The Best Laid Plans: Why the World Health Organization’s Hand Hygiene Campaign Will Fail – Matt Pappas

Imagine that you’re a young physician in a busy outpatient practice. You have only seven minutes with each patient and you’re booked through lunch. You leave one patient’s room, pick up the next patient’s chart, and knock on the door. Looking through the chart absentmindedly, you notice that Mr. Smith has asked you to come in, so you open the door. He extends his hand, and you reciprocate. In that moment, you have failed.

Hospitals are dangerous places. In 2002, according to the Centers for Disease Control and Prevention (CDC) (1), the U.S. saw 1.7 million health care-associated infections and almost 99,000 deaths associated with those infections. Methicillin-resistant Staphylococcus Aureus (MRSA) alone is responsible for over 18,000 deaths annually, with most of those cases contracted in the course of receiving health care (2). Handwashing has been known to reduce transmission of (specifically) staphylococci since the 1960s (3), and to reduce nosocomial infections for over 150 years (4). The problem with handwashing is inconsistency: health care workers simply don’t wash their hands often enough.

The World Health Organization (WHO) is in the midst of what it calls an “unprecedented global initiative” to address handwashing among health care workers. It’s hard to fault their thoroughness: they have leaflets, instruction sheets, brochures, situation analysis grids, a 64-page guide and a 40-page manual, all designed to get physicians to undertake the simple task of washing their hands.

What they don’t have are the makings of a successful campaign. Unfortunately, the WHO’s approach will not improve health care worker handwashing because it fails to account for the paradox of choice, has not selected the best intervention for its target audience, and does not improve physicians’ sense of self-efficacy.

Simplicity is Everything

This “unprecedented global initiative” is really multiple programs; this distinction, however, is difficult to extract from the unwieldy names and labyrinthine organization. There’s the “Global Patient Safety Challenge,” the “World Alliance for Patient Safety,” the “Clean Care is Safer Care” theme (also called in some of the WHO’s literature a program in its own right), a “Multimodal Improvement Strategy,” pilot and complementary testing, task forces, an office called the “Joint Commission International Center for Patient Safety,” information sheets, leaflets, posters, banners, and a screen saver (5). The documentation is awash with consultant buzzwords, which aren’t clear to health care professionals. Such an information overload prevents the WHO from issuing a simple, clear message.

The methods are as complicated as the materials. One instruction sheet, obtained by writing to the WHO, portrays rubbing hands with a hand sanitizer gel as an 8 step process, with step 1 further subdivided into “1a” and “1b.” In this instruction sheet, the health care worker is told to:

Apply a palmful of product in a cupped hand, covering all surfaces, rub hands palm to palm, right palm over left dorsum with interlaced fingers and vice versa, palm to palm with fingers interlaced, backs of fingers to opposing palms with fingers interlocked, rotational rubbing of left thumb clasped in right palm and vice versa, rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa.

The problem of handwashing, though, isn’t the lack of rotational rubbing of the left thumb clasped in the right palm – it’s handwashing at all. By providing a 9-step process for hand sanitizing, the WHO has obfuscated the important step: use sanitizer. This instruction sheet is only one of several such documents incorporating instructions for handwashing and/or hand sanitizing, every one of them just as complicated.

This level of detail is counterproductive. As Iyengar and Lepper (6) found, too much choice frequently leads to indecision. They presented either six or 24 flavors of jam at a supermarket, and found that customers bought more jam when presented with only six varieties than when presented with 24. By providing so many messages and programs, the WHO is encouraging physicians to stop listening. Because of the “paradox of choice,” (7) health care workers presented with so many different slogans, instructions, and programs are more likely to remain at the status quo than if the WHO had proffered a single, clear message.

I Know What You’re About to Say

Furthermore, The World Health Organization’s focus on educating health care workers is inappropriate in the industrial world. Chin and Benne would categorize the WHO’s efforts as rational-empirical, focused as they are on education of the target audience. An approach aimed at persuading health care workers – Chin and Benne’s normative-re-educative category – would have been more appropriate. Western physicians know that lack of handwashing transmits disease. Semmelweis first badgered his employees into scrubbing their hands with chlorine in 1847 (4), and Lister published his seminal article on antisepsis in 1867 (9). After 150 years, continued efforts at education are unlikely to have dramatic impacts in the West.

This is not to say that gaps do not exist. One 5-year educational program improved awareness that touching patients without handwashing contributes to spread of antimicrobial-resistant pathogens from (a surprisingly low) 75% of health care workers to (a still surprisingly low) 82% (10). The industrial world is not immune to misconceptions. Still, a 7% improvement over five years is inadequate in a country with 1.7 million health care-associated infections (1). A normative-re-educative approach is better suited to the existing knowledge base of the western world, and more likely to have significant impacts than a rational-empirical approach.

Now, the WHO’s program has enrolled countries as disparate as the U.S. and Uganda. A rational-empirical approach may well be optimal in participating countries with less rigorous medical training or smaller health care expenditures. Such countries could see improvements far greater than 7% over 5 years from educational programs. The United States, though, is not among them.

Don’t Tell Me What To Do

In providing extrinsic solutions, rather than empowering health care workers to solve problems, the WHO does not provide health care workers with a sense of self-efficacy. As Ozur and Bandura have pointed out, self-efficacy is a critical component of behavioral change (11). Campaigns attempting to change a behavior as refractory as handwashing would do well to heed their work.

Indeed, in one of the few handwashing campaigns that seems to have succeeded in recent years, Jerry Sternin and colleagues have been using an approach called “positive deviance.” Positive deviance is intended to solicit suggestions for improvement from the target audience rather than imposing the conclusions of a consultant upon them (12). As Sternin described their approach later, “if we had any dogma going in, it was: Thou shalt not try to fix anything” (13).

It might seem odd to set out to improve handwashing by “not try[ing] to fix anything.” Still, the difference between this approach and earlier attempts isn’t what was attempted – replacing hand gel dispensers, placing sinks where they would be most convenient, and so forth – but who suggested those solutions. Something about changes suggested by members of the target audience, rather than an “outsider” (read: consultant) made the changes more likely to “stick.” Instead of fixing health care workers’ problems, the positive deviance approach encouraged health care workers to find and fix them.

Sternin and his colleagues, among other things, forced health care workers to improve their sense of self-efficacy. They persuaded physicians and nurses that the ability to improve handwashing practices was not only within their power, but also within their collective wisdom. They used self-efficacy to their advantage. The World Health Organization could stand to do the same.

This is not the End

In fairness, the WHO’s is not the first, and will not be the last, thwarted handwashing attempt. As penicillin has become passé, polio has been eliminated from the western world (and is nearing global eradication), as artificial hips and automatic defibrillators have come into practice, the simplest, best-supported intervention imaginable – consistent, rigorous handwashing – has proven to be one of the most difficult to implement. We still need satisfactory solutions. So handwashing improvement campaigns will continue. For now, a “positive deviance” technique, with well-considered, unambiguous messages focused on a normative-re-educative approach, appears most likely to be successful. Because the World Health Organization’s design incorporates none of these elements, its campaign will be only the latest in 150 years of impassioned but unsuccessful pleas to improve handwashing.

References

(1): Klevens RM et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports 2007; 122:160-166.

(2): Klevens RM et al. Invasive Methicillin-Resistant Staphylococcus Aureus Infections in the United States. Journal of the American Medical Association 2007; 298:1763-1771.

(3): Mortimer EA, Wolinsky E, Rammelkamp CH. The transmission of staphylococci by the hands of personnel (pp. 187-99). In: Maibach HI, Hildick-Smith G, ed. Skin bacteria and their role in infection. New York, NY: McGraw-Hill, 1965.

(4): Nuland S. The Doctors’ Plague: Germs, Childbed Fever, and the Strange Story of Ignac Semmelweis. New York, NY: Norton, 2003.

(5): The World Health Organization. WHO | The first Global Patient Safety Challenge. Geneva, Switzerland: http://www.who.int/gpsc/en/index.html

(6): Iyengar SS and Lepper MR. When Choice is Demotivating: Can One Desire Too Much of a Good Thing? Journal of Personality and Social Psychology 2000; 79:995-1006.

(7): Schwartz B. The Paradox of Choice: Why More is Less. New York, NY: HarperCollins Publishers Inc., 2004.

(8): Chin R and Benne KD. General Strategies for Effecting Changes in Human Systems (pp. 22-45). In: Bennis WG et al., ed. The Planning of Change, Third Edition. Holt, Rinehart and Winston, Inc., 1976.

(9): Lister J. Antiseptic Principle of the Practice of Surgery. The Lancet 1867; 90:353-356.

(10): Wisniewski MF et al. Effect of Education on Hand Hygiene Beliefs and Practices: A 5-Year Program. Infection Control and Hospital Epidemiology 2007; 28:88-91.

(11): Ozur EM and Bandura A. Mechanisms Governing Empowerment Effects: A Self-Efficacy Analysis. Journal of Personality and Social Psychology 1990; 58:472-486.

(12): Zeitlin M, Ghassemi H, and Mansour M. Positive Deviance in Child Nutrition - With Emphasis on Psychosocial and Behavioural Aspects and Implications for Development. Tokyo, Japan: United Nations University Press, 1990.

(13): Gawande, A. Better: A surgeon’s notes on performance. New York, NY: Metropolitan Books, 2007.

Physical Activity Recommendations in an Obese America: Too Vague, Too Aggressive, Too Bad –Tyler Aiken

One of the most alarming trends in America is the growing rate of childhood obesity. From 1988-2006 there has been an average 7% increase in the prevalence of overweight children ranging from two to nineteen years of age(1). The obesity trend will affect future generations. It puts our nation’s youth at a higher risk for developing early onset chronic diseases like diabetes and cardiovascular disease (2,3) . Today’s society is a more health conscious America then it was 50 years ago, yet there are unseen factors that are changing the body composition of our children. According to The Centers for Disease Control and Prevention, behavioral, environmental, and genetic factors are leading to the growing obesity epidemic (1). This is not the most accurate frame to portray the issue because there is an unequal contribution by each of these factors. Obesity does have a genetic component, but the gene pool does not change that drastically in a 30 year period (4). Removing genetics from the equation, it is concluded that the obesity trend is a direct result of both behavioral and environmental changes. It is therefore most beneficial if we create interventions that target these underlying causes.

Increasing physical activity in our daily lives is one possible way of combating the growing obesity epidemic (5). The 2005 Dietary Guidelines for Americans indicate that children and adolescents should engage in at least 60-minutes of physical activity on most, preferably all, days of the week(6). The 60-minute duration was based on multiple studies looking at duration of activity on physical and clinical health outcomes. Science supports the fact that 60-minutes of physical activity will benefit health outcomes (7), yet despite this knowledge there is still an increase in childhood obesity. The national 60-minute physical activity recommendation is an ineffective intervention against childhood obesity because it does not consider the total external factors, self-efficacy, and readiness to change of its target population.

Diverse Exposure to External Factors

The 60-minute physical activity recommendation fails because it does not account for the diversity in exposures to external factors. External factors are defined as any influence outside of ones internal thoughts, self perceptions, and beliefs (8). A person’s beliefs and actions are shaped by where they live, their social network, and by past experiences. Social Cognitive Theory explains how these social and environmental factors impact thoughts and decisions. Socioeconomic status (SES) and geographical environment have an important role in the effectiveness of a physical activity recommendation. These two factors highlight the issue of opportunity. The problem with the physical activity recommendations are they assume that everyone has the same access to facilities and programs that help promote physical activity. It has been shown that adolescents living in areas with less transportation, less recreation areas, and high crime rates had significantly lower physical activity levels when compared to their counterparts(9). Children of high income families have also been shown to exhibit higher levels of physical activity (10). It is made apparent that children face a wide range of barriers in regards to physical activity, and that making a broad-based recommendation will not fit every at risk population.

The physical activity of a child’s social network also affects the child’s physical activity outcomes. Social Cognitive Theory refers to this as “modeling” or “vicarious learning”. Children are five times more likely to be physically active if both of their parents were physically active (11). Obesity is linked to physical inactivity, it is therefore important to look at the parents body composition in relation to their children’s health behaviors (2,3). Parental obesity was associated with significantly lower amounts of physical activity in their children (12). It becomes quite apparent that we cannot advise a child to increase physical activity, when arguably; the most influential people in their lives have no intention of doing the same.

Self Efficacy Not Taken into Consideration

External cues are not the only factors that these national physical activity recommendations overlook. They do not relate to the obese population on an individual level, specifically their self efficacy. Self-efficacy refers to a person’s belief in their ability to take action, in this case increasing physical activity to meet national recommendations (8). Self-efficacy plays a role in numerous health behavior theories. Its use in the Health Belief Model (HBM) and Social Cognitive Theory will be addressed in this paper. HBM theorizes that health outcomes are based on what the person perceives as their benefits and barriers in performing a specific action, and self-efficacy acts as an underlying influence to these factors. A person will be more likely to perform an action when they believe they can succeed and that their potential benefits outweigh potential barriers. Recommending 60 minutes of physical activity to an obese child is ineffective because the barriers to increasing physical activity are extremely high. For example, when left with a choice of playing their favorite video game or participating in tag outside, an obese child may say to themselves, “Tag is too strenuous and I won’t be able to keep up, so I will stay in and do something I can actually do well.” They exhibit very low self efficacy, and this self-doubt becomes their main barrier to participating in physical activity.

Self efficacy is also molded by past experiences. Social Cognitive Theory relies on the basis of reciprocal determinism. Reciprocal determinism is when a person acts based on individual factors and social and environmental cues, responds by changing a behavior, and acts again (8). Obese persons will look at their past experiences with exercise, and will decide to change a behavior based upon their internal feelings of those experiences. Recommending 60 minutes of physical activity to a child who most likely does not have the most favorable experiences with physical activity is just as effective as telling a child to go play with a dog that has bitten them in the past. Due to these previous events an obese child is going to have extremely low self-efficacy compared to a child who has succeeded in incorporating exercise into their daily lives. The discussion of self efficacy in this paper has only related to theoretical examples, yet it is also pertinent to examine supporting scientific research. Random samples of adolescents were asked both psychosocial and environment questions regarding exercise. The results showed that the obese population within that group had significantly lower physical activity levels and self efficacy toward exercise, when compared to the non-obese population (13). Low self efficacy had a direct impact on their levels of physical activity. A study conducted almost 20 years ago highlighted self-efficacy as having a direct correlation to physical activity levels, and recommended that these issues be targeted in future intervention strategies (14). The concept of creating effective interventions that target behavior have been around for decades, yet the current recommendation for 60-minutes of physical activity still does not consider an individual’s self efficacy.

Readiness to Change of Population

This campaign also fails because it assumes that all participants are ready to change their exercise behaviors. In order to effectively change and implement a new behavior, the individual needs to have at least thought of changing that behavior. In other words, this person needs to have some intent to change. A perfect example is to think how effective it would be to tell someone they need to stop smoking when they love it and have no intent to stop. It is important to target interventions based on a person’s readiness to change. Physical activity recommendations are ineffective when a person does not intend, or have the motivation and interest to change at that specific point in time. This concept relates to another health behavior model called The Transtheoretical Model (TTM). TTM states that individuals undergo health behavior changes based on their readiness to take action (8). The model is based on stages, and that persons can enter the model at any stage, and can move between stages. For example, an obese child who has never exercised nor thought about exercising would be at what the model identifies as the “precontemplation stage”. The precontemplation stage identifies persons who have not intended to change or do not know there is a problem with their current behaviors (8). Individuals in this stage benefit from educational tools that make them aware of the problem or potential problems. While another obese child who has thought about increasing exercise and intends to sign up for spring baseball would be categorized in the “preparation stage”. The preparation stage refers to a person who is prepared to change and more importantly has the intent to change in the near future (8). These persons are already familiar with the benefits and barriers to the change; all they need is an environment to facilitate how to make the adjustment. Relating these concepts to the 60-minute physical activity recommendation, you cannot expect to effectively target both these children with the same intervention when one has not even thought of exercising. By considering the previous effects of external cues, past experience, and internal self-efficacy on an obese youth it is safe to say that the majority of our obese youth population would fall into the earlier stages of TTM. This would render the broad 60-minute physical activity recommendations useless, because you are telling children how to change. Instead the emphasis should be on why it is important to increase physical activity and therefore planting the seeds of change.

The 60-minute physical activity recommendation needs to consider there target population’s stage of change in order to create a more effective intervention. The goal of the intervention should be to move the subject into the next stage of change. This can initially be done through increasing the knowledge about physical activity. It has been shown that persons known to be in the precontemplation and contemplation stages of change benefit more from educational tools about physical activity than just exposure to physical activity alone. (15) This study illustrates that fact that if you target populations in the earlier stages of TTM, with appropriate interventions like education tools to increase awareness, there can be a higher chance of stage progression. The experiment group in this previous study was not given any specific exercise routines or durations, they were just given general information and were encouraged through that information to increase physical activity. Specifically recommending 60-minutes of physical activity time is not the most appropriate means of changing precontemplation adolescents’ exercise behavior.

Concluding Remarks

The issues presented today all come back to one central theme: there is a growing childhood obesity epidemic and the current recommendations for physical activity are an ineffective means to elicit a change in behavior. It has been shown that obese children are at higher risk for adult obesity(16), and that they are at a higher risk for developing hyperlipidemia, glucose intolerance, and hypertension(2,3). The health of our future population is at risk. It is crucial that policy makers not emphasize how much physical activity is needed to improve health parameters, but rather, what interventions can most effectively increase obese children’s behaviors and perceptions of preventative measures, like physical activity. Policy should rely more on treating the underlying causes of physical inactivity, specifically the social and environmental factors discussed on this paper.

In order to make this current recommendation effective it needs to rely on health behavior models. It needs to target the higher risk population and focus on behavioral change, not just the amount of exercise needed to improve health outcomes. The most effective way to re-structure this recommendation is to frame it in a different context. Do not leave the responsibility of accumulating physical activity in the hands of the children Create a mandate that all schools enact a curriculum based physical education program that emphasizes behavior change through education and physical activity. Reframe the 60-minute physical activity recommendation and use a health behavior based intervention that focuses on “how” rather then “how much”.

REFERENCES

1. Centers for Disease Control and Prevention. Prevalence and Overweight Among Children and Adolescents 2003-2004. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm

2. Must A et al. Risks and923 consequences of childhood and adolescent obesity. Int J Obes Relat Metab Disord. 1999 (23) S2-S11.

3. Dietz WH et al. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. 1998 (101) 518-525.

4. Hill, James O., and Trowbridge, Frederick L. Childhood obesity: future directions and research priorities. Pediatrics. 1998; Supplement: 571.

5. Weinsier RL et al. The etiology of obesity: relative contributors of metabolic factors, diet, and physical activity. Am J Med 1998; 105:145-150.

6. The 2005 Dietary Guidelines for Americans.

http://www.mypyramid.gov/professionals/pdf_framework.html

7. Stronget al. (2005). Evidence based physical activity for school-age youth. The Jounral of Pediatrics. 146(6). 732-737.

8. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones and Barlett. 2007. pg 53.

9. Davidson et al. Do attributes in the physical environment influence children's physical activity? A review of the literature. Int J Behav Nutr Phys Act. 2006; 3: 19.

10. Gordon-Larsen et al. Determinants of Adolescent physical activity and inactivity patterns. Pediatrics. 2000. 105; e83.

11. Moore LL et al. Influence of parents' physical activity levels on activity levels of young children. Pediatrics. 1991 Feb;118(2):215-9

12. Klesges RC et al. Effects of obesity, social interactions, and physical environment on physical activity in preschoolers. Health Psychology. 1990;9(4):435-49.

13. Trost et al. Physical activity determinants of physical activity in obese and non-obese children. Int. J. of Obesity. 2001. (25) 822-829.

14. Reynolds et al. Psychosocial predictors of physical activity in adolescents. Prev Med. 1990 (19) 542-552.

15. Woods et al. Physical Activity Intervention: A Transtheoretical Model-based intervention designed to help sedentary young adults become more active. Health Education Research. 2002. (17). 451-460.


16. Whitaker RC et al. Predicting obesity in young adulthood from childhood and parental obesity. New Eng J Med. 1997 (337) 869-873.

The Pathways Obesity Prevention in American Indian Schoolchildren Program: Wrong Path for Indian Country – Kristi A. Prellwitz

The rising rate of overweight and obese people in the United States has become a great concern over the last thirty years. Of particular interest is the growing number of overweight and obese children. An analysis of the data from the National Health and Nutrition Examination Study (NHANES) estimated that 17.1% of United States children (age 2-19 years) were overweight in 2003-2004 (1). This number dramatically increased from the early 1970s, when only 5% of children were overweight (2). No ethnic group is quite as affected as American Indians. Although national data for this group is limited, the estimated number of overweight American Indian children is between 25% and 46% (3, 4). This is of great importance as overweight children are more likely to be obese as adults and develop health problems, such as type II diabetes, which exists at high rates in American Indian populations (5).

A recent intervention to prevent overweight and obesity in American Indian schoolchildren is the Pathways Obesity Prevention in American Indian Schoolchildren Program. This full-scale study was developed after a three-year pilot study that tested for the feasibility of using the Pathways Program as an intervention (6). The program itself was designed to use culturally appropriate school curriculum for American Indian children in grades three thru five to promote healthy eating and physical activity (7). The cultural components included stories about American Indian children participating in healthy lifestyles, information about local and traditional food choices, and physical activity that included cultural games (6). In addition to the school-based components of curriculum, food services, and physical activity, the program tried to promote healthy living in other areas of life by including families in the intervention (7). Unfortunately, the Pathways Program has failed due to its strong emphasis on the use of Social Learning Theory, its failure to acknowledge the history and current social and economic factors affecting American Indians, and its inability to recognize the level of acculturation of the population.

Social Learning Theory Does Not Guarantee Proper Action

While it is important for American Indian populations to reduce the amount of obesity and complications associated with this health crisis, the Pathways Program falls short of this goal by basing its intervention on the Social Learning Theory. The study did show that the children had increased knowledge about healthy lifestyles and an increase in physical activity while in school, but the children did not have a reduction in average body weight or adiposity at follow-up (8). By using Albert Bandura’s Social Learning Theory, the program is unable to have an effect on weight change because of the theory’s key principle of vicarious learning through modeling (9). The intervention does not focus enough on the need for reinforcement of the behaviors that the children were to model.

Central to the Social Learning Theory is the idea that learning will occur through observation or modeling (10). The idea put forward is that the person will begin to imitate a reinforced behavior, not just gain knowledge about it. However, modeling did not work in the Pathways Program because of lack of reinforcement. At the beginning of the intervention, most children did not participate in the healthy behaviors that the program prescribed (8). Additionally, family members learned the behaviors as the children did when a child brought home a challenge sheet or when parents attended a family fun night (7). Therefore, few community members actually possessed these skills in the beginning. The hope was that by using American Indian storybook characters to model the intended behavior, the children would imitate the behavior. While storybook characters were a good initial model, the actual conditions in the environment are essential to behaviors continuing (10). A child rereading the book is not enough to reinforce the behavior; he must actually see other community members participating in the behavior in order to learn it. The changes in health behaviors the children accomplish in school may only be superficial or temporary and may stop if the children are unable to self-reinforce the behavior (11). While the children were able to understand cognitively what the program taught, they were unable to adopt the behaviors in their own lives without a good source of reinforcement from the community. Since an intervention using Social Learning Theory as a basis cannot guarantee adoption of taught behaviors, it is ineffective to use solely Social Learning Theory for an intervention influencing behavior (12).

Failure to Acknowledge Historical Effects on Social and Economic Status

For many groups, history continues to affect how members of a group experience life presently. Particularly when social standing does not change much over time, group members continue to experience social and economic situations similar to those of the past. By ignoring the history of American Indian people, the Pathways Program failed. While the focus of this intervention was school-based, it is apparent that components were supposed to change the overall lifestyle of children and their families (8). Therefore, an examination of the history and current social and economic status of American Indians is necessary to see if the American Indian family is able to adhere to the protocol prescribed or if it is simply out of its reach.

The American Indian history of oppression led to the economic and social disadvantages that American Indians experience today. Placement of American Indians on reservations and in boarding schools was the means of oppressing this group. The use of this combination was interesting. On the one hand, the reservations were places of poor land quality where seclusion of American Indians was to take place (13). On the other hand, boarding schools were places of assimilation for children where they would learn the ways of mainstream America (14). While the skills learned were appropriate based on the American standards, American Indians were unable to put these skills into practice because of lack of resources on reservations and the resistance of white settlers to accept American Indians into society (15). Because of the experience of being socially unaccepted, American Indians, in turn, were more reluctant to adopt programs developed by the white majority. The negative experiences of both institutions continue to affect the American Indians’ ability to survive, particularly socially and economically.

American Indians, especially those on reservations, continue to suffer. The Oglala Sioux of the Pine Ridge Indian Reservation, one group included in the Pathways Program, experience many challenges of living on reservation land. On the reservation, American Indians continue to be suspicious of the American school system. Suspicion causes American Indians to have the highest high school dropout rate with less that 50% of American Indians graduating from high school (12). Lack of education makes it difficult for American Indians to support themselves. Estimates of the median income on the Pine Ridge Reservation are only between $2,600 and $3,500 annually (16). Furthermore, there is an unemployment rate 0f 45%, a backlog of substandard housing (including 4% of families being without housing), and lack of transportation (both public and private) (17). Modern conveniences of telephones, electricity, plumbing, and running water are lacking in some parts of the reservation (18).

These factors may help to explain why American Indian families cannot follow the healthy eating habits prescribed by the Pathways program. Mistrust of the school system is likely to make it difficult for families to accept the Pathways message. Even when American Indians desire to follow the program, there are obstacles. It is obviously difficult for these families to get from one location to the next, particularly those living outside towns and lacking a car to reach the nearest towns. The towns that are near the reservation all have populations less than 5,000 people (17). Even if the families are able to travel to these towns, it is unlikely they have the same variety of foods that are available in a larger city. Furthermore, since the American Indian income is considerably lower than that of the general population, it may be beyond difficult to choose healthier, more expensive foods over cheaper, less nutritious foods. While students and their parents were taught and could understand healthy eating habits, it may be too difficult to implement this knowledge into action, especially when the decision is between keeping food on the table (healthy or not) and providing other necessities, like electricity or gas.

Focus on Tradition Interventions versus a Bicultural Approach

The culture of American Indians is considerably different in comparison to other minority groups that have undergone assimilation in the United States. Unlike these groups, which tend to remove themselves from their country of origin over time, American Indians practice biculturism, in which they seek and maintain connections with both cultures (19). American Indian children often connect to traditional culture, but the majority culture of the United States still influences them. The Pathways Program failed by focusing solely on traditional elements of American Indian culture. Even though traditional interventions have worked, it is necessary that investigators begin to look at all cultural influences, both traditional and non-traditional (20).

While it was advantageous for Pathways to address traditional norms, they failed to account for differing levels of acculturation between the various tribes and even between participants of the program (20). Examining the level of acculturation of a particular tribe is necessary to determine if a purely traditional model is appropriate. In some tribes, traditional activities no longer are passed down through the generations (21). If children in the Pathways Program did not relate to an activity for either of the above reasons, the stories and physical activity skills learned may have felt inappropriate. The children that could not relate would not have a reason to reinforce these behaviors.

As acculturation strengthens, the media has influenced more American Indian children, particularly through television. Like any other American child, American Indian children enjoy watching television. Sociologists and anthropologists believe that exposure to the media is a powerful way for American Indians to be assimilated into the dominant culture (22). Beyond using for pleasure, American Indian families turn to television (84%) as a way to relieve stress, compared to talking to friends and family (76%), praying or meditating (64%), and exercising (67%) (23). When families use the television for pleasure or for coping, American Indian children see the messages of the dominant culture. Particularly, they see the way other Americans eat through advertisements for high fat, high calorie foods. This food promotion directly links to the eating habits of children (24). Therefore, addressing television use (and potentially other mainstream influences), is important to the success of a program. Just as it is necessary to use traditional techniques to which American Indians can relate, it is also necessary to apply techniques that work in the majority culture when appropriate.

Concluding Remarks

The Pathways Program was an inappropriate attempt to reduce obesity and being overweight in American Indian children. Social Learning Theory posits vicarious learning through modeling. Students may learn the behaviors modeled for them, but without reinforcement, they are likely to forget the behaviors and imitate the actions they see around them. The intervention also failed to acknowledge the importance of historical and social information about the study participants. The intervention may have taught both children and their parents new information about health, but it should have made sure there were ways to put the knowledge into practice. Finally, by not emphasizing a bicultural model, the intervention did not adequately take into account the totality of influences that American Indian children experience from the majority culture. These majority culture influences may play as large or an even larger role in health behaviors.

A more appropriate approach would address underlying factors that might affect a participant’s ability to follow the prescribed intervention. Since American Indians are a creative group, it might be effective to combine Social Learning Theory with other theories or ideas. For example, teach children a skill and let them expand on it. This might involve teaching dance steps and allowing them to create their own dance. By attaching ownership, the children become inclined to continue the behavior. Instead of just teaching a behavior, a better way to get children and their families to eat healthily may have been to give food vouchers to families to redeem healthy foods or bringing food stands to families that are far from grocery stores. Additionally, accurately determining the level of acculturation is necessary, particularly in American Indian tribes, where the level of acculturation can vary by and within a tribe. This will affect the accuracy of the intervention. By considering details prospectively, an intervention has the ability to succeed. Using this front-end approach acknowledges areas where there are barriers and removes them before an intervention hits a dead end.

REFERENCES

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5. Story M, Evans M, Fabsitz RR, Clay TE, Holy Rock B, Broussard B. The epidemic of obesity in American Indian communities and the need for childhood obesity-prevention programs. American Journal of Clinical Nutrition 1999; 69:747S-754S.
6. Johns Hopkins Bloomberg School of Public Health. Pathways: obesity prevention in American Indian schoolchildren. Baltimore, MD: Johns Hopkins University. http://www.jhsph.edu/chn/Research/pathways.html
7. The Pathways Curriculum. Intervention Components of Pathways Model. Albuquerque, NM: University of New Mexico. http://hsc.unm.edu/pathways/.
8. Caballero B, Clay T, Davis S, Ethelbah B, Holy Rock B, Lohman T, Norman J, Story M, Stone E, Stephenson L, Stevens J. Pathways: a school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren. American Journal of Clinical Nutrition 2003; 78:1030-1038.
9. Edberg M. Social, cultural, and environmental theories (part 1) (pp. 51-64). In: Riegelman R, ed. Essentials of health behavior: social and behavioral therapy in public health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
10. Compas B and Gotlib I. Models of development, behavior, and personality (pp. 87-114). In: Introduction to clinical psychology: science and practice. New York, NY: McGraw-Hill Company, Inc., 2002.
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18. Kraus B. Wealth, success, and poverty in Indian country. Poverty and Race 2001; 10.
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The Negative Effects of Criminalizing Mothers Who Use Illicit Drugs During Pregnancy – Marilyn M. St. Fleur

Over the last two decades several states have passed legislation to punish pregnant women for behavior that endangers their fetuses. The laws prosecute pregnant women who use drugs on the basis of child abuse, neglect, delivery and distribution of controlled substances, and involuntary manslaughter (6). Over 200 women in 34 states have been prosecuted in criminal courts for substance use during pregnancy. Many others have faced charges of child endangerment or neglect in civil proceedings, or have had their children removed from their care because they tested positive for drugs at the time of birth (6).

The behavior of pregnant women is closely monitored, largely because children are socially viewed as a vulnerable population. As a result the welfare of children is often widely protected through effective legislation. However, the current punitive approach that prosecutes pregnant women who use illicit drugs in an effort to protect the fetus is flawed. The new drug legislation fails to adequately solve this public health problem because it does not address the experiences of the mothers who use illicit drugs; the extreme punitive measures deter mothers from seeking proper healthcare, and it fails to protect from discriminatory application.

The Lives of Mothers

A weakness in the drug legislation is its inability to address the lives of pregnant mothers who use illicit drugs. For several of these mothers’ illicit drugs use is one of many factors present in their lives that can negatively impact their fetus. Studies have shown that up to half the women with drug and alcohol problems are depressed or have other diagnosed mental illnesses (1). Studies also found that women who use substances during pregnancy suffer higher rates of sexual abuse and domestic violence (1). Further studies demonstrate that without careful consideration of additional factors protection and incarceration of mothers can harm of the fetus prior to and post birth. As a result the individualistic approach that addresses drug use alone is simply a “band aid” on a large wound.

The approach of protecting the fetus but not the mother is flawed because the health of the mother has a direct effect on the fetus prior and post birth. In essence protecting one without the other has a high potential of leading to a chain of negative health outcomes. The focus of this intervention is on the fetus rather than the mother. The legislation is analyzing drug use independent of other factors that have large effects on the situation at hand. This approach focuses on the fetus, blames the mother, and has therefore become an intervention that can be harmful (11).

A situation that can parallel the harmful affects of this legislation in found in an individuals access to health care. Studies have proved the unhealthy behaviors and inadequate access to health care among people of low socioeconomic status account for only 10-16% of the socioeconomic differences in health (9). This is not to discredit the impact of addressing unhealthy behavior and access to health care, but to demonstrate the need to take other contributing life factors, like education level attainment and race/ethnicity, into account when creating policies. The legislation that seeks to protect the fetus of mothers who use drugs fails to take an adequate holistic approach and is therefore flawed and ineffective.

Fear - A Counteractive Tactic

Furthermore, the drug legislation prosecuting pregnant woman is a counteractive approach. Drug use and trafficking is part of a socially constructed “underground” silent economy (4). Women who are tested for drugs, for example during doctors’ visits, are often tested without their consent (1,6). In several states those that test positive are turned over to police, threatened with prosecution, forced into treatment, tried as criminals, and often sentenced to prison (1,6). These measures are likely to entice fear amongst pregnant woman who use illicit drugs and push them further underground. In essence the punitive measures close a line of communication between health care providers and mothers. Pregnant women who wish to avoid criminal prosecution may avoid seeking health care, which in turn can harm both the mother and the fetus.

Legislators must also be weary of the fact that very fearful mothers may even go to the extreme of terminating their pregnancy through self-inflicted harm to avoid punishment (6). For some very fearful or confused mothers it is the destructive nature of illicit drugs that motivates and supports their risky behavior -in addition to the addictive nature of the drugs - (12). Rather than scaring pregnant women away from health care, the legislation should be getting mothers who use drugs into health care and into treatment on a voluntary rather than punitive basis. Punishing women who have used drugs or alcohol during pregnancy by prosecuting them or incarcerating them may feed a sense of social retribution but does nothing to promote infant well-being (1,10). In efforts to protect the fetus these policies place pregnant women in prison exposing them to violence, infectious diseases, extreme stress, humiliation, stigma, and emotional distress (1,10) Nevertheless, legislators must understand that there is a psychological root as to why drug users choose to participate in such risky behavior, and it is important that the legislation passed not have counteractive effects that lead to further risky behavior.

Discriminatory Applications

Though the legislation seems broad and neutral it has been applied using discriminatory practices. Studies have shown that illicit drug laws of all kinds are used more often on racial minorities and the poor. Selectivity in drug screening is an example of how this is done. In South Carolina healthcare personnel look for indicators such as the absence of prenatal care as criteria to drug test mothers (1,6). The criteria targets low-income and minority populations because both groups have a greater tendency to not seek healthcare (5). Their lack of use of the health care system is due to a number of reasons, such as inadequate access to care, cost, quality, mistrust, religious beliefs and a lack of or restricted insurance policies(5). Discriminatory application of the legislation has lead to higher rates of prosecution and imprisonment in minority and poor communities. In Charleston, a city in South Carolina, forty-one mothers were arrested for illicit drug use during pregnancy (1). Forty of the forty-one mothers were black women (1). Nevertheless, when legislation enforcers use the number prenatal care visits as criteria to test mothers they place minority and poor mothers at a higher risk of punishment than other mothers.

In addition to screening, several states are enforcing the legislation only in public hospitals located in poor communities (1,6,3,7). The legislation in South Carolina – and other states – has not been equally applied to white and affluent neighborhoods. Physicians who found substances often associated with middle and upper class populations, such as methamphetamine and heroin, made referrals to social services, not to law enforcement (7). Evidence shows that criminal sanctions against pregnant women are applied unequally. Poor and minority women bear the brut of suspicion and prosecution. Punishing pregnant mothers who use illicit drugs during pregnancy by prosecuting or incarcerating them may seem lawfully right in protection of the fetus, but does nothing to promote infant well being (10). The legislation is flawed because it does not provide regulation or means to protect against discriminatory affects. Instead the legislation contributes to the social pressure and injustice faced by poor and minority groups.

Implications for Future Public Health Recommendations

Legislation that prosecutes drug users should incorporate a method to offer women help and control over their lives prior to taking any punitive measures. Once addicted to illicit drugs pregnant women face many barriers to getting help. Programs need to be put in place to help pregnant mothers who use illicit drugs understand the epidemic and provide them with ways of getting safe health care. A great deal can be done to safeguard maternal and child health, including providing universal access to high quality pre-and postnatal maternal care, mental health care, drug and alcohol treatment, health education, and healthy living environments in early childhood (1,5,6). Offering pregnant women medical, social, and educational services is a sustainable way of helping both the mother and the child.

Conclusion

The health of a woman is as important as the health of their fetus. Legislation must start supporting women, so that they, in turn, can be there for their children. Pregnant mothers, who turn to drugs as the result of their mental health or abusive and traumatic childhoods, need our compassion and access to treatment, not imprisonment (1). The new drug legislation fails to adequately solve this public health problem because it does not address the experiences of the mothers, instead it deter mothers from seeking proper healthcare, and does not protect from discriminatory application.

Several states are currently debating on whether women who abuse drugs during their pregnancies should be subject to criminal punishments. If the goal of such policies is to protect the health of future children, we as a society must question policies that drive underground women who need and may want treatment, and criminalize those brave enough to seek care (1). The power-coercive measure that states like South Carolina has taken to address the issue, is an ineffective approach. Criminalizing maternal drug use can lead to potentially tragic consequences for pregnant women, their fetuses, and their families. When pregnant women fear that they will be prosecuted for their drug use, they are less likely to seek prenatal care (1). It appears to drive drug-using women out of the health-care system and isolates them in their drug use rather than helping them have healthy pregnancies and healthy babies. Legislators must recognize this as truth and provide a means for pregnant woman who use illicit drugs to receive help for both themselves and their fetus.

References:

1. Armstrong E. Drug and Alcohol Use During Pregnancy: We Need To Protect, Not Punish, Women. Women’s Health Issues, Elsevier Inc. 2005; 15:45-47.

2. Billings Gazette. Meth-pregnancy bill criticized. Jofe Enterprises. http//www.billingsgazette.net/articles/2007/02/08/news/Wyoming.

3. CNN Health. Criminally Pregnant. http://archives.cnn.com/200/HEALTH/10/30/ethics.matters/index.html.

4. Destiny’s End. Socio-economic factors of the underground economy. http://www.wmich.edu/destinys-end/index.html

5. Edberg M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett Publishers, 2007.

6. Gostin L. The Rights of Pregnant Women: The Supreme Court and Drug Testing. The Hastings Center Report 2001; 31:8-9.

7. Harris L. The Status of Pregnant Women and Fetuses in US Criminal Law. American Medical Association 2003;289:1697-1699.

8. Harris L. Rethinking Maternal-Fetal Conflict:Gender and Equality in Perinantal Ethics. The American College of Obstetricians and Gynecologist. Elseiver Science Inc. 2000;96:786-91.

9. Lu, N., Samuels M. et. al., Socioeconomic Differences in Health: How Much Do Health Behaviors and Health Insurance Coverage Account for. Journal of Health Care for the Poor and Underserved 2004;15:618-630.

10. National Advocates for Pregnant Women. SC Supreme Court Hears Appeal: Don’t Punish Women for stillbirth. South Carolina. http//advocatesforpregnantwomen.org/issues/criminal_cases

11. Pearce, N. Traditional Epidemiology, Modern Epidemiology, and Public Health. American Journal of Public Health 1996; 86:678-683.

12. Siegel M. The importance of formative research in public health campaigns; an example from the area of HIV prevention among gay men (Appendix 3-A).Siegel M, doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers 2004; 66-69.

Why Lack of Understanding of PTSD is Preventing Effective Screening for Iraq Veterans – Jay Myung

The term post-traumatic stress disorder slowly made its way into existence in the period following the Vietnam War. At the time, symptoms resembling PTSD were labeled shell shock and were blamed on veterans themselves for having gone to war in the first place. The American public and government were highly scrutinized for their degradation of returning soldiers, and since then numerous support groups as well as the Vietnam Veterans Memorial in Washington, D.C. have been dedicated in support and recognition of Vietnam veterans.

In 2003, Operation Iraqi Freedom was launched representing the largest ground operation effort since the Vietnam conflict (2). Approximately two-thirds of those deployed to Iraq are aware of someone that was killed or seriously injured. Ground forces have experienced more explosive warfare in the current conflict compared to any previous combat.

It is this type of explosive warfare that has specifically been associated with PTSD (3). Recent studies suggest an unprecedented number of soldiers returning from Iraq with symptoms of PTSD since their deployment in 2003 (1-8, 13). One study conducted in 2004 showed PTSD among 17% of returning soldiers, while another study conducted in 2006 showed positive screening for 19% of those deployed. In comparison, 15.2% of Vietnam veterans involved in close combat were diagnosed with PTSD (5).

PTSD that is not recognized and treated can have devastating consequences. Panic attacks, substance abuse, depression, and ultimately suicide are all known complications. Among Iraq veterans with PTSD, eleven fatalities from suicide were reported during 2003-2004. The following year twenty-two cases were reported.

Current screening interventions primarily consist of a pre and post deployment checklist. This checklist screens for general medical and mental health conditions and was updated in September 2007 to include additional questions on behavioral health and traumatic brain injury. Additional screening measures include active screening by primary care physicians, as well as an online voluntary self-assessment that can be taken at any time.

Altogether, these measures do not yield significant improvements in PTSD screening among soldiers returning from Iraq [4, 6]. The screening checklists contain a superficial set of questions that lack an understanding of PTSD. They address observable symptoms while ignoring that they occur within an environment, and that the military environment in particular carries with it unique considerations. The remainder of this discussion involves a look into how current screening checklists are missing a significant portion of PTSD among Iraq veterans due to stigmas, awareness of PTSD, and differences in gender.

The PTSD Stigma

There are generally two stigmas surrounding PTSD in the military. The first involves the perception that those with PTSD are weak (13). From boot camp, social inoculation to be strong and disciplined is heavily emphasized. Cadets model one another as well as their commanding officers in cognition and behavior. The presence of nightmares, anxiety, and depression can therefore be seen as outside the realm of accepted behavior. Soldiers can easily be looked down upon by peers and commanding officers (13). And since PTSD is not rank-specific, higher-ranking officers may have a more difficult time coming to terms with surrounding stigmas.

The second stigma involves job placement. It is common knowledge among soldiers that reporting positively to any of the questions on screening surveys may result in a mandatory visit to a physician or mental health professional. A recommendation produced from this visit can jeopardize consideration of current and future military jobs and assignments. This is especially true if a particular ailment warrants detachment from the military for either a temporary or prolonged period (12, 15). Recently, a soldier with eight years of combat experience and two tours in Iraq was arrested for seeking treatment for PTSD. He described receiving inadequate recognition and treatment within the military. His ailments were so detrimental to his daily functioning that he had to leave the army to seek treatment elsewhere. His withdrawal was not recognized by the military and he was subsequently arrested (19).

To the general public, these stigmas may not appear strong enough to deter one from reporting symptoms and seeking treatment. According to one study involving the general population, stigmas associated with future job prospects accounted for only 10% of failures to seek medical attention, while embarrassment from peers accounted for 13%. The same study conducted among soldiers returning from the Bosnia conflict showed that 61% of participants were reluctant to seek recognition and treatment specifically due to worries about their career, while 43% were worried that they might be looked at differently or down upon by peers (12). The numbers illustrate a marked contrast between the worries of life in the military compared to that of the general public.

Now consider that of the soldiers reporting symptoms resembling PTSD, only 23%-40% sought medical attention for their ailment. The soldiers that sought treatment were also twice as likely to admit that stigmas presented a barrier to seeking care and reporting symptoms (13). In another study, the two most commonly perceived barriers to admitting symptoms and seeking treatment were career risks (50%) and altered peer perceptions (50%-65%)(8). These two stigmas clearly carry significant weight with regard to how soldiers report symptoms on screening forms. The data suggest that the number of soldiers that denied symptoms due to such barriers may in fact be substantial. These soldiers remain at large suffering panic attacks and generalized anxiety on a daily basis.

Beliefs About PTSD

PTSD is a condition that requires medical attention just like any other disease. According to the health belief model, behavior in response to a condition is based on perceived severity, vulnerability, barriers, and benefit. The combination of these factors may predict whether a behavior will be taken. Barriers in the form of stigmas were described above. Perceived severity, vulnerability, and benefit may provide further explanation regarding denial of symptoms on screening checklists.

Soldiers returning from war may be more apathetic towards seeking treatment than the general public. In a study conducted among the general population, more than 50% of subjects reported that they did not perceive an adequate benefit associated with seeking medical attention. More than 30% did not consider their mental health condition severe enough to seek attention (16). Among Iraq soldiers, 85% of those screened positively for a mental health condition recognized that they had a problem, but only 45% were interested in seeking treatment. The avoidance was mostly due to a perceived lack of severity and benefit. For instance, 55% avoided care because it was too difficult to get off of work, while 25%-38% expressed a lack of trust in healthcare professionals (13).

Is the perceived lack of severity justified? Suicide as a direct result of PTSD is approximately 0.13%, higher than in the general population (11). However rates may in fact be higher due to the intervening depression, substance abuse, anxiety disorders, and chronic PTSD that often precede suicide attempts. These chronic complications are often overlooked or considered insignificant when compared to suicide, and may account for the low sense of severity.

Is the perceived lack of benefit from care justified? The patients may not be aware that PTSD can be managed with medications, and that sufficient benefit and prevention can result from seeking care (13). Other interventions such as cognitive-behavioral therapy might be regarded as having a low probability of success. CBT actually produced the most benefit compared with many therapies when combined with medication (10).

The lack of awareness of treatment success combined with the notion that PTSD is not a significant condition can therefore easily lead to an intentional denial of symptoms on screening forms. The data suggest that these factors cannot be ignored.

PTSD and Gender

A clear understanding of gender differences was not recognized when developing the screening questionnaire. While this may not lead to an extensive number of missed cases, it may promote the increased morbidity for those women that were overlooked.

Past studies have clearly shown that PTSD is more common in women and that women are more likely to display different symptoms (10). For instance, women are more likely to experience physical manifestations in response to stimuli resembling previous traumatic episodes, and are more likely to avoid personal or environmental associations. The current screening form addresses this symptom in a single question. The problem is that there are only four questions addressing PTSD and a screening form is considered positive for PTSD when at least three of the questions are answered in the affirmative, regardless of whether the subject is male or female. While this may represent a gap in detection for anyone, women are particularly at risk of not getting screened appropriately because the symptoms they tend to experience are summarized in a single sentence and worth only a single point out of four.

Detection of PTSD among women is particularly significant due to increased risk factors and higher rates of complications. Women have higher rates of depression, suicide attempts, and anxiety than men (10). Women also respond differently to various treatments. Prolonged-exposure cognitive-behavioral therapy in particular appears to produce a significant improvement in PTSD symptoms and complications compared to other modalities for women in the military (10).

Implications

Vietnam veterans still suffer from chronic PTSD. The depression, anxiety, and withdrawal affect everyone involved. PTSD does not have devastating consequences such as those linked with smoking, but instead yields slow changes manifested in family, friends, and peers. These changes can be prevented but must first be recognized. Continued use of checklists as the primary method of screening for PTSD will undoubtedly allow many cases to go unnoticed.

References

1. Kolkow TT, Spira JL, Morse JS, Grieger TA. Post-traumatic stress disorder and depression in health care providers returning from deployment to Iraq and Afghanistan. Military Med. 2007 May;172(5):451-5.
2. Erbes C, Westermeyer J, Engdahl B, Johnsen E. Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan. Military Medicine. 2007 Apr;172(4):359-63.
3. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine. 2007 Mar 12;167(5):476-82.
4. Greenburg DL, Roy MJ. In the shadow of Iraq: posttraumatic stress disorder in 2007. Journal of General Internal Medicine. 2007 Jun;22(6):888-9.
5. Nau JY. One quarter of American soldiers serving in Iraq and in Afghanistan suffer from mental health disorders. Review of Medicine Suisse. 2007 Mar 28;3(104):837.
6. Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. American Journal of Psychiatry. 2007 Jan;164(1):150-3.
7. Rona RJ, Hooper R, Jones M, Hull L, Browne T, Horn O, Murphy D, Hotopf M, Wessely S. Mental health screening in armed forces before the Iraq war and prevention of subsequent psychological morbidity: follow-up study. BMJ. 2006 Nov 11;333(7576):991.
8. Hoge CW, Castro CA. Post-traumatic stress disorder in UK and US forces deployed to Iraq. Lancet. 2006 Sep 2;368(9538):837
9. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association. 2007 Feb 28;297(8):820-30.
10. Schnurr PP, Friedman MJ, Engel CC, Foa EB, Shea MT, Chow BK, Resick PA, Thurston V, Orsillo SM, Haug R, Turner C, Bernardy N. Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. Journal of Affective Disorders. Volume 68, Issues 2-3, April 2002, Pages 183-190
11. Arif Khan, Robyn M. Leventhal, Shirin Khan, and Walter A. Brown . Suicide risk in patients with anxiety disorders: a meta-analysis of the FDA database. Journal of Affective Disorders. 2002 Apr;68(2-3):183-90.
12. Britt, T.W. (2000). The stigma of psychological problems in a work environment: Evidence from the screening of service members returning from Bosnia. Journal of Applied Social Psychology, 30, 1599-1618.
13. Hoge, C.W., Castro, C., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351, 13-22.
14. Kimerling, R., & Calhoun, K.S. (1994). Somatic symptoms, social support, and treatment seeking among sexual assault victims. Journal of Consulting and Clinical Psychology, 62, 333-340.
15. Meltzer, H., Bebbington, P., Brugha, T., Farrell, M., Jenkins, R., & Lewis, G. (2000). The reluctance to seek treatment for neurotic disorders. Journal of Mental Health , 9, 319-327.
16. Reiger, D.A., Narrow, W.E., Rae, D.S., Manderscheid, R.W., Locke, B.Z., & Goodwin, F.K. (1993). The de facto U.S. mental and addictive disorders service system: Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50, 85-94.
17. Kudler H. The need for psychodynamic principles in outreach to new combat veterans and their families. Journal of the American Academy of Psychoanalytic and Dynamic Psychiatry. 2007 Spring;35(1):39-50.
18. Ann Scott Tyson. Repeat Iraq Tours Raise Risk of PTSD, Army Finds. The Washington Post. Wednesday, December 20, 2006; Page A19
19. AWOL Soldier Seeking Treatment Arrested. The Associated Press. November 15, 2007. Http://www.military.com/NewsContent/0,13319,156277,00.html.

El Paso CATCH Falls Short: The Failure of a School-Based Health Education Program to Reduce Obesity on the U.S.-Mexico Border – Jessica Fargnoli

Since the 1980’s the prevalence of childhood overweight and obesity has been steadily on the rise. Now, with an estimated 17.1% of children and adolescents overweight, this trend has become an alarming public health problem with serious ramifications for the health of American children (1). Risk factors for cardiovascular disease such as hypertension, high cholesterol, and impaired glucose tolerance are manifesting themselves in overweight children at increasingly early ages (2). More shockingly, Type 2 diabetes, a disease traditionally occurring in middle-aged adults, is now being diagnosed in children (2). As in adults, the burden of this epidemic of childhood overweight and obesity is not shared equally among all Americans. The prevalence of obesity in Mexican-American children aged 6-11 is 22.5% compared with 17.7% in non-Hispanic white children (1).

Clearly, childhood obesity, particularly among Mexican-American children, is a pressing public health concern. Numerous interventions have been developed to address this problem, many of them focused on reducing the prevalence of childhood obesity by altering the school environment. One of the most popular and widely institutionalized interventions, the Coordinated Approach to Child Health, or CATCH, (formerly the Child and Adolescent Trial for Cardiovascular Health) focuses on reducing childhood overweight and obesity with the major goals of: 1) Reducing the amount of total and saturated fat in school lunch; 2) Increasing the intensity of physical activity in school physical education programs; and 3) Improving students self-reported eating and physical activity behaviors (3). CATCH seeks to accomplish these goals through a classroom health curriculum focused on nutrition and exercise with accompanying family materials, a physical education curriculum, and a school foodservice component focused on reducing fat and sodium content in school lunches (4). CATCH’s approach of modifying the school environment and distributing nutrition and exercise information to families was deemed a success when tested in 96 elementary schools across the country (3). After 3 years of implementation, students at CATCH schools had lower self-reported energy from fat intake and higher daily physical activity; however, there were no differences in BMI, blood pressure, or cholesterol levels between CATCH students and control students (3).

After the success of CATCH in its target elementary schools, researchers began implementing the program in schools in Texas, where there is a particularly high risk for childhood obesity. Since the prevalence of overweight and obesity are higher in Mexican-American children, the first site chosen to test the program was El Paso, Texas, which lies on the US-Mexico border and has a population that is 78% Hispanic (5). Each site selected was also designated a Title I school, meaning that most of the children in attendance came from low-income families. Though the researchers involved sought specifically to reduce childhood obesity in low-income, predominantly Hispanic schools, no alterations were made to the program to account for the economic and social challenges to obesity reduction this population. CATCH has not been sufficient to reduce childhood obesity in El Paso because it does not take into account the effect of economics, social networks, and immigrant perceptions of US social norms surrounding food and obesity in this region of the US.

Failure to take economics into consideration

El Paso CATCH does not account for the prevalence of poverty in its target population, and the consequent lack of access to nutritious foods and opportunities for physical activity. Changing the school environment alone will not significantly improve the health of El Paso’s children if the positive changes cannot be continued once they leave school.

The El Paso CATCH curriculum includes recommendations for families on nutrition at home. Advice includes buying more whole grains, fruits, and vegetables and avoiding fast food and “food of minimum nutritional value” (6). While this is clearly good advice, CATCH does not address the way economics in the United States promote obesity in low-income families. Energy-dense foods tend to be lower in cost, and poverty is associated with lower available expenditure for food (7). As a result, low-income families often spend less money on food but have a higher caloric intake, mostly from fats and sweets. Research has shown that healthy diets like the one CATCH promotes, which are associated with the USDA nutritional recommendations, also cost more money (about $1.75 more per person per day on average) (8). Thus, educating low-income families about nutrition, as El Paso CATCH does, is not sufficient to improve their diets if they still cannot afford to purchase the recommended foods.

El Paso CATCH also makes recommendations to increase physical activity during and after school (6). However, low-income areas offer fewer opportunities for physical activity. The availability of exercise facilities, both in and out of school, is lower in communities with higher levels of deprivation, such as El Paso (9). In addition, children from low-income families may have trouble affording the physical examinations required to join sports teams (10). Moreover, Title I schools, which are often scrambling to meet state and national standards in academic subjects, often devote much less time to physical education than schools in higher income communities (11). Since it is not possible for some students in to obtain a healthy amount of physical activity during school hours, it is extremely important to have programs in place to encourage and facilitate exercise after school. CATCH neither provides after school access to exercise facilities nor coordinates sports and other games in which children can be physically active outside of school. CATCH educates children and their families about healthy food choices and exercise, but this is unlikely have an effect on the prevalence of childhood obesity in El Paso if the students do not have access to nutritious foods or exercise facilities.

Social Network Theory is not utilized

By focusing solely on school health education, improving school lunches, and increasing physical activity in school, El Paso CATCH fails to include Social Network Theory in its intervention, and does not take into account the relationships children with obesity have with their peers. Social Network Theory, first formulated by sociologists, explains individual behavior in the context of the relationships between individuals (12). Relationships are defined in terms of social networks, and one individual may interact with many different types of networks, such as family, work, and school. Social Network Theory proposes that these networks play a large role in whether or not an individual engages in a certain health behavior. Thus, conducting a successful intervention involves researching the pertinent social networks and intervening appropriately on aspects of these relationships that will promote a certain health behavior.

Clearly, one of the most important social networks in the life of a child is made up of peers at school. This social network could be used to encourage children with obesity to participate in healthy activities during school. As it stands, children who are overweight and obese are often stigmatized by their peers at school, which could prevent them from participating in physical education. Overweight and obese school children are more likely to be both the victims and perpetrators of bullying than normal weight children (13). In addition, children with overweight or obesity are more socially isolated, tending to have fewer friends and be less likely to participate in school activities than their normal weight peers (14). Weight stigma can also lead to body dissatisfaction and low self-esteem, among other psychosocial consequences (15).

A child with low self-esteem who is stigmatized by his or her peers may feel uncomfortable with participating in physical education in school. Since such a child is also less likely to participate in school activities such as sports and games, he or she will probably not benefit from the school programs that CATCH offers. CATCH does not take into account the social isolation or low self-esteem that overweight children experience by developing programs to improve the acceptance of these children within their school social network. Even if the health and physical education activities that are offered by CATCH are well designed, they will not have an effect if their target audience is prevented from participating by isolation from their school social network. Social Network Theory could help intervention programs like CATCH target the crucial peer relationships that govern a great deal of children’s health behaviors. In order to more effectively reduce childhood obesity, El Paso CATCH should utilize the school social network to encourage and support the target behavior of increased physical activity.

Social norms are not addressed

When implementing the CATCH program on the US/Mexico border, Mexican-American body weight norms and the changes in food norms associated with acculturation were not taken into account. Mexican-American norms associated with healthy body weight may differ from the medically accepted ideal healthy body weight. A study conducted on the US-Mexico border found that mothers’ perceptions of whether their children were overweight were not dependent on BMI, but rather on whether the child was active and could lead a normal life (16). In another study of mothers’ perceptions of body image, every mother viewed her daughter’s body size as ideal, even though 34% of the daughters enrolled in the study were overweight (17). This research suggests that it may be necessary to address social norms surrounding overweight and obesity at the family level before CATCH’s education programs can reduce childhood obesity in El Paso.

The large immigrant population in El Paso may also lead to other barriers for the CATCH. Immigrants’ perceptions of what is acceptable for an American to eat may lead to less healthful food choices. Acculturation is associated with changing ideas about what constitutes a “normal” diet and less healthy food choices in Mexican-Americans. CATCH makes no attempts are made to address these issues. As Mexican-Americans become more acculturated to the US, their diets are associated with higher fat intake and lower fruit and vegetable intake than their less acculturated counterparts (18). Risk of obesity also varies by levels of acculturation in Mexican-Americans. Those born in Mexico are less likely to be overweight than US-born Mexican-Americans, and there is an increased risk of obesity with increasing years of residence in the United States (19). These trends are likely due to an attempt to adapt to American culture by adopting what is perceived to be a “normal” diet in the United States. CATCH misses an opportunity to encourage Mexican-Americans to embrace traditional dietary practices, which include higher consumption of fresh fruits and lower consumption of fats than in the US. CATCH does not research or take into account the social norms of its target population and address them in its intervention. Differing ideas about what constitutes a healthy body weight and “normal” American diet could undermine the advice offered by the CATCH program. By ignoring the social norms of its target population, El Paso CATCH may be misunderstood and thus, be ineffective in reducing childhood obesity.

Conclusion

As overweight and obesity continue to increase in the United States at alarming rates, interventions must be developed to successfully reduce the prevalence of childhood overweight and obesity, particularly in Mexican-Americans. The Coordinated Approach to Child Health attempts to meet these needs on the border of US and Mexico through a school-based education program, but fails to address the social issues necessary to reverse the rate of childhood obesity in Mexican-American children. While this program tries to educate children and their families on the importance of a healthy diet and increased physical activity, it does not into account the economic barriers to nutrition and exercise in low-income communities, the effect of school-based social networks on overweight and obese children’s willingness and ability to participate in physical activity programs, or the social norms surrounding obesity and food in Mexican-American communities. CATCH could be more successful in El Paso if it helped increase the availability of nutritious foods and opportunities for exercise in the area or helped families learn about affordable and healthy food and exercise options. CATCH could also introduce programs to increase students’ self-esteem and encourage healthy peer relationships, and operate within social norms by addressing misconceptions about healthy body weight and “normal” US food patterns with families and the community. The ignorance of the social influences on childhood obesity means that these and other important opportunities for intervention have been lost, impeding the ability of CATCH to be effective in El Paso, TX.

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