Challenging Dogma - Spring 2010

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

2010-05-20T08:25:00.000-04:00

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.

References

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. www.cdc.gov/mmwr/preview/mmwrhtml/mm5705a1.htm.
2. Bureau of Justice Statistics. National Crime Victimization Survey: Criminal Victimization, 2007. 2008. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. http://www.ojp.usdoj.gov/bjs/pub/pdf/cv07.pdf.
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. http://ep.yimg.com/ca/I/fvpfstore_2101_454719.
8. Family Violence Prevention Fund. Health Care and Domestic Violence Posters. Reproductive Health Posters. San Francisco, CA: Family Violence Prevention Fund. http://ep.yimg.com/ca/I/fvpfstore_2101_122906.
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.

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

2010-05-18T09:00:00.002-04:00

Introduction

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.

Conclusion

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 CalorieCount.com’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?

References
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. http://schools.nyc.gov/Offices/Health/GenProgServ/Wellness. 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. stacyssnacks.com/#/?page=products.
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. http://www2.kelloggs.com/Product/ ProductDetail.aspx?brand=202&product=11011&cat=poptarts.
11. Kellogg's. Kellogg's Nutri-Grain Cereal Bars Blackberry. Battle Creek, MI: Kellog’s. http://www.nutri-grain.com/ProductDetail.aspx?product=12270.
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:// www.nytimes.com/2010/03/17/dining/17bakesale.html

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

2010-05-12T16:24:00.002-04:00

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.

Conclusion:

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.

References:

1. The Boston Public Health Commission’s Safe Nail Salon Project. Available at: www.bphc.org/safenails (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: http://www.mass.gov/?pageID=ocaterminal&L=4&L0=Home&L1=Licensee&L2=Division+of+Professional+Licensure+Boards&L3=Board+of+Registration+of+Cosmetologists&sid=Eoca&b=terminalcontent&f=dpl_boards_hd_about&csid=Eoca (accessed 2/28/10)

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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.

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Why the Soda Free Summer Campaign’s Reliance on the Health Belief Model Limits Its Efficacy in America’s Fight Against Obesity

2010-05-11T15:19:00.002-04:00

The Added Sugar That’s Making Us Fat

Obesity in the United States has reached epidemic levels. 32.2% of adult men and 34.5% of adult women can be classified as obese (with a body mass index of 30 or more) (1) and many see sugar-sweetened beverages as a major contributor to the fattening of America. The Nurse’s Health Study II found that consumption of sugar-sweetened soft drinks was positively correlated with caloric intake, weight gain, and incidence of diabetes (2). A prospective observational study found that for each additional serving of sugar-sweetened drink consumed, body mass index and frequency of obesity both increased after adjusting for anthropometric, demographic, dietary, and lifestyle factors (3). Soda consumption in particular, has also been negatively associated with children’s nutrient intake, specifically vitamin A in all age strata, calcium in children under 12, and magnesium in children 6 years and older (4). The American Association of Pediatrics recommends that doctors suggest limiting intake of sugar-sweetened beverages to all children but those below a 5% body mass index (5).

The Soda Free Summer Campaign aims to reduce obesity and obesity-related diseases by inspiring individuals to abstain from drinking soda and other sugar-sweetened beverages for a 10-week period during the summer. The campaign, first implemented in the San Francisco Bay Area, recruits people to sign a pledge card to commit to a soda free summer and log their progress. To support the campaign they distribute informational pamphlets and promotional materials such as wrist bands, conduct Be Sugar Savvy workshops showcasing sugar content of beverages, and spread their campaign messages via local media outlets (6).

This critique of the Soda Free Summer Campaign postulates that the campaign’s reliance on the health belief model (7, 8) limits its efficacy through its focus on the individual, assumptions of rationality and unfaltering self-control, its lack of environmental and policy considerations, and its failure to provide compelling visuals or appeal to core values.

If Only Our Behavior Was Truly Individual, Rational, and Subservient to Our Long-Term Health Goals

The view that lifestyle is determined simply by the sum of behavioral choices and some intrinsic personality characteristics is antiquated at best. No consumer ever entered a restaurant demanding a bottle filled with high fructose corn syrup; consumer choices are made based on which products are produced and promoted by corporations whose goal is profit maximization (9). The idea that this consumer should be the sole target of a campaign to reduce obesity is a predictable, individualistic, and simplistic western response (10) especially given that there is little evidence that individual level interventions have had much success at the population level (11). Dietary behavioral change is not always as easy as simply deciding to make a change but is instead a complex interplay between availability and cost of alternatives, social supports, and consistent positive feedback that outweighs the barriers to making the change (12). After all, if it were as simple as deciding to make a positive change we would all stick to our New Year’s Resolutions, strictly adhere to our diets, and exercise regularly.

We humans are deeply irrational beings (13). The world in which we rationally weigh the costs and benefits of each possible choice and do only that which we intend, while remaining uninfluenced by those around us or by the environment around us, is called an economic model. In reality, we judge people’s personalities differently if we’ve been exposed to different temperatures (14), we start diets and then decide to have one more piece of chocolate cake (15), and we fail to adhere to healthy behaviors even after we’ve actually experienced a negative health outcome like cardiovascular disease, hypertension, or diabetes (16).

Rather than being isolated and independent actors, we are deeply affected by the behavior of others (17-19). Teenage girls who see other teenage girls having children are more likely to have children themselves and the GPA of a college freshman’s randomly assigned roommate can essentially predict her GPA (20). Quantitative analysis done using data from the Framingham Heart Study demonstrated that over a 32 year period individuals connected by social ties gained weight and quit smoking in concert. A person’s chance of becoming obese increased if she had a friend, spouse, or sibling who became obese in a given interval but was not affected by a neighbor becoming obese (21). In the same vein, smoking cessation of a spouse, friend, sibling, or co-worker at a small firm considerably reduced a person’s chances of smoking (22).

Consumption of sugar-sweetened beverages in particular, has been associated with other dietary patterns (23), clustered with TV viewing among teens (24), and influenced by parental consumption among Latinos (25). The focus on individual and isolated behavior ignores social influence and our current understanding of human irrationality.

Left to Our Own Devices: Why Environmental and Policy Changes Shouldn’t Be Ignored

While the 2009 Soda Free Summer Campaign gauged public support for policy changes (26), its failure to incorporate any environmental or policy nudges as part of the intervention weakened its efficacy. This decision, in keeping with the simplistic view of the health belief model, relies heavily on an individual’s self-control and fails to take advantage of the power of a small environmental nudge in the right direction.

Recent research showing the degree to which we underestimate context and overestimate our ability to behave in accordance with our good intentions has underscored the usefulness of policy and environmental interventions. It turns out that different parts of the brain are involved with planning and doing: the planner part looks out for our long-term welfare while the doer easily succumbs to temptation; a man on a diet might agree to go out with colleagues thinking that he can resist the wine and desert options but immediately orders wine once at the restaurant (27). The farther removed we are from a temptation the more self-control we have and the more self-control we believe we will have when tempted. This is why so many pregnant women say they will refuse drugs during labor but so often change their minds once actually experiencing the pain of childbirth (28) and why when given the choice of $100 in 30 days or $110 in 31 days nearly everyone chooses $110 in 31 days but when given the choice of $100 today or $110 tomorrow nearly everyone chooses the instant $100 (29).

Small environmental and policy changes can help steer us toward healthier choices without mandating or controlling our behavior. Smaller portion sizes can nudge us to eat less (30-31), musical stairs can coax us off the escalator (32), and greater access to physical activity resources encourages us to be physically active without telling us to be (33). Taxing unhealthy products is another social disincentive policy at our disposal. Cigarette taxes are seen as a useful way of reducing smoking and increasing state revenues (34) and some states have begun to implement soda taxes (35) in the same vein. Some also call for a ban on food advertising to children (36) citing studies like one published in Health Psychology showing that children consumed 45% more when exposed to food advertising (37).

In the case of sugar-sweetened beverages, a randomized, controlled pilot study almost completely eliminated sugar-sweetened beverage consumption in a diverse group of adolescents and showed a beneficial effect on body weight through delivering beverages with no added sugar to the homes of adolescents (38).

Environmental interventions and policy changes can be effectively used to incentivize healthier behaviors, discourage unhealthy behaviors, improve availability of healthy alternatives, restrict access to unhealthy foods, control marketing and advertising, and create communities that support healthy lifestyles (39). With such potential to influence behavior at the population level, they should not be ignored.

Selling Health and Statistics: No Match for the Coke & Pepsi Promise

The Soda Free Summer Campaign promises a reduction in weight gain, a reduced risk of diabetes and heart disease (40,41) and the chance at a few raffled prizes in exchange for giving up soda (42). The health promises are backed up by statistics about sugar consumption and obesity-related diseases. The campaign also created a video that reiterates the same statistics on their website and fails to provide compelling visuals or appeal to core values like independence and control.

While the Soda Free Summer Campaign sells health benefits, Coke and Pepsi make grand promises and appeal to consumers’ core values. Coke promises its consumers happiness with its “Open Happiness” advertising campaign (43) and “Share Happiness” slogan for its new 2 liter bottle and backs up its promise with images showcasing beautiful, young people looking incredibly happy (44). Pepsi makes similarly grand promises: if you drink Pepsi you will belong to a larger movement of youthful change makers (45) appealing to American values of community and positive social change. Both Coke and Pepsi have recently launched “movements”, further capitalizing on Americans’ hunger for positive change, with the Pepsi Refresh Project which awards grants to “refreshing” ideas (46) and Coke’s Live Positively Campaign which supports environmentalism, active lifestyles, and volunteerism (47).

If indeed Americans saw health as a core value, the Soda Free Summer Campaign and other health promotion campaigns who promise health would be more effective and we might see fitness facilities marketing health benefits rather than attractiveness. Time and time again, health does not motivate our behavior (48). The 5 A Day Campaign is largely considered a failure (49, 50), nutritional knowledge has been shown to have only a peripheral impact on children’s food preferences (51), and smokers who overestimate the prevalence of heart disease and cancer in smokers continue to smoke (52). This is only magnified by the fact that we have an incredibly strong optimistic bias, so that even if we know and understand the health risks and statistics related to diseases like obesity and diabetes we think our own susceptibility is below average (53, 54).

While the Soda Free Summer Campaign utilizes promotional materials, reaches out to local media, and contains a short video, it fails to be an effective social marketing campaign. An effective campaign must have a unified core position, evoke desired visual images, employ recognizable catch phrases, suggest appropriate metaphors, showcase its program as the solution, and must not attribute the problem to the individual (55). The Soda Free Summer Campaign fails to suggest any appropriate metaphors or use compelling visual images and attributes responsibility solely to the individual.

The Soda Free Summer Campaign also runs the risk of inciting reactance through its negative messaging. The campaign tells you that soda and other sugar-sweetened beverages should be completely given up, essentially a “just say no” campaign. Between the request to give up something that for many may be a daily habit and the adults in the video barraging you with facts and statistics, the campaign may elicit psychological reactance. In a study done with heavy drinkers, those exposed to “Don’t Drink” messages drank significantly more directly after exposure to messaging than those exposed to a “Drink Moderately” message (56). A video on youtube in response to New York City’s Pouring on the Pounds Campaign (57) is a concrete example of this kind of response, showcasing New Yorkers who feel angry and rebellious toward a campaign which they see as the government telling them what to do (58).

An effective social marketing campaign could go a long way in the fight to reduce American consumption of sugar-sweetened beverages but we won’t get there by putting seemingly far-off health promises up against happiness.

A Different Approach: How Using the Social Ecological Model and Advertising Theory Could Nudge People Toward Healthier Drinks And Create a Social Movement

The social ecological model with a strong social marketing component modeled on the Truth Campaign’s success has the potential to effectively reduce sugar-sweetened beverage consumption, obesity, and obesity-related diseases at the population level. The social ecological model has many advantages over other public health models as it provides an effective framework for real people living in complex environments (59). Prominent agencies like the U.S. Centers for Disease Control have used this framework to assess and coordinate school health services (60) due to its comprehensive structure that addresses the macrosystem (laws, history, culture, economic system, social conditions), exosystem (extended family, community centers, neighborhoods, mass media), and microsystem (family, peers, siblings) components that surround each individual (61).

Policy initiatives that eliminate corn subsidies, tax sugar-sweetened drinks, or even ban high fructose corn syrup, mandate 0 sugar-added drinks in schools, government buildings, and government funded community centers, and ban sugar-sweetened beverage advertising to children could significantly alter the demand and availability of sugar-sweetened beverages and nudge people to make healthier choices. A broad-based social marketing campaign modeled on the Truth Campaign’s use of advertising theory (62) could include a series of ads that promise unity and social change with desired visual images. The campaign could also harness reactance to create positive behavioral change by appealing to people’s distrust of government and corporations and inspire a Tea Party-esque outrage about corporate profit margins and institutionalized racism (63) and the government’s subsidization of the high fructose corn syrup that’s making our country fat.

Beyond Door-to-Door: How We Can Effectively Target the Population

The social ecological model and advertising theory are both group-level models. For these models we need not assume that humans make decisions in rational vacuums and we avoid the typical western trap of blaming the individual; we actually take advantage of the social influence we have on one another instead of ignoring it. Corporations like Coca-Cola and Pepsi who produce and promote sugar-sweetened beverages have always successfully aimed their promotion efforts at the population, so why should we go door-to-door?

The ecological model allows us to target the population and see population level results. Shape Up Somerville is an ecological wellness intervention that has successfully reduced body mass index of elementary-aged children at the population level (64). Its initiatives have encouraged an entire city’s children to become more active not by targeting individual children but by creating an environment that supports activity for all.

Effective social marketing like the Truth Campaign also have an essential role in modern public health promotion (65). They successfully target a wide range of groups in an array of settings (66) and address the population as a whole (67). Successful campaigns have increased demand for everything from condoms in Zambia (68) to syphilis testing among gay and bisexual men in San Francisco (69).

Nudged: How Environmental and Policy Changes Can Help Us Make Healthier Choices

Policy and environmental changes give the planner in us a chance to follow-through on our good intentions by creating an environment that supports healthier options. We have seen these interventions work to combat smoking (70) and increase healthy behavior in schools (71).

Getting rid of corn subsidies would eliminate the artificially low price of high fructose corn syrup, a base ingredient in the most popular sugar-sweetened drinks. A sugar-sweetened beverage tax would further increase the price and a ban on high fructose corn syrup might be considered given its other negative health effects (72-74). The American Public Health Association supports a soda tax citing that it is just as appropriate as a cigarette tax and could help pay for the $47.5 billion a year that the government spends on medical care related to obesity through Medicaid and Medicare (75). Economists estimate that a 58% soft drink tax would result in a small but real decrease in body mass index (a reduction of 0.16 points) (76) so just think what a broader sugar-sweetened beverage tax could do.

Mandating 0 sugar-added drinks in schools, government buildings, and government funded community centers and a ban on sugar-sweetened beverage advertising to children would improve environmental support for healthy choices and allow for mindless choosing of healthier options in schools and other public institutions. This could improve health and change social norms in much the same way as cigarette bans have (77, 78).

A New Truth: High Fructose Corn Syrup, Sugar-Sweetened Beverages and Obesity

Public Health campaigns have an enormous opportunity to learn from commercial branding and marketing strategy. We need to cultivate brand recognition, promise core values, and deliver on those promises (79). If we strategically reframe the issue of sugar-sweetened beverages we can affect population consumption by selling core values, harnessing reactance, and starting a social movement.

The VERB Campaign and the Truth Campaign were highly successful social marketing campaigns that used advertising theory to begin positive social movements and significantly increased physical activity (80, 81) and reduced smoking respectively. The VERB Campaign and associated advertisements promised community and opportunity. The campaign sent yellow balls all over the country and put kids in charge. VERB challenged kids to invent new games that could be played with the ball and then pass the ball on to someone else giving kids an opportunity to feel in control (82). The Truth Campaign appealed to adolescent values of rebellion and independence (83) and created a counter-industry movement that significantly reduced the prevalence of smoking in Florida teens (84-88).

The issues surrounding sugar-sweetened beverages, high fructose corn syrup, and obesity are rife with material that would make an excellent Truth Campaign. Instead of selling abstinence of sugar-added beverages, a social marketing campaign could sell freedom, independence, control, and rebellion. It could inspire a movement that stood for community and rebellion against the corporations and government subsidies that conspire to make Americans fat. The “product” being sold would be identity as a fit and attractive person in charge of her appearance and rebellion against the feelings of unattractiveness and lack of control over her appearance (89).

Uniting Against Obesity: Conclusion and Call to Action

The Soda Free Summer Campaign has severe limitations due to its reliance on the health belief model, its focus on isolated and rational behavior, its failure to address policy and environmental change, its weak promise backed up by statistics, and its failure to provide compelling visual imagery. The campaign could be improved by addressing any one of these failures.

Obesity is arguably the most serious health issue in America today. The public health community needs to incorporate best practices from successful public health marketing campaigns and ecological model approaches in order to target the population and stop blaming the individual, nudge us toward healthier choices with smart policy and environmental supports, and inspire us to join a movement where we stand up against government subsidies and corporate agendas and say enough is enough.

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(55) Bensley LS, Wu, R. The role of psychological reactance in drinking following alcohol prevention messages. Journal of Applied Social Psychology 1991; 21.13:1111+.

(56) New York City Department of Health and Mental Hygiene. Health Department Asks New Yorkers if They’re Pouring on the Pounds. http://www.nyc.gov/html/doh/html/cdp/cdp_pan.shtml

(57) The American Beverage Association. What Real New Yorkers Think. http://www.youtube.com/watch?v=K65TAi_siCo

(58) Grzywacz, JG, Fuqua J. The social ecology of health: leverage points and linkages. Behavioral Medicine 2000; 26.3:101-116.

(59) Lohrmann, David K. A complementary ecological model of the coordinated school health program. Public Health Reports 2008; 123.6:695+.

(60) Eisenmann JC, Gentile DA, Welk GJ, Callahan R, Strickland S, Walsh M, and Walsh DA. SWITCH: rationale, design, and implementation of a community, school, and family-based intervention to modify behaviors related to childhood obesity. BMC Public Health 2008;8.223:223.

(61) The Truth Campaign. About Us. http://www.thetruth.com/aboutUs.cfm

(62) Yancey AK, Cole BL, Brown R, Williams JD, Hillier A, Kline RS, Ashe M, Grier SA, Backman D, McCarthy WJ. A Cross-Sectional Prevalence Study of Ethnically Targeted and General Audience Outdoor Obesity-Related Advertising. The Milbank Quarterly 2009; 87.1: 155+.

(63) Economos C, Hyatt R, Goldberg J, Must A, Naumova E, Collins J, Nelson M. A Community-Based Environmental Change Intervention Reduces BMI z-Score in Children: Shape Up Somerville First Year Results. Obesity 2007; 15:1325-1336.

(65) Evans, W. Douglas. Health education: What social marketing can do for you. British Medical Journal 2006; 332.7551:1207+.

(66) Gordon, Ross, et al. The effectiveness of social marketing interventions for health improvement: What's the evidence? Public Health 2006; 120.12: 1133+.

(67) Kolodinsky J, Reynolds T. Segmentation of overweight Americans and opportunities for social marketing. The International Journal of Behavioral Nutrition and Physical Activity 2009; 6.13:13.

(68) Van Rossem R, Meekers, D. The reach and impact of social marketing and reproductive health communication campaigns in Zambia.(Research article). BMC Public Health 2007;7.352:352.

(69) Montoya, Jorge A., et al. Social marketing campaign significantly associated with increases in syphilis testing among gay and bisexual men in San Francisco. Sexually Transmitted Diseases 2005; 32.7: 395+.

(70) Story M, Nanney MS, Schwartz MB. Schools and Obesity Prevention: Creating School Environments and Policies to Promote Healthy Eating and Physical Activity. The Milbank Quarterly 2009; 87.1:71+.

(71) McGoldrick DE, Boonn AV. Public Policy to Maximize Tobacco Cessation. American Journal of Preventive Medicine 2010; 38.3:S327-S332.

(72) Stanhope KL, Havel, PJ. Fructose consumption: recent results and their potential implications. Annals of the New York Academy of Sciences 2010; 1190:15+.

(73) Gaby, Alan R. High-fructose corn syrup and trans fatty acids: a double whammy. Townsend Letter Dec. 2009:34.

(74) Le, Kim-Anne, et al. Fructose overconsumption causes dyslipidemia and ectopic lipid deposition in healthy subjects with and without a family history of type 2 diabetes. American Journal of Clinical Nutrition 2009; 89.6:1760+.

(75) APHA urges soda tax as revenue tool. The Nation's Health 2009; 39.6:2.

(76) Fletcher JM, Frisvold D, Tefft, N. Can soft drink taxes reduce population weight? Contemporary Economic Policy Jan 2010; 28.1:23-37.

(77) Menke, J. Michael. Bar patronage after a smoking ban. Journal of Drug Issues 2009; 39.2:401+.

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(79) Evans, WD, Hastings G. Public Health Branding (Chapter 1) In: Evans, WD, Hastings G. Public Health Branding: Applying Marketing for Social Change. New York, NY: Oxford University Press, Inc., 2008:366-387.

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(81) Huhman, Marian E., et al. The influence of the VERB campaign on children's physical activity in 2002 to 2006. The American Journal of Public Health 2010; 100.4:638+.

(82) VERB. Verb Yellow Ball Summary Video: http://www.youtube.com/watch?v=c2ZWZlswTBU

(83) Hicks, Jeffrey J. The strategy behind Florida's 'truth' campaign. Tobacco Control 2001; 10.1:3.

(84) Hersey, James C., et al. The theory of 'truth': How counterindustry media campaigns affect smoking behavior among teens. Health Psychology 2005; 24.1:22+.

(85) Farrelly, Matthew C., et al. Evidence of a dose-response relationship between 'truth' antismoking ads and youth smoking prevalence. The American Journal of Public Health 2005; 95.3:425+.

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(87) Niederdeppe J, Farrelly MC, Haviland ML. Confirming 'truth': more evidence of a successful tobacco countermarketing campaign in Florida. The American Journal of Public Health 2004; 94.2:255+.

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Hyperlinks:

Soda Free Summer Campaign Video:

http://www.sodafreesummer.org/news.html

Coca-Cola Commercials:

http://www.youtube.com/watch?v=3hj0JMCHZpI

http://www.youtube.com/watch?v=nlpZRK2Yfd0

Coca-Cola Live Positively Project:

http://www.livepositively.com/#/home

Pepsi Commercial:

http://www.youtube.com/watch?v=-Ob2HGQtQWo

Pepsi Refresh Project:

http://www.youtube.com/pepsi?utm_source=pepsi&utm_medium=banner&utm_content=panel&utm_campaign=refresh#p/u/17/2fS39FitsoQ

Sprite Commercial:

http://www.youtube.com/watch?v=KtJ6bXnoQxE

The Truth Campaign Commercials:

http://www.thetruth.com/videos/

NYC’s Pouring on the Pounds Campaign:

http://www.youtube.com/watch?v=-F4t8zL6F0c

ABA’s Response to NYC’s Pouring on the Pounds Campaign:

http://www.youtube.com/watch?v=K65TAi_siCo

The Fun Theory:

http://www.youtube.com/watch?v=2lXh2n0aPyw

People get fat in groups:

http://content.nejm.org/cgi/content/full/357/4/370/DC2

People quick smoking in groups:

http://content.nejm.org/cgi/content/full/358/21/2249/DC1

A World With(out) Polio: A Critique of the Polio Eradication Campaign in Nigeria – Alix M. Wilson

2010-05-10T10:20:00.000-04:00

For much of the western world the crippling effects of polio remain only as a mere memory from the lives of our ancestors. We categorize poliomyelitis as a disease of the past, yet polio remains a serious concern in other areas of the world. The virus remains active in four endemic countries including India, Afghanistan, Pakistan, and Nigeria (3). As of 2010 these countries accounted for 85% of all new polio cases worldwide (7). Although significant progress has been made, there is still much work to be done in areas where poliovirus still infects populations. As the World Health Assembly turned their attention and energy to eradicating polio, they were committed to global eradication by the year 2000 (6). Today, exactly one decade later polio has not disappeared from the global agenda. However, more than any other endemic area, Nigeria’s eradication movement has demonstrated the dangerous effects and setbacks that can come of a failed campaign. The lessons learned in Nigeria are of grave importance for future efforts towards polio eradication. Without careful examination and remediation of Nigeria’s campaign, a world without polio will remain out of reach.

Although the effects of poliomyelitis had been known throughout the 20th century, the virus gained worldwide attention in 1955 with the announcement of the first vaccine against polio by Dr. Jonas Salk (6). During the early 1900’s polio was being referred to as the most serious and most frightening public health problem of the postwar era. (14). By 1952, polio was responsible for killing more children than any other disease at the time worldwide (15). The symptoms of the disease are often not fatal, however polio is an acute viral disease that is highly contagious and frequently passed through the fecal-oral route (7). Most commonly, people acquire the infection from ingesting contaminated food or water. Infection with poliovirus may result in different outcomes. In most cases, polio infections are asymptomatic. However, in 1% of cases, the virus enters the central nervous system and selectively destroys motor neurons resulting in paralysis, permanent loss of limb function, and often death (7). Furthermore, once paralytic damage has occurred there is no treatment to reverse the polio paralysis (6). This muscle paralysis can sometimes result in permanent skeletal deformities, joint tightness, clubfoot, and severe movement disability (14).

As Salk’s announcement to the world brought hope and optimism into the picture of despair created by polio, nations were in dire need of vaccination campaigns. With polio spreading among populations in developing nations where sanitation was lacking, the devastation was even more evident. Finally, in 1988 as the World Health Organization (WHO) launched the global eradication program, Nigeria became one of many countries flooded with health care workers bringing Salk’s vaccine to stop the spread of a disease that had claimed thousand of innocent lives (9). The eradication endeavor around most of the world was achieved, but by the year 2000 Nigeria remained one of four countries still endemic with poliovirus. With success having been achieved in a multitude of different cultures and among all sects of governments around the world one has to ask – why did the campaign falter in Nigeria?

The failure of the public health intervention to eradicate polio in Nigeria can be attributed to three distinct factors. First and most importantly, health workers were not prepared on how to effectively address resistance to vaccination stemming from a lack of perceived susceptibility and unfounded beliefs surrounding the treatment. Second, the campaign efforts failed to fully take into account the viewpoints and core values of Nigerian citizens. Lastly, in conjunction with sociopolitical context, the approach to vaccinate children was too reliant on a top down, vertical strategy with little to no community involvement. Each of these setbacks presented unique challenges and extended the initial deadline past its goal set for the year 2000.

Propelled by the incredible success of smallpox eradication, the case for polio eradication seemed the next feasible step in a global effort to limit infectious disease. The donor world gave billions of dollars to scale up polio eradication efforts, just as it had done previously for smallpox (20). As health workers were sent to Nigeria to scale up vaccination efforts as a part of the global polio eradication campaign, they had one goal in mind: to eradicate polio through vaccination by the year 2000. However they were quickly met with increasing resistance that they were not prepared to resolve. As vaccination campaigns spread throughout Nigeria there was an increasing resistance encountered to accepting the vaccination (21). Without adequate knowledge or any perceived susceptibility, parents were unwilling to allow health care workers to administer the vaccine to their children. As the Health Belief Model indicates, people who have a low perceived susceptibility to a disease or fail to understand the consequences of being infected with a particular disease will be highly unlikely to adopt any behavior targeted to prevent infection (5). Unlike smallpox, the majority of those infected with poliovirus were unaware they had the infection. In fact, polio only results in paralysis in 1 in every 200 of the people who are infected (8). Consequently, if one person is discovered to have polio after displaying signs of paralysis, they have likely already passed along the infection to others who can remain asymptomatic (10). These victims are the most dangerous in the realm of public health. They pass along the disease unknowingly and simultaneously increase the notion of low perceived severity.

The detrimental impacts of perceived susceptibility and perceived severity as defined by the Health Belief Model were extremely underestimated in the vaccine campaigns designed to eradicate polio in Nigeria. In a study conducted in Gombe State, Nigeria, a total of 216 parents out of 422 of those interviewed believed that their children were not susceptible to poliovirus (15). In other words, less than half of these parents had any degree of perceived susceptibility. Moreover, 55.7% of these respondents did not know the route of transmission for poliomyelitis (15). Furthermore, misconceptions about the vaccine’s safety were rampant throughout much of Nigeria (15). In Between 2003 and 2004, the oral polio vaccine was withdrawn from use in the State of Kano due to strong beliefs that the polio vaccine was more harmful than beneficial (16). These barriers are defined in the Health Belief Model as perceived benefits of taking action (5). If parents do not believe there are any perceived benefits to taking action, or worse yet, those results will be harmful, they will be highly unlikely to take up the behavior (5). Without proper evaluation of the low levels of perceived susceptibility, severity, and or benefits to taking action that existed in Nigeria, health care workers were fighting a loosing battle from the very beginning of the campaign. Regardless of the access to and availability of the vaccine for children in this area, immunization days were unsuccessful in vaccinating a large percentage of children (11). Research that led to the development of the Health Belief Model in the 1950’s was based around findings similar to these. At the time free tuberculosis screenings were being offered, but despite easy access turnout was extremely low. Investigation by Hochbaum and his collegues led them to the conclusion that people are more likely to engage in a preventive behavior if they thought they were at risk and believed they would benefit from that behavior (5). These findings are congruent with those in Nigeria. Regardless of whether the other components of the Health Belief Model were addressed, without any perceived susceptibility or need to change their behaviors, parents in Nigeria were not motivated to adopt the behavior being promoted by the vaccine campaigns. Although the Health Belief Model may not be the entire story behind the breakdown of the eradication campaign, it certainly points out the failure in addressing the populations’ attitudes and beliefs regarding vaccination.

However, not all parents were unaware of the serious consequences polio infection or of the intended benefits vaccination could bring to their child and thousands of others. In fact, despite those who were not motivated to participate and remained passive to the campaign, there was a large outcry against the vaccine campaign as well (11). As the polio vaccine eradication went into full swing in Nigeria, people began to question Westerner’s intentions. With a country still suffering from a multitude of preventable diseases, such as diphtheria, pertussis, typhoid fever, and hepatitis B, polio is just one of the many challenges remaining in the battle of childhood survival (8). Consequently, when free polio vaccines began pouring into the country, Nigerian citizens began to question the Westerner’s approach of focusing all their efforts on one problem. They were well aware of the ongoing threat of other treatable diseases that were killing even more children than polio. From their perspective, fighting the battle against polio was important, but was only a small piece to improving childhood survival rates (11). As a result, frustrations arose and Nigerians began to actively resist vaccination efforts (17).

As this active resistance increased throughout the country it became clear that the approach being taken by Westerner’s, although good intentioned, was faltering. In 2004, Nigeria’s head of primary health care, Dr. Muhammad Ali Pate expressed concerns that the gains made by polio eradication will never hold without a broader health-care system (8). He shared common beliefs held by many Nigerians that vertical attacks on single diseases are ineffective and ultimately ignore the larger problem of stopping infectious diseases. In public health promotion in developing nations, donors tend to ignore the wants and needs of the population they will be serving (8). The polio eradication campaign in Nigeria did exactly this, falling into the dangerous pattern of formulating public health interventions based around intuition rather than research. Too often in public health, practitioners base their campaigns or interventions on what they feel people should want (18). As marketing theory has demonstrated, public health practitioners can be much more effective in achieving their goals by first identifying what it is the people actually desire before designing their intervention (18). The key to establishing an effective campaign is creating a program that addresses the core values of the target population (18). The polio eradication campaign in Nigeria did not address the main concern of the audience it was trying to serve. Nigerians wanted a broader approach. They wanted to eradicated polio, but not at the expense of allowing other diseases to continue to ravage their population. The eradication campaign failed to address the core values of the audience they were serving. Nigerians shared the same concern of controlling the spread of polio, but what they really wanted was control and autonomy over where efforts were being focused. They watched donor money being poured entirely into the polio fight while their sons, daughters, and grandchildren died of a multitude of other diseases that were entirely preventable. As time went on and polio continued to be a problem, Nigerians became frustrated with the narrow approach underway and became resistant to, what they felt, was a loosing battle.

In addition to the failure of the polio campaign to address the core values and desires of those it was meant to serve, the campaign also lacked community involvement. As a result, Nigerians felt no sense of ownership to the campaign efforts or impacts and thus were not invested in the programs. As the World Health Organization (WHO) developed the implementation strategy for polio eradication efforts in Nigeria they stressed the inclusion of political, community, and religious leaders, but evidence demonstrates that none of these players were involved effectively (11). When WHO was ready to role out the eradication campaign, they met with the Minister of Health, but did not include political or religious leaders in gaining support for immunization programs (11). Consequently, the polio eradication campaign in Nigeria transformed into a top-down approach with little to no involvement of community leaders and influential citizens.

This lack of community involvement likely weekend the campaign efforts. Specific theories address the importance of community involvement and are applicable to public health approaches. As Rothman and Tropman stated in their theory of community organization developed in 1987, community change is most effectively accomplished through the involvement of a broad cross-section of members in the community (1). They expand upon this definition by stating that community change is most likely to occur through consensus building, cooperation, and a coordinated effort by the community to address its own concerns (1). Without a sense of involvement in the campaign efforts, Nigerians became subjects of the intervention rather than agents of change. They were simply being vaccinated to fulfill the eradication goal, rather than participating in making this goal a reality. Moreover, there was no involvement on the part of their influential superiors, both religious and community members, to incite motivation. Lastly, the intervention lacked a key component of community organization theory, which was empowerment. According to the theory, empowerment is defined as a process by which communities gain mastery over their lives by being enabled to effectively transform or change their environments (12). Essentially, individuals gain self-efficacy on the community level and these gained confidences and skills are essential to bring about behavior change on a large scale. However, the lack of empowerment in conjunction with few influential and respected leaders at the helm, Nigerians felt no sense of ownership to the cause. With a top-down approach in full scale, the polio eradication in Nigeria continued to suffer further setbacks.

As the campaign was continuing to face further challenges, it became clear that the original goal set for the year 2000 would have to be pushed back. Many people questioned how smallpox eradication could have been so quick and so effective, while polio was proving to be more challenging as each day of the campaign went on. Although smallpox had encountered challenges along the way, the vertical campaign approach along with compulsory vaccination ultimately proved to be successful when the last case of smallpox was reported in 1979 (20). However, the eradication of polio has proved to be more complicated. With increasing opposition and lack of motivation on the part of Nigerians to comply with polio vaccinations, it will be necessary for the campaign to adopt a new strategy. In order to overcome the variety of obstacles encountered in the Nigerian polio eradication campaign, the intervention approach must be altered. Namely, several health behavior models in combination with marketing theory must be understood and applied to meet the resistance being faced to create a solution, rather than a mandate for compulsory vaccination or a continuation of strict vertical strategies.

First, the campaign must address the issues of perceived susceptibility and severity. By increasing the awareness and knowledge about poliomyelitis, parents will understand the importance of getting their children vaccinated. Furthermore, they will appreciate the potential consequences of this infectious disease for their own child as well as other children. In order to accomplish this goal, the campaign workers should collaborate with community leaders to develop information cards. Information cards have been utilized successfully in childhood nutrition programs through South America, where a lack of knowledge about breastfeeding and complimentary feeding have left thousands of children malnourished (22). These cards contain pictures on the front side depicting the message being relayed, while the backside of the cards contain simple words, guidelines, or messages about the public health intervention. These cards can be carried by health workers and posted throughout the community. In the case for polio, the cards could display a picture of a child suffering from polio on one side with information and pictures on the back indicating how the disease is transmitted, what health effects it causes, and how vaccination prevents transmission and infection. These cards will serve to accomplish barriers identified by the Health Belief Model. Many parents do not know how crippling the effects of polio can be. The picture and listed health effects will serve to increase the parent’s perceived severity. Also, the information on the mode of transmission will influence parents’ perceived susceptibility as they learn how infectious poliovirus is among the population. Lastly, the utilization of pictures in combination with words to display messages about the health effects and transmission of polio makes these cards a quick and easily viewable device that transmits a powerful message. Moreover, even though Nigeria has a 72% literacy rate (13) and most citizens will be able to read the accompanying messages, those who are illiterate will not miss out on the message. As the cards a distributed by health care workers and spread throughout communities, the messages can transform the views concerning perceived susceptibility and severity and break down these harmful barriers to vaccination.

With this first step underway, the Nigerian community can begin to see the benefits of taking action. However, in order to motivate people to act, it will be necessary to address the needs and desires of community members. Many people in Nigeria feel that polio eradication efforts ignore the larger issues concerning health care and childhood diseases rampant in the country (8). In order to better quantify and qualify these concerns, campaign workers should be deployed to hold focus groups in collaboration with influential community members throughout Nigerian states. At these focus groups, citizens can have their voices heard about what issues they feel need to be addressed immediately, where they believe resources should be allocated, and in addition to polio, which diseases they feel are of most importance for donors to address. Once these focus groups have been conducted, community leaders and campaign workers can combine their findings for submission to the donor agencies. Given that polio is the mission of this eradication campaign, citizen feedback will serve to increase multiple vaccination efforts or other sanitation projects that will directly address the desires of the people as an extended portion of the eradication campaign. By recognizing the core values of the Nigerian people, mainly their desire to surmount the multitude of diseases currently affecting them, the campaign can redefine and repackage its goals towards these desires. As marketing theory predicts, if public health practitioners offer programs that the target population values and demands, they can more effectively face the challenges of inciting behavior change (18). Instead of working against the Nigerians to incite change, they will be able to work with them. If donor agencies can adopt this strategy, their implementation of polio eradication will be more well rounded and successful.

To bring the campaign full circle, another component for a successful strategy is to incorporate community members as well as influential political, and religious leaders. The polio eradication campaign is too focused on a top-down strategy that disregarded the importance of involvement and community leadership throughout Nigeria. It has become evident throughout the global campaign that wherever community involvement has been low, vaccination coverage has also remained low, directly resulting in the failure to eradicate polio (9). There is no question as to whether community involvement will be beneficial; the only question remaining is how to implement these strategies.

To incite and propagate community involvement health care workers should seek out influential leaders in the political and religious sectors. Health care workers should seek out many of these leaders in every state to ensure all parts of Nigeria are initiating community leadership and involvement. Moreover, once these relationships are established, responsibilities must be defined and shared between the health care worker and the community advocate. They should not simply serve as a voice, but also an agent of change. Research has indicated that active community leadership and community involvement in planning and implementing your own health care is vital to successful health projects (1). If Nigerians can be incorporated into the eradication campaign strategy, they will have the leverage to encourage their counterparts to do the same. In addition, it is generally accepted that people are more willing to follow the advice of those they feel a connection or similarity with (2). Furthermore, religious leaders can be utilized to dispel misconceptions surrounding the dangers of the polio vaccine that surfaced among religious groups in 2003. Again, those who were influenced by these misconceptions are more likely to listen to their own leaders who share common morals and values, than they are to Westerner’s attempts at dispelling these delusions (2). The involvement at the community level is expected to have drastic implications in inciting behavior change by encouraging Nigerians to take an active part in creating a polio-free world. With the increased awareness being created through cards and media to address perceived susceptibility, they will have the tools and a reason to join the cause. Finally, with attention paid to their own needs in the realm of global health initiatives, they will have a more genuine commitment to the cause.

The set backs that have been encountered in the Nigeria are not by any means entirely avoidable. However, with the proper planning and evaluation through known public health strategies such as the Health Belief Model, Marketing Theory, and Community Organization Theory, these set backs can be overcome in a systematic way. Today the world is a decade past its original goal set for polio eradication. Polio has dodged a 20-year effort to eliminate it along with the disbursement of $8.2 billion dollars supplementing the ongoing human effort worldwide (8). Cleary, a new approach is in order. It is expected that the major leaders in polio eradication including WHO, UNICEF, and the CDC will announce a reorganized plan and strategy to address the failures of campaigns like those in Nigeria this week (8). The world can only hope that these strategies address the roots of the problem, taking into consideration the beliefs and viewpoints of those on the ground and the involvement of community and religious leaders in creating new, effective strategies. If these strategies are implemented effectively the world may finally be free of polio once and for all.

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(8) Guth R.A. “Gates Rethinks His War on Polio”. Wall Street Journal 23 April 2010.

(9) Lahariya C. Global Eradication of Polio: The Case for “Finishing the Job”. Bulletin of the World Health Organization 2007; 6:421-500.

(10) Miyamura T. Global polio eradication program: fundamental lessons for the control of infectious diseases. National Institute of Infectious Diseases 2009; 2:277-286.

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(12) Ndiaye S.M., Quick L., Sanda O., Niandou S. The value of community participation in disease surveillance: a case study from Niger. Health Promotion International 2003; 2:89-98.

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Drinking Life Away in New York City: A Critique of the Pouring on the Pounds Campaign

2010-05-10T09:56:00.003-04:00

In the past 20 years the incidence of obesity has been continuously rising in the U.S. and most recently around the world (1). The prevalence of obesity is a serious public health concern because it is a major risk factor for cardiovascular disease, certain types of cancer, type 2 diabetes, and lifetime morbidity (2). According to the Centers for Disease Control and Prevention (CDC), in 2007-2008 around 33% of Americans were obese and nearly 68% were overweight, ranking the U.S. as the number one country in the world with the highest rate of obesity (1). If current trends continue, it is estimated that 75% of Americans will be overweight or obese by 2015 (3). Research has stated that the rising trend of obesity in the U.S. has been consequent to the suboptimal eating habits and sedentary lifestyles of Americans (2). This unfavorable lifestyle leads to the lack of energy balance, which is the precise cause of overweight and obesity (4). Consequently, obesity and overweight occur over time when you take in more energy or calories than you use.

To combat this trend, many intervention programs have been designed to encourage consumption of healthier foods along with heightened physical activity. In 2009, the New York City Department of Health and Mental Hygiene implemented the Pouring on the Pounds public communications campaign in order to highlight the health impact of sweetened drinks (5). The campaign was designed in lieu of the proposed, but highly debated, 18% “obesity tax” on sugary sodas and juice drinks (6). Instead, the Health Department decided to target drinking habits to combat obesity by designing a public awareness campaign. Sugary drink consumption was chosen as the area of focus for this campaign because research has shown that more than 2 million New Yorkers drink at least one sugar-sweetened beverage a day, adding as many as 250 empty calories to their diets, which puts the human body at increased risk for a multitude of diseases (5). The campaign urges people to drink lower-calorie alternatives or limit their portions.

The message of the campaign is disseminated through public ads in city subways, educational brochures, the campaign website and most recently through a viral Internet video. The main component of the ad is a poster of disgusting, unadulterated, gelatinous fat substituting for soda as it pours into a cup. The video, titled Man Drinking Fat, shows a man pouring fat out of a soda can and drinking it as it drips out of his mouth. It ends by exhorting the audience to choose healthier alternatives like water, seltzer or low-fat milk. The ads work to demonstrate that we are literally pouring on the pounds and drinking ourselves fat by consuming soda and other sugary beverages. According to the Health Department, the video was produced to playfully send out the message that sugar-sweetened beverages are fueling the obesity epidemic and disabling millions of New Yorkers (5). The goal of the campaign is to shift drinking habits even slightly by gruesomely depicting the health impact of sweetened drinks.

Although the campaign was recently launched, it has had successful exposure due to the mediums of communication used. Not only has the Health Department chosen to place their ads in highly trafficked city subways, but also set up and placed ads in social media networks such as youtube.com/drinkingfat and facebook.com/DrinkingFat. Together, these networks have had over half a million hits in the past few months and word-of-mouth exposure is becoming viral. However, aspects of the campaign are flawed and susceptible to scrutiny.

The Campaign Does Not Account for Behavior Influenced by Context
The goal of the Pouring on the Pounds campaign is to change human behavior by embedding nauseating images of the health impact of sugary drinks. The first assumption of the campaign is that behavior is planned and rational. It is assumed that by viewing the gruesome ads, people will be disgusted and decide to eliminate or reduce sugary drinks from their diet. This concept is partly correct. In a hot state, during exposure, people might discard their beverages or avoid drinking for a few hours (7). However, the objective of the campaign disregards the concept that human behavior is dynamic and that it is influenced by context (7). It is visceral drives, or instinctive unreasoning, that control people’s behavior (7,8). Visceral factors refers to a wide range of drive states, including hunger, thirst, and sexual desire. According to a research studying the effects of emotions on economics, visceral factors can alter desires rapidly because they are affected by changing internal bodily states and external stimuli (7). The emergence of a new situation generally alters the present course of action and alters behavior (7). For example, a person purchasing a drink at Starbucks will transition to an alternative hot state to accommodate their environmental context. Exposure to images and menu options at the store or restaurant will now influence their purchasing behavior. Their decision is based on situational awareness defined by the context of their environment. This concept further suggests that the environmental context has a greater impact on unfavorable eating habits. This could be demonstrated by the considerable gap in the prevalence of obesity found among neighborhoods or cities with differing socioeconomic levels.

East Harlem, a low-income minority community, has the highest rates of obesity in New York City (9). According to a report by the Health Department published in 2006, one third of East Harlem adults are overweight or obese (9). The demographic profile of the neighborhood consists of predominantly African-American and Hispanic residents. Over 38% of the population in the community is below the national poverty level, which is nearly twice as high as in Manhattan and NYC overall (9). Similar to other low socioeconomic communities, the built environment of the neighborhood is comprised of fast food restaurants, bodegas and affordable energy-dense food grocers (10). The area also has 18 schools with fast-food restaurants within one-tenth of a mile (10). This is not surprising since researchers in New Orleans recently discovered that fast-food restaurants are geographically associated with low income, and in particular African-American, neighborhoods (11). These neighborhoods average twice as many fast-food restaurants per capita as white neighborhoods, making fast food a more likely choice for their residents (11).

High rates of obesity in low-income neighborhoods demonstrate that a stronger correlation exists between eating habits and the neighborhood residential context (12). A recent report stated that studies have not been able to link a uniform change in perceived control of health, but instead suggest that environmental and social factors can affect one’s sense of control over one’s own health (12). Therefore, public service announcements that seek to modify human behavior will only work if risk factors are modified or reduced within the context of the built environment.

The Perceived Cost Undermines the Perceived Benefit
Motivating people to modify behavior remains a critical and unmet challenge in the U.S.(13). This is especially true with modifying eating habits and physical activity. Research suggests that there are four motivational factors that are modifiable and may be influenced by education, experience and coaching: 1) Perceived chances of success, 2) Perceived benefit of the goal, 3) Perceived cost, and 4) Inclination to keep old habit (13). The most pertinent factors for this campaign are perceived costs and perceived benefits of giving up sugary beverages. This is so because people ultimately decide whether to adopt or reject behavior based on the balance of the appraisal of these factors.

Applicable to the Pouring on the Pounds campaign, the perceived benefit of modifying behavior is losing 10 pounds a year by not drinking one can of soda a day. Although it is not mentioned in the ads, it is implied that this change will ultimately reduce the risk of obesity as well. Conversely, the perceived cost of the campaign is eliminating or reducing sugary drinks from their diets. Instead of deciding to drink sugary drinks, the ad encourages consumer to drink water, seltzer or low-fat milk. The perceived cost in this equation, however, has a high significance in the U.S. due to the embedded traditions of sugary, not healthy drink, consumption (14). Events such as happy hours, bar-b-ques, sports outings, etc., have accustomed Americans to a drinking habit that often promotes sugary drinks. These habits have given significant social value to the context around sugary drink consumption. Although the campaign aims at changing life-long habits, if fails to connect healthy habits to the rhythm of life. Stating alternative drinks as bland and boring options does not strengthen the proposal to change drinking habits. Expecting people to change lifelong sugary beverage consumption needs to be supported by a strong promise to the consumer (15). Instead, stating that only a 10 pound weight gain could be prevented weakens the perceived benefit of giving up sugary beverages and associated social norms. To a portion of the population, especially those who are overweight, a 10 pound difference might not be worth the cost of giving up their drink of choice. To these people, the perceived chance of successfully modifying habits involves more than just giving up sugary drinks. This is especially true when linking behavioral risk factors, aside from social norms, to drinking habits. Instead, perceived capability and confidence has a stronger influence on initiation and self-efficacy (16). To this effect, the campaign fails to frame the issue in a way that gives strength to a change in social norms and ultimately a rippling effect on individual behavior. The intention to modify behavior is focal and crucial, yet the content of the campaign dominates the message instead of the outcome. Moreover, the campaign also uses the unadjusted approach that one sugary beverage is consumed every day. Therefore, those who consume less sugary beverages will consider the ad irrelevant instead of incorporating the overall message.

To overcome the common obstacles of modifying behavior, framing the issue in a way that gives people control and a broad sense of choices must be used (17). If the goal of the intervention is to get a high level of reactance, a program that implies a change in social norms will be more influential than targeting individual behavior (18).

The Campaign Reinforces Negative Social Stigma Towards Unhealthy Weight
Obesity has had in increasing trend for the past two decades. Yet as Americans are becoming more overweight, the standard for attractiveness remains thin and fit while overweight people are widely stereotyped as lazy, unattractive, and lacking self-discipline (19). The constant exposure to the idea of beauty as slim and proportioned has created a negative and stigmatized perception towards the overweight and obese. Not only has this created a pool of isolation, but numerous studies have examined a variety of social stressors, including discrimination, stigma and low socioeconomic status, all of which have been linked to poor health outcomes (20).

Weight-based stigmatization is defined as “negative weight-related attitudes and beliefs that are manifested through stereotypes, bias, rejection, and prejudice towards people because they are overweight or obese” (20). Acknowledging this perception, it is assumed that most obese people would like to become more fit. However, for so many leading a healthy lifestyle is a very difficult undertaking. They may give much energy towards trying to change their personal behaviors to acquire attractiveness, but their attempts continually fail.

The message of the Pouring on the Pounds Campaign reinforces this social stigma by producing a disgusting reaction of fat, which reflects a negative view of unhealthy weight. This is opposed to a good or proactive view of healthy weight. The message only serves to further internalize negative association of unhealthy eating habits. Studies that have examined the relationship between weight-based stigmatization and psychosocial functioning, state that in addition to affecting emotional well-being and social functioning in obese people, stigmatization can also negatively impact health behaviors (20). Stigmatization or the perceived threat, as the campaign message indirectly implies, has been associated with increased weight concerns, dieting, binge eating and unhealthy weight control and bulimic behaviors (21-23). This suggests that the objective of the message could be counterproductive and ineffective to prevalent cases of obesity.

Addressing and Implementing an Obesity Intervention in New York City: A Cultural Approach
The demographic profile of New York City is unique in its level of diversity. According to the U.S. Census Bureau, in 2006 over 3 million or 36.7% of the population in New York City was foreign-born (24). A recent report by the Department of City Planning states that the Newest New Yorkers, or immigrants, tend to live in enclaves of highly dense low-income neighborhoods (25). Intertwined with socio-economic disadvantage, obesity is also largely prevalent in these neighborhoods of the city (11). These neighborhoods are mostly comprised of minority or immigrant families who have assimilated to some degree to U.S. eating habits. This is evident by contrast of the Latino Paradox which refers to the epidemiological finding that Latinos in the U.S. tend to paradoxically have substantially better health than the average population in spite of what their aggregate socio-economic indicators would predict (26). Instead, the high prevalence of obesity, especially among Black and Hispanic children, supports the concept that the health status of immigrants deteriorates after acculturation to U.S. norms (26). Although obesity is widespread, a behavior modifying intervention should be targeted towards those at higher risk. Hence, due to the demographic profile of those at risk in NYC, changing the current campaign material to a culturally appropriate awareness campaign is proposed.

In order to combat obesity, we need to recover the traditional values of immigrant people. Similar to the Pouring on the Pounds campaign, the proposed campaign This is my Neighborhood, This is my Food aims to create awareness through community mediums of eating habits among immigrant families. The proposed campaign aims to emphasize traditional customs for maintenance of protective behaviors. The program is based on the concept that prevention begins in the home and embedded as tradition to future generations. Three major components will be the focal point of the campaign:
(1) Create awareness of the built environment by informing the community about their vulnerability as target consumers of fast and energy-dense processed foods,
(2) Empower perceived benefits by encouraging traditional eating habits, and
(3) Focusing on a proactive view of healthy weight.

These methods will serve as motivators to empower the community to integrate traditional customs in food consumption and preparation.

The components of the campaign will be disseminated through prominent mediums of communication in the community. Similar to the Pouring on the Pounds campaign, the material will be posted in city subways, near bus stops and near supermarkets in low-income communities around the city. Language specific material will be designed and posted in corresponding neighborhoods. However, knowing and adjusting to the most effective mediums of communication for immigrant families will be a major component of the campaign.

Create Awareness of Behavior Induced by the Built Environment
Although obesity can have many causes, most studies agree that environmental
influences are the primary factor in the current epidemic(11). The proposed campaign is based on the fact that modifying urban development is much more challenging that modifying human behavior (27). Therefore, the campaign serves to inform residents of their risk factors and susceptibility to fast food consumption. This is based on the idea that disseminating awareness of the environmental context transfers empowerment to the communities’ purchasing power of healthier foods. In low-income communities, the built environment is usually comprised of fast food restaurants, small shop bodegas and energy-dense foods (11). Unapparent to many local residents, this urban planning makes them highly susceptible to purchasing high-fat foods instead of healthy option. Therefore, informing the community about their controlled behavior by the built environment will hopefully produce a rebellion against this force. Consequently, a plan of action will be implied in the campaign ads. Encouragement to revert to traditional methods of food consumption and preparation will lead to an overt action of healthier eating habits. This plan of action however, must imply that unfavorable health outcomes were not as prevalent when practicing traditional eating habits. Therefore, proposing an awareness campaign that implies power, freedom and the perceived benefit of reverting back to traditional protective customs will be hopefully overcome the risk factors induced by the built environment.

Empowering Perceived Benefits of Traditional Values
In contrast to the traditional lifestyle in households, immigrants have been increasingly adapting to U.S. eating habits and forgoing the rice, vegetables, and fresh fruit drinks their grandparents ate and drank (26). Dietary standards in a traditional immigrant household consist mostly of home-made food with locally grown and purchased produce. Most recently, however, assimilation to U.S. eating habits has led people to flock to U.S.-style fast food and calorie-laden dishes once reserved for special occasions. Adaptation of food tailored for the mainstream American market usually is also very different than food typically served in other countries as well. This leads to the production of convenient, frozen, packaged foods and soft drinks that are widely available in local markets. To combat this trend, the campaign will serve to remind the target population that the unfavorable health outcome has occurred because of the adaptation to U.S. eating habits further induced by the built environment.

Contrary to the Pouring on the Pounds, the perceived costs of the proposed campaign are undermined because it does not discourage habits embedded in lifelong traditions. Instead, it incorporates them back into diets. By discreetly informing women that traditional values in eating habits have changed and their children’s health is at risk, women will realize that they have the power to change the outcome. This concept of the campaign strengthens perceived benefits by promoting healthy habits through tradition sustainability. It aims at changing culturally adaptive social norms, thereby allowing less perceived threat of freedom. Ultimately, the content in the material will be framed in a way that gives people control of their purchasing and eating behavior.

Focusing on a Proactive View of Healthy Weight
The focus of the This is My Neighborhood, This is My Food campaign is to modify the perception of social norms in eating habits. This is done by pointing out and targeting the risk factors, such as the context of the built environment and assimilation, of unhealthy eating habits. The campaign avoids placing blame on individuals for their eating habits, but instead implies power and freedom of taking charge of their communities and eating habits. To some extent the campaign shifts the problem from individual responsibility to corporate responsibility. In a way, the campaign skips eating habits and links obesity to the risk factors. Similar to the concept of the causation of lung cancer, the blame should be placed on tobacco manufacturers instead of smoking (28).

Transferring the association of obesity to external factors eliminates the threat of stigmatization on individuals. Instead the campaign will induce a comparison between traditional and current norms and the change in the prevalence of obesity. To this end, disseminating risk factors, encouraging modified behavior that provides empowerment and promoting proactive methods of healthy weight will prove more effective in reducing and preventing obesity in New York City communities.

References
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(3) Wang Y. Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiologic Reviews. 2007.
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(6) Chan S. New York Times. New Salvo in City’s War on Sugary Drinks. August 31, 2009. http://cityroom.blogs.nytimes.com/2009/08/31/new-salvo-in-citys-war-on-sugary-drinks/?hp. Accessed 4/19/10.
(7) Loewenstein G. Emotions in Economic Theory and Economic Behavior. Preferences, Behavior and Welfare. May 2000;90(2):426-432.
(8) Loewenstein G. Out of control: Visceral influences on behavior. Organizational Behavior and Human Decision Processes. 1996;65(3):272-296.
(9) New York City Department of Health and Mental Hygiene. Community Health Profile: East Harlem. 2006.
(10) Dwyer JC. Hunger and obesity in East Harlem: Environmental Influences on Urban Food Access. 2005.
(11) Block J, Scribner R, DeSalvo K. Fast food, race/ethnicity, and income: A geographic analysis. American Journal of Preventive Medicine. 2004;27(3): 211-217.
(12) Black JL, Macinko J. Changing distribution and determinants of obesity in the neighborhoods of New York City, 2003–2007. American Journal of Epidemiology. 2009;
(13) Phillip EM. Schneider JC, Mercer GR. Motivating elders to initiate and maintain exercise. Arch Phys Med Rehabil. 2004;85(3):S52-7.
(14) Hill J, Wyatt HR, Reed GW, Peters JC. Obesity and the environment: Where do we go from here. Science. 2007;299(5608):853-855.
(15) Vakratsas D, Ambler T. How advertising works: What do we really know? The Journal of Marketing. 1999;63(1):26-43.
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(17) Nelson TE, Oxley ZM, Clawson RA. Towards a psychological of framing effects. Political Behavior. 2004;19(3):221-246.
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(19) Crocker J, Park LE. The costly pursuit of self-esteem. Psychological Bulletin. 2004;( 130): 392-414.
(20) Gray WN, Kahhan NA, Janicke DM. Peer victimization and pediatric obesity: a review of the literature. Psychology in the Schools. 2009;46(8):720-727.
(21) Hayden-Wade HA, Stein RI, Ghaderi A, Saelens BE, Zabinski MF, Wilfley DE. Prevalence, characteristics, and correlates of teasing experiences among obese vs. non-obese peers. Obesity Research. 2005;13:1381–1392.
(22) Thompson JK, Shroff H, Herbozo S, Cafri G, Rodriguez J, Rodriguez M. (2007). Relations among multiple peer influences, body dissatisfaction, eating disturbance, and self-esteem: A comparison of average weight, at risk of obese,
and obese adolescent girls. Journal of Pediatric Psychology. 2007;32:24– 29.
(23) Neumark-Sztainer D, Falkner N, Story M, Perry C, Hannan PJ, Mulert S.Weight-teasing among adolescents:Correlations with weight status and disordered eating behaviors. International Journal of Obesity. 2002;26:123 – 131.
(24) U.S. Census Bureau. Access Community Survey. 2006-2008.
(25) New York City Department of City Planning. The Newest New Yorkers. 2000.
(26) Abraído-Lanza AF. Chao MT. Flórez KR. Do healthy behaviors decline with greater acculturation?: Implications for the Latino mortality paradox. Social Science and Medicine. September 2005;61(6):1243-1255.
(27) Hill JO, Wyatt R, and Peters JC. Modifying the Environment to Reverse Obesity. Essays on the Future of Environmental Health Research. 2006:108-115.
(28) Boos J. Cigarette Smoking-Who is to Blame? University of Maryland. 2009.

Social Behavioral Theory and Marketing Fundamentals Missing from GE’s healthymagination Campaign – Cristina Cruz

2010-05-10T09:50:00.003-04:00

This paper will analyze the fundamental components of a public health campaign that are missing within GE’s healthymagination initiative, specifically a tailored message, target audience and relatable messenger. Through an analysis of socio-behavioral theories utilized to formulate public health initiatives and referencing studies on successful public health interventions, this paper will pinpoint where GE went wrong. By highlighting the benefits of a social ecological approach and market research as exemplified in the SISTA and truth campaign, this paper will show how these three fundamentals can improve GE’s health initiative.
Healthymagination’s Mission and Implementation

General Electric’s (GE’s) recent, web-based public health initiative, healthymagination, was released in conjunction with the 2010 Winter Olympics in Vancouver (1). In the initiative’s mission statement, GE hopes to help people “become healthier through the sharing of imaginative ideas and proven solutions” (1). This involves making health information more comprehensive, accessible and approachable for site visitors. Healthymagination’s site is composed of multiple projects. The “Better Health Study,” conducted with the Cleveland Clinic and Oschner Health System, reveals the way people perceive their health and how they relate to their doctors. The “Better Healthy Conversations” project, formed in partnership with WebMD, allows patients to prepare a customized list of questions for their next doctor visit. The “Howcast” page is composed of “Healthy-How-to” informational youtube videos geared toward adolescents and college-aged students, presenting pseudo-health information guised in a comical skit. The site also acts as a forum for health discussion by posting the latest in health news through the “Sharing Healthy Ideas” portion of the site. Visualizing Data uses colorful graphs and interactive charts to take complicated health statistics and make them more comprehensive for the general public.
A Lack of Theoretical Application: No Target Audience, No Message

When browsing through the site, it becomes evident that GE has some of the best marketing and communications experts designing and facilitating the site. With a closer look, one can see that healthymagination is a public health campaign that focuses more on presentation than substance. Fundamental elements of social behavioral theory and marketing theory are absent in the initiative’s execution. The root flaw is the lack of a defined audience. With no audience, the minds behind healthymagination cannot tailor their message to their audience’s “core values” (5). To properly “frame” the message of the desired behavior and make the initiative successful, campaigners must appeal to core values in the community (5). These values can include rebellion against authority (an ideal often appealed to in campaigns designed for adolescents (3)) or “fairness” and “justice” (5).

Without a properly framed message, healthymagination isn’t showing why having access to better health is important. This framed message will not only “fulfill important core values,” but it will also show how “maintaining the [targeted] behavior is actually conflicting with these values” (11). Thus, GE isn’t showing that there’s any consequence to not being healthy. Without the proper “packaging and positioning [of] the product-” health- there is nothing special about the information GE provides. Despite its high-quality graphics and videos, the healthymagination site does not effectively promote healthy behavior purely by providing health information.

Health Education: GE’s Implementation of the Health Belief Model
In the healthymagination mission statement, GE claims that “almost everyone wants to make healthier choices, but they don’t know how.” (1)
GE’s belief that better knowledge can lead to better health behaviors is rooted in the Health Belief Model (HBM). This model assumes that a person will change their health behaviors once he/she realizes that he/she is susceptible to a severe disease after weighing the pros and cons of changing his/her health behavior with a new health behavior. Once this person decides the best course of action, he/she will then adopt a new, better health behavior into his/her lifestyle (2).

The first problem in utilizing this model as the foundation for the healthymagination initiative is assuming that people always decisions in a systematic manner. One critique of the HBM is that it “assumes an internal, rational process” that should lead to one conclusion and that all persons have “equal access to, and an equivalent level of, information from which to make the rational calculation” (2). Therefore, the minds behind this project presented health facts and statistics through several forms of multi-media to supplement these rational thought processes. However, much of this information is referenced from other websites in a feedback, user-based platform. Essentially, this is common health information people could easily access elsewhere. In a study on the effects of national anti-drug campaigns, researchers found that the “My Anti-Drug” campaign was ineffective because adolescents had been saturated with information from previous advertisements that repeatedly alerted them to the dangers of smoking (3). In this case, more information did not lead to target behavior deterrence because the campaign’s “implicit message” was not novel and “incremental exposure was small.” Healthymagination’s delivery has a similar issue in that it is not presenting a unique message about health and through so much information, there is little direct impact.

The issue with using the Health Belief Model as the basis for this campaign is that the HBM ignores the effects of social and environmental circumstances on a person’s decisions and assumes that everyone has equal access to the same, pertinent information (2). GE’s concerted efforts in providing instantaneous information through videos, blogs, iPhone applications and online news articles show that they assume all people viewing this information will understand these statistics through multi-media. However, this assumption neglects a very critical population. The nearly 56 million people on Medicaid not only have limited funds for health care, but they also “face serious communication barriers related to limited literacy, language, culture and disability” (10). GE’s utilization of the HBM and presentation does not really take into account the low-income groups who need more tailored information to learn how to make healthy decisions in their daily lives.

Healthymagination’s Non-existent Messenger
The premise of healthymagination’s “Sharing Healthy Ideas” project is “when one person inspires a healthy idea, good health catches on…Let’s make Healthy decisions together” (1).

The “Sharing Healthy Ideas” project is a forum of continuously updated health topics prevalent in the media, healthcare industry and among medical specialists. Popular topics include autism, Alzheimer’s, nutrition, physical fitness and cancer risks. Users are provided multiple social networking sites to peruse these topics. Some are news media outlets, such as the New York Times. Others are trendier, facilitated through users’ contributions, such as iVillage. And, naturally, the minds behind healthymagination maintain their own blog.

The issue with this presentation is that there is no face to the voice providing this information. Studies have shown that audiences respond better to information from someone who is similar to themselves (4). This hearkens to the idea of Albert Bandura’s Social Learning Theory, whereby “individuals observe other people’s actions and. . . adopt those patters of action as personal modes of response to problems, conditions, or events in their own lives” (12). Having a person similar to the audience deliver a message about health is more compelling because that messenger lives by similar norms that exist in the audience’s community. This is how socialization occurs, by learning from others in the community (12). These similarities could be exhibited through a person’s race or ethnicity, level of education, housing situation and family life or simply similar tastes.

In a study on compliance, researchers found that “similarity increases the positive force toward compliance by increasing liking” and it “also increases the communicator’s credibility” (4). Healthymagination’s advisory board is comprised of high-profile politicians and other leaders within the medical industry. They compose a demographic that is not highly affected by the nation’s most pressing health issues. These are the consistent faces of the initiative that don’t appear to have much in common with the female African-American population that suffers from high HIV infection rates (8) or the adolescents that rebel through smoking (13). Utilizing similar messengers is particularly important when targeting adolescent populations who often feel threatened by authoritative figures who are trying to tell them what to do (13). When the truth campaign used young actors to promote their message, they were able to deliver a message that effectively reduced youth smoking by appealing to adolescents’ core value of rebellion with a tone that was not authoritative and helped them see how the smoking industry was controlling their lives through an addiction to smoking (13).

The absence of a relatable messenger is best exemplified by the “Visualizing Data” portion of the site. This project is solely comprised of graphics that condense statistical data into a more colorful, engaging chart. Some issues discussed include: stress at the workplace, the cost of medical treatment for different age groups, and the main causes of death in the nation per ethnic group. The “Causes of Death info-graphic” is summed up as “a reminder to make choices that will keep you healthy” (1). The nation’s various ethnicities and races are boiled down to percentages in relation to age and health problems. According to the social learning theory, these charts are not utilizing a “model” with whom site visitors can identify and learn “functional” behaviors, that “will bring about some desired result if [they are] imitated” (12).

The secondary problem with not using a person to relay this information is that GE assumes anyone can interpret these graphs. A study that addressed patients with limited health literacy (LHL) noted that clinicians often “overwhelm the patient with too much information, using jargon and technical terminology, relying on words alone, and failing to assess patient understanding” (9.) These graphs are taking a similar approach to relaying health information: facts and figures, but little verification of comprehension. This is problematic when “approximately half of the U.S. adult population has LHL” (9). Presenting data in a more interactive manner would allow patients to better absorb the information, particularly those with LHL who “often rely solely on verbal communication” (9).

A Reconstruction of Healthymagination using the Social Ecological Model
A New Approach: Creating Multiple Messages for the Nation’s Audience
By lacking a message, GE is lacking an audience to be receptive to its better health goal. One of the first rules of marketing for public health involves identifying the audience’s core values (5). With these core values, one can then develop a campaign that delivers a compelling message about health that coincides with these values. Healthymagination appears to have identified better access to health information as its audience’s core values. Since the site itself has merit in its design and use of graphics, GE could build upon the healthymagination mission by showing site visitors what current health issues look like by focusing on different topics through a variety of communities in the nation. Using real stories to show a health intervention applied to a community would create a “model” for the visitor to relate to and, subsequently, create an audience by profiling different demographics with whom visitors can relate. Ultimately, by focusing on specific health issues in certain communities, GE’s healthymagination campaigners can create framed messages that will apply to those populations, giving their health information more pertinence in the site visitors’ daily lives.

Using a Broader Approach: The Social Ecological Model
The first thing that could be done to make Healthymagination a more effective public health intervention would be to break away from the simplistic approach of the HBM and create an intervention for the nation’s health from a holistic approach. Implementing change that will stay has to occur on all levels and not through a program that is “oriented solely toward modifying individuals’ behavior” (6.) This means turning away from the individualistic approach touted by the Health Belief Model to put more emphasis on the environmental, social and cultural circumstances that influence a person’s health behaviors. Thus, healthymagination should adopt the Social Ecological Model, which places an emphasis on “creating an environment conducive to change...to facilitate adoption of healthy behaviors.” (6) Providing information to separate individuals does not create the kind of change within the community to see that those health behaviors last.

As more public health campaigns have turned to adopting a marketing approach, multiple studies have shown that targeting a health issue from a group-level has been most effective (8). Healthymagination can use a group-level approach with the social ecological model by placing multiple interventions within different communities across the nation. With a specific demographic represented through each project, the proper marketing research can be performed to determine an effective “message design” implemented through “channels widely viewed by the target audience” (7). Each project can then address different issue areas in their assigned location (i.e., nutrition in Mississippi; physical activity in New York City’s urban population; preventive care in Montana’s rural communities). This approach would separate the nation into “subgroups based on important characteristics” addressing “demographic variable’s [and] risk characteristics” (7).

Utilizing a social behavioral theory that emphasizes the use of models and the role of social factors is essential to developing an effective public health campaign. A 1996 study by Wingood and DiClemente showed that in order to develop the most effective HIV prevention program for African American women the initiative would need: to be driven by a public health theory, target a specific group (in their study, women were the target audience), be “peer led,” focus on the external, everyday factors that influence women’s sexual health practices, and “require multiple sessions” to establish follow-up (8). Wingood and DiClemente’s HIV intervention, SISTA (Sisters Informing Sisters About Topics on AIDS), targeted toward African American women was based on these tenets and showed remarkable success for its “social skills intervention” when compared to the “control condition” it tested against (8).
While still using its current tools of video, engaging graphics and user feedback, GE will have a stronger impact on viewers once they see the anecdotes of people similar to them dealing with prevalent health issues in their community. Giving the messenger (each project’s target community) a sense of place (thereby identifying environmental factors and social norms) appeals to the social skills and needs as exemplified in the SISTA project (8). Multiple sessions of the intervention could be recorded in a video series for each community. By utilizing discussion boards and hosting podcasts with intervention participants, healthymagination could re-enforce its message through follow-up to see how the interventions’ behaviors were incorporated to the community’s daily lifestyle.

By using a person’s life story to convey what it’s like to live with AIDS or to battle with weight loss in the “Better Health Study” project, site visitors can develop an understanding of how to apply the advice from the “Sharing Healthy Ideas” articles. Each location investigated in the “Better Health Study” could have a central topic covered by a video. This video’s web page could have links to the related articles already posted on healthymagination’s site in the “Sharing Healthy Ideas” portion of the site.

Addressing Limited Health Literacy: A Multi-lingual Site
To make their health information most accessible, Healthymagination needs to address the English-language barriers among immigrant populations who frequently have limited health literacy (9). The site’s designers could best explore this avenue by implementing a drop-down menu that could change the language preference of the entire site that pops up when initially connecting to the home page. This could include placing subtitles on all of the videos in the desired language (when specified) and links to verbal translations of podcast scripts in multiple languages. If implemented properly, this could bridge the gap between Western physicians and their non-native patients.

When teaching a new health behavior, especially to patients with LHL, it is best to follow through with a “confirmation of understanding” (9). This could best be done in a web-based format through summary points presented at the end of each video to re-affirm the main message (healthy eating habits, reasons for getting a breast cancer screening, etc.). These final points would automatically be formatted in the selected language the site visitor chose when he or she first entered the site.

Branding the Healthymagination Initiative
After covering the bases of creating an audience through regional health stories and addressing the community’s core values by teaching these communities how to apply healthy behaviors to their everyday life, healthymagination can brand itself. A brand is used to convey the “personality of a program or policy” (5). For Healthymagination, this could involve creating a logo that symbolizes the act of sharing to coincide with its mission of people coming together to make “better health for more people” (1). This symbol could be placed on t-shirts, bumper stickers, pins or any other paraphernalia to give a look to healthymagination’s purpose. This brand would be placed throughout the Healthymagination site, giving new visitors something to identify with when returning to the site.

Both the truth and SISTA campaigns capitalized on the branding technique. When deciding to make a brand for the truth campaign, Jeffrey Hicks and his colleagues recognized that brands “serve as a shorthand way for youth to identify themselves to the world” (14). By visiting the truth website, one can see how the truth campaign (in its apparel, games and videos) identifies itself with rebelling against the tobacco companies, emphasizing the autonomy adolescents crave (14, 3). The SISTA campaign utilized the acronym SISTA in its “project motto” in a “culturally appropriate” way that appealed to young African America women’s values (8). “SISTA love is strong. SISTA love is safe. SISTA love is surviving” speaks to the intervention’s goal of promoting safer sex, re-affirms the women’s ability to be a decision-maker in their relationships by emphasizing strength, and appeals to the African American history of overcoming oppression by ending the motto with the note of survival (8). By making these interventions a part of the target audience’s daily lives, through clothing or by appealing to the audience’s culture, these brands make the intervention more accessible and relatable (5).

A Tailored Approach to a Broad Mission
By properly applying social behavioral theory to its healthymagination initiative, GE can create more compelling messages to which multiple site visitors can relate through a variety of messengers with similar social and environmental circumstances. Research has shown that health interventions have been most successful with a message tailored to the defined audience’s needs and core values that is delivered by a messenger similar to the audience. Since GE’s healthymagination’s site utilizes engaging graphics and popular social media tools, applying these standards to their current broad-based mission would allow greater impact on multiple, diverse communities.

REFERENCES
1. Healthymagination. General Electric. http://www.healthymagination.com.
2. Individual health behavior theories (Chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2008. Pp.35-49.
3. Hornik R, Jacobsohn L, Orwin R, Piesse A, Kalton G. Effects of the National Youth Anti-Drug Media Campaign on Youths. American Journal of Public Health 2008: 98, pp. 2229-2236.
4. Silvia P.J. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
5. Siegel M, Doner L. Marketing Public Health- an Opportunity for the Public Health Practitioner (Chapter 6). Marketing Public Health: Strategies to Promote Social Change (2nd edition). Sudbury, MA: Jones & Bartlett Publishers, Inc., 2007, pp. 127-152.
6. Glanz K and Bishop D. The Role of Behavioral Science Theory in Development and Implementation of Public Health Interventions. Annual Review of Public Health, 2010, 31:399-418.
7. Noar, Seth. A 10-Year Retrospective of Research in Health Mass Media Campaigns: Where Do We Go From Here? Journal of Health Communication, 2006: 11, pp. 21-42
8. Wingood GM, DiClemente RJ. The theory of gender and power: A social structural theory for guiding public health interventions (Chapter 3). In DiClemente RJ, Crosby RA, Kegler MC, eds. Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. San Francisco, CA: John Wiley & Sons, Inc. 2002, pp. 313-346.
9. Sudore, R L, Schilligner, D. Interventions to Improve Care for Patients with Limited Health Literacy. Journal of Clinical Outcomes Management. 2009 January 1: 16 (1), pp. 20-29.
10. Neuhaser, L, Rothschild B, Graham C, Ivey S, Konishi, S. Participatory Design of Mass Health Communication in Three Languages for Seniors and People with Disabilities on Medicaid. American Journal of Public Health December, 2009: 99 (12).
11. Siegel M. Marketing Social Change: An Opportunity for the Public Health Practitioner (Chapter 3). Marketing Public Health: Strategies to Promote Social Change (2nd edition). Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 45-71.
12. DeFleur ML, Ball-Rokeach SJ. Socialization and Theories of Indirect Influence (Chapter 8) Theories of Mass Communication (5th edition). White Plains, NY: Longman, Inc., 1989. pp. 202-227.
13. Hicks JJ. The stategy behind Florida’s “truth” campaign. Tobacco Control 2001: 10: 3-5.
14. truth. The American Legacy Foundation. http://www.thetruth.com.

MyPyramid – MyFriend or MyFoe? – Alison Krajewski

2010-05-10T09:48:00.001-04:00

Introduction
Since its inception, the Food Guide Pyramid has used the same nutritional standards for everyone, regardless of age, height, or weight. To address the inadequacies in these nutritional standards, the United States Department of Agriculture (USDA) restructured its design and introduced MyPyramid. The new MyPyramid campaign has began to implement a personalized plan of action; however, there are still many revisions that still must be completed. Some of the modifications to consider are the following: enhance education on how to use MyPyramid, understanding the dietary guidelines, and the importance of healthy eating; incorporate societal input to gain an understanding of how to effectively market their campaign, as well as the public’s knowledge of MyPyramid; and increase accessibility not only to information about MyPyramid, but also to healthy foods, such as fruits and vegetables.

The Food Guide Pyramid was created in 1992 by the USDA. The pyramid provided suggested daily nutritional guidelines for carbohydrates, vegetables, fruits, proteins, and oils through a illustrative diagram of a pyramid (Figure 1). This graphical representation was used a general guide for individuals to choose healthy foods that were right for them. The Food Guide Pyramid was created with three key concepts at its core: variety, proportionality, and moderation (1). Variety was considered to be a balanced mixture of all food groups; proportionality was based on the recommended serving sizes; and moderation referred to the means to control one’s eating from being excessive (1). The Food Guide Pyramid became the basis for nutrition and healthy eating in America, taught in schools, appeared in countless media articles and plastered on cereal boxes and food labels. Every five years, the USDA reassesses the current guidelines for necessary revisions and updating when emerging nutritional issues arise. Such was the case in 2005 when the Food Guide Pyramid was up for review. Consideration of its effectiveness, in addition to how to incorporate new trends in eating, such as vegetarianism and veganism were focal points. Hence, the USDA retired the old Food Guide Pyramid and replaced it with MyPyramid, a new symbol and “interactive food guidance system” (2). Additionally, MyPyramid was supposed to help stop the increase of obesity rates; however, obesity rates in adults and children continue to rise and obesity-related diseases, such as cardiovascular diseases, are also increasing. Thus, MyPyramid has come under scrutiny over its effectiveness. Currently, the United States is once again working to re-evaluate its dietary recommendations for the general population.

MyPyramid was designed to be a simplistic representation for dietary standards. The new design is color coded and depicts a stick figure ascending stairs on the pyramid to represent the importance of physical activity, which the previous pyramid neglected to represent (Figure 2). The core concepts that were previously used for the Food Guide Pyramid were expanded upon to incorporate the necessary changes in nutrition and maintenance of healthy lifestyles. Now, the anatomy of the pyramid consists of proportionality, variety, moderation, activity, personalization, and gradual improvement. Proportionality is represented by the widths of the food bands; variety is symbolized by the six colored bands; moderation is represented by the narrowing of each food group from the bottom to top; activity is represented by the steps and the person climbing them as a reminder of the importance of daily physical activity; personalization is represented by the person on the steps and the word “My” in MyPyramid; and gradual improvement is encouraged by the slogan “Steps to a healthier you” (3). Although this new pyramid is an improvement from the previous design, it still lacks information for people to make informed choices about their diet. With rates of obesity and obesity-related diseases, such as type 2 diabetes and cardiovascular disease, soaring, the pyramid has once again come under intense scrutiny (4). Currently, the USDA is assessing the dietary guidelines, and it is predicted that revisions will be made to MyPyramid in 2010 (3). The question remains whether there needs to be change in how nutritional information is conveyed to the public or if the problem lies elsewhere.

Critique 1: Usability
The new design of MyPyramid was meant to be substantially simpler than the original version. However, there are issues with the new design. The design is ultimately too simple, MyPyramid is impossible to interpret without the accompanying online tool (5). The colored bands are ambiguous as they do not indicate what food groups are associated with which color (5). For example, orange represents grains, green for vegetables, red for fruits, a teeny band of yellow for oils, blue for milk, and purple for meat and beans (3). There is no logic behind the color coding, making it difficult to interpret. Without visiting the website, one would never know what the colors represent. Furthermore, making MyPyramid solely internet based limits the availability to only those with internet access. Millions of Americans who do not have access to the internet, most often those of low socioeconomic status, are considered to have the least knowledge about nutritional information since most people now get this type of material from the web (5). Consequently, the people in most need of MyPyramid are the ones who cannot obtain the information readily. Although the government has made a valiant effort to keep up with the use of modern technology as a way to convey public health messages, the restricted access to MyPyramid as an interactive online tool puts limitations on its usability.

MyPyramid does not follow the traditional representation of a pyramid. The original Food Guide Pyramid outlined portions American should eat, from the most at the base (grains) to the least at the apex (fats, oils, sugars) (6). With MyPyramid, however, the shape of the pyramid has nothing to do with serving size like the original. Furthermore, without text on the design, it is necessary to visit the website in order to learn what the nutritional recommendations are for each food group. These nutritional recommendations were designed to be personalized, based on age, sex and activity level; however, the online tool makes it optional for the user to include body size (height and weight) – the most important determinant of caloric needs (5). The generated recommended intake can thus be inappropriate for one’s body size or weight, easily recommending hundreds of calories per day too high or too low (5). Additionally, MyPyramid fails to incorporate any other specific dietary needs. Although USDA boasts that the new pyramid is personalizable, the online questionnaire does not take into account adjustments for special dietary needs such as individuals with diabetes, heart disease, high blood pressure, high cholesterol or food allergies.

MyPyramid was designed to be simple. Yet the simplicity of this new design limits its usability. With information about the dietary recommendations only available through interactive online tools, it restricts the accessibility. Furthermore, the dietary recommendations provided by MyPyramid do not take into account the needs of individuals with dietary restrictions due to health-related illnesses, such as diabetes or heart disease.

Critique 2: Dietary Recommendations and Serving Sizes
The Food Guide Pyramid and MyPyramid were created as a way to inform the public about nutritional information through easy-to-read diagrams (3). Dietary guidelines provided individuals with recommended dietary allowance and serving sizes for each food group. USDA defines recommended dietary allowance as the dietary intake level that is sufficient to meet the nutrient requirement of nearly all healthy individuals in a particular life stage and gender group (7). This term is most commonly known as recommended serving, not to be confused with serving size. Serving size, as defined by USDA, is a standardized amount of a food, such as a cup or an ounce, used in providing dietary guidance or in making comparisons among similar foods (7). Adding to the complexity, serving size is sometimes confused with portion size, which is defined as the amount of a food consumed in one eating occasion (7). The terms as defined above are often undifferentiated amongst the general public, and this confusion can result in over or under eating of the dietary guidelines.

The previous Food Guide Pyramid recommended a range of serving sizes without elaborating on why there was a difference in serving sizes. For instance, the pyramid recommended 6-12 servings of grains every day, but did not specify who was supposed to eat 6 servings and who was supposed to eat 12 servings (6). Instead, MyPyramid uses recommended servings in conjunction with the theory of planned behavior, which states that individuals take personal responsibility and utilize moderation to make healthier choices (6). This technique of personal responsibility and moderation to make the “right” food choices is a major downfall for many people because of lack of self-control, lack of knowledge, or even lack of awareness of the issue. Furthermore, the MyPyramid campaign fails to incorporate the importance of self-efficacy, meaning that an individual believes s/he will be able to perform the behavior of healthy eating. It also neglects to incorporate personal empowerment which allows an individual to overcome the obstacles and perform the behavior of healthy eating. Individuals will not be able to successfully navigate their way through MyPyramid if they do not understand the information provided to them or believe that s/he will be able to follow the guidelines.

After using the online form to enter in one’s age and physical activity level – weight and height are optional – the personalized MyPyramid Plan appears. It is when one enters in this information that s/he is able to see the appropriate serving sizes. Nevertheless, as a population, we still have issues understanding what constitutes as a serving and portion control. Portion size per serving has increased in the last thirty years, which continues to affect the rising obesity rates (8). Larger portions encourage people to eat more (8). With the on-the-go lifestyles that many people live, fast food options are ideal. Fast food corporations pride themselves on their larger sizes, like Supersizing at McDonald’s. The Big Mac Meal at McDonald’s has 1350 calories, nearly 68 percent of the total calories an average adult should consume in an entire day (9). Many would take this meal as one portion, which it is clearly is not. Furthermore, chain restaurants promote large portions on their menus and in marketing campaigns, such as the grand slam breakfast at Denny’s. At minimum, this breakfast meal contains 820 calories and 1270 mg of sodium (10). It is difficult for people to control their portions and follow the dietary recommendations of MyPyramid when they are constantly bombarded with media campaigns suggesting that they abandon those principles.

The dietary recommendations for MyPyramid are supposed to be the most up-to-date and based on scientific evidence (3). There has been speculation that the USDA is influenced by the agricultural and food industry groups such as the National Dairy Council, the National Cattlemen’s Beef Association, and the U.S. Potato Board, to incorporate their products in MyPyramid rather than solely depending upon scientific research to make dietary recommendations (11). The tiniest change to the guidelines or pyramid can swing food companies’ sales by millions of dollars, either way (11). Thus, it is suggested that the guidelines are promoting the sales of certain types of foods rather than promoting healthy eating. For example, the guidelines suggest that it is fine to consume half of our grains as refined starch. However, since refined grains behave like sugar, they act simply as empty calories when incorporated into the diet (2). The U.S. Potato board and baked goods lobby groups are depending on this recommendation to keep sales steady by continuing to have recommendations for refined starches (11). The guidelines continue to lump together red meat, poultry, fish, and beans and ask consumers to judge these proteins by the total fat content to make choices that are lean, low-fat, or fat free (3). This guideline ignores scientific evidence that all these proteins have different types of fat, like the heart healthy omega-3 fats found in fish. Furthermore, this recommendation completely ignores the scientific evidence and research studies which have found that replacing red meats with a combination of fish, poultry and beans provides numerous health benefits, such as a reduction of the risk for coronary heart disease (12). This recommendation could be the result of pressure from the National Cattlemen’s Beef Association on the USDA to keep consumption of red meats in the guidelines to keep their products in demand (11). Although recommending fish as a replacement for red meat has been shown to have a multitude of health benefits, this recommendation does not address the issues of methylmercury found in fish. Methylmercury can have profound adverse side effects of the nervous system, especially in pregnant women (13). The recommendation should include which types of fish contain the least amounts of methylmercury or a caution that fish should be consumed sparingly. Lastly, MyPyramid recommends consuming either three glasses of low-fat milk or other dairy products per day even though such a recommendation adds more than 300 calories to one’s daily intake (3, 2). It is unclear whether the recommendation is based on scientific research that says consuming dairy products has health benefits or if it is based on pressure from the National Dairy Council to keep dairy sales steady. These recommendations need to be reassessed to incorporate the most accurate scientific research studies, instead of integrating the interests from agriculture and food industry lobbyists.

In a recent interview with restaurant chefs, it was found that 60 percent of chefs serve steaks that are 12 ounces or larger, which is four times larger than the recommended three ounce serving according to the MyPyramid dietary guidelines (3, 14). In addition, the survey found that most restaurant chefs dish up one to two cups of pasta with a meal; a serving is half cup (14). When eating at restaurants or fast food establishments, people automatically assume that what they are ordering and eating is one serving. It is difficult to see how people are supposed to make healthy food choices when they are confused about what is a recommended serving versus serving size or how a portion size relates to MyPyramid dietary recommendations. If the USDA hopes to be successful in promoting their campaign of MyPyramid, then they need to simplify what a serving size is versus a portion size and how the recommended dietary allowance fits into everyday life.

Critique 3: The Use of Theory of Planned Behavior
MyPyramid is based on the theory of planned behavior (TPB). TPB focuses on rational, cognitive decision-making processes, meaning that people think about what they are going to do before they actually do it (15). TPB derives from the theory of reasoned action (TRA). TRA is defined as behavioral intention that is influenced by an individual’s attitude toward performing a behavior and by beliefs about whether individuals who are important to the person approve or disapprove of the behavior, the subjective norms (16). TPB includes one additional construct - self-efficacy. Self-efficacy, or perceived behavioral control as applied in context with this intervention, means that a person believes that they can control a particular behavior, in this case, food consumption (16). This decision-making process does not apply here because eating, the defined behavior, is not always planned and rational; sometimes it is based on spontaneous, irrational decisions. A person may believe that they can control their food intake but in reality may not be able to do so.

MyPyramid was designed to be an interactive online tool. As stated above, the details of how to use the pyramid, dietary recommendations, and physical activity advice is only available on the website. Only the most motivated people will take the time to fully explore the website (5). The majority of people will not utilize the tools on the website to find out their specific caloric needs and plan their meals accordingly. One study found that 47 percent of the household food budget is consumed out of the home, which translates to the increased consumption of fast food or take out (5). With the on-the-go lifestyle that many people have, their dietary recommendations as provided by MyPyramid are the least of their worries. Thus, people are more likely to neglect their dietary recommendations and disregard planning their meals based on MyPyramid guidelines for whatever is most convenient.

Although TPB considers the influence of peers, it underestimates how influential peers can be on an individual, ultimately deterring that person away from the desired healthy behavior. Individuals who work in corporate settings are often persuaded into making unhealthy decisions during the work week. Many corporations order fast food on a daily basis and provide light snacks like starchy cookies and sugar-laden sodas. Even if an individual packs a brown bag lunch, these day-to-day temptations lure otherwise healthy people into the fattening and detrimental world of fast food. It is easy for many employees to disregard their healthier meals from home for those with little nutritional value and thus abandon the principles of MyPyramid in order to join their co-workers in an unhealthy lunch time meal. Though they may have been good intention to eat food that is healthy, the need to go along with the majority is stronger than individual choice in this case. Therefore, the TPB did not work for this group of individuals. They planned a behavior and performed a behavior that was based on the subjective norms of their peers. The intended behavior was to eat a nutrient-rich lunch, which was replaced by eating the catered fast food. The planned behavior was neglected, which demonstrates the failure of TPB.

The guidelines of MyPyramid assume that people are eating for the sole purpose of nourishment and does not take into consideration the phenomenon of emotional eating. People use eating as a sort of emotional crutch and will eat out of depression, happiness, or even boredom. When an increase in food intake is in response to negative emotions it is called emotional eating (17). Emotional eating can be considered to be an ‘inapt’ response (17). Emotional eating is a consequence of the inability to distinguish hunger from other aversive internal states, or of using food to reduce emotional distress, probably because of early learning experiences (18). Research studies have found that emotional eating increases the consumption of sweet and high-fat foods in particular (19). Emotional eaters overeat in response to negative affects because they have learned that it alleviates them from aversive mood states (17). When people eat for emotional reasons, it is spontaneous and irrational; they are not going to stop their behavior because it does not fit into their dietary recommendations, thus, abandoning the principle theory for which the intervention was created.

As humans, our actions are not always rational or planned. Using a social behavioral theory like the theory of planned behavior for the MyPyramid campaign, will often result in failure. Norms created by larger society will often influence the behavior of an individual. The previous examples demonstrated that people do not always use logic to make nutritional choices. Sometimes when individuals do plan to make rational decisions, those plans are thwarted by peer pressure. Human behavior is a dynamic process that does not always rely on sensible decision making and thus, using a model that is too rigid to predict health outcomes will be unsuccessful.

Proposed Intervention
While MyPyramid has its faults, there are a few things that are beneficial about it. First, regardless of whether people understand MyPyramid or even the older Food Guide Pyramid, it is widely recognizable. The pyramid shape divided into the six food categories is an iconic symbol in the world of nutrition. Secondly, the new design incorporates the importance of physical activity, which was neglectfully left unincorporated in the last design. Lastly, MyPyramid employs the use of current technologies to try and circulate information about dietary recommendations. Any successful intervention will continue to use these principles and then expand on them to further utilize the MyPyramid campaign to its fullest potential. It is also commendable that USDA did not use statistics and information that is unfamiliar or incomprehensible to the general public in this campaign.

Defense of Intervention: Education
Possibly the simplest but most necessary addition to the MyPyramid campaign is education. Not only because of the simplicity of the design, but in general, people still do not fully understand that the symbol represents dietary recommendations. It is important for people to understand that the balance of nutrition, exercise, and eating healthy does not need to be a difficult process. Education that clarifies definitions like the recommended dietary allowance and serving size will simplify the MyPyramid campaign. The addition of clear and straightforward explanations to the MyPyramid campaign will encourage members of the general public to look into MyPyramid.

Using the online tools for MyPyramid is beneficial, but first, people have to know the website exists, have access to the internet, and then understand how to navigate the website. To fix this issue, there first needs to be awareness of the MyPyramid campaign and that there is an accompanying website. Although one may use the website, it does not mean that the individual will understand the information provided. Information on the website, including the recommended dietary allowance and serving size, needs to be stated in way that is understandable to the general public. Information about how healthy eating and physical activity relates to obesity and obesity-related diseases should be made available for all. Furthermore, in addition to the online tools, local community centers need to have copies of MyPyramid and supporting documents so that those without internet access can have the information. In addition, the local community centers should hold classes on nutrition, guiding people on how to properly utilize the resources of MyPyramid.

Education about the MyPyramid campaign in schools would also be beneficial. Children are greatly influenced by what they see their parents or other adults around them doing. If a parent is constantly eating fast food, foods high in fats and sugars, children will also develop those habits. Teaching children the importance of healthy eating at an early age will help them develop and stick with healthy eating habits throughout their lives. In addition to educating children, parents need to be educated as well. They are the ones buying the groceries, packing lunches, and preparing meals. They are the food role models for their children, and they need to understand how important it is for children to develop a healthy relationship with food.

Defense of Intervention: Societal Input
To find the best way to reach the target audience for MyPyramid, there needs to be societal input. While education is an important first step in any successful campaign, societal norms and roles need to be accounted for as well. One of the best ways to do this is to go directly to the source. For example, in 1998, Florida launched its own version of the “truth” campaign. This campaign was a youth anti-tobacco education and marketing program that was extremely successful. From the beginning, this campaign involved youth. The marketing team convened a 500 person youth summit to gain insight into where youth felt the effort should head (19). They provided the team with what they did and did not like and provided positive feedback to help guide the creative process (19). One of the successful strategy techniques that the team used was interviewing youth about the reasons behind their decision to smoke. They then used all this information to brand their “product” (the “truth” campaign). The key strategy to this campaign was the direct involvement of the target audience. By utilizing the resources available to them, the team was able to build a campaign that proved to be a success – teen smoking decreased by 7.4 percent in middle school and 4.8 percent in high school (19).

The strategy that was employed by the Florida “truth” campaign could also be fruitful in branding MyPyramid. The USDA should employ a marketing team to research the reach and awareness of the MyPyramid campaign. This outreach program could be done through surveys. In addition, the team should interview individuals from all different age groups to fully understand what compels them to eat, their awareness of MyPyramid, their knowledge portion sizes and serving sizes, and the feelings towards following the USDA’s dietary recommendations. Conducting interviews, surveying the target audience, and having the direct involvement of that audience will strengthen the power of the campaign.

Defense of Intervention: Accessibility
The main goal of the dietary recommendations set forth by USDA is to promote eating a healthy balanced diet among the six food groups; however, solely promoting this is not enough, there needs to be accessibility too. National data indicates that less than three percent of men and less than six percent of women aged 19 to 50 years consume the daily servings of fruits and vegetables recommended by MyPyramid (20). National surveillance data and numerous other research studies consistently indicate that low-income populations are less likely to meet recommended fruit and vegetable intake levels, compared to high-income populations (20). Whole grains, fruits, and vegetables tend to be higher in price than other groceries; consequently, millions of Americans either cannot afford these items or would prefer to purchase more affordable items. One research study found that low-income neighborhoods had more convenience stores and fast food establishments and fewer supermarkets, fruit and vegetable markets, specialty stores and natural food stores (21). If the MyPyramid campaign is to be used by all people, regardless of socioeconomic status, then all people need to have equal access to healthy foods like fruits and vegetables.

A solution to the disparities in the accessibility to food is community gardening programs. Community gardens are defined by the American Community Gardening Association as any piece of land gardened by a group of people (20). Researchers have found that community gardening readily provides opportunities for community involvement and experiential education about growing, as well as opportunities to strengthen community ties and build social capital (20). Researchers have concluded that community gardening programs increase the intake of fruits and vegetables in low-income communities (19). By involving the community directly in gardening programs, it gives people the opportunity to access fruits and vegetables. Research has illustrated that when people are directly involved in the process of planting and harvesting, they tend to be more willing to increase their intake of fruits and vegetables, which ultimately reinforces the goal and outcome expectancies of the MyPyramid campaign (19, 20).

Conclusion
The Food Guide Pyramid and now MyPyramid were created to promote nutritious, well balanced eating among Americans; however, these tools have been unsuccessful for the most part. In order to increase the successfulness of MyPyramid, there needs to be substantial modifications to the current campaign. Public health officials, nutritionists, and physicians need to better educate people of the importance of maintaining a healthy lifestyle through eating sensibly as well as engaging in daily physical activity. In addition to education, there needs to be access to healthy foods such as fruits and vegetables. Creating community gardening programs gets people directly involved in the process, while providing them with produce they may not have access to otherwise. Lastly, societal input is key in developing a successful campaign. Knowing how to reach the target audience and what is important to them will create a more successful campaign for nutrition and healthy eating.

References:

1. Knaust G, Foster I M. Estimation of Food Guide Pyramid Serving Sizes by College Students. Family and Consumer Sciences Research Journal. 2000; 29(2): 101-110.
2. Harvard School of Public Health. (2010). Nutrition Source. Retrieved April 2, 2010, from Harvard School of Public Health: http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/pyramid-full-story/index.html#dga2005
3. United States Department of Agriculture (USDA). (2010, March 24). MyPyramid.gov. Retrieved April 8, 2010, from USDA: http://www.mypyramid.gov/index.html
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Sincere Efforts Do Not Always Yield Desired Results: A Critique Based On The Montana Meth Project- Kimberly Ann Lobo

2010-05-10T09:38:00.002-04:00

Introduction:
Fractured families, overburdened law enforcement, crime, health consequences, rape, suicide and death are just some of the destructive results of drug addiction (1). Methamphetamine (meth) is a psychotic stimulant drug. It has a high potential for abuse and is an FDA approved drug in the United States, under the trademark name Desoxyn (2). Methamphetamine causes a number of physical, psychological and withdrawal effects such as anorexia, hyperactivity, tachycardia, bradycardia, hypertension, hypotension, blurred vision etc (3). The psychological effects include euphoria, anxiety, excessive sleeping, increased appetite and depression (3) (4).

In the United States, Montana has one of the highest per capita treatment admission rates for methamphetamine overdose and its use has a substantial economic impact on the state. About 53 % of children in Montanan foster care are there due to methamphetamine costing the state $ 12 million per year, 50 % of Montana’s prison population are in jail due to meth related crime costing the state $ 60 million per year and 20 % of adults are undergoing treatment for substance abuse are there in treatment for meth related symptoms costing the state $12 million per year (5). The Montana Meth Project, founded by Montana’s software billionaire and rancher Thomas M. Siebel, was instituted in September 2005 as a large scale prevention program aimed at reducing meth use in the state. Although its efforts were aimed in the right direction, it has failed to bring about any decrease in Montana’s per capita meth use. The Montana Meth Project has published their own reports indicating its success, however other published findings from unrelated organizations show that such anti drug campaigns cause no favorable changes in youth drug use and that such campaigns might create a significant norming effect wherein greater exposure to these ads will result in a more positive attitude towards drug use overall (6). There is no evidence that reductions in meth use are due to the advertising campaign. Rates of methamphetamine use have declined in recent years, but dependence and abuse have significantly increased (7).

One of the primary reasons for the failure of the Montana Meth Project was its use of the Health Belief Model which does not account for irrational behavior of individuals and self efficacy, two crucial factors in promoting behavioral change. Despite its documented failure, the Montana Meth Project is still running today.

Background:
The Montana Meth Project was founded to educate youth about the risks, health and psychological effects associated with meth use and aimed to reduce meth use throughout the state. The first campaign of the Montana Meth Project focussed primarily on the individual user. This project instituted a statewide advertising campaign distributed via television, radio, print and the internet. Its advertisements featured graphic depictions of the risks and harmful consequences of meth use aimed at warning youth about its dangers (8). As of September 2005, the Meth Project had introduced 71,000 television ads, 64,000 radio ads, 140,000 print impressions and 21,000 billboards (8). With this, a sudden burst of images of young individuals and their nightmarish trappings became omnipresent on the state’s billboards (8). Tom Siebel rocketed into place as the state’s largest advertiser.

The Meth Project was initially declared a great success primarily because of its aggressive approach. Currently, Montana officials are looking for funds to sustain this project and ways to export it beyond the state borders. The Meth Project officials believe that equipping youth with knowledge about the consequences of meth use will reduce the appeal of the drug thus reducing its experimental use in the population.

Critique 1: Misuse of Labeling and Stigma Theory
The Montana Meth Project inappropriately uses Labeling Theory and Stigma Theory to help youth overcome drug addiction. This project uses slogans such as, “My friends and I share everything, now we share HIV and Hepatitis”, “Before Meth, I had a daughter, now I have a prostitute” (8) ,“Before Meth I had a brother, now I have a thief” (8), hitting the site visitors hard in the face.

This project does not consider the fact that social stigma and labeling are some of the biggest hurdles affecting treatment of people (9). Stigma is the use of negative labels to identify a person. Trends have shown that stigmatized teenagers fear facing reality and are hesitant in dealing with their problems and seeking the help they need (10). Society believes that addiction is a blemish or a limitation that is incurable. Fear often forces children to hide the problem from their parents and when parents do find out, stigma makes them feel accountable. The Montana Meth Project appears to be insinuating the same message to the youth. This project, with the aim of bringing about a behavioral change is actually stigmatizing and labeling meth addicts which not only affects them on an individual level but also affects efforts of anti drug media campaigns which are aiming to help the community at large. Research has shown that it is because of stigma that people don’t get treatment, some doctors won’t treat addicts and some families won’t accept their own (11). An examination of the literature on stigma within the drug using population can best be anchored in sociological theories such as the labeling perspective which explains stigma in terms of these processes (12)(13). The Stigma Theory was put forth by Goffman and he categorized stigma as an attribute that is extremely “discrediting” (12). The labeling perspective further argues that the stigmatized person becomes, by virtue of the label, isolated from non-stigmatized groups in society (14). This can severely limit the individual’s ability to fully participate in the daily life of society, such as holding a job, having a home, getting access to any needed services and enjoying mutually supportive relationships with family and friends (15). In effect, the stigmatized individual who is denied legitimate social roles adopts “a deviant social role” (15). This has profound implications for an individual’s view of his or her self. A study on the Psychological Mediation Framework by Mark L. Hatzenbuehler, Yale University has shown how stigma related stress causes elevations in emotional deregulation, social and interpersonal problems and also affects the cognitive process (16). A similar study carried out at University of California, Community Health Department has revealed that depression is strongly correlated with both dimensions of stigma-internalized shame and perceived stigma. Both these dimensions are significant predictors of depression (17). The Montana Meth Project should instead battle with stigma by stopping broadcasting of the negative connotations with words like addict, alcoholic, abuser, thief, prostitute which only strengthen and support stigma by creating negative images.

Critique 2: Failure to depict behavior youth would want to model-Use of negative imagery
The Montana Meth Project uses negative imagery to educate youth about the risks associated with meth use. One television commercial opens with an image of students walking down a typical high school hallway. A teenage boy’s voice talks over the picture saying, "This is the high school he dropped out of" (8). The scene changes to show an area of ground under the bleachers. The voice says, "This is where he beat up his best friend” (8). Images of a fight between two teenage boys flash across the screen and then disappear. The scene transitions to show the pair of rusty scissors he used to dig imaginary bugs out from under his skin to the isolation room in a mental institution where he now spends 23 hours a day. Finally the narrator of the story, a teenage boy, appears on camera. He looks up and says: "...and this is what I said, when he told me he was going to try meth." The boy falls silent and just stares into the lens (8). While this commercial is a true story, it represents such an extreme that most teens viewing it will be unable to identify with the situation and will not think it could ever happen to them. This kind of television ad fails to connect with its target audience.

Fear mongering has been widely used to strengthen the anti-drug propaganda. Another Montana Meth Project advertisement is set in a filthy restroom reading “No one thinks they would lose their virginity here-Meth will change that” (8). This statement is bold, brazen and quite shocking. While it is appropriate to educate youth about the dangers and risks associated with meth use, this message and the way it is portrayed is ineffective. Youth of today would have difficulty in relating to such images and messages. This kind of negative imagery can reduce self efficacy of youth and can come in the way of them making a behavioral change. A study on the Effects of “Dual Focus” Mutual Aid on Self Efficacy for Recovery and Quality of Life has shown that self efficacy is crucial in the recovery process (19). Theory and prior research with people receiving help for substance abuse also suggests that self efficacy is an important factor in improving subjective quality of life (19).

Rather than using self efficacy the Montana Meth Project uses bold, ugly and gruesome imagery to actually bring about a behavioral change in youth. Images alone cannot bring about such behavioral changes. By improving their self efficacy, youth can be empowered to avoid the use of meth. Trends have shown that use of negative imagery and scare tactics to influence behavior in youth is often ineffective and can lead to defiant and resistant behavior (20). Negative images are found to be an important causal factor in social phobia (20). Unpleasant images can be linked to personal experiences, negative experiences, images and memory distress (20). In the Montana Meth Project, most of the commercials are exaggerated and education through exaggeration is an ineffective way of informing the public and in particular youth.

The anti drug media campaign writers fail to take into account truly positive peer pressure which can empower the youth to “just say no” and avoid succumbing to an unhealthy behavior when offered one. Studies have shown that there could be a positive effect against drug abuse among teens whose peers resorted to prosocial behaviors (21). Thus, self efficacy and identification of a positive role model with a focused, determined and motivated attitude can influence youth and enable them to overcome fears, come to terms with reality and identify their strengths, interests and future goals without resorting to drug use (21)

Critique 3:
Use of the Health Belief Model and other individual theories in the Montana Meth Project:

The Health Belief Model has been used as the basis of this anti drug media campaign. The Health Belief Model was developed by researchers of the U.S. Public Health Service (22). The key constructs of the Health Belief Model are given below (23) (24):

Table1: Key Constructs of the Health Belief Model
Constructs Key points
Perceived Susceptibility The degree to which a person feels at risk for a health problem
Perceived Severity The degree to which a person believes the consequences of the health problem will be severe
Perceived Benefits The positive outcomes that would result from the action
Perceived Barriers The negative outcomes a person believes will result from the action

The above constructs motivate a person to make a behavioral change by an explicit weighing of the benefits and costs of that change in behavior and how that would impact their lives. The Montana Meth Project, in an attempt to use the Health Belief Model, presents the idea that if you view these ads and take into account the severity of risks involved you would rationally make an informed decision and chose not to use meth. This project is based on the assumption that individuals think rationally and that every individual assesses the degree of risk involved in a particular behavior and makes a cost benefit analysis about whether or not they should engage in a preventive or health oriented behavior (25). It primarily focuses on the individual and does not address social and environmental factors (25). Also, this project is based on the assumption that everyone has equal access to and the same amount of information to make rational decisions. Studies have shown that people make poor decisions based on personal experiences. Hence biases creep into the decision making process (26). A study on Confirmation Bias in Psychology by Scott Plous in 1993 show that individuals are willing to assimilate facts that support certain conclusions but disregard other facts supporting other conclusions (26). Additionally, the onset of puberty in adolescence confers an increase in “sensation-seeking, risk-taking and reckless behavior” (27). This study has also shown that it is completely normal for a teen to admire a drug user, take risks and be free to do he pleases (27). Teens also desire to gain attention and popularity among their friends’ circle and may succumb to peer pressures. A study on Adolescents and Peer Pressure has shown that the motivation behind an individual’s risk taking behavior is the need to be accepted and the need to improve ones status among friends (28). This project however, fails to consider the fact that although teens may understand that use of meth is harmful, they may succumb to it based on their own personal experiences and frame of mind.

Designing Better Interventions:
The Montana Meth Project uses graphic depictions of teens prostituting themselves, picking at imaginary insects on their skin, beating up members of their families, going into convulsions, attempting suicide and betraying their loved ones. This has reached over 90 % of teens in Montana (8). The Meth Project claims that it is successful in using ad saturation, gruesome depictions and scare tactics to warn teenagers about risks of meth use (7). For the most part, viewers are told what not to do. The ads fail to improve self efficacy of youth by inflicting stigma on them. Interventions should be designed in such a way so as to improve self esteem and self efficacy and reducing the stigma associated with drug use. These interventions should be targeted at young audiences. Drug addiction afflicts millions of people of all ages and all walks of life. Evidence has shown that adolescents' affiliation with friends who engage in risk behavior is a strong predictor of adolescents' own health-risk behavior, at least for substance use (22)(24)(25). This association likely results from a combination of selection effects (26) wherein adolescents choose friends who engage in similar types of behavior and implicitly or explicitly influence one another to engage in these behaviors (27)(28).

From a public health perspective, drug addiction is associated with a number of physiological, psychological effects and physical effects. The Montana Meth Project certainly has many flaws in their campaign. However, it has at least succeeded in getting public attention. It needs to incorporate interventions into its media campaign designed so as to empower youth overcome drug addiction. Education about the problem is the first step in effective behavioral change. In addition, contact with members of society and identification of a role model will go a long way in improving self efficacy of youth and in changing public stigma associated with drug use.

Defense of Intervention 1: Education
Educating the public about drug addiction is probably one of the simplest additions that can be made to the Montana Meth Project’s anti drug campaign. Education is important in order to bring about behavioral change as this will help reduce the stigma associated with drug use. Since this is the age of the internet, the Montana Meth Project can update its website easily and inexpensively which will reach its target audience. This website can provide information to youth and the public at large about drug addiction. The Montana Meth Project can make DVD documentaries and short films showing how drugs can affect teens and why teens actually turn towards drugs. These films must capture the downside of drug use along with honesty and human dreams that have instant, long lasting and commanding impacts. Broadly changing public attitudes about drug addiction will diminish perceived barriers to seeking help to treat the problem by youth. This will improve compliance with programs aimed at helping youth overcome drug addiction. Education programs can also lead to significant improvement in the attitudes of the public about drug addiction. Results of research on adult Education Strategies have shown that brief education programs have led to significant improvement in public attitudes (29). Research has also shown that education programs help people identify the inaccurate stereotypes about the problem and replace those stereotypes with factual information (29). Thus it is important to increase awareness about negative stereotypes. This can be accomplished by providing basic facts about the problem to an audience or by contrasting myths and facts about drug addiction. Either way, the objective is to provide simple facts so that many of the myths about addiction disintegrate and will also reduce the stigma associated with it. A study on Contextualizing Education and Health Status among African Americans has shown that the education gradient in health is one of the most robust factors in promoting behavioral change, achieving social mobility and reducing inequality (30). Higher levels of education often lead to better employment opportunities, greater economic resources, access to social networks and lifestyles that reduce risk taking behavior all of which result in better health outcomes (31) . Both direct and indirect effects of education on heath have been noted (32). It is important to keep in mind that education alone is not sufficient in bringing about a complete behavioral change. However, it is definitely a first step in the right direction and the Montana Meth Project needs to deliver this message about drug addiction to as many people as possible with the aim of reducing stigma which can then empower youth to eventually make a behavioral change.

Defense of Intervention 2: Changing stigma through effective contact with peers and members of society
The Montana Meth Project uses Labeling and Stigma theories to overcome the problem of drug abuse among youth in Montana. This project fails to consider the negative impacts of stigma and labeling, particularly among youth. Health belief theorists have shown that a rational consideration of the costs and benefits of participating in specific treatments will directly impact whether a certain route of intervention is pursued (33). A significant barrier to engaging in behavioral change is the stigma associated with it (33). Stigma has a direct impact on treatment access, participation in substance abuse recovery programs and adherence to medication. Research suggests that many people who meet criteria for treatment, and who are likely to improve after participation, either opt not to access services or fail to fully adhere to treatments once they are prescribed because they are labeled or stereotyped (33). The Montana Meth Project can organize recovery programs for drug users in order to help youth battle with this stigma. Contact with members of society and peers will help in combating this problem of drug addiction. Trends have shown that members of the general public who are more familiar with such problems are less likely to endorse prejudicial attitudes (29). It has also been noticed that members of the public who engaged with a person with an addiction problem as part of an anti-stigma program have shown significant changes in their attitudes about the problem (29). These studies have shown that attitude change which results from contact maintains over time and is related to a change in behavior. Substance abuse recovery programs facilitate contact with members of society who also have similar problems. These programs provide individuals with a platform to share their personal experiences. The issue of stigma will be directly addressed. The speaker will discuss the impact of stigma on his/her behavior change, how stigma made the experience even worse and how they overcame the addiction. In this way the Montana Meth Project can be more effective by bringing about interaction of youth with the community and peers which improves their belief that they are effective in life and they have equal rights just like every other member of society.

Defense of Intervention 3: Improving Self Efficacy among youth
The Montana Meth Project uses individual level models as the basic propaganda strategy in each of its ad campaigns. It fails to focus on the interaction between individuals and their environment and how that can impact behavior. The Social Cognitive Theory (SCT) was developed by Albert Bandura in the 1960s and holds that people learn not only through their own personal experiences but by watching and following the behaviors represented by a person with whom they can identify (34). Self efficacy is an important tenet of the SCT and it is the belief that you are capable of behavioral change. If you believe you are capable of making a behavioral change then you will be more successful in doing so. The SCT can be used to empower youth to avoid drug use. Studies have shown that participating in activities, bonding with friends and family and religion will enable youth to improve their self efficacy and will also build their self confidence and coping skills (35). This will then emulate individuals to model their behavior and shun substance use (35). The Montana Meth Project uses television as a platform to bring about a behavioral change among youth. However, the content of these commercials is what is important. The ads of the project currently fail to connect with youth. Pat Fleming, Director of Salt Lake County’s Division of Substance Abuse in Utah says, "Very few of the meth users actually end up looking the way they do in the Montana Meth Project.” She says, "We know that some kids say, 'Did you see those crazy ads? I use it on weekends and I'm not a meth fiend who's robbing laundry mats or stealing money.’” Thus the Montana Meth Project must alter its commercials in order to deliver the right message to youth. Commercials featuring both celebrities and regular individuals who were into substance use will help youth overcome drug use. These commercials can have the spokespersons talk about their experience with drug addiction, risks involved and how they were able to overcome it. Commercials can also display a list of recovery programs that youth can attend to help them combat this problem and improve their self efficacy.

Messages that target attitudinal beliefs, normative beliefs and self-efficacy beliefs have had promising results in changing behaviors (35). Previously conducted studies have found that friends' prosocial behavior may exert a positive influence on adolescents and perhaps would be related to lower frequencies of adolescents' health-risk behavior which will improve their self efficacy (36). Thus, by improving self efficacy, the Montana Meth Project can empower youth to make a behavioral change and hence enhance the quality of their lives.

Conclusion:
The Montana Meth Project began with good intentions to educate youth about drug use. However, the Montana Meth Project’s fear based approach, failure to overcome stigma associated with drug use and use of individual level models render it ineffective in reducing meth use among youth. If millions of dollars are poured into this project, it is important to demonstrate effective results. Irrespective of the results of this campaign, the Montana Meth Project is still active, still being funded and is still targeted towards a young audience. In order to see effective results, previous evidence needs to be considered in this field in addition to developing effective interventions that connect with youth. It is the need of the hour to target this population before adolescents are enticed into unhealthy practices.

References:

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12. Erving Goffman, Stigma: Notes on the Management of Spoiled Identity, Prentice-Hall, 1963, ISBN 0-671-62244-7.
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Battling the Obesity Epidemic: Why the Small Steps Campaign Does Not Work – Anar Pardhan

2010-05-10T09:34:00.003-04:00

Obesity is a serious problem in the United States and a growing concern for public health. The Merriam-Webster dictionary defines obesity as “having excess body fat,” (1) and the CDC measures obesity by the body mass index – a number based on weight and height (2). Recent data estimates that one third of all Americans are considered to be obese (3). One of the most alarming facts is that childhood obesity has tripled in the past twenty-five years (4). The problem with obesity is not the excess body fat, but what the excess body fat can do to the overall health of an individual. People who are obese have a myriad of health issues: hypertension, hyperglycemia, type 2 diabetes, heart disease, stroke, liver and gall bladder disease, sleep apnea, respiratory problems, osteoarthritis and certain types of cancers (5). With a high prevalence of obesity in the U.S. and the host of health problems that it can create, it then poses a great financial burden on the health care system (6). Economists estimated the cost of obesity in 2000 was approximately 117 billion dollars (7), and it was also estimated that 300,000 deaths per year were associated with obesity (7). Hence there have been many campaigns implemented to address this serious issue that some have called an epidemic.

In 2004, the federal government implemented the Small Steps campaign to combat obesity (www.smallstep.gov). The goal of this campaign according to the Health and Human Services Secretary at that time, Tommy Thompson, “is to have people take small, achievable steps to improve their health and reverse the obesity epidemic” (8). The website has many different features; for example, it offers different health tips of day called “small step tips,” it offers the facts and consequences about obesity, gives tips on what to eat and what foods to avoid and gives recipes that even include desserts. The campaign also featured a series of television and print ads that focused on the body. In one television ad, a boy is playing outside and he discovers a body part; a fake large human belly. In another television ad, a couple of normal body weight are about to take their seats at a movie theatre, and the women ends up sitting on some fake back fat. In both ads, the message trying to be conveyed is that if you skip the extra serving or go for the small portion amount, you can lose belly fat and back fat. In several of the print ads, very close up shots of a heavy stomach, thighs and buttocks are portrayed. The ad indicates that these body parts can be slimmed down by becoming more active or eating healthier. The message of these television and print ads is very important, but making overweight bodies look disgusting and ugly can be very offensive to people who are overweight. Hence, how effective can these ads be if they portray the overweight body in a negative way?

The first flaw with these particular ads is that they perpetuate stigma against the obese. Renowned sociologist Erving Goffman defined stigma as “a process by which the reaction of others spoils normal identity” (9). It is well known that overweight or obese people are stigmatized in society, for example children that are obese have been teased and bullied by other children (10), and health professionals also treat their obese patients differently (10, 11). The role of stigma in public health is not new. The United Nations has recognized that stigma plays an important role in the HIV epidemic and has recommended providing funding to reduce HIV stigma (12). The opposite is the case for obesity campaigns. Stigma is not considered a problem in most campaigns (11, 12). In fact, some believe that stigma can be used to help control obesity (11). The perception is that stigma will motivate individuals to change their habits and engage in healthy behaviors like exercising and eating healthy. If weight stigma was able to do this, then obesity should be of no concern to the health community and obesity rates should be extremely low. Sadly, this is not the case. Instead of obesity rates declining, in the past decades they have been drastically rising (3). Also, studies have shown that individuals who have internalized obesity stigma are more likely to engage in binge eating and avoid exercising (11). In a study conducted by Puhl and Brownell, they asked over 2400 overweight or obese women on how they cope with stigma. 79% of the women said that they coped by eating, and 75% said that they also coped by refusing to diet (14).

Weight stigma can also cause decreased psychological health (11). By internalizing stigma, an individual may increase psychological stress as well. Psychological stress itself can cause compromised physical health such as: hypertension, heart disease, type 2 diabetes, and other conditions associated with obesity (15). When people are stressed they also tend to engage in unhealthy behaviors. For example, they may smoke more or start smoking again to cope with the stress. Therefore, it is not surprising that rates of smoking among obese individuals are very high (15). Smoking alone has its own host of health problems. Not only does obesity pose a wide range of health issues, one also has to take into account the impact stigma has on health, specifically stress and smoking.

Since obesity poses a negative risk to a person’s health, individuals who are obese should seek medical care on a regular basis and should be participating in preventive screening programs like cancer screening. Unfortunately, this is not the case. Obese individuals avoid seeking medical help because they feel that they are being disrespected and not treated the same as people who are considered to be thin (11, 13, 14). For these reasons, the Small Steps campaign’s use of weight stigma to educate Americans is not having a positive impact. Instead, the use of stigma engenders the opposite of what this campaign is trying to achieve.

Another flaw with this campaign is the negative image it portrays of obese individuals. It does this by addressing the labeling theory, which states that a person will behave in a particular way if they are described in that way (16). For example, if a female student is told that she will not be able to excel in calculus because she is a girl, she now believes that she will be unable to do well. This belief creates a self-fulfilling prophecy, and she will perform very poorly when she does start calculus. In the Small Steps campaign, a Health Tip is featured everyday on the website. Health tip #92 states: “Walk instead of sitting around” (www.smallsteps.gov). This particular tip is insinuating that obese individuals sit around all day and do nothing. Hence, this creates a negative label: that all overweight or obese people are lazy, and they sit around all day doing nothing. Society already views obese individuals as being lazy, lacking self discipline and having poor will power (17). By having this type of negative labeling, the campaign is blaming the individual for his or her weight problem, which can cause further psychological stress to the individual. Studies have indicated that obese individuals are reluctant to seek medical care, because they feel that the health care providers are blaming them for their weight problems (11, 14). According to the labeling theory then, obese people will internalize this label and view themselves as lazy and having poor will power. Therefore, the very goal of this campaign will not be met; instead of helping and encouraging a healthy lifestyle that promotes physical activity and healthy eating habits, it is contributing to the obesity epidemic.

Additionally, the negative imagery in this campaign will cause the individual’s self efficacy to be very low. Albert Bandura’s social cognitive theory and the concept of self-efficacy state that in order for a person to perform a certain behavior successfully, he or she must believe that he or she has the power to complete the behavior with the desired outcome (18, 19). In other words, the individual has to believe that he or she can succeed in a particular task in order to be successful at it. But how is this possible when the campaign does not give individuals the power that they need to be successful at weight loss? Focusing on the appearance of the obese body is not appropriate, because it only will add to the obese person’s dissatisfaction with his or her body image. All of this will cause the individual’s self-efficacy to be low and not high. The individual will not believe that they are able to do behaviors that will make them successful at losing weight so they will not even bother to try it. This campaign is creating an environment that does not promote positive thinking and it is not giving the tools that are necessary to promote self-efficacy. Therefore by having the campaign focus on imagery of body parts that are considered to be obese, is not only offensive but it is also very insensitive to overweight and obese individuals. Obese individuals have body image dissatisfaction and low self-esteem and this can cause a negative impact on their behavior, quality of life and psychological wellness (20).

A third ineffective aspect of the ads in the Small Steps campaign is that the message is delivered at the individual level. This is a weakness, because an individual’s behavior is affected by the groups that he or she belongs to. There is an increased risk of obesity when you have friends that are obese (21). A study done to examine smoking cessation showed that individuals did not stop smoking by themselves; instead, clusters of individuals stopped smoking at once (22). In the “get active” tab in the campaign’s website, it shows a very attractive slender young women stretching. Instead of having a single person stretching, the campaign can show a group of individuals stretching at an aerobics class or a group of people walking together at the beach or park. When a group of young adults were interviewed, they considered socializing more important than exercising or eating healthy (21). If the campaign can feature ads targeting young adults as a social group, this can be more effective than targeting individuals, according to social network theory. By targeting a group of people who belong to the same social circle or network, one does not have to work at the individual level because groups of individuals can be affected at the same time. Social norms theory also applies here. Social norms theory states that “much of people’s behavior is influenced by their perception of how other members of their social group behave” (23). For example, if a group of college friends party every Friday and Saturday night and get drunk each of those nights, then a new person who wants to join this group will believe that he or she also needs to behave the same way. On the other hand, if the same group of people goes for a run every Saturday or Sunday morning, the new person will believe that he or she also needs to go for a run every Saturday or Sunday morning. Therefore, if the anti-obesity campaign focuses on influencing behavior at the group level, it will be much more effective in capturing a larger number of Americans rather than trying to influence behavior one person at a time.

While there are many flaws with this campaign, there are some aspects of it that I would keep. I would keep the section on health tip of the day and make sure that the tips chosen are not negative in any way and promote overall health. For example, I would keep health tip of the day #149: “Be realistic. Make small changes over time in what you eat and the level of physical activity you do. Small steps often work better than giant leaps.” I would also keep the online recipes, because people who are unable to cook often fail to eat healthy foods. I would also keep the desserts in the recipe section, because this can teach people how to eat sweet foods in a healthier way.

In the improved campaign, I would include a section of ads featuring overweight and obese individuals that follows their progress over time. In addition to following individuals, I would also follow a family that is overweight and show their progress toward healthier behaviors. On the website, there would be an entire section devoted to these people detailing their progress. Each participant would have an online diary detailing how they feel throughout the journey to a healthier lifestyle and letting the public know about their struggles and joys. I would also, with the permission of the participants, print medical data on their cholesterol levels, blood pressure, triglyceride levels and weight; before and after they started this journey. This would show the public that by changing to a healthier lifestyle their overall health can improve through reducing the risk of obesity related diseases. In the new campaign, I would also have section on the website that is devoted to groups or clubs that want to join and make a pledge of becoming healthier. This could be something as simple as a group of stay at home moms pledging to walk thirty minutes three times a week or the math club at the local high school pledging to train and run in a five kilometer race.

By having ads that feature overweight or obese people going through their journey of getting healthy, the new campaign tells a personal story to the American public. Overweight or obese individuals can relate to this story and become inspired to pursue healthier behaviors. These will be real stories about real people and models or actors will not be used in the campaign at all. The Massachusetts Department of Public Health (MDPH) ran an anti-smoking campaign many years ago that featured young mother Pam Laffin, who was suffering from emphysema. In this campaign, they featured her story and her health struggle as a result of smoking. This ad had a profound effect on the public, and smoking rates among the youth decreased a great amount (24). By showcasing individuals, this can help to motivate others in their struggle to achieve a healthy lifestyle.

In the story of the family that is featured, I would choose a family whose children have health problems because of their weight. I would not have any statistics of obesity related health issues because the public does not relate to numbers as well as it does personal stories. Most people tend to have optimistic bias. That is, people tend to underestimate the risk that applies to them and convince themselves that this will not happen to them (24). Hence, by focusing on one family’s struggle with weight and health problems, this will motivate other parents who are in the same situation to act now before it is too late. By motivating parents to make positive changes in their health and lose weight, their children will be encouraged to lose weight as well. Studies have shown that parent’s weight is a strong indicator for childhood obesity, and studies have also shown that children do lose weight in combined parental and child weight loss programs (25). Since childhood obesity is a great concern today, it is important to address this issue in the campaign.

As mentioned earlier, The Small Steps campaign is targeting the audience at the individual level. Having groups join the campaign and make a pledge will motivate and encourage them to become healthier. If the group chooses, they can keep track of their progress on-line for the entire public to see. This way, they can inspire other groups to do the same thing. By targeting groups and changing their perception on health and weight, one can change the social norms of that group, thereby changing or influencing the behavior of others. Special attention will be made to groups that are teenagers or young adults, because trends have shown that most individuals will become obese before the age of 35 (21). Hence if the campaign can target groups before they turn 35, progress can be made in the obesity battle. One group in particular that can be targeted is young adults who attend college. People who attend college gain weight much quicker than the general population (21) and this puts them at a greater risk for obesity related diseases. Since socializing is a large part of the college experience, we aim to allow students to socialize while being physically active. This way, they are not only doing something that they enjoy (socializing), but they are also doing something that is positive for their health.

Additionally, the campaign can provide support to the colleges by helping them create a healthier environment for their students. By creating a healthier environment, it makes it easier for students to make the changes needed to become healthier. For example, they can put up posters in the dining halls or the classrooms that promote healthy eating or regular physical activity. But instead of saying how this will improve your health, the poster can say that these activities will give you more energy, reduce your stress and improve your social life. These are the core values that are important to this age group. In contrast, being healthy is not very important for this age group; preventing heart attacks or diabetes is not on their radar at this point in their life. Hence, by choosing a message that college age kids can relate to will convince them to adapt to a healthier lifestyle.

Lastly, the improved campaign will feature positive imagery of overweight or obese individuals rather than the negative ones currently portrayed. I would remove all ads that feature body parts of obese individuals, because this very insulting to them. I would also replace all pictures of slender, attractive models and replace them with photos of real people who are overweight or obese. Instead of having the picture of the slender women stretching, I would have a picture of an overweight women stretching, indicating that overweight and obese individuals are not lazy and that they do exercise. This will help to remove the negative label that obese people are lazy. A positive image also helps to create a higher level of self-esteem and belief in oneself. Once again, instead focusing on the core value of health, the ads would then focus on the core value of self-esteem. If health was an important core value, then one third of Americans would not be obese. Also by removing the label of laziness, not only will the individual’s self-esteem improve, but this will also give the individual hope and power to make positive changes in their life. Again, the core value of health does not factor in on these ads. So by improving the individual’s self-esteem and by giving them hope and power, their level of self-efficacy will increase. When their level of self-efficacy is high, then, according to Bandura, they will believe that they have the power to complete a specific task with the desired outcome (18, 19). In this case, the task is physical activity or healthy eating and the outcome is improved health.

In conclusion, obesity is not only a problem in America, but it is a problem throughout the world. Experts predict that by 2025, obesity will be the world’s number one health problem (10). A campaign that perpetuates weight stigma and negative body images and that is only implemented at the individual level will not be effective at all and it will only continue to contribute to the obesity problem. The new campaign will not focus on the individual but on groups of people. Therefore, it will change the societal attitudes and eventually the social norms. It will also feature ads with positive imagery and remove all negative labels to instill self-esteem, power and hope. Finally, the campaign will feature stories of normal Americans, including an entire family, and how they have made positive changes in their lives. It will demonstrate their improved quality of life. Taken together, these changes will result in a better, more effective campaign.

REFERENCES
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The National Breastfeeding Awareness Campaign: Failure to Contextualize Individual Behavior Change – Eloesa McSorley

2010-05-10T09:23:00.002-04:00

In June 2004, the Office of Women’s Health, as part of the US Department of Health and Human Services (USDHHS), launched the National Breastfeeding Awareness Campaign (NBAC). The campaign was a result of directed funding to increase the proportion of women who initiate breastfeeding with their first infant and who exclusively breastfeed during the first six months post partum (1). This objective was articulated in Healthy People 2010 as to increase the percentage of women that breastfed in the early postpartum period from 64% (1998 baseline) to 75% by 2010 (2). Additionally, objectives of percentage increases were put forth for the rate of breastfeeding at 6 months (from 29% to 50%) and at 1 year (from 16% to 25%) (2).

With these goals in mind, the USDHHS Office of Women’s Health produced the HHS Blueprint for Action on Breastfeeding (3). The report evaluated the state of breastfeeding in the United States and established four specific goals that would lead to fulfillment of the Healthy People 2010 objective (3). With the charge of the report the Office of Women’s Health established the National Breastfeeding Awareness Campaign. The overall goals of the Campaign were those established in the Healthy People 2010 document (1). The campaign had two main components: a nationwide media outreach campaign and sixteen community based demonstration projects (1). Both components sought to increase rates of breastfeeding through empowering women to commit to breastfeeding (4). The Office of Women’s Health worked with the Ad Council to create and disseminate the campaign which ran through April 2006 (5).
The campaign, though well crafted and supported by valid and thorough scientific research, failed to fulfill its goals. I argue that this is partially due to three problems in t he campaign. First, the campaign failed to include all relevant information necessary for women to make an informed decision regarding the decision to breastfeed, in particular information regarding infant formula. Second, the campaign failed to consider all of the stages of change that a woman would go through to initiate and continue breastfeeding. And finally, the campaign only sought to address women themselves, ignoring others that may influence a woman’s decision and capacity to breastfeed, and failing to appropriately contextualize the health behavior.

I. Failure to fully implement the Health Behavior Model

The nationwide media outreach component of the NBAC sought to recast the benefits of breastfeeding to have a greater perceived consequence (4). The health related behavioral principals that underlie this campaign strategy come from the Health Belief Model (HBM) (5). The HBM views health related behavior change as related to an individual’s perception of the severity of risk associated with not changing behavior, along with perception of their individual susceptibility to the risk (6). Additionally, the HBM posits that people will also consider the potential benefits of implementing a behavior change and the likelihood that they can implement the change (i.e. what barriers they face to changing) (6). A critical flaw of implementation in the nationwide campaign was that the campaign only told half of the story about risk, and therefore failed to fully implement the HBM, underutilizing its potential for change in this situation.

The NBAC used a strategic implementation of framing via the print portion of the nationwide media outreach campaign to invite expectant mothers to think about breast-feeding as a risk reduction strategy (i.e. to think about not breastfeeding as imposing a risk upon a child). They cleverly used images associated with the risk being addressed portrayed in such a way as to represent breasts. Two dandelions were used to represent a possible decrease in respiratory illness in breastfed babies, ice cream scoops with cherries on top represented a decreased likelihood of childhood obesity in children exclusively breastfed for the first six months of life, and otoscopes represented a decrease in the likelihood of childhood ear infections obtained by exclusive breastfeeding (1). Public Service Announcements (PSAs) designed for television portrayed pregnant women engaging in activities that would be universally understood to carry a substantial risk of injury to a fetus, such as log rolling and riding a mechanical bull, and were accompanied by the text, “You wouldn’t take risks before your baby was born. Why start after. Breastfeed exclusively for 6 months.” (1) Both media campaigns were clever, catching and humorous. Additionally, they both encouraged further inquiry into the subject.

However, these ads were created and disseminated in the context of a moms and future moms having a perception of breastfeeding as the “ ‘ideal,’ not the standard” (6). This begs the question: what, then, is the standard? Of course, the answer to this is that the majority of those mothers that are not exclusively breastfeeding their infants up to six months or a year postpartum, are feeding them infant formula. Knowing this, a goal of the campaign was to establish breastfeeding as the standard, as opposed to the ideal (6). The statements about risk that are included in the print and TV ads are lacking the essential information that increased risk is not only associated with women not breastfeeding, but, logically, with women instead using baby formula as a primary source of nutrition for their infants. There have been many critiques made of the Health Belief Model, one being that it assumes that individuals act rationally and empirically when presented with a risk benefit analysis of potential health behavior implementation (7). However, before addressing such an aspect of a public health intervention based on the HBM, one must observe a well constructed intervention based on the HBM in the first place. NBAC not only omits discussion and information about risks associated with using baby formula, they also fail to embrace an opportunity to remove clout from (or insert uncertainty into) the perceived benefits of using baby formula. By leaving this out of its ad campaign, the NBAC fails to give consumers of the ads adequate information about risks and benefits of breast feeding in contrast to the risk and benefits of the oft used replacement, baby formula.

Of course, the NBAC does imply that breastfeeding is associated with health benefits and reduced risks to health compared to baby formula, simply by addressing the risks associated with not breastfeeding. Doing this does, in a sense, tie risks to formula feeding, but by addressing formula feeding in this indirect way, it places the context in which a mother makes a decision to breastfeed or formula feed, unrelated to a risk/benefit analysis, in a neutral place. The environment in which mothers make these decisions is far from neutral. Barriers to breastfeeding have been cited by a variety of studies and include social environment, conflicts with employment, inadequately trained hospital support staff, among others (8-10, 3). These types of barriers can and are being addressed through media campaigns, changes to policy in work settings and training programs. Such interventions all have to do with creating an environment in which a mother feels that it is both the right choice and the accessible choice to breastfeed (3). However, the other side of the environment in which a mother initiates and continues to breastfeed or does not, is one that is heavily influenced by the marketing and influence of formula companies that exploit the existence of the barriers stated above in order to make formula feeding an acceptable and an easy choice.

The infant formula is an $8 billion a year industry, and as it is an industry, there is strong investment in seeing that products are consumed (11). Formula companies use both direct to consumer advertising, as well as advertising and distribution of free samples in hospitals and other birthing environments. Without getting into business ethics or the impact of consumer or doctor marketing, what makes the story of the influence of the infant formula industry on the NBAC campaign unique is the emergence of information that the industry, upon reviewing the original marketing plans of the Ad Council, exerted pressure and influence to have certain ads withdrawn that did more directly address breastfeeding in comparison to formula feeding (12). In particular, original manifestations of the ads were to include specific statistics about increased risk associated with formula feeding and also were to include information on leukemia and diabetes (12). The change in stance of the NBAC only goes to highlight that an understanding was at hand about the strength of a message making a comparison between the benefits and risks and breastfeeding versus infant formula. To water down the message is to remove agency from expectant mothers in their capacity to make decisions, all else equal, given the most complete information.

II. Implementation strongly addressing only initial stages of change

Ideally, the transtheoretical of behavior change can describe the process that a woman may go through in her decision to breastfeed if she is exposed to the NBAC. In her stage of precontemplation, she doesn’t know how she will feed her infant after it is born, perhaps she hasn’t really thought about it yet. She may then be exposed to a television or print ad produced by the campaign and may gradually move into the contemplation stage, wherein she decides that she will breastfeed her baby. Next she maybe will tell her partner, her doctor and her family of her plans, perhaps buy a breast pump – this is all part of the preparation stage. Immediately post-partum, a woman would, ideally, initiate the action and begin breastfeeding her child. She would then maintain this behavior through at least the first six months post partum (7).

The NBAC has two distinct, but related goals. It aims to increase the proportion of women who breastfeed and it aims to increase the proportion of women who breastfeed exclusively for the first six months postpartum (1). Paramount to the fulfillment of these goals is that women initiate breastfeeding immediately postpartum (13). The concern with the implementation of a campaign the focuses exclusively on awareness is that it envisions its primary effect to be had on women in either the precontemplation or contemplation stage. It doesn’t address aspects of planning or steps that a women might take to plan for breastfeeding. It doesn’t address the myriad of elements that go into the crucial moment that a women “decides” to breastfeed her baby immediately post-partum. And it doesn’t address ways in which women can continue to breastfeed, considering the environment in which breastfeeding is going to realistically be carried out.

In terms of addressing the initiation of breastfeeding immediately postpartum, though a new mother may be aware of the benefits of breastfeeding, and the risk associated with not breastfeeding, the risk benefit equation that she is theoretically weighing is considered at a key moment defined by the extremely emotionally and physically demanding act of giving birth. There is a likelihood that she will cease to think rationally about the decision in that moment, and “decide” to not breastfeed. Or, she may even think very rationally and consider how exhausted she is, how there are no nurses around to help her breastfeed, how, perhaps, despite all those adds about risk and not breastfeeding, she is a new mom and doesn’t know how to breastfeed and is worried she may do it wrong. The NBAC campaign relies solely on the idea that mothers will be so concerned with the potential risks of not breastfeeding that they will do whatever is necessary to initiate breastfeeding. The campaign, self-styled as an awareness campaign, fails to give moms ideas for how to begin breastfeeding, ignoring a preparation stage. It also fails to address the importance of initiation in the first moments of a child’s life, an aspect crucial to mothers moving into the action, and then maintaining the health behavior.

III. Changing the perception of breastfeeding among many social levels

By implementing a risk-based awareness approach to its campaign, the primary target of the NBAC is expectant mothers. In making expectant mothers the primary target of the campaign, the framers of the campaign are making an assumption that mothers are the people that would 1) be most concerned with their expected child’s health and well being, 2) be the individuals who will carry out the act of breastfeeding and 3) initiate the act of breastfeeding in a self-determined way, according to their will. Secondary to targeting mothers, the ad campaign attempts to indirectly address co-parents, recognizing that the father, in particular, plays an important role in a mother’s decision to breastfeed (5). By changing the perception of breastfeeding from the “ideal” to the “standard,” the campaign attempts to establish and normalize breastfeeding as the standard for the co-parent, thereby fostering a sense of acceptance and support among in the family structure so that mothers will feel comfortable breastfeeding (5).

This aspect of the campaign speaks to individual behavior change alongside a primary interpersonal relationship that will affect child-rearing choices. However, it does not address other relationships and obstacles that a mother contends with when evaluating support for her decision and capacity to breastfeed. Specifically, the ad campaign does not do enough to normalize breastfeeding at all levels of the socio-ecological framework, nor does it do enough to disrupt a static notion of breastfeeding as tied to limiting perceptions femininity and motherhood.

The socio-ecological framework acknowledges that the social environment is made up of multiple levels of influence that effect health behavior, including intrapersonal, interpersonal, institutional or organizational, community and public policy factors (14). The NBAC targeted its efforts to the intrapersonal and interpersonal level of this framework, and largely ignored addressing efforts and awareness at the institutional/organizational, community or public policy level. This is particularly damaging to a breastfeeding awareness campaign, because there are a variety of environments that a women could potentially breastfeed in, in which she is discouraged from doing so due to social norms. Additionally, by only targeting the intrapersonal and interpersonal relationships that could affect a mothers decision or capacity to breastfeed, the ad campaign does not create sufficient space in which it could have begun to restructure notions that are held about breastfeeding and notions and images that are portrayed related to breastfeeding throughout society. In their study on the factors that determined infant-feeding practices, McIntyre, Hiller and Turnbull (1999), found that a primary reason that women gave for not breastfeeding was potential embarrassment. The HHS Blueprint for Action on Breastfeeding noted that efforts were needed to address the social perceptions of breastfeeding and the subsequent social support that mothers had in their endeavor to breastfeed. The NBAC, despite its clever tactic for the print portion of the campaign, may even reinforce the idea that breastfeeding is something to be done in private, that breasts, as a vehicle for infant sustenance, should be hidden. By using images that are not, in fact, breasts and by removing women completely from its print campaign, the NBAC reinforces the idea that breastfeeding itself is too lewd, too exposed, to convey in a print advertisement.

Related to the fact that the campaign only addressed intra- and interpersonal aspects of behavioral influence, is the fact that the campaign does not attempt to change normative ideas about breastfeeding generally, nor ideas that are tied to limited and limiting notions of motherhood specifically and of womanhood, more broadly. By placing the onus of responsibility in breastfeeding initiation on the mother and by excluding direct images of women breastfeeding, the campaign reinforces a notion that breastfeeding is an exclusive act between mother and child and an act that is private, and should be kept private. While on the surface, it is true that the actual act directly involves two parties, the mother and the baby, reinforcing this notion of exclusivity and privacy recalls generations of public images related to breastfeeding that portray breastfeeding as a concealed, near spiritual act, that essentializes motherhood as something characterized by the intense caring and nurturing feelings that we expect mothers to have towards their babies when engaged in this act. As Rebecca Kukula notes, the imagery shows “mother and infant…locked into a dyadic and private relationship of mutual attention that excludes the rest of the world” (15). The portrayal of this relationship (or the fact that the NBAC campaign recalls it) reinforces ideas about motherhood and femininity that do not coincide with the complex world that mothers live in where they may have to breast feed at work, in a store, or while doing another task that any woman has the capacity to be involved in. The idea that breastfeeding is the be all end all of womanhood and of motherhood needs to be challenged. Furthermore, the fact that humor is tied into the imagery of breasts, simultaneously makes breasts themselves more one dimensional (i.e. private) and also reinforces social norms about objectivity related to breasts that create social spaces hostile to breastfeeding, viewed as part of female sexuality, in the first place.

Proposed intervention:

The National Breastfeeding Awareness Campaign had many strengths, but ultimately was lacking in key areas that would have given it more widespread and significant success. There are specifics ways in which amplification and adjustment of the campaign could be implemented to addresses the specific areas of weakness critiqued above. For a proposed intervention, I will focus on such amplification as opposed to designing a multifaceted campaign that could address not only awareness and understanding of breastfeeding, but also policy implementation that would facilitate and encourages breastfeeding among women in hospitals and in places of employment, acknowledging that for uptake of breastfeeding on a larger scale, such policies are essential (3). Directly answering the critiques discussed above, I put forth three suggestions for amplification and adjustment to the campaign. First, the campaign should include information about risk reduction via breast feeding compared to baby formula, while also removing neutrality from baby formula and the baby formula industry and placing it within the context of a business with a target audience. Second, the campaign should increase ad space and information to hospitals where women are giving birth. This will also increase campaign exposure to key individuals that will influence a mother’s decision and capacity to begin breastfeeding, so that she will have more potential to implement early initiation – a predictor for future breastfeeding and exclusive continuation of breastfeeding. Finally, the campaign should broaden its scope to target diverse members of the community through portrayal of diverse manifestations of motherhood and breastfeeding. These three amplifications and adjustments to the NBAC would build upon it s original structure to have a more widespread effect on changes in behavior and attitudes related to breastfeeding.

Defense I: Acknowledging alternatives to breastfeeding

If as a premise for changing behaviors related to breastfeeding, we assume that giving individuals (mothers in particular) information about the risks and benefits of breastfeeding, it is essential that we not withhold information critical to making an informed decision. By framing the issue of providing nutrition and sustenance narrowly to include only breastfeeding, the NBAC fails to acknowledge the oft used alternative, which is using baby formula. The new campaign should not only compare health outcomes, in a direct way, of breastfeeding versus formula feeding, but should also portray information about motives of formula feeding companies (i.e. profit).

In a study by Nommsen-Rivers, Chantry, Cohen and Dewey, comfort with the notion of formula feeding was the strongest (negative) predictor in a mother’s intention to breastfeed, compared to exposure to breastfeeding, comfort with ideas of breastfeeding and breastfeeding self-efficacy (cite). Specifically, Afriacn-American women were more comfortable with formula feeding and less comfortable with breastfeeding than their white and Hispanic counterparts (16). This is of particular importance, as African-American women are much less likely to breastfeed than other racial and ethnic groups, showing lower rates of both initiation and continuation (13).

Comfort with formula feeding can be disrupted by portraying scientifically supported information about the increased risks associated with formula feeding. Additionally, apart from increased risk to a child’s long term health, neutrality can be taken away from formula feeding by directly addressing the business aspect of the formula industry. This could be done in a clever way, comparing the for-profit aspects of formula feeding to the non-profit aspects of breastfeeding. Or the fact that the formula industry is an $8 billion dollar industry could be contrasted with the money and resources that go into the “breastfeeding industry.” This could be done directly by talking about the amount of money and resources that go into the actual campaign alongside other campaigns and maternal health interest groups, or it could be done indirectly by making a comparison to the “production capacity” of a woman’s breasts.

Defense II: Targeted timing and support of intervention

The second adjustment to the campaign would be to increase ad space to places that women are giving birth so as to target women closer to the moment of parity, and to target health care professionals that are an important source of support for women that may breastfeed. Additionally, the campaign should address behavioral change methods not only related to risk, but also related to action and continuation.

While increasing awareness of breastfeeding and of risks associated with not breastfeeding does directly address individuals in the precontemplation and contemplation stages of change, and even indirectly will affect people in further stages and in relapse, more decisive messages need to be implemented to prepare women to breastfeed, to move women into action, and to encourage continuation. Information should be provided to women regarding how she might feel when she first gives birth, and relative to that, how important it is to initiate breastfeeding as early as possible, if not immediately. Included in this information should be data on why breastfeeding in the first days of newborn life is particularly important for continued health and well-being (3).

Continuation of breastfeeding is already somewhat addressed in the current campaign, making a point of stating that breastfeeding should be done exclusively in the first 6 months of life (1). Continuation is very dependent on a mother’s work environment and support system (3). While these aspects can be addressed through policy in initiatives, continuation can also be addressed by including information in ads about how women can integrate breastfeeding into their lives: perhaps showing an actual picture of a women breastfeeding while working, or of a breast pump and some line of text about how giving babies breast milk can manifest in diverse ways.

Defense III: Normalizing of breastfeeding among all community members

A critical fault of the NBAC is that it does not appropriately or adequately consider the social context in which women breastfeed and as such does not attempt to change social norms about breastfeeding. As discussed above, the campaign only attempts to influence behavior change at intrapersonal and interpersonal levels, ignoring that these behaviors, especially significant with behaviors related to breastfeeding, are influenced by all levels of a socio-ecological model.

Particularly useful to an evaluation of current breastfeeding imagery and social perception of breastfeeding and to the development of new campaigns that attempt to change norms is the implementation of theory related to gender and power. In applying the theory of gender and power to a health behavior, we are drawn to consider what the risk factors are, created by historically unequal and differential perceptions of gender related to power, for a woman to engage in “harmful” health behavior (17). In other words, what are the factors that women face, determined by unequal power structures, that put her at an increased risk to not breastfeed? This, of course, has been stated in more benign ways, usually within the context of discussing barriers to breastfeeding. However, it is critically important to break down these barriers with an understanding of their social and historical roots in the relegation of women to a domestic sphere, the view of women as solely mechanisms of reproduction only, and sexism and objectification of women’s bodies. While this is no small task, a breastfeeding campaign that considers such a strategy could begin to reshape how society at large, and mother’s in particular, think about breastfeeding.

The sexual division of labor is particularly important in considering a women’s capacity to breastfeed in that policy may not be in place to allow her to breastfeed. The baseline from which policy is created is one in which the normative action by employers is not to consider roles of parenthood that women take on in the professional sphere, because they have historically been placed in a domestic sphere. While policy implementation is important, more significant is changing perceptions of breastfeeding as private and domestic to normal, diverse and professional. The campaign can address this by showing images of women using a breast pump at work. This could influence not only women in their self-efficacy to continue breastfeeding, but also workers at large to feel normal about such an action.

It will be important to show all types of women breastfeeding in a variety of situations. Kukla points out that two authoritative sources on breastfeeding, the American Academy of Pediatrics breastfeeding guide (AAP 2002) and the book What to Expect When You’re Expecting (Murkoff et. al 2002), are both resources that do not include images of women of color breastfeeding. Furthermore, images usually associated with breastfeeding show women that are “able-bodied, conventionally pretty and feminine, normally shaped… and endowed with normal-sized breasts” (15). This is especially shocking given the low rates of breastfeeding among African-American women, and reinforces the idea that if you are not the normative image of femininity or of a mother, then perhaps breastfeeding is embarrassing. An ad campaign needs to balance its message of breastfeeding as important to the health of the mother and the baby while not making it the defining characteristic of motherhood or womanhood, to give it weight, but in the context of the complex personal and social material that make up every woman. To understand how to change concepts of breastfeeding, the context of breastfeeding must be understood: both the physical reality (breastfeeding in work cloths or while engage in other activity) and the theoretical interpretation (as part of a social environment influenced by gendered power relationships and sexism). Then the portrayal of breastfeeding must reflect this reality, the ideal being that the health behavior can be achieved in the context, thereby changing the context.

Works Cited

1. Office of Women’s Health. National Breastfeeding Campaign. Washington DC: US Department of Health and Human Services. http://www.womenshealth.gov/breastfeeding/programs/nbc/#a
2. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.
3. U.S. Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. 1ed. Washington, DC: U.S. Department of Health and Human Services, Office on Women’s Health, 2000
4. Office of Women’s Health. Presentation on Breastfeeding Campaign with Campaign Research Findings. Washington DC: US Department of Health and Human Services. http://www.womenshealth.gov/breastfeeding/programs/nbc/results/index.cfm
5. Haynes, SG. (2006, April). Breastfeeding and Public Opinion: Before and After the Launch of the National Breastfeeding Awareness Campaign. Presented at the 134th Annual Meeting and Exposition of the APHA, Boston, MA.
(accessed from http://apha.confex.com/apha/134am/techprogram/paper_123944.htm)
6. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
7. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.
8. McIntyre E, Hiller JE, Turnbull D. Determinants of infant feeding practices in a low socio-economic area: Identifying environmental barriers to breastfeeding. Australian and New Zealand Journal of Public Health 2008; 23 (2): 207-209
9. Barber-Madden R, Petschek MA, Pakter J. Breastfeeding and the working mother: Barriers and intervention strategies. Journal of Public Health Policy 1987; 8 (4): 532-541
10. Dobson B and Murtaugh MA. Position of the American Dietetic Association: Breaking the barriers to breastfeeding. Journal of the American Dietetic Association 2001; 101 (10): 1213-1220
11. National Resources Defense Council. Issues: Health; Healthy Milk, Healthy Baby. Washington, DC: National Resources Defense Council. http://www.nrdc.org/breastmilk/formula.asp
12. Peterson, M (2003, December 4). The media business: Advertising; Breastfeeding ads delayed by a dispute over content. New York Times. Retrieved from http://www.nytimes.com/2003/12/04/business/media/04adcol.html?pagewanted=1
13. Centers for Disease Control and Prevention. (2010). MMWR weekly: Racial and ethnic differences in breastfeeding initiation and duration, by state – National Immunization Survey, United States, 2004-2008. Retrieved April 28, 2010 from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5911a2.htm
14. Schneider MJ. Introduction to Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2006.
15. Kukla R. Ethics and ideology in breastfeeding advocacy campaigns. Hypatia 2006; 21(1): 157-180.
16. Nommsen-Rivers LA, Chantry CJ, Cohen RJ, Dewey KG. Comfort with the idea of formula feeding helps explain ethnic disparity in breastfeeding intentions among expectant first-time mothers. Breastfeeding Medicine 2010; 5(1): 25-33.
17. Wingood GM, DiClemente RJ. The theory of gender and power: A social structural theory for guiding public health interventions (Chapter 3). In: DiClemente RJ, Crosby RA, Kegler MC, eds. Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. San Francisco, CA: John Wiley & Sons, Inc., 2002, pp. 313-346.

Works Consulted

-Bakalar, N (2010, April 19). Despite advice, many fail to breastfeed. New York Times. Retrieved from http://www.nytimes.com/2010/04/20/health/20stat.html
-Chatterji P and Brooks-Gunn J. WIC participation, breastfeeding practices, and well-child care among unmarried, low-income mothers. American Journal of Public Health 2004; 94(8): 1324-1327
-Fein SB, Labiner-Wolfe J, Shealy KR, Li R, Chen J, Grummer-Strawn LM. Infant feeding practices study II: Methods. Pediatrics 2008; 122: S28-S35
-Grummer-Strawn LM and Shealy KR. Progress in protecting, promoting, and supporting breastfeeding: 1984-2009. Breastfeeding Medicine 2009; 4: S31-S39
-Merewood A and Heinig J. Efforts to promote breastfeeding in the United States: Development of a National Breastfeeding Awareness Campaign. Journal of Human Lactation 2004; 20 (2): 140-145
-Wolfe JH. Low breastfeeding rates and public health in the United States. American Journal of Public Health 2003; 93(12): 2000-2010

Where Did The Boys Go? A Critique of Teen Pregnancy Prevention Approaches – Cynthia Schoettler

2010-05-10T09:13:00.005-04:00

Introduction
Teen pregnancy has always been a looming and difficult issue for American Society. While the average teen birth rate has declined dramatically since the highs recorded in the 1980s, it has shown an increase in recent years (1). In fact, in 2006, over 400,000 babies were born to a teenage mother (2). This accounts for over 9% of all births in the US (3).

Teenage motherhood is not without risks both medically and socially. Medically, the outcomes are worse than babies born to women in their 20s (4) and added cost of supporting teenage parents to society, in dollars, is upwards of $16,000 per year, per child (5). Young mothers are also at higher risk of dropping out of high school and achieve lower educational attainment (6) thus limiting their own potential for growth. Additionally, the female children of teenage parents are at least twice as likely to become teen parents themselves (7), thus repeating the cycle of additional risks, costs and poor outcomes.

But, these statistics and the majority of academic literature available regarding teenage pregnancy are all in regards to young women. For example, a cursory search on PubMed, one of the major search engines for scientific and medical literature, for “teenage pregnancy, (female or girl)” yields roughly 2.6 times the number of results that “teenage pregnancy, (male or boy)” does (http://www.ncbi.nlm.nih.gov/pubmed). While this may be a reflection of the fact that in society, the onus of child rearing usually falls upon the woman, especially in cases unintended pregnancies, it neglects the biological fact that creating a traditional pregnancy requires two individuals; one female and one male. Consequently, when confronting the issue of teen pregnancy, it is crucial to acknowledge the role that young men play.

This is not to minimize the current efforts targeting the role that young women have and need to take charge of their own bodies, their futures and themselves. Keeping young women at the forefront of teenage sexual education and prevention of teen pregnancy should always remain a priority. Instead, I wish to argue that because teen pregnancy is the result of two players, neglecting one half is akin to dancing the tango alone – awkward and not nearly as effective as when done in tandem.

Nowhere is this lonely dance more apparent then in current, widely publicized campaigns to prevent teen pregnancy. Among the most common campaigns such as MTV’s 16 and Pregnant (http://www.mtv.com/shows/16_and_pregnant/season_2/series.jhtml) , StayTeen.org’s teen pregnancy page (12) and the Candie’s Foundation (www.candiesfoundation.org). The campaigns and messages are frequently lauded for being appealing to teens and for employing star power or drama to propel their message to a willing audience. They are also relatively even handed when it comes to giving out information regarding the options that teens have in both preventing pregnancy and what to do if a pregnancy occurs.

However, much like the empirical research regarding teen pregnancy, these prevention of teen pregnancy campaigns focus on targeting young women. This focus is especially surprising given that some of the drop in teen pregnancy rates in the early 2000s has been attributed to shifting sexual behaviors in adolescent males (8). In order to demonstrate how the paucity of campaigns targeting young men has not met its potential I will critique this approach through pointing out the three major fallacies of neglecting young men in teen pregnancy prevention campaigns, and then argue for the addition of a male centered campaign.

Critique #1 – Ignoring the Male Interest

One of the most widely talked about teen pregnancy public service announcements (PSAs) this spring has been Brisol Palin’s warning about teen pregnancy by the Candie’s Foundation. In this PSA, Bristol Palin talks directly about her experience and the consequences of her actions. At no point is the role of the father mentioned. Furthermore, most of the other PSAs or posters put out by the foundation feature mainly teen girls (9). This focus on young women is further evidenced in its media material where the colors are black and neon pink, the majority of spokespeople are women and the promotional T-shirt is displayed by and comes in only women’s sizes.

By ignoring the male interest through creating campaigns that feature female celebrities or PSAs that talk about the girl’s experience in such detail, the announcements might as well be talking about menstruation, dangly earrings or anything else that teenage boys typically find beyond their realm. Anyone who knows teens will be able to tell you that one of the fastest ways to be ignored is to be completely uninteresting to them and un-relatable (32). By focusing so heavily on the teen girl’s point of view or experience, the promoters of these campaigns are essentially doing just that.

Instead, the campaign needs to take a note from their own manifesto and “use celebrities that teens can relate to” (9) - male celebrities talking about the male perspective of teen pregnancy. This approach is key because despite recent movements towards gender equality, concrete gender differences regarding sexual knowledge, attitudes and behavior remain (10).

Utilizing differences to attract specific audiences is nothing new. Traditionally, marketing firms research the target audience extensively to better understand what they relate to and even more importantly, what they pay attention to. This is called “Formative Research”, and is the foundation of any successful marketing campaign (11). Yet in the teen pregnancy campaigns, this basic principal of marketing seems to be forgotten.

Critique #2 – Portrayal of the Male Role

The second area where teen pregnancy awareness and education campaigns fail is in portraying the male role. In the Candie’s Foundation campaign, the male is featured as an accessory to the crime who then disappears when the girl is handed a baby (9).

In the information regarding teen pregnancy presented by StayTeen.org, eight of the 12 facts presented focus on the consequences for teen girls. This is 75% of what was presented. For the remaining quarter, one fact talks about fathers not marrying the mother, another talks about how the male children of teen mothers are more likely to go to prison and the other two are simple statistics about teens and pregnancy in general (12). It is clear that nowhere is there any information or anecdotes about how the pregnancy was created by or affects the father of the child.

If teen pregnancy campaigns are going to engage the adolescent male through scenarios, anecdotes and information, why is there no representation of his involvement? This blatant omission of the simple biological fact that the young man was involved in creating a pregnancy is akin to pardoning him from any and all responsibility – for the act and repercussions.

The result of this omission is profound. Labeling theory tells us that creating a perception or a label of a certain demographic essentially creates a self-fulfilling prophesy – for society and especially for the labeled individual (13). Consequently, by communicating that adolescent males are exempt from responsibility for and the results of teen pregnancy, we are setting them up to believe and act so.

One very public example of this is featured in the 16 and Pregnant MTV reality show where many of the teen fathers are blatantly uninvolved (14). By placing these young men in the spotlight the show is inadvertently endorsing their behavior and furthering the reputation of teen fathers as irresponsible and irrelevant.

By widely presenting teen males as superfluous and exempt from teen pregnancy, the campaigns are essentially publicizing that the male is expected to do nothing. Because social expectations are so powerful, often acting as rules that govern the day to day functioning of society (15), these PSAs are acting to further perpetuate the exact problem they wish to solve. A result of this is that adolescent males frequently place contraceptive responsibility to females and have lower perceptions of the risk of pregnancy (16; 8).

Socially and biologically, the male exemption from teen pregnancy has many effects. Children of uninvolved adolescent fathers are more likely to drop out of school, have developmental and behavioral problems and become teen parents themselves (17). Some may argue that this may be due, in part, to the fact that teen fathers indeed are often uninvolved in the rearing and support of their children. Some statistics report that only 15% of unwed fathers provide regular support (18).

Even so, the fact of the matter is that even when disengaged, teen pregnancy does affect the father. Sullivan (19), reports that the inability to provide support in the life of their child is often viewed as a manifestation of a loss of manhood. Other studies show that teen fathers don’t necessarily view disengagement as a desirable outcome (20). Thus, in order to help stop the cycle of self-fulfilling labeling and to help better support teen fathers it is doubly important to show them exactly what their role was, how becoming a parent will affect them and how important it is for them to be involved.

Critique #3 – The Reality of Men Are From Mars

Whether it is comfortable to admit or not, there are distinct gender differences in the psychological and sexual profiles of adolescents. For example, teen boys often have less conservative attitudes about sex than teen girls (8). They also react differently to information regarding sexual health and procreation (21).

As a reflection of these differences, teen boys have been known to discontinue any use of an effective method of contraception if a current method is deemed uncomfortable (socially or physically) (22). This is worrying because some studies have shown that male methods account for half of all adolescent contraceptive use (23).

This difference likely results from the fact that adolescent males become aware of their potential to procreate at later years than adolescent females (24). This consciousness is also activated differently, through problem solving alongside the direct envisioning of of procreation (21). Adolescent females, on the other hand, become more aware of their sexuality through active experiences and often before the onset of menarche (25).

Another realm where adolescent males differ from females is in reactance to information, instructions and especially to campaigns (32). Adolescent males consistently produce higher behavioral and verbal reactance scores than their women counterparts (26). This means teen boys react less favorably when simply instructed to do something and more favorably when presented with options – much like Hutchinson et al determined when studying male awareness of sexuality and sexual situations. By ignoring these differences between the genders, potentially effective campaigns fail to meet their potential and end up impotent.

Proposed Intervention

As stated earlier, many of the current wide-reaching initiatives are lauded for being [initially] appealing to teens as a general population, for employing star power and drama to propel their message to a willing audience. Yet, they fall short in being able to specifically target the male audience, portray adolescent males as involved in the creation of a pregnancy and the aftermath and in acknowledging the fact that adolescent males view and react to sexuality and messages different from adolescent females. Therefore, I propose to add male oriented, Public service announcements, posters and information to the present teen pregnancy prevention campaigns.

For example, piggy-backing off of the Candie’s PSA featuring a passionate scene of a teen couple in a car, instead of suddenly switching to an awkward moment with a baby, the couple would be faced with what to do because the guy just found out he has no condoms. The options would be to go ahead or be a real man and pause [the tagline of the campaign] to fix the problem. A simple change such as this would address all three of the main problems of the current campaign by a) appealing to the male interest in general and in relation to sexual health by featuring a guy the viewers can relate to, b) portraying him as a responsible partner in the act and c) acknowledging his thought patterns and reactions by placing the decision in his hands.

Defense of Intervention - Marketing Techniques

Publicity campaigns for commercial products are so successful because they are able to employ the core traits of marketing theory and framing with great skill. For example, the clothing brand Abercrombie and Fitch is able to sell rather common looking T-shirts at high prices because they appeal to teenagers’ ideals of strength and independence.

Likewise, these same tools can be re-appropriated for the prevention of teen pregnancy by incorporating them into the campaigns. It is only after being able to “get under the skin of their target audience and explore the core values” (11) that one is then able to redefine the product [teen pregnancy prevention] in a way that will be able to grab attention and make the message appealing.

One way to do this for the male addition to the teen pregnancy campaign is by changing the way the information is presented. One way is to appeal to values young men embrace – such as independence or virility. For example, instead of showing an unhappy teen father alone, contrast him to an independent and sexy teen who is not a father. A different approach would be to appeal to a teen male audience would be to portray activities, such as afterschool programs that have been proven to reduce teen pregnancy and emphasize teen success (8) in a light that also would make the participant more desirable to the opposite sex.

Another way to capture the male interest would be to present the issue as something they are affected by; to make the issue of teen pregnancy relevant to the adolescent. An effective method for this would be to feature clips of real, or admired, teenage boys talking about how preventing teen pregnancy allows them to remain independent (and still be cool). By keeping the personal stories positive the campaign would help create a positive promise for the young men that they would embrace more readily (27). Similar approaches have been used in individually focused teen prevention initiatives with great success (8), but would reach a larger target audience if part of nationwide publicity campaigns.

Furthermore, as an extension of the visual support the commercials following this formula would lend to the message, the information sections of these websites would need to also appeal to male values and interest. This would mean completely re-formatting the layout. Perhaps the websites could follow the format of Sports Illustrated, AskMen.com or GQ Magazine – any site that is specifically designed for and read by this demographic.

The information given on such informative websites would also have to focus on the ways in which a pregnancy affects the male and be nuggets of information that teen boys react to. Examples include giving statistics on how there is a threat to independence and that future achievements can be thwarted by the new responsibility and financial burden of raising a child (8). This would help fix the problem that the current sites have featuring women and the color pink (one of the colors most widely associated with women and girls) or by being gender neutral and hence less interesting to boys.

Defense of Intervention – Social Influences

Focusing on the adolescent male in broad public service campaigns is especially important because one of the remaining effects of the perception that ‘boys will be boys’ is that the sexual education of teen boys is often neglected (28) and that teen boys are essentially exempted from responsibility for creating a pregnancy (18). Thus, to counteract this attitude, the campaigns need to publicly show that teen pregnancy is indeed affects young men, and as something that they can and should control.

The first step would be to reduce the optimistic bias experienced by adolescent males (8, 34) and most individuals who engage in common high-risk behaviors (29). To do this, the new male focused campaign could continue with its format of featuring relatable teens, but also feature young men who became teen fathers and the way their new responsibility has affected their lives. By engaging the audience with a compelling personal story, the consequences become less abstract and more real. As a result, teen boys would be less apt to believe that a pregnancy won’t happen to them, and will be more willing to pursue options for its prevention.

A second component to changing opinions regarding the male role in teen pregnancy would be to model safe sex or abstinence behaviors in a way that preserves the ideal of manhood. This would also remove the perception that engaging in safe sex behaviors or refusing intercourse is damaging to one’s self-image or loosing the respect of one’s peers (30). Instead, it would add the perception that [the male] taking responsibility is expected and desirable. An example of this could be a commercial asking the question “What is a real test of strength, 100 pushups in a minute or saying no to sex without condoms?” The end result of a sustained and successfully executed campaign with these components would be an eventual shift in society’s perceptions and expectations [of the guy’s responsibility] and young men would follow suit (15).

While this approach may seem far sighted and impossible in some areas given the pervasive culture of machismo in nearly every social group of teen boys, current programs already promoting this approach, such as the Young Men’s Clinic in New York City (8) have proven to be very successful. They are successful because they consistently present young men with positive role models who achieve many of the same goals as the adolescents aspire to. While not as interactive as an group specific outreach program, a national information and media campaign with the same message would begin the process of normalizing the responsible adolescent male.

Defense of Intervention – Irrational Decision Making

The current campaigns fail to address the reality of the way individuals, especially adolescent males, make decisions. For example, in the Candies campaign, one PSA beings well with a very passionate scene of a teen couple (9). While this opening is an excellent use of context by creating a hot state for the viewer, it falls short in the delivery of the message. This is because after creating the hot state, the scene suddenly changes to a cold one by cautiously presenting the guy with a baby in a pram and no information about how to prevent this reversal of situation. Based on our knowledge of how adolescent males think about procreation, the PSA would be much more effective if it continued to give its information in the hot state and presented the male viewer with a quick dilemma and subsequent solutions (21).

Tailoring the message to the way adolescent males made decisions is crucial because especially in middle adolescence, teen boys do not respond well to scare tactics and instead are pushed to take the exact risks they have been warned about (8). Therefore, by engaging the teen in problem solving and by framing the options as a choice, the campaign takes advantage of the teens’ need to make their own choices and exercise their growing ability to reason (31).

As a result of such an approach, the teens would begin to feel more involved in their own actions and in the protection of themselves and their livelihood. This is especially important because when individuals feel ownership over themselves, an object or even something as abstract as a brand, they are more willing to go to great lengths to maintain the situation (33). By creating an adolescent ownership of responsible sexuality or abstinence through the media campaign, through showing believable threats to their situation and through enabling teens to feel ownership through decision making, they will naturally be more apt to maintain what they have and stay pregnancy free.

Lastly all individuals, but especially adolescents, respond with less negative reactance and stronger agreement when the communicator is viewed as more similar to the target audience (32). So, by continuing to present popular yet relatable young men who act responsibly when it comes to sex the new campaign would garner greater credibility and allow adolescent males to take ownership over their actions because they would view their options as both desirable and reachable (33).

Conclusion

The end result of all these elements playing a role in the addition of a male oriented branch to current teen pregnancy prevention efforts would be to essentially create a sought after brand that is the responsible and involved teen male – who just happens to engage in safe sex practices or abstinence. The campaign would shift the current paradigm away from ignoring the male interest, promoting the lack of male responsibility for the creation of a pregnancy and the sequelae, and blatant lack of recognition of the male psyche. Instead, it would create an awareness of the benefits of avoiding teen pregnancy through effective marketing strategies, create favorable associations between the teen and the outcome through facilitating realistic decision making for the teen male and last but not least create loyalty to the prevention of teen pregnancy through promoting social expectations of responsibility.

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A Critique of Why the "Are You Pouring on the Pounds?" Campaign Will Not Prevent Weight Gain -Kate Sullivan

2010-05-10T09:13:00.002-04:00

Introduction

Soda, Gatorade, lemonade and ice tea. Refreshing drinks or dangerous drinks? What do these drinks have in common? Tons of sugar. These non-nutritive beverages are wreaking havoc on the weight of millions of Americans. What used to be an occasional treat has turned into a basic food group.
“Gross”, “disgusting”, “I can’t look at it” were comments made by passengers on the New York City subway system late last year (3). What these people were commenting on was a new public health campaign organized by the New York City Department of Health and Mental Hygiene (NYCDHMH), called “Are You Pouring on the Pounds?” The posters placed in the subway system show a soda or other beverage being poured out of a can or bottle into a cup and as the liquid reaches the cup, it turns into yellow globs of fat riddled with blood vessels. The department wanted a shocking campaign to catch people’s attention by focusing on the hazards of sugar-sweetened beverage consumption and to increase people’s awareness of how soft drinks contribute to weight gain and eventually to obesity (1). The campaign was short and focused. It ran for three months at the end of 2009. The message accompanying this image exclaims “Don’t drink yourself fat.” (1) NYCDHMH spent three years and $277,000 researching and developing this campaign.
The New York City Department of Health and Mental Hygiene was stirred to action because of studies showing connection between health problems and sugar-sweetened beverage consumption. To understand the SSBs consumption habits of its citizens, the health department conducted a survey. The 2007 Community Health Survey found that among adult New Yorkers, two million adults drink at least one SSB each day for a caloric intake of 250 calories (1). Serving sizes have increased and with that, increased consumption of empty calories. The department is looking to raise awareness of its citizens through the “Are You Pouring on the Pounds?” campaign about the hazards of SSBs. They are recommending substituting water, seltzer or low fat milk as alternatives (1).
It may be common knowledge that too many calories consumed leads to weight gain. SSBs have played a special role in the rising obesity rates is adults and children. From 1977 to 2001 the consumption of SSBs increased by 135% (7). Besides the infiltration of sodas into the American diet, SSBs also take the form of teas, sports drinks and fruit-based juices. SSBs all contain large amount of sugar. The calories contained in SSBs are empty calories and provide little nutritional value. When people drink SSBs, rarely do they take into account the extra calories. A randomized, double-blind study was conducted by Raben et al to compare the effect of calorically sweetened beverages with that of diet beverages (8). The study showed that the calories from SSBs did not replace food calories, but were additional calories to the diet (8). Those participants who were given the caloric sweetened beverages gained weight during the study and those who drank diet beverages did not (8). This is why the New York City Department of Health and Mental Hygiene is trying to decrease SSBs consumption.
Articles about the campaign are plentiful. Journalists from The New York Times, The Daily News and the British Broadcasting Corporation discussed the effectiveness of the “shock” campaign and interviewed various people. Opinions were mixed. Some people interviewed felt that this kind of campaign would work, others thought it wouldn’t. Many websites and blogs discussed the merits of the campaign (4). Claire Prentice, writing for the BBC News, interviewed a mother and daughter who were riding on the subway. The daughter was quoted as saying “gross” and the mother claimed that she never realized the amount of sugar in SSBs (3). Prentice spoke with a NY psychologist, Jonathan Alpert. He supports the shocking advertising and claims that in makes people think about what they are putting in their bodies. On the flip side, an advertising expert, George Parker, was critical of the campaign. He warned that it might backfire because the image is so gruesome people will turn away before the whole message is absorbed (3). The New York Times interviewed Cathy Nonas, director of Physical Activity and Nutrition programs. She said that the campaign was definitely going for shock value. She also said that the campaign was tested on focus groups and the “graphic in-your-face” approach would work (2). In the Daily News, Adam Lisberg spoke with Associate Commissioner Geoff Cowley. Cowley claimed that “being ‘positive and encouraging’ is not always useful in getting people to change behavior, sometimes you have to get into people’s faces to get attention (4).”
The New York City Department of Health and Mental Hygiene is not the first health department to raise awareness of the link between SSB consumption and obesity. During the summer of 2008, the Bay Area Nutrition and Physical Activity Collaboration in the San Francisco area conducted a campaign called “Soda Free Summer.” The idea behind this campaign was to get people to pledge not to drink soda over the course of a summer. The tools of this campaign included log books, pledge cards and wrist bands which were designed to keep the participants engaged through out the summer (5). Another campaign, called the global “Dump Soft Drinks” campaign is an international effort to improve children’s health and diet around the world. The campaign has succeeded in persuading Coke and Pepsi to provide more healthy alternatives at school vending machines is the Unites States and European Union (6).
There are three flaws in the “Are You Pouring on the Pounds?” campaign. The first flaw is that the campaign relies on the Health Belief model. This traditional model puts the onus on the individual to make a change. It relies on rational thought processes and planned behavior. The second flaw is that the campaign used fear to get the message across to the target audience. The third flaw is that the campaign targeted the proximal causes of SSB consumption.

Critique 1
“Are You Pouring on the Pounds?” is a campaign geared towards the individual. The NYCDHMH is asking each citizen of New York City to reconsider his/her SSB habit and substitute water, seltzer, or low-fat milk. This campaign is modeled on the Health Belief Model which is a traditional health behavior model. It is based on the motivation of the individual to adopt healthy behaviors and is comprised of several factors: perceived susceptibility, perceived severity, perceived benefits of an action and perceived barriers to taking that action (9).
The campaign is geared towards the individual: “Don’t drink yourself fat” (1); it is based on rational thought: “I will stop drinking SSBs now”; and it is planned behavior: “Next time I choose a beverage, I will drink water or milk.” The perceived benefits are less chance of obesity. The perceived susceptibility and severity is whether or not the individual believes that drinking any amount of SSBs will cause them to gain weight and to what extent will they become over weight and suffer health consequences if they don’t follow the health advice of the campaign. The perceived barriers to reducing SSBs consumption may be price of other beverages (fruit drink and soda are cheaper than milk); convenience (most SSBs do not need to be refrigerated while milk requires refrigeration) and water may not be appealing (SSBs are tasty and enjoyable, and therefore hard to give up). People may not be willing to spend money on bottled water but also may feel that tap water in their home is not good for them. Water fountains are not well maintained, many are broken, in disrepair or they look unhygienic so people are unwilling to drink from them.
Because this campaign is based on rational and planned behavior of the individual, it fails to take into account the irrationality of the individual. The campaign has created an expectation that if a person continues to drinking SSBs, he/she will become obese and have health problems. This campaign tries to educate individuals on the hazards of drinking SSBs and gives healthy alternatives, but it does not acknowledge that individuals really like SSBs and do not want to give them up; people “own” their SSB consumption.
The campaign is asking the individual to make a decision regarding beverage choice. If the individual does not follow the recommendation, something bad will happen: the individual will gain weight. The campaign is over estimating the ability of any one person, on their own, to make a change and gives no long term support to the individual.
Self-control is also an issue in this campaign. Whenever one wants to give up something, there are always others around who are doing the behavior. It’s hard to say no to soda when your best friend is drinking it. The individual faces added pressure about beverage choice because not only is drinking SSBs socially acceptable, people have been lead to believe through incessant advertising, that SSBs will make you socially acceptable.
The developers of this campaign used the Health Belief Model when they developed this campaign but fell into the “EZ program structure illusion.”(9). The message it provides “SSBs turns to fat” and people should stop drinking it for the sake of their health seems simple enough but the campaign fails to take into account expectation, ownership, framing of core values, context and self-control.

Intervention 1
Juxtaposed to the Health Belief Model with its emphasis on the individual is the Ecological Model for Health Promotion which recognizes that behavior is complex and there are many “factors” involved. The factors involved in this model are intrapersonal factors, interpersonal factors, institutional factors, community factors and public policy (10). The Ecological Model for Health Promotion recognizes that a range of strategies are necessary in health promotion activities (10).
One can understand the desire of the New York City Department of Health and Mental Hygiene to want to reach as many people as possible throughout the city. Putting the ads in the subway system would logically reach a lot of people in a short amount of time. Although their intentions were good, they wasted their money. The ads are catchy, and have a good tag line but are soon forgotten once the individual leaves the subway.
New York City Department of Health and Mental Hygiene would have been wise to target a community in which SSBs consumption is the highest. According to a survey conducted by the NYCDHMH, the Bronx had the highest consumption rates of all the boroughs surveyed (11). The ecological model says that intervening at the individual level is not enough. The community should be part of the intervention: “the purpose of an ecological model is to focus attention on the environmental causes of behavior and to identify environmental interventions” (10).
The Soda Free Summer campaign would have been a good model for New York City to use in the Bronx. The Bay Area Nutrition and Physical Activity Collaborative used an inter-disciplinary approach to reduce SSB consumption. “The soda free summer campaign consisted of a variety of activities to reach residents in the six San Francisco Bay area counties.” (5) The campaign involved the individual by distributing pledge card and logs to track progress through out the summer. The completed pledge cards could be turned in and entered into a raffle to win a prize. Promotional material was distributed to remind people of the program. Wrist bands were distributed to the participants that helped maintain a sense of community: “you are not alone in your endeavor”. Workshops were offered to educate participants on the sugar content of beverages and the health risks associated with sugar consumption. Community factors were applied to the program: school districts, public health departments, community groups, clinics and hospitals assisted in the campaign through a variety of outreach channels. Public policy factors were employed. Political leadership was engaged in the campaign (5). By using aspects of the ecological model, the campaign was a success: 47% of the participants reported a decrease in their soda consumption as a result of the campaign (5).
Money may have been a factor but if the New York City Department of Health and Mental Hygiene had used this model to target a particular community such as the Bronx, they might have made an impact by reducing this type of beverage consumption on the community with the highest consumption level of SSBs. This could then have been used as a model for other communities throughout New York.

Critique 2
The New York City Department of Health and Mental Hygiene framed their campaign with fear. The fear in this campaign is weight gain from drinking SSBs. “Fear appeals are persuasive messages designed to scare people by describing the terrible thing that will happen to them if they do not do what the message recommends” (12). Whether a message is rejected or not depends on the level of threat as well as the level of efficacy, i.e. the ability to do something about it. (12).
Many public health campaigns have used fear to motivate individuals to change their behavior. For example, the drug-resistance campaign that used a frying egg to simulate how a person’s brain looks on drugs used fear to change people’s behavior (12). Fear models such as the Extended Parallel Process Model (EPPM) use the elements of fear appeal as the basis of their model (12). There are four important components to the fear appeal process: fear, threat, efficacy and outcome variables (12).
A fear appeal can be explained by examining the content of the fear appeal, (gory pictures of crash victims) or fear appeals can be explained by the reaction of the target audience. The target audience can give self-reported levels of fear or instruments can be used to measure the physiological state of the target audience. The fear appeal targeted to the audience in this campaign is that if you drink soda, you will gain weight and have health problems (12). Fear is a negative emotion and has been described by various researchers as anxiety, concern, worry or physiological arousal (12). In this campaign, the fear of weight gain may cause anxiety. Since the campaign does display a glob of fat riddled with blood vessels, negative emotions are aroused and the images in the campaign are labeled as ‘gross” (3). Threat is an external stimulus variable that exists whether a person knows it or not (12). Threats are categorized based on severity of threat (12). In this campaign, the threat can be categorized as the severity of the weight gain and extent of health problems. A person may gain a couple of pounds or hundreds of pounds; have few health problems or many. Efficacy is the targeted audience’s ability to perform the recommended response (12). In this campaign, efficacy is the ability of the target audience to reduce the amount of SSBs in their diet. In the fear appeal, the researcher is looking for message acceptance as an outcome. The outcome does not always lead to message acceptance. Sometimes avoidance and reactance are the outcome (12). The outcome of the campaign is the actual response of the target audience to the message. The target audience may reduce consumption of SSBs, therefore the message was accepted. There may be no change in consumption habits in which case the message was avoided. The worst outcome would be an increase of consumption in defiance of the message, indicating the message had the opposite effect.
Although the campaign fits into the EPPM and this model can explain how the target audience will react to the fear appeal, researchers don’t know how effective fear campaigns are. “Beck and Frankel (1981) noted that the parallel process model is the most broad of the fear appeal theories and although virtually untestable, offers a nice frame work in which to further theorize (12).”
If the EMMP provides a framework, other researchers have explored reinforcement in relation to fear appeal. The effective use of fear is when fear is coupled with reinforcement; this is called “response- fear offset pairing (13).” An example of the type of situation that uses “response-fear offset pairing” is the pairing of seatbelt use with an outcome. Seatbelt-use campaigns have tried to get the target audience to use seatbelts. The underlying message of wearing seatbelts is that if you don’t wear seatbelts, you could die. Even though this could happen, the likelihood of it happening is very small, so the target audience rejects the message. When seatbelt-use messages are reinforced with laws that allow police to ticket and fine non-seatbelt users, the target audience embraces the message and wears seatbelts (13).
This campaign did not use fear successfully. “The use of fear is only likely to work under particular circumstances involving the identification of specific behaviors which successfully reduce the fear aroused (13).” Although the images of fat in a glass are unsettling, the threat of weight gain and the risk of poor health are not strong enough to trigger a change in the target audience because there is no appropriate reinforcement i.e. response-fear offset pairing. A reasonable reinforcement could be a tax added to sugar-sweetened beverages. Increasing the price of SSB would impact the “wallet” of the target audience.
When changing a behavior it is also helpful to see immediate results of the change (13). The target audience may feel that they have been drinking soda for a long time and it has not caused them any harm. Even if the target audience did give up drinking soda, it may be along time before they saw any positive results (weight loss). In addition, it would be impossible to judge if in fact the target audience was able to avoid poor health outcomes from reducing SSB consumption. Researchers recognize that health promotion should not be the removal of unhealthy behaviors but of the reinforcing of healthy behaviors (13). The overall message of “Are You Pouring on the Pound?” is a fear-invoking message dictating the decrease of SSB consumption instead of a positive message encouraging consumption of water or milk.

Intervention 2
The New York City Department of Health and Mental Hygiene should take some cues on promoting healthy beverage choices from the “got milk?” campaign. The campaign used humor and what the advertisers called a milk deprivation strategy (14).
For years drinking milk was promoted as “the key to good health”. Dairy advertising, public relations efforts and the government worked together to encourage milk consumption. For a while the idea of good health from drinking milk worked. But in the 1990s due to other beverage choices made available to consumers, milk consumption declined. SSBs were fun to drink; their packaging was colorful and had innovative designs. This was in contrast to milk which was packaged in boring cardboard cartons and plastic jugs (14). In order to increase sales of milk, the California Milk Processor Board hired a San Francisco ad agency to create a new campaign. “Got milk?” campaign became one of the 1990s most popular and critically acclaimed advertising campaigns (14).”
Money aside (the advertising agency had a $23 million per year budget) the advertisements were effective because they appealed to a core value that was something other than health. Although many people surveyed thought of milk as a compliment to certain foods, the advertising team decided not to sell milk as a complement to those foods (14). Instead, the ad agency used a milk deprivation strategy mixed with humor. The television ads showed people put in silly situations where milk was not available. For example, one commercial showed a man going to heaven and there were chocolate chip cookies everywhere. As he ate the cookies, he grabbed carton after carton of milk, and they were all empty. He began to wonder if he was in heaven after all. This helped to sell milk because the commercials were humorous and people could relate to that feeling of being without milk when it was needed it most (14).
What the New York City Department of Health and Mental Hygiene could have done to “sell” water was use a deprivation strategy. The campaign could reach the target audience by portraying people performing strenuous activities and then not having the most thirst quenching beverage available: water. Posters with an image of someone in the dessert seeing a mirage of water, but not being able to reach it might have portrayed a water deprivation scenario. Making the image enjoyable and positive would have a greater impact than showing an image that is disturbing and negative.

Critique 3
“Are You Pouring on the Pounds?” addresses the proximal causes of weight gain. It maintains that if you drink soda and other soft drinks you, the individual, will gain weight. Telling the individual to cut back on SSB consumption is futile in light of marketing tactics, availability, social norms and policies. Beverage companies target children and teens in their advertising campaigns. For example, the Sprite “Obey Your Thirst” campaign featured rap artists and basketball players combined with “playful cynicism” to create a brand that became popular with urban youth (14). The availability of alternatives such as water fountains is not taken into consideration. The campaign doesn’t take into account the wide availability of SSBs. Everything is geared towards making drinking beverages easy. There are reminders every where that you too can be carrying a beverage. SSB are available everywhere: in corner stores, vending machines, grocery stores, and street vendors. The fact that people bring their drinks where ever they go is not addressed. There are very few places where it is not acceptable to carry around a beverage. Schools allow students to have drinks in class. Cars have beverage cadies as do strollers and shopping carts. SSBs are portable, inexpensive and do not spoil if not refrigerated.
SSBs are served to the youngest members of society, usually in the form of fruit juices. At an early age, children are given juice during the day are snack or meal time. They are conditioned at an early age that sweetened beverages are normal. The Federal Government endorses the consumption of sweet beverages (juices) because there is concern that young children are not getting an adequate amount of fruit in their diet. The Dietary Guidelines for Americans recommends fruit juice consumption by children (15). Since SSBs are a normal part of every day life from early on, asking people to give up SSBs is not practical.
People are taught from early on that sugar-sweetened beverages are a normal part of their diet. This is further reinforced by the wide-spread availability and social acceptance of SSBs. SSBs are ingrained in the American diet. It is unrealistic to expect people to change their behavior when even the government is encouraging people to drink SSBs.

Intervention 3
Efforts to reduce SSB might be better addressed at the distal level. From a rational point of view, the individual has control to a certain extent but people are not rational. Putting policies in place such as requiring beverage manufacturers to make some labeling changes and even levying a tax on sugar-sweetened beverages would go along way in changing people’s relationship to SSBs.
Sugar-sweetened beverages are packaged and bottled in various configurations. Some juices are packages in colorful cartoon featuring favorite cartoon characters. Each juice box represents one serving. The box is around 6-8 ounces and may have a calorie content of 100 calories. This is a reasonably sized portion and represents the small end of the scale for size. Many SSBs are available in 2 liter or ½ gallon-sized bottles. These SSBs contain numerous servings. Most people would agree that this size is not a single serving size and would adequately serve a number of people. This represents the large end of the scale. In between the juice box and the 2 liter bottle is a landscape of bottles of various sizes and shapes. Are the bottles in between single serving containers or are they multiple serving bottles? Even though the 20 ounce soda bottle claims that it contains 2.5 servings, how many people are really going to share that bottle? In actuality, the 20 ounce bottle is one serving. Even if a smaller size beverage is available, it is not priced as favorably as the larger size so one may feel a little “ripped off” buying it. Larger sizes are considered a “value” because they are cheaper per unit measure. Buying in bulk is cheaper on the wallet but drinking in bulk carries the hidden cost of weight gain.
Bottlers have been getting better about labeling their bottles. They may still consider that the 20 oz bottle provides 2.5 serving, but some bottlers are also putting the calorie content of the entire bottle on the nutrition label as well as the calories “per serving”. This type of labeling was recommended by the FDA’s Obesity Working Group “encourage manufacturers immediately to take advantage of the flexibility in current regulations on serving sizes and label as a single-serving those food packages where the entire content of the package can reasonably be consumed at a single-eating occasion. For example, a 20 oz bottle of soda that currently states 110 calories per serving and 2.5 servings per bottle could be labeled as containing 275 calories per bottle.”(16) Not all bottlers are doing this but consistent labeling of the calorie content of the bottle will help consumers make better choices.
Another way to reduce SSB consumption from a distal vantage point that has caused a lot of controversy is taxing SSBs. Public health groups advise taxing SSBs would lead to decreased consumption and subsequently reduced health problems. Many consumer groups see taxes as regressive, affecting poorer people disproportionately (17). On the other hand, poorer people have greater health problems related to a nutrient-poor diet and would benefit from reducing the consumption of sugar-sweetened beverages (17). According to Brownell and Frieden, the best way to implement the tax is to use an excise tax (17). This type of tax structure taxes a fixed cost per ounce at the manufacturing level. This cost would be passed on to the consumer and it would be seen as the true purchase price of the beverage (17). The sales tax, on the other hand, is added on to the beverage at time of purchase. At this point the consumer has already made their choice or feels obligated to pay since they are already at the cash register (17).
According to Brownell et al, taxing SSBs would reduce the amount of consumption because of “price elasticity” which is described as consumption shift caused by price (18). The price elasticity for all soft drinks is the range of -0.8 to -1.0 (18). This means a decrease in consumption from 8-10% if there was an 8-10% increase in price of the beverage. Consumers would switch to diet beverages (which would not be taxed) if their favorite SSB becomes too expensive, or perhaps to a smaller size container if available (18).
Reducing consumption of SSBs through taxation would in turn lower risks of obesity, diabetes and other diseases. The tax money raised could go to obesity prevention programs geared towards children and teens.

Conclusion
The New York City Department of Health and Mental Hygiene sponsored a campaign that was geared towards getting people to change their sugar-sweetened beverage habit. The campaign focused on the individual instead of looking at the larger community, it used fear instead of positive reinforcement and it targeted the proximal causes of weight gain instead of looking at distal causes. One New Yorker said it well, “They look kind of lame (the posters). We’re bombarded with so many messages and these don’t stand out (3).” Unfortunately, the message may not be heeded and New York City will likely have wasted taxpayer money.

References
1 New York City Department of Health and Mental Hygiene. Are You Pouring on the Pounds? Health Bulletin, 2009.
2 Chan, Sewell. “New Targets in the Fat Fight: Soda and Juice.” New York Times. 01 September 2009. Web. 02 April 2010.
3 Prentice, Claire. “Anti-obesity as shocks New Yorkers.” BBC News. 07 October 2009. Web. 31 March 2010. http://news.bbc.co.uk/go/pr/fr/-/2/hi/americas/8281203.stm.
4 Lisberg, Adam. “Controversial new subway billboards show human fat being poured out of soft drink bottles.” Daily News. 21 August 2009. Web. 02 April 2010.
5 Bay Area Nutrition and Physical Activity Collaborative. Getting the Soda Free Message. San Francisco, CA: Bay Area Nutrition and Physical Activity Collaborative. 2009. www.banpac.org.
6 Center for Science in the Public Interest, International Association of Consumer Food Organizations. Global Dump Soft Drinks campaign. Web. 02 April 2010. http://dumpsoftdrinks.org/index.html.
7 Malik, Vasanti S, Schulze, Matthias B., Hu, Frank B. Intake of sugar-sweetened beverages and weight gain: a systematic review. American Journal of Clinical Nutrition 2006; 84: 274-88.
8 Bray, George A., Nielsen, Samara Joy, Popkin, Barry M. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. American Journal of Clinical Nutrition 2004; 79: 537-43.
9 Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
10 McLeroy, Kenneth R., Bibeau, Daniel, Steckler, Allan, Glanz, Karen. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly. 1988; 15(4): 351-377.
11 New York City Department of Health and Mental Hygiene. Are You Pouring on the Pounds? Press Release # 057-09. http://www.nyc.gov/html/pr057-09.shtml. 31 August 2009. Web. 09 April 2010.
12 Witte, Kim. Putting the fear back into fear appeals: the extended parallel process model. Communication Monographs, 1992; 59: 329-349.
13 Job, R.F. Soames. Effective and Ineffective Use of Fear in Health Promotion Campaigns. American Journal of Public Health, 1988; 78(2): 163-167.
14 Holt, Douglas B. Got milk? Advertising Educational Foundation. 2002. Web. 08 April 2010. http://www.aef.com.
15 United Stated Department of Agriculture. Is Fruit Juice Dangerous for Children? Washington, DC: Center for Nutrition Policy and Promotion. March 1997.
16 Food and Drug Administration. Calories Count: Report of the Working Group on Obesity. Obesity Working Group. 2004. Web. 15 April 2010. http://www.fda.gov/food/labelingnutrition/reportsresearch/ucm081696.htm.
17 Brownell, Kelly D., Frieden, Thomas R. Ounces of Prevention-The Public Case for Taxes on Sugared Beverages. New England Journal of Medicine 2009; 360(18): 1805-1808.
18 Brownell, Kelly D. et al. The Public Health and Economic Benefits of Taxing Sugar-sweetened Beverages. New England Journal of Medicine 2009; 361(16): 1599-1605.

Does Abstinence-only Education Work? – Daniel M Purnell THE PROBLEM

2010-05-10T09:10:00.001-04:00

Adolescent sexual behavior is related to a number of public health problems, such as teen pregnancy, abortion, and STIs. The most recent research from the Centers for Disease Control and Prevention (CDC) report that nearly half of all high school students (students aged 15-19) have had sexual intercourse; and of those, 39% did not use a condom the last time they had sex (1). Earlier data had suggested that over 50% of both males and females between ages 15 and 19 had engaged in oral sex (1). 14% of all HIV/AIDS diagnoses in 2006 were in young people aged 13-24 (2). Each year, half of the approximately 19 million newly diagnosed STIs occur in people aged 15-24.4 (3). In addition, most recent teen pregnancy rates from 2006 reported nearly 500,000 births to mothers aged 15-19, the majority of which were unintended pregnancies (4). Also in 2006, adolescents aged 19 years or less underwent 116,613 abortions (5).

In light of these numerous health risks, a public health intervention to address risky adolescent sexual behavior is clearly warranted. Given the data above, it would seem the most logical solution would be to use public schools to provide all young Americans with information regarding the dangers of sex (e.g., how many teens have STIs, the probability of catching certain STIs, the financial and emotional cost of having a child, etc.) and essentially telling them to abstain from sexual intercourse until marriage and/or adulthood. Indeed, a number of these so-called abstinence-only programs (discussed in greater detail below) have sprung up around the country. In this editorial, I will argue that Abstinence-Only sex Education (AOE) fails as a public health intervention because federal policy defining AOE is based on moral values and supported by biased, poorly conducted research; because it does not take into account all of the factors that play into whether or not a teenager chooses to abstain from sex; because proponents of AOE improperly frame the issue of sexual education of adolescents; because the message is delivered only by adult teachers in an educational setting; because it ignores important teen health issues; and because it goes against what the majority of parents want for their children. I will conclude by proposing a general solution to the problem.

Federal Policy and AOE Models
AOE programs are often based on individual level health education models, which focus on education through talking about the risks of sex and values and attitudes toward sex, and assumes that when kids know how risky and harmful sex can be, they will make the choice to be abstinent. Teen-Aid, an AOE program founded in 1981, focuses on what they call “risk avoidance education” (6). Values and Choices focused on the Theory of Reasoned Action and used values-based education to change teen attitudes toward sex (7). Facts and Feelings, similar to Values and Choices, was a home-based program emphasizing values-based education at the individual level (7). Success Express, Project Taking Charge and Sex Respect all have a similar values-based, individual focus (7). However, even assuming this is a useful model for AOE (see page 4 for further discussion), current federal policy outlining criteria for these AOE programs raises a number of problems in the context of health belief and health education models.

First, a recurring theme in these policies is alleged “harmful psychological and physical effects” stemming directly from sexual activity “out-of-wedlock” (8). Yet a recent review paper by John Santelli and colleagues uncovered no studies showing a causal link between adolescent sexual activity and mental health problems (9). Any papers that do address mental health and sexual activity in this population appear to suggest that early sexual activity may be an effect of pre-existing psychological harm, rather than a cause of it (9). A review by Robert Anda and colleagues concluded that adverse childhood experiences and their subsequent effects on behavior were strongly related to age of first sexual activity (10). Related studies have yielded similar results (11-14). The policies also imply harmful psychological effects for teens who become pregnant and undergo abortions (8). Yet several studies suggest the exact opposite is the case (15-18). It is difficult to determine, in light of these findings, what facts, if any, were relied on in the development of these policies.

Second, abstinence appears to be defined in the criteria as not engaging in “sexual activity” until marriage. But there is no explicit definition of what constitutes sexual activity and, ergo, what constitutes abstinence (8). A survey conduct by Mark Schuster and colleagues suggested that adolescent beliefs and behaviors regarding what abstinence is can vary, such as whether or not oral or manual stimulation counts as a loss of virginity (19). AOE program directors and instructors also differ in how they define abstinence. A study by Patricia Goodson revealed “substantial variation” in how directors, instructors, and hence, participant youth defined abstinence (20). It would seem that before developing policy regarding how to teach abstinence to teens, it would be helpful if those involved came to an agreement on what abstinence is.

Third, there is an obvious pro-abstinence moral bias in these policies. Here, abstinence is often not discussed in the context of health, but in the context of character and moral values, often religious in nature (8). This is problematic when one considers children who have been raised with a particular set of moral values asserting that sex out-of-wedlock is common and acceptable. What would teachers following an AOE program say to them? The inherently subjective nature of moral values not only raises a serious ethical question as to whether or not it is acceptable to use them to develop nationwide policy in this context, but also raises serious doubts as to the credibility of the federal policies as a whole.

Finally, nowhere in the policies is there any indication that a discussion of healthy sexual behaviors, such as proper contraceptive use or what to do in the case of a pregnancy or STI scare, would be necessary. In fact, from the policies it appears that this information has been intentionally excluded (8). This seems to endorse the preposterous notion that the best way to reduce undesirable behaviors is to altogether avoid a discussion of those behaviors or their consequences. It is as if we were to decide that the best way to increase road safety was to never discuss what causes accidents or what to do if one occurs.

So what does all this mean for the Health Belief, Health Education, the Theory of Reasoned Action, and the AOE programs that use them? These programs, as shown, focus on risks, protective factors, and moral values-based arguments for being abstinent. They seem to assume that if teens have full knowledge of the risks of sex and are taught to be “chase” and “virginal”, they will weigh a desire for sex against the risk of disease or unwanted pregnancy, and in so doing, will choose to abstain. However, assuming these models could be successful, fundamental to their success is the veracity and general applicability of the information they teach to teens. How can one reliably or accurately weight risks and benefits in making a choice if the information one has is related to that choice is based on values-based personal biases, lies and incomplete information? Evaluations conducted on each of the aforementioned AOE programs are telling: Teen-Aid, Values and Choices and Sex Respect showed changes in attitudes in the desired direction, however say nothing about whether behavior changed, and a lack of comparison group coupled with the fact that all these studies were conducted in Utah using predominately Mormon subjects greatly reduces generalizability; Facts and Feelings showed no desired effects whatsoever at 12 month follow up, on either attitudes or behavior; Project Taking Charge appeared to increase knowledge but did not affect values or behaviors; and Success Express actually caused an increase in precoital sexual activity among participants (7). It should be noted that these evaluations suffered from a number of design flaws, such lack of a comparison group, small, non-representative study sample, and possible selection bias (7). However, two more recent reviews, one by Douglas Kirby (21), and one by Jennifer Manlove (22), which employed more stringent inclusion criteria, have been unable to find any scientific evidence that AOE programs effectively promote abstinence.

Decades ago, follow up research on the Drug Abuse Resistance Education program showed the program had failed to curb adolescent drug use (23). There is no reason to think that the same strategy will lead to a different outcome in this case.

Hot States versus Cold States
Another major problem with AOE programs and how they educate is the assumption that the choice to abstain will be made in a rational state of mind. The emotional intensity of a sexual situation compared with the relative emotional neutrality of an educational situation implies this may not be the case. A study conducted by behavioral economist Dan Ariely on a group of male students at UC Berkeley asked a series of personal questions related to sexual behavior which focused on types of sexual behavior in which students would likely be comfortable engaging. The questionnaire was administered twice, once while the students were in a non-aroused or “cold” state, and again in an aroused or “hot” state. The general goal was to determine whether level of arousal had an effect on decision making. Surprisingly, the results showed that those in a “hot” state were significantly more willing to perform all of the described sexual behaviors, even behaviors were unusual or unethical (e.g., bestiality or getting a partner drunk in order to have sex with them, respectively) (24).

The fact that different emotional states seem to affect decision-making poses a problem for AOE programs. Since all AOE programs are obviously administered to teens in a “cold” state, how effective will such educational efforts be when it matters; specifically, when an individual is in a “hot” state? In the moment, just saying no may be easier said than done.

It may be pointed out that this appears to be an indictment of sexual education in general. However, the data above studies suggests that, although decision-making was significantly affected, it was not entirely impaired (24). This seems to imply that sexual education is still to some degree useful. However, assuming that an individual will give in to desire at some point – indeed, statistically, most Americans do not wait until marriage to have sex (25-26) – such education will likely only be useful in a “hot” state if it is comprehensive in nature. Again, AOE programs (see discussion of federal policy above) are not comprehensive. Along these lines, a study by Bearman and colleagues on teens who had followed the virginity pledge movement showed that 88% ended up having vaginal intercourse before marriage in spite of their pledge (27). A related study focusing on STI-related behaviors within the same population of teens compared to teens who had not pledged abstinence showed that teens who had made the pledge were less likely to see a doctor for STI testing (28). All of this strongly suggests that many teens whose education has focused on abstinence only in many ways fare no better, and in several important ways fare worse, than teens who receive comprehensive education. Thus, while comprehensive education may still be useful, it is doubtful that the same is true for AOE.

Framing
Another significant problem, related to the moral bias issue discussed above, is how this issue is framed by researchers and advocates.

The research The research cited promoting AOE programs is often suspect. A review of AOE programs conducted by Robert Rector concludes that AOE programs do work, and cites ten AOE programs in support of this claim (29). However, six of the ten program evaluations he cites are those cited above, all of which are either unproven or have been shown to be ineffective (7). Like these six, the other program evaluations have also been criticized as methodologically flawed. A review of these programs published by Douglas Kirby for the National Campaign to Prevent Teen Pregnancy revealed that nine of them failed to show any evidence that they delayed initiation or frequency of sexual intercourse. The only program that showed any effect (a mass communications campaign called Not Me, Not Now) is still suspect because it was not possible to control for confounding factors (30). Kirby concluded that “[there] do not currently exist any abstinence-only programs with strong evidence that they either delay sex or reduce teen pregnancy” (30). Additionally, note that this study was supported by the Heritage Foundation, an institution with a strong conservative bias that advocates for public policy based on “traditional American values” (31).

The most recent study promoting AOE, published this year in February, appeared to show that AOE programs might be an important factor in “adolescent sexual involvement” (32). However, in the section describing the AOE intervention, instructors teach kids in this group to remain abstinent until they are “prepared to handle the consequences of sex”; that a “moralistic tone” is not permitted; and that the efficacy of condoms should not be questioned (32). Upon referring to the federal policies defining AOE, it becomes clear that the investigators have essentially taken a comprehensive sex education and framed it as AOE, an act which is clearly misleading and makes the results favoring AOE essentially meaningless.

The advocacy More generally, along with policymakers, advocates for AOE often frame the issue improperly. According to the Santelli review, a common argument used by proponents of AOE programs is that abstention is the only method of safe sex that is one hundred percent effective. There are several problems here.

First, recall that nearly all Americans have sex before marriage and that the goal of AOE is abstinence until marriage. Presented in this straightforward way, concluding that AOE programs are not effective appears inescapable. So how do advocates of AOE use framing to get around this fact? One way is by pointing out that evaluations of AOE programs like those mentioned above show that AOE programs are similar in effectiveness or more effective than non-AOE programs. The problem with these studies, in addition to those discussed above, is all of them assess efficacy through periodic follow up and define success by how long the teen remained abstinent (7, 32), rather than by whether or not the teen actually had sex before marriage. Framed in terms of abstinence until marriage, the actual goal of the intervention, AOE programs suddenly appear much less effective.

Another way proponents of AOE improperly frame this issue is by focusing on the simplistic and misleading statement that abstinence is one hundred percent effective and therefore better than any other form of safe sex. There are several problems here. For one thing, it is completely misleading to call abstinence “the safest sex.” The term safe sex implies sex is already happening. Presenting abstinence as safe sex is misleading, and may even be “potentially harmful because it conflates theoretical effectiveness with the actual goal of abstinence” (9). Indeed, the two reviews mentioned previously regarding the efficacy of virginity pledge movements offer support for AOE programs causing harm (27-28). However, if the issue is re-framed by comparing AOE program effectiveness in terms of those who remain abstinent until marriage and those who do not, the claims loses its credibility. For proponents of AOE programs, the more honest and complete statement appears to be that abstinence is one hundred percent effective as long as you remain abstinent. This is, of course, nonsensically circular. It would be like saying that your car brake is one hundred percent safe as long as it always works. Any public health intervention can be theoretically successful. What matters is whether or not it succeeds in practice, whether behavior has actually changed.

Summarily, it appears that opponents of AOE focus on the health problems that may result from poor sexual choices, whereas advocates frame sexual activity as the problem itself.

Other Programs
A general problem with programs seeking to educate lies with the teacher. Research by Paul J. Silva on the Concept of Psychological Reactance, which is a term denoting a rebellious reaction to a perceived threat to freedom (33), has demonstrated that the threat perceived from telling someone something which conflicts with their personal beliefs was significantly reduced when there was similarity between the speaker and the listener. In other words, who is delivering the message may be just as important as its content. There is evidence of this rebellious nature in teens. A report discussing the methods of the highly successful truth campaign against smoking showed that the main reason many teens choose to smoke is precisely because adults tell them they shouldn’t (34). This suggests that teens may be more likely to engage in behavior that adults forbid them to do. Although this can be seen as a problem for sex education in general, the fact that AOE programs can only focus on a very limited number of facts, and essentially tell teens that they shouldn’t have sex at all, makes this problem particularly difficult for AOE programs.

In reference to the aforementioned study on STI prevalence among teens who joined the abstinence pledge movement, it bears reiterating that the only major difference between teens who had made the pledge and teens who had not made the pledge appeared to be how likely they were to receive STI testing (27-28). That a program intended as a public health intervention targeted at teens might make teens less likely to seek needed medical attention is, needless to say, highly problematic.

Finally, it should also be considered what information the majority of parents want for their children. Data has consistently shown that teens’ parents overwhelmingly support sexual education programs (90%) and that, of that of those, support programs that include information on contraception (86%), abortion (85%), masturbation (77%), oral sex (72%), etc. In contrast, only 15% of those polled supported AOE (35-36).This data suggests that any sexual education program which follows an abstinence only model will not be well received by the majority of parents.

Based on the problems discussed above, AOE should be abandoned as an ineffective public health intervention and ineffective public health policy.

THE SOLUTION
In light of the nationwide, strong parental support for comprehensive sex education, in order to fight AOE and improve sex education in general, I am proposing the development of an organization consisting of parents who oppose AOE programs and support sexual education reform. They would advocate against AOE programs and in favor of sexual education reform in two ways: lobbying for policy change, and starting a national media campaign intended to raise awareness of and re-frame the problem.

Lobbying for Policy Change
Since federal policy explicitly endorses AOE, lobbying for policy change is a crucial element in the fight against AOE. If there is no clear definition of abstinence, it will be difficult, if not impossible, to effectively teach it to teens (20). If policy continues to not only permit but support programs that ignore crucial topics such as proper condom use and where to get STI testing, teens will be less likely to seek help when they need it (27-28). Without policies that are clearly written, morally neutral, and above all, based on sound behavioral health research, sex education simply will not be effective (8, 9). Finally, it has also been argued that, from the perspective of medical ethics, policies supporting AOE are unethical because they deny teenagers access to complete and accurate health information (8, 9).

Lobbying federal government for policy change would also be supported as a public health intervention by Social Expectations Theory. Social Expectations Theory, according to an article by Melvin Defleur and Sandra Ball-Rokeach concerns the norms, or general rules, of attitude and behavior that develop over time in a given group of people. Importantly, policies are identified as one source of these norms (37). Thus, efforts to change these policies would likely, over time, cause a positive change in norms related to issues of adolescent sexuality. Additionally, policy change is also important in this case because federal funding for sex education is currently tied to teaching AOE as defined in Section 510 of the Social Security Act (8). This puts any sex education program wishing to teach comprehensive education at a clear disadvantage. Lobbying for policy change would help to correct this problem.

National Media Campaign
The media can be a powerful tool for communicating a message targeted at adolescents. There are numerous examples illustrating the power of the media to bring about attitude and behavior change. Sesame Street and Blues Clues were highly successful television programs aimed at providing basic education to pre-teen children (38). The ad campaign identifying the act of pouring a Guinness beer as a ritual through the use of the slogan “perfection can’t be rushed” caused sales to skyrocket and literally saved the company (39). The most relevant example is the truth ad campaign mentioned above. Their ads ran in magazines, on television, and on the internet. A follow up evaluation revealed across the board reduction in youth smoking (34).

Since the media has been used successfully to positively affect attitudes and behavior toward all the issues above, it is reasonable to conclude that the media can positively affect teen attitudes and behavior toward sex. To accomplish this, the parent organization can develop a national, multimedia ad campaign. An example commercial of such a campaign might consist of an adolescent man and woman alternately telling a story about a recent house party they attended. They would talk about how they were about to have sex, but just before they did, the man realized he didn’t have a condom. The story would conclude with the teens ultimately deciding not to have sex. Then the man and woman would each say their name and the campaign slogan (e.g., “my name is David, and I made the right choice”). The commercial would end by flashing the campaign website name on the screen: maketherightchoice.org. This commercial would be effective for a number of reasons:

Research has shown that people respond well to the use of personal stories. When Pam Laffin, a 31 year old mother of two from Malden, Massachusetts, was dying from emphysema, the CDC and the Massachusetts Department of Public Health made a video of her story and ran it on television (40). Within hours, an anti-smoking hotline called 1-800 QUITNOW received a huge influx of callers (41). In passing the health care bill, President Obama spoke at length about Natoma Canfield, a woman who had died of cancer because she did not have adequate health insurance. His reasoning was that every reasoned policy argument had been used (42-43). Indeed, politicians running election campaigns often stick to personal stories for exactly this reason. Thus, an ad campaign consisting of attractive, trendy-looking young people talking about personal sexual situations in which they acted responsibly would therefore be much more effective than, for instance, a simple discussion of disease statistics.

This ad campaign could also have other positive affects. According to theories in marketing and advertising, any ad campaign is more effective when it sells core values that are important to its target audience (44). The positive tone of this commercial, the physical appearance of the actors, the campaign slogan, and the overall theme of personal choice exemplify known core values such as love, beauty, youth, independence, trust and control (44). Independence and control were two major core values that explained the appeal of the truth campaign (34). The slogan for the proposed commercial mentioned above also exemplifies the concept of Branding, which states that the goal of selling any product is by linking it with a particular set of important values in the mind of the consumer (44-45). Based on these theories, the message of this series of commercials is “if you make responsible sexual choices like these teens, you will feel more beautiful, more independent, and more loved.” Such advertising would counteract the message delivered by proponents of AOE by focusing on the positive aspects of sex and help to re-frame the problem by shifting the discussion from how to convince teens to stay abstinent to the idea that being healthy and safe is a way to feel independent and in control, and to feel more loved.

These commercials would also address the aforementioned psychological reactance problem by the fact that they featuring young, attractive people talking about sexual situations and feelings which are familiar to the average teen. The designers of the truth campaign interviewed adolescents about the reasons they chose to smoke prior to developing their campaign. They credit the interviews as a major factor in the campaign’s success (34). This also fits with the research on psychological reactance (33). Similarly, in developing this campaign, the parental organization could work with adolescents to develop the scenarios for each commercial in the series. Unlike AOE, this campaign would directly involve adolescents in their own sexual education, making them more likely to adopt responsible sexual behaviors.

In addressing the “Hot State-Cold State” issue, in his book, Predictably Irrational, Dan Ariely offers two suggestions: emphasizing condom use and availability, and focusing education less on biology and physiology and more on the powerful emotions that come with sexual arousal. The proposed ad campaign described could be modified to incorporate both of these suggestions. When the website name “maketherightchoice.org” appears on the screen, a voice could be added saying “visit maketherightchoice.org for more information on taking control of your sexual health and how to order condoms discreetly, online, for free.” Conversation about the emotions that accompany sexual arousal could be encouraged by modifying the commercial to feature parents and their teens. They would describe how initially they were embarrassed to talk about sex as a family, but once they did, they were glad they had. These ads would appeal to families for the same reasons the ad described above would appeal to teens.

In conclusion, it is likely that sexual health during adolescence, and the best way to teach it, will always be a controversial topic. Discussing such sensitive and personal topics with minors may conflict with deeply held religious or moral beliefs, or may simply be a source of embarrassment. However, given that as a matter of biological fact, puberty starts in most humans between the ages of ten and sixteen (46), and that this change is accompanied by sexual maturation and the capacity for reproduction (46). No policy, religion, or set of moral values can alter these simple facts. Once this happens, the only way to keep adolescents mentally and physically healthy, and safe, is to make sure they fully understand and feel comfortable with what is happening to their minds’ and bodies’, and feel personally empowered and motivated to keep themselves sexually healthy. Aggressive lobbying efforts in support of sex education programs that require full and honest disclosure, coupled with a media campaign, targeted at both parents and their teens, that identifies sexual health with love, beauty, independence, trust and control, is the best way to accomplish this.

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