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

Common wisdom within bicycle campaigns suggests that the finding of strong positive correlation between helmet legislation and head injuries supports the adoption of legislation for certain age groups (1,2). In 2005, there were 784 fatalities and an additional 45,000 injuries sustained in traffic crashes. Nearly one-fifth (18%) of the fatalities involved cyclists aged 10-20 years old; a number disproportionate to the population size (3). As such the issue of bicycle safety, especially among youth, is one that merits a concerned and thorough public health discussion. However, campaigns have failed to employ comprehensive interventions that successfully target this at-risk group.
As H. L. Mencken would say, for every complex problem, there is a solution that is simple, neat, and wrong. This paper contends that helmet legislation as the primary thrust and cornerstone of bicycle safety campaigns among youth is a cookie cutter solution for three primary reasons. First, it misplaces the focus of campaigns and detracts from other safety behaviors. Second, it is an individual-level intervention that ignores a range of societal and structural factors that increase bicycle safety. Finally, it fails to take into account the importance of youth attitudes and social dynamics as important behavioral determinants. The overall effect is a myopic paradigm with which bicycle safety is approached, and this has harmful consequences for the overall aim of campaigns.
Misplaced Focus
Legislation misplaces the focus of bicycle safety campaigns by putting helmets at the helm of the issue. Compliance with helmet laws is hailed as the primary safety behavior whilst the notion of a comprehensive attitude of safety is set on the back burner. Even non-legislative interventions such as research into helmet safety and aesthetic design, helmet giveaways, and educational programs for proper fit are spin-offs of the centrality of helmet usage. The implications of this tunnel vision are significant. The chance of an accident decreases significantly when cyclists use hand signals, are equipped with a safe bicycle and appropriate lighting equipment, travel at safe cycling speeds, and are unimpaired in their judgment by poor visibility or intoxication (4). Unfortunately, there has been a lack of emphasis upon such aspects of behavior in bicycle safety campaigns.
There is significant debate polarized around the misplaced center of helmet legislation. Opponents of legislation often argue that it constitutes unwarranted infringement of civil liberties of cyclists, and turns a pleasant leisure activity into ‘medicalized behavior (4,5).’ As a retort, proponents often portray wielders of such arguments as being unwilling to adopt relatively minor behavioral changes for the sake of safety, and dismiss them as being unreasonable (6). Such debates have tied up bicycle safety campaigns in judicial and policy-making circles, and because of the emphasis on the primacy of legislation, have precluded the widespread implementation of other measures. In addition, the political presumption that legislation is a primary solution to the problem of safety has crept into the public health domain. The issue has been defined, assessed, intervened upon and evaluated through the lens of helmet usage. In particular, evaluative studies often either control for or mention in passing a range of safety behaviors deemed confounding to the true object of study-- the efficacy of helmet legislation (1). This generates a cycle of less than optimal interventions and evaluations.
The focus on legislation may be an impediment to those who lack the self-efficacy to wear a helmet. These cyclists automatically assume themselves more prone to accidents and fail to adopt other behaviors that would greatly increase safety, even if helmets are not worn. This introduces a compounding phenomenon where the choice to not wear a helmet actually becomes a risk factor for not adopting other safety behaviors. In other words, the very population that campaigns hope to target is the same population that may feel marginalized and begin to characterize themselves as being ‘unsafe cyclists.’ This may preclude them from adopting a holistic attitude towards safety. Studies in support of this theory have shown that those who do not wear helmets are also less likely to “ride in... bicycle paths than city streets, obey traffic laws, wear fluorescent clothing and use lights at night (8).” This may be the most dangerous impact of all. While a helmet may serve as protection in the event of an accident, a behavior such as using a bicycle light may prevent an accident altogether (9). The chance of an accident relates directly to the visibility of the cyclist to motorists and pedestrians. Based on this principle, French law omits legislation pertaining to helmets, but mandates instead that retailers equip bicycles with lights and gives police the authority to stop cyclists for non-compliance with light laws (10).
Individual-Level Intervention
Helmet legislation places the responsibility for accident prevention squarely on the shoulders of the cyclist. It is an individual-level intervention that fails to highlight a range of societal and structural factors that increase bicycle safety. To begin with, the behavior of motorists is crucial to overall road safety. Significant injuries to a cyclist are 3-5 times more likely in collisions with motor vehicles as compared to bike only crashes. In most cases, both parties are at fault. Unfortunately, blame often falls on the cyclist, thanks in part to the societal expectations that they be the ones to exhibit safe behavior. The National Highway Traffic Safety Administration reinforces the importance of mutual responsibility and respect so that each party knows they are responsible for safety (4).
The speed at which vehicles are traveling greatly impacts safety. Trial zones in which 20mph limits were enforced had significantly lower incidence of injuries and fatalities than their control counterparts (11). Injury criteria to the head (79%), chest (30%), and pelvis (16%) were reduced with a 6 mph decrease in speed (12). In this particular intervention, legislation may be a powerful tool to increase road safety.
Structural factors also play an important role in reducing the chance of collision. The 2006 NHSTA Bicycle Report shows that 66% of fatalities occur in urban areas between the hours of 5 and 9 p.m, the busiest hours of traffic. It recommends the addition of additional bike paths and lanes in urban environments that limit the co-mingling of traffic and bikes. As a stark example of the successes of bicycle-specific road constructs, there were 225 bicyclist fatalities In New York City between 1996 and 2005, but only one of these occurred when a bicyclist was in a marked bicycle lane (13). Other important structural contributors to safety are “Share the Road” signs and up kept roads.
One of the most serious accusations leveled at helmet legislation is that it decreases the number of cyclists on the road and thereby increases risk per remaining cyclist—whether or not they are compliant with the enforced laws. The Safety in Numbers theory proposes that the incidence of fatalities and injuries does not increase linearly with the number of cyclists. Instead, it follows a power curve whereby the risk of collision decreases by roughly -0.6 the power of the number of people cycling. Thus a two-fold increase in numbers of cyclists would cause collisions to only disproportionately increase by a 32% and summarily benefit everyone (14). In societies where a larger proportion of society actively participates in cycling, motorist are more likely to be cyclists themselves and be more aware of other cyclists, hence avoiding more accidents (9).
Youth Culture and Attitudes
Youth, especially those who deliberately engage in dangerous cycling activities, are inevitably bound to the youth culture. As such, interventions need to be developed in a culturally sensitive and competent manner (15). This is particularly true given that youth between the ages of 11 and 20 years have the lowest helmet usage rates (16). Among youth, attitude is a particularly strong behavioral determinant. The Truth campaign, a highly successful anti-smoking intervention directed at Florida youth, was based on the premise that adolescents want to be told the facts and then left to make their own educated decisions (17). Safety helmet legislation may come across as being restrictive and dogmatic, inciting some youth to respond negatively and potentially participate in more dangerous behaviors as a means of resisting authority.
Rebellious attitudes aside, many youth have logical and practical reasons for their choice to not wear helmets. Research on college-aged youth has showed that they think helmets are uncomfortable (20%), restrict the natural feeling one gets from riding a bike (23%), make them look silly (36%) or are a nuisance to store between rides (33%) (11). Some of these perceptions may seem trivial but are apparently significant barriers to helmet use. While it must be conceded that legislation may be the positive tipping-point factor in the decision to wear a helmet, the manner in which youth reach the decision is crucial. It will inevitably effect how they frame the issue in their discussions with peers and how they will behave in the absence of enforcement or once they reach an age that excludes them from jurisdiction. Importantly, a choice that is self-initiated is more likely to be maintained. A detailed report comparing pre- and post-legislation counts concluded that youth were particularly resistant to changes not self-enforced. In the year following helmet legislation, teenagers registered a 44% drop in helmet usage compared to a 29% drop in adults (18). It is therefore crucial that youth be viewed in the context of their own youth culture, and that they be viewed as rational individuals. Interventions that take these considerations into account will lead to safe behavior being internally motivated rather than a forced.
Social Dynamics
Social dynamics also play crucial roles in decisions youth make about their behavior. A recent study based on social psychological models showed the subjective norm to be the strongest predictor of the intention to use a bicycle helmet (18). Only one in four students would not mind wearing a bicycle helmet even if friends did not wear them, leaving the other three to depend on the opinions and decisions of their friends (19). Instead of viewing this trend as an impediment to the encouragement of safety behaviors, campaign project researchers should embrace a community-based approach that positively incorporates social dynamics. Change should be instituted at a grassroots level instead of using the legislative thrust. A highly successful campaign at the University of Southern Carolina coupled this approach with social marketing. The student-initiated campaign developed the slogan “The Grateful Head” and succeeded in raising the helmet use across campus from a baseline mean of 27.6% to a mean of 49.3% by the last weak of intervention (20).
Another useful social theory is the Diffusion of Innovations Theory. It offers the concept of “early adopters”-- individuals who pick up on the benefits of a certain innovation and through social contacts, ideally spread the acquisition of the innovation. Using this model as a critique of current campaigns, it may be said that potentially beneficial sources of social influence are seldom incorporated. For instance, some bicycle interest groups appeal to youth and their subcultures but do not explicitly endorse helmet usage among their following. They often organize and compete in local competitions wherein incentives for the most popular bikers to speak up for bicycle safety could have widespread ripple effects. Bicycle retail shops are also often rider run, and because they already have a profit-driven motive to sell safety equipment, they are potentially an important voice for pushing bicycle safety. As a final note, campaigns should more actively employ the arm of media advocacy. Hip cycling or extreme sport personalities could be portrayed as early adopters of safe behaviors and encourage their following to do likewise. Therefore, a consideration of social dynamics among youth may open up a potential goldmine of interventions that could replace the lagging benefits of legislation.
Conclusion
The health benefits and environmental friendliness of cycling are undeniable. Bicycle safety campaigns strive to decrease in mortality and rate of injury while simultaneously increasing access to the cycling-- a task particularly challenging with regard to the younger generation. This paper suggests that the use of helmet legislation as a primary thrust of bicycle safety campaigns has been deleterious to their overall aims.
Instead, a bicycle safety needs to be approached with a much more comprehensive attitude. This will reduce the skew of interventions towards helmet usage and place greater emphasis on the societal and structural factors that factor into safety. In addition, such an attitude will demand a revision of the approach towards understanding the target audience of youth. This may involve the soliciting of youth specialists, the extensive use of sociological models, and the observation of youth trends and cultural shifts. Campaigns should be assured that such efforts will not go unrewarded as positive decisions internally motivated are likely to carry on into adulthood and so confer long-lasting impact. To reach this aim, significant reforms need to be made to the paradigm through which bicycle safety is viewed.
REFERENCES
1. Macpherson AK, To TM, Macarthur C, Chipman ML, Wright JG, Parkin PC. Impact of mandatory helmet legislation on bicycle-related head injuries in children: A population-based study. Pediatrics 2002; 110:e60.
2. Attewell RG, Glase K, McFadden, M. Bicycle helmet efficacy: a meta-analysis. Accid. Anal. Prev. 2001; 33:345-352.
3. NHTSA’s National Center for Statistics and Analysis. Bicyclists and other cyclists. Traffic Safety Facts 2005, DOT HS 810 617, http://www-nrd.nhtsa.dot.gov/Pubs/810617.PDF.
4. London Cycling Campaign. Cycle helmets. London: LCC, 1999.
5. Skrabenek P. The death of human medicine and the rise of coercive healthism. London: Social Affairs Unit, 1994.
6. Sheikh A, Cook A, Ashcroft R. Making cycle helmets compulsory: ethical arguments for legislation. J R Soc Med 2004; 97:262-265.
7. Cook A, Sheikh A. Trends in serious head injuries among cyclists in England: analysis of routinely collected data. BMJ 2004; 321:1055.
8. Lajunen T, and Rasanen M. Can social psychological models be used to promote bicycle helmet use among teenagers? A comparison of the Health Belief Model, Theory of Planned Behavior and the Locus of Control. Journal of Safety Research 2004; 35:115-123.
9. Williams J, and Boyd H. Howard Boyd on: In training England’s cyclist. Interview of Howard Boyd, Bicycle Forum 1982; 8:24-31.
10. Osberg JS, Stiles SC, Asare OK. Bicycle safety behavior in Paris and Boston. Accid Anal. and Prev. 1998; 30: 5:679-687.
11. Geffen R. Portsmouth, Newcastle and Southwark to become 20mph zones. Cycle Digest 2006; 48:4.
12. Robinson DL. Reasons for trends in cyclist injury data. Injury Prevention 2004;10:126-127.
13. New York Department of Health and Mental Hygiene, 2005. Bicyclist Fatalities and Serious Injuries in New York City. www.nyc.gov/html/dot/downloads/pdf/bicyclefatalities.pdf.
14. Jacobson PL. Safety in numbers: more walkers and bicyclists, safer walking and bicycling. Injury Prevention 2003; 9:205-209.
15. Rosenfeld SL, Fox DJ, Keenan PM, Melchiono MW, Samples CL, Woods ER. Primary care experiences and preferences of urban youth. Journal of Pediatric Health Care 1996; 10:4:151-160.
16. Rodgers GB. Bicycle helmet use patterns in the United States: A description and analysis of national survey data. Accid. Anal. and Prev. 1995; 27:1:43-56.
17. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.
18. Hagel BE, Pless B. A critical examination of arguments against bicycle helmet use and legislation. Accid. Anal. Prev. 2006; 38:2:277-278.
19. Everett A, Price JH, Bergin DA, Groves BW. Personal goals as motivators: predicting bicycle helmet use in university students. Journal of Safety Research 1996; 27:1:43-53.
20. Ludwig TD, Buchholz C, Clarke SW. Using social marketing to increase the use of helmets among bicyclists. Journal of American College Health 2005; 54:1:51-58.

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

The Development of the Healthy People 2010 Campaign
Over the past thirty years there has been an increasing interest from United States public health officials to promote wellness among the population. Since 1979, initiatives to combat specific health issues with obtainable goals were pursued to promote health and prevent disease. Similarly, at the turn of the century the newest public health initiative to promote health and to prevent illness, disability, and premature death launched as the Healthy People 2010 campaign sponsored by the U.S. Department of Health and Humans Services. The Healthy People Consortium developed a campaign which consisted of an alliance of over 350 national organizations and 250 state public health agencies. The campaign addressed 226 health objectives in 28 categories to achieve over 10 years, with the key mission of increasing quality and years of healthy life, and eliminating health disparities (1-2). The issues targeted range from access to health care, to environmental health issues, to physical fitness activity, substance abuse and others. To date, the Healthy People 2010 campaign has seen much success. However, it is under the Immunization and Infectious Disease Category objective 14.8 that targets Lyme disease where the Healthy People 2010 campaign failed in developing and executing a plan of action to effectively lower rates of Lyme disease throughout the country.
The Healthy People 2010 consortium’s only strategy to combat Lyme disease was based on the availability of the LYMErix vaccine. The vaccine was developed by SmithKline Beecham Pharmaceuticals and was the only Food and Drug Administration (FDA) approved Lyme disease vaccination at the launch of the campaign. However, the vaccine was taken off the market by the manufacturer in 2002 due to poor sales and reported unspecified adverse effects (4). Since 2002, as incidence of Lyme disease has increased steadily there has been no additional public health intervention to combat incidence (5). Such negligence poses an unwavering obstacle for the Healthy People 2010 target to be reached. Therefore, the Healthy People 2010 initiative to combat the incidence of Lyme disease is a failed intervention due to its reliance on a vaccination as the primary means of control absent from necessary media involvement and educational support.
Lyme Disease: An Emerging Epidemic
Lyme disease is the most commonly diagnosed vector-borne disease in the U.S. The disease is prevalent in 48 states, especially in endemic areas such as the Northeast, Wisconsin, Minnesota, and Northern California (2). Contraction is caused by exposure to areas infected by Borrella burgdorferi-infected ticks and is categorized by a variable incubation period. Lyme disease is a multi-system disease described as having early and late stages. Persons of every age, race, and demographic are at risk for contracting the disease, with elevated rates occurring in children 2 to 15 years old, and adults 30 to 55 (3). Because the disease targets such a wide scope of the population, Lyme disease is a high-risk public health concern. However, despite the persistence of the disease, Lyme disease is controllable by individually targeted mechanisms.
The Healthy People Consortium confirmed that their plan of action to control incidence of Lyme disease was encouraging at-risk populations to receive the LYMErix vaccination. At the launch of the campaign there were a reported 17.4 new cases per 100,000 population. The Healthy People 2010 goal was to reduce this rate to 9.7 new cases per 100,000 population; a 44% decline (4). Since setting the target, cases of reported Lyme disease have more than tripled. To date, 32.5 new cases per 100,000 population in endemic regions have been reported annually (5).
Raising Public Awareness
The first step in targeting a public health problem is raising awareness that a problem exists. An effective way to increase awareness about any growing issue or epidemic is involving the media. The Agenda-Setting Theory, introduced by Maxwell McCombs and Donald Shaw in 1973, states that the mass media has the ability to convey to the public, information about issues of concern, thus influencing the public’s agenda (6-7). Involving the media in Lyme disease prevention at the launch of the Healthy People 2010 initiative would have been most beneficial in increasing awareness about the precautions at-risk populations may take to prevent contraction of disease.
As previously noted, the LYMErix vaccination was taken off the market in 2002 largely in part to poor sales (4). If the Healthy People 2010 Committee on Immunization and Infectious Disease had engaged the media to follow an agenda which promoted protection from Lyme disease, at-risk populations would have been more aware of Lyme disease as an impending epidemic. This increased awareness would have developed a desire for the public to obtain protection from contraction, resulting in an increased demand for the vaccination. Such an increase in demand would have boosted sales and prevented the vaccine from going off the market.
The existence of a vaccine to control the prevalence of Lyme disease is simply not enough to combat the epidemic. The Healthy People Campaign could have taken a much more productive approach by involving the media, also advertising the necessity of the vaccine. Similarly, the media could have educated the public on simple behaviors that at-risk populations could take, such as avoiding grassy areas, or knowing how to recognize ticks (7). Even though raised public concern would have not guarantee the at-risks populations becoming vaccinated, if the issue were brought to the public’s attention the media would have at least instigated public thought about the issue (6-7). Press intervention in the case of the Lyme disease epidemic could have controlled the increasing rates of incidence by bringing the issue of Lyme disease to the public’s attention.
Framing an Issue for Successful Intervention
Increased attention from the media regarding the dangers of Lyme disease and fear of contraction would have only been effective if the issues were framed correctly. Supplemental to agenda-setting theory which focuses on which issues are portrayed to the public, framing focuses on how issues are portrayed by the media to the public (6-8). Agenda-Setting Theory and Framing Theory work hand in hand, and incorporating both is crucial when attempting to influence a population’s behavior.
The Healthy People 2010 campaign never utilized the media effectively in targeting incidence of disease especially in how the issue was framed. Published articles reporting the possible failures of the LYMErix vaccine have run rampant in newspaper and magazines, “framing” the issue of vaccination as a dangerous means of prevention. Other articles reported the ineffectiveness of the vaccine (8). Reports also suggested that recipients of the vaccination were at risk for developing Lyme arthritis and other chronic arthritic disorders (8). Though such potential effects may be considered unwanted, the unspecified adverse effects of a vaccination seem miniscule compared to the definite effects of Lyme disease. Included in such effects are flu-like symptoms, fever, fatigue, muscular pain, secondary skin lesions, and facial paralysis occurring in the initial stages of the disease. Long-term untreated effects include distinctive arthritic, neurologic and cardiac problems (7).
However, if the media framed Lyme disease as a controllable epidemic that could be prevented with effective care and proper precautions, rates of incidence would not persist. Instead, the media raised awareness to the failure of the Healthy People 2010 campaign by publishing articles which did not support vaccination control (8). A national public health problem, such as Lyme disease, targets a wide scope in the political arena. Proper framing of the issue was necessary for any intervention to succeed. Unfortunately, Healthy People 2010 failed not only in engagement of the media, but in positively framing the LYMErix vaccination as a step towards prevention.
Failing to Provide Educational Support
In conjunction with the lack of Agenda-Setting and appropriate framing of Lyme disease, the Healthy People 2010 campaign to target incidence of Lyme disease also lacked a necessary education component. As reflected by the Rational-Empirical approach, education for at-risk populations about an issue is critical when influencing the adoption of a behavior (9). The goal behind the theory is to influence behavior without fear or persuasion. By providing persons with rational and logical information, at-risk persons will adopt a behavior if the behavior can be justified as beneficial (10-23). In 1999 before the launch of the campaign, the FDA, Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH) all agreed that education was the most important step to prevent Lyme disease contraction (7). By just relying on a vaccine-based strategy to combat incidence, the Healthy People 2010 campaign failed to utilize the necessary educational component.
Educational support could have benefited the Healthy People 2010 initiatives on Lyme disease. As previously mentioned, in line with the Healthy People 2010 plan of action, using agenda-setting and appropriate framing to educate the public about the LYMErix vaccine would have been effective. Education regarding disease management and general information about disease etiology would have been beneficial for at-risk populations. If accurate information is supplied to an individual, then a person can decide for him or herself the course of action that best addresses his or her needs (9). Perhaps vaccination was not the best approach for everyone. However, vaccination was the best choice for some, and education about the vaccination would have resulted in additional protection for those at risk.
Is Future Progress a Possibility?
In 2007, seven years after the launch of the Healthy People 2010 campaign, the Immunization and Infectious Disease Committee faulted the removal of the LYMErix vaccine as their main obstacle in lowering the incidence of Lyme disease. They discussed new approaches to the issue, strategizing about educational approaches they may take to promote safety by targeting school-aged children. They also discussed environmental steps that can be taken to promote practices that will reduce tick habitats near homes, suburban and residential areas (5). Unfortunately, the Healthy People 2010 committee on Immunization and Infectious Disease is still ignoring the fundamental causes that contributed to the campaign’s failure in the first place, which is supporting an intervention absent from media engagement and education about the disease for at-risk populations.
The way in which the media presented the issue of Lyme disease to the public highly influenced perceptions and actions towards vaccination. The lack of integration between media influences and education for the population is the reason behind the failed public health intervention of advocating the use of a vaccine to prevent contraction. When analyzing the campaign, it is apparent that the initiative never fully advocated the use of the vaccine. A remedy for a problem is useless unless vulnerable populations are aware that an effective remedy exists. The Healthy People 2010 Consortium failed to achieve the proper engagement to make the necessity of the vaccination known. Unless public health officials are willing to incorporate different social behavior models into one intervention, hope is slim that incidence of Lyme disease will decrease in time to reach the Healthy People 2010 target.
REFERENCES
1. U.S. Department of Health and Human Services. Healthy People 2010 Understanding and Improving Health. Washington, DC: U.S. Dept. HHS, 2000.
2. Brody J. Fighting Lyme Disease, With a Pinhead as the Enemy. The New York Times, 2003. .
3. LYMErix Lyme Disease Vaccination. SmithKline Beecham Biologicals. Philadelphia: SmithKline Beecham, 1998. .
4. Groch J. Lyme Disease Worsens in Endemic States. Medpage Today, 2007. .
5. U.S. Department of Health and Human Services. Healthy People 2010: Progress Review Immunization and Infectious Diseases. Washington, DC: Office of Disease Prevention and Health Promotion, 2007.
6. McCombs, M., Shaw, D., and Weaver, D. Communication and Democracy. Mahwah: Lawrence Erlbaum Associate, 1997.
7. Lewis C. New Vaccine Targets Lyme Disease. FDA Consumer Magazine 1999. http://www.fda.gov/fdac/features/1999/399_lyme.html.
8. Kliger C. Is the Lyme Disease Vaccine a Lemon? WebMd Medical News. Washington, DC, 2001. .
9. Siegel M. Education and persuasion versus coercion as public health approaches. The Rest of the Story: Tobacco News Analysis and Commentary (blog). May 4, 2006. http://tobaccoanalysis.blogspot.com/2006/05/in-my-view-education-and-persuasion.html.
10. Chin R, Benne KD. General strategies for effective change in human systems. In Bennis W et al. (eds.): The Planning of Change (3rd edition), pp. 22-45. New York: Holt, Rinehart and Winston, 1976.

Critique of the National Diabetes Education Campaign - Shreya Patel

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

REFERENCES
1. Chan CB, Ryan DA, Tudor-Locke C. Health benefits of a pedometer-based physical activity intervention in sedentary workers. Prev Med. Dec 2004;39(6):1215-1222.
2. Gilson N, McKenna J, Cooke C, Brown W. Walking towards health in a university community: a feasibility study. Prev Med. Feb 2007;44(2):167-169.
3. Matthews CE, Wilcox S, Hanby CL, et al. Evaluation of a 12-week home-based walking intervention for breast cancer survivors. Support Care Cancer. Feb 2007;15(2):203-211.
4. Toole T, Thorn JE, Panton LB, Kingsley D, Haymes EM. Effects of a 12-month pedometer walking program on gait, body mass index, and lower extremity function in obese women. Percept Mot Skills. Feb 2007;104(1):212-220.
5. Tudor-Locke C, Bell RC, Myers AM, et al. Controlled outcome evaluation of the First Step Program: a daily physical activity intervention for individuals with type II diabetes. Int J Obes Relat Metab Disord. Jan 2004;28(1):113-119.
6. Winett RA, Anderson ES, Wojcik JR, Winett SG, Bowden T. Guide to health: nutrition and physical activity outcomes of a group-randomized trial of an Internet-based intervention in churches. Ann Behav Med. May-Jun 2007;33(3):251-261.
7. Araiza P, Hewes H, Gashetewa C, Vella CA, Burge MR. Efficacy of a pedometer-based physical activity program on parameters of diabetes control in type 2 diabetes mellitus. Metabolism. Oct 2006;55(10):1382-1387.
8. Eakin EG, Mummery K, Reeves MM, et al. Correlates of pedometer use: results from a community-based physical activity intervention trial (10,000 Steps Rockhampton). Int J Behav Nutr Phys Act. 2007;4:31.
9. Hultquist CN, Albright C, Thompson DL. Comparison of walking recommendations in previously inactive women. Med Sci Sports Exerc. Apr 2005;37(4):676-683.
10. Hyman DJ, Pavlik VN, Taylor WC, Goodrick GK, Moye L. Simultaneous vs sequential counseling for multiple behavior change. Arch Intern Med. Jun 11 2007;167(11):1152-1158.
11. Rooney B, Smalley K, Larson J, Havens S. Is knowing enough? Increasing physical activity by wearing a pedometer. Wmj. 2003;102(4):31-36.
12. PR Newswire US. Tony the Tiger Goes to Hollywood to Help Families Get in Step!;Kellogg Company Launches Fitness Program on the Famous Hollywood Walk of Fame. September 27, 2005, 2005.
13. Geoghegan T. The 10,000-step guide to fitness. BBC News Online Magazine Vol October 12,2004; 2004.
14. Ethridge M. Low-cal Happy Meals Target Health-Conscious Consumbers; Mcdonalds reinvents the Box. Akron Beacon Journal May 11, 2004, 2004;business: D1.
15. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2005.
16. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. Feb 1 1995;273(5):402-407.
17. Iwane M, Arita M, Tomimoto S, et al. Walking 10,000 steps/day or more reduces blood pressure and sympathetic nerve activity in mild essential hypertension. Hypertension Research. Nov 2000;23(6):573-580.
18. Rooney BL, Gritt LR, Havens SJ, Mathiason MA, Clough EA. Growing healthy families: family use of pedometers to increase physical activity and slow the rate of obesity. Wmj. Jul 2005;104(5):54-60.
19. Tudor-Locke C, Bassett DR, Jr. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med. 2004;34(1):1-8.
20. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury: Jones and Bartlett Publishers, Inc; 2007.
21. Walk away from diabetes and heart disease. The most natural of human activities is also the best medicine for these connected health problems. Harv Heart Lett. Sep 2003;14(1):6-7.
22. Morris JN, Hardman AE. Walking to health. Sports Med. May 1997;23(5):306-332.
23. Wilde BE, Sidman CL, Corbin CB. A 10,000-step count as a physical activity target for sedentary women. Res Q Exerc Sport. Dec 2001;72(4):411-414.
24. Welk GJ, Differding JA, Thompson RW, Blair SN, Dziura J, Hart P. The utility of the Digi-walker step counter to assess daily physical activity patterns. Med Sci Sports Exerc. Sep 2000;32(9 Suppl):S481-488.
25. Moreau KL, Degarmo R, Langley J, et al. Increasing daily walking lowers blood pressure in postmenopausal women. Med Sci Sports Exerc. Nov 2001;33(11):1825-1831.
26. Sugiura H, Sugiura H, Kajima K, Mirbod SM, Iwata H, Matsuoka T. Effects of long-term moderate exercise and increase in number of daily steps on serum lipids in women: randomised controlled trial [ISRCTN21921919]. BMC Womens Health. 2002;2(1):3.
27. Tudor-Locke C, Ainsworth BE, Whitt MC, Thompson RW, Addy CL, Jones DA. The relationship between pedometer-determined ambulatory activity and body composition variables. Int J Obes Relat Metab Disord. Nov 2001;25(11):1571-1578.
28. Iwane M, Arita M, Tomimoto S, et al. Walking 10,000 steps/day or more reduces blood pressure and sympathetic nerve activity in mild essential hypertension. Hypertens Res. Nov 2000;23(6):573-580.
29. Tudor-Locke C, Jones R, Myers AM, Paterson DH, Ecclestone NA. Contribution of structured exercise class participation and informal walking for exercise to daily physical activity in community-dwelling older adults. Res Q Exerc Sport. Sep 2002;73(3):350-356.
30. Tudor-Locke C, Ainsworth BE, Thompson RW, Matthews CE. Comparison of pedometer and accelerometer measures of free-living physical activity. Med Sci Sports Exerc. Dec 2002;34(12):2045-2051.
31. Tudor-Locke CE, Myers AM, Bell RC, Harris SB, Wilson Rodger N. Preliminary outcome evaluation of the First Step Program: a daily physical activity intervention for individuals with type 2 diabetes. Patient Educ Couns. May 2002;47(1):23-28.
32. Wilcox S, Castro C, King AC, Housemann R, Brownson RC. Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States. J Epidemiol Community Health. Sep 2000;54(9):667-672.
33. Lavizzo-Mourey R, Cox C, Strumpf N, Edwards WF, Stinemon M, Grisso JA. Attitudes and beliefs about exercise among elderly African Americans in an urban community. J Natl Med Assoc. Dec 2001;93(12):475-480.
34. King AC, Castro C, Wilcox S, Eyler AA, Sallis JF, Brownson RC. Personal and environmental factors associated with physical inactivity among different racial-ethnic groups of U.S. middle-aged and older-aged women. Health Psychol. Jul 2000;19(4):354-364.
35. Owen N, Leslie E, Salmon J, Fotheringham MJ. Environmental determinants of physical activity and sedentary behavior. Exerc Sport Sci Rev. Oct 2000;28(4):153-158.
36. Brownson RC, Housemann RA, Brown DR, et al. Promoting physical activity in rural communities: walking trail access, use, and effects. Am J Prev Med. Apr 2000;18(3):235-241.
37. Humpel N, Owen N, Leslie E. Environmental factors associated with adults' participation in physical activity: a review. Am J Prev Med. Apr 2002;22(3):188-199.
38. Owen N, Humpel N, Leslie E, Bauman A, Sallis JF. Understanding environmental influences on walking; Review and research agenda. Am J Prev Med. Jul 2004;27(1):67-76.
39. Giles-Corti B, Donovan RJ. Socioeconomic status differences in recreational physical activity levels and real and perceived access to a supportive physical environment. Prev Med. Dec 2002;35(6):601-611.
40. Eyler AA, Brownson RC, Bacak SJ, Housemann RA. The epidemiology of walking for physical activity in the United States. Med Sci Sports Exerc. Sep 2003;35(9):1529-1536.
41. Ball K, Bauman A, Leslie E, Owen N. Perceived environmental aesthetics and convenience and company are associated with walking for exercise among Australian adults. Prev Med. Nov 2001;33(5):434-440.
42. Ewing R, Schmid T, Killingsworth R, Zlot A, Raudenbush S. Relationship between urban sprawl and physical activity, obesity, and morbidity. Am J Health Promot. Sep-Oct 2003;18(1):47-57.
43. Lopez R. Urban sprawl and risk for being overweight or obese. Am J Public Health. Sep 2004;94(9):1574-1579.
44. Saelens BE, Sallis JF, Black JB, Chen D. Neighborhood-based differences in physical activity: an environment scale evaluation. Am J Public Health. Sep 2003;93(9):1552-1558.
45. Humpel N, Owen N, Leslie E, Marshall AL, Bauman AE, Sallis JF. Associations of location and perceived environmental attributes with walking in neighborhoods. Am J Health Promot. Jan-Feb 2004;18(3):239-242.
46. Lopez RP, Hynes HP. Obesity, physical activity, and the urban environment: public health research needs. Environ Health. 2006;5:25.
47. Wilson DK, Kirtland KA, Ainsworth BE, Addy CL. Socioeconomic status and perceptions of access and safety for physical activity. Ann Behav Med. Aug 2004;28(1):20-28.
48. Seefeldt V, Malina RM, Clark MA. Factors affecting levels of physical activity in adults. Sports Med. 2002;32(3):143-168.
49. Walking in L.A.: One Way; 1982.
50. Ross CE. Walking, exercising, and smoking: does neighborhood matter? Social Science & Medicine. 2000;51(2):265-274.
51. Greiner KA, Li C, Kawachi I, Hunt DC, Ahluwalia JS. The relationships of social participation and community ratings to health and health behaviors in areas with high and low population density. Soc Sci Med. Dec 2004;59(11):2303-2312.
52. Skinner BF. The behavior of organisms: An experimental analysis. New York: Appleton-Century; 1938.
53. Thomdike EL. Animal Intelligence: An Experimental Study of the Associative Process in Animals. Psychology Review Monographs. 1898;2(55):1-553.
54. Horner R, Day H. The effects of response efficiency on functionally equivalent competing behaviors. J Appl Behav Anal. 1991;24(4):719-732.
55. Airhihenbuwa CO, Kumanyika S, Agurs TD, Lowe A. Perceptions and beliefs about exercise, rest, and health among African-Americans. Am J Health Promot. Jul-Aug 1995;9(6):426-429.
56. Laitakari J, Vuori I, Oja P. Is long-term maintenance of health-related physical activity possible? An analysis of concepts and evidence. Health Education Research. 1996;11(4):436-477.