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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

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

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

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

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

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

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

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

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

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

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

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

“The Fear Factor”, How The Breastfeeding Advocacy Campaign Failed Through Manipulation – Regina Njoroge

In June 2004, the U.S. Department of Health and Human services Office on Women’s Health and the Ad Council launched a national campaign encouraging first time mothers to breastfeed exclusively for six months. The campaign’s tagline was “Babies were born to be breastfed.” The overall goal of the campaign was to increase the proportion of mothers who breastfeed their babies exclusively in the early postpartum period to 75% and those within 6 months postpartum to 50% by the year 2010 (1-2). Exclusive breastfeeding according to the World Health Organizations (WHO) definition is feeding an infant only breast milk without any additional food or drink (3). Besides trying to raise breastfeeding initiation rates, the campaign stressed the negative effects of not breastfeeding such as lower respiratory tract infections, middle ear infections, eczema, childhood obesity and Type 2 diabetes among others.

The main theme of DHHS campaign was to focus on the consequences of not breastfeeding rather than on the benefits. This was based on the assumption that, once the mothers know the risk they are taking by not breastfeeding, they will automatically take action and chose to breastfeed. However, results from the National Immunization Survey (NIS) show that the strategy has failed. An August 2007, MMWR report shows that while more women are choosing to initiate breastfeeding, the percentage of those who continue to breastfeed exclusively for three months is very low. Rates for exclusive breastfeeding through ages 3 months and 6 months among infants born in 2004 were 30.5% and 11.3%, respectively, below target (4). Based on this data one can conclude that The DHHS “babies were born to be breastfed” campaign is a flawed public health intervention.

The campaign fails to address the social perception of the act of breastfeeding in the general public
The campaign assumes that knowledge of the risk factors associated with not breastfeeding will lead to behavior change. It fails to acknowledge the subjective norm principle of the Theory of Planned Behavior (TPB). The subjective norm is the belief that others expect one to perform or not to perform a behavior, and the motivation to comply with these expectations. According to the TPB, if people evaluated a suggested behavior as positive (attitude), and if they think their significant others wanted them to perform the behavior (subjective norm), this results in a higher intention (motivation) and they are more likely to perform the behavior (5).

The “Babies were born to breastfeed” campaign fails to recognize that there are many prevailing social and cultural norms that contribute to a woman’s choice on whether to breastfeed or not. Research has shown that infant feeding decisions are most often made prior to pregnancy or during the first trimester. The decision is based more on the socio-cultural environment that the woman is in other than on individual choice or preference (6-7). Similarly, a woman’s social network can significantly contribute to either making breastfeeding successful or difficult. Studies on women who initiate breastfeeding at birth have shown that encouragement from parents and relatives is significantly associated with breastfeeding patterns of mothers (8-9). The campaign addresses the issue of breastfeeding as an individual decision that a mother has to make and fails to consider the social network that surrounds the pregnant woman, such as husbands, parents, grandparents, friends and employers among others.

The campaign does not try to improve the social acceptability of breastfeeding in public. The sexual perception of breastfeeding in the United States also plays a prominent roll in a woman’s decision to breastfeed. While the act of breastfeeding was once a natural biological act, in today’s society particularly in the US, the social and sexual significance of the female breast rivals, if not exceeds, its biological significance (10. In North America and in many other westernized countries woman's breasts are a taboo; they are supposed to be hidden. Exposing a woman's breasts in public is considered shameful and inappropriate ("indecent exposure") even while breastfeeding (11-12). As a result women have been thrown out of restaurants, airplanes and business premises and accused of indecent exposure because they were nursing their babies. Such incidences indicates that some people still perceive breastfeeding as an indecent, disgusting, animalistic, sexual, and possibly even perverse act (10). Such incidences have a very strong impact on a woman’s decision to breastfeed, because they send the message that women who chose to breastfeed in public risk facing discrimination or evoking negative emotional reactions. As a result, even women who breastfeed may have difficulties doing it exclusively because of other people's attitudes towards them.

Another issue that the DHHS campaign fails to address is the social obstacles that women face when they go back to work. In the united State, women are entitled to only 3 months of unpaid maternity leave. Studies show that one third of women return to work within three months, while two-thirds return within six months of having a baby. Many of these women are forced to return to work because they are unable to go without the additional income (13). The decision to work while breastfeeding is a complex one, according to Dr. Frances Biagioli of Oregon Health and Science University, new mothers must negotiate the emotional distress of leaving a baby behind, social aspects such as a fear of leaking, lack of an appropriate space to pump (other than a bathroom stall), finding time for breaks and fatigue (14). Consequently, breastfeeding is discontinued. The campaign approach was unfair to women who choose to or have to go back to work by suggesting that they are putting their child in danger by not breastfeeding when it's so difficult to breastfeed exclusively and work. There should have been more focus on working with employers to provide more work place support to breastfeeding mothers such as, paid maternity leaves, lactation rooms and flexible schedules.

The Media Ads were contradictory to the campaign slogan
The television ads failed to address why breastfeeding is important and what its benefits are for the baby and the mother. One television ad has a scene at a ladies nightspot, with music playing in the background and a crowd cheering as a pregnant woman rides on a mechanical bull. As she is thrown off the bull, a message appears on the screen “you wouldn’t take the risk before your baby is born, why start after?” A second advertisement shows two women competing in a log rolling game. As one of the women plunges into the water, again the message appears on the screen “you wouldn’t take the risk before your baby is born, why start after?” Both ads conclude with a voice- over quickly stating, “Recent studies show babies who are breastfed are less likely to develop ear infections respiratory illnesses and diarrhea; Babies were born to be breastfed” (15). According to the Ad council, these new Public Service Announcements (PSAs) should speak to parents clearly about the consequences of not breastfeeding, which may help encourage more mothers to initiate and continue to breastfeed exclusively for six months. This effort fails to effectively apply the power of persuasion in changing behavior. According to researcher Ruth Faden of John Hopkins University “persuasion succeeds by improving and not by undermining a person’s understanding of her situation”. Faden notes that public health uses communication of information to mold behavior for the purpose of promoting social and individual welfare. She proposes that information must be packaged to enhance rather than cripple understanding (16). The DHHS TV ads serve to mislead women about the true risk of not breastfeeding by setting up inappropriate comparisons. The suggestion that mechanical bull riding while pregnant is comparable to not breastfeeding your child during the first six months is misleading. The idea of a pregnant woman going out on a ladies night and riding a mechanical bull portrays an irresponsible woman who would take risk to harm her child in order to pursue her own pleasure. Comparing the danger of riding a mechanical bull to formula feeding grossly misrepresents non-breastfeeding women as equally negligent and irresponsible.

The ads also portray women’s failure to breastfeed not only as an extremely risky choice, but also as a completely voluntary individual choice, similar to log rolling or mechanical bull riding. The message ignores the fact that there are women who may not have a choice to breastfeed, such as women with HIV infection, women on interacting medication, or women who might risk domestic violence. Telling these women that they are harming their child by not breastfeeding feeding leaves them with feelings of failure, shame, self-blame.

The fear appeal message failed to promote self-efficacy in pregnant women and new mothers
Based on The Social Cognitive Theory, a person’s decision to engage in a particular behavior is highly influenced by his or her self-efficacy; the belief in one's capabilities to organize and execute the courses of action required to produce given attainments, or the extent to which a person believes they can master or be successful in performing a task (17). Generally, people with a high level of self-efficacy are more likely to expend more effort, and persist longer in a task than those with low efficacy (18). Even though the DHHS acknowledges that women already know the benefit of breastfeeding, it fails to acknowledge that most women perceive breastfeeding as a difficult task. Hence, they lack the confidence that they can actually do it successfully. Knowing that breastfeeding a baby reduces the risk for several diseases might motivate one to initiate breastfeeding. However, for women to maintain breastfeeding practices, they need to feel that they can actually be successful in doing it. Studies have shown that lack of confidence is associated with a shortened duration of breastfeeding (8). The campaign could have focused more on how to breastfeed successfully rather than focusing exclusively on the harms of not breastfeeding.

Additionally, focusing on the harms of not breastfeeding could serve as a turn-off to low-income and minority women, who are the very group that the campaign was trying to target. According to the MMWR report, low breastfeeding rates persist among mothers who are low income, black, young or with low education (19). It is important to note that this group has in many cases been labeled for making bad health choices such as smoking while pregnant, use of illicit drugs, and poor diet. Hence, a fear appeal message could actually do more harm than good by decreasing their sense of self-efficacy to breastfeed. The fear appeal theory postulates that utilizing a message that instills a sense of fear and dread in the audience has the exact opposite effect that it intends. That is, it completely turns the recipient off, not only to hearing the message, but also to heading the content or advice contained within that message (20). Targeting this group of women calls for a more positive message, that would improve and not undermine self-efficacy.

Conclusion
The DHHS breastfeeding promotion campaign should start by acknowledging that most women are aware of the benefits of breastfeeding. However, the decision to breastfeed has many intertwined layers of emotional, social, economic factors that need to be addressed. The campaign should adjust the content of the promotional materials to take into consideration social issues such as support from family and friends, the acceptability of breastfeeding in public places and employer support. Additionally, the content, manner, and tone in which the promotional messages are conveyed should be positive and seek to empower pregnant women and new mothers. If these issues are not addressed with a positive tone, the DHHS campaign is unlikely to substantially increase breastfeeding rates. The current approach is more likely to instill fear and guilt other than change behavior.

References

1. US Department of Health and Human Services: HHS blueprint for action on breastfeeding. Office on Women's Health, 2000.
2. US Department of Health and Human Services. Healthy People 2010 midcourse review. Washington, DC: 2005. Available at http://www.healthypeople.gov/data/midcourse
3. World Health Organization. Promoting proper feeding for infants and young children. Geneva. 2004. Available at http://www.who.int/nutrition/topics/infantfeeding/en/
4. Centers for Disease Control and Prevention. Breastfeeding Trends and Updated National Health Objectives for Exclusive Breastfeeding: United States, Birth Years 2000—2004. Atlanta, GA: Mortality and Morbidity Weekly Report, 2007.
5. Ajzen, I. From intentions to actions: A theory of planned behavior (pp. 11-39). In Kuhl, J.& Beckman, J. n ed. Action-control: From cognition to behavior. New York: Springer-Verlag, 1985.
6. Baranowski T, et al: Social support, social influence, ethnicity and the breastfeeding decision. Journal of Human Lactation 1992; 8: 122–124.
7. Bentley et al. Sources of Influence on Intention to Breastfeed Among African-American Women at entry to WIC. Journal of Human Lactation 1999; 15: 27-34.
8. Ertem IO, Votto N, Leventhal JM. The timing and predictors of the early termination of breastfeeding. Pediatrics 2001; 107: 543-548
9. Baronna-Vilar, C., et al. A qualitative Approach to Social Support and Breastfeeding decisions. Journal of Midwifery 2007; 1: 1-8.
10. Forbes, G.B et al. “Perceptions of the woman who breastfeeds: the role of Erotopia, Sexism, and attitudinal variables”. Sex Roles: A Journal of Research 2003; 49: 379-388
11. Dettwyler, K. "Beauty and the Breast: The Cultural Context of Breastfeeding in the United States." Sexuality and Breastfeeding. Journal of Human Lactation 1995; 11: 263
12. Latteir, Carolyn. Breasts: The women’s perspective on an American Obsession. Haworth Press Inc, 1998.
13. Ryan, A. et al. The Effect of Employment Status on Breastfeeding in the United States. Women’s Health Issues 2006. 16: 243-251.
14. Bhatia, J. Breastfeeding Push Turns to Workplace Obstacles. Women’s eNews, New York: 07/13/2006.
15. US Department of Health and Human Services: National Breastfeeding awareness Campaign-Babies were born to be breastfed. Washington, DC: Office on Women's Health, 2000. Available at http://www.4women.gov/breastfeeding/index.cfm?page=Campaign
16. Faden, Ruth R. Ethical issues in government-sponsored public health campaigns. Health Education Quarterly 1987: 14: 27–37.
17. Wikipedia. Self-efficacy. Wikipedia Foundation Inc. http://www.en.wikipedia.org/wiki/Self-efficacy.
18. Schunk, D.H. Goal setting and self-efficacy during self-regulated learning. Educational Psychologist 1990. 25: 71-86
19. Centers for Disease Control and Prevention. Racial and socioeconomic disparities in breastfeeding in the U.S. Atlanta GA: MMWR 2006.
20. Ruiter A.C. The Role of Coping Appraisal in Reactions to Fear Appeals: Do We Need Threat Information? Journal Health Psychology 2003; 8: 465-474

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

Introduction

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

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

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

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

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

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

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

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

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

This Commercial Fails to Promote Self-Efficacy to Seek Help

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

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

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

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

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

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

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

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

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

Conclusion

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


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