002 January; 176(1): 12-14

Nutritional Interventions in Elementary Schools Fail to Ameliorate Childhood Obesity– Charlotte DeLeo

2007-12-13T17:24:00.000-08:00

Childhood obesity and public health’s educational approach
Childhood obesity is arguably the worst health trend our country faces, due in part because of its potential prevention (10). The incidence of overweight and obese children is rising rapidly and there is no indication that it might slow down (17,31). According to the Centers for Disease Control and Prevention, the prevalence of overweight children between the ages of six to eleven years old has risen from 6.5% to 18.8%, and between the ages of twelve and nineteen has risen from 5.0% to 17.4% in the past three decades (21). Childhood and adolescent obesity is a particular concern because at a young age, kids are unconsciously forming their lifelong habits (4). Overweight children are predictably destined to become overweight adults (10). As their waistlines grow, children unknowingly increase their risk factors for a myriad of diseases in their adult life such as heart disease, type-2 diabetes and hypertension. This has devastating implications for future health care costs. Furthermore, children do not realize through their young perspective that unhealthy eating habits and physical inactivity inadvertently affect their energy levels, mood, social relationships, self-confidence and general well-being.
Schools should recognize the great opportunity they have to improve the health of future generations; they provide an ideal setting for implementing public health interventions because kids spend the majority of their day at school (19,26). The current public health approach taken to address the childhood obesity epidemic has been to implement school-based programs where teachers incorporate nutrition education into the curriculum of other classes. The rationale is that programs will teach positive dietary messages and knowledge that will influence the dietary behavior of children (20). Although there are many nutritional based programs nationwide, childhood obesity has reached epidemic proportions.
A recent study assessed the overall effectiveness of school-based prevention programs in reducing obesity and found that only four of 57 programs reported both statistically and clinically significant outcome differences between intervention and comparison groups (28). Although there have been many childhood obesity programs, findings show that these interventions are only producing meager results without meaningful public health impacts (3). Results, if any, are short-term and after a short period of time effects are diminished by personal and social barriers not addressed by current interventions (32).
The current design of educationally based programs is not effective. Educational interventions based on traditional behavioral theories fail because they are too confined to the classroom and assume that knowledge will translate directly into behavior. There is not a goal to improve children’s self-efficacy which is the foundation for individual behavioral change. Finally, school-based programs are too isolated and need to take a more collaborative approach including extending support to families and teaming up with the community to promote active living.
Failure to incorporate physical activity programs alongside nutrition
Public health’s method of educational approaches in elementary schools is flawed because the programs largely draw on Social Learning Theory, which assumes nutritional knowledge will translate into kids changing their health behavior. Social Learning Theory posits that people learn from one another via observation, imitation and modeling (7). The assumption is that children will observe a teacher and be motivated and capable to transfer that knowledge into their own behavior. According to Social Learning Theory, one forms an idea of how new behaviors are performed by observing others, and this coded information serves as a guide for action on future occasions (12). In reality, regardless of what a child learns, there is no way to predict that a child is able to perform that behavior. A child also has no desire to make a change unless they feel motivated to do so. A teacher is not an empowering role model who effectively motivates a child to change his or her attitude towards the issue of nutrition. Having an authority figure dictate good nutrition in a non-enthusiastic, non-engaging tone does not inspire a child to pick fruits or vegetables over more sugary foods they have decided are more tasty and fun to eat. Physical activity programs need to be implemented in schools alongside nutrition, so that children will perform healthy behavior, rather simply observing it. In addition, through sports programs, children can serve as models to their own peers, which may serve as a more effective model than authority figures.
The failure in limiting interventions to the classroom is that exercise is being largely ignored as a factor which will improve childhood obesity. Children need to be given the opportunity to feel the benefits of physical activity. Many factors dictate whether a child will be physically active and a child’s attitude toward the activity will significantly affect their participation (15). Failure to incorporate sports programs tends to misplace the emphasis on weight without the balance of a total health message which can lead to unhealthy and unsustainable dieting (15). When children enjoy exercise, it will demonstrate to them that food is not evil, but a balance should exist between energy input and output. Eating and exercise are both fun and important. School-based policies fail to give adequate opportunity for exercise, and policy is only worsening as schools cut out critical physical activity programs.
Even the most basic program of physical education classes are being sacfrificed more and more due to funding. Faced with shrinking budgets and increased pressure to perform on standardized state tests, physical education (PE) classes have been replaced with classroom nutrition programs that only encourage children to stay active instead of offering them the opportunity to exercise. In 2006, only 4 percent of elementary schools provided daily physical education and overall, 22 percent of schools did not require any physical education (30). If PE classes do exist today, they would be most useful to emphasize the behavioral skills associated with developing an active lifestyle, such as how to become less sedentary (15), rather than simply teaching new sports skills they can only use on certain occasions. In some cases, recess has also been cut out of a child’s school day. In 2005, between 12- 17% of elementary schools in the U.S. reported they did not provide daily recess (9). A survey of Chicago Public Schools found that out of 396 schools, only 43% of those offered recess (6). Recess should be a built into the daily schedule of every elementary school. Studies have shown that children experience more concentration problems on days without recess (11). It is an important break which allows children unstructured physical activity where they can release energy and stress, and restore their concentration for the classroom (11,26).
One strategy is that schools could encourage children to walk and bike to school (24). This would require crossing guards and bike racks outside the school. To make this possible in some areas, states may need to revamp sidewalks to make them safe enough, so parents can feel comfortable allowing their children to have that independence. A Walk or Bike to School Program might have a group of students go together accompanied by an adult to be safe enough. If active commuting programs are feasible and implemented, they have the potential to establish early habits of lifestyle physical activity that can be sustained through adolescence and adulthood (29).
Ideally, schools need to incorporate after school sports programs were children become part of a team, build better relationships with their peers to encourage each other, and let them feel the rewards of physical activity. One intervention tested the efficacy of an after-school dance program to reduce television viewing and weigh gain in African-American girls and the program succeeded with high participation, significantly reduced television viewing and trends towards lower BMI than the control group (22). Expanding after-school sports programs competitive and non-competitive will give kids the incentive to get moving and have fun, instead of going home to watch TV. Nutritional interventions are doomed to be ineffective if they are not paired with interventions to increase energy expenditure through physical activity.
Increasing self-efficacy and fostering positive attitudes towards healthy living
Education-based nutrition interventions have failed to address children’s individual self-efficacy- a major predictor of whether they will succeed or even attempt a new behavior. There needs to be a focus on increasing children’s attitudes, self-confidence, and self-efficacy. Based on Social Cognitive Theory, regardless if a behavior is positively modeled, children have to believe they are able to change their behavior in order to be successful (1,7). Teachers should focus on constantly offering positive affirmations to all children equally.
The concept of BMI “report-cards” that some schools have adopted as a policy for childhood overweight and obesity only breaks down a child’s self-confidence. Labeling a child as “fat” is absolutely detrimental to a child’s self-efficacy. These children are likely to have terrible body image and this strategy is guaranteed to isolate overweight kids, make them feel ashamed of themselves and perpetuates them towards negative self-image. The implications will inevitably lead to decreased academic performance, depression, hopelessness, and social problems with peers, teachers and siblings along with, body dysmorphia, eating disorders and lifelong unhealthy relationships with food (2).
Children will become motivated and be inspired to live healthy if the message comes from a voice that they feel more connected to, one that is less authoritative than that of a teacher (23,25,27). This channel of communication will build their self-confidence and make goals more realistic and appealing. It has been found that overweight youth engage in more intense activity when in the presence of peers (23). The “Peer Power” initiative in Dare County, North Carolina provides an excellent example of an effective peer-driven program that has produced positive health behavior changes in the areas of physical activity and nutrition. This initiative trains high school students to be health educators and mentors for younger elementary and middle school children, thereby making health education more relevant and interesting. Findings indicated that the program improved students’ nutrition and activity-related health choices significantly and also decreased average BMI by 4 percent in two thirds of students (27). Another similar program “Healthy Buddies” found a student-led curriculum which focused on nutrition, physical activity, and healthy body image improved healthy behavior in both the older and younger buddies, and older buddies showed weight loss (25). Peer-peer interactions and support can serve to increase kids’ excitement about getting active, increase energy levels, foster friendships and improve social bonds and feelings of acceptance (23). A positive support-system among classmates is essential for kids to feel mentally healthy and encourage them to participate. Programs that strengthen activity levels and peer-peer support systems will ultimately serve to relieve anxiety, boredom, possibly reduce youth violence and improve social problems, such as being teased, loneliness, or low self-esteem (26). By fostering positive attitudes and a positive social atmosphere, this improves the social environment for children to learn and grow in. In a type of atmosphere where they feel comfortable, children will develop improved self-confidence and feel more internally motivated to try new foods and not be lazy.
Food-policy changes within schools and parental participation to achieve continuity
Educational campaigns are too focused on individual level models and fail to consider the child’s environment as a major factor mediating behavior. Both the school environment and the environment children return to after school need to be considered. Based on the Stages of Change model, the major component that dictates potential relapse is whether the individual can maintain their behavior (7). A revised stages of change model with social influences as a component to the maintenance stage would be more helpful to use. The original Stages of Change model school nutritional programs seem to be based on fails to account for social influences, whether or not resources are available and familial support. The assumption is being made that children have the power to make healthy choices and that necessary resources are available to them, when in reality they often are not. Looking at current nutritional education programs, children are simply unable to maintain the behavioral change, or put what they learn into practice due to social and environmental blocks.
Beyond an educational campaign, this needs to be an institutional-level change, which would include simply replacing foods in cafeterias high in grease, fat, salt and sugar with more moderate ones. States, districts and schools must examine their food-related policies and make healthier alternatives more accessible to students in terms of appearance, taste and cost (16). One study assessed that American students at 86% of high schools, 62% of middle schools, and 21% of elementary schools have access to foods and beverages through vending machines, and there is widespread availability of food high in fat, sodium, and added sugars. The result is a paradox; when students are taught about good nutrition and healthy food choices in the classroom but are surrounded by a school environment offering primarily low nutritive foods, they receive an inconsistent message (18). There needs to be continuity in the message to convince students to change. Vending machines need to be eliminated during school hours to avoid the temptation and habits of snacking on innutritious items throughout the day when children should just wait until lunchtime to eat. Furthermore, the availability of competitive foods sold to children through vending machines and snack bars has been found to negatively correlate with fruit and vegetable consumption, displacing healthy foods and therefore contributing to excess fat and saturated fat intake (13,26). A child cannot be taught one lifestyle in the classroom and then enter a school cafeteria that is full of contradictions. Environmental changes are going to improve the health of children.
Nutrition should be a part of the general operating budget of state funding for schools. Children have to be given healthy food options because at a young age they do not necessarily have the perspective to seek out healthy foods on their own. By changing district policies on what is served in cafeterias, children will become healthier not only in terms of weight, but will also benefit by a decrease in hyperactivity and lethargy that follows a sugar-high and increased ability to focus. One example of the potential impact a change in the food-environment can have is with the Natural Ovens program in Appleton, Wisconsin where there has been a district-wide commitment to healthier eating and lifestyles. Policy makers in Wisconsin have decided to invest in feeding students quality, nutritious foods now, instead of potentially paying for health care costs associated with obesity in the future (5). Prior to the program’s launch in 1997, teens in the pilot school were described as rude, obnoxious and ill-mannered with so discipline problems a police officer was on staff. Since the beginning of the high school program, students became more calm, well-behaved with less angry outbursts and more receptive to learning. In the area middle schools, teachers report students more clam, less bouncy and more alert (5). The number of kids who have dropped out, been expelled, been found using drugs, carrying weapons or who have committed suicide has been zero in every category. Overall, throughout the 200 schools implementing this food-environment change, it is evident that kids enjoy the benefits (5) of better nutrition and how it makes feel both physically and psychologically. This exemplifies the possibility that schools can completely eliminate the grease and kids will learn to appreciate the fresh food. When kids are given the opportunity to eat better and experience positive results, the change will eventually become their habit.
Finally, children can never maintain what they practice for half their day if there is no there is no continuity to the parental sector. Nutritional education interventions fail to address the upstream source of students’ unhealthy lifestyles which starts at the family level and at home (14). Because parents provide a child’s contextual environment (8), they should be key participants in promoting a healthy and active lifestyle for their child. Children may go home and watch television for the rest of the night when some individuals have working parents who cannot be home. If there is a strong effort made at school to change the health behaviors of children then parents need to be aware of that and involved in helping their child maintain eating habits and physical goals. A partnership between teachers and parents should exist to promote realistic approaches for healthful eating for the family and suggestions for physical activities they can do with their kids outside of school. There needs to be family interventions that send home innovative flyers, encourage participation in community-based social and physical events that foster positive attitudes toward healthy living. National, state, and local leaders should encourage citizens to cooperate to establish state and local coalitions to plan and promote physical activity among young people and their whole families on a community-wide level.
Conclusion
Public school nutrition programs are flawed in a number of fundamental ways and therefore have failed to create consistent and lasting effects in kids. The internal motivation for nutrition and activity behavioral change is problematic with current methods of classroom-based nutritional education interventions. Schools need to divert away from solely educational endeavors and move towards taking real action. Simply educating a child is not enough; they need to feel the change of nutritious food themselves and decide it is the better choice. Once children feel the benefits of physical activity, exercise will become something they look forward to, seek out and want to do on their own. Elementary schools should consider this as an opportunity to inspire children to live healthier lifestyles, which will ultimately help kids build self-confidence, improve academic performance and foster better attitudes and support amongst peers.
References
1. Anderson, E.S., Winett, R.A. and J.R. Wojcik. Self-Regulation, Self- Efficacy, Outcome Expectations, and Social Support: Social Cognitive Theory and Nutrition Behavior. Annals of Behavioral Medicine 2007; 34(3): 304-312.
2. BMI Report Cards: The ‘F’ is for ‘Futility’. The Center for Consumer Freedom, 2006. http://www.consumerfreedom.com/news_detail.cfm/headline/2980
3. Boon C.S. and Clydesdale F.M. A review of childhood and adolescent obesity interventions. Critical Reviews in Food Science and Nutrition 2005; 45(7-8): 511-525.
4. Brodersen, N.H., Steptoe, A., Williamson, S. Sociodemographic, Developmental, Environmental, and Psychological Correlates of Physical Activity and Sedentary Behavior at Age 11 to 12. Annals of Behavioral Medicine 2005; 29 (1): 2-11.
5. A Different Kind of Lunch. Feingold Association of the United States, 2002. http://www.feingold.org/PF/wisconsin1.html
6. Duffrin, E. Survey: recess, gym class shortchanged. Catalyst Chicago 2005; 17(2): 20.
7. Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston MA: Jones and Bartlett Publishers, 2007.
8. Golan, M. and S. Crow. Parents are Key Players in the Prevention and Treatment of Weight-related Problems. Nutrition Reviews 2004; 62 (1): 39-50.
9. Greene, B. Calories In, Calories Out: Food and Exercise in Public Elementary Schools. National Center for Education Statistics, 2005. http://nces.ed.gov/pubs2006/nutrition/02E.asp.
10. Hampson, S.E., Andrews, J.A., Peterson, M. A Cognitive-Behavioral Mechanism Leading to Adolescent Obesity: Children’s Social Images and Physical Activity. Annals of Behavioral Medicine 2007; 34 (3): 287-293.
11. Jarrett, O.S. Effect of Recess on Classroom Behavior: Group Effects and Individual Differences. Journal of Education Research 1998; 92(2): 121- 126.
12. Kearsley, G. Social Learning Theory: A. Bandura. The Theory Into Practice Database, 2007. http://tip.psychology.org/bandura.html.
13. Kubik, M.Y., Lytle, L.A., Hannan, P.J. The association of the school food environment with dietary behaviors of young adolescents. American Journal of Public Health 2003; 93(7): 1168-1173.
14. Lindsay, A.C., Sussner, K.M., Kim, J. The role of parents in preventing childhood obesity. The Future of Children 2006; 16: 169-186.
15. Moving to Prevent Childhood Obesity. International Food and Information Council, 2007. http://www.ific.org/foodinsight/1997/ja/obesityfi497.cfm.
16. Neumark-Sztainer D., French S.A., Hannan P.J. School lunch and snacking patterns among high school students: associations with school food environment and policies. International Journal of Behavioral Nutrition and Physical Activity 2005;2:14.
17. Ogden, C.L., Carroll, M.D., Curtin, L.R. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006; 295 (13): 1549-1555.
18. O’Toole, T.P., Anderson, S., Miller, C. Nutrition services and foods and beverages available at school: results from the School Health Policies and Programs Study 2006. Journal of School Health 2006; 77: 500-522
19. Peterson, K.E. and Fox, M.K. Addressing the epidemic of childhood obesity through school-based interventions: What has been done and where do we go from here? Journal of Law Medicine and Ethics 2007; 35 (1): 113
20. Powers A.R., Struempler B.J., Guarino A. Effects of a nutrition education program on the dietary behavior and nutrition knowledge of second-grade and third-grade students.” Journal of School Health 2005; 75 (4): 129-133.
21. Prevalence of Overweight Among Children and Adolescents: United States, 2003-2004. Centers for Disease Control and Prevention: National Center for Health Statistics, 2007. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm
22. Robinson, T.N., Killen, J.D, Kraemer, H.C. Dance and reducing television viewing to prevent weight gain in African-American Girls: the Stanford GEMS pilot study. Ethnicity and Disease 2003; 13(1):S65-77.
23. Salvy, S.J., Bowker, J.W., Roemmich, J.N. Peer Influence on Children’s Physical Activity: An Experience Sampling Study. Journal of Pediatric Psychology Advance Access 2007.
24. Santos, M.P, Gones, H. and J. Mota. Physical Activity and Sendentary Behaviors in Adolescents. Annals of Behavioral Medicine 2005; 30 (1): 21-24.
25. Stock, S., Miranda, C., Evans, S. Health Buddies: a novel, peer-led health promotion program for the prevention of obesity and eating disorders in children in elementary school. Pediatrics 2007; 120(4): 1059-1068.
26. Story, M., Kaphingst, K.M. and French, S. The role of schools in obesity prevention. Future of Children 2006; 16(1): 109-142.
27. Thomas, A.B. and E. Ward. Peer-peer power: how Dare County, North Carolina, is addressing chronic disease through innovative programming. Journal of Public Health Management Practice 2006; 12(5): 462-467.
28. Thomas, H. Obesity prevention programs for children and youth: why are their results so modest? Health Education Research 2006; 21 (6): 783-795.
29. Turdor-Locke, C., Ainsworth, B.E. and B.M. Popkin. Active commuting to school: an overlooked source of children’s physical activity? Sports Medicine 2001; 31(5): 309-313.
30. U.S. Schools making progress in decreasing availability of junk food and promoting physical activity. Centers for Disease Control and Prevention: Data and Statistics, 2006. http://www.cdc.gov/datastatistics/2007/shpps/
31. Wang, Y. and T. Lobstein. Worldwide trends in childhood overweight and obesity. International Journal of Pediatric Obesity 2006; 1(1): 7-10.
32. Wilfley, D.E., Stein, R.I., Saelens, B.E. Efficacy of Maintenance Treatment Approaches for Childhood Overweight: A Randomized Control Trial. JAMA 2007; 298: 1661- 1673.

Anti Drug and Marijuana Ad Campaigns Fail To Dissuade Youths From Smoking – Aaron Manders

2007-12-13T17:21:00.000-08:00

Anti marijuana advertisement campaigns have failed to effectively curtail marijuana use amongst adolescents. A report by Westat, Inc. written by Orwin, et al., showed that increased exposure to certain anti marijuana advertisements has been linked to an increase in weakened anti drug norms among adolescents and the increased perception that their peers are using marijuana. Their latest report detailing the effectiveness of the largely anti marijuana anti drug campaign (1998-2004) sponsored by the National Youth Anti-Drug Media Campaign (NYADMC) and the National Institute on Drug Abuse (NIDA) showed no attributable benefit to the campaign. Furthermore, higher exposure to the anti marijuana portion of the campaign was correlated with an increased smoking initiation and lacked a correlation between increased exposure and decreased use or quitting (1).
Although the federal government failed to create a campaign that significantly decreased marijuana usage, smaller scale campaigns have shown positive results in adolescent populations (2,3). Thus, the failure of the campaigns sponsored by NIDA and NYADMC are inexcusable. National campaigns to lower adolescent use of marijuana have been largely ineffective because they either focus on fear or absurd over exaggeration. In addition, the campaigns failed to consult and apply adequate research, did not appeal to teenage sensibilities, failed to apply relevant social science theories, nor are they congruent with messages portrayed in mass media or state government legislation.
In Focus: Recent Anti Marijuana Advertising
The following will focus on recent marijuana campaigns, specifically, the advertisements that were created during the Bush presidency. Before President Bush appointed John Walters anti drug messages had focused on a variety of drugs, but once Walters was appointed he decided to focus on marijuana use. Ben Wallace-Wells reported that Walters dismissed scientific data that failed to find a significant connection between marijuana use and later use of other illicit drugs. Walters’ tenure as drug czar led to the creation of ads with a variety of approaches (4). Some ads are more effective than others, but according to Westat, Inc’s data have culminated in an overall failure (1).
In the past the ad campaigns have been ineffective because they relied primarily on scare tactics, focused on negative consequences, and used obvious exaggeration rather than focusing on issues important to adolescents. Ad campaigns focused on fear and negative consequences have been shown to often be counter productive (5). Furthermore, the research that provided the basis for recent anti marijuana ad campaigns was focused on self reporting by adolescents. Self reporting of substance abuse may be an inaccurate representation of the actual actions of teens (6,7). In addition, influences such as peer pressure, a desire to conform, and cynicism of the messages of adults may further distort self reported analysis (8). Brandweek conducted a series of focus groups in order to discover adolescents’ feelings on anti drug messages directed at their demographic. The adolescents reported that they wished for life like scenarios that were plausible in their own lives. The adolescents also expressed a desire for truth in advertisements. Brandweek’s focus groups, as well as National Research Council reports point to the reasons why the campaigns have failed (9,10). However, nine years after publication and one campaign failure later, the Above the Influence campaign is still putting forth comical and unrealistic advertisements to decrease adolescent marijuana use (1,11).
A Sample of the Advertisements
Three ads highlight approaches that have been continually unsuccessful. First, the “Stoners in the Mist” series available at AboveTheInfluence.com documents a jungle survey team researching the native habits of the not so elusive “stoner.” The series of public service announcements are outlandish, silly, unlike anything teens truly encounter, provide fodder for ridicule form media sources and potential contempt from their target demographic. Another ad shows a talking dog telling a high teen that he misses her as a friend. The talking dog insinuates that marijuana will make you hallucinate, which adolescent’s will recognize as untrue, deceptive, and consequently reject the desired premise of the ad that smoking marijuana will push you out of your peer group. Finally, a girl walks out of her house to find that pictures of her doing something wild, obscene, or embarrassing have flooded the internet and have subsequently ruined her life - because she “got high.” The ad attempts to use the popularity of social networking sites and the ability to spread data quickly to try to scare teens out of using marijuana. Once again, the claims are sensationalized and there is no mention of alcohol consumption which lowers inhibitions (11). Also, the plot is too simple to not draw the cynicism of the target demographic. In addition, the ads are at odds with other ads in the campaign which note that nothing bad is going to happen if you smoke marijuana other than wasting your life on a couch (12). The incongruent advertisements highlight the mixed messages which are extremely detrimental to the effectiveness of anti marijuana advertisement.
Mixed Messages
There are mixed messages between the federal government’s own advertisements, current laws regarding marijuana possession, and the message of the media (print, television, radio, movies and now the internet). The anti marijuana advertisements fail to consider the overwhelming and increasingly pervasive role of agenda theory in a web based culture. Agenda theory states that media outlets have a large portion of control over which messages will be related to the public and therefore largely influence which issues the public finds important (13). Increasingly, mainstream media outlets have aired programs challenging the government’s policy. Media sources such as ABC News, Salon, the Daily Show, Slate, the Washington Post, and the Huffington Post have all produced segments or articles that are contrary to the government’s anti marijuana agenda. The internet also provides adolescents with a portal to less mainstream media such as web logs and emergent web sites such as Digg, Reddit, and Plastic that provide a constant stream of messages often opposed to that which the federal government is trying to set forth. Furthermore, individual states and cities have proposed and passed legislation legalizing medical marijuana use as well as decriminalizing marijuana possession (14,15). The laws help increase confusion and distrust with the anti marijuana message from the federal government. With the increased importance pervasiveness of today’s varied media culture, pro or anti marijuana challenging messages can be easily spread through an adolescent’s social network.
Adolescents are subjected to a large amount and variety of messages every day. They are bombarded with advertisements and other social influences. The combination of media, rumors among social networks and peers, heavy emphasis on anti marijuana campaigns and severe penalties associated with marijuana may all push to internalize a message of mass marijuana use amongst teens when the numbers are not alarmingly high. Only 6.6% of 8th graders, 15.2% of 10th graders, and 19.8% of 12th graders surveyed by the NIDA had used marijuana in the past thirty days (16). Although communicative efforts have been shown effective at changing perceived norms, the advertisements perpetuate the norm of widespread marijuana use (17). For example, one Above the Influence ad depicts a teen driving around his high friends while informing the viewer how he’s still part of the group even though he does not smoke. The ad makes the point that remaining a vital member to your social group without smoking marijuana is possible. However, the ad fails because it perpetuates the perceived norm that smoking marijuana is the norm rather than the exception. Messages such as the one in the previous ad may become internalized. Internalization occurs when an idea, action, or norm is accepted and adopted by an individual. The internalization versus the absence of internalization, which Kelman referred to as compliance, is an important distinction. If a message is internalized the message need not be as strongly supported by an individuals referent group which includes peers, family, or significant others (18,19). For example, a perceived norm that is actually false may be perpetuated even though person’s social network does not support that norm (19). Perceived norms of high levels of marijuana use among the adolescent populations may be similarly perpetuated. The government has created advertisements that reinforce the perceived norm and help aid internalization of said norm. When the perceived norm of marijuana use is further reinforced by the messages of mass media the norm may become difficult to alter. Advertisements that reinforce a perceived norm is neither realistic nor beneficial to the goals of anti marijuana advertisements.
Thus far, the anti marijuana ad campaigns have failed to provide a consistent message that appeal to teens sensibilities and values that include the need to fit into social norms, conform to peer and social groups, and suspicion of adult messages. Studies have shown a significant link between exposure to illicit drug use in peer networks and use of illicit drugs (20). Yet, most ads fail to take exposure within peer groups into account. Certain ads have addressed the importance influence of social networks and social influences. One Above the Influence ad tried to address the issue of social networks and the influence of peers. The ad titled “S.L.O.M.” depicts a school which has a problem with kids sticking leaches on themselves as an analogy to marijuana use. The advertisement is meant to connect marijuana use with a completely absurd action, in addition to drawing on the adolescent’s desire to be an individual. However, the ad fails miserably in several ways. First, the ad affirms the perceived norm of widespread marijuana use. Secondly, the ad it misinterprets an adolescent’s want to be an individual in the context of his overall environment with an adolescent’s desire to be an individual while conforming to social norms within valued peer groups. Finally, the ad fails because it makes SLOMing look cool. The students SLOM in the bathrooms, hallways and even classrooms at school while befuddling and frustrating the adults which the adolescent’s so desire to rebel against. “S.L.O.M.” shows that you can be cool, attractive, fit in, and stick-it to the teachers by smoking marijuana.
Although the advertisement creators mistakenly portrayed marijuana use in a desirable light, they have advanced beyond focusing on negative consequences in ads. The “just say no” attitude is condescending to the perceived intricacies of an adolescent’s life (8,9). Past ads focused on the supposed horrors of marijuana use rather than relating to important factors in an adolescents life. Ads that tell adolescent’s that their marijuana habit is funding terrorism, or going to cause them to run over a little girl on a bicycle, or shoot their friend in the face in no way approach teens on their level.
In Summation: Failure and the Future
Anti marijuana advertisements aimed at adolescents must take into consideration a whole range of factors including peer networks, social norms, the media’s agenda, and adolescent’s perceived needs and desires. Addressing all of these issues simultaneously may be nearly impossible and fortunately for the public, but not for the NYADMC, the media’s agenda is largely out of their control. Unlike the Truth campaign which focused on rebelling against tobacco corporations while still showing the negative effects of cigarette smoke, anti marijuana advertisements lack the corroboration of overwhelming and consistent scientific data regarding the drug’s deleterious effects. However, the anti marijuana campaigns still have hope. Ads that focus on the important values of adolescent life – peer acceptance, social status, and conforming to social norms could be addressed more effectively. The Above the Influence campaign has shown promise and a cautiously favorable media reaction (21). However, many of the ads still sensationalize, and either do not address the core values of adolescents or do so in a manner that is comical to the point of satirizing itself (i.e. Stoners in the Mist). Although the advertisements have promise further research must be conducted in order to create cohesive messages that truly appeal to and effect the target adolescent demographic.
References
1. Westat, Inc. Evaluation of the National Youth Anti-Drug Media Campaign: 2004 Report of Findings, Executive Summary. Washington DC: Westate, Inc. 2006.
2. Grabmeier, J. New Anti-Drug Program Shows ‘Phenomenal Success’ by Focusing on Positives. Research Communications, OSU. http://researchnews.osu.edu/archive/antidrug.htm, 2006.
3. Palmgreen, et al., Television Campaigns and Adolescent Marijuana Use: Tests of Sensation Seeking Targeting. American Journal of Public Health. 2001; 91: 292–296.
4. Wallace-Wells, B. How America Lost the War on Drugs. In: Rolling Stone Magazine. Nov. 2007. http://www.rollingstone.com/news/story/17438347/how_america_lost_the_war_on_drugs
5. Varshavsky, T. Media Drug Prevention and Public Service Advertising: Evaluating The National Youth Anti-Drug Media Campaign. Tufts University, 2003.
6. Fan, et al., An Exploratory Study about Inaccuracy and Invalidity in Adolescent Self-Report Surveys. Field Methods. 2006; 18: 223-244 (2006)
7. Williams, R and Nowatzki, N. Validity of Adolescent Self-Report of Substance Use. Substance Use & Misuse. 2005; 299-311.
8. Hill, D. “Drug Money” Brandweek. 1998; 39: 20-27.
9. Desperately seeking solutions. Brandweek. 1998; 39: 29-32.
10. National Research Council. Policy on Illegal Drugs. What We Don’t Know Keeps Hurting Us. Committee on Data and Research for Policy on Illegal Drugs. Washington D.C.: National Academy Press, 2001.
11. Carleton College. Blood Alcohol Concentration. Northfield, MN. http://apps.carleton.edu/campus/wellness/info/alcohol/bac
12. National Institute on Drug Abuse. Pete’s Couch Advertisement. Washington, DC. http://uk.youtube.com/watch?v=2yfEvfJ9XAw
13. Carroll, C. and Combs, M. Agenda-setting Effects of Business News on the Public’s Images and Opinions about Major Corporations. Corporate Reputation Review. 2003; 6: 35-46.
14. Oregon Medical Marijuana Program (OMMP). Oregon, USA. http://www.oregon.gov/DHS/ph/ommp/, 2007.
15. O'Driscoll, P. Denver votes to legalize marijuana possession. USA Today; http://www.usatoday.com/news/nation/2005-11-03-pot_x.htm, 2005.
16. National Institute on Drug Abuse. NIDA InfoFacts. Washington, DC: National Institute on Drug Abuse, 2006.
17. Borsary, B., & Carey, K.B. Descriptive and injunctive norms in college drinking: A meta-analytic integration. Journal of Studies on Alcohol. 2003; 64: 331-341.
18. Kelman, H.C. Process of Opinion Change. Public Opinion Quarterly. 1961; 25: 57-78.
19. Lapinski, M., Rimal, R. An Explication of Social Norms. Communication Theory. 2005; 15: 127-147.
20. Kuntsche, El & Delgrande Jordan, M. Adolescent alcohol and cannabis use in relation to peer and school factors Results of multilevel analyses. Drug and Alcohol Dependence. 2006; 84: 167-174.
21. Stevenson, S. This Is Your Ass on Drugs: The New Case on Pot? It Makes You Lazy. http://www.slate.com/id/2150334/, 2006.

The Failure of the Minnesota ENABL Campaign – Monica Sawhney

2007-12-13T17:18:00.000-08:00

Introduction
In 1996 Congress passed The Personal Responsibility and Work Opportunities Reconciliation Act. While this act primarily concerned welfare reform, it also provided funding to states for abstinence only sexual education programs. These programs went on to be established through Title V of the Social Security Act. One such initiative created as a result of Title V was the ENABL (Education Now and Babies Later) campaign in Minnesota in 1998. It is a program targeted at youth and their parents or guardians throughout Minnesota. Its aims are to reduce adolescent pregnancy by reducing sexual activity and encouraging abstinence until marriage. The program teaches adolescents how to avoid involvement with sexual activity and how to open up the lines of communication with their parents (12).
The ENABL program in Minnesota focuses on teen pregnancy. Its initiative promotes the idea that abstinence is the best way to avoid teen pregnancy, using both a curriculum and family based approach. Youth are taught an in school curriculum revolving around the risk of teen pregnancy and STDs and are encouraged to use abstinence as their approach to these problems. The curriculum does not include information about the use of contraceptives. The ENABL campaign also aims at making parents more proactive. It provides resources and lessons for parents on how to discuss sex with their children. These resources are accessible online and in community centers (12).

Evaluation of ENABL
The ENABL campaign was evaluated in 2002, 4 years after the program was initiated. The analysis of the program was based on surveys determining attitudes toward sex and abstinence by students who had completed the curriculum. The results of the evaluation found that overall, the program had failed. The rate of students who were having sexual intercourse or those who said they would within the next 12 months almost doubled (9). The percentage of students who said they would talk to their partner about abstinence and avoid risky behavior fell. The rate of students who said they believed “sex was only something adults should do” also fell. The program did increase the frequency with which parents and children discussed sex. The analysis concludes with a recommendation that programs about sexual education would be more useful if they include information on both abstinence and safer sex (8).
Since the ENABL program was initiated, there has been no increase in the rates of teens abstaining from sex. An analysis of the program showed that the incidence of teen sex actually rose during this period of time. One of the biggest problems with this initiative is that it did not take many aspects of behavioral theory into account. The program did not take the Theory of Reasoned Action into account, neglecting to adequately address social norms and pressures adolescents may face. It also ignored Social Cognitive Theory by failing to address self-efficacy. These failures created a program that did not achieve the majority of its goals. By looking beyond the Health Behavior Model into other theories of behavior, the ENABL program may have been successful.

Failure of the Health Belief Model
A key problem with the ENABL program is that it is essentially based on the Health Belief Model. The Health Belief Model states that there are two conditions that must be met in order for a person to perform healthy behavior. The person has to believe they are susceptible to a problem that is severe, and that there are benefits to taking action against this problem without too many barriers (5). By teaching students that sex can lead to pregnancy and STDs, instructors assumed that teens would accurately assess the perceived susceptibility and severity of having sex. They also assumed that by teaching them to abstain from sex, teens would consider abstinence beneficial and free of many barriers. Even if youth were to perceive premarital sex in this way, research has shown that the Health Belief Model does not necessarily predict behavior (4). The statistics of the ENABL program speak for themselves. Even though adolescents were learning about the risks involved with having sex, the incidence of those who did engage in sex or said they would within one year nearly doubled. While the susceptibility and severity of pregnancy and STDs were presented to the teens as relevant to them, many did not perform the behavior.

Incorporating the Theory of Reasoned Action
The ENABL program did not account for the Theory of Reasoned Action, which may explain why the students did not respond to the curriculum. The Theory of Reasoned Action is based on the idea that a person’s intentions to carry out a behavior are based on their attitudes toward that behavior and their perception of subjective norms in regards to the behavior (5). Subjective norms are social standards in society that people see as prevalent and common. This idea of subjective norms is very important, especially when an initiative is directed at youth. Adolescents are also more susceptible to social norms than adults. They are less likely to perform a behavior if they are worried about how others will see them. They also have a stronger desire to fit in with their social groups, and therefore are more likely to adapt to these social norms. Norms are dictated not only by peers, but also the media. Both of these aspects have a strong influence on youth. These social norms often do not reinforce the idea of abstinence; many times they do the exact opposite.
Based on previous statistics, the idea of premarital sex has permeated throughout American society; it is therefore a social norm. Studies have shown that exposure to media with sexual content can result in an increase in sexual behavior. The perception of friends’ attitudes toward sex is also predictive of a teen’s own behavior (1). The ENABL program must focus on these subjective norms and attitudes toward behavior if it wants youth to practice abstinence. The approval of premarital sex is so widespread in the U.S. that it is hard to overcome these social norms. This campaign fails because it is unable to show adolescents that premarital sex is not a norm for teens in society. By changing the perceptions of the social norms, students may be able to change both their attitude and intention toward the behavior.
One study seems to have utilized the Theory of Reasoned Action in relation to HIV-risk reducing behavior in men who are HIV-positive. This experiment created an intervention in which men were educated and taught skills to reduce HIV-risk behavior in the context of social norms, self-efficacy, and communication in-group sessions. After the study, men who had participated in these sessions were more likely to use condoms with their sex partners. They were also more likely to divulge their HIV status and to inquire about a potential partner’s status. By addressing social norms and communication, this initiative was able to increase desired behavior (10). The ENABL campaign could have similar results if it was able to effectively change the way teens viewed the norms surrounding sex. If adolescents believed that many of their peers abstained from sexual activity, they may find it easier to do the same.

The Role of Self-Efficacy
Another problem with the ENABL campaign is that it does not address the issue of self-efficacy. Self-efficacy is a concept central to Social Cognitive Theory. It states that a person is not likely to change their behavior if they do not believe that they have the ability to do so. A person must have confidence in their capabilities to both do the behavior and to rise above challenges that may attempt to hinder the behavior (5). Recent studies reflect the pressures and realities faced by many youth today to engage in premarital sex. 47% of high schools students in the U.S. have had sexual intercourse by the time they graduate (13). It has been shown that by age 20, 75% of Americans have had premarital sex (6). While the ENABL program specifically targets youth, it is clear that sex before marriage is very prevalent in the U.S. today. Through the media, friends, and family, teens are constantly exposed to the idea of having premarital sex. In the face of this pervasiveness, youth may come to believe that premarital sex is the norm and in fact, unavoidable. If the ENABL program wishes to maintain its abstinence only policy, it must come up with effective ways to convince teens that they have the ability to abstain and to overcome the pressures not to abstain that frequently occur.
Numerous studies have shown that self-efficacy is a successful technique in helping people achieve a behavior. One such study involved predictors of condom use among African American college students. It found that self-efficacy was the most important factor related to condom use and safer sexual practices within the past six months. It was also related to an increasing frequency of condom use and overall lifetime condom use (2). Another study was done comparing the susceptibility to sexual risk-taking behavior and self-efficacy in Sierra Leonean students. It found that higher self-efficacy was related to rejecting sexual advances, which lead to significantly less sexual risk-taking behavior (3). These studies demonstrate the necessity for self-efficacy in order to deter risk-taking behavior. Teens who feel that they are actually able to abstain from sex will be much more likely to do so than those who feel like they cannot.

The Need for a Comprehensive Program
While the ENABL campaign is supposed to reach youth throughout Minnesota, it could also have had the effect of alienating certain adolescents in their programs. The initiative has one simple message, based on heterosexuality, and a curriculum built around that focus. The program has not been created in a way that addresses anything other than heterosexuality. Teens who may be homosexual, transgender, or of any other sexual orientation do not receive relevant information. They are not able to relate the messages in the curriculum to own their lives (11). An abstinence only initiative is also not relevant to teens who are already sexually active. Adolescents who have engaged in sexual behavior will not learn anything from the program since it does not apply to their actions or intentions. The program also does not teach youth methods for decreasing risks if they are engaging in sexual behavior. Teens who are sexually active may not be aware of the various options available to prevent the spread of STDs and lower the risk of pregnancy. As a result, they may continue to have sex but without proper protection (11).
Recent studies have shown that comprehensive sex education can be more effective than abstinence only education, especially with teens who are sexually active. One study compared results between an abstinence only program and a safer sex program in African American adolescents. The results showed that teens who were already sexually active engaged in less sexual intercourse after the program if they were in the safer sex group, as opposed to in the abstinence only group. Teens in the safer sex group were also more likely to use protection when they did have sex (7). By alienating certain groups of students from their program, the ENABL campaign could not reach all youth, as was its intention. By not adequately addressing the needs of all teens in its program, it may have even put them at a greater risk.

Conclusion
The ENABL campaign of Minnesota failed because it did not take certain behavioral concepts into account. If the campaign had utilized the Theory of Reasoned Action, it may have been more successful in changing teens’ views of social norms toward sex. If it had relied more on Social Cognitive Theory, it could have addressed the issue of self-efficacy. An emphasis on this concept could have enabled teens to believe that they were capable of abstaining from sex. The campaign also focused only on heterosexual adolescents who had not yet engaged in sexual activities. The curriculum did not address those who were already sexually active or not heterosexual, potentially missing a significant portion of teens. The curriculum’s focus was also strictly on abstinence, and not a comprehensive sex education course. If the campaign had taken these concepts into account, it may have been much more successful. Various studies have shown that social norms and self-efficacy play an important role in changing behavior. It is also more efficient for a campaign to be all encompassing, rather than focusing on particular groups of people that emphasizes one course of action. Taking these theories into account could have lead to ENABL’s success.

References

1. Brown, Jane D., and Kelly Ladin L'engle. "Sexy Media Matter: Exposure to Sexual
Content in Music, Movies, Television, and Magazines Predicts Black and White Adolescents' Sexual Behavior." PEDIATRICS 117 (2006): 1-18-1027. 10 Nov. 2007 .

2. Burns, Myron J., and Frank R. Dillon. "AIDS Health Locus of Control, Self-Efficacy forSafer Sexual Practices, and Future Time Orientation as Predictors of Condom Use in African American College Students." Journal of Black Psychology 31 (2005): 172-188.

3. Carter, Robert T. "The Effects of HIV/AIDS Knowledge, Sexual Self-Efficacy and
Susceptibility on Sexual Risk-Taking Behavior in Sierra Leonean Students of Higher Education (Immune Deficiency)." DigitalCommons@Columbia. 1997. Columbia University. 12 Nov. 2007
.

4. Choi, Kyung-Hee, Gust A. Yep, and Eugene Kumekawa. "HIV Prevention Among Asian and Pacific Islander Men Who Have Sex with Men." AIDS Education and Prevention 10 (1998): 19-30.

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

6. Finer, LB. "Trends in Premarital Sex in the United States, 1954-2003." PubMed. 2007. National Center for Biotechnology Information. 12 Nov. 2007 .

7. Jemmott, John B., Loretta Jemmott, and Geoffrey Fong. "Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents." Journal of the American Medical Association. 279 (1998): 1529-1536. 12 Nov. 2007 .

10. Randall, Lm, and Mk Lapinski. "Prevention Options for Positives: Evaluation of a Theoretically Based Prevention Intervention Targeted to HIV-Infected Men Who Have Sex with Men." Gateway. July 2003. National Library of Medicine. 12 Nov. 2007 .

11. Santelli, John, and Mary A. Ott. "Abstinence-Only Education Policies and Programs: a Position Paper of the Society for Adolescent Medicine." Journal of Adolescent Health 38 (2006): 83-87. 12 Nov. 2007 .

12. Say Not Yet! to Sex. 2003. Minnesota Education Now and Babies Later. 11 Nov. 2007 .

13. "Sexual Risk Behaviors." Healthy Youth! 22 May 2007. National Center for Chronic Disease Prevention and Health Promotion. 10 Nov. 2007 .

Critique of the National Diabetes Education Campaign - Shreya Patel

2007-12-13T17:08:00.000-08:00

An epidemic is defined as a disease with a strikingly high incidence rate that supercedes the expected rate of occurrence (1). Few may realize that the Centers of Disease Control and Prevention have termed the chronic condition, Diabetes, as an epidemic in the United States (2). To address the epidemic, the National Institute of Health and the Centers of Disease Control and Prevention have launched a massive public health intervention, The National Diabetes Education Program (NDEP). NDEP consists of educational campaigns which focus on diabetes prevention and management (3). Although its campaigns are informative, the intervention is weak because it seems to rely on the concepts of individual behavior change, behavioral intention, and narrow social networks. These principles are reflective of three popular theoretical models used by public health practitioners to design interventions. Specifically, NDEP seems to reflect the incorporation of the Health Belief Model (HBM), Theory of Reasoned Action (TRA), and Social Network Theory (SNT) (4). However, diabetes has a multi-causal societal origin (1). Therefore, an intervention which seems to be based on individualistic principles is unlikely to generate a successful outcome.
Individual Behavior Change - HBM
The HBM states that preventative behavior is contingent upon one’s perception of the susceptibility and severity of an illness and the perceived benefits and barriers of taking preventative actions. If one realizes that the benefits outweigh the severity of an illness, then the individual will make an effort to prevent it. Therefore, interventions based on the HBM are informative, with the objective of making individuals aware of their vulnerability and the greater benefits of prevention. NDEP’s campaigns seem to reflect these principles (4). One of NDEP’s campaigns entitled: “Be Smart about Your Heart, Control the ABCs of Diabetes” emphasizes that the management of blood glucose, blood pressure, and cholesterol will reduce diabetes induced strokes and heart attacks. Like HBM interventions, this campaign emphasizes the greater benefits of disease management as opposed to the negative consequences of inaction (5). Also, one of the campaigns entitled “Small Steps. Big Rewards. Prevent Type 2 Diabetes,” provides self assessment tools to help one determine if he or she is pre-diabetic. This reflects the HBM component of perceived susceptibility (5). HBM interventions also promote self-efficacy, an individual’s faith in his or her ability to take action. The principle of self efficacy was added to the HBM in 1988 after social learning theories became influential. (4). It seems that self efficacy is integrated in a campaign entitled: “We Have the Power to Prevent Diabetes.” This segment encourages susceptible populations that they have the ability to take control over their health. Fact sheets and motivational articles are provided to induce confidence. (6). However, NDEP’s basis on what seems like HBM principles is not the best strategy to induce behavior change.
By focusing on preventative education, NDEP does not seem to integrate social context. Because they are a strong determinant of peoples’ behaviors, social factors must be taken into consideration (1). For example, studies indicate that African Americans with a lower socioeconomic status (SES) are more likely to prematurely develop diabetes (7). Therefore, any intervention to reduce the prevalence of diabetes must address the conditions associated with different SES gradients. To elaborate, NDEP advises individuals to eat a healthy diet, but this may not be feasible for those who have lower SES and reside in areas where grocery stores are scarce, as seen in low income African American communities (1). Furthermore, evidence indicates that HBM public health interventions that do not consider social factors fail to attain their mission. For example, a study to examine the shortcomings of a HIV intervention among Asian and Pacific Islander American Men exemplifies that the intervention was not as successful because it failed to take into consideration the effects of families, communities, and racism(8). The analysis indicates that simply education was not sufficient and that future interventions must integrate social factors (8). Similarly, NDEP campaigns are primarily educational. This similarity reflects why the NDEP lacks potential in succeeding.
Do Intentions Lead to Behaviors?
It appears that NDEP’s tactic is to also modify behavioral intention, the central concept of the Theory of Reasoned Action (TRA). The TRA states that an action is derived from behavioral intention, which is shaped by attitudes and subjective norms. Behavioral intentions are then translated into behavior. (4). NDEP’s campaigns seem to attempt to change attitudes towards healthy behavior. For example, one of its awareness campaigns is entitled: “Small Steps. Big Rewards.” It emphasizes that one does not have to work excessively hard to engage in a healthy lifestyle. Instead small steps such as simply talking with one’s doctor about diabetic risk are beneficial. Another small step is to reduce snack intake (9). It seems that the campaign attempts to modify individuals’ attitudes towards healthy behavior in order to make them believe that prevention does not require overbearing effort. As a result, the campaign seems to attempt to positively shape behavioral intentions, in hopes people will intend to carry out healthy behaviors. (9). However, this may not be the best technique for at risk populations that reside in close-knit communities.
NDEP’s design appears to assume that after learning how easy it is to be healthy, one will intend to do so. Then, once the intention is established, will behave accordingly. However, research indicates that intentions do not translate into expected behavior (10). One may intend to engage in healthy behaviors but cultural influences may intervene and prevent the behavior from occurring. Research indicates that one’s intentions are highly influenced by cultural contexts. A published review of the patterns of diabetes in Great Britain indicates that dietary habits, which stem from cultural beliefs, could help explain why in particular, Asian Americans, are vulnerable to developing diabetes (10). In this example, the group of Asian Americans, may intend to eat healthy but due to their customary dietary habits, the intention may not translate into the healthy behavior. Similarly NDEP seems to excessively focus on behavioral intention without integrating cultural contexts. Therefore, past research implies that NDEP’s campaigns will most likely be ineffectual.
Narrow Social Networks
By focusing on the patient provider and student-teacher networks, NDEP seems to incorporate Social Network Theory (SNT). SNT interventions focus on developing projects that will suit the specific characteristics of a given social network (4). NDEP has resources for providers which advise them on how to consult diabetic patients and how to practice efficient disease management. In addition, there is a guide for school personnel on how to provide aid to students with diabetes (5). However, NDEP’s focus on these networks is narrow. Like all individuals, diabetic people interact with larger social groups other than providers and teachers. Important networks include peers, religious groups, professional groups, and ethnic communities. (4) For an individual, another social group’s influence may take precedence over the advice of a single doctor or teacher. Therefore, NDEP should address broader networks because individuals are influenced by a variety of greater groups.
Clarification of Critique
This paper is not a critique of the theoretical models. It is the critique of NDEP’s supposed concentration on certain individualistic principles to resolve a problem that seems to stem from structural causes. The models are not ineffective, for they have many useful strategies. However, the models’ strategies are not directly transferable to diabetes interventions. With regards to their positive attributes, the HBM is well structured in outlining perceived susceptibility, severity, benefits and barriers (4). Vulnerable populations must be initially informed of these components as a first step to influencing them to make a rational decision. However, informative campaigns are not sufficient. The TRA attempts to positively shape behavioral intention. Such an influential component is also necessary in order to make an impact on the target population. The TRA also takes into consideration subjective norms, which are the beliefs of social groups and how they influence intentions (4). However, NDEP seems to fail to incorporate this social component in its campaigns. Lastly, as the SNT states, interventions should target other audiences that the target population interacts with. This is also a very effective strategy in an intervention because it targets other social groups who may have an influence on the at risk populations (4). But heavily focusing on patient- provider and student-teacher interactions, NDEP seems to fail to take into consideration broader networks such as cultural and religious communities. Overall, the theoretical models do have effective principles, but given the complex societal context associated with diabetes, they may not be as applicable.
Resolution
A significant debate has been ongoing in the field of social and behavioral sciences regarding whether to shape interventions to target individuals or social groups (11). Many have come to the resolution that a combination of social and individual level efforts will be the most effective. In a study examining the shortcomings of an HIV intervention targeting AIDS among Asian and Pacific Islander men, a conclusion was reached to integrate individual and environmental components to design a more effective program (8). Nonetheless, NDEP will encourage individuals to make healthier decisions. However, as studies on similar interventions have indicated, the incidence of diabetes will remain high as long as social factors are not taken into consideration (8). Consistent education, promotion, and motivation will most likely not translate into healthy behavior. In order to be truly effective, NDEP must undergo reform.
References
1. Weitz R. The Sociology of Health, Illness, and Health Care. Belmong, CA: Thomson Wadsworth, 2007.
2. Diabetes Data and Trends. Atlanta, GA: Centers of Disease Control and Prevention. http://apps.nccd.cdc.gov/ddtstrs/default.aspx.
3. National Diabetes Education Program. Bethesda, MD: Department of Health and Human Services. http://www.ndep.nih.gov/about/about.htm.
4. Edberg M. Essentials of Health Behavior. Boston, MA: Jones and Bartlett Publishers, 2007.
5. National Diabetes Education Program. Bethesda, MD: Department of Health and Human Services. http://www.ndep.nih.gov/diabetes/pubs/NDEP_Overview_Brochure.pdf.
6. National Diabetes Education Program. Bethesda, MD: Department of Health and Human Services. http://www.ndep.nih.gov/campaigns/SmallSteps/SmallSteps_powertoprevent.htm
7. Gaillard, TR, et al. The Impact of Socioeconomic Factors on Cardiovascular Risk Factors in African Americans at Risk for Type II Diabetes. Implications for Syndrome X. Diabetes Care. 1997; 20: 745-752. http://care.diabetesjournals.org/cgi/content/abstract/20/5/745.
8. Choi, K. HIV Prevention among Asian and Pacific Islander American Men Who Have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention 1998; 10:19-30.
9. National Diabetes Education Program. Bethesda, MD: Department of Health and Human Services. http://www.ndep.nih.gov/campaigns/SmallSteps/SmallSteps_getrealhtm
10. Hawthorne, K, et al. Cultural and Religious Influences in Diabetes Care in Great Britain. Diabet Med 1993; 10(1):8-12.
11. Marks, D. Health Psychology in Context. Journal of Health Psychology 1996; 1(1):7-21.

Public Health Intervention Failures in Reducing the Incidence and Mortality Rates of Prostate Cancer Among African-American Men- Anthony Agosto

2007-12-13T11:27:00.000-08:00

Prostate Cancer is a disease that develops in the prostate, a gland in the male reproductive system, which occurs when there is a mutation within the cells of the prostate leading to an abnormal multiplication. Prostate Cancer is the second leading cause, after lung cancer, of cancer deaths of men in the United States, and the third leading cause of cancer deaths among African-American men. Although mortality rates for prostate cancer in the United States have declined for all racial/ethnic groups, there are studies showing that the incidence and mortality rates are higher among African-American men than any other racial/ethnic group. The purpose of this paper is to critique Public Health intervention failures in addressing certain aspects of three important health models; The Health Belief Model, Ecological Model and Theory of Reasoned Action, which have led to both higher incidence and mortality rates of prostate cancer among African-American men.

Failure in Addressing Certain Aspects of The Health Belief Model

According to the oldest and most widely used individual model, the Health Belief Model, individuals act upon reasoned behavior, whereby if they are able to perceive that positive outcomes outweigh negative barriers, then they are most likely to engage in preventive health action. Public Health interventions, based on the Health Belief Model, have failed to address how African-American men will overcome their fear of being diagnosed with prostate cancer, which is the greatest barrier that has limited their participation in preventive measures.

There is direct correlation between a fear of diagnosis as such, a corresponding reluctance to engage in preventive action such as DRE (Digital Rectal Examination) and PSA (Prostate Specific Assay) and higher incidence and mortality rates among African-American men. According to various studies, African-American men are most susceptible among racial/ethnic groups to a fear of diagnosis that is so consuming that they are likely to drop out of screening programs, if they participate in them at all (1). In addition, it is evident that the embarrassment and stigma associated with having a doctor insert a lubricated glove into the anus to check for prostate abnormalities during a DRE has led African-American men choose private prostate cancer appointments or self care, over mass screening programs, and to seek prostate-related complementary and alternative medicines. In order to be most effective, Public Health interventions for prostate cancer using the Health Belief Model need to be aware of how powerfully fear and embarrassment influence patients in their willingness to take precautionary measures to monitor their health periodically.

Failure in Addressing Certain Aspects of The Ecological Model

Behavioral decisions are influenced by many individual factors and by the environment which, when taken together, form the Ecological Model. Within this model, the important factor of preventive knowledge has not been considered when implementing public health interventions for prostate screening among African-American men. According to recent studies, there have been recommendations by professional organizations to inform men about known risks and potential benefits of screening, and even so, there continues to be limited knowledge among men, particularly African-American men (2). As stated in the American Journal of Public Health (AJPH) “ There is an uncertainty between what African-American men know and what they ought to know in order to make an informed decision about screening”. This uncertainty was addressed by coming to an understanding of the basic facts that all men should know in order to make an informed decision regarding preventive health measures, moreover, there is also limited knowledge that screening test may reduce prostate cancer mortality rates, but that they do occasionally result in false-positive, negative results. Twenty-two percent of African-American men believed, wrongly, that DRE (Digital Rectal Examination) was a blood test for prostate cancer (3). It is therefore important to focus on this target group, first by highlighting the essential facts they must know about screening that will hopefully demystify the process and destigmatize the experience of screening or treatment, leading to greater efficacy.

Failure in Addressing Certain Aspects of The Theory of Reasoned Action

Limited faith among African-American men in the efficacy of screening or treatment has been another deterrent in taking preventive health measures for prostate cancer. There is no scientific evidence to prove that screening tests for prostate cancer do in fact decrease the incidence of mortality. Public Health interventions have difficulty convincing African-American men to take preventive actions in light of this culture of stigmatization and fear. The Theory of Reasoned Action, an individual-oriented theory, incorporates an individual’s attitude regarding preventive measures based on expectations of (limited) positive or negative outcomes. Without evidence confirming that the benefits of screening outweigh the discomfort of the experience for many, it is unlikely that men’s attitude will shift towards taking preventive health action for prostate cancer more seriously. Research has suggested that faith in the efficacy of screening or treatment correlates more frequently with a willingness to take preventive action for prostate cancer (4).

Public Health interventions have failed to consider those aspects of the health models; The Health Belief Model, Ecological Model, and Theory of Reasoned Behavior, which may explain higher incidence and mortality rates of prostate cancer among African-American men. In order to develop effective public health interventions for prostate cancer among this target group, there needs to be further research and funding readily available for such interventions, informative material distributed that would be self-explanatory regardless of patients’ educational background and effective communication between providers and patients. Most importantly, there needs to be continuing effort to promote more informed decision-making, so that men can overcome hesitation they may have about screening and be more fully engaged in the prevention and treatment of prostate cancer.

References

1. Roumier, X. Azzouri. Adherence to an annual PSA screening program over 3 years for brothers and sons of men with prostate cancer. European Urology, 45, 280-286.

2. Denmark-Wahnefried W, Strigo T, Catoe T. Knowledge, beliefs and prior screening behavior among blacks and whites reporting for prostate cancer screening. Urology. 1995; 46:346-351.

3. C.Y. Chan Evelyn, MD Vernon, W Sally, PhD, T O’Donnel Frederick, MS. Informed Consent for Cancer Screening with Prostate-Specific Antigen: How Well are Men Getting the Message? The American Journal of Public Health 2003; 93:779-784.

4. Consedine S Nathan, PhD, Horton David, Ungar Tracy, PhD, Joe. K Andrew, MD, Ramirez Paul, PhD and Borrel Luisa, PhD. Fear, Knowledge, and Efficacy Beliefs Differentially Predict the Frequency of Digital Rectal Examination Versus Prostate Specific Antigen Screening in Ethnically Diverse Samples of Older Men. The American Journal of Public Health 2007; 1:29-42.

5. Edberg Mark. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Washington, DC, 2007.

Advance Provision of Emergency Contraception and its effects on Prevention of Unintended Pregnancies- Diego Martinez-Vasquez,M.D

2007-12-13T11:18:00.000-08:00

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution—the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and—thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control (1).

The most recent cycle of the National Survey of Family Growthdemonstrates that, despite a reduction in unintended pregnanciesamong adolescents, college-educated, and higher-income women,49% of all pregnancies in 2001 (3.1 million) were unintended. Of these unintendedpregnancies, 42% ended in abortion. Furthermore, 48% of unintendedpregnancies occurred in women who were using contraception duringthe month of conception (2, 3).

Unintended and teenage pregnancies (49%) are major public health concerns in the United States (see above). Emergency contraception (EC) is used to prevent pregnancy after failure of a contraceptive method or after unprotected intercourse. EC can prevent pregnancy when taken within 120 hours of unprotected intercourse (4). Several types of EC regimens exist, including an estrogen-progestin combination (sometimes called "combined regimen" or "Yuzpe regimen"), levonorgestrel alone (plan B), and mifepristone.

Some clinical trials have been studied the benefits of providing EC in and advance manner (AEC) to facilitate females in their use (4). The idea begin was to determine if when giving AEC can reduce the rates of unintended pregnancy when compared to regular EC. These clinical trials did not showed any benefit in reducing unintended pregnancies in females who received AEC compared to EC.

Contraceptive counseling. A Healthy People 2010 objective is to increase the rate of intended pregnancy to at least 70% of all pregnancies (5). One approach to reducing rates of unintended pregnancy is providing contraceptive counseling during primary care visits. The National Survey of Family Growth defines birth control counseling as “counseling about whether to use birth control methods, how to get them, information about different methods, and how they are used.

EC for a woman, who has unprotected intercourse,requires several steps to reduce the risk of unintended pregnancy.She must perceive that her risk of pregnancy is real and mustbe motivated to prevent it. She must be aware that a post-coitalcontraceptive method exists that could reduce her risk of conception.She also must have specific knowledge about how to obtain itand time its administration. She must have access to it, includinga place to get it, a way to pay for it, and the time to investin getting it. Any of those steps can be barriers to actuallyusing emergency contraception after unprotected sex.

One of the current and likely been a very significant barrier to making EC part of routine contraceptive counseling is that providers are unlikely to initiate discussions regarding EC or offer an advance prescription (AEC). One particular barrier to the provision of EC information may be lack of a standardized manner in which to deliver information and the option for EC. Major health organizations and groups, such as the World Health Organization, American College of Obstetrics and Gynecology and the International Consortium for Emergency Contraception, have guidelines regarding key points to be included in EC counseling. However, despite increases, knowledge is still limited and EC provision does not occur in a majority of visits(6).

Contraceptive counseling is defined as a form of interpersonal (as opposed to public) communication. It includes information-giving as well as opportunities for clients (patients) to express their concerns, values, and preferences and to ask questions. Information may be provided through multiple communication channels, and using multiple channels may have a synergistic impact, with written or video material reinforcing oral communication. In health care settings, counseling may include face-to-face discussions between the patient and her provider; group discussions; peer counseling; telephone hot lines or information resource lines; print or video materials made available in information kiosks or resource centers; and telephone or mail follow-ups or reminders. In the case of contraceptive counseling, the goal is to empower women to prevent unintended pregnancy (1, 2, 6).

Counseling is conceived as having three dimensions: 1) exposure refers to whether or not any counseling occurs through any communication channels; 2) content refers to the information imparted during counseling; and 3) personalization refers to the degree to which women’s needs and preferences are addressed. Little research on U.S. populations has addressed the relationship between counseling and contraceptive adoption or continued use (7).

The plausibility of the hypothesis that counseling is associated with contraceptive use is supported by evidence that provider counseling influences women’s use of other preventive tests and interventions. Studies of mammography screening find that one of the most common reasons reported by older women for not obtaining mammograms is that their physicians did not recommend it.

Theories of health behavior attempt to explain how individuals adopt or fail to adopt health-promoting behaviors (e.g., exercise, smoking cessation, use of screening mammography) or maintain those behaviors over time. Theories such as the health belief model, the theory of planned behavior, and the transtheoretical model provide a basis for examining the relationship between contraceptive counseling in the health care setting and contraceptive behavior. These theories recognize that knowledge alone is not sufficient to motivate individuals to adopt health-promoting behaviors and that factors such as values, expectations, and social influences also are important determinants of health behaviors. In addition, these theories draw attention to intervening steps between the acquisition of information and health-promoting behavior, such as building self-efficacy and forming behavioral intent.

The function of counseling in the health care setting can provide information and help clarify the options available to the individual, thus empowering individuals to make informed decisions with respect to their health. Counseling can help alleviate fears about specific options or reduce anxiety about social consequences of options, thus addressing some of the nonrational components of health decision making. Providing information and enabling individuals to cope with their concerns help build self-efficacy for behavior change. Counseling also can help individuals move from one stage of behavior change to another—for example, from the precontemplation stage, in which there is no intent to take action, to the contemplation stage, when an intent is formed to change behavior in the near future—or to maintain a health behavior once adopted.

Increase risky sexual behavior, increasing the risk of pregnancy or sexually transmitted diseases. Several studies have looked into AEC in effort to circumvent some of these obstacles. (8, 9). The studies showed that there is no evidence that suggests that providing AEC causes adolescents to have more unprotected intercourse or less consistent contraceptive use. Indeed, contrary to many health care providers and the public's views, the AEC group participants reported significantly higher condom use. The problem with this studies is that these studies failed to showed reduction in unintended pregnancies when compared to standard access situations (defined as routine contraceptive counseling, provision of information on emergency contraception, or emergency contraception on request) (4).

These trials share a common weakness. Reported information on use of emergency contraception, frequency of unprotected intercourse, and changes in contraceptive patterns was of unknown validity. Since these self reports lacked objective verification, this information should be viewed with caution. Objective evidence indicates that self reports on use of contraceptives other medications are inaccurate, and that self-report of unprotected intercourse is inferior to other ascertainment methods. Some degree of underreporting of pregnancies may have occurred in both the advance provision and control groups in these trials, particularly those trials using only self-reported data. Unintended pregnancies terminated by induced abortion are routinely underreported. However, results from the trials relying on pregnancy testing were consistent with results from the trials using self-reports of pregnancy(4).

None of the adequately powered trials showed difference in pregnancy rates, despite increased use, multiple use and faster use of AEC (4).

This conclusion conflicts with earlier optimistic projections of the potential public health impact of improved access. This intervention could have failed because the way women perceives pregnancy risk or because concerns about side effects, and inconvenience(10, 11).

Health care coverage or insurance. Although men and women have some similar challenges with regard to health insurance, women face unique barriers to becoming insured. More significantly, women have greater difficulty affording health care services even once they are insured. On average, women have lower incomes than men and therefore have greater difficulty paying premiums. Women also are less likely than men to have coverage through their own employer and more likely to obtain coverage through their spouses; are more likely than men to have higher out-of-pocket health care expenses; and use more healthcare services than men and consequently are in greater need of comprehensive coverage. Moreover some females don’t have coverage of prescription contraceptives. The direct medical costs of unintended pregnancies were US$5 billion in 2002 and direct medical cost savings due to contraceptive use were US$19 billion (12, 13).

In summary, advance provision of emergency contraception does not decrease unintended pregnancies nor increase sexual risking behaviors or sexual transmitted diseases. In order to decrease unintended pregnancies using advance provision of emergency contraception, routine and consistent counseling by health providers (physicians, pharmacists, nurse practitioners and physician assistant) in emergency contraception has to be provide to any female who is sexually active. Health behavior models like the health belief model, the theory of planned behavior, the transtheoretical have to be use in combination to assess the specific needs of each patient. Health coverage and insurance has to be taken in account when prescribing or recommending AEC. Overall not having access to medical coverage directly impacts the availability of physicians and health care providers. Moreover new programs have to be implemented to increase access of this population to health care.

Finally more studies need to be performed to asses the use of advance provision of emergency contraception. These studies need to be conducted looking at counseling and behavior model as described above. Nevertheless new programs that facilitated easy access to AEC for uninsured sexually active females have to be implemented through out the federal or state level.

References:

1. Benagiano G, Bastianelli C, Farris M. Contraception today. Ann N Y Acad Sci 2006;1092:1-32.

2. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23 2005(25):1-160.

3. Martinez GM, Chandra A, Abma JC, Jones J, Mosher WD. Fertility, contraception, and fatherhood: data on men and women from cycle 6 (2002) of the 2002 National Survey of Family Growth. Vital Health Stat 23 2006(26):1-142.

4. Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev 2007(2):CD005497.

5. Services DoHAH. Healthy People 2010; 2007 October.

6. Petersen R, Albright JB, Garrett JM, Curtis KM. Acceptance and use of emergency contraception with standardized counseling intervention: results of a randomized controlled trial. Contraception 2007;75(2):119-25.

7. Pisaniello ML. Importance of counseling patients about contraception. Am Fam Physician 2007;75(5):624; author reply 624.

8. Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004;17(2):87-96.

9. Raymond EG, Stewart F, Weaver M, Monteith C, Van Der Pol B. Impact of increased access to emergency contraceptive pills: a randomized controlled trial. Obstet Gynecol 2006;108(5):1098-106.

10. Adler NE. Contraception and unwanted pregnancy. Behav Med Update 1984;5(4):28-34.

11. Moreau C, Bouyer J, Goulard H, Bajos N. The remaining barriers to the use of emergency contraception: perception of pregnancy risk by women undergoing induced abortions. Contraception 2005;71(3):202-7.

12. Lindrooth RC, McCullough JS. The effect of Medicaid family planning expansions on unplanned births. Womens Health Issues 2007;17(2):66-74.

13. Trussell J. The cost of unintended pregnancy in the United States. Contraception 2007;75(3):168-70.

Does an Apple a Day Keep the Doctor Away? – Vanessa Holley

2007-12-12T10:11:00.000-08:00

Does an Apple a Day Keep the Doctor Away? The Failure of the 9 a Day Campaign to Reduce the Risk of Diet Related Diseases in African Americans.

The Center for Disease and Control reports that everyone should consume fruits and vegetables because they contain essential vitamins and minerals needed to protect against chronic diseases such as cardiovascular disease and certain cancers (1). Vitamin A and C, fiber, and potassium are just some of the many nutrients found in fruits and vegetables that may help protect people against these chronic diseases. Studies suggest that those who do not eat fruits and vegetables daily are twice as likely to get cancer and increasing the intake of fruits and vegetables can reduce cancer rates by more than 25% (2). Eating fruits and vegetables is important, but it is the amount you consume that theoretically reduces the risk of certain diseases.

According to the National Institute of Health, on average people consume 2.9 servings of fruits and vegetables daily (2). As an association was clear between fruit and vegetable intake and chronic diseases, the National Institute of Health and the National Cancer Institute developed a program, 5 a Day for Better Health, to increase the awareness of eating more fruits and vegetables daily to reduce the risk of diseases. The 5 a Day program recommends everyone to eat at least 5-9 fruits and vegetables daily to reduce the incidence of chronic diseases. People were encouraged to maintain a healthy lifestyle, diet regularly, and consume at least 5 fruits and vegetables daily to reduce the risk of diseases. As the campaign progressed and continued to address the issue of fruit and vegetable intake and chronic diseases, small populations of Americans were still disproportionately affected by diet related and chronic diseases, especially African American men.

African American men suffer disproportionately in numerous health conditions. African American men have the highest rates of cancer and mortality rates among any other ethnic group (3). They develop diabetes and high blood pressure very young and suffer severe side effects (3). They are also twice as likely to get diabetes than whites. Overall, African American men are 140% more likely to die from cancer than whites (4). African Americans are severely affected by diet related diseases, yet they have the lowest consumption of fruit and vegetable intake overall (4). On average, African American men eat 3.1 fruits and vegetables daily (4). The 5 a Day campaign became concerned with the high rates of diseases among African American men so they extended their program to a 9 a Day campaign, a program designed for African American men to eat 9 fruits and vegetables daily to reduce their risk of diet related disease. The 9 a Day campaign needs to ultimately change the eating habits of African American men to reduce their risk of disease. The U.S. Department of Health and Human Services and the National Cancer Institute 9 a Day Campaign to reduce chronic disease among African American men fails in its attempt to recognize factors that influence eating habits.

Accessibility of Fruits and Vegetables

The 9 a Day campaign does not take into account accessibility of fruits and vegetables. African American men will be unable to eat at least 9 fruits and vegetables daily if they are not readily accessible to them. Geographic location of healthy food stores, lack of transportation and affordability of fruits and vegetables are main components that prohibit African American men from having access to fruits and vegetables.

The campaign fails in its’ attempt to understand how the local environment can influence consumption of fruits and vegetables. Low-income neighborhoods are made up of a disproportionate number of African Americans and predominately white neighborhoods tend to have higher average incomes. Lower income neighborhoods have fewer healthy food stores compared to higher income neighborhoods and therefore is not accessible to many African American men (5). Higher income neighborhoods have 5 times more supermarkets compared to only 8 % of low-income communities made up of African Americans living near at least one supermarket (5). Supermarkets carry more variety of fruits and vegetables than local grocery stores and would be a resource of obtaining needed fruits and vegetables. As more supermarkets continue to migrate to the suburbs and more independently own grocery stores are being built in low-income neighborhoods, a greater proportion of African American households will not have access to essential fruits and vegetables. It is impossible for African American men to eat 9 fruits and vegetables daily if resources (healthy food stores and supermarkets) are not readily available within their specific neighborhoods.

Transportation would also have to be readily accessible to get access of fruits and vegetables needed. If healthy food stores are not located in African American neighborhoods, African Americans would be forced to travel across town to get the food they need. Those without a car rely on public transportation to get around. What father of 3 would waste 2 hours of their time to get on the bus with children in tow to get the necessary 9 fruits and vegetables needed to maintain a healthy lifestyle. Whites have 3 times greater access to transportation than African Americans and have a better chance of purchasing the food they need (5). Those with limited transportation are forced to shop nearby in grocery stores where supermarkets are generally smaller in size, carry a narrower range of products, and are usually more expensive (6). The program cannot be effective unless African American men have access to purchase the fruits and vegetables needed to reduce diet related diseases.

African American men will be unable to eat at least 9 fruits and vegetables daily if they cannot afford to purchase these items. Increasing fruit and vegetable consumption is very difficult because consumer food choice is closely linked to food costs (7). Fruit and vegetable availability decreases in the home as the costs per serving for fruits and vegetables increases (7). As prices steadily rise for fruits and vegetables, African American men will not be able to afford them. The 9 a Day campaign expects all African American men to eat 9 fruits and vegetables daily, but they can eat that many servings if they are unable to afford these items. There is also an association between income and fruits and vegetables. Lower socioeconomic status is linked to the consumption of fruits and vegetables because many cannot afford to purchase fruits and vegetables. There are more African Americans considered within the lower socioeconomic class than whites, which would affect African American men food consumpti0n even more.

Lower income households spend little on fruits and vegetables because they allocate their limited income to other items they deem desirable such as housing, clothing, and other foods (8). Many African American men find that providing for their families essential needs is more important than buying 9 fruits and vegetables a day. A father would first pay rent to provide a roof over his families head than to purchase numerous fruits and vegetables. Although they make less than higher income households, lower income households spend more of their income on food (5). Food is a big part of their budget and they would prefer to buy the necessary food items to feed their family. Many consider fruits and vegetables as an additional expense, and would prefer not to exchange usual food items for healthier options (8). The 9 a Day campaign cannot expect African American men to buy 9 fruits and vegetables if they do not have enough disposable income to actually buy the food items. The campaign cannot be effective unless the men can actually afford to purchase the fruits and vegetables needed to reduce diet related diseases.

Thus, the 9 a Day campaign does not take into account accessibility of fruits and vegetables to African American men. Lower income neighborhoods made up of a disproportionate number of African Americans have fewer healthy food stores. Those without access to transportation are unable to go to the store and buy the recommended fruits and vegetables. Also, many African Americans are unable to afford these items due to their limited incomes, and may opt to prioritize other resources over fruits and vegetables.

Cultural Norms and Fruits and Vegetables

The 9 a Day campaign does not take into account differences in cultural norms of African American men. African American men will not eat 9 fruits and vegetables daily if it is not part of their normal diet. Many cultural differences exist between food consumption and Social Expectations Theory explains how it would be hard for African Americans who are used to consuming the same foods to change their daily eating habits.

African American families purchase fruits and vegetables based on preference, cultural significance and family traditions (7). Food patterns vary according to regional and social influences of each community. African American food patterns have drawn on eating habits of several cultures including seventeenth and eighteenth century West African culture associated with American slavery and post-civil war rural South (9). Slaves had limited access to ingredients and preparation tools to cook food (9). Fruits and vegetables were not readily accessible to many slaves. As a result, many traditional African American families do not eat fruits and vegetables as there food patterns are similar to that of slaves. Many other cultures such as the Haitian community have a high intake of meat, rice, plantains, and beans. Those of Caribbean descent have a high intake of jerk and curry chicken, rice and peas, and sugar cane. Different foods associate with different cultures. Many of these cultures simply may not know how to prepare the fruits and vegetables you find here. These cultures are used to preparing the food of their specific culture. These cultures also have these specific items because they are cash crops of these countries and are easily available to the people of that land (9). Those that migrate to the states are still going to consume those foods of cultural significance. There is deep ethnic variation in the consumption of fruits and vegetables.

The 9 a Day campaign does not consider cultural differences in African American men. The Social Expectations Theory in which behavior is dictated by social norms shows how cultural differences in the consumption of food will change how people feel about consuming 9 fruits and vegetables daily. Those who are used to consuming the same foods within their specific culture will not want to change their daily behavior. Those cultures are not susceptible to change if they are use to their specific social norms. The 9 a Day campaign would have to change the cultural norms of a community in order to change their specific eating habits. The 9 a Day campaign falls short in changing the daily norms of these deeply enriched cultures.

Thus, the 9 a Day campaign does not take into account differences in cultural norms of African American men. Ethnic variations exist between eating habits and fruit and vegetable consumption may not be a big part in their diet. The Social Expectations Theory helps to explain that if the men are use to their specific social norms then consequently they will not be inclined to change their daily diet.

Self-Efficacy and Fruits and Vegetables

African American men will not eat fruits and vegetables if they do not think they can consume 9 fruits and vegetables daily. Social Cognitive Theory helps to address this failure of the 9 a Day campaign. Social Cognitive Theory provides a framework for understanding what influences the mens’ human behavior through self-efficacy.

Within the theory, self-efficacy is a person’s notion that they are capable of performing certain behaviors (10). Those who believe they have the power to change will ultimately change their behavior. People are more inclined to take on a task if they believe they can do it. Likewise, those who believe they cannot change are not inclined to perform a specific task. In Social Cognitive Theory, perceived self-efficacy is a key determinant in changing and inflicting behavior (10). The problem with the 9 a Day campaign is that it does not take into account self-efficacy as a means of changing behavior. African American men will not eat fruits and vegetables if they do not think they can consume 9 fruits and vegetables daily. Many African American men may find that eating 9 servings a day an unattainable goal (11). Simply put, 9 fruits and vegetables are a lot to eat in one day, especially if a person works a 9-5 job and takes care of their children. People may find that they have no time to eat so many fruits and vegetables and opt not to eat any fruits and vegetables all together. Studies indicate that men appear to need increased confidence in their ability to include fruit in their diets as they consider and commit to such a change (11). The 9 a Day campaign fails to recognize the actual ability of these men to change their diets to include 9 fruits and vegetables. Also, accounting for accessibility and affordability, African American men will find it even harder to eat 9 fruits and vegetables. Those who face the barriers to fruit and vegetable access and affordability are discouraged from pursing a healthy behavior according to the Social Cognitive Theory (11). Increased consumption of fruits and vegetables is associated with high levels of self-efficacy (12) and the 9 a Day campaign fails to boost people’s perception that eating 9 fruits and vegetables is an achievable goal. The 9 a Day campaign should just focus on the importance of consuming fruits and vegetables versus mandating 9 fruits and vegetables daily to achieve a healthy lifestyle. Requiring 9 fruits and vegetables seems unattainable to many.

Thus, the 9 a Day Campaign does not take into account self-efficacy as a means of changing behavior. African American men simply do not think that they can consume 9 fruits and vegetables daily. 9 fruits and vegetables is a lot to consume in one day and many African American men find this an unachievable goal.

Conclusion

Overall, the U.S. Department of Health and Human Services and the National Cancer Institute 9 a Day campaign to reduce chronic disease among African American men fails in its attempt to recognize factors that influence eating habits. The 9 a Day campaign does not consider accessibility of fruits and vegetables. A systematic geographic difference exists between those who simply do not have access to healthy food stores and supermarkets. Accessibility is an issue when many do not have transportation to healthy foods stores and supermarkets. Many also simply cannot afford to purchase numerous fruits and vegetables. The 9 a Day campaign does not consider cultural norms of African American men. Ethnic variations exist between eating habits and fruit and vegetable consumption may not be a big part in their diet. The 9 a Day campaign also does not consider self-efficacy as a means of changing behavior. African Americans simply do not believe that they can eat 9 fruits and vegetables daily. The 9 a Day campaign will continue to be a failure unless these factors that influence eating habits are recognized. The 9 a Day campaign can become effective if they work to change the underlying social conditions that cause differences in access, cultural differences, and motivation.

REFERENCES

1. Centers for Disease Control and Prevention. Fruits and Veggies Matter. Atlanta, GA: Centers for Disease Control and Prevention. http://www.fruitsandveggiesmatter.gov/benefits/index.html

2. Produce for Better Health Foundation. 5 a Day for a Better Health Program

Monograph. Wilmington, DE: Produce for Better Health Foundation. http://www.pbhfoundation.org/pdfs/pulse/research/5adayresearch/NCImonograph.pdf

3. The University of Texas MD Anderson Cancer Center. Cancer Wise. Houston, TX: The University of Texas MD Anderson Cancer Center. http://www.cancerwise.org/June_2003/display.cfm?id=D9F10E7A-FCE4-4AF6-9329DF2B425D18D6&method=displayFull&color=green

4. US Department of Health and Human Services. HHS News. Washington D.C.:

http://www.nih.gov/news/pr/apr2003/nci-24.htm

5. Roux A., Moreland K., Wing S. The Contextual Effect of the Local

Food Environment on Residents’ Diets: The Atherosclerosis Risk in Communities Studies. American Journal of Public Health 2002; 92:1761-1767.

6. Krebs-Smith S., Kantor L. Choose a Variety of Fruits and Vegetables

Daily: Understanding the Complexities. The Journal of Nutrition 2001; 22:487-501.

7. Ard J., Fitzpatrick S., Desmond P., et al. The Impact of Cost on

the Availability of Fruits and Vegetables in the Homes of Schoolchildren in Birmingham, Alabama. American Journal of Public Health 2007; 97:376-372.

8. Blisard N., Jolliffe D., Stewart H. Low-Income Households’

Expenditures on Fruits and Vegetables. Agriculture Information Bulletin 2004; 792:1-2.

9. Klassen A., Shankar S. Influences on Fruit and Vegetable Procurement

and Consumption among Urban African-American Public Housing Residents, and Potential Strategies for Intervention. Family Economics and Nutrition Review 2001; 13:34-46.

10. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall,

1977.

11. Betts N., Greene G., Hoerr Sharon., et al. Self-Efficacy, Perceived

Benefits, and Weight Satisfaction Discriminate Among Stages of Change for Fruit and Vegetable Intakes for Young Men and Women. Journal of the American Dietetic Association 2002; 102:1466-1470.

12. Barbeau E., Dubowitz T., Stoddard A., et al. The Influence of

Social Context on Changes in Fruit and Vegetable Consumption: Results of the Health Directions Studies. American Journal of Public Health 2007; 97: 1216-1227.

Promoting Abstinence—Unsuccessful among Teenagers and Government’s Public Health Failure to Educate – Crystal Warren

2007-12-12T07:25:00.000-08:00

One of the biggest problems and fears American society faces today is sexual activity among the adolescents because of the behavior’s risky nature and the possible consequences like pregnancy and sexually transmitted infections (STIs). Even though rates of teenage pregnancy and birth have declined in the United States (US) since the 1990s, American teenagers still have the highest birth rate and one of the highest rates of STIs compared to their peers in the industrialized world (1). Experts in the public health community believe these statistics relate to the quality of sex education the youth receive today. One form of sex education teaches abstinence and contains additional information on safe sex practices by, for example, providing condoms and explaining its proper uses. On the other hand, there are also education programs that are strictly about abstinence-only-until-marriage. In 2002, both federal and state governments spent about $1.5 billion on a wide variety of contraception promotion and pregnancy prevention programs for teens and more than one-third of that spending went specifically towards funding contraceptive programs for the same age group. However, abstinence programs received only $144 million that year; so for every dollar spent on encouraging abstinence, the government spent $12 to promote contraception (2). Thus, lack of a sufficient investment into abstinence-only education programs has contributed to their failure in reducing STI and pregnancy rates among teenagers in the US. Abstinence-only has been a failure because of the improper framing of the issue (Framing Theory) in addition to flaws in its marketing tactics to teenage targets (Marketing Theory) and over reliance on social networks to change behavior (Social Network Theory).

Sexual activity connotes risky behavior, and the adolescence, constituting pre-teenagers and teenagers (ages 10-19), often model behaviors of risk-taking. Clinical psychiatrist, Lynn Ponton states that all teenagers take some risk as a normal part of growing up. Risk-taking is the tool an adolescent uses to define and develop his or her own identity (3). They like to experiment, try new things, satisfy their curiosity, and above all, rebel; it is all a part of their nature and growth. However, the decision to engage in sexual activities is a choice that teenagers can make. Even though, in the end, they are responsible for their own actions, parents and the government still feel obligated to protect their children.

According to the online campaign 4Parents.gov, a government-affiliated promoter of abstinence, telling the youth to wait until after marriage is the best answer to dealing with the problem with teenagers and sex. Delaying sexual activity is what will protect them and reduce putting their health at risk. As a national public education campaign, 4Parents.gov serves as an information guide for parents to attain the necessary skills and facts to help their children make healthy choices and steer away from risky ones. It encourages every parent to talk to the adolescents who are most prone to participating in sexual activities (4). To facilitate these discussions, the website provides three categories of information for parents: talking about waiting, youth behaviors, and sexual development and reproduction. The website also presents a national media campaign video, which emphasizes the importance of parents talking to their children about sex. Although all of these features of the 4Parents.gov campaign appear to be a productive government strategy to address the nation’s problem with teenagers having sex and pregnancy, it has largely been a failure. The campaign’s attempts to indirectly influence adolescent sexual behaviors and decisions through parents are largely ineffective because information on it may apply to some people and not to others. In addition, 4Parents.gov makes assumptions and misconceptions, based on social and behavioral science principles, about parents’ perceptions and beliefs about sex and their teenage children.

Framing a guide that only some, not all, can use
The 4Parents.gov is a failed campaign because of how the government frames the issue for the public. In this way, there is selectivity for who can use the guide and apply it to parents’ personal lives when talking to their teens. Without properly framing the problems in sexual activity among the adolescents, there is minimal chance for a change in behavior at the social level, especially when the website is addressing parents for behavior change among their children. Sex and abstinence is an issue about teenagers that pertains to all parents because at some point, every child will reach puberty. According to the Framing Theory, how one frames an issue influences behavior because it affects how people respond to it. Effort is devoted towards shaping the public’s views on health issues and the power of these campaigns is revealed in often contentious battles over what information should be presented (5). In 4Parents.gov, the government structures its arguments around its own values regarding sex and abstinence rather than helping parents incorporate their own values. For example, for parents who have a child that is sexually active, they are told how to convince their teens to stop having sex by telling their children that they are “worth it” (4). But, there are no further suggestions for parents who do not convince their teen to stop being sexually active implying that these youth are not “worth it.” Instead of a parenting guide to promote abstinence, 4Parents.gov’s so-called advice for communication between a child and parent is merely a framework of parenting rights and wrongs in beliefs systems. Thus, the focus of the issue with teens and sex appears to shift into more of a parent concern at the individual level from what was thought to be a problem for teenagers at the group level.

The government shapes teenagers and sex as a problem for parents by emphasizing how parents are responsible for their children and the importance of voicing their expectations and values to them. Therefore, parenting the right information about abstinence is important. The Framing Theory shows how a group is different than a collection of individuals because a group can be affected at the same time in behavior. Even though 4Parents.gov claims to be a guide intended for all parents, it only addresses a select few because it has pro-life and anti-gay framing implications. The website suggests that for pregnant teenagers, adoption may be the best choice for the baby and the teen parents. It also states that abortions results in women saying that they feel sad and there are some who use more alcohol or drugs than before (4). Not only do these statements apply to some and not all females who receive abortions, but they leave no parental advice for people who are pro-choice. By advising adoption, there is no effect or any connection to supporting abstinence but merely political support for life. By not reaching out to the population of already pregnant female teens, they do not know the needed details to making healthy choices thereafter, another promise of the website.

The government labels teenagers, who are lesbian, gay, bisexual, and transgender, as an “alternative lifestyle” and proposes to parents the possible need of special counseling, like therapy. To Frank Floyd and Terry Stein, sexual orientation is not a matter of lifestyle but an aspect of gender identity (6). The 4Parents.gov fails to meet the unique needs of these parents and in effect, cannot offer a way for them to encourage abstinence among their children. Nevertheless, along with excluding parents of sexually active teens, the campaign leaves parents of already pregnant girls out as well as parents with children who are lesbian, gay, bisexual, transgender, and experimenting in sexual orientations. In this way, 4Parents.gov appears to be specifically for the select few who are parents of the nonsexual and heterogeneous youth, based on its framework. Thus, it gives no results in telling parents that teenagers should not be having sex. Giving advice always has its drawbacks; not everyone can apply it to their lives. Under the circumstances of unfit framing implications that only present parenting information for exclusive individuals instead of parents as a group, 4Parents.gov fails to provide a guide for all to use.

Unsuccessful marketing
The Bush Administration advertises the 4Parents.gov campaign in the media, but it still falls short in sending out its message of abstinence by misusing the Marketing Theory. Not only is it unclear who the target audience is in the commercial but it also contains confusing information which, in effect, could keep the campaign even further away from its intended goal. First, the commercial features a group of pre-teenagers and teenagers asking their parents to talk to them about sex and how if they do not talk to them, there are other ways to be informed (i.e. the internet and friends). As a result, the ideal choice is to talk with them personally on living healthy. Nevertheless, the use of the youth’s innocent voices and how it may touch a parent catches the audience however, as the commercial concludes, the narrator abruptly enters telling parents to talk to their children about not having sex until after marriage. This completely negates the original message in that it now misleads parents into thinking the whole purpose of this “talk” with their teenagers is to discourage them from having sex entirely instead of what they thought to be a promotion of healthier lifestyles, especially if their child engages in sexual activities. Also, parents initially may not know this is a message for them with all the youth talking; they may think it is a commercial for kids prompting them to change channels before it is over. The narrator encourages parents to go on its website for information but material on it may be more suitable for the adolescents making it unclear who the true intended target is in the campaign. For example, definitions of penis and vagina are rather elementary for an adult crowd possibly making the site look more appealing and interesting to the youth. Because the government is using parents to communicate with teenagers, its tactics give divergent results.

Marketing to parents, but presenting messages that educate teenagers does not work because there is no definitive target audience. According to the Marketing Theory, messages in advertisements should reflect what the public wants. Waiting until marriage to have sex is not necessarily a public consensus nor is it realistic because in truth, almost all Americans have premarital sex and take such behavior as the norm. By age 20, about 75% of people have had premarital sex (7). A statistic like this definitely questions the effectiveness of the campaign and brings doubt that promoting abstinence is even proper education. Therefore, a commercial with the core message like waiting until marriage is not the best advertising tool for promoting abstinence among the youth, especially when the statistical figure does not reflect it. The message also leaves adolescents, the biggest group among rebels, with nothing but even greater curiosity and more interest in sex. It does not help parents in communicating with their children either.

The Marketing Theory says that a campaign should find out what the public wants and mold its messages to fit the demand; similarly to social marketing, the promotion goal is voluntary but has to be presented as attractive in the sense of its costs and benefits (8). In this particular commercial, 4Parents.gov presents the goal of abstinence with “rewards” such as potential awkwardness between parent and child and confusion. Without personal incentives, not all adolescents want to talk to their parents about sex, a topic that can make them uncomfortable and embarrassed. Nonetheless, despite its efforts to market to either parents or the youth over the years, 4Parents.gov is still unsuccessful. As of 2005, nearly half (47%) of high school students had ever had sexual intercourse. Of approximately 19 million new STIs, almost half were among the age group 15-24. Lastly, for all pregnancies in 2000, 13% of them occurred among adolescents (9). With these astounding numbers, this proves the government’s needed improvement in its campaigning for abstinence, even if it is via a universal marketing tool like television.

Adolescents act on their own behalf
Promoting abstinence by way of the 4Parents.gov website does not work because it appears to rely and incorporate principles of the Social Network Theory. This theory assumes behavior changes on the social level, that is, depending on the people around and associated with the individual. The key to a social network, though, is the relationship between and among individuals and how the nature of those relationships influences beliefs and behaviors (8). Adolescents mostly belong to social networks including their family and friends because these networks play important roles in whether these individuals act in ways that are either risky or good for their health. Social networks determine whether someone adopts a certain behavior or not. In this case, the networks teenagers are associated with definitely affect how they act, but not necessarily in a positive way.

Besides their parents, teenagers’ greatest source of communication and a social life is with their friends and peers. At the most prominent age of “rebellion,” young adults are not expected to listen to their parents. Instead, they follow whatever is “in” and most popular among their own social networks of friends; the goal is to expand their circle of friends (10). Even if teenage friends influence each other, it is not necessarily the intentions of 4Parents.gov and that is to promote abstinence. The campaign should not rely on parents to influence their children’s behaviors because as a part of their nature, they will not listen. Also, not only do the youth feel embarrassed about talking about sex with their parents; they fear their parents are not open either and will constantly badger them. To avoid awkwardness and confrontation with parents, there is always education from entertainment, including music, television, magazines, and the Internet (11). However, the greatest source is their own friends because they know that their own peers are going through the same experiences. Adolescents are inclined to emulate their peers because it is how they gain desired feelings at their age, like intimacy, social status, and even sexual pleasure (12). Also, they hear typical reasons to do something, like “everyone is doing it.” Pressure to feel accepted and liked often leads teenagers to make risky choices and partake in dangerous activities, including having sex, only to prove themselves in society among others in their social networks. For the government to put responsibility and assume parents can single-handedly change teenage behavior—by simply telling them to wait until marriage—is thoughtless and shows weaknesses in its campaign. Using parents to manipulate their children is a bad idea because in the end, teenagers act on their own behalf, and not through others, especially their parents. After all, they are more inclined to be influenced by their social network of peers.

Conclusion
Campaigns that affect and address everyone’s sexual health have great potential to help people, especially the most vulnerable and innocent group like the adolescents, in adopting healthy behaviors. Successful abstinence-only programs are ones that can educate and help people make use of in hopes of changing the “teen sex epidemic.” However, with no declining numbers in teenage pregnancies, sexually transmitted infections, and simply the number of sexually active teenagers, a campaign like 4Parents.gov proves that perhaps influential abstinence-only programs do not exist. To promote a universal topic like abstinence is difficult and must be handled carefully because it relates to everyone and it starts at youth. This government-run guide for parents is ineffective and fails at improving the well-being of teenagers because it is not a tool for everyone and it makes an indirect attempt at addressing the true target: adolescents. Framing tactics, the media, and social networks all affect people; the way the Bush Administration used the three in their campaign sure was not to their advantage in behavior change. In this way, the site comes off to be rather insensitive and confusing. To make a change among the youth, there must be better ways to communicate and voice the ideal behaviors that not only improve their health but those in the future as well.

References
1. Advocates for Youth. Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact. Washington, DC: Advocates for Youth, 2004.
2. Pardue M.G. Government Spends $12 on Safe Sex and Contraceptives for Every $1 Spent on Abstinence. Backgrounder of The Heritage Foundation 2004; 1718: 1-23.
3. Ponton L. The Romance of Risk. Mothering Magazine 1998.
4. United States Depart of Health & Human Services. 4Parents.gov. Washington, DC: HHS. http://www.4Parents.gov.
5. Rothman A.J. and Salovey P. Shaping Perceptions to Motivate Healthy Behavior: The Role of Message Framing. American Psychological Association 1997; 121:1, 3-19.
6. Floyd F.J. and Stein T.S. Sexual Orientation Identity Formation among Gay, Lesbian, and Bisexual Youths: Multiple Patterns of Milestone Experiences. Journal of Research on Adolescence. 2002; 12:2.
7. Warner J. Premarital Sex the Norm in America. WebMD Medical News. 2006. http://www.webmd.com/sex-relationships/news/20061220/premarital-sex-the-norm-in-america.
8. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.
9. National Center for Chronic Disease Prevention and Health Promotion, Division of Adolescent and School Health. Sexual Risk Behaviors. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2007.
10. Irvine M. Survey illuminates teen social networks. USA Today. 2007.
11. MacNeil J. Parents and Teens Find it Hard to Talk about Sex. Village Life News. 1996.
12. Habib L. Why Do Young Teens Have Sex? WebMD Medical News. 2006. http://www.webmd.com/news/20060614/why-do-young-teens-have-sex.

Why “Buzzed Driving” is not “Drunk Driving”: A Look at a Misleading Driving Under the Influence Campaign – Amber Solivan

2007-12-12T07:21:00.000-08:00

Alcohol related motor vehicle accidents account for approximately 40% of all motor vehicle deaths. This is a prime public health concern as an additional 18,000 deaths would be prevented if drivers did not drive while intoxicated. Men that are involved in a motor vehicle accident are twice as likely as women to be intoxicated. Persons aged 21 to 34 comprise the highest percent of persons driving under the influence however men aged 18 to 21 reported driving under the influence more frequently than any other age group. Additionally 159 million people self-reported driving while intoxicated however only 1.4 million drivers were arrested for this offence (1,2).

The effects of alcohol on driving safety were not studied in the United States until the 1930’s. Initial observations were made in 1934 by Heise about how alcohol impairs driver judgment and overall safety; however, it was not until 1968 that the US Department of Transportation and National Highway Traffic Safety Administration (NHTSA) began reviewing alcohol-crash associations and initiating ways to try to prevent alcohol related vehicle crashes (3). Over time many different campaigns have been used to educate and prevent alcohol related car accidents and deaths. In 1992 the US Department of Transportation and the NHTSA began the most historic and well known anti-drunk driving campaign “Friends Don’t Let Friends Drive Drunk” (FDLFDD) (4). Although this campaign brought drunk driving levels to historic lows in the late 1990’s the incident of deaths from drivers with a BAC over the legal limit rose from 13,000 in 2004 to 15,000 in 2006 (3,5).

In response to the rise in drunk driving deaths the NHTSA commenced a new campaign in 2005, “Buzzed Driving is Drunk Driving” (Buzzed Driving). This campaign used public service announcements (PSA) on TV and radio as well as billboards. It is unclear exactly what the message was, but I believe the message is that if you feel “buzzed,” you are impaired and over the legal limit. Statistically significant data about the direct success of the campaign is not readily available however since 2005 there has been no change in the number of drunk driving accidents and there has been an increase in the number of drunk driving deaths. The campaign sought to build on the success of the FDLFDD campaign however it was a flawed public health intervention because of its failure to provide a clear and accurate message. The campaign also failed to account for social norms surrounding social drinking in the US population, especially among 21 to 34 year olds. Finally the campaign used properties of an inappropriate model.

Buzzed Driving Campaign Failed to Relate a Clear Message
An essential part of a public health campaign is that the target audience understands the message that is being conveyed. The Buzzed Driving is Drunk Driving campaign failed to relate a clear and strong message causing confusion and misleading the audience. The TV PSA used for this campaign consisted of two categories of people aged in their early twenties to their mid thirties. The first category is someone that is clearly over the legal limit and is shown moving with impaired motor skills, and acting uninhibited. The second category is someone that takes a few sips of a drink that is still half full and then picks up their car keys to drive home. The PSA is making the inference that the person taking that “last sip” from a partially full drink is “buzzed” and should not drive home, however because there are not multiple empty glasses shown and the drink that is being drank from is still half full the visual message being portrayed is that having any alcohol before driving is illegal, which is untrue.

When the NHTSA launched this campaign they sought to address the impaired driver with the message that if you have had enough to drink to feel “buzzed” or in any type of altered state than you are too impaired to drive (2). However neither the NHTSA nor any other organization has defined the feeling of a “buzz” for the population. The concept of a “buzz” is undefined but is a term used in popular culture to describe someone’s physical state in relation to impairment. Intoxication is measured by the amount of alcohol in your blood commonly referred to as a blood alcohol concentration or level (BAC). The BAC is a percent of alcohol in your blood stream measured by the weight of alcohol in a certain volume of blood at a certain point in time and reflects the amount of alcohol you consumed within 30 to 70 minutes (4). There is not a BAC to reflect a “buzz,” nor is there a certain level of impairment that coincides with a “buzz”. Research has shown that at a BAC of 0.02% an individual may experience a relaxed state and visual function may decline, while at a BAC of 0.05% the person may have exaggerated behavior and experience reduced coordination (4). However neither of these BACs and the resulting impairments was associated with a “buzz” in the campaign message. Therefore, the campaign is in essence leaving it up to the individual to determine their limits and their ability to drive, the campaign is not educating the audience. The audience already knows that drinking to intoxication can lead to impaired judgment possibly leading to motor vehicle accidents, arrest, or even death. They have been determining their own limits yet they have been choosing to drive with a “buzz”. Further these are consequences known by a rational population; however, someone who is impaired is not rational and therefore is unable to make these associations. If the issue being addressed by the campaign is actually “buzzed”= drunk than the social norm definition of “buzzed” needs to be changed by the PSA. If the issue being addressed by the campaign is actually “buzzed”= impaired and impaired=dangerous than the social norm of no drinking and driving must be changed by the PSA. Neither of these issues was addressed by the PSA.

Further misdirection of this campaign can be seen when researching the reactions of people after the campaign was launched. A popular legal blogger, Blonde Justice, made this statement on her blog, “The point of this ad campaign, I believe, is to draw the following line of thought: Buzzed Driving = Drunk Driving = Illegal...Therefore, Buzzed Driving = Illegal[…]It's a clear misstatement of the law…it is only illegal to drive while legally intoxicated.”(6) The Idaho Transportation Department misinterpreted the definition of impairment and interpreted the PSA similarly to the blogger as buzzed driving is illegal, they failed to clearly state the purpose of the campaign or interpret the word buzzed (7). A prominent news caster from ABC Laura Marquez, translated “impaired” as anyone with a BAC above 0.08% (8). Unfortunately this important message about impairment was lost on ineffective advertising and inconsistent messages. Different BACs lead to different levels of impairment, this important information was missing from the campaign and could have been used to strengthen or at least clarify its message.

Buzzed Driving Campaign Fails to Account for Social Norms
Consuming alcohol with friends and family is a social norm in this country and many other countries. The Buzzed Driving campaign makes the implication that consuming an alcoholic beverage and driving is equivalent to drunk driving. The NHTSA assumes that individuals at a social function where there is consumption of alcohol will perceive themselves as being at risk. This perception of individual risk contributes to the campaign’s failure to define “buzzed” for the audience and the audience’s failure to establish safer personal limits. Many people do not feel that they can or want to attend various social functions and not consume any alcohol because it is part of their social norm. Therefore because they do not desire not to drink they will most likely continue with the assumption that they know their limits and not pay close attention to how many drinks they have had. In the perceived threats theory an individual must feel that a particular behavior or action will be a threat to them. In this instance 159 million people drove under the influence and only 1.4 million were arrested in 2006 (1), even more people have at one point had a drink and driven and they have not had adverse consequences, therefore in this case the perception of danger must be changed for the behavior to change.

Social norms have a strong influence on how people behave. The relationship between social norms and drinking has been studied extensively. Multiple studies have been conducted and shown that people often overestimate the alcohol consumption of their peers which encourages an overall increase in their own alcohol consumption (9). The Buzzed Driving campaign does not address this social norm and is especially flawed due to the misleading visuals of the campaign. One PSA used depicts a man getting ready to leave a wedding. Among drinkers, it is a social norm to drink at a celebration, in this case a wedding where the social norm often includes a champagne toast. The misleading visuals of the PSA suggest that it is not safe to have a drink at a wedding and then drive home. The social norms would not agree with this deduction, as many people have had a drink and drove and not suffered consequences, and therefore this campaign fails.

In addition to effect of perceived alcohol consumption, research performed on college campuses across the country have shown that college students were more likely to drink and to drink to intoxication based upon the social event and celebration they were attending (10). Studies have also shown that the amount of drinking on campus can be decreased by distributing accurate information on the amount of alcohol that is actually consumed by the other students, which is frequently less than their peers expected (11). These social norms identified among college students may be applied to the social norms among the general population on a lesser scale where celebratory drinking is the practiced norm and as such individuals are not likely to feel the need or desire to deviate from this norm. Drunk driving statistics support this as 21 to 34 year olds that are still drinking to excess and driving which matches their college counterparts on these occasions.

Buzzed Driving Campaign Misuses of Models
The Buzzed Driving campaign used aspects of the health belief model (HBM) which incorrectly assumes that intention is a direct predictor of behavior. It also used the theory of planned behavior (TPB) which incorrectly focuses on rational and reasoned behavior by the individual. The HBM does not take into account influences on decisions such as learned behavior and perceptions surrounding drinking. The HBM also does not account for the social norms surrounding drinking previously discussed.

The principles the campaign uses from the HBM fail to account for the social influences and norms that surround individuals. Social influences include those influences and norms felt by society and by one’s peer group. As stated previously it is well documented that persons who perceive their peers as drinking heavily will they themselves drink heavily (12). Additionally it has been found that norms predict drinking; however, drinking does not predict the perceived norms (12). Therefore if the perceived norm is changed the behavior will change. The behavior will not change the norm.

The principles the campaign uses from TPB assumes that those who have been consuming alcohol will rationally consider their decisions. This model assumes a high level of rational thought by the individual which is contradictory to being under the influence of alcohol. Research performed by the NHTSA indicated that judgment becomes impaired with a BAC as low as 0.02%. The campaign takes for granted that an individual who is “buzzed” would be able to understand their level of impairment. This level of rational thought may be a reason that the FDLFDD campaign was so successful; the responsibility was in the hands of someone who was thinking rationally and not in that of the impaired.

Conclusion
The Buzzed Driving campaign potentially holds an important message to all drivers; although the intended message is unclear, it potentially holds that driving when you feel any effect of alcohol is impairment and is dangerous. The NHTSA was very successful in bringing to light the dangers of drunk driving; however the NHTSA’s “Buzzed Driving is Drunk Driving” campaign is a flawed public health intervention because it failed to convey a clear and therefore compelling message. This unclear message was compounded by the neglect to account for social norms surrounding drinking at social occasions. The campaign was also flawed because it used aspects of inappropriate behavioral models that lead to its lack of efficacy. It is unclear whether the NHTSA was trying to change the social norm of consuming any alcohol and then driving. This lack of clarity in message further negates the merits of this campaign.

REFERENCES
1. Centers for Disease Control and Prevention. Impaired Driving. Atlanta, GA. http://www.cdc.gov/ncipc/factsheets/drving.htm
2. National Highway Traffic Safety Administration. Traffic Safety Facts: 2006 Traffic Safety Annual Assessment – Alcohol Related Fatalities. Washington, DC: NHTSA’s National Center for Statistics and Analysis, August 2007.
3. US Department of Transportation. National Highway/Traffic Safety Administration. Alcohol and Highway Safety 2001: A Review of the State of Knowledge, 2001.
4. Ad Council. Drunk Driving Prevention. http://www.adcouncil.org/default.aspx?id=49
5. National Highway Traffic Safety Administration. The ABCs of BAC: A Guide to Understanding Blood Alcohol Concentration and Alcohol Impairment. Washington, DC, 2005.
6. Blonde Justice. Buzzed Driving is…Legal. No location, 2005. http://blondejustice.blogspot.com/2005/12/buzzed-driving-is-legal.html
7. Idaho Transportation Department. ITD reminds drivers that "buzzed" driving is drunk driving this St. Patrick's Day. Boise, Id: Office of Highway Operations and Safety, 2007.
8. Marquez, Laura. Buzzed Driving is Drunken Driving. ABC News.com, December 28, 2005.
9. Dunnagan, T., Haynes, G., Linkenbach, J, Summers, H. Support for Social Norms Programming to Reduce Alcohol Consumption in Pregnant Women. Addiction Research and Theory,August 2007; 15(4):383-396.
10. Glindermann, K., Wiegand, D., Geller, E. Celebratory Drinking and Intoxication. Environment and Behavior, 2007; 39(3): 352-366.
11. The Higher Ed Center. The Social Norms Approach: Theory, Research and Annotated Bibliography: What is the Effect of Correcting Misperceptions? Successful Interventions Utilizing the Social Norms Approach. August 2004. http://www.higheredcenter.org/socialnorms/theory/interventions.html
12. Neighbors, C., Dillard, A.J., Lewis, M.A., Bergstrom, R.L., and Neil, T.A. Normative Misperceptions and Temporal Precedence of Perceived Norms and Drinking. Journal of Studies on Alcohol, 2006, 67(2): 290-299.

Ten Thousand Steps a Day: An Overly-Simplistic Strategy to Increase Physical Activity – Sandy Askew

2007-12-12T07:12:00.000-08:00

Step counting has become a popular means for increasing physical activity. Several studies have used pedometers and step counting as a central component in physical activity and weight control campaigns and interventions (1-6), including those which urge participants to take 10,000 steps a day (7-11). The interest in these types of interventions has grown because walking seems like a simple exercise and monitoring steps doesn’t require large or expensive equipment. In fact, some pedometers are so affordable to produce, McDonald’s restaurants and Kellogg’s cereal company were able to give thousands away in adult happy meals and cereal boxes during their own pedometer campaigns (12-14). Despite this seemingly simple solution, half of all American adults don’t meet current recommendation of 30 minutes or more of moderate physical activity 5 or more days per week for a healthy lifestyle (15, 16). Evidence from intervention studies suggests that most people who try one of these walking programs will be unlikely to maintain it long term (8, 17, 18). Despite their simplicity, or perhaps because of it, these campaigns are not achieving wide spread success. In creating these step count programs, many intervention designers have limited their thinking to individual-oriented approaches to behavioral change which will continue to have limited success. Physical activity interventions focused on a step count recommendation are overly simplistic because they rely heavily on an individual-oriented approach and assume that by changing a person’s attitudes and intentions toward walking, they will change behavior. These interventions seldom consider more complex consider social and behavioral factors like social norms, competing behaviors and perceived behavioral control, which may have a greater impact on physical activity adoption.

Background: 10,000 Steps
One popular pedometer intervention recommendation is to take 10,000 steps a day. Based more on an advertising campaign than scientific research, the popularity of the 10,000 steps figure grew from “Manpo-kei”: the advertising slogan of a 1960’s pedometer which literally means “10,000 steps meter” (19). As the recommendation was not created through research, there was no formal theoretical model used to develop it. Nonetheless, the recommendation is clearly an individual-oriented approach urging each person to walk 10,000 steps a day for better health and focusing on creating positive attitudes about walking and its effects. Like some traditional models, including the Health Belief Model and the Theory of Planned Behavior, the 10,000 steps approach assumes that behavior will follow intention: If people adopt a goal of 10,000 steps a day, they will walk more to reach that goal (20). Like the theoretical framework of the intervention, the step goal did not originate in scientific evidence leaving it open to scientific inquiry and criticism. While the idea of walking 10,000 steps for wellness has spread throughout Japan and to other parts of the world, researchers have been attempting to find evidence to support it.

Is 10,000 Steps an Achievable Goal?
A growing body of research supports the idea of increased walking for health, although no clear consensus has developed regarding the figure of 10,000 steps per day. The Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) recommend that adults engage in moderate-intensity physical activities, like brisk walking, for at least 30 minutes on 5 or more days of the week (15, 16). Walking as a form of moderate exercise may reduce a person’s risk for cardiovascular disease, diabetes, hypertension certain cancers and obesity (21, 22). Some researchers have found the 10,000 steps recommendation to approximately match the CDC’s and ACSM’s recommendation (19, 23, 24) and that it could lead to improvements in glucose tolerance and lipid profiles, lower body fat and blood pressure as well as other health benefits (25-28). Yet other studies have reported that a 10,000 steps goal may be difficult for some people to achieve and maintain, even with 30 minutes of activity a day (23, 28, 29) and some evidence suggests fewer steps may be needed to achieve some health benefits (26, 30, 31). This raises questions about the impact of the figure of 10,ooo steps on a person’s self-efficacy and if it is wise to promote such a high figure if it is unnecessary or unrealistic. While 10,000 steps a day may be considered an easy to remember, concrete goal (19), if it is too high people may quickly grow discouraged with it or not adopt it at all. Further, if interventions don’t address other influences on self-efficacy and barriers to walking, even a lesser figure may be unattainable.

Although 10,000 steps interventions attempt to improve physical activity self-efficacy by focusing on a simple exercise behavior, they fail to account for an individual’s perceived behavioral control. Even if an individual wants to walk more, he may feel there are barriers beyond his control which prevent him from doing so. Features of the physical environment may serve as barriers to physical activity, including an activity as simple as walking (32-38). Urban sprawl, poor neighborhood aesthetics, poor street connectivity, high traffic, no sidewalks or poorly maintained sidewalks and no streetlights have all been found to have a negative association with walking activity (38-45). Concerns about neighborhood safety may also inhibit people from walking (33, 34, 37). The Theory of Planned Behavior postulates that a person’s attitude toward a given behavior, as well as his perceived and actual behavioral control, will help determine his intention to engage in that behavior (20). However, step count interventions often don’t address environmental barriers which may make a person feel that walking is unpleasant, difficult or even unsafe. Instead, these interventions focus on the simplicity of walking more without realizing that for many people it is not at all simple. On the other hand, some aspects of the environment may encourage walking. For example, the presence of nearby shops, parks, beaches and walking paths is positively associated with walking (39, 41, 45-48). A concept taken from ecological psychology explains that there are “behavioral settings”: places or situations which promote or discourage certain behaviors (38). Living proximal to parks and shopping centers may encourage walking activity through design: They lessen the perceived barriers to walking more. Alternatively, living near one of these settings may also lessen perceived barriers through social mechanisms by providing both social models and social expectations, or norms, to walk because other people are walking there. Unfortunately, these kinds of social influences are also seldom addressed in physical activity interventions built on step counts like 10,000 steps.

The Importance of Social Norms
Ten thousand steps interventions focus largely on the individual and fail to address social norms which may inhibit adoption of physical activity recommendations. According to the Theory of Planned Behavior an individual is more likely to adopt a behavior if it is supported by the norms of their social networks (20). “Nobody walks in L.A.” is an expression popularized by a song in the 1980’s (49), but more than that, it may be an expression of the social or cultural norms of a city and other places like it. A person who lives in a place where walking is not the norm, or is even seen as distasteful, will be less likely to walk. The social acceptability, or unacceptability, of the behavior has a direct effect on a person’s intention because he may feel he will be stigmatized or socially sanctioned for engaging in that behavior. The literature on the impact of neighborhood norms on walking behavior is limited, but some authors have described the influence of these norms through a “contagion” perspective where people are influenced by the behaviors of those around them, copying behaviors, whether they are positive or negative, and thereby creating acceptable norms in the neighborhood (50, 51). This perspective includes ideas presented in Modeling theory where people emulate the behaviors they see in other people, gaining self-efficacy vicariously by observing successful behaviors (20). It also includes aspects of Diffusion of Innovations theory where, as with the spread of some diseases, a few people may initially perform a behavior, but it slowly begins to spread (20). When it reaches a tipping point, it will spread rapidly through a population, becoming normalized. If a physical activity campaign could manipulate these norms and use theories like Diffusion of Innovations to their advantage, physical inactivity could become an oddity. Unfortunately, 10,000 steps and other step count interventions fail to address these norms. While it is easy to recommend that someone take a walk at lunch or use the stairs instead of the elevator, many people may be very uncomfortable deviating from the norms of their peers. They may feel self-conscious walking through a neighborhood where walkers are observed as unusual or the subject of suspicion. Unless interventions find a way to help participants beyond those feelings or to normalize walking, they will continue to have limited success.

Behavioral Principles and 10,000 steps
Step counting interventions fail to consider that although an individual may intend to walk more, competing behaviors may be given higher priority if they seem more equally or more rewarding. Perhaps essential to altering norms or changing individual behaviors is to understand and use basic behavioral learning principles to affect behavior. At the core of the Behavioral paradigm in psychology are the concepts of reinforcement and punishment. Reinforcement is anything which leads to an increase in the performance of a behavior and punishment is anything which leads to a decrease in the performance of a behavior (52). At any given time, a person has a nearly limitless repertoire of behaviors he can perform; however according to Behavioral principles, the behavior he perform s will likely be the one he perceives, consciously or not, to be most rewarding (53, 54). Step count interventions try to lower the costs of increasing physical activity by focusing on an exercise that, for most people, is physically easy to perform and to promote the rewards of better health. Unfortunately, while doing so they usually fail to address behaviors which may more attractive because they are supported by an individual’s attitudes, culture or social norms and perceived as more rewarding. For example in a qualitative study conducted by Airhihenbuwa et al., the cultural beliefs of African Americans about health were explored through a focus group (55). The study observed that the African Americans in the focus group seemed to value rest over exercise, believing it to be as important or more important to health (55). If one’s values conflict with the performance of a behavior central to an intervention, it is unlikely that behavior will be successfully adopted. If two behaviors are believed to serve a similar function, like promoting health or relieving stress, but one perceives one behavior, like rest, as somehow more beneficial or reinforcing, than the other behavior, like walking, it is likely he will chose to rest rather than to walk.

A major difficulty public health interventions have is that health behaviors don’t typically have strong or immediate reinforcers or punishers, so the psychological link between health and the health behavior is relatively weak. This means that other behaviors which are produce faster or stronger feedback are likely to win when they compete with health behaviors. To many people, playing video game, for example is more enjoyable than going out for a walk. Feeling sweaty or tired may seem more important to avoid right now than the possible risk of heart disease a long time from now (56). A person may fully intend to walk and increase their step count in order to lower their health risks, as some theoretical models like the Health Belief Model would predict (20), but that behavior may continually be prioritized under more instantaneously gratifying activities. To be successful, step count interventions would do better to try to pair other types of reinforcement with physical activity along with potential health benefits. Reframing exercise as social or exciting by combining it with other activities or encouraging group activity is one way to do this. The more potential a behavior has to be rewarding, the more likely it is to be adopted and continued.

Conclusion
Step count interventions have some undeniable strengths. They are simple and affordable and therefore can be implemented on a large scale. A 10,000 step goal is concrete and easy to remember and might match CDC and ACSM recommendations for physical activity for many people. For long-term or wide-spread adoption, however, these interventions, as usually presented, are too simplistic to have maximum success. To build on the strengths of these kinds of interventions, intervention and campaign designers need to address a wider range of behavioral determinants, including environmental, social and cultural determinants. They also need to draw on the knowledge of other disciplines like behavioral psychology to understand what motivates behavior and to push beyond creating intention into generating behavior change. By addressing social as well as individual components, step count intervention like 10,000 steps can take a multilevel approach to improving physical fitness and reach far greater levels of success than it will by depending on the simplicity of their goal setting alone.

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Don’t Hold Your Breath-Changes Needed in Lung Health Education- Rachel Hill

2007-12-12T07:04:00.000-08:00

The National Lung Health Education Program (NLHEP) is a group of professionals including doctors, respiratory therapists, and esteemed members of the American Association of Respiratory Care (AARC) who are dedicated to increasing the awareness of Chronic Obstructive Pulmonary Disease (COPD) across the spectrum of healthcare and the general population. They utilize pamphlets, speaking engagements, and documented research to help further their goal. I am going to argue that the NLHEP has failed in its goal to create a successful program of intervention and early detection of COPD in its early stages among the population at risk, and to increase awareness of COPD within the general public or among healthcare professionals. The NLHEP has also been unsuccessful in raising awareness among primary care physicians about the use of simple spirometry testing as a tool for early detection and diagnostic criteria of COPD. And focus even less on early intervention of those at risk for COPD. This is the primary method to which this institution states it uses to achieve its goals of increasing awareness, early intervention, and early diagnosis of COPD. Their goals of increasing awareness and promoting early screenings, while great ideas, are not being executed in the best possible methods.

The NLHEP campaigns have traditionally not focused on any specific population. Their target population as stated in the mission statement is “all smokers, former smokers, and people who are regularly exposed to environmental tobacco smoking or occupational exposures” as well as, “physicians, all health care professionals, patients and the public” (6). The population target is just too broad and expansive with each group requiring specific needs in order to have any form of success within each target group. Physicians require a more medical message of screening and diagnosis using statistics and peer reviewed studies. The general population message needs to focus more on awareness and risk factors. By trying to figure out the best most understandable message for each group instead of focusing on one single message that is either too elementary or too complex, they would be more successful in having more people being aware of COPD in the dimension that makes the most sense for each group. For Example: A person with no medical training does not need (or want) to know what the specific diagnostic numbers in the spirometry testing formally point to the diagnosis of COPD. Nor does a physician need someone telling them what COPD stands for and what diseases encompass COPD.

Based on Social Marketing Theory which is basically figuring out what people want and understand and tailoring the message to that target population. We can not deliver a message to physicians in the same manner as we would address the public. Physicians require a different language and tone in order to capture their attention (generally more scientific and statistical) than the general public which has little (if any) medical training and varying educational backgrounds. Not only does each group have specific requirements regarding message delivery, they also have different outlooks about lung health (2, 7). Physicians are generally ready and able to promote lung health, while the general population does not see lung health as an overt problem until symptoms arise. This is partly shown by the number of late stage diagnoses of COPD and emergency room visits for shortness of breath by the general public whom if diagnosed earlier would be better managed (8). Among people aged 45-54 years 32% had an unscheduled emergency doctor’s visit for their COPD and 27% among the same population had emergency room visits for COPD. Had these people been diagnosed earlier they would have been better managed and not needed so many emergency services. COPD is not getting diagnosed in this population who is most at risk until they exhibit such severe symptoms it warrants emergent trips to a physician or the ED. This is proof that the word about COPD is not out in public and the message is obviously not clear, people continue to remain in denial of COPD until it is too late.

People generally lack a self-efficacy around their lung health status, especially the smokers. They tend to feel that the damage is already there and they can do nothing to change it. There is a nihilistic attitude among smokers and even among healthcare workers about the status of their lungs. The NLHEP campaign messages should emphasize that behavior change can make a difference in the status of their lung health, not the nihilistic attitude that you did this to yourself now you have to deal with it. Once people start to realize that it is not too late to quit smoking or make a lifestyle change and they will still make a positive impact on their health, I think people will develop a more positive attitude towards taking control of their lung health.

Physicians tend to focus on secondary prevention (or diagnosis and cessation) and in the general population it is primary prevention that is needed specifically around the area of what COPD is and ways to prevent it (such and not smoking). There is no mention of primary interventions of COPD within the NLHEP.

People need to realize that COPD starts up to 20 years prior to symptoms. Our bodies are amazing in that they will compensate as long as they can, functioning at a lower level (of oxygen) until something happens and it just can not compensate anymore. The importance of a primary care physician being able to do a simple spirometry is that the physician is able to earlier diagnose COPD and act through early interventions (education, medication, etc…) so our bodies do not have to keep compensating. This is part of the mission behind the NLHEP however; there is no plan within the mission for reimbursement for spirometry testing. The cost of doing this test, while relatively small, would just be another added expense to the overhead unless there was a way to reimburse for the test. Currently insurances do not reimburse for spirometry screening, only spirometry as a means of diagnosing symptoms. If it were possible to conduct this simple test more often, we would be able to diagnose earlier and provide earlier intervention (1). There have been a few studies that show that when a diagnosis of COPD is coupled with intervention of smoking cessation there is a much higher rate of success quitting smoking. NLHEP encourages health care professionals to use simple spirometry to conduct prescreenings of patients, primarily those at risk, in the same way we use mammography, for early detection of COPD. This is a great idea, however, they go on to only support certain brands of spirometers fail to propose ways for physician’s offices to be reimbursed for the expense of doing the test. Because of the challenges physicians face with reimbursement for spirometry testing, only 20% of primary care offices (in the US) even have a spirometer to screen patients (4). This means that if a physician would want to screen a patient (or test a patient) they would have to send the patient out to another facility for testing, wait for the test to be scheduled, wait for the results to be read by the physician at the referral facility, wait for a copy of the test to be sent, schedule a follow up visit or follow up testing, the potential for this process to take months is not unusual. Also, the test that would be done would be a full pulmonary function test, a very time consuming and expensive test of which all portions may not be necessary to diagnose and stage COPD compared to the simple spirometry. The initial cost of a spirometer and its set up (computer software, disposable mouthpieces, and other necessary equipment) is expensive estimated at $2000 and up according to several medical device companies including medicalresources.com. Why would a physician spend the money out of pocket with no means of reimbursement? Looking closer into what the physician would want/need in order to comply with the goals of screening all patients (at least those most at risk) for COPD the two things most important to the physician is autonomy in which spirometer they feel most comfortable using. Forcing someone to use equipment they do not like or do not understand is not helpful is furthering the goal of getting this particular population to use the spirometer. The other issue is monetary. While we all would like to see as many patients screened for COPD as possible, if the physician is going to lose money on the project, they can not be expected to give their services away for free. Would you do that? The importance of financing this screening program with the insurance companies, Medicare but more importantly the private insurances and Medicaid is fundamental in the program’s success. We are aiming to identify these people with COPD in early stages, before they qualify for Medicare which is why the private insurances and Medicaid is most important.

NLHEP needs to rally with other groups to start lobbying for more reimbursement coverage for screening of COPD with simple spirometry, especially with Medicare. By working to get more coverage, more and more physicians will be able to afford to test their patients earlier and physicians will be more likely to consider having a spirometer in their office.

The NLHEP has many professional affiliates including the American Thoracic Society, American College of Physicians, American College of Allergy, Asthma, and Immunology, The National Heart, Lung and Blood Institute, and several other prestigious groups (6). Among their affiliates there are several missing key affiliates. Those would be the grassroots affiliates by using community leaders as “elite opinion”. By using these significant people (such as a clergy person, school principal, or social action leader) within their target audience groups (neighborhood, religious, or cultural communities, for example) for their message of prevention and early intervention there is a higher chance of getting the message of COPD translated within that community. This is the institutional diffusion model (7). By using the elite within the community they are able to translate behavior throughout the institution including policy changes, and social norms which in turn affects individual behavior (such as smoking) (7). A person’s attitude towards a specific behavior is based on the person’s perception of social norms associated with that behavior. This means that by getting grassroot affiliates (especially the elite) involved in helping to pass on the word of lung health chances are more likely that people in that target group would be more likely to listen.

Using combinations of Social diffusion models which focus on changing public norms and Institutional diffusion models which focus change from a higher perspective we can incorporate many different uses of grassroot community leaders (Social Network Theory, Social Marketing Theory, Diffusion of Innovations). We can change policy to effect change of individual behavior as well as using social networks to invoke behavior change (7).

Social Networks are a way grassroots organizations can play a vital role in the passage of health promotional messaging. It starts out with just one person being diagnosed with COPD and they tell their family/friends to get themselves checked out before it’s too late. Those people pass it on to their friends/family and pretty soon the group gets larger and larger. People generally belong to more than one community (neighborhoods, jobs, religious, social circles). As more individual communities become more aware of COPD and testing their lungs, the faster the information gets spread. By utilizing a small amount of strategically placed resources we could have a larger influence over a larger population than by just utilizing physicians alone. The use of chain reaction techniques and grassroots organizations could also raise awareness among populations who do not always trust the medical systems. This would work very well among the younger populations (under age 50) who do not necessarily think that they are at risk for COPD. And as we stated earlier, these are the people we need to focus on. This method, although slow moving, has the potential when planned correctly to be more effective and long lasting than the traditional “because the doctor said so” methods. This method is the same as any fashion trend. One person starts a habit such as dying their hair and before we know it everyone is dying their hair. Although a juvenile comparison, the comparison fits. People want to do what is popular. So the goal would be to make testing your lungs popular.

While the NLHEP has many great ideas, their process of implementation is drastically flawed. By applying a more varied method in the way they approach the different target groups they would probably get a more effective message across. They should support a physician’s choice in equipment, not mandate only certain brands. They should also collaborate with the more influential grassroot organizations to develop better strategies to notify and involve the general population in the process of education and intervention. Until the NLHEP opens its eyes to the flaws in its prevention and intervention messages and strategies, they will continue to be unsuccessful in their attempts to decrease the number of people dying from COPD.

References
1. Diagnosis of Airflow Limitation Combined with Smoking Cessation Advice Increases Stop Smoking Rate, Gorecka, D et al. Chest 2003; 123:1916-1923
2. Global Initiative for Chronic Obstructive Lung Disease, Executive Summary 2005, www.goldcopd.org
3. Mechanisms and Management of COPD, Chest/113/4/April, 1998 Supplement
4. Office Spirometry: Key to Ventilatory Assessment. The Clinical Advisor; July/August, 2002
5. Confronting COPD in America; Schulman, Ronca, Bucuvalas, Inc. Access at www.lungusa.org
6. The Early Recognition and Management of Chronic Obstructive Pulmonary Disease, Doherty, Dennis et al, National Lung Health Education Program, http://www.nlhep.org/
7. Edberg, Essentials of Health Behavior, Sudbury, MA Jones and Bartlett 2007
8. GlaxoSmithKline. COPD in America. The Burden of COPD. 2007 http://www.copdinamerica.com/burden.html

The Forbidden Fruit Is Always Sweeter: The Problems With Abstinence-Only Education—Jessica Assiamah-Ansong

2007-12-12T06:56:00.000-08:00

Ignorance may be bliss in some circumstances but in the situation of unprotected sex, ignorance can be deadly. Not knowing how to use condoms or other forms of contraception during sexual activity may place an individual at risk for various diseases including sexually transmitted infections (STI’s) and HIV/AIDS. HIV is one of the leading causes of death between people ages 18 to [25]. Policy makers understand that sexuality is a topic that must be addressed; therefore, policy makers are encouraging sex education in schools. The Bush administration is of the opinion that students’ curriculum should include sex education that is strictly focuses on abstinence and neglects information on contraception or condom use. Moreover the federal government will only fund programs that strictly emphasize abstinence from sexual activity. They believe that sharing contraceptive information with teenagers will put them at a higher risk of becoming sexually active [1]. The Bush administration also suggests that abstaining from sexual activity is 100% effective against STI’s, HIV and pregnancy. Finally, in the government’s opinion, sex is only appropriate in the confines of a marriage. Sex outside of marriage is the cause of many illegitimate births, the AIDS epidemic, poverty and the destruction of the nuclear family.

Many of these points are valid; however, they completely ignore the fact that adolescents are having sex. In fact, by senior year, there are more high school students who are sexually active or have been sexually active than seniors who are virgins [2]. Furthermore, lecturing rebellious teenagers about abstaining from sex may encourage them to engage in sexual behavior. Lastly, the media fails to educate or value abstinence as it is flooded with thousands of sex images, scripts and innuendos. In the following paragraphs, I will use the arguments stated above to support my belief that abstinence-only education is not effective.

Overview of Sex Education in the U. S.
It is important that adolescents learn about sex in schools. Engaging in risky sexual behavior places individuals at risk for teen pregnancy, STI’s, HIV and other emotional distress. The US has one of the highest teen pregnancy rates in the developed world [5]. Teen unintended pregnancy rates are twice as high as those in England, Wales or Canada and nine times as high as the rates in the Netherlands and Japan [5]. There is plenty of evidence that suggests that sex education is necessary.

Sex education refers to the education of human sexuality contraception with the intention to reduce teens’ risk of contracting STI’s, HIV and getting pregnant [5]. There are two types of sex education—abstinence-only-until-marriage or abstinence-only and comprehensive sex education or abstinence-plus. Each program’s main objective is to reduce STIs, HIV and unintended pregnancies, but they use different strategies to reach their goal. An abstinence-only curriculum refers to a curriculum that promotes abstinence from sex [1]. By emphasizing that abstinence is the only 100% effective way to avoid STI’s, HIV and unintended pregnancies, school teachers fail to discuss contraception or condom use [1]. A comprehensive sex education, on the other hand, acknowledges students who are sexually active and the students that will eventually become sexually active by providing them with contraception and condom use information [1]

As of 1996, the federal government has funded only programs that provide abstinence-only education [6]. They allocated $50 million each year for abstinence-only education [6]. The federal government forbids “abstinence-only” education to discuss contraceptive methods unless they are discussing failure rates, but emphasize that sex outside of wed-lock is wrong [5]. Recently, the Sexuality Information and Education Council of the United States (SIECUS) released report indicating that that policymakers decided to raise funds by $28 million for abstinence programs that have failed to make an impact on adolescents’ behavior [7]. This increase in funding for abstinence-only education will not reduce the spread of HIV/AIDS or STI transmission. Abstinence-only education is simply ineffective and the government should adapt another method for educating students about sexual education.

Abstinence-only education does not account for adolescent’s need for independence; therefore, it may lead them to engage in sex as an act of rebellion against authority figures.
Adolescents, who value independence, want to exercise the freedom of making their own decisions without authority figures enforcing rules or beliefs upon them. For example, teenagers can be described as rebellious, moody and restless. A teenager is anxious to drive and get his own car; persuades his parents to extend his curfew and wants a job to pay for his clothes. Typically, teenagers strive for independence. They want to be free to have their own beliefs and make their own decisions.

During adolescence, Erikson, a psychologist who is known for his theory of psychosocial development, argues that teenagers strive for autonomy and to find an identity [10]. It is important that parents and other authority figures allow their teenager to explore their identity. Health professionals recommend that parents do not judge or enforce beliefs among a teenager [8]. They recommend that parents refrain from enforcing their opinion on the teen’s identity, such as clothes and the type of music the teen enjoys [8]. Teenagers want to feel that they are in control.

An adolescent’s autonomy is challenged by abstinence-only education’s attempt to persuade them to refrain from all sexual activity. A teacher that strictly enforces abstinence-only messages may produce an alternate result—it may encourage a teen to experiment with sex. Santrock, an author of an adolescence textbook, suggests that developing a sexual identity is another task that an adolescent must complete [10]. Sexual identity refers to ideas about sexuality and the decision to engage in sex. These decisions are influenced by social, physical and culture factors, as well as peers and the media [10]. Therefore, there are a multitude of variables that influence the behavior of adolescents. It is not guaranteed that an abstinence-only education would convince adolescents to postpone sex until marriage. Forbidding a teenager from doing something only strengthens teenagers’ desire to engage in sexual activities.

The majority of adolescents have already become sexually active and abstinence-only education fails to give them the proper instructions on how to protect themselves.
Abstinence-only education does not apply to the population of students who have already made the decision to engage in sex. Research suggests that American teens are engaging in sexual behavior at earlier ages and are having multiple sex partners [21]. Social scientists suggest that the majority of the adolescent population will not wait until marriage to engage in sexual activities [5]. Most teenagers will initiate sexual activities during their adolescent period [10]. There is plenty of scientific evidence indicating that adolescents are not waiting until marriage to initiate sexual activity. A nation-wide survey entitled the Youth Behavioral Risk Surveillance-2005 estimated that 46.8% of students have been sexually active [2]. This rate only increases as the students matriculate through high school. The Alan Guttmacher Institute suggests that 6 out of 10 teenage women and 7 out of 10 teenage men have had sexual intercourse by their 18th birthday [5]. For a teenager who has already made a decision to have sex, abstinence-only education may not be relevant.

Abstinence-only education does not reach sexually active adolescents. Studies have shown that sexually active teenagers are not influenced by abstinence-only messages [9]. In fact, these teens were more likely to drop out of these programs [9]. One study found that abstinence-only education was only effective upon boys who were already sexually abstinent [23]. Other studies suggest that abstinence delays sexual activity; however, it does not completely eliminate it until marriage [9]. Previous scientific studies indicate that sexually active teens do not adhere to abstinence-only messages.

An abstinence-only curriculum fails to provide adolescents with information that could protect them while engaging in sexual activity. A curriculum that is not comprehensive may actually be more detrimental than beneficial. When adolescents decide to become sexually active, they do not know how to protect themselves. Previous research has indicated that abstinence-only education deters contraceptive use among sexually active adolescents. This may increase the amount of STI’s among the adolescent population [5]. Other researchers argue that some research supporting abstinence-only education programs have many flaws; therefore, it is hard to make an accurate conclusion out of the data [26]. A recent report suggested that students desired to learn more about contraception information if they were forced into sexual situations [14].

Media has become the sex educator for today’s teens and is providing them with erroneous information.
All forms of the media abide by the notion that “sex sells.” Sex is used to sell anything from toothpaste to cars. Although sexual content is ubiquitous in the media, the media fails to acknowledge the negative consequences and risks of sexual behaviors. Unfortunately, the media, full of faulty information, is one of the major sources of sex information for adolescents. Furthermore, the average American youth spends a significant amount of time exposed to the media.

The average American youth is exposed to media one third of each day. The majority of the youth’s time spent watching television occurs in the absence of parents [16]. Research suggests that teenagers watch more than three hours per day of television. Moreover, when adolescents finish high school, they will have watched 16,000 to 20,000 hours watching TV and only 14,000 hours learning in a school classroom [16]. The data indicate that the media may have a potentially greater impact on teens’ behavior than schoolteachers.

After spending eight hours in school, they come home to environment inundated with various forms of media—Internet, television and radio—which all provide messages that contradict the lessons in an abstinence-only curriculum. Contrary to the messages adolescents hear in school, media messages glamorize recreational sex outside of marriage [20]. In fact the majority sexual interactions between individuals in the media occur between two unmarried individuals [17, 24]. The attractive individuals engage in sexual activities frequently and seldom discuss contraceptives or the risk of participating in unprotected sex. The media makes sex appealing to teenagers. Unfortunately, teens have a lack of experience and cannot discern the messages presented in the media from reality [20, 22]. The media tends to overemphasize the positive aspects of sex while leaving out the negative consequences of sex [20, 22]. A teen with very few experiences, is very vulnerable and can be heavily influenced from these media messages. Research suggests among all television programs with sexual content, only one out of eleven of them mention the possible risks of engaging sex [22].

Given the inaccurate information in media, it remains a major influence on the decisions of adolescents [22, 24]. Studies have revealed that viewing sexual content on television was significantly related to early initiation of sex among adolescents [19]. The amount of exposure to sexual content in media was related to sexual behavior [24, 25] Many models, theories and researchers support the notion that the media makes a large impact on adolescents’ behavior [15]. Strasburger [13] suggests that teens perceive their peers to be influenced by media messages. The messages of abstinence-only education taught within a classroom from a mediocre teacher cannot compete with the glamorous music videos featuring artists who discus their sexual escapades and glamorous life. The media is a greater influence on the decisions of adolescents than schoolteachers.

It an ideal world, teachers could follow an abstinence-only curriculum that would significantly change teenager’s behavior. Unfortunately, there are so many contradictory messages on sexuality that compete for adolescents’ attention. Regrettably, some adolescents may succumb to the pressure. The unfortunate truth is that research has shown that the majority of adolescents will not wait until marriage to engage in sexual activity. Therefore, sex educators should aim to present information for the teenagers who are sexually active and for those they may eventually become sexually active. A more comprehensive education will not only provide sexually active teens information on how to protect themselves during sexual activity, but also complement the adolescent mentality. Adolescents desire to be treated as adults and value independence. A more comprehensive sex education would teach teenagers how to protect themselves from teenage pregnancy, STI’s and HIV.

References
1. Collins, C., Alagiri, P. & Summers, T. (2002). “Abstinence Only vs Comprehensive Sex Education What are the arguments? What is the evidence?” (Policy Monograph Series – March 2002). AIDS Policy Research, Center for AIDS Prevention Studies, AIDS Research Institute: University of California, San Francisco.
2. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance—United States, 2005. Surveillance Summaries, June 9, 2006. MMWR 2006: 55(No. SS-5).
5. The Alan Guttmacher Institute (2002). Facts in Brief Sexuality Education.
6. Advocates for Youth. (2007, July). History of Federal Abstinence-Only Funding. Washington, DC: Marcela Howell.
7. Sexuality Information and Education Council of the United States (2007). Congress Loses Its Bearings and Supports Bush’s Request for Abstinence-Only Until Marriage Programs. Retrieved from www.siecus.org/media/press/press0155html.
8. Yale-New Haven Children’s Hospital. Adolescent rebellion: A Survival Guide for living with a teenager. Retrieved from http://www.ynhh.org/pediatrics/behavior/adolescent_rebellion.html November 12, 2007
9. Haignere, C. S., Gold, R., McDaniel, H. J. (1999). Adolescent Abstinence and Condom Use: Are We Sure We Are Really Teaching What is Safe? Health Education & Behavior, 26, 43.
10. Santrock, J. W. (2007). Adolescence (11th ed.) New York: McGraw-Hill.
11. Ott, M. A., Pfeiffer, E. J., Fortenberry, J. D. and Fortenberry,, M. A. (2006). Perceptions of Sexual Abstinence among High-Risk Early and Middle Adolescents. Journal of Adolescent Health, 39, 192-198.
12. Kunkel, D., Eyal, K., Finnerty, K., Biefly, E., Donnerstein, E. (2005). “Sex on TV A Kaiser Family Foundation Report.”
13. Strasburger, V. C. (2005). “Adolescents, Sex, and the Media: Ooooo, Baby Baby—a Q & A. Adolescent Medicine Clinics, 16, 269-288.
14. The Henry J. Kaiser Family Foundation. (2000). Sex Education in America A Series of National Surveys of Students, Parents and Principals. California: Henry J. Kaiser Family Foundation.
15. Chaves-Escobar, S. L., Tortolero, S. R., Markham, C. M., Low, B. J., Eitel, P., and Thickston, P. (2005). “Impact of the Media on Adolescent Sexual Attitudes and Behavior.” Pediatrics. 116, 303-326
16. Roberts, D. F. (2000). “Media and Youth: Access, Exposure, And Privatatization.” Society for Adolescent Medicine, 275, 8-14.
17. Ward, L. M. Talking About Sex: Common Themes About Sexuality in the Prime-Time Television Programs Children and Adolescents View Most Journal of Youth and Adolescence, 24 (5), 1995
18. Social Implicatons of music videos on youth. Greeson, le.
19. Collins,, R. L., Elliott, M. N., Berry, S. H., Kanouse, D. E., Kunkel, D., Hunter, S. B., and Miu, A. (2004). “Watching Sex on Television Predicts Adolescent Initiation of Sexual Behavior.” Pediatrics, 3, 280-389.
20. Ward, L. M. (2003). “Understanding the role of entertainment media in the sexual socialization of American youth: A review of empirical research.” Developmental Review, 23, 347-388.
21. Escobar-Chaves, S. L., Tortolero, S. R., Markham, C. M., Low, B. J., Eitel, P. And Thickstun, P. (2005). “Impact of the Media on Adolescent Sexual Attitudes and Behaviors.” Pediatrics, 116, 303-326.
22. Brown, J. D. and Keller, S. N. (2000). “Can the Mass Media Be Healthy Sex Educatiors?” Family Planning Perspectives, 32, 255-256.
23. Aten, M. J., Siegel, D. M., Enaharo, M., and Auinger, P. (2002). “Keeping Middle School Students Abstinent: Outcomes of a Primary Prevention Intervention.” Society for Adolescent Medicine, 31, 70-78.
24. Pardun, C. J., L’Engle, K. L., Brown, J. D. (2005). “Linking Exposure to Outcomes: Early Adolescents’ Consumption of Sexual Content in Sex Media.” Mass Communication & Society, 8, 75-91.
25. L’Engle, K. L., Brown, J. D., Kenneavy, M. A. (2006). “The Mass Media are an important context for adolescents’ sexual behavior.” Journal of Adolescent Health, 38, 186-192.
26. Kirby, D. (2002). “Do Abstinence-Only Programs Delay the Initiation of Sex Among Young People and Reduce Teen Pregnancy.” Washington DC: National Campaign to Prevent Pregnancy.

Viewing Scared Straight as a Public Health Failure—Tyler James

2007-12-12T06:55:00.000-08:00

Introduction
Public Health interventions have failed to address the adverse health outcomes of adolescents vacillating back and forth between the criminal justice system. Research has documented that adolescent labeled as juvenile delinquents experience higher rates of illicit substance abuse, mental health issues, and higher rates of violent death than non-delinquent adolescents do(1-4). The philosophy behind these efforts suggests that reducing delinquency will improve the health outcomes among at risk adolescents. This paper will focus on the Lifer’s Juvenile Awareness Project captured in documentary “Scared Straight”, a prison-aversion program presented itself during the seventies as a possible method from deterring adolescents from criminal behavior and risky health behaviors. There have been mixed reports about the success of the Scared Straight program, this intervention represents a public health failure.

The Birth of Scared Straight
In 1978, Arnold Shapiro directed a documentary examining the “Lifer’s Juvenile Awareness Project,” implemented at the Rahway State Prison in New Jersey. The “Lifers Juvenile Awareness Program,” was offered as an alternative choice for adolescents who faced prison time for their involvement in criminal activity. The goal of this intervention was to give youth an experience of what life would be like in the prison system. The outcome that this intervention was hoping to achieve was to reduce adolescent’s risk of committing criminal or risky behaviors. The “Lifers Juvenile Awareness Program,” used real prisoners or Lifers to implement the intervention to adolescents. Lifers would “keep it real” and used excessive graphic language, violent images of men and women assaulted in prison, and role-playing to illustrate how engaging in delinquent behaviors ultimately leads to undesirable consequences, mainly landing in prison and suffering through its daily hardships.

Shapiro titled the documentary Scared Straight, and it aired nationally in 1979. In the finale of Scared Straight, Shapiro claimed that there was an 80% deterrent effectiveness among all participating adolescents and that there was 100% deterrent rate among the intervention participants during the filming of the documentary. With the lifer’s graphically demonstrating how their negative behaviors led to their imprisonment and the hardships they face inside of prison, rational thought suggests the intervention would discourage juvenile delinquents from continuing their destructive behaviors (5). This national exposure gave credibility to its effectiveness and it inspired 38 states to adopt prison-aversion programs modeled after the “Lifer’s Juvenile Awareness Project”, which due to the popularity of the documentary the public colloquially referred to as Scared Straight (6). State’s implementation of the program was very similar to the aggressiveness and intimidation tactics employed by the prisoners of the original documentary. Also, states used various criteria to determine eligibility for the intervention. Some juveniles participating in the intervention are first time offenders while others committed several criminal offenses.

Substance Use and Scared Straight
Scared Straight encompasses several of the Health Belief Model constructs used to inspire behavioral change in an individual. The behavioral outcome the intervention seeks to achieve is eliminating recidivism and encouraging adolescents to adopt more socially acceptable behaviors. According to the program, juvenile delinquents should have a high-perceived susceptibility since their behaviors led to their interaction with the criminal justice system. However, juvenile delinquents experience a high likelihood of illicit substance use and have difficulty making and maintaining a rational decision such as avoiding crime or remaining sober without assistance (1). Therefore, the co-occurrence of other issues among juvenile delinquents makes the rational thought process difficult to follow.

The glaring issue that makes this intervention a public health failure is that the intervention fails to recognize the importance of the co-occurrence of other issues among juvenile delinquents. Scared Straight fails to address the negative health outcomes such as illicit substance abuse or mental health needs of juvenile delinquents that cause them encounter the criminal justice system. Research has shown that recidivism coincides with more serious drug use—moving from marijuana to cocaine for instance (1). Studies have also shown that imprisonment negatively affects the health of individuals, particularly mental health (7-8). Solely relying on Scared Straight to address the co-occurrence of issues among juvenile delinquents represents a public health failure and evidence that treatment services need to be involved in reducing recidivism rates.

Scared Straight Fails to Provide an Effective Skills Set
Scared Straight consist of hours of Lifers talking to adolescents in an aggressive manner and use the role-playing exercises of the intervention to humiliate juvenile delinquents rather than help them learn how to perform more socially acceptable behaviors. The Scared Straight intervention fails to provide juvenile delinquents with an appropriate skill set for effectively avoiding recidivism and other delinquent behaviors. The co-occurrence of criminal behavior and illicit substance use suggests that juvenile delinquents need a new set of skills to perform more socially acceptable behaviors in mainstream society. Failing to address these issues will not engender change among juvenile delinquents because they lack the tools/resources to do so. Research supports the use cognitive-behavior therapy to change behavior successfully. Cognitive-behavioral treatment includes problem solving, negotiation, skills training, interpersonal skills training, rational-emotive therapy, role-playing and modeling, and cognitively mediated behavior modification (9).

Scared Straight Does not involve the Community or Positive Role Models
Research has shown that interventions seeking to combat recidivism prove to be more effective when the interventions are conducted in a community setting rather than institutions such as a prison (9-10). Lifers encourage juvenile delinquents to become socially responsible members within their community, yet the intervention excludes the community environment. There is a great disconnect between the goal of the intervention and the actual environments of juvenile delinquents. Not only does the intervention fail to incorporate the community within the program, juvenile delinquents do not receive information about the resources their communities or nearby communities have to offer. This is critical since the treatment services within the public sector are not easily available (1).

Evaluation
Unlike adolescents not labeled as at-risk or delinquent, juvenile delinquents have not experienced a decrease in illicit drug use. Prison-aversion programs such as Scared Straight have been unsuccessful in their attempts to decrease recidivism rates and negative health outcomes among juvenile delinquents due to their reliance on Health Belief Model constructs. Juvenile delinquents need additional resources and therapy to address co-occurring issues in conjunction with intervention leaders illustrating the negative consequences of their behaviors. This is the reason why independent evaluation of the Scared Straight intervention suggests the program is not effective. The intervention emphasizes the consequences of criminal behavior but fails to instruct juvenile delinquents from performing such behaviors. Once juvenile delinquents encounter the criminal justice system, they are aware of the consequences of their criminal behavior. Since states implemented the program with the same criterion and with the same expected outcomes stated in the “Lifer’s Juvenile Awareness Project,” they have not achieved their desired target goals in the reduction of youth coming into prison and reduction of recidivism among those that have been in the incarceration system.

Conclusion
Despite the promoted effectiveness of Scared Straight this interventions has failed to reduce recidivism effectively among juvenile delinquents. The structure of Scared Straight lacks the critical elements identified by research on efficacious methods of reducing recidivism. The major flaws of the intervention are it is not continuous, it inadequately addresses co-occurring issues such as substance abuse, it fails to provide juvenile delinquents with appropriate skills set for maintaining socially responsible behaviors, and it does not involve the community environments of juvenile delinquents.

With the dearth of public treatment services, linking juvenile delinquents with positive role models is critical to assist them in becoming socially responsible members of their communities. The Lifers serve as models of behavior for juvenile delinquents not to adopt, but, since the prisoners are removed from society, they fail to serve as an effective model for adolescents to emulate when they return to their communities. Positive community role models are imperative because not only do they serve as effective models for juvenile delinquents, but they also provide long-term assistance for juvenile delinquents as well. Juvenile adolescents need to interact with mentors who have reformed their criminal behaviors or maintained sobriety, and now behave as socially responsible individuals.

Since the program does not employ these crucial components, Scared Straight fails to combat recidivism and it reiterates what juvenile delinquents learned upon their first encounter with the criminal justice system; that is, their delinquent behaviors will result in negative consequences. Without this intervention teaching juvenile delinquents how they can combat recidivism and other co-occurring issues, Scared Straight will remain a public health failure.

References
1. Dembo R, Williams L, Schmeidler J, Drug Abuse among Juvenile Detainees Annals of American Academy of Political and Social Science 1992; 521: 28-41
2. Lennings CJ, Copeland J and Howard J Substance Use Patterns of Young Offenders and Violent Crime Aggressive Behavior 2003; 29:414-422
3. Teplin L, * McClelland GM, Abram KM, and Mileusnic D, Early Violent Death Among Delinquent Youth: A Prospective Longitudinal Study Pediatrics 2005; 115: 586-1593
4. Wiesner, M; Michael Windle Young Adult Substance Use and Depression as a Consequence of Delinquency Trajectories During Middle Adolescence Journal of Research on Adolescence 2006; 16:239-254
5. Petrosino, A; Carolyn Turpin-Petrosino, James O. Finckenauer Well-Meaning Programs Have Harmful Effects! Lessons From Experiments of Programs Such as Scared Straight Crime & Delinquency 2000; 46: 354-379
6. Buckner JC, Chesney-Lind M Dramatic Cures For Juvenile Crime An Evaluation of a Prisoner Run Delinquency Prevention Program Criminal Justice and Behavior 1983;10:227-247
7. Freedenthal, S., M.Vaughn, J. Jenson, and M. Howard Inhalant Use and Suicidality Among Incarcerated Youth Drug Alcohol Depend. 2007; 90:81-88
8. Teplin La, McClelland GM, Dulcan MK, Mericle AA Psychiatric disorders in youth in Juvenile Detention Arch Gen Psychiatry 2002; 59: 1133-1143
9. Pearson F, Lipton D, Cleland C, Yee D The Effects of Behavioral/Cognitive-Behavioral Programs on Recidivism Crime & Delinquency 2002; 48:476-496
10. Greenwood P, Zimring F One More Chance: The pursuit of Promising Interventions Strategies for Chronic Juvenile Offenders Santa Monica, CA:RAND, 1985)

Got Fear?: The Failures of The Health and Human Services Campaign to Overcome the Barriers to Breastfeeding – Elmy Trevejo

2007-12-12T06:44:00.000-08:00

The benefits of breastfeeding have been well documented for years. It is believed that breastfeeding saves 5-6 million children’s lives annually. According to the Lancet Child Survival Series, it is estimated that 1.3 million additional lives could be saved annually if women were enabled to achieve six months exclusive breastfeeding with continued breastfeeding thereafter (6). Infants that are not breastfed have decreased survival rates due to physical conditions such as NEC (necrotizing enterocolitis), diarrhea, respiratory illnesses, sepsis, and pneumonia. Bottle fed infants are more likely to suffer from otitis media, atopic dermatitis, gastroenteritis, and asthma (5,6,11). Other studies have found that infants that are bottle-fed may be more susceptible to increased cardiac risk factors such as obesity, diabetes and childhood leukemia (6). The benefits to the mother are quite substantial as well, and include decreased risk of breast cancer, ovarian cancer, and type two diabetes mellitus. There is also an association between breastfeeding and decreased cases of post partum depression (6, 12).
“ ...[Breastfeeding] represents the normal and expected way to feed infants and young children, yet continues to suffer from cultural and commercial barriers that make it difficult for mothers to adhere to the medical recommendations to breastfeed exclusively for six months, and to continue breastfeeding with appropriate complementary foods for one year and beyond (15, p. 552).”

Breastfeeding rates in the United States are considerably lower than in other parts of the world. The American Academy of Pediatrics recommends that women breastfeed for >12 months, and thereafter for as long as mutually desired (13). The latest data compiled by the Center for Disease control states that in 2004, the rates for breastfeeding early postpartum, at six months, and at twelve months was 73.8, 41.5, and 20.9, respectively. US Healthy People 2010 target is to increase the proportion that breastfeed their babies at birth to 75% and for six months to 50% (12). As a public health initiative the Department for Health and Human Services developed a marketing campaign to address this growing public health crisis.

The campaign featured two television ads, radio spotlights, and print media coverage. The commercials, which aired from June of 2004 to December of 2005, became the center for significant controversy due to the manner in which HHS targeted the audience. The first commercial shows two women, late in their pregnancies, in a logrolling competition. A message is briefly displayed on the screen that states, “You wouldn’t take risks with your baby before their born. Why start after?” The logrolling women are then back on the screen, and a voiceover states that studies show that babies that are breastfed for six months are less likely to develop ear infections, respiratory illnesses, and diarrhea. The end of the commercial shows the final message, “Babies were born to be breastfed.” The second commercial that HHS created depicted a woman in her third trimester being helped on top of a mechanical bull, and riding it until she falls off. The same message is displayed, “You wouldn’t take risks with your baby before their born. Why start after?” The same voice over is heard that quickly states some of the benefits of breastfeeding. In this paper, I am going to discuss the reasons that the HHS campaign for breastfeeding failed to be an effective public health initiative. The Health and Human Services campaign failed to be an effective public health initiative because it 1) uses a scare tactic/bullying approach, 2) fails to address the barriers that new mothers face that may hinder their compliance, and finally 3) the campaign fails to address the growing duality that exists between women and their bodies in American culture.

The Health and Human Services campaign uses a scare tactic approach towards breastfeeding
This tactic is discussed in the Protection Motivation Theory developed by Rogers in 1983. Protection motivation theory was first developed within the framework of fear-arousing communication. As stated by Boer and Seydel, protection motivation is the result of the threat appraisal and the coping appraisal. The appraisal of the health threat and the appraisal of the coping responses result in the intention to perform adaptive responses (protection motivation) or may lead to maladaptive responses. Protection motivation is a mediating variable whose function is to arouse, sustain and direct protective health behavior. It facilitates the adoption of adaptive behaviors and can best be measured by behavioral intentions (2). The HHS campaign uses this tactic in order to “frighten” their audience. The assumption is made that if knowing that one is causing harm to their child, mothers will be more apt to adopting breastfeeding practices. This is the major flaw in the campaign. The campaign uses callous blaming in order to get the audience’s attention. The message that is portrayed is that women who choose not to breastfeed are essentially harming their children, and goes as far as to compare it to dangerous activities such as mechanical bull riding, and logrolling. Although the message is supposed to be humorous, the underlying message is riddled with blame and has a tone of judgment that is not effective.

The campaign, in essence, labels women that bottle-feed as “bad mothers” or mothers that do not care about the well being of their children. The strategy used was designed to notify the public that on all counts breastfeeding is better for infants. The problem is that the campaign assumes that people are unaware of this. Studies have shown that when asked, non breastfeeding mothers state that they are aware that breastfeeding is superior to bottle-feeding, but the barriers that they faced to breastfeed outweighed the potential benefits. As stated by the HHS in June of 2004, “Research has shown that many women know that breastfeeding is the best nutrition for babies. This knowledge has not translated into changed behaviors, and breastfeeding rates have hit a plateau.” Pregnancy and birth are highly stressful and anxiety provoking events for most women, and instead of trying to empower and encourage women to embrace breastfeeding for the numerous benefits that it has, the HHS campaign bullies women into feeling like “incompetent mothers,” if they choose not to breastfeed.

The Campaign fails to address professional and social barriers
Another issue that I have with the HHS campaign is that it fails to address any of the barriers that women face when making the decision to breastfeed or bottlefeed. One of the biggest barriers that women face is related to lack of support in the workplace, and shortened maternity leave. One third of mothers return to work within three months of having a baby, and two thirds return within six months from birth (14). As stated by C. Barona-Vilar, “Among employed women, structural support linked to working conditions has a decisive role on breast-feeding election and duration. Duration of breastfeeding tends to be longer when maternity leave is longer, especially among women with higher professional qualifications and permanent contracts. Among women with lower professional qualifications, and women whose high level of precarious work and low income converges, breast-feeding duration is substantially reduced (1)” The United States guarantees three months of unpaid maternity leave. When compared to other countries, this is appalling. In Norway, more than 97% of women breast-feed their infants during the immediate postpartum period, 80% continue at 3 months, 20% breast-feed beyond 12 months. Women can take maternity leave for 42 weeks with full pay or for 52 weeks with 80% pay. After returning to work, they are entitled to 1-1 ½ hour breaks each day to feed their infant (13). Many women are forced back into the workplace early because they are unable to go without the additional income, adding another layer of complexity to breastfeeding their infants.

Another complaint that new mothers have is regarding the stigmas regarding workplace pumping. As suggested by Caroline Jane Gatrell, “mothers face hostility if they breastfeed infants, or express milk, within workplace spaces. Consequently, shortened breastfeeding duration rates among employed mothers have attributed to organizational discouragement (3). It was originally suggested by Witters-Green that even where employers are aware of the issues, they fail to offer suitable spaces for breastfeeding. This is partly for cost-related reasons but also because employers are ‘discomfitted’ and ‘offended’ by the idea of breastfeeding mothers (14). There are false perceptions regarding breastfeeding in the workplace. Women often choose not to continue breastfeeding after returning to work, because of the way they feel their coworkers will react (8). In this country, breastfeeding has become something that should be hidden and done discretely, in order to keep everyone comfortable, instead of acknowledging it as a natural and biological necessity. Some women even feel that if they were to breast feed or expel milk at work, their professional life would suffer from negative consequences. Without addressing these concerns, the message of the HHS campaign is useless. It is easy for the campaign to blame women for their inability to care for their infants appropriately, but we as a society need to change policy and the workplace environment to assist and encourage women to feel that breastfeeding is socially acceptable.

The Campaign fails to acknowledge the dichotomy between breastfeeding and sexuality
It is well known that in Western cultures, breasts have become increasingly oversexualized. The social norm has changed the focus of the breast from its biological function to a sexual male fetish. As stated by Iris Young in her essay, Breasted Experience, “To be understood as sexual, the feeding function of the breasts must be suppressed, and when the breasts are nursing they are desexualized. A great many women in this culture that fetishizes breasts are reluctant to breastfeed because they perceive that they will lose their sexuality. They believe that nursing will alter their breasts and make them ugly and undesirable (17, p. 199).” This process may contribute to the reason women choose not to breastfeed. If women are afraid that by breastfeeding they are in essence “desexualizing” themselves, they are less likely to adopt the behavior. They are more likely to view the behavior in a negative way. The dichotomy that prevails creates a disassociation for most women. Although they want to do their best by providing nutrients for their infant, it puts their own sexual identity at risk.

According to Dettwyler, a well-known breastfeeding advocate, she states that the sexualization of women’s breasts underlies the taboo against breastfeeding in public. “It is ironic that breastfeeding an infant in public is still widely frowned upon, denying the natural function of the breasts at the same time as objectifying them for the sexual gratification of men” (3, p. 204). Women are concerned that they will no longer be considered attractive to their male partners. A survey conducted by Ward in December 2006, found that men were more likely to endorse traditional gender ideologies that portray men as sexually driven, and women as objects of sexual desire. It was difficult for men to accept the duality of female sexuality, and the biological need to provide nutrition for their infants. “These findings support the notion that traditional masculine ideation focuses on the sexual aspect of women’s breasts and bodies, thereby making it more difficult for men to embrace the reproductive functions (16).”

The failure of the HHS campaign is that it does not acknowledge that this duality exists. As long as women’s bodies are objectified to the degree seen now, it will be extremely difficult to change breastfeeding compliance rates without addressing the root issue. In our society, we do not object to media shots of women in skimpy outfits that accentuate their breasts, but we become very uncomfortable with the image of a woman nursing. Western culture continues to see the breast as an object for sexual gratification, and has made any other views of the breast perverse. The Health and Human Services campaign fails to broach the social stigma that our culture has towards a “desexualized” breast. It fails to acknowledge the dichotomy, and therefore cannot be effective in persuading mothers to breastfeed.

In conclusion, the Department of Health and Human Services breastfeeding campaign fails to be effective due to its judgmental and “bullying” strategy. To combat this public health issue, we cannot alienate and label women as inadequate mothers without addressing the social and professional reasons that contribute to the decision making process. The fire and brimstone campaign approach to breastfeeding is insulting and fails to encourage women to adopt the behavior. Instead of focusing on changing policy and also trying to address the manner in which women now objectify themselves, the health and human services campaign puts the blame and focus on the individual mother. It is obvious that this issue is multi-layered, and must be addressed in that manner, as well.

References
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