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

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.

Viewing Scared Straight as a Public Health Failure—Tyler James

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)

A Failed Eating Disorder Intervention For Young Girls: Why Telling Girls To Stop Being Anorexic Just Doesn’t Work—Anonymous

Introduction

In 1978, Hilde Bruch’s seminal book “The Golden Cage: The Enigma of Anorexia Nervosa” first described anorexia as “the relentless pursuit of excessive thinness,” appropriately placing emphasis on the individual’s psychological state rather the disease’s physical manifestations (1, 2). Her book was one of the first attempts to truly understand the psychology behind anorexia; it went beyond the conventional wisdom of the day, which was blaming the girls themselves for not eating and “treating” them by telling (or forcing) them to eat (1). The disease was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, and the most recent edition of the manual gives four diagnostic criteria to identify anorexia: [1] refusal to maintain appropriate bodyweight, [2] intense fear of gaining weight, even if underweight, [3] disturbance in how bodyweight/shape is experienced or denying seriousness of low bodyweight, [4] absence of at least three consecutive menstrual cycles (3).

While by definition a mental illness, anorexia manifests itself through starvation and is thus marked by a wide array of physical health problems (4-5). These range from the relatively benign (inability to think clearly, excessive facial hair) to the extremely serious and possibly fatal (osteoporosis, stunted sexual development, kidney problems, arrhythmia, stroke, and cardiac atrophy) (5-6). The disease is both more common and more fatal than one might suppose. The DSM-IV estimates that one in every 250 girls will suffer from the disease, and in 2001, the National Institutes of Health estimated anorexia’s mortality rate at .56% per year (5-6). This makes anorexia the biggest killer of American teenage girls—the rate is said to be “12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population” (6).

This brief overview of anorexia has already shown that it is an incredibly serious disease. This paper will continue to explain why any intervention which attempts to help those suffering from it will need to respect the fact that it is a psychological disorder with a variety of causes, not the least of which are societal. The Face the Issue commercial fails to do this. The animated commercial was aired on television stations catering to teenage viewers, such as MTV, and is currently available online (7). The commercial, called “You’ll be dead before you’re thin enough,” is narrated by Julianne Moore, a well-known, very attractive, and skinny actress. It lists the negative effects of anorexia, including baldness, infertility, inability to think clearly, and death. The narrator concludes by saying: “it’s not cool and it’s not pretty. You’ll be dead before you’re thin enough. Your choice.” The commercial ends with a link to the sponsoring organization’s website, which is simply a forum for girls to talk—it does not provide any guidance for how to go about obtaining treatment for yourself or a loved one. Since the commercial’s narrator directly addresses anorexic girls, its intent does not appear to be agenda setting, but rather a genuine desire to change behavior.

There are three crucial problems with this intervention, each of which will be discussed in more detail. The first is that the commercial’s apparent reliance on the health-belief model does not accord with the psychological underpinnings of the disease. The second is that the commercial fails to promote self-efficacy because it does not provide feasible first steps towards recovery for those who suffer from the disease, nor does it provide guidance on how to help a loved one get the proper treatment. Last, the commercial ignores the cultural and social influences behind anorexia.

This Commercial Fails Young Girls by Relying on the Fallacies of Choice and Intentional Action

The Health Belief Model (HBM) has long been a basis for public health interventions, and the underlying assumptions made in this commercial indicate that its creators had this model in mind. HBM theorizes that for an individual to take action to avoid a disease, she would need to believe: [1] that she is personally susceptible to it, [2] that the occurrence of the disease would have at least moderate severity on some component of her life, [3] that taking a particular action would be beneficial by reducing her susceptibility to the condition or its severity if the disease occurs, and [4] that it would not entail overcoming important psychological barriers such as cost, convenience, pain, or embarrassment (8). In layman’s terms, the model is based on the theory that people thoughtfully consider the “pluses” and “minuses” of a certain health behavior and rationally decide whether they would like to adopt that behavior; they then act in accordance with that intention. This intervention is the embodiment of HBM because it is premised on the idea that anorexic girls make the rational choice to engage in this self-destructive behavior. The commercial provides a litany of anorexia’s negative effects in an attempt to make the perceived costs outweigh the perceived benefits, and thus change the intention to engage in anorexic behavior. This reliance on HBM shows a lack of understanding of the psychological forces behind anorexia. First, those suffering from anorexia do not make the rational choice to become anorexic, and second, even if someone who was suffering from the disease desired to become healthy, the nature of the disease is not such that intention can be expected to result in a change of behavior without receiving a wide range of therapies (1,2).

In his book “Anatomy of Anorexia,” Steven Levenkon identifies four stages of anorexia (5). The first stage is familiar to almost all women—it is simply dieting, prompted by a desire to be thin and “socially acceptable.” It is at this stage that those who are predisposed towards anorexia become, in a sense, addicted to the “declarations of praise, admiration, and envy from others.” These people proceed to the second stage, where the compulsion to lose weight essentially becomes a life-absorbing obsession. The third stage is marked by “assertiveness”; since girls who develop anorexia tend to be non-assertive, a girl who develops this disease realizes this is her first real act of assertiveness and she develops a sense of defiance, but it’s only with respect to this one thing—her anorexia. Thus to give up anorexia would be to give up her assertiveness. Last is the “pseudo-identity” stage, where the girl feels as though she has achieved a special identity for herself because her appearance and actions have caused all those around her to react—this “pseudo-identity fills in the emptiness she has secretly felt about herself for some time.”

As this framework makes clear, one does not truly “choose” to become or stay anorexic; it is instead a process that one who is genetically or psychologically predisposed to anorexia may go through when prompted by outside circumstances (5). That is, while someone who develops this disease may initially choose to diet, anorexia as a disease does not exist until the compulsion to lose weight becomes an obsession, at which point the idea of simply choosing to eat more is clearly unrealistic. Further, since anorexia is not about health, and, once the disease has officially presented itself, is not even about “coolness,” appeals to the detrimental health and social effects of anorexia are bound to fail (1,2). While perhaps it could be argued that the commercial was trying to target girls still in the first stage of dieting, it still managed to disregard a large part of the social sciences’ literature about how that first stage of anorexia is initiated.

This four stage framework also shows why HBM’s theory that intention, once developed, can be expected to result in a change of behavior is particularly ill-suited to a problem such as anorexia. Even if the commercial did prompt someone who was suffering from anorexia to desire avoiding the negative side effects listed and thereby creates an intent to eat (and that’s a very serious “if”), the psychological nature of the disease means there is no reason to think intent will necessarily translate into action (2,4,8). Levenkon’s four stages establish that someone suffering from anorexia is not only in the midst of obsessive behavior, but giving up that behavior is also giving up an entrenched, defining and (to herself) highly valued part of her personality (5). Clearly, she cannot act on an intent to start eating the same way that someone can act on an intent to get a mammogram. This model does not allow for a situation where one intends something intellectually (e.g., to eat) but is still psychologically incapable of that action without serious mental health treatment (1,2). As the experience of one female anorexia patient, as described by her doctor, illustrates: “Despite developing intellectual insight about [how her preoccupation with her thinness obsession prevented her from achieving her real goals], she had great difficulty letting go of her obsession to be thin. She saw the anorexia as an ogre who had an unyielding hold on her” (9).

This Commercial Fails to Promote Self-Efficacy to Seek Help

Social cognitive theory posits that self-efficacy is an important predictor of change, and this idea was adopted by the health belief model to explain how intention transforms into action (10-11). Self-efficacy is “the conviction that one can successfully execute the behavior required to produce the outcomes” (11). Thus, in the anorexia context, whether or not a young girl or woman ceases engaging in self-destructive anorexic behavior depends on her belief that she is capable of taking the necessary steps.

This commercial fails to recognize the role self-efficacy plays in enabling change by trying to do too much too soon. The commercial essentially tells girls not to be anorexic (which, as the previous section shows, anorexic girls may not believe they are capable of doing) instead of telling girls to make a phone call to a hotline (which can provide initial counseling and references to appropriate resources) or to talk to a friend about how they’re feeling. These latter actions are ones girls may believe they are actually capable of performing, and therefore providing these feasible first steps towards recovery seems like a much more effective approach. By gaining confidence through these first few steps they may be able to get themselves the help they need to really work towards recovery. According to the self-efficacy theory, conquering small steps is one of the ways that an individual can build self-efficacy for the task as a whole (10). Treatment for anorexia may require an overwhelming array of therapies, including interpersonal therapy, family and group therapy, an internist, a nutritionist, an endocrinologist, and a psychopharmacologist (2). To think that someone could even contemplate beginning this process by going to the website provided by the commercial is simply absurd.

The more realistic role that self-efficacy plays in the anorexia context, however, is with respect to the friends and family members of those who suffer from the disease—they must believe there is something they can do to help. Anorexia is unique in that perhaps the best intervention is not one targeted to the person whose actions the intervention is attempting to change because those who suffer from anorexia often do not realize they have a problem (9). One patient treated by Dr. Lucas and described in his book “Demystifying Anorexia Nervosa,” is quoted as saying that “[d]enial was another big part of my anorexia. Although people commented daily that I was too thin or sick...I never saw myself as thin. I denied everything and wondered how everyone else could be so wrong and blind”(9). She continued that it took “forceful efforts from [her] parents and friends to get [her] professional help, because [she] truly didn’t think [she] was eating disordered”(9). Dr. Lucas noted that this experience is typical (9). Thus, it is truly incumbent upon family and friends to seek the necessary help. As organizations such as the American Dietetic Association and Anorexia Nervosa and Related Eating Disorders Inc., make clear when encouraging parents and friends to intervene, this is not an easy task because even the very first step of confrontation can be enormously difficult (12-14). However, as one guidebook to eating disorders notes, “[h]ealth-care professionals can’t afford to wait until the person with the problem is willing to seek help”(4). The Face the Issue intervention ignores the role of family and friends altogether, and therefore obviously fails to promote self-efficacy amongst those groups.

This Commercial Fails to Account for the Cultural and Social Influences Behind Anorexia

Three categories of factors are currently recognized as contributing to the development of anorexia: genetic predispositions, psychological predispositions (e.g. traits of perfectionism and compulsiveness, anxiety disorders), and cultural and social influences (3). The first two factors are stable individual-level factors which a media-based intervention is never going to be able to influence. The proper role for a media-based intervention is to try to change the cultural and social norms surrounding thinness in women. The commercial’s meek attempt at showing that anorexia isn’t “cool” is hardly forceful enough to counteract the powerful messages regarding the import of thinness that girls constantly receive from society. Moreover, the fact that the message is delivered by an actress who is remarkably skinny arguably undermines the legitimacy of the message. This section discusses how society has contributed towards the growth of anorexia and concludes that interventions like the Face the Issue commercial are doomed to fail because they neglect these societal causes.

One clear way that society influences the development of eating disorders is by glorifying thin women through the media. Over a decade ago, one expert on advertising and gender issues noted that ‘[t]he current emphasis on excessive thinness for women is one of the clearest examples of advertising’s power to influence cultural standards and consequent individual behavior. Body types, like clothing styles . . . are promoted by advertising” (19). Further supporting this link between the media and anorexia, a Harvard study found that Fijian women who started watching American TV such as Melrose Place and Xena Warrior Princess at least three times a week were 50% more likely to see themselves as too fat and 30% more likely to diet, even though their culture traditionally valued rounder women (17). The effect of thinness in the media has become so profound that even the fashion industry is starting to recognize the harmful role it can play: last year a Madrid fashion show took the step of prohibiting women with very low BMIs from participating so as to not promote unsafe eating behaviors (18).

External social rewards embrace and affirm the media’s glorification of thin women. For instance, the stereotypes that overweight people are lazy and that thin people are in control of their lives has been found to extend to the business world, where thinner people are said to have an easier time getting jobs and being promoted, and are generally found to experience greater success than those who are overweight (4). If fact, one author has gone so far as to say that obesity may cause poverty, rather than vice-versa (21). The author came to this conclusion after discovering a study which found that thin women tend to have upward social mobility while overweight women experience the opposite trend of downward social mobility (lower income than their parents). She considered this trend in conjunction with several other studies exploring how obesity affects the chances of getting into a better college and marrying wealthier men, and concluded that “fat people are systematically denied economic success” (21). One of the foremost doctors in treating eating disorders remarks in his book that “[a]norexia is unique among obsessional disorders because society invites girls and women to try to lose more weight than is healthy,” and notes that women at dinner parties joke to him about “getting some of that anorexia” (5).

Tied into these ideas of the media’s glorification of thin women and external social rewards for thinness is the age-old concern of peer pressure and the desire to belong. Desire to look attractive for a significant other and desire to gain membership into social organizations such as sororities and cheerleading squads can instigate unhealthy dieting amongst females (4). This desire can even cause girls to emulate anorexia to be “cool.” The medical director at the Western New York Comprehensive Care Center for Eating Disorders recently stated in an interview that some teenagers think if they get very skinny or develop an eating disorder they’ll become popular (22).

These cultural and societal factors are precursors for anorexia, and an intervention which targets those factors could be successful. This commercial, however, commits what Sharon Schwartz refers to as a “Type III error,” which is confusing the reasons behind the distribution of a public health problem across a population with the causes for that health problem’s increase in the general population over time (23). For instance, obesity has been linked with genetic predisposition, but that cannot be the cause for the increased rates of the disease because genetic variation can’t change that quickly, and thus it is the environmental factors that will explain any variation in obesity’s distribution over time. As this paper has shown, anorexia works the same way—there are genetic and psychological predispositions, but they are unlikely to explain the increased rates of anorexia over the past few decades. Thus, if anorexia interventions are based on individual-level factors (as this commercial is), then they are bound to be ineffective because “the cause of the rate increase is left unaddressed” (23). The causes of anorexia’s rate increase are likely the factors previously discussed—society’s overvaluation of thinness and punishment of the overweight. The Face the Issue intervention’s failure to address those factors in any meaningful way, deciding instead to oversimplify the issue and urge girls not to “choose” anorexia, is a serious deficiency which likely renders the intervention useless.

Conclusion

The Face the Issue anorexia intervention may have all the same tools as mainstream media—a web page, catchy graphics, and celebrity power, but this superficial similarity is simply not enough to stop the harmful behavior it’s targeting. Unlike successful commercial advertisements, the intervention’s creators failed to conduct the psychological and sociological research necessary to understand what drives anorexic behavior in young girls and how they ultimately get on the path to recovery. Further, its message that anorexia is somehow a choice may do more harm than good. If young girls who start dieting believe it’s a choice, will they think they can “try out” anorexia for a bit and then stop when they decide it’s time? Will girls who recognize they have a problem blame themselves because they don’t feel like they can stop? Even more disturbing, there’s evidence that some education-type methods of eating disorder interventions actually promote the disease (2). Will this commercial increase interest in anorexia, and will healthy girls who visit the website, which is a forum for girls who have the disease to talk, have a desire to gain their sense of community? These are all questions that the Face the Issue intervention seems have entirely ignored, to the detriment of healthy and anorexic girls alike. This intervention desperately needs to reevaluate its methods and find a model that accommodates for the unique barriers to recovery that anorexia presents.


REFERENCES
1. Bruche, H. The Golden Cage: The Enigma of Anorexia Nervosa. Cambridge, MA: Harvard University Press 1978.
2. Bruche, H. The Golden Cage: The Enigma of Anorexia Nervosa. 2001 Forward. Cambridge, MA: Harvard University
Press 1978.
3. Yager, J. & Arnold E. Anderson. Anorexia Nervosa. New England Journal of Medicine 2005; 353:1481-8.
4. Kittleson M. The Truth About Eating Disorders. New York, New York: Facts on File Inc. 2005.
5. Levenkron, S. Anatomy of Anorexia. New York, New York: W.W. Norton & Company, Inc., 2000.
6. National Institutes of Health. Eating Disorders: Facts About Eating Disorders and the Search for Solutions.
Washington, DC: National Institutes of Health. http://www.nimh.nih.gov/health/publications/eating-disorders-facts-
about-eating-disorders-and-the-search-for-solutions-booklet.pdf.
7. Face the Issue. Dying to be Thin. http://www.facetheissue.com/anorexiamovie.html.
8. Rosenstock, I. Historical Origins of the Health Belief Model. Health Education Monographs 1974; 2:328-33.
9. Lucas, A. Demystifying Anorexia Nervosa. New York: Oxford University Press, 2004.
10. Edberg, M. Essentials of Health Behavior. Sudbury, MA: Jones and Barlett Publishers, 2007.
11. Salazar, M. Comparison of Four Behavioral Theories. AAOHN Journal 1991; 39: 128-35.
12. Anorexia and Related Eating Disorders, Inc. When you want to help a friend or loved one.
http://www.anred.com/hlp.html.
13. Anorexia and Related Eating Disorders, Inc. For Parents, Partners, and Other Family Members.
http://www.anred.com/pnp.html.
14.American Dietetic Association. Helping a Friend with an Eating Disorder.
www.eatright.org/cps/rde/xchg/ada/hs.xsl/home_4418_ENU_HTML.htm.
15. U.S. Department of Health and Human Services, Office on Women’s Health. Eating Disorders.
http://www.4woman.gov/owh/pub/factsheets/eatingdis.htm.
16. The Klarman Eating Disorders Center at McLean Hospital. Harvard Medical School Affiliate.
http://www.mclean.harvard.edu/patient/child/edc.php.
17. Harvard Medical School Office of Public Affairs. Sharp Rise in Eating Disorders in Fiji Follows Arrival of TV. 1999.
http://www.hms.harvard.edu/news/releases/599bodyimage.html.
18. CNN.com. Skinny Models Banned From Catwalk. Sept. 13, 2006.
http://www.cnn.com/2006/WORLD/europe/09/13/spain.models/index.html.
19.Kilbourne, J. Still Killing Us Softly: Advertising and the Obsession with Thinness (395-418). In: Fallon, P. et al eds.
Feminist Perspectives on Eating Disorders. New York: The Guilford Press, 1994.
20. Wolf, N. The Beauty Myth. New York: Harper Perennial, 2002.
21. Rothblum, E. “I’ll Die for the Revolution but Don’t Ask Me Not to Diet”: Feminism and the Continuing Stigmatization
of Obesity (53-76). In: Fallon, P. et al eds. Feminist Perspectives on Eating Disorders. New York: The Guilford
Press, 1994.
22. USA Today. Bauman, V. “Wannarexic” Girls Yearn for Eating Disorders. August 4, 2007.
http://www.usatoday.com/news/health/2007-08-04-wannarexic_N.htm.
23. Schwartz, S. et al. The Right Answer for the Wrong Question: Consequences of Type III Error for Public Health
Research. American Journal of Public Health. 1999; 89: 1175-80.

“Fat Chance:” The MetroWest Community Health Care Foundation’s Flawed Childhood Obesity Public Education Initiative – Leslie Judge

The prevalence of overweight and obesity in the United States is rising. In 2005, nearly 21 percent of Massachusetts adults were obese (defined as a body mass index [BMI] >30), while nationally, the rates of obesity are even higher (1). Paralleling the rate of concern over adult weight issues, child and adolescent obesity (defined as >95^th percentile according to CDC weight-for-height charts) has become a pressing public health concern. Since 1980, rates of overweight have doubled for children and tripled for adolescents (2). Nationally, 17.1 percent of children aged 6-19 were overweight in 2006 (approximately 9 million children) (2). The problem of childhood obesity is especially concerning because it threatens the physical health of our nation’s youngest citizens. Being overweight increases a child’s risk of developing Type 2 diabetes and the symptoms of cardiovascular disease at a younger age (2). In addition, the likelihood that other conditions, like asthma, sleep-apnea and depression may develop is increased if a child is overweight (2).

In an effort to combat the rising rates of childhood obesity, many public health initiatives have arisen, employing various methods to address the problem. One such initiative was started by the MetroWest Community Health Care Foundation (MCHCF) of Framingham, Massachusetts, in January of 2007. The campaign consisted primarily of billboards and television advertisements, targeted at parents to address the issue of childhood obesity. One billboard, which featured the image of a child’s chubby legs and feet on a scale stated, “Fat chance: Obese children are a good bet for Type 2 diabetes, heart disease, stroke, cancer, sleep-apnea and depression” (3). Another billboard depicted an overweight child from the back and included text asking, “If that’s your kid, what are you waiting for?”(3) The television commercial featured an overweight child snacking and playing video games, while parents danced around the child, in an effort to symbolize parents, ‘dancing around the issue’(3). The media campaign was designed to catch the eye of parents. As Dr. Jerry Wortzman, chairmen of pediatrics at the MetroWest Medical Center stated, “…the campaign is directed at parents, not children…issues surrounding food are mainly controlled by parents. They buy the groceries” (4).

The MCHCF failed to consider several factors when designing their public health initiative. Although the campaign was directed at parents, the derogatory images displayed in the media campaign were easily visible to children, increasing the likelihood that overweight children would self-identify with the negative images portrayed. In addition, the campaign used fear and blame as methods to motivate parents, and therefore decreased their self-efficacy. Finally, by using deprecating images of children, the initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help. The childhood obesity public education initiative, launched by the MetroWest Community Health Care Foundation (MCHCF), was flawed because it failed to take into account basic social and behavioral science principles.

Labeling Theory: The obese label decreases self-efficacy

The MCHCF’s public education initiative to raise awareness of childhood obesity was flawed because it supported the Labeling Theory. Although the campaign was directed at parents of overweight children, the billboards were displayed on highways where they were easily viewed by children and potentially missed by driving adults. These billboards labeled overweight children as the object of ridicule and deemed them socially unacceptable. Depicting overweight children in this negative manner only served to increase the likelihood that overweight children would identify with the socially unacceptable label of ‘obese,’ which decreased self-efficacy among this population (5, 6).

The Social Cognitive Theory (SCT) was developed by Albert Bandura in the 1960s and was based on the earlier Social Learning Theory to explain behavior (6). The Social Learning Theory is based on the concept that individuals learn by modeling the behaviors of others. Bandura took this theory one step further and added the concept of self-efficacy to create the Social Cognitive Theory (6). The concept of self-efficacy is defined as a person’s belief that they have the ability to perform a behavior (6). In essence, the SCT presumes that individuals learn by observing and modeling the behavior of others, but ultimately an individual’s behavior is influenced by whether or not they believe they can do that behavior.

An individual’s self-efficacy is challenged by the concepts developed in Labeling Theory. Labeling Theory explains the behavior of an individual as the result of their identification or ‘label’ as a member of a particular group. An individual’s identification as a member of a particular group allows that person to adopt the characteristics as defined by membership in the group, and therefore influences the person’s behavior (5). Labels come with their own connotations; some positive and some negative. Often times, labels are used in society to stereotype people and deem them “socially unacceptable.” Applying negative labels to members of a group decreases their self-efficacy and encourages society to further stigmatize that group (5). As Link and Phelan state in their article entitled Stigma and its Pubic Health Implications, “…when people are labeled, set apart, and linked to undesirable characteristics, a rationale is constructed for devaluing, rejecting, and excluding them” (5). If an individual is identified with a particular label, for instance “obese” or “fat”, and believes the negative characteristics that society uses to define that label like, “lazy”, “ignorant”, “ugly” and “undesirable”, than a person may identify themselves with these characteristics and adopt these shameful attributes (5).

In an article examining the stigma of overweight in U.S. culture, Crocker and colleagues identify stigmatizing conditions as labels that, “…lead to the rejection of individuals because those individuals have an attribute that compromises their humanity in the eyes of others” (7). Crocker et al goes on to talk about the fact that although there are numerous conditions for which a person may be stigmatized in society, including racial or ethnic group membership, religious affiliation, physical handicaps and sexual orientation, the stigma of being overweight may be the most debilitating (7). Unlike some conditions that are deemed socially unacceptable but can be concealed from others, like sexual preference, overweight is immediately visible to society. Further blurring the lines between stigmatized groups is the fact that overweight and obesity is more prevalent in certain ethnic and racial populations, particularly among African Americans and Mexican Americans (7). In addition, unlike other stigmatizing conditions like physical handicaps or being seen as ‘poor’ or ‘disadvantaged’ which might elicit sympathy or understanding, Crocker states that, “people who are overweight elicit almost uniformly negative responses from others”(7). In this way, being overweight in society packs a double punch. Being overweight is viewed as, “…both an abomination of the body that elicits immediate negative responses from others on the basis of aesthetically displeasing qualities, and a character stigma that carries with it shame and guilt of self-blame for a moral failure (8).

Applying labels to groups does not encourage the individuals within that group to change in order to avoid the label. In fact, the result of labeling is quite the opposite. According to Allon, overweight people tend to interpret their social experiences in terms of their weight and are more likely than members of other stigmatized groups to see their weight as the cause of their social outcomes, particularly negative outcomes (8). Overweight individuals are much more likely to blame themselves for the negative reactions their weight provokes from society rather than blaming the prejudice that society condones against the overweight (8). As Allon states, “…consequently, overweight persons may be vulnerable to depressed affect and low self-esteem” (8).

If we apply the label of “obese” to children the effects are just as harmful as in their adult counterparts. In a study that evaluated the contributions of weight, skin tone, peer teasing, and parental appraisals of a child’s size to self-esteem in African American children ages 5-10, Young-Hyman et al found that being overweight was associated with low self-esteem and increased body size dissatisfaction (9). In addition, parental perception of child’s size as “heavier than average”, and the child’s own skin tone dissatisfaction were also associated with low self-esteem in the children studied (9). Young-Hyman found that heavier children were also more apt to act out in school or be reported as having behavioral and psychosocial problems (9). Overweight children in this study also reported that weight-related peer teasing was especially hurtful, and direct correlations were observed between the amount of teasing a child experienced and their decreased self-esteem (9). Several other studies in children from various ethnic and racial groups have reported similar findings in the relationship between obesity and decreased self-efficacy regarding weight in children and adolescents (10-12). The result of declining self-efficacy in children is especially problematic because their experiences in childhood largely shape their perceptions of their abilities as they move towards adulthood (10-12).

Billboards touting the MCHCF’s anti-childhood obesity message were displayed prominently on highways and busy streets in suburban Massachusetts. Although the MCHCF’s campaign was directed at parents of overweight children, the billboards were displayed in locations where they were easily viewed by children and potentially missed by driving adults. As one resident of Natick, Ma noted, “I don’t know where they got the idea that kids can’t see these billboards…fat kids are already teased mercilessly” (3). In addition, television commercials were shown during regular nightly programming and on weekend afternoons, which are both times that children are likely viewers. These billboards and TV ads contributed to the social labels of overweight children by portraying them as socially unacceptable and undesirable. Depicting overweight children in this negative manner, and in locations clearly viewed by the children themselves only served to increase the likelihood that overweight children would identify with the socially unacceptable label of “obese,” which decreased self-efficacy among this population.

The Blame Game: Decreased self-efficacy in parents of overweight children

As previously discussed, the concept of self-efficacy states that a person’s ability to perform a behavior is directly impacted by their belief that they can do the behavior (5). The MCHCF’s public education initiative was flawed because it did not take into account the concept of self-efficacy as defined by the Social Cognitive Theory. Placing blame for the rising childhood obesity epidemic on the shoulders of parents only served to decrease self-efficacy among parents of obese children. Billboards that asked, “If that’s your kid, what are you waiting for?” and a television commercial that featured an overweight child snacking and playing video games, while parents danced around the child, in an effort to symbolize parents, ‘dancing around the issue’ unfairly targeted parents. Parents were ridiculed as the cause of the problem, making parents feel shunned and outcast by a society that favors thinness.

Blaming parents for their child’s overweight decreases the self-efficacy of the parents in addressing the problem. Attributing blame, in an effort to inspire feelings of shame, fear and guilt to motivate parents was the strategy that the MCHCF hoped to employ. However, utilizing fear of their child’s overweight and its potential health implications to motivate parents was not an effective strategy. As noted by Vedantum in a Washington Post review of current research on effective motivation strategies to influence health behaviors, “scaring people about the health risks of smoking and obesity…is an ineffective way to change their behavior…giving people the confidence that they can make such changes is far more effective, according to an analysis of hundreds of research studies involving 47 different kinds of behaviors” (13). The article noted that in contrast to motivational strategies that used positive messages to increase self-efficacy, “…public interest methods that seek to induce fear, guilt, or regret were ineffective” (13).

In addition to being a poor strategy for motivation, creating feelings of fear, guilt and shame in the minds of parents of overweight children might actually contribute to the decreased health of the children. The vilification of parents potentially decreases the likelihood that overweight children will receive appropriate medical care. Research supporting this concept has not been documented in parents of overweight children to date but the phenomenon has been considered in parents who smoke around their children and it can be argued that the situations have many similarities. As parents of overweight children are often deemed “abusive” or “neglectful” for allowing their children to eat too much or remain sedentary, parents who smoke around their children are also considered to be “bad parents” for exposing their children to potentially harmful cigarette smoke (14-15).

With the recent attention on the effects of secondhand smoke on children, parents who smoke around their kids have been blamed for increased rates of childhood asthma and ear infections and threatened with policies that would make their conduct unlawful (14). Similarly, the mother of an eight year-old British boy was recently threatened with removal of the child from her care because his obesity was deemed to be her fault for “allowing” him to gain so much weight (16). Laws and policies put in place to seemingly “protect” children might not achieve their desired outcomes. As Siegel argues in his blog from 2006, “…imposing criminal or even civil penalties, referring parents who smoke around their children to authorities, or treating smoking around children as a form of child abuse, we would actually be imposing a huge barrier to children’s access to appropriate medical treatment for conditions that are associated with secondhand smoke exposure” (14). Siegel goes on to compare this problem to that of the children of illegal immigrants. It is well-documented that many immigrant families are reluctant to seek proper medical care because they fear the discovery of their “illegal” status and the potential for deportation (14, 17). In the same way, it can be argued that blaming parents for their child’s overweight might decrease the likelihood that parents would take their overweight child to the physician. In this way, overweight children are placed at greater medical risk if parents believe that they will be judged or criticized at the pediatrician’s office if their child presents with a weight-related problem like Type 2 diabetes or high blood pressure.

Flawed Purpose: Perpetuating prejudice against overweight individuals

In addition to being an ineffective motivational strategy to parents and a method of decreasing self-efficacy in both parents and their overweight children, the MCHCF’s public education initiative was flawed because it contributed directly to the ongoing prejudice against overweight individuals. The use of negative images to portray overweight children on billboards and on television only contributed to the idea that it is acceptable in present culture to ridicule people based on their weight. In this way the public education initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help.

In an article examining childhood obesity in a societal context, Schwartz and Puhl state, “the societal message about being fat in the 21^st Century is clear: it is bad to be fat. But why is it bad? Clearly, there are serious medical consequences of obesity…However, obese people are not discriminated against because they are medically compromised. They are stigmatized because their obesity is viewed as a reflection of poor character” (18). Schwartz and Puhl go on to discuss the manner in which overweight children are increasingly becoming the objects of ridicule. They cite prejudiced attitudes from other children that lead to bullying and on a daily basis, in addition to the more covert stigmatization that overweight children face from teachers, doctors and parents (18).

The stigmatization that overweight people face from parents, health professionals, and in the academic setting is particularly astounding. A study of obese college-aged females reported that once in college, female obese students receive less financial support from their parents than their non-obese peers receive, even when parents have similar income, family size, and number of children (19). Negative attitudes about obese patients have been documented among physicians, nurses, and medical students (20). Common perceptions among health professionals include beliefs that obese patients are, “unintelligent,” “unsuccessful,” “weak-willed,” and “lazy” (20). This prejudice may lead to poor medical care for obese patients as physicians admit not intervening as much as they should with obese patients simply because weight loss counseling is “inconvenient” (20). The same study found that nurses were hesitant to “touch” obese patients and 24% of nurses described obese patients as “repulsive” (20). At the college level, educational discrimination based on weight has also been documented (20). Obese students are less likely to be accepted to college than average-weight students, despite having equivalent application rates and academic performance (20).

What is perhaps more concerning is the fact that negative attitudes towards overweight children are learned at a young age. One study found that pre-school children aged 3-5 years old judged an overweight child to be a “mean” and a “less desirable playmate” than another child of average weight (21). The study found that 3 year-olds associate overweight children with the traits of being “mean”, “stupid”, “ugly”, “selfish”, “lazy”, “stupid”, “dishonest”, and “subject to teasing”, while average weight children were considered, “clever”, “healthy”, “attractive”, “kind”, “happy”, “popular” and “desirable playmates” (21). Another study looked at the negative stereotyping associated with overweight among fourth– and sixth-grade students (21). The study found that these children endorsed negative stereotypes of both children and adults who were overweight (22). The beliefs of the fourth- and sixth-graders were also assessed about the controllability of obesity and overweight. The study found that most fourth- and sixth-graders believed that obesity was under personal control and that this belief was positively associated with negative stereotyping (22).

The attitudes expressed by the preschool and middle-school children in these studies are a product of social norms that are widespread in current culture. The early stigmatization of overweight children may explain their lower self-esteem and greater shame, humiliation compared with normal-weight children (23). To make matters worse, the level of negativity in the way overweight children are viewed by their peers, increases as children get older, suggesting a steady rise in the ridicule and prejudice experienced by overweight children throughout their development (23). One study conducted by Adams and colleagues observed the way that parents may subtly convey their stereotypic beliefs about obese children at home (24). In the study parents were given three pictures of children (an average-weight child, a handicapped child, and an obese child) and asked to tell a story about each picture to their own child. In the stories, the parents portrayed the obese child as having the most negative attributes and lowest self-esteem of all three children (24). In addition, there were striking differences in the rate of successful outcomes at the end of the stories. The obese child had 0% successful story outcomes while the handicapped child had 85% successful story outcomes and the average-weight child had 45% successful story outcomes (24). This study supports the idea that parents communicate with their children in ways that endorse stereotypes about obese children. It also shows that parents themselves house the stereotypes that may potentially influence their own treatment of obese children in addition to their children’s treatment of obese children in society.

It is clear from current research that there is a connection between depression and childhood obesity (10-12), but researchers have not clearly determined a path of causality between the two factors. Are overweight children more prone to depression considering the social stigmatization that confronts them on a daily basis, or are depressed children more prone to obesity due to their poor self-esteem and lack of self-efficacy? This is a question that continues to be hotly debated. What can be unequivocally determined is that overweight children are the objects of ridicule, and these children do have higher rates of depression and poor self-esteem than normal-weight children (10). The MCHCF’s public education initiative was flawed because it contributed directly to the ongoing prejudice against overweight children. The use of derogatory pictures to portray overweight children on billboards and on television only added to the negative and prejudicial images present in current society that condone discrimination based on weight. In this way the public education initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help.

Conclusions

The MCHCF failed to consider several factors when designing their public health initiative. Although the campaign was directed at parents, the derogatory images displayed in the media campaign were easily visible to children, increasing the likelihood that overweight children would identify themselves with the negative images portrayed. In addition, the campaign used fear and blame as methods to motivate parents, and therefore decreased their self-efficacy. Finally, by using deprecating images of children, the initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help. The childhood obesity public education initiative, launched by the MetroWest Community Health Care Foundation (MCHCF), was flawed because it failed to take into account basic social and behavioral science principles.

References

1. The Massachusetts Health Policy Forum. Overweight and Obesity in Massachusetts: Epidemic, Hype or Policy Opportunity? Boston, MA: The Massachusetts Health Policy Forum, 2007.
2. National Conference on State Legislatures. Childhood Obesity – 2006 Update and Overview of Policy Options. Washington, DC: National Conference on State Legislatures. http://www.ncsl.org
3. Haneisen R. The politics of fat. The Framingham Tab. February 16, 2007
4. Drake J. Obesity ads aim to jolt parents. The Boston Globe. January 28, 2007.
5. Link BG, Phelan JC. Stigma and its public health implications. Lancet 2006; 367:528-529.
6. Edberg M. Social cognitive theory (pp. 51-61). In Edberg M: Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
7. Crocker J, Cornwell B, Major B. The stigma of overweight: Affective consequences of attributional ambiguity. Journal of Personality and Social Psychology 1993; 64:60-70.
8. Allon N. The stigma of overweight in everyday life (pp.130-174). In: Woldman B.B., ed. Psychological aspects of obesity. New York, NY: Van Nostrand Reinhold, 1982.
9. Young-Hyman D, Herman-Wenderoth L, Bozylinski K. Obesity, Appearance, and Psychosocial Adaptations in Young African American Children. Journal of Pediatric Psychology 2003; 28: 463-472.
10. Mustillo S, Worthman C, Erkanli A, et al. Obesity and psychiatric disorder: developmental trajectories. Pediatrics 2003;111: 851-859.
11. Sheslow D, Haasink S, Wallace W, DeLancey E. The relationship between self-esteem and depression in obese children. Ann NY Acad Sci. 1993;699:289-291.
12. Csabi G, Tenyi T, Molnar D. Depressive symptoms among obese children. Eat Weight Disord. 2005;5:43-45.
13. Vedantam S. Fear is a weak motivator. The Washington Post; A02:September 29, 2006.
14. Siegel M. Making it unlawful to smoke around children could have detrimental effect on childrens’ health, especially among disadvantaged populations. The Rest of the Story: Tobacco New Analysis and Commentary (blog). May 22, 2006. Available at: http://tobaccoanalysis.blogspot.com/2006/05/in-my-view-making-it-unlawful-to-smoke.html.
15. Davison K.J,Birch L.L. Weight status, parent reaction, and self-concept in five-year-old girls. Pediatrics 2001;107: 46-53.
16. Bannerman L. Go on a diet or be taken into care, 14-stone boy is told. The Times: February 26, 2007.
17. The Access Project and the National Health Law Program. Immigrant access to health benefits: a resource manual. Washington, DC: National Health Law Program, 1999-2000.
18. Schwartz MB, Puhl R. Childhood obesity: a societal problem to solve. International Association for the Study of Obesity 2003; 4: 57-71.
19. Crandall CS. Do parents discriminate against their heavy-weight daughters? Pers Soc Psychol Bull. 1991;21:724-735.
20. Puhl R, Brownell KD. Stigma, discrimination, and obesity (pp 109-110). In: Fairburn CG, Brownell KD, eds. Eating disorders and obesity: A comprehensive handbook. New York, NY: Guilford Press, 2002.
21. Cramer P, Steinwart T. Thin is good, fat is bad: How early does it begin? J Appl Dev Psych 1998;19:429-451.
22. Tiggermann M, Anesbury T. Negative stereotyping of obesity in children: The role of controllability beliefs. J Appl Soc Psych 2000; 30:1977-1993.
23. Latner JD, Stunkard AJ. Getting worse: The stigmatization of obese children. Obes Res 2003; 11(3): 452-456.
24. Adams GR, Hicken M, Salehi M. Socialization of the physical attractiveness stereotype: Parental expectations and verbal behaviors. Int J Psychol 1988;23:137-149.

Failures Of The Jump Up & Go Campaign: What is Really Making Adolescents Unhealthy? – Diane Wheaton

Introduction: A rational-empirical approach to solving the nation’s obesity epidemic

The Jump Up & Go campaign is a multidimensional intervention campaign that aims to address some important health issues in today’s youth and adolescents. In recent years, the prevalence of overweight and obesity has reached epidemic proportions. Currently, approximately 66% of American adults aged twenty and above are overweight (BMI > 24.9), while approximately 32% are obese (BMI > 29.9) (1). Of even greater concern is the prevalence of overweight among children and adolescents. Approximately 19% of children aged 6-11 and 17% of adolescents aged 12-19 are overweight (1). All of these statistics have increased dramatically within the last decade (2). These numbers present an area of concern because individuals who are overweight as children or who have overweight parents have a significantly increased risk of being overweight or obese as adults. The comorbidities associated with overweight and obesity present an additional set of issues, which the US healthcare system struggles to address every day. Some of these include increased risks for hypertension, heart disease, diabetes, stroke, poor bone and muscle strength, some types of cancers, and social and emotional problems (3). The economic consequences of these conditions as they relate to overweight and obesity totaled approximately $92.6 billion in 2002 (3). A quick review of these statistics immediately reveals the urgent need to address the nation’s rising obesity epidemic, especially among children and adolescents.

The Jump Up & Go campaign has identified and targeted three factors that are currently contributing to the obesity epidemic among youths. These factors are physical inactivity, poor diet and nutrition, and an overabundance of “screen time” including time spent watching television, playing video games, or using a computer. The Jump Up & Go campaign takes a rational-empirical approach to addressing these issues by attempting to educate children, parents, teachers, and healthcare providers on the importance of establishing healthy lifestyle behaviors at a young age. The focus of the campaign is the ‘5-2-1 philosophy’, which advocates for five or more servings of fruits and vegetables, fewer than two hours of screen time, and one or more hours of activity every day (4). The campaign promotes these behaviors by educating and providing resources to children, parents, teachers, and physicians such as healthy recipe ideas and nutrition tips, activities for the classroom, daily logs, and other materials for evaluating and promoting healthy behaviors within school systems (4). However, this approach does not consider some important implications that are central to public health interventions among children. The Jump Up & Go campaign is inadequate in addressing the public health concerns associated with physical activity, poor nutrition, and excessive “screen time” in children and adolescents because it does not consider the underlying social contributors or behavioral models that are essential in youth development.

Issues associated with access to a healthy lifestyle

One of the most important factors to consider when developing a public health campaign is the availability of resources beyond the control of the target population. The Jump Up & Go campaign fails to address this. When a child or family does not have access to healthy food choices or venues for safe physical activity, these interventions are doomed to fail. Research shows that regardless of the level of knowledge one may have regarding appropriate health behaviors, the inability to access healthy foods and physical activity will remain a constant barrier to behavior interventions (5). These issues are exaggerated especially in low socioeconomic neighborhoods and populations (6).

Access to healthy foods is a key determinant in the success of a nutrition intervention program. The Jump Up & Go campaign encourages children to consume at least five servings of fruits and vegetables every day. The campaign assumes that such fruits and vegetables are readily available. However, increasing costs of fresh produce and increasing prevalence of fast food restaurants have contributed significantly to the decreasing levels of fruit and vegetable intake among children (6). In addition to the rising cost of fresh produce, families may find it difficult to buy fruits and vegetables due to inconvenient locations of grocery stores. The concept of built environment has recently become a topic of discussion among public health professionals due to its contributions to urban sprawl and to many families’ inability to shop at healthful grocery stores (5). In addition to the lack of access to healthy foods, many children and their families find that the plethora of fast food restaurants and unhealthy snack options available in schools and stores offer cheaper and more satisfying meal choices (5). In today’s capitalist society, fast food chains like McDonald’s, Taco Bell, Dunkin Donuts, Domino’s, and Dairy Queen can dominate the food market and offer a wide range of inexpensive food options that are high in fat and sugar, low in vitamins and minerals, and in portions that far exceed the caloric needs of adolescents, directly contributing to the rising rates of pediatric obesity. The Jump Up & Go campaign does not address these issues of access to nutritional food choices and therefore cannot possibly expect to obtain full compliance with their five-a-day recommendation for fruits and vegetables.

Access to physical activity opportunities presents another significant barrier to healthy behaviors, which the Jump Up & Go campaign does not address. The campaign advocates for children to engage in physical activity for at least one hour every day. However, in order to fulfill this requirement, children must have access to safe parks, playgrounds, recreational facilities, and neighborhood streets. These venues are often not available for children on a daily basis. Oftentimes public parks and playgrounds are too far away for children to access by walking or biking. Working parents may not be available to drive their children to such activity centers. Neighborhood streets may be unsafe due to traffic, poor lighting, or crime rates (5). All of these barriers combined result in many children remaining indoors, entertaining themselves with television and video games (5). A study conducted by the Department of Kinesiology and Physical Education at the Wilfrid Laurier University in Canada proved that the leading causes of resistance to behavioral change as it relates to physical activity among adolescents are infrastructural in nature and include low access to proper physical fitness centers (7). In addition to the physical barriers to activity, there exist mental barriers as well. Numerous studies have demonstrated correlations between an individual’s perceptions of their surrounding environments and the levels of physical activity (8). When a child or parent feels that their community is not “activity-friendly” or dangerous, they will often fail to engage in regular physical activity. Contributors to a community’s “activity-friendliness” include crime rates, street lighting, distances between residential and commercial areas (also known as ‘land use’), aesthetics, modes of transportation, traffic, and building and land maintenance (8). The Jump Up & Go campaign does not consider theses barriers to physical activity when they try to promote one hour of physical activity. When a child or parent cannot gain access to physical activity centers, exercise levels cannot increase, regardless of educational and promotional interventions.

The Jump Up & Go campaign attempts to educate children, parents, teachers, and physicians on the necessity of adequate nutrition and activity. However, by simply attempting to educate and inform, the campaign fails to consider issues of access to good nutrition and physical activity. Barriers such as these require more than just a rational-empirical intervention. They require policy change and government involvement. The Jump Up & Go campaign cannot possibly expect children to change their dietary and activity patterns while these barriers remain in place.

The Theory of Self-Efficacy: When is it too much?

Another negative reflection of the Jump Up & Go campaign is its failure to consider the Theory of Self-Efficacy. The Theory of Self-Efficacy centers on the idea that an individual’s personal expectations and perceptions regarding their ability to change will determine how effectively they will make that change (9). If an individual believes with conviction that he or she can successfully execute the necessary processes to make a behavioral change and to obtain the perceived outcomes and benefits, the person is more likely to be successful (9). Many public health interventions have employed the Theory of Self-Efficacy due to its widely applicable standards to almost any population and any behavioral change (10). However, the Jump Up & Go campaign does not utilize the messages of this theory and therefore cannot truly be successful.

The Jump Up & Go campaign establishes the 5-2-1 goal: five servings of fruits and vegetables, two or fewer hours of screen time, and one or more hours of physical activity every day. These changes could indeed contribute to an overall improvement in a child’s lifestyle, however, executing so many changes may be difficult if not impossible for most children and their families to make at the same time. Telling a child to make these changes is not sufficient to make them see the potential benefits, which may deter him or her from trying to make any changes at all (11). Additionally, attempting to enforce so many changes all at once, may overwhelm the child and their family, making them feel that they cannot achieve such lofty goals. This could in turn cause the family to abandon the suggestions entirely (11). In cases such as this, or in cases where the child does attempt to make the changes and fails, the campaign does not offer any suggestions for alternative methods of behavioral change. This could cause the family to relapse into old behaviors rather quickly. By challenging the target population to make so many changes, the campaign may in fact deter children and families from making any positive adjustments (11).

The Jump Up & Go campaign further violates the Theory of Self-Efficacy by involving too many stakeholders in the change process. The campaign provides educational and promotional materials for children, parents, teachers, school administrators, and medical care personnel. All of these materials offer suggestions that pertain to each stakeholder’s role in the child’s life, however, they do not integrate well with each other, nor are there sufficient opportunities for the stakeholders to engage in group decision making. As a result, the child may receive slightly different suggestions from each role model, which can cause conflict (12). A school administrator and a parent may want different things for the child or have different motivations and resources available to them. As a result, conflict and confusion may result within the child causing him or her to ignore the suggestions altogether (7). An example of what happens when too many authority figures are involved in an intervention, will be provided later in this paper. If the campaign took a more active approach to engaging all stakeholders in a group decision process, the result could be a more clear and thorough message for the child, which could enable the child to feel more confident in his or her ability to make the suggested behavioral changes.

The Theory of Self-Efficacy is a widely accepted and utilized behavioral theory in public health. Its implications in a program such as the Jump Up & Go campaign are important to the success of the intervention. This campaign fails to consider the central concepts of the theory by forcing too many changes at once and involving too many individual stakeholders. These factors combined may decrease the child’s self-efficacy resulting in a failure to make a change.

Social Learning Theory: The importance of understanding how children really learn

A second theory that has great implications on public health interventions is the Social Learning Theory. The Social Learning Theory maintains that individuals learn behaviors through their observations of others (10). This theory is especially important among children, who are very impressionable and quickly observe and imitate the habits that parents, siblings, teachers and friends exhibit (12). When public health officials try to promote behavioral change in youth and adolescents, they must consider the ways in which children really learn. The Jump Up & Go campaign contends that the best way to impart a behavioral change is through education and knowledge. This is inconsistent with the messages of the Social Learning Theory. The use of knowledge and education is ineffective by itself in implementing any significant behavioral change because it lacks a modeling component that is essential in youth development (12).

Children learn their behaviors from the individuals around them (12). Therefore, if children are expected to make changes, they must receive consistent signals from their role models. Role models must not only demonstrate the desired behavior, but also must demonstrate the benefits of performing the behavior. The child must see and understand why the desired behavior is important and how they can practice the behavior themselves (11). Additionally, parents, teachers, and friends, must portray the behavior as something that is attainable but also fun; children often do not respond well to harsh instructions. Telling a child that they must do something is inefficient for establishing a desired behavioral change (12).

Additionally, demonstration of behavioral changes must be consistent among all role models. It is essential that parents, teachers, physicians, and friends, exhibit and promote the same behaviors. This will increase the child’s feeling of self-efficacy as previously discussed as well as help to ensure that the desired action is more effectively engrained in the child’s mind. It is important that all role models send the same signals so that the child receives a consistent message that is easy to follow and understand (12). The Wilfrid University study found a striking association between lack of physical activity and mixed messages from authority figures. Many parents of adolescents were telling their children that sports were a waste of time, which detracted from their academic studies. Teacher and school administrators, however, supported athletes and encouraged further leisure time activity for all students. The result was a decrease in behavioral change (7). The Jump Up & Go campaign does not ensure consistencies among authority figures, which can allow for situations such as the one described in the Wilfrid study. There is limited interaction between the many stakeholders in this campaign, which may lead parents, teachers, and other involved members to take individual approaches. When too many stakeholders are involved, as in the Jump Up & Go campaign, it can be extremely difficult to keep everyone on the same page regarding the best course of action to promote behavioral change.

Social Learning Theory can have very important implications in behavioral interventions, especially among children. Until the Jump Up & Go campaign realizes and successfully implements the messages of this theory, the intervention can never reach its full potential. The campaign must go beyond an educative approach to behavioral change and incorporate important modeling theories as well.

Conclusion

Massachusetts’ Jump Up & Go campaign has the potential to impart some excellent behavioral changes in today’s youth, however the campaign comes up short in many aspects. The campaign attempts to promote healthier lifestyles in children at a young age so that they may retain those behaviors through life. These behaviors include increased fruit and vegetable consumption (along with general improved nutrition), decreased “screen time,” and increased physical activity. These three goals are legitimate and well founded however, the Jump Up & Go campaign will be unsuccessful in initiating and maintaining such changes. The campaign does not consider the issues surrounding access to proper nutrition and physical activity opportunities. The campaign also ignores the Theory of Self-Efficacy and the Social Learning Theory, both of which are essential in developing behavioral interventions, especially among children and adolescents.

Public health campaigns that aim to impart behavioral changes must look at the evidence supporting the real ways in which children learn and grow. Rational-empirical approaches will always fall short when they stand on their own, especially when children are involved. Behavioral interventions must go beyond education and move into the domain of teaching by example. They must recognize the inherent capabilities and cognitive limitations of children so as not to enforce too much change at once. Finally, behavioral interventions must recognize the factors affecting behavior that are beyond the control of the individual. Social factors such as built environment and access to proper nutrition require political and governmental resources as well. The Jump Up & Go Campaign has great potential to make changes however, there are serious flaws that the campaign must address if it expects to obtain all of the goals in their 5-2-1 philosophy.

REFERENCES

1. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Hyattsvile, MD: National Center for Health Statistics 2004.

2. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Sysetem. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion 2005.

3. Center for Disease Control and Prevention. Overweight and Obesity. Atlanta, GA: Department of Health and Human Services 2007.

4. Blue Cross Massachusetts. Jump Up & Go!. Blue Cross Massachusetts. Bluecrossma.com.

5. Sallis JF, Glanz K. The Role of Built Environments in Physical Activity, Eating, and Obesity in Childhood. The Future of Children 2006; 16(1): 89-108.

6. Burton NW, Turrell G, Oldenburg B. Participation in Recreational Physical Activity: Why do Socioeconomic Groups Differ?. Health Education & Behavior 2003; 30:225-240.

7. Berry T, Naylor PJ, Wharf-Higgins J. Stages of Change in adolescents: an examination of self-efficacy, decisional balance, and reasons for relapse. Journal of Adolescent Health 2005; 37:452-459.

8. Brennan Ramirez LK et al. Indicators of Activity-Friendly Communities: An Evidence-Based Consensus Process. American Journal of Preventive Medicine 2006; 31(6): 515-524.

9. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39(3): 128-135.

10. Choi KH, Yep GA, Kumekawa E. 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.

11. Bradley RH, Corwyn RF. Home Environment and Behavioral Development During Early Adolescences: The Mediating and Moderating Roles of Self-Efficacy Beliefs. Merrill-Palmer Quarterly 2001; 47(2): 165-187.

12. Hoelscher DM, Evans A, Parcel GS, Kelder SH. Designing effective nutrition interventions for adolescents. Journal of the American Dietetic Association 2002; 102(3): S52-S63.