Thursday, May 20, 2010

A Critique of Domestic Violence Awareness and Outreach: What Message the Faces of Battered Women Really Conveys – Vina Chhaya

With one in four women in the United States experiencing violence at some point in her life (1), an average of 500 rapes per day reported in 2007 (2), and more than $8.3 billion spent on associated medical and mental health care services (3), domestic violence is an issue that needs to be addressed. Many organizations have made it their aim to increase awareness around domestic violence, particularly in health clinics and patient waiting rooms, where outreach materials are able to have the most impact and translate most immediately into action. While these venues present the perfect setting to increase awareness around domestic violence, the outreach material currently being used has not been demonstrated to reduce the prevalence of domestic violence or increase treatment seeking behavior among patients. These images of solemn women, often alone, or having bruises, are ineffective at increasing the number of women disclosing violence to their provider and also fail to empower women with the sense of security and control they need to perhaps make progress towards seeking treatment. Additionally, the statistics presented shown in posters, brochures, and stealthy tear-away cards fail to appropriately engage women who are experiencing abuse in their relationships and are in denial that this is happening to them. Finally, the overall approach to increasing screening is currently provider-initiated, which does not facilitate long-term behavior and norm change among victims of domestic violence to feel a sense of control, empowerment, or comfort with providers enough to talk with them about such a pressing issue.

Using the transtheoretical, or stages of change, model as a basis to explain the thought process of women experiencing domestic violence, we see that even while attempting to take action, there is a lot of cyclical transition between stages (4). The stages of change model identifies five distinct phases of the thought process and helps define a person’s readiness to perform a concrete action or make a decision (5). By understanding the stages of precontemplation, contemplation, preparation, action, and maintenance, and determining which stage a patient is in, the provider can better understand the dynamics of domestic violence in the patient’s thought process to provide referral to more appropriate resources (6). Women in precontemplation and contemplation are the intended target audience for domestic violence outreach materials, as these are the women who need to confirm the existence of abuse in their relationship and be nudged to take action. Those victims in the preparation stage have already been empowered to take action and have a plan, needing to be reminded that resources exist (5). For the purposes of increasing self-disclosure of domestic violence and empowering women to engage in treatment seeking behavior, outreach material should target women in precontemplation and contemplation.

During precontemplation, people experiencing domestic violence have no intention to take action in the foreseeable future. There is no desire to understand more about domestic violence and these women are not informed of the consequences. As a result, there is a great need to confirm to these women that domestic violence is affecting them and show them that a network of support exists (5). Contemplation, on the other hand, is where the woman self-identifies with being in an abusive relationship and is thinking about the available resources and consequences of her actions. These women exhibit ‘behavioral procrastination’ as they continue to weigh options and think about the presence of domestic violence in their relationship (5). Women in contemplation need to be shown the availability of resources and encouraged to take action, preferably in a manner that empowers them and leads to changing behavioral norms surrounding treatment seeking.

Thus, women in precontemplation are trying to understand that their relationship is abusive, while women in contemplation are evaluating how to manage their relationship (4). Outreach material should be made with the intent of targeting women in both these stages, taking into account the different thought processes involved in each stage. With regard to these two preceding stages preparing women for action, whether it is disclosure or searching for specific resources to manage their relationship, there should be outreach materials with images focusing on empowering these victims, use of statistics according to stage, and an overall approach geared towards patient-initiated action and empowerment.

Argument 1: Images and Overall Tone of Material

Current domestic violence outreach material includes the solemn faces of women, sometimes battered (7), and often always alone (8). While these images are powerful, they highlight only the negative realities of being a victim of domestic violence; namely that one suffers and is alone.

During the precontemplation stage, the victim may express an optimism bias, meaning that she understands the realities facing victims of domestic violence and knows her own situation, but is unable to logically connect her current situation with possible future events. Evidence has shown this bias to result in underestimation of risks and in some cases the victim may return to the abuser failing to realize the likelihood of abuse happening again (9). Outreach material images also fail to make women reading these materials in examination or waiting rooms connect to the faces of women, most often, being abused, portrayed in posters and brochures. While the term ‘you’ is used, it can still be interpreted as referring to the generic population and does nothing to help self-recognition, connecting the realities of abuse in a relationship to abuse in my relationship (10). This demonstrates confirmation bias as well, when the woman fails to identify with abuse in her own life, but can appreciate the effect it has in the lives of others. Overall, there is no strong message showing the realities of domestic violence, in the form of isolation and injuries, and allowing a person viewing the image to have the space to make the connection between the image and themselves.

Additionally, victims of domestic violence, when moving between stages of change, are connected to existing support networks and consult family, friends, or community organizations to address the realities they are facing in an abusive relationship (4). Even with the presence of friends, family, or other resources, women have indicated that they are comfortable being asked by their provider, often lingering at the end of appointments in the hopes of the provider asking (11). With current outreach material showing women in isolation, it fails to reinforce the existing support system many victims do have and use. Regardless of the stage a victim is in, existing outreach material fails to remind them of available networks, further preventing realization of the abuse for women in precontemplation or transition toward action for those women in contemplation.

Finally, certain campaigns have chosen to employ a fear tactic approach to raising awareness about domestic violence. While research has demonstrated that there is a linear effect between fear and the effect it has on behavior change (12), there have also been instances where this method has produced the opposite effect intended in the target population, specifically a domestic violence campaign in Scotland (12).
Fear campaigns also make many assumptions about the target population and are designed to be most effective among those who are better equipped psychologically and socially to understand the message (12). This ostracizes women experiencing violence, who are already vulnerable and feeling isolate and who the campaign was originally intended to reach, and makes them feel more vulnerable to the abuse. Another school of thought is that fear tactics, if used often enough, tend to desensitize the public from the severity of the issue (12). This, again, results in wasted resources and an ineffective approach to identifying with abuse and then taking action towards disclosing or seeking other resources. Use of fear has been shown to be effective in commercial campaigns, where a clear brand, image, and message already exist (12). However, with only a few images in posters and on brochure covers available to get a clear message across, perhaps donning the bruised faces of women to give an existing message direction is not the best approach. This is especially true when this message showing the consequences of abuse is not appropriate to target women who have yet to self-identify with the abuse or are in a state of contemplation about the abuse and remain cycling between stages of change.

Argument 2: Statistics and Information
Public health is a discipline that has evolved around facts and statistics, with a strong evidence base informing programming and policy decisions. While informative and convincing to those who understand what the numbers actually indicate, they fail to do much to affect behavior change in victims of domestic violence who are in the precontemplation stage.

A main issue with statistics is confirmation bias for women in the precontemplation stage. For these women, who have yet to identify with the harmful health effects of their abusive relationship, this information in pamphlets fails to help with recognition of their abuse and consequently with any movement towards action. While having these materials available for all women in waiting rooms and bathrooms appears to be beneficial in capturing women in the contemplation stage, passing out this material during a visit may be fruitless for women in precontemplation. The valuable information presented is lost on these women because they know the facts, but are unable to apply this to what they are experiencing, not having come to terms with their own abusive relationship yet.

Women do appreciate educational materials, particularly if in the contemplation stage when they have already recognized that the abuse is affecting them. In fact, women indicated that having outreach materials in the exam rooms and bathrooms were helpful (4). Simple language to assist in self-recognition was also found to be beneficial to women in the precontemplation stage (9). However, any additional information beyond a few statistics and screening question was found to be unproductive (4).

In general, there is limited evidence demonstrating the effect of existing interventions on women, specifically posters, brochures, and other domestic violence outreach material (13). More research focuses on the impact of provider training, tools or surveys used to assess the presence of domestic violence, and systemic approaches to increase provider-initiated screening in primary care settings (13). However, one can extrapolate from existing research that the impact of outreach material must be minimal since immediately following an intervention that used posters, there was only a small increase in domestic violence cases reported, and this rise fells to near its original level over a few years (13).

Nevertheless, without research focusing on the impact of outreach material alone, specifically to women in different stages of change, better posters and pamphlets to achieve desired increases in self-disclosure or resource-seeking behavior will not be achieved. In fact, without proper assessment, including too many facts, words, or the wrong images could have a deleterious effect in the intended target population (13). This could result in more apathy towards domestic violence screening and resistance to any attempts linking victims to resources.

Argument 3: General Outreach Approach
The current domestic violence awareness and outreach approach focuses on provider-initiated screening to capture victims of domestic violence and provider training to deal with referrals to appropriate resources in primary care settings. While provider-initiated screening has actually been beneficial and is preferred by women (10), it focuses on alleviating provider’s fears of appropriate methods of handling disclosure. Strengthening domestic violence screening programs by increasing provider self-efficacy surrounding disclosure of violence by victims during visits has been shown to increase screening rates (10) and result in better linkages to resources and referrals. It is estimated that 7% to 25% of domestic violence cases presenting in health care settings are actually identified, being the impetus to focus on system-level interventions targeting providers (14). By enhancing the clinic setting to support screening and referral, reminding providers to screen, and giving providers confidence in their ability to deal with disclosure, Thompson et al. showed that 3.9 times as many women were screened and 1.3 times as many cases presented (14).
Even though the benefits of training health center staff to be more aware of domestic violence is clear, the effects of the training seems to wane over time (13). While they did demonstrate high levels of screening and case finding nearly 2 years after the intervention, there was no measure of how effective provider-initiated screening and referral was for women self-identifying and then moving towards action. Furthermore, there is no indication that as the facility sees staff turnover and other changes over time that screening rates and case identification will remain at post-intervention levels.

During time spent between patients and providers, the burden of raising the topic is on the provider. Given the limited patient-provider time during visits, among other barriers to screening, the complexity of assessing the stage of the woman, and the fact that the woman may not identify with the abuse herself, it is difficult to completely put the burden of identifying cases of domestic violence on the provider. With examinations in place to address other patient complaints, which may suggest domestic violence, providers can only do so much during the limited time they are given. While increased screening by providers has shown to increase patient satisfaction, which increases self-disclosure rates over time (9), there is not much done with this intervention to empower the victim to feel comfortable enough with the issue and her provider to disclose at that moment. Crafting appropriate materials to shift some of the burden onto the victims by encouraging them to disclose may increase self-disclosure rates both immediately after the intervention and long-term as well.
Thus, while the focus on provider-initiated training helps alleviate fear of offending the victim and how to deal with disclosure and educates providers on the prevalence of domestic violence in their patient population (15), there are other interventions to increase self-disclosure and assist in a victim’s progression towards action, including creating a supporting environment and empowering victims to feel comfortable enough to disclose. There is evidence indicating that women prefer to be screened alone and by a health history form compared to being questioned by a social worker or relying on handouts (15). Of the 133 women participating in this study, only 11 (7.9%) said they would be offended if a provider asked about domestic violence (15). However, reliance entirely on provider-initiated screening could result in disparity of care, just as reliance on selective screening and self-disclosure would (16). These missed opportunities to intervene and prevent additional health consequences of domestic violence are also seen more among victims who have not identified with the abuse, those in the precontemplation stage (16, 17). Even if 80 to 85% of women would disclose if asked by a provider, designing outreach materials for the purpose of empowering women to seek existing support networks, encouraging women to disclose, and initiating the conversation with their provider may tip these women on the verge of contemplation into discussing the issue (or even into preparation).

Proposal 1: Images and Overall Tone
Given the use of solemn and sometimes fearful images in domestic violence outreach material (7,8), I propose to create outreach materials depicting a victim of domestic violence surrounded by family, friends, or another existing support network. This positive framing, in addition to affirming the reality of the abuse, will reinforce the fact that there are resources and people who can help. Additional images could focus on the patient-provider relationship and patient-initiation of disclosure. In both cases, the environment depicted would convey a comfortable, nurturing setting where victims of domestic violence, specifically those who have acknowledged the abuse and begun to evaluate the pros and cons of actions, would be encouraged to disclose or connect with resources.

Another message that needs to be clear is for women in precontemplation, who have experienced the abuse but fail to connect information on the abuse and its damaging effects on her health with her own health (10). For these women, there should be materials showing a victim, still surrounded by a group of people, with the words, “I’m just like you,” then followed by thoughts common to women who are still trying to identify with the abuse. This opening statement would cause any woman waiting for her appointment to continue reading and then perhaps upon seeing the similarity between this woman’s relationship and her own, may slowly move towards contemplation.

Finally, use of the fear tactic to move victims along towards action should be avoided (11,12). During these complex stage transitions, victims of domestic violence are extremely vulnerable and harsh images could provoke the opposite response. Although the campaign would increase awareness surrounding the issue for the general public, it could reduce self-disclosure and impede progression towards action, further isolating the intended target audience (12). Overall, the images and tone of domestic violence outreach material should be nurturing and provide a sense of control for victims. There should be a push to regain control for those women who have self-identified and are making progress towards decisive action and planning by transitioning to the preparation stage. Consequently, those women in precontemplation should be made to realize that by succumbing to abuse they are giving up an element of control in their lives. Framed positively and tailored for women in two stages of domestic violence primed for intervention, precontemplation and contemplation, outreach material could impact self-disclosure, empowerment, and the public’s attitude about domestic violence.

Proposal 2: Statistics and Information
When creating material specific for women in both precontemplation and contemplation, it is important to understand the value of statistics and educational information around domestic violence issues for each group. These statistics stating that one in every four women has experienced abuse at some point during her life (1) and facts to indicate the effect of abuse on health and well-being over time are valuable as general outreach material. However, for women who have yet to recognize the existence of abuse in their own relationship, the importance of this information is lost. Optimism bias is emphasized as they recognize the harmful effects of abuse in general, but fail to apply it to themselves. For women in contemplation, however, who have already self-identified, this information could help them understand specific health outcomes and consequences of not taking action and allowing the abuse to continue. Thus, as part of provider training, providers will learn to do a stage assessment when screening patients to give them material appropriate for their specific stage.

For posters, the language should be kept simple (9), avoiding the heavy use of statistics and information on health outcomes, to focus on creating a clear message to women in all stages to self-identify, to reach out to existing support networks, and to take control of the decision to disclose. The purpose should focus on helping women in precontemplation self-identify or encouraging women in contemplation to disclose and/or seek resources. Detailed information on health outcomes of abuse should be restricted to brochures, pamphlets, or other material that can be dispensed on an individual level and stage-matched to patients to provide optimum impact of the information. Information provided in the form of a questionnaire or checklist that someone can pick up as they wait for their appointment may also help increase access to services (18). Thus, perhaps creating material with simple language and minimal use of educational information specifically for women in precontemplation along with providing stage-matched material during visits may help preventing women from feeling overwhelmed when they haven’t even identified with the abuse yet.

Finally, in order to truly craft appropriate materials that are having the intended outcomes of increasing self-identification with abuse and encouraging women to seek resources and value their health, research needs to be conducted to formally evaluate the impact of specific outreach materials. Content, images and information, in addition to the placement should be evaluated. At present, it appears that there are standard locations for posters, small information cards, and brochures (18), but understanding where women value their presence most may help use resources effectively. In a similar manner to testing commercials for appeal, images and content to be used for domestic violence outreach materials should be tested on groups of patients, victims and non-victims, to assess for effectiveness and whether or not any material could be considered offensive.

Proposal 3: General Outreach Approach
Concerning the overall approach to domestic violence screening and referral, which currently emphasizes increasing provider education and sensitivity around the topic, I recommend developing materials that empowers women to self-disclose. While there is no evidence to demonstrate that creating an environment for women to regain control over their abusive relationships does not already exist, there is limited evidence to show the effect of outreach materials on disclosure (13) and specifically that providing this empowerment results in increased self-disclosure. Thus, before scaling up this intervention, a pilot test to determine the effect on self-disclosure and possibly shift to contemplation, through increased confidence, should be measured. At present, provider-initiated screening and training to alleviate fear resulting from possible patient disclosure does result in higher screening rates and case findings, but does nothing to affect behavior change in the target population of victims of domestic violence.

Provider training and connecting primary care settings to domestic violence resources, by providing materials or having advocates on-site could also increase access to services and lead to increased disclosure rates. Thus, I recommend keeping these measures in place as evidence has shown increased case finding in the short-term (10). However, more research should be undertaken to determine the impact of provider training on screening and disclosure rates in the long-term. While it may be the case that improving the infrastructure of a health care facility is the only way to strengthen a domestic violence program, combinations of other interventions should be evaluated and any process shown to maintain the initial impact over time should be documented for replication at other sites.

Posters and brochures should encourage women to disclose abuse to providers, reminding them that providers have other things on their mind. Clever thought bubbles and the image of a patient and physician in an examination room could persuade people to talk to their physician about not only their relationship, but also other issues concerning their health. Shifting at least a portion of the burden of talking about domestic violence on victims may help victims develop confidence, leading them towards action, and result in stronger patient-provider relationships overall. Finally, these outreach materials should also include media which reduce optimism bias (9). Making images on posters familiar and having items in a checklist that a victim could identify with could help women in precontemplation realize that she is, in fact, a victim of domestic violence.

With recent research shedding light on the increasing costs of health care associated with domestic violence and 25% of women in the US affected by some form of violence or abuse, domestic violence is a public health issue in need of attention. While many outreach organizations exist, the link to primary care settings is often poorly defined and women are lost once they are identified by providers and referred to the proper resources. Outreach materials, though, in the form of brochures, pamphlets, and posters, have the capacity to affect behavior change in victims of domestic violence. Current materials show women in isolation, often with bruises or other injuries, and provide a very negative frame for domestic violence. While it is a tragic behavior, the reaction to abuse in a relationship doesn’t have to be associated with pain. In addition, outreach materials fail to provide appropriate stage-matched images and information for those women in precontemplation and contemplation, which could help increase self-disclosure. Finally, the overall approach taken in domestic violence awareness and outreach to sensitize and train providers fails to focus on victim empowerment and self-efficacy. Thus, I propose critically evaluating the impact of outreach material, both images and information, to understand how to best assist women in precontemplation identify with the abuse and women in contemplation move towards disclosure. Positively framing outreach materials, keeping language simple, and showing effective images to promote using existing networks of friends, family, providers, or other resources, could empower a vulnerable population of victims and reshape the way the public understands domestic violence.


1. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Adverse Health Conditions and Health Risk Behaviors Associated with Intimate Partner Violence. Atlanta, GA: Centers for Disease Control and Prevention.
2. Bureau of Justice Statistics. National Crime Victimization Survey: Criminal Victimization, 2007. 2008. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics.
3. Max W, Rice DP, Finkelstein E, Bardwell R and S Leadbetter. The Economic Toll of Intimate Partner Violence Against Women in the United States. Violence and Victims. 2004; 19(3): 259-272.
4. Zink T, Elder N, Jacobson J and B Klostermann. Medical Management of Intimate Partner Violence Considering the Stages of Change: Precontemplation and Contemplation. The Annals of Family Medicine. 2004; 2: 231-239.
5. Velicer WF, Prochaska JO, Fava JL et al. Smoking cessation and stress management: Applications of the Transtheoretical Model of behavior change. Homeostasis. 1998; 38: 216-233.
6. Fraiser PY, Slatt L, Kowlowitz V and Glowa PT. Using the stages of change model to counsel victims of intimate partner violence. Patient Education and Counseling. 2001; 43: 211-217.
7. Family Violence Prevention Fund. Health Care and Domestic Violence Posters. Are you tired of making excuses for him? San Francisco, CA: Family Violence Prevention Fund.
8. Family Violence Prevention Fund. Health Care and Domestic Violence Posters. Reproductive Health Posters. San Francisco, CA: Family Violence Prevention Fund.
9. Martin AJ, Berenson KR, Griffing S et al. The Process of Leaving an Abusive Relationship: The Role of Risk Assessments and Decision-Certainty. The Journal of Family Violence. 2000; 15(2): 109-122.
10. McCaw B, Berman WH, Syme L, and EF Hunkeler. Beyond Screening for Domestic Violence: A Systems Model Approach in a Managed Care Setting. American Journal of Preventive Medicine. 2001; 21(3): 170-176.
11. Ramsay J, Richardson J, Carter Y et al. Should health professionals screen women for domestic violence? Systematic review. British Medical Journal. 2002; 325: 314.
12. Hastings G and M Stead. Fear Appeals in Social Marketing: Strategic and Ethical Reasons for Concern. Psychology & Marketing. 2004; 21(11): 961-986.
13. Soames Job, RF. Effective and Ineffective Use of Fear in Health Promotion Campaigns. American Journal of Public Health. 1988; 78(2): 163-167.
14. Garcia-Moreno, C. Dilemmas and opportunities for an appropriate health-service response to violence against women. The Lancet. 2002; 359: 1509-1514.
15. Thompson RS, Rivara FP, Thompson DC, Barlow WE et al. Identification and Management of Domestic Violence: A Randomized Trial. American Journal of Preventive Medicine. 2000; 19(4): 253-263.
16. Thackeray J, Stelzner S, Downs SM and C Miller. Screening for Intimate Partner Violence: The Impact of Screener and Screening Environment on Victim Comfort. Journal of Interpersonal Violence. 2007; 22(6): 659-670.
17. Phelan, Mary Beth. Screening for Intimate Partner Violence in Medical Settings. Trauma, Violence, & Abuse. 2007; 8(2): 199-213.
18. McNutt LA, Carlson BE, Rose IM and DA Robinson. Partner Violence Intervention in the Busy Primary Care Environment. American Journal of Preventive Medicine. 2002; 22(2): 84-91.

Tuesday, May 18, 2010

Chancellor Promotes Unwholesome Foods & Hinders Children’s Development & Empowerment: NYC Ban of Homemade Goods at School Bake Sales– Annabelle Ho


Kellog’s frosted brown sugar cinnamon Pop-Tarts are allowed to be sold at school bake sales while homemade banana bread and Greek spanakopitas are not? In New York City’s Public Schools, this is the case. This past February, New York City’s Department of Education (DOE) revised Regulation A-812, Competitive Foods, “to improve the quality and nutritional value of foods and beverages that are available for children” (1). According to this revision, students may only sell food items at school that are in the DOE’s approved list between the time school begins and 6:00 pm, with one exception for PA/PTA fundraising sales. This exception allows PTAs to hold a fundraiser once a month with non-approved foods during the school day after the last lunch period, as long as the sales occur outside the cafeteria. The DOE’s list of approved foods to sell during the school day currently includes all fresh fruits and vegetables and around forty or so packaged items, including low-fat Cool Ranch Doritos, brown sugar cinnamon Pop-Tarts, and blackberry Nutri-Grain cereal bars (2). These packaged items all meet the DOE’s Food and Snack Guidelines, which, among other specifications, state that the products are each in single serve packages and meet a specific nutritional profile.

According to the Child Nutrition and WIC Reauthorization Act of 2004, an act which is to be renewed this year, school districts that participate in federally funded meal programs are required to develop and institute a wellness policy (3). According to this act, schools’ wellness policies need to incorporate goals for nutrition education and physical activity, and guidelines that promote student health and reduce childhood obesity (4). The DOE’s regulations regarding Competitive Foods will become a part of the DOE’s 2010 Wellness Policy, which is currently still under revision. The wellness policy addresses the obesity epidemic in the United States, which has become a growing problem, especially over the past few years. In 2003-2004, the National Health and Nutrition Examination Survey (NHANES) estimated that 17.1% of U.S. children who were between 2-19 years of age were overweight (5). This shows a significant increase in overweight children from previous years, as the percentage of overweight children of 2-19 years of age were 13.9%, 15.4%, and 17.1% in 1999-2000, 2001-2002, and 2003-2004, respectively.

Although the revision of A-812 was meant to promote student health and reduce obesity, there are many problems with this intervention. A-812 allows approved foods that meet “healthy food guidelines.” However, the food that is in the DOE’s approved list can be of much lower nutritional quality than fresh, homemade goods. In addition, preventing students and parents from selling homemade goods at bake sales during the school day inhibits children’s development as evidenced by the Ecological Systems Theory, and disempowers children according to the Empowerment Theory.

A-812 Does Not Promote Nutritious Foods

Although regulation A-812 was meant to promote student health and reduce obesity as part of New York City’s 2010 School Wellness Policy, the regulation and approved food list promote unwholesome foods. The Food and Snack Guidelines state that products must meet a specific nutritional profile. For example, each product must contain 200 calories or less, 200 mg of sodium or less, less than .5 g of trans fat per serving, and at least 2 g of fiber per serving if the snack is a grain-based product (2). However, even if a food meets the specified nutritional profile, this does not mean that the food is nutritious. For example, the main ingredients of Stacy’s Cinnamon Sugar Pita Chips, which are in the DOE’s approved list, are enriched wheat flour, sunflower and/or canola oil, and sugar (6). Stacy’s Cinnamon Sugar Pita Chips contains less than 2% of whole wheat flour, organic sugar, brown sugar, cinnamon, sea salt, active yeast, oat fiber, compressed yeast, malted barley flour, and inactive yeast. While Stacy’s Cinnamon Sugar Pita Chips do meet the nutritional guidelines set forth by the DOE, the main ingredients of these pita chips are not nutrient-rich. Regular consumption of whole grains and whole grain products, as opposed to refined grain products, has been associated with reduced risks of various types of cardiovascular diseases (7). Whole grains naturally contain phytochemicals and antioxidants that work synergistically to create health benefits, and these synergistic effects cannot be replicated or recreated by simply enriching refined grains with the vitamins that are known to be lost during the grain-refining process.

Many homemade baked goods can be very nutritious. While many of the approved snacks on the DOE’s list contain a combination of whole and refined grains, children cannot sell homemade 100% whole wheat bread or rolls under A-812, even if the whole wheat bread or whole wheat rolls did meet the DOE’s required nutritional profile. Homemade banana bread is also not permitted, even if whole wheat flour, healthy oils, such as olive oil, and bananas, a fruit that naturally contains protective antioxidants and phytochemicals, are used. Many health benefits have been attributed to olive oil. Olive oil is said to reduce risk factors of coronary heart disease, have protective effects against various cancers, modify immune and inflammatory responses, and contain many healthy phytochemicals including polyphenolic compounds (8). In addition, bananas and fresh fruits and vegetables naturally contain antioxidants and phytochemicals, and it has been found that the total antioxidant activity from these foods comes from the combination of phytochemicals (9). One antioxidant cannot replace the combination of phytochemicals naturally found in fruits and vegetables to produce health benefits, because it is the additive synergistic effects of phytochemical activity that are responsible for these antioxidant and anticancer activities. The collaborative effects of phytochemicals naturally found in foods cannot be replicated by simply enriching or fortifying snacks, because there are many compounds in food that remain to be identified. The health benefits found in foods naturally high in antioxidants and phytochemicals cannot be found in processed food products that do not contain these nutritious ingredients, even if the Brown Sugar Cinnamon Pop-Tarts are fortified with niacin, thiamin, iron, riboflavin, folic acid, vitamin A, and vitamin B6 (10). Although an individual may believe a packaged snack contains fruit, the actual amount of fruit in the product may be considerably less than he or she may have initially believed. For example, even though an individual might expect to have some fruit from a Nutri-Grains Blackberry Cereal Bar, a product which is approved by the NYC’s DOE, blackberries are actually the fourth ingredient in the cereal bar filling (11). The first three ingredients of the cereal bar filling in order are high fructose corn syrup, corn syrup, and glycerin. While any fresh fruits and vegetables are allowed to be sold during bake sales, teaching students and parents learning how to incorporate these healthy foods into baked goods, rather than letting the manufacturers do the work, is important and can be very educational.

A-812 Hinders Proximal Processes and Child Development

A-812 hinders proximal processes and child development according to the Ecological Systems Theory. Two main propositions define the Ecological Systems Theory. Proposition I states that human development takes place throughout life through processes of increasingly more complex reciprocal interactions between active, evolving human organisms and the persons, objects, and symbols in its immediate environment (12). For interactions to be effective, they need to be mostly on a regular basis over long periods of time. These continual forms of interactions in the immediate environment are known as proximal processes. A corollary to Proposition I is that the developmental power of proximal processes is enhanced during circumstances in which the persons involved have developed strong emotional attachments to one other. Meanwhile, Proposition II states that the form, power, content, and direction of the proximal processes affecting development vary steadily as a combined function of the characteristics of the developing person, the immediate and remote environment, and the nature of the developmental outcomes under consideration.

In the ecological model, the developing individual is also influenced by five successive systems, with each system contained within the next (13). The microsystem includes the setting in which an individual lives, while the mesosystem involves connections between two or more settings which both involve the developing individual. The exosystem includes two or more contexts, at least one of which does not contain the developing individual but which influences the individual. Macrosystems involve the culture in which the developing individual lives, and the chronosystem involves change or consistency in the developing individual and their environment over time.

Child development can thus be hindered if only packaged snacks are typically allowed at school bake sales. As indicated by the Ecological Systems Model, children are most affected by proximal processes, close relationships, and factors in their immediate environment (13). This has implications in school bake sales, especially if children are baking homemade goods with their parents. Cooking is becoming a lost art in the United States, and children increase their development, cooking ability, and ability to interact with others if they have more complex interactions with other people, such as by cooking with their parents. Furthermore, as indicated in Proposition I, these interactions are enhanced when these interactions occur regularly. If PTA bake sales with non-approved goods can only occur once a month, the interaction and experience of the child cooking with his or her parent is rather infrequent, particularly if a parent is busy at one month and cannot cook with the child until the next month. This infrequency decreases the amount of interaction the child has with the parent and can thus hinder a child’s development.
Foods that children make with their parents are more meaningful than packaged food items. For instance, home-baking is important in relation to a child’s culture, a part of the macrosystem (13). A student may get more from a cooking experience with a parent if the food that they are making has a familial and cultural background. Helen Martineau-Kraus, a parent from New York City, used to make mini-spanakopitas, a pastry characteristic of Greece, with her two daughters for their school bake sales (17). Under A-812, homemade spanakopitas can only be sold at the exceptional PTA bake sale once a month. According to the Ecological Systems Theory, a child would learn much more from making and selling a homemade treat that is characteristic of their family and culture, which has much more meaning as compared to a retail packaged item. Meanwhile, the corollary to Proposition I notes the importance of strong emotional attachments in relation to proximal processes and individual development (12). While a child’s relationship to a General Mills Strawberry Team Cheerios Cereal Bar may involve a television commercial, the emotional attachment between a child and parent is much stronger and more meaningful. In effect, learning how to cook a healthful, homemade baked good with a parent increases a child’s development much more than reselling a packaged food item provided by a manufacturer. In addition to hindering proximal processes and child development, A-812 is disempowering.

A-812 Disempowers Children

Regulation A-812 disempowers children by preventing them to sell homemade goods at school bake sales during the school day. Empowerment is “the process of gaining influence over events and outcomes of importance to an individual or group” (14). At the individual level, empowerment refers to a process in which individuals gain control and mastery over their lives, and a critical understanding of their environment (15). The empowerment theory predicts that participating in decision making can enhance an individual’s feeling of empowerment, and that empowered individuals are more likely to participate in community organizations and activities (16).

Various studies explore the Empowerment Theory in more depth. In a study performed by Prestby and colleagues, it was found that organization empowerment may be linked to person-environment fit through their research of the connection between incentive management and organization activity (16). Organizations that have shared decision making, open leadership, and communal projects may be empowered by individuals motivated by factors including social ties, skill building, and helping others (16). In 1990, Chavis and Wandersman proposed that the sense of community is important in the development of personal control and participation, and found that a sense of community had a direct effect on an individual’s level of involvement in a neighborhood association (16). Chavis and Wandersman also suggested a reciprocal relationship between “a sense of community and participation and a sense of personal power and participation” (16).

The DOE’s restriction of only being able to sell foods from their approved list disempowers children from being able to decide what goes into the foods sold at school bake sales. Yes, students can submit a retail package with a nutritional label, ingredient list, and allergen list if they want the proposed, packaged food to be reviewed by a chef and nutritionist to be added onto the approved list (2). However, limiting children to only selling foods that they did not make themselves removes is disempowering, decreases their sense of control, and leads to decreased feelings of community and motivation.

Experiences from several parents emphasize the importance of community and empowering children through school bake sales. By contributing homemade goods to bake sales in the past, students and parents felt a sense of community. Helen Martineau-Kraus, a parent in East Village, New York, stated “Everybody contributes, everybody feels more like they are part of the school community. They try things that other people have baked. In such a big city it’s really nice to have that small community feeling” (17). In addition, these bake sales are often used as fundraisers. Geraldine Neary, a parent at the Renaissance Charter School in Jackson Heights, Queens, NY, said her school’s weekly bake sales, which made around $200-$300, made enough money to send eleven students to Mexico last year (17). School bake sales are important in bringing students, parents, and the school staff together. Again, allowing children to sell only foods that appear in an approved food list restricts their feeling of empowerment, feelings of organization responsibility, and likelihood to participate in community activities.


There are better ways to promote health and reduce obesity in school and school bake sales than by preventing children from selling homemade goods at school bake sales. Homemade goods should be allowed in school bake sales during the school day, because they can provide nutritious options that processed foods do not offer. Baking homemade goods fosters the development of the child. In addition, allowing children to sell homemade goods at school bake sales empowers the children and promotes the feeling of community.

The New York City 2010 Draft Wellness Policy does include goals for nutrition education and promotion (4). For example, SchoolFood is a program that will work with and partner with the New York City Public Schools and the community. Partnership meetings will include discussions of nutrition-related topics and the school food service program, and invited participants can include students, a school administrator, a parent coordinator, the school nurse, and the SchoolFood manager (4). Meanwhile, the Office of Fitness and Health Education will address “nutrition education in professional development trainings for the Department’s recommended comprehensive health curricula, HealthTeacher (for grades K-5) and HealthSmart (for grades 6-12)” (4). The DOE encourages schools to promote parents’ efforts to provide a healthy diet and regular physical activity for their children as well. According to the 2010 Draft Wellness Policy, schools can offer healthy-eating seminars for parents, send home nutrition information, post nutrition advice on school websites, and provide nutrition analyses of school menus (4).

Although the 2010 Draft Wellness Policy does address nutrition education and promotion by educating staff and promoting parental awareness of nutritional food choices, selling homemade goods at school bake sales during the school day should be viewed as an educational opportunity for the children, parents, and school staff in regards to nutrition. Instead of preventing children from selling homemade goods at bake sales, children and parents should be educated about ways to incorporate healthy ingredients into their cooking and homemade treats, such as by substituting shortening, which may contain trans fats, with healthier options, such as olive oil. Instead of using refined white flour, students and parents can be taught that whole wheat flour is more wholesome and contains more health benefits than white flour, and that whole wheat flour can be a complete or partial substitute for white flour in recipes. When educating parents and children about the importance of fruits and vegetables in the diet, recipes and creative ideas to incorporate fruits and vegetables in baked goods can be recommended, such as by incorporating raisins in baked cookies or breads.

Homemade goods can meet specified nutritional guidelines as much as manufactured food can. For a food to be accepted on the approved foods list, the food item must be available in single serve packages and meet a specific nutritional profile (2). Instead of disempowering students by preventing them from selling homemade goods, students and parents should instead be given the resources to not only learn how to make food that is more nutritionally sound, but also be given the resources that will help them to evaluate whether their foods meet recommended dietary guidelines. There are even free recipe analyzers online, such as’s Recipe Analyzer, where individuals can enter the ingredients in a recipe to create a nutrition label of the food. After generating a nutrition label, students can revise the recipe if necessary, or keep the recipe if it meets the nutrition standards set forth by the DOE. Subsequently, children can divide the homemade goods into individual portions, and provide ingredient lists and nutrition labels when selling homemade goods at bake sales.

The new nutritional standards set forth for products sold in New York City schools should can seen as a way to educate the students and parents about what they eat and make at home, and not as a way to disempower children and by restricting them to sell retail and processed products at school. Children and parents are able to make nutritionally sound food just as well as any manufacturer can. After all, what’s life without a little dessert?

1. Regulation of the Chancellor. Competitive Foods - A-812. New York City, NY: New York City Department of Education, 2010.
2. Office of SchoolFood. Nutritional Guidelines for Products Sold in Schools. New York City, NY: New York City Department of Education, 2010.
3. New York City Department of Education. General Programs/Services and Other Information – Wellness Policy. New York City, NY: New York City Department of Education, 2010. htm.
4. The New York City Department of Education. Draft: The New York City Department of Education Wellness Policies on Physical Activity and Nutrition - January 2010. New York City, NY: New York City Department of Education, 2010.
5. Ogden C., et al. Prevalence of overweight and obesity in the United States, 1999-2004. Journal of the American Medical Association 2006; 295(13):1549-1555.
6. Stacy's Pita Chips. Our Products. Dallas, TX: Stacy’s Pita Chips. http://www.
7. Liu, R. Whole grain phytochemicals and health. Journal of Cereal Science 2007; 46:207-219.
8. Stark, A. and Madar, Z. Olive Oil as a Functional Food: Epidemiology and Nutritional Approaches. Nutrition Reviews 2002; 60(6):170-176.
9. Liu, R. Potential synergy of phytochemicals in cancer prevention: mechanism of action. The Journal of Nutrition 2004; 134:3479S-3485S.
10. Kellogg’s. Kellogg's Pop-Tarts 20% DV Fiber Frosted Brown Sugar Cinnamon toaster pastries. Battle Creek, MI: Kellog’s. ProductDetail.aspx?brand=202&product=11011&cat=poptarts.
11. Kellogg's. Kellogg's Nutri-Grain Cereal Bars Blackberry. Battle Creek, MI: Kellog’s.
12. Bronfenbrenner, U. Ecological Systems Theory (pp. 129-133). In: Kazdin, A, ed. Encyclopedia of Psychology, Volume 3. Washington, D.C.: American Psychological Association, 2000.
13. Bronfenbrenner, U. Ecological Models of Human Development (pp. 37-43). Reprinted in: Gauvain, M. and Cole, M. Readings on the development of children, 2nd Ed. NY: Freeman, 1993.
14. Foster-Fishman, P., et al. Empirical support for the critical assumptions of empowerment theory. American Journal of Community Psychology 1998; 26(4):507-536.
15. Zimmerman, M., et al. Further explorations in empowerment theory: an empirical analysis of psychological empowerment. American Journal of Community Psychology 1992; 20(6):707-727.
16. Zimmerman, M., et al. Taking aim on Empowerment research: on the distinction between individual and psychological conceptions. American Journal of Community Psychology 1990; 18(1):169-176.
17. Kershaw, S. Taking the Bake out of Bake Sale. NY: The New York Times. http://

Labels: ,

Wednesday, May 12, 2010

Improving Living Conditions in the House of Beauty: Nail Technician Participation in Policy Change - Tiffany Skogstrom

DISCLAIMER: This is my personal opinion. The opinions expressed here represent my own and not that of my employer or any of the mentioned organizations.

The current regulations enforced by the Massachusetts Board of Registration of Cosmetologist’s (BORC) fails to protect public health from the emerging issues of infections, sanitation and safety in nail salons. Regulations must be reformed to involve and meet the needs of the stakeholders who can make real change – nail salon workers. The current method of regulation is designed to prevent stakeholder participation, marginalizes the largely immigrant workforce and lacks necessary reassessment to proactively deal with newly materializing public health issues.

Awareness of safety and sanitation problems in nail salons stems from a series of nail salon complaints regarding sanitation and infection reported to the Boston Public Health Commission (BPHC) in 2009. The heightened number of calls may be a consequence of raised awareness generated by the Safe Nail Salon Project – a program working with nail salons on environmental health and chemical safety issues (1). Attention to this public health problem culminated when on December 31, 2009 BPHC closed down a nail salon after a consumer was hospitalized and treated for a Methicillin-resistant Staphylococcus aureus (MRSA) infection believed to have been contracted via a manicure with unclean tools. Research reveals that outbreaks of a variety of foot-spa related skin infections have occurred in Georgia (2, 3), California (4), Ohio (5) and Kentucky (5). Many nail salon infections are likely to go unreported. Although the Safe Nail Salon Project educates nail technicians on protecting themselves from chemical exposure while at work, staff was blindsided by the emerging concern about sanitation and infection.

The Massachusetts BORC is the sole regulating agency with which the nail technicians have interaction. The agency guides hygiene, sanitation and general salon standard operating procedures and its stated mission is to protect “the health and safety of the public by maintaining high standards for the industry.”(6) The BORC’s expectation that nail technicians will follow Massachusetts regulations is built upon the Health Belief Model (7). For example, once a nail technician has passed her examination for licensure, she is aware of the Massachusetts regulations. A licensed nail technician knows that not following those regulations would make her ‘susceptible’ to disciplinary action and that the ‘severity’ of penalty could result in a loss of license or closure of her salon. Once she has become a legally trained nail technician, there are no ‘barriers’ to her following the regulations. The ‘benefits’ of following the regulations are employment and a safe work environment. All of the above circumstances are ‘cues’ that should bestow in her the ‘intention’ to abide by the law and then ‘act’ on that intention. When a nail salon worker does break the law, she is faced with penalties and left on her own to remedy the situation.

A more holistic and inclusive approach would be the better method for bringing nail salons into compliance. The problem with applying the Health Behavior Model to this program is that “there is no attempt to facilitate empowerment of those involved in the (research) process, nor is there opportunity for reflection.”(8) To put this into context, it is important to note that nail technicians in Boston and beyond consist of a young, female and mostly immigrant workforce. Working long hours for low wages and being exposed to an array of toxic chemicals, nail salon workers are so marginalized that Time Magazine identified their job as being one of the worst in America (9). The BORC online licensing database shows that more than a third of working Vietnamese immigrants in the Boston area work in nail salons (10). Furthermore, according to an article titled Results from a Community-based Occupational Health Survey of Vietnamese-American Nail Salon Workers by Roelofs and Azaroff, “Nail salons are the core of the Vietnamese immigrant and refugee community’s economic support. Low entry requirements, limited need for English language skills, ethnic business networks, and flexible work schedules draw many Vietnamese women and some men to the work.”(11) The BORC, on the other hand, does not have any Vietnamese representation (12).

While it is not surprising that the BORC would fail to mirror the demographics of the people working within the salons, several of its outdated policies impede participation and some are even detrimental to worker and public health. It would be to the benefit of the BORC and public health to have nail technicians participate in the revision of regulations, and to identify how to remove barriers to compliance.

The theory of frame alignment states that pitfalls in organizational participation include: failure to correctly interpret the communal grievance; treating constituent participation as a static means to an end; and over-generalization of participation-related processes (13). This paper will demonstrate these shortcomings as a road blocks for stakeholder involvement in the BORC and reinforce the idea that nail technicians need to be linked and mobilized within an alternative organization that is external from, and can put pressure on, a government agency.

The Three Frame Alignment Participation Pitfalls:

The BORC and Interpretation of Grievances (13)

The grievance most often heard from nail salon workers relates back to language barriers and takes the form of economical and job security concerns. The main complaint is that while in other states, such as California, “the nail salon industry draws so many Vietnamese workers that Vietnamese is one of the primary foreign-language option for the license examinations” (14), the Massachusetts BORC requires all examinations for licensure to be taken in English and refuses to allow translation. The BORC website declares that “EFFECTIVE OCTOBER 1, 1998, all examinations for licensure by the Board of Registration in Cosmetology will be administered in English only. Interpreters, dictionaries and other translation aids will not be permitted at any of the examination sites as of October 1, 1998. The decision of the Board to discontinue the use of interpreters and foreign language examinations is based on public health and safety concerns relating to the proper use of chemicals in the cosmetology profession and examination security issues in general.” (15)

The BORC ‘English-only’ policy for nail technician license exams forces people to work unlicensed and untrained in sanitation or any other trade skills. As a result, competing nail salons use cheap and unlicensed labor and undersell the businesses who are in compliance and abiding by the letter of the law. This also fosters potential for an underground economy for the buying and selling of nail technician licenses resulting in various forms of indentured servitude, and in extreme cases, human trafficking (16, 17, 18).

As outlined in Social Conditions as Fundamental Causes of Disease by Link and Phelan, “health policymakers should consider whether a proposed intervention will have an impact on just one disease or whether, because of its influence on a fundamental cause, it will affect many diseases.” (19) Failure to address the language grievance not only prevents the Vietnamese nail technicians from participating in mainstream government and society but also perpetuates the cycle of poverty, unsafe working conditions, unsanitary salons and general exploitation that has become ‘business as usual’ in nail salons.

The BORC and Dynamic Participation (13)

Nail technicians interactions with the BOC are a one-way relationship. Once nail technicians have passed their examination for licensure, the only expected interaction is through license renewals or a chance salon inspection. In 2003, there were 3 BORC inspectors and 1,206 salons in the state of Massachusetts (20). The BORC websites shows that a during a 2009 strike of 163 Boston beauty salon inspections, “56 were cited for violations ranging from unsanitary conditions to employment of unlicensed individuals and unlicensed shops.” (21) That one out of three of the businesses that were inspected had serious violations provides a telling snapshot of salon conditions. Salon employees tell tale of being issued citations without a clear understanding or direction on how to resolve the offenses. To draw an analogy from Siegel’s The Importance of Formative Research in Public Health Campaigns: An Example from The Area of HIV Prevention Among Gay Men, “public health efforts to change” a marginalized group’s “behavior must include efforts to change the way society treats” that group (22).

The BORC and Participation-Related Processes (13)

The BORC has put up many barriers for nail technician’s participation. For this reason, in June of 2009, a group known as the Massachusetts Healthy Cosmetology Committee met with the BORC with the goal of ‘nudging’ the agency to reconsider and revise some of cosmetology regulations for the sake of public health (23). This committee sought, among other things, to address:

·Allowing testing, training and hearings in languages other than English.

· The current requirement that nail technician licenses (as well as individual ‘health certificates') (24), which include home addresses, be prominently displayed in salons. The committee recommended that licensees’ home addresses not appear on licenses due to a story of a licensee being followed home and mugged for her tips.

· Clear and effective instructions for sanitation of nail salon tools (25).

· Eliminating the requirement for Steri-Dry (26) (dry sanitizer) and prohibit the use of any formaldehyde-based chemical in salons including Steri-Dry and formalin. Formaldehyde is a carcinogen, asthmagen, and strong irritant (27) and is unnecessary to assure salon hygiene and sanitation.

With the exception of the language request, the BORC was in agreement with the above mentioned items. However, rather than go through the process of rewriting and revising legislation, the BORC informed the committee that it was applying a ‘non-enforcement’ policy on those issues. The problem lies in the fact that if the laws are not formally changed, the nail technicians are unaware of which BORC rules are enforceable and which ones are not. In order to comply with regulations, nail technicians will continue to implement practices that put themselves and the public in harm’s way.

The BORC reluctance to make adjustments to outdated regulations demonstrates “collective conservatism” or ‘the tendency of groups to stick to established patterns even as new needs arise.” (23) The groups’ resistance to consider any outside suggestions, especially those with which they are in agreement, shows that the only way to participate in the BORC is if you are an appointed member of the Board or on the receiving end of a disciplinary action. Working conditions, sanitation, and environment cannot improve or get resolved with the current lack of opportunities to reevaluate situations. Even though the BORC agreed with most of the recommendations for improvements, the entity refused to be nudged. As stated in Klandermans’ Potentials, Networks, Motivations, and Barriers, “willingness is a necessary but insufficient condition of participation.” (28) The method of participation is ‘one-size-fits-all’, meaning that impermeability ensures that no one outside of the BORC gets to participate.

Analysis of the Three Participation Pitfalls and the BORC

The issues presented in the three pitfalls to participation reveal the BORC as an entity that works counter to its mission statement to “protect the health and safety of the public by maintaining high standards for the industry.” (6) The rigidity of the organization in terms of adapting to the training needs of the Vietnamese workforce results in consumers contracting infections. In any language, the BORC regulations continue to be outdated and unclear, and fail to address emerging infections or salon conditions.

Furthermore, during these turbulent economic times, low wage service workers are even more desperate for income and happy to do the work as unlicensed and exploited nail technicians. Unlicensed workers not only hurt the local economy by underselling their law abiding competitors, but create the perfect circumstances for indentured servitude where licenses can be bought and are worked off for exorbitant prices. The English-only examination policy further alienates an already marginalized community of people and makes young immigrant women even more vulnerable to exploitation through cheap labor and human trafficking.

Clearly there is no method to work within the BORC to make the necessary public health and worker safety changes. For this reason, Vietnamese nail technicians must link with an organization that shares their values, ideologies and beliefs in order to externally pressure the regulating agency to make important policy changes. Furthermore, the process of reviewing the pitfalls is valuable to make improvements because “efforts to reduce risk by changing behavior may be hopelessly ineffective if there is no clear understanding of the process that leads to exposure”.(19) Proactive public policy and interventions can be created by reflecting on the shortcomings of existing regulations.

The Intervention:

Frame alignment is a theory of collective action where un-mobilized individuals and an organization are linked together based upon shared ideology and a need to act (13). Social movements are comprised of people working together as ‘framing agents’ to define the world within which they live (29). According to Snow and Benford, the ongoing and necessary processes of a successful social movement are frame bridging, frame amplification, frame extension and frame transformation.

The four processes of frame alignment act as an organizational prophylactic against participation shortcomings and are necessary, flexible and fluid parts that aim to ensure momentum. Frame bridging (13) is the process of linking two or more ideologically congruent ‘frames’ (individuals and an organization) and building momentum through recruitment, leadership development and activities that are consistent with the shared ideology. Frame amplification (13) consists of value and belief amplification. Value amplification is the process where the group decides upon goals and mobilizes on them. Belief amplification is faith that the value amplification actions will have the desired impact. Frame extension (13) is the organization’s flexibility in what it can offer and incorporate to meet the needs of its constituents. Frame transformation (13) is the process of redefining or nurturing new values to find commonalities between the individual and organization that may not be immediately obvious. Frame transformation can be ‘domain specific’ where actions result in a change in status for a group of people, or ‘global interpretive’ which is a philosophical process of being “the change you want to see in this world.” (30) When linked together, the four frame alignment processes inoculate against the three pitfalls of participation and can create meaningful change.

1. Frame Alignment and the Interpretation of Grievances:

The first step of the process, known as frame bridging, involves identifying the organization best capable of properly interpreting the Vietnamese nail technician’s grievances and with which they would be best aligned. The Vietnamese – American Initiative for Development (Viet-AID) is a prominent organization within the Vietnamese community. Viet-AID’s mission to “provide comprehensive economic development programs and services to alleviate poverty and advance civic participation” (31) is complementary to the values and reflects the grievances of the nail technicians’ struggle for decent employment. Viet-AID has good relationships with the Vietnamese business leaders and plays a major role in the Safe Nail Salon Project and the Massachusetts Healthy Cosmetology Committee. This sets the stage for aligning the un-mobilized nail technicians with Viet-AID in a pact to force policy change.

Nail technicians working with Viet-AID for changes in the salons would vicariously be partnering with the BPHC Safe Nail Salons Project. BPHC is a governmental agency, and a population such as the Vietnamese community, who fled their country of origin to escape an oppressive government, may be gun-shy at the prospect of such a partnership (22). Through frame transformation, ‘regulatory’ values and activities would have to be made appealing to participants. Activity examples include creating model regulations that would be adopted by various municipalities across Massachusetts that would: require annual nail salon registration with the health department; make Safe Nail Salon training a condition of the annual registration; and create specific local requirements for sanitation.

To appeal to nail technicians, these regulatory methods must be framed to address nail technician’s grievances of an unsafe work environment, inequity amongst business’ underselling practices and low wages. The unlikely partnership between a government agency and the Vietnamese workers is made more attractive by revealing how BPHC’s public services might be beneficial. The BPHC Safe Nail Salon Project has a rich history of frame extension through helping people access health care and providing valuable public health services. Therefore, the closer relationship with a local government agency would be a partnership to bring nail technicians into the mainstream, rather than an additional regulatory burden.

While BPHC focuses on local regulations, Viet-AID may be the more appropriate vehicle to turn nail salon worker’s grievances into an active campaign to put external pressure on the BORC. These simultaneous efforts could lead to effective public health change.

2. Frame Alignment and Dynamic Participation

Frame bridging is needed to mobilize leaders and interpret grievances into movement activities. Viet-AID’s frequent visits to the salons helps recruit leaders who participate in activities, get the community talking about the problem and encourage others to take part. As stated by Klandermans, “informal recruitment networks are necessary conditions for the arousal of motivation to participation.” (28) This paves the way for frame value and belief amplification, where nail technicians “employ an ‘injustice framework’ that links personal and vicarious experiences of stigma and discrimination” (32) to Viet-AID’s mission of social and economic development.

Frame value and belief amplification involve articulating grievances in terms of ‘injustice’ and forming them into solution oriented actions. The conditions of belief amplification (13) are that people will mobilize when (a) they believe there is a serious problem; (b) there is an antagonist (the BORC) that is defined as the source of the problem and (c) with whom the constituents have stereotypical beliefs about power; (d) people believe that the identified actions will lead to change; and (e) there is importance in standing up together to overcome the injustice.

The frame transformation is domain specific, where actions result in the change in status of how a group of people are treated by the BORC. Potential actions, depending upon the will of the constituents, could include letters to the editor or public demonstrations demanding that the governor command the BORC to provide examination translation, or Vietnamese representation on the BORC. The dynamic participation feeds the recruitment aspect of frame bridging where “people show more of a tendency to participate in collective action if they expect that others will do so as well.” (28)

3. Frame Alignment and Participation-Related Processes

The theory of frame alignment requires that participants are active in all processes. Participation-related processes consist of recruitment and leadership development of frame bridging, identifying goals and strategic activities during frame amplification, recognizing innovative ways to meet the ongoing needs of the community through frame extension, and nurturing new values that serve the benefit of the community through frame transformation.

Where Vietnamese nail technicians have been alienated by the BORC, the frame alignment process of this proposed campaign welcomes participation in the ‘linked’ organization at all levels. If the frame alignment recipe is followed correctly, the result will be a functioning organization that serves the needs of its constituents. The processes could be the blueprint for a Nail Salon Business Leadership Council that might be housed within Viet-AID. The new leadership group would autonomously decide the best course of actions in the interest of nail technicians. It would drive its agenda through participation in other economic and social justice initiatives, and ideally, the BORC itself.

Ongoing success is only guaranteed if all of the frame alignment processes are participant driven. Furthermore, it is necessary to reevaluate and adapt all processes to meet emerging needs and realities in order to retain and accumulate constituents. An ideology that becomes set in stone will lose members and momentum (29), and becomes susceptible to mirroring the rigidity of the entity that it seeks to influence.


In absence of the nail technician’s ability to participate in the BORC, the most sensible intervention involves collective action to improve public health policy. The most fundamental change would be to allow nail technicians to test for licensure in their own language. This single policy change will have astounding results such as giving people access to safe and well paying jobs and safer nail salons. While municipalities can put out fires by implementing city regulations, real change must happen within the BORC to tackle the root of these problems.

The frame alignment process has potential to bring a historically marginalized group of people into the mainstream. The multi-level methods address health inequities through strengthening individuals and communities, improving people’s access to services, and fostering economic and cultural change (33). This proposal builds meaningful, innovative and sustainable partnerships and a model that could be emulated in other parts of the country, further building momentum for social change.


1. The Boston Public Health Commission’s Safe Nail Salon Project. Available at: (accessed 2/27/10).

2. Gira AK, Reisenauer AH,, Hammock L, Nadiminti U, Macy JT, Reeves A, Burnett C, Yakrus MA, Toney S, Jensen BJ, Blumberg HM, Caughman SW, FS Nolte. Furunculosis Due to Mycobacterium mageritense Associated with Footbaths at a Nail Salon. Journal of Clinical Microbiology April 2004; Vol 42, No. 4: 1813 – 1817.

3. Cooksey RC, de Waard JH, Yakrus MA, Rivera I, Chopite M, Toney SR, Morlock GP, Butler WR. Mycobacterium cosmeticum sp. nov., a novel rapidly growing species isolated from a cosmetic infection and from a nail salon. International Journal of Systematic and Evolutionary Microbiology 2004: 2385–2391.

4. Winthrop KL, Albridge K, South D, Albrecht P, Abrams M, Samuel MC, Leonard W, Wagner J, Vugia DJ. The Clinical Management and Outcome of Nail Salon-Acquired Mycobacterium fortuitum Skin Infection. Clinical Infectious Diseases January 1, 2004: 38–44.

5. Redbord KP, MD; Shearer DA, MD; Gloster H, MD; Younger B, MD; Connelly BL, MD; Kindel SE, MD; Lucky AW, MD. Atypical Mycobacterium furunculosis occurring after pedicures. Journal of the American Academy of Dermatology March 2006; Vol. 54; No. 3: 520–524.

6. Massachusetts Board of Registration of Cosmetologists. About the Board of Registration of Cosmetologists. Available at: (accessed 2/28/10)

7. Edburg, M. Individual Health Theories (p 35 - 49). In: Edburg, M. Essentials of Health Behavior. Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers. 2007

8. Thomas LW. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice and Education. Journal of Professional Nursing July – August 1995; Vol. 11; No. 4; 246 -252.

9. Kaplan J, Fitzpatrick L. The Worst Jobs in America. Time Magazine. 7/30/07. Available at:,8599,1648055,00.html (accessed 2/27/10)

10. Doan, T. New Ecology Inc. (NEI). Toxicity, Safety and Performance Evaluation of Alternative Nail Products. Cambridge, MA. January 2006 (p 7) Available at: (accessed 2/27/10)

11. Roelofs, C, Azaroff, LS. Holcroft, C. Nguyen, H. Doan, Tam. Results from a Community-based Occupational Health Survey of Vietnamese-American Nail Salon Workers. Journal of Immigrant and Minority Health 2008; 353 - 361.

12. Massachusetts Board of Cosmetologists and Aestheticians: Board Members. Board of Registration of Cosmetologists. Available at: (accessed 2/27/10)

13. Snow DA., Rochford EB, Worden SK, Benford RD. Frame Alignment Processes, Micromobilization, and Movement Participation. American Sociological Review 1986; Vol. 51; No 4; 464 - 481.

14. Quach T, Nguyen KD, Doan-Billings PA, Okahara L, Fan C, Reynolds P. A Preliminary Survey of Vietnamese Nail Salon Workers in Alameda County, CA. Journal of Community Health May 2008; 336 – 343.

15. Massachusetts Board of Registration of Cosmetologists. Statutes and Regulations. Board Policies and Guidelines. State Board Examinations: English Language Requirement. Available at: (accessed 2/28/10).

16. Logan TK, Walker R, Hunt G. Understanding Trafficking Victims in the United States: Where Are They? Trauma, Violence and Abuse January 2009; Vol. 10; No.1; 9.

17. Lee, R. Pair Sentenced for Modern-Day Slavery at Local Nail Salons; The Nail Salon Owner Received the Toughest Sentence of the Two – 90 Days in Jail – For Participating in Human Trafficking. York Daily News / York Sunday News. 2/11/10. Available at: (accessed 2/27/10)

18. Ramakrishnan, M. Human Trafficking Exists ‘Right Here, Right Now’. Allston / Brighton TAB. 1/15/10. Available at: (accessed 2/27/10)

19. Link BG, Phelan J. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior 1995: p 80 - 94.

20. Roelofs C. Regulations for Manicurists / Nail Salon Operation: Massachusetts vs. Other New England States and New York. 11/19/03

21. State Inspectors Visit Boston to Ensure Safety and Compliance at Barber Shops and Beauty Salons. Board of Registration of Cosmetologists. Available at: (accessed 2/27/10)

22. Siegel M, Lotenberg LD. The Importance of Formative Research in Public Health Campaigns: An Example from The Area of HIV Prevention Among Gay Men (p. 73 - 78). In: Siegel M, Lotenberg LD. Marketing Public Health. Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers, 2007.

23. Thaler RH, Sunstein CR. Following the Herd (Chapter 3 p 53 - 71). In: Thaler RH, Sunstein CR. Nudge. Improving Decisions About Health Wealth and Happiness. Yale University Press, 2008.

24. 240 CMR 3.01(7) Licensure of Salons. Available at: (accessed 2/28/10)

25. 240 CMR 3.03 Equipment and Hygiene Procedures. Available at: (accessed 2/28/10)

26. 240 CMR 3.03 (17) b. 2. Equipment and Hygiene Procedures. Available at: (accessed 2/28/10)

27. Agency for Toxic Substances and Disease Registry. ToxFAQs for Formaldehyde. How can formaldehyde affect my health? June 1999. Available at: (accessed 3/3/10)

28. Klandermans B, Oegema D. Potentials, Networks, Motivations, and Barriers: Steps Toward Participation in Social Movements. American Sociological Review August 1997; Vol. 52; No. 4: 519 - 531.

29. Snow DA, Benford RD. Center for Advanced Studies in the Behavioral Sciences, Stanford. Clarifying the Relationship Between Framing and Ideology in the Study of Social Movements: A Comment on Oliver and Johnston.

30. Mohandas Karamchand Gandhi, 10/2/1869 – 1/30/1948.

31. Viet-AID’s Mission and History. Available at: (accessed 3/1/10)

32. Martin DD. From Appearance Tales to Oppression Tales: Frame Alignment and Organizational Identity. Journal of Contemporary Ethnography April 2002, Vol. 31, No. 2: 158 – 206.

33. Marks DF. Health Psychology in Context. Journal of Health Psychology 1996; Vol 1: 7 - 21.

Labels: , , ,