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

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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Merely Lying Dormant Under the Obama Administration, the Global Gag Rule Needs to Be Put to Rest for Good -Noël Hatley

As the global population increases and health in third world countries declines, people are in dire need of family planning assistance. With the increasing numbers of children that women have, comes the increasing chances of maternal mortality and infant mortality. The United States’ Mexico City Policy, a policy that limits international organizations from performing or giving information on abortions, tries to eradicate abortion. Instead of helping reduce the number of abortions, it has actually caused the number of maternal deaths due to unsafe abortions to increase. Even with substantial historical evidence of governments trying to restrict people’s actions, such as in prostitution and the prohibition of alcohol, the actions do not cease, and yet the U.S. government still tries to restrict abortions (6, 9, 17, 31, 36). Even though the Mexico City Policy has been around for only three decades it is a part of a larger debate, the debate on abortion and family planning that is unlikely to resolve in the near future, and the policies of family planning will shift as the political and social views shift over time. Within a few weeks of the inauguration of Barack Obama the policy was rescinded, however only temporarily. Eventually, the political powers will shift with the election of a new president and congressional members, which could bring the Mexico City policy back on the table.
In 1973, before the Mexico City Policy was in place, the United States Supreme Court legalized abortion from the ruling in the case Roe v. Wade. At the same time, Congress passed the legislation containing Helms Amendment, which meant U.S. moneys could not be used overseas to fund abortion services. The conflicting views of the U.S. government remain for the entirety of this debate (31, 38). It was not until 1984 that President Reagan introduced the Mexico City Policy at the International Conference on Population. It was his belief that no organization should be funded if they provide information, counseling, referrals and services for abortion. Reagan did not want to fund Non-Governmental Organizations and governments that would spend U.S. money and other funders’ money on anything to do with abortion (38). Since people are not allowed to even discuss abortion or give out information, the Global Gag Rule nickname came into place.
The Global Gag Rule not only increases the rate of maternal mortality, it forces NGOs and clinics to choose between adherence to these policies and restriction of their free speech or risk the loss of financial aid. Since USAID can decide to rescind all funding to NGOs, the NGOs take excessive precautions to make sure they do not violate any of the rules of the policy. Ironically, the U.S. Supreme Court’s decision Rust v. Sullivan in 1991 ruled that governmental restriction of an organization’s legal activities is a violation of that organization’s right to free speech (27). According to the study done by Julia Ernst and Tzili Mor of The Center for Reproductive Rights, one of the largest NGOs located in Ethiopia lost its U.S. family planning assistance for refusing to follow the gag rule policy, forcing them to end vital community-based contraceptive distribution programs (17). Not only were these organizations providing abortion services, they were also providing contraceptives. By hurting the organizations providing abortion information, the gag rule hurt programs for contraception and ultimately undermined women’s abilities to control their lives and bodies from unwanted pregnancies and STDs (17). With prohibited speech and prohibited abortions women are subjected to unsafe abortions, fear, and stigma.
Throughout the years the policy has been apart of a political tug-of-war: rescinded and reinstated with each change in political power. It is time the policy was laid to rest, for good. Introduced to the House of Representatives in 2007, the Global Democracy Act seeks to create a permanent, legislative barrier to attempts to reinstate the detrimental policy (25). With the end to this policy in sight, I will attempt to explain using social science theories why the Global Gag Rule caused more harm than good and why it is ineffectual. I will also explain better, more efficient ways to reduce abortions without banning them and infringing on free speech.

Argument 1: Policy Makers Assume Women Follow the Health Belief Model When Making Abortion Decisions

The first critical miscalculation policy makers made was assuming women would stop having abortions if they were not funded and banned. The only way that would take place is if women seeking abortions followed the Health Belief Model when decision-making. The Health Belief Model is based on the idea that people’s decisions are a rational, cost-benefit analysis (35). People weigh the perceived benefits and the perceived barriers and based on the conclusion act accordingly. Once the analysis is complete, people act. In the scenario that policy makers believe will undoubtedly play out, a woman debating on having an abortion will follow these rational steps: compare the benefits of having an abortion to the costs. Proponents of the gag rule believe that either the lack of availability of safe abortion practices or the illegality of abortions will be the deciding factor and ultimately deter women from having abortions (9, 17, 31, 38). The facts state otherwise: In 2007 alone, while the gag rule was in practice, out of the 42 million abortions performed, 20 million women worldwide risked their lives and health to undergo unsafe abortions (24).
The health belief model is not only insufficient in mapping women’s actions regarding abortion, it assumes that “human behavior is determined by an objective, logical thought process” (35). Firstly, becoming pregnant is not done after careful consideration of one’s costs and benefits. It has been estimated that 40% of all pregnancies around the world are unintended (39). An estimated 51 million unintended pregnancies occur in developing countries every year because of lack of contraception and another 25 million occur because of incorrect use and misperceptions of contraception, say otherwise (1). Additionally, pregnancy and abortion are processes not so simple as for one to weigh the health benefits and health barriers before decisions are made. Pregnancy, especially in developing countries, can be surrounded by a range of emotions including happiness, pride, shame, and guilt and can be met with a multitude of societal forces and factors including stigma, socio-economic status, and social support systems (24). The process of abortion, like that of pregnancy, is not cut and dry when weighing the pros and cons. Just because a safe abortion is illegal, nor available, does nothing to deter women from seeking alternative, more harmful abortions or self-inducing abortions (24, 39).
If, for example, one were to act extremely rational, as the policy makers assume, and map out the perceived benefits one would begin by identifying one’s perceived susceptibility and one’s perceived security. In the case of abortion, the perceived susceptibility would include anything that makes one feel susceptible to the negative consequences of having a child. Negative consequences may include a multitude of effects ranging from banishment by one’s social group (because of a pregnancy out of wedlock, for example) to a lack of independence because of the unintentional thrust into motherhood. The perceived severity is indicative of the chances of the negative consequences happening because of having a child. Both of these steps in the model include so many differing factors, that the model quickly becomes too complicated for a simple mental cost-benefit analysis, and we did not even completely identify one’s perceived benefits nor begin to indentify one’s perceived barriers. The model is only useful if health factors were to satisfy the perceived benefits and barriers, but abortion is much more convoluted, including social, emotional, economic and political factors (35). For such a complicated action, the health belief model falls short in representing a woman’s thought processes and actions.

Argument 2: Restricting actions and speech motivates people to rebel against confining policies

Another important effect that policy makers and governments in general overlook when enforcing freedom-restricting policies is psychological reactance. Psychological Reactance theory states that people will rebel against policies, and direct orders when personal freedoms are restricted. According to Brehm, psychological reactance is defined as a motivational state directed toward the reestablishment of the threatened or eliminated freedom, which should manifest itself as an increased desire or an actual attempt to engage in the relevant behavior (5). In order for reactance to occur, one must be aware that the particular freedom exists and one must have the ability to exercise that freedom (20). In the case of reproduction, control of one’s reproduction abilities is a decision of “when” and with reliable contraception and availability of abortion allows women to be in greater control of the timing of motherhood and offspring. Eliminating resources of contraception, including abortion, through funding cutbacks and bans, infringes upon the control one has over their reproductive abilities. In the absence of contraception and safe abortions, women are forced to resort to unsafe and self-induced abortions (17, 36). When faced with restrictive policies, the freedom-threatening influence attempts can backfire, in that pressure toward change created may induce a person to do just the opposite (8). In the case of the gag rule, women resort to harmful and drastic solutions.
In an article about the psychological analysis of drug prohibition, it was found that restrictions on drugs and people’s freedom of usage drives people to overcome that restriction and reclaim the freedom that was once theirs (30). The same holds true with the availability of abortion and other contraceptives, because the loss of reproductive freedom is ultimately the loss of control over one’s body.

Argument 3: Abortion stigma

As defined by Hessini and others, abortion stigma is a negative attribute ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of womanhood (24). The global gag rule stigmatizes in two ways: first it marginalizes abortion services by physically isolating them from other health services and second it seeks to silence and obstruct abortion advocacy. Not only does the global gag rule enforce this stigma it creates and fortifies a stigma cycle. Known as the prevalence paradox, the cycle is a social construction of deviance despite the high incidence of abortion. Under the global gag rule and other anti-abortion laws, women underreport and intentionally misclassify abortion behavior for fear of retribution. Because of such underreporting, abortion is thought to be uncommon and a social norm is perpetuated that abortion is deviant. From such a norm, women who have abortions face discrimination causing women to fear stigmatization for engaging in abortion behavior, which causes women to continue underreporting (22, 24, 26). This vicious cycle, only perpetuated by the global gag rule, does not end abortion rather it marginalizes women and causes rifts in societies. Labeling abortion-seeking behavior as deviant, forces women to terminate pregnancies on their own or follow through with the unwanted pregnancy. In Zambia, one-third of schoolgirls and two-thirds of women studied reported attempting an abortion alone, often using caustic substances (24).
Stigmatizing abortion services and labeling abortion-seeking behavior as deviant, has forced women into secrecy. Secrecy does assist women in avoiding certain disapproval and social conflict, however it only hinders women in the process of healing and coping (22). In trying to eliminate abortion and save unborn fetuses, the policy makers of the U.S. have only hurt the women around the world in more ways than necessary. Not only are women around the world plagued by societal stigmas of abortion, internalized abortion stigma causes women to feel shame and guilt when abortions are sought out. Since the mid 1980s, organizations against abortion have used shame and guilt to their advantage (24). Such organizations seek to position shame as a natural and necessary response of the procedure and not as a consequence of societal scorn and marginalization of women.

Alternative approach to reduce the need for and incidence of abortions

The high number of abortions worldwide indicating the staggering number of unplanned pregnancies points to a failure in family planning and contraception availability. The global gag rule eliminates funding to international organizations that provide abortion services and information. What the policy fails in recognizing is that most if not all of the organizations that are cut from U.S. aid are the same organizations that provide family planning assistance, contraception, reproductive counseling and psychological support (17). For the Family Guidance Association of Ethiopia, the first and largest non-profit organization in Ethiopia to provide family planning services, the cut in U.S. funding was detrimental. Over 35% of their funding disappeared over night and technical assistance, including training for staff, was completely terminated. The organization was forced to drastically cut back on its distribution of supplies and vital services (32).
In order to reduce the incidence of abortions, we need to make abortions less necessary, however still available. I propose the United States fund all family planning organizations, regardless of the availability of abortion services. Organizations providing abortion services, information and referrals should also provide alternative information. Women seeking abortions should not be turned away or condemned by staff members. Contraceptive methods such as male and female condoms as well as education on the correct usage should be made readily available to the population served. The United States should focus its funding on organizations that provide access to emergency contraception, programs curtailing domestic violence and sexual abuse, comprehensive sexual education programs that include medically accurate information about abstinence and contraception, and also programs that work to provide public funding for family services. Such programs are already out there and only need a bit of funding to be successful. Instead of limiting the services available to women, U.S. policy should work to make available as much support and services possible, to ensure adequate and available options.

Defense 1: Better family planning services

If the United States were to fund organizations providing comprehensive family planning services, the need for abortions would be reduced. As seen in a study in Bangladesh, abortion rates were significantly lower in an area introduced to an intervention containing better family planning services than an area without the intervention. Better family services were characterized as having more choice, greater accessibility, and higher quality of care. Prior to the study intervention, both areas had similar rates of abortion (11). In the United States, it has been shown that an increase in the use of contraceptives and the introduction of other contraceptives available, led to the reduction of unintended pregnancies and the reduction of abortions, based on surveillance data (40). An increase in better family planning services internationally would help lead to a reduction in the rates of unintended pregnancy and abortion.

Defense 2: Education

One of the best ways to reduce unintended pregnancies and by extension, abortions, is to increase education. Funding organizations and programs that effectively educate the populations served ensure that people are made aware of their options. Education should be part of better family services, so that people have access. Educational resources should include quality data that is relevant to the specific population. Even education and additional contraceptive methods given after abortions help to reduce the occurrence of abortions in the future, as was seen in a study in Zimbabwe. Many women worldwide who have had unsafe abortions lack access to contraceptive services. As a result, many have subsequent unplanned pregnancies and some have more unsafe abortions. The results of the study suggest that post-abortion family planning services reduce the incidence of repeat abortions (7). Not only should the U.S. and other countries fund sex education in organizations, but also in schools. According to Kirby and others school-based sex and contraceptive education in developing countries have reported reduced risky behavior, especially programs that included peer-led education (28). Education is empowering, as it places control back into a woman’s hands.

Defense 3: Reactance theory revisited

Using reactance theory in a positive manner helps to restore lost freedoms and one’s sense of control over reproduction. According to Deatrick and others, the use of restoration postscripts to restore freedom shows positive outcomes of change (12). In order to reduce the incidence of abortion, we do not need to make it illegal, just increase efforts into education and other forms of contraception. By restoring the lost freedom of choice through the returned funding of abortion and also restoring women’s choice in contraceptives, increases one’s overall sense of freedom. The key is to increase the availability of options in family planning, options gained from education, and including options for when a woman is pregnant. The idea is to place the control of a woman’s body and control of her own reproduction in her own hands, where it belongs.

Conclusion

The policy known by some as the Mexico City Policy and by others as the Global Gag Rule has made a profound impact on the way NGOs and governments around the world deal with family planning. The ongoing debate on whether to fund organizations that perform and address abortion as a means of family planning has governments around the world split and there seems to be no compromise in sight, just a battle between the two sides of the debate. Even though the Obama administration has repealed the policy, nothing stands in the way of the next administration bringing it back into use. If the Global Democracy Act is passed, it will put an end to the gag rule for good. Flawed from the start, the gag rule relied too heavily on stigmatization, control, and the belief that the decision to have an abortion is based on health effects. The ongoing struggle in the abortion issue should not hinder women when it comes to contraception. In the end the U.S. should focus more on funding organizations and programs that work to educate, provide family planning assistance, contraception, counseling, and abortion services in order to give women the best possible support in reproductive health.

References

1. Åhman, E., Henshaw, S., Sedgh, G., Shah, I. H., and Singh, S. Induced abortion: estimated rates and trends worldwide. Lancet 2007; 370:1338-1345.
2. Åhman, E., and Shah, I. Unsafe abortion: global and regional incidence, trends, consequences, and challenges. Journal of Obstetrics and Gynecology Canada 2009; 31(12):1149-1158.
3. Bahamondes, L., Bahamondes, M. V., Fernandez-Funes, J., Palena, C., and Schenk, V. High rate of unintended pregnancy among pregnant women in a maternity hospital in Cordoba, Argentina: a pilot study. Reproductive Health 2009; 6(11).
4. Bankole, A., Drescher, J., Henshaw, S. K., Sedgh, G., and Singh, S. Legal abortion worldwide: incidence and recent trends. International Family Planning Perspectives 2007; 33(3):106-116.
5. Brehm, J. W. A theory of psychology reactance. NewYork: Academic Press, 1966.
6. Bush, George W. United States. President. The White House. Memorandum of March 28, 2001 on the Restoration of the Mexico City Policy. .
7. Chipato, T., Farr, S. L., Johnson, B. R., and Ndhlovu, S. Reducing unplanned pregnancy and abortion in Zimbabwe through postabortion contraception. Studies in family planning 2002; 33(2):195-202.
8. Clee, M. A., and Wicklund, R. A. Consumer behavior and psychological reactance. The Journal of Consumer Research 1980; 6(4):389-405.
9. Cohen, Susan A. Global gag rule revisited: HIV/AIDS initiative out, family planning still in (issues and implications). The Guttmacher Report on Public Policy, 2003.
10. Condelli, L. Social and attitudinal determinants of contraceptive choice: using the health belief model. The Journal of Sex Research 1986; 22(4):278-491.
11. DaVanzo, J., Rahman, M., and Razzaque, A. Do better family planning services reduce abortion in Bangladesh? Lancet 2001; 358:1051-1056.
12. Deatrick, L. M., Lane, L. T., Miller, C. H., Potts, K. A., and Young, A. M. Psychological reactance and promotional health messages: the effects of controlling language, lexical concreteness, and the restoration of freedom. Human Communication Research 2007; 33:219-240.
13. Dillard, J. P., and Shen, L. On the nature of reactance and its role in persuasive health communication. Communication Monographs 2005; 72(2):144-168.
14. Dixon-Mueller, Ruth. Population Policy and Women's Rights. London: Praeger, 1993.
15. Edwards, S. M., Lee, J. H., and Li, H. Forced exposure and psychological reactance: antecedents and consequences of the perceived intrusiveness of pop-up ads. Journal of Advertising 2002; 31(3):83-95.
16. Epstein, Susan B., Connie Veillette. State, Foreign Operations, and Related Programs: FY2008 Appropriations. Congressional Research Service. Washington D.C.: Library of Congress.
17. Ernst, Julia, and Tzili Mor. Breaking the Silence: the Global Gag Rule's Impact on Unsafe Abortion. The Center for Reproductive Rights. New York: The Center for Reproductive Rights, 2003.
18. Family Planning Methods and Practice: Africa. Centers for Disease Control 1984.
19. Fascell, Dante B. United States. Cong. House. International Cooperation Act of 1991. 102nd Cong., 1st sess. HR 2508.
20. Förg, M., Frey, D., Heinemann, F., Jonas, E., and Traut-Mattausch, E. How should politicians justify reforms to avoid psychological reactance, negative attitudes, and financial dishonesty? Journal of Psychology 2008; 216(4):218-225.
21. Gipson, J. D., Hindin, M. J., and Koenig, M. A. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Studies in Family Planning 2008; 39(1):18-38.
22. Gramzow, R. H., and Major, B. Abortion as stigma: cognitive and emotional implications of concealment. Journal of Personality and Social Psychology 1999; 77(4):735-745.
23. Guttmacher Institute. Costs and benefits of family planning, 2009.
24. Hessina, L., Kumara, A., and Mitchell, E. M. H. Conceptualizing abortion stigma, Culture, Health & Sexuality 2009; 1-15.
25. House of Representatives. Global Democracy Promotion Act. (H. R. 619, A Bill). Washington, DC, 2007.
26. Kleinman, A., Keusch, G. T., and Wilentz, J. Stigma and global health: developing a research agenda. Lancet 2006; 367:525-527.
27. Knudsen, Lara M. Reproductive Rights in a Global Context. Vanderbilt University, 2006.
28. Laris B. A., Kirby D., and Obasi A. The effectiveness of sex education and HIV education interventions in schools in developing countries. World Health Organ Tech Rep Service 2006; 938(103):317-41.
29. Luker, K. Taking Chances: Abortion and the decision not to contracept. University of California Press, 1976.
30. MacCoun, R. J. Drugs and the law: a psychological analysis of drug prohibition. Psychological Bulletin 1993; 113(3):497-512.
31. Nowels, L., and Veillette, C. International Population Assistance and Family Planning Programs: Issues for Congress. Congressional Research Service. Washington D.C.: Library of Congress, 2006.
32. Population Action International. Impact of the global gag rule in Ethiopia. Global Gag Rule Impact Project, 2005.
33. Rohlinger, D. A. Framing the abortion debate: organizational resources, media strategies, and movement-countermovement dynamics. The Sociological Quarterly 2002; 43(4):479-507.
34. Severity and cost of unsafe abortion complications. International Family Planning Perspectives 2008; 34(1).
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36. The Center for Reproductive Rights. Breaking the silence: the global gag rule’s impact on unsafe abortion, 2003.
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38. United States. Policy Statement of the United States of America At the United Nations International Conference on Population, 1984.
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No. Effective: How Nolita’s “No Anorexia” Ads Failed In Making A Statement – Lauren Kennedy

Amongst the glitz and glamour of Milan’s fashion week in September of 2007 a revealing ad aimed at addressing the problem of eating disorders, in particular Anorexia nervosa, made its debut. The clothing company Nolita commissioned the ads, and hired the controversial Oliviero Toscani to photograph it. The series featured the Isabelle Caro naked against a black and grey background, with the slogan “No. ANOREXIA” and the brand name “No-l-ita” in hot pink. Caro is a French actress who suffers from anorexia nervosa (1-3). At the time the photograph was taken, she weighed a mere 70 pounds at 5 feet and 5 inches (1). From a clinical perspective, she is 56% of the recommended body weight for her height, and severely underweight from very advanced anorexia nervosa. Her gaze is blank and haunting, a woman clearly deeply suffering the debilitating effects of her disease. This campaign, worth only its weight in shock value, fails to deliver an appropriate public health message.
The ads caused quite a controversy in the mass media, and were banned by Italy’s Publicity Control Institute shortly following release. In a statement on the company’s website, Nolita defended the ad, stating that it [used]”this nude body [to show] the reality of this illness, which in the majority of cases is caused by stereotypes caused by the fashion world (1).” Toscani claimed that “looking at [his] ad, girls with anorexia would say to themselves that they have to stop dieting (1).” These statements reflect adherence to the Health Belief Model (5).
According to the Health Belief Model, people make decisions about health according to four constructs: perceived susceptibility, perceived severity, perceived barriers, and perceived benefits. Additional components are cues to action and self-efficacy (5). Using this model, developers of the “No Anorexia” ads hoped that the disturbing image of this emaciated, nude woman who is clearly extremely sick would educate girls about the severity of anorexia nervosa. Given that they are women interested in fashion, they will appreciate that they too are susceptible to this disease. Thus, the perceived benefit of avoiding the development of anorexia nervosa will be weighed against the perceived barriers associated with refraining from dieting. Given all this information, the woman decide that the benefits outweigh the barriers this cue to action would drive them to stop dieting, thus preventing the progression of anorexia nervosa or another eating disorder. This sequence is all contingent on self-efficacy, the person’s belief in his or her ability to take action (5).

Argument 1: The problem of the Health Belief Model

While useful for some situations, the health belief model itself has some limitations in application to public health interventions. First of all, this model assumes rationality (6). If people behave rationally, then if given all the facts they will make the decision that promotes health. The general population is questionably rational (6,7). The population of people with eating disorders is arguably even less rational. Eating disorders are classified as a psychiatric disorder. Among the symptoms of eating disorders are psychopathological symptoms which include preoccupation with weight and shape and a disturbance in the way body is experienced. There may be an intense fear of weight gain. Often, people with eating disorders deny something is wrong. They may compare their body with others’ bodies (8). A typical woman with an eating disorder would most likely not be able to rationally and objectively weigh the benefits and barriers based on the image in the campaign. Her perspective will be skewed from what the expectation is under the model. For example, a woman with anorexia nervosa may not perceive the level of extreme thinness as undesirable as a result of this distorted perception of reality. Perhaps even worse, the sight of the image may trigger a competitive drive to be a thin as her, regardless of the possible consequences. Many people with eating disorders are in denial that they have a problem. Thus, a person with an eating disorder may not even perceive him or herself as susceptible to developing the severe manifestations of the disease. Thus, the constructs of the health belief model are not appropriate for the population of people with eating disorders.
A second problem with the health belief model is that it assumes that intention to perform a healthy behavior translates to action. However, this unfortunately is often not the case (6). Especially with eating disorders, even a will to recover does not necessarily mean success (8). Tragically, for many people with eating disorders, the will to change does not mean that their behaviors will change right away. Recovery from eating disorders is a slow process that requires intensive care and a multidisciplinary approach8. A simple picture will do nothing to alleviate the symptoms of eating disorders and as mentioned earlier, may even add fuel to the fire.

Argument 2: A violation of theory

While the health belief model is going out of style so to speak, new models are emerging in public health practice that more appropriately represent and predict human behavior. Models which take into account the group level of influence and the fundamental irrationality and spontaneity of many human behaviors (6). Three examples of these models are the social ecological model, marketing theory and psychological reactance theory. The Nolita ad campaign violates the principles and constructs of all three of these important models.
The social ecological model highlights the importance of both the individual and the environment and the dynamic relationships between all individuals and all environments (9). The Nolita ad campaign fails to use this model by ignoring the internal environment of people with anorexia nervosa and other eating disorders. For people with eating disorders, the body becomes the object of obsession. This can manifest in body checking, body avoidance, or body image disturbance (8). In the “No Anorexia” ad, the very object of obsession for the person with an eating disorder is put on display in an extremely exploitative fashion. This fact only serves to reinforce the distorted internal environment in which the person with an eating disorder experiences. In this way, the Nolita ad campaign fails to associate the external environment with the internal environment. Furthermore, for those without recognized eating disorders or disordered eating behaviors, it creates a negative environment. By introducing an image that is extremely disturbing for most, it disrupts the peacefulness of their environment. It creates an atmosphere of negativity surrounding eating disorders and may reinforce the idea of a woman’s body being “disgusting”, particularly given the media’s reaction (2,3). The ad does nothing to try to explain the image or the illness. An individual’s internal environment may be shaken with grief or shock. Thus, people are met with something that they do not understand which will likely lead them to criticism rather than action. This reality is exemplified in the reaction of the media. Most media outlets and newspaper articles only talked about the shock of the campaign and the controversy surrounding it, rather than brainstorming what can be done to prevent eating disorders from occurring (1-3). Importantly, the campaign only serves to shock the environment, and does nothing to promote lasting environmental change. It does not create an environment more conducive to preventing the development of eating disorders and worse, may add to the hostility of the environment towards eating disorders.
Marketing theory is a group level model that has important implications for population level behavior change. The marketing paradigm first asks what the people want, and then works to create and package a product that meets the desires of the people. The traditional public health paradigm promotes a stark contrast to the marketing paradigm. This paradigm first asks what people should want and then sells the product based on appealing to the desire for health. However, health is a weak core value for many people. Even people in poor health can be extremely happy, hopeful, and joyful. Better core values are love, acceptance, freedom, power, purpose, security and self esteem (6). The desire and need for these core values are especially in the population of people with eating disorders or people at risk for developing eating disorders. They are more likely to have low self esteem and low self concept (10). In a special way, they are yearning for love and acceptance, and the desire for these important values contributes to the development of eating disorders in the first place. The core value that Nolita’s ad is trying to promote is health. In essence, the ad is trying to say “look at how unhealthy she is, you need to stop dieting”. However, for a population with such a strong desire for the core values of love and acceptance, they may interpret the message as “look at how much attention she’s getting”. In this way, the ad fails both in appealing to the weak core value of health and the potential for being misinterpreted in what core values it promotes. The campaign would be more effective if it directly appealed to the strong core values of the target population by packing their message in a package that met those needs.
The psychological reactance theory is based on the idea that the reaction of a person to a message, in particular being told what to do, has a great deal of influence on how they receive and enact the message. If people feel that their freedom is being compromised, they will react to the threat in an attempt to restore their freedom. The path to least resistance and reactance is to use the most reason to support the message, particularly with visual aids. In particular, similarity builds trust (6). While many people with eating disorders may identify with Isabelle Caro, this may not necessarily be a good thing. For one, Caro has extremely severe clinical anorexia nervosa (8). Perhaps a better person to identify with would have already overcome the disease, so people with eating disorders could identify with someone who had been there, but recovered from the disease and are in remission. While Caro is surely a very strong woman who is capable of recovering from anorexia nervosa, she is still very much affected by the disease herself and may not be the best person to identify with for women with anorexia nervosa. Tragically, given the psychological manifestations common in eating disorders (8), Isabelle may serve as an example of the “perfect” anorexic to some because the clinical manifestation of her disease is so advanced. This may drive inspiration toward more disordered eating behaviors. The general population will probably not be able to relate to Isabelle at all based on her shockingly underweight status and the exploitative way in which she is portrayed in the picture. The ad will only serve to betray the trust of the general population by trying to shock them into action. In these ways the campaign fails in reaching both people with and without eating disorders.

Argument 3: The ethical problem of Nolita’s ad campaign

All professionals are expected to act justly in all matters. This is especially important with regards to public health professionals, who are expected to be promoting the well being of the population. This campaign is fundamentally flawed in that it is an unethical campaign that exploits a very sick woman. Although Isabelle Caro chose to pose for the ad, it can be argued that she is not autonomous and therefore did not choose to do so freely. Caro suffers from a severe, recognized psychological disorder and is severely malnourished (8). She is not well either emotionally or physically. Thus, her ability to make decisions that promote her best well being can reasonably be questioned. Fabiola DeClercq, founder of an Italian association against anorexia, bulimia, and obesity who herself suffered from an eating disorder for many years, says it best. She states, “this girl needs to be in a hospital, not at the forefront of an advertising campaign(3).” At its core, this campaign exploits an extremely ill woman in an ad arguably designed to promote a brand.
The tagline itself also promotes a negative and insensitive message. Obviously the goal in campaigns like this is to reduce the prevalence of eating disorders, but this cannot be at the cost of alienating those who already suffer from them. With the statement: “No. Anorexia” the campaign alienates those enduring anorexia nervosa. It creates an atmosphere in which a recognized illness is treated with contempt. It oppresses a population of people who are already extremely ill and vulnerable. The message is especially inappropriate given that many people with eating disorders suffer from low self esteem. Ad developers are arguably some of the most creative minds in the world; surely they could come up with a slogan that is cleverer and less stigmatizing.
Given all these facts, one can surely conclude that the “No anorexia” campaign was a failure both theoretically and ethically. The campaign relied on a flawed model, ignored tested important theories, and was ethically impermissible. Hopefully this will campaign will serve as a learning experience to future interventions.

No. Negativity: “Love Freely” as an effective public health intervention

University females are a population at high risk of developing eating disorders (8). Thus, an intervention developed to address some of the root causes of eating disorders, low self esteem and low self concept clarity (10), would be effective in reducing the incidence of eating disorders. It could also help women who are already practicing some disordered eating behaviors to recover. The goal of the intervention is to empower women by integrating leadership and community involvement with active learning and workshops targeted to help women feel better about their bodies and have a healthy relationship with food and exercise. The setting of the intervention would be a college or university, because of the high risk of the population and availability of resources. The intervention would feature a campaign entitled “Love Freely” to reach out to the University population. It would be complimented by a women’s center to foster an environment where women are empowered to discover who they are, celebrate themselves, and build healthy relationships through active participation and leadership.
Trained interventionists would initiate the program (11), with the goal of growing through training leaders in the University. To begin, they would recruit upperclassman women and give them monetary incentive to participate in an extensive summer course on leadership with body image workshops. The curriculum would consist of activities such as discussions, art and music activities, role plays, guided mediations, yoga classes, cooking demonstrations, massage therapy, and other activities to actively engage and encourage students to become strong internally and to be prepared to lead others (12). The goal of the workshops would be both to reinforce in women the conviction that they are beautiful at any size and to empower them with a greater sense of self to prevent them from internalizing the messages of the media (13). It would also include topics related to weight such as weightism as a social justice issue (12). Then, both the original interventionists and the upperclassman women who participated in the summer course would hold similar workshops during the school year.
A media campaign would run at the school both to encourage women to resist pressures that breed unhealthy eating behaviors as well as direct women to the positive community workshops held on campus. The campaign would be entitled “Love Freely”. Media spread throughout the campus would encourage women to question society’s messages that they are not “good enough” as they are. The ads would not focus on the body or on food directly, because these things can be a focus of obsession for people with eating disorders (8). Rather, the campaign would use clever graphic designs and words to get the message across. For example, one tag line would be: “r*EVOL*ution: turn the tables; love who you are, love freely”. Another slogan could be “*EVOL*ve: change the world; love who you are, love freely”. Campaign messages would be subjected to focus groups of university women to assess acceptance and to gain ideas. Additionally, as part of the effort to engage women and help them discover their identity, the women targeted for the intervention or upperclassmen involved in leadership could take part in designing slogans and messages for the media campaign.
To assess the effectiveness of the campaign, interventionists would both hold focus groups and surveys. The incentive for completing the surveys and participating in focus groups would be monetary. Participants would either get a small sum of money or be entered in a raffle to win a gift or a greater sum of money. The information that they would gather would be information about perceptions of the message of the program, as well as information about self-esteem, self-concept clarity, internalization of societal standards of attractiveness, body image concerns, and dieting behaviors (10-13).

Argument 1: Finding freedom

The intervention “Love Freely” satisfies the principles of the Psychological Reactance Theory. Many public health campaigns fall short in that they demand that women love their bodies. According to the Psychological Reactance Theory, simply telling a person what to do is not enough, and even detrimental in some cases. It can cause a reaction in the target audience to do exactly the opposite of what the campaign suggests (6). The Love Freely campaign invites and encourages women to question society’s definitions of who they should be and gives them a means to find this out for themselves. The messages uses clever visuals and ideas to support this message, rather than relying on disturbing and exploitative images of the body. The campaign invites women to take control and be free rather than shocking or scaring them into submission. Women in college, particularly freshman are vulnerable in that they are in a new and foreign place, for many it is the first time living away from home. In this susceptible time, women are in greater need of being accepted and loved, rather than alienated by an intervention. Importantly, the intervention is designed for assessment of both student acceptance and effectiveness in changing women’s self concept and behaviors. These programs of measurement will test the messages being put forth in order to ensure that the intervention is portraying the right message. Secondly, the intervention focuses on training peer leaders. The upperclassmen women who will be involved in the intervention are experiencing or have experienced the same fears and emotions associated with college. Thus, their example and leadership will serve to develop trust in other women targeted in the intervention.

Argument 2: No (wo)man is an island

According to the Social Ecological Model, environments and individuals are dynamic, multidimensional, and interconnected (9). An area where many public health campaigns fall short is in underestimating the role of the environment in promoting health behavior. Even well planned campaigns can be unsuccessful if the environment does not foster the behavior change (6). In the Love Freely campaign, public health messages are targeted to female youths, but it does not end there. Built into the campaign is an environment where women can be nurtured and grow to accept themselves and their bodies. Furthermore, the marketing messages of the campaign are positive, reinforcing an environment that is welcoming, rather than relying on fear mongering and scare tactics. Importantly, the environment offered by the program is one of engagement. Women are encouraged to take action, to lead, to question, to talk, to participate, and to learn together. Inventions which include a variety of activities rather than just passively pass on information have proved to be effective in the primary prevention of eating disorders (11,12). The campaign offers workshops that not only teach about body image and body acceptance but also offer outlets to increase self confidence and help women explore their identity, interests and talents. The campaign gives a direction for the target audience to move toward, instead of becoming another message in an environment laden with thousands of other stimuli. In theory, the nurturing environment of the women’s community and the positive messages of the campaign will replace society’s ideals in the target audience’s internalizations. The ultimate goal of this environment is to equip women to deal with the societal pressures to be thin in future situations.

Argument 3: Inspiration from Innovators

The diffusion of innovations theory is a group level model that can predict behavior at the population level. First, “early adopters” pick up the behavior or product. Then, there is a critical point called the tipping point where a majority of the population catches on to the behavior or product. There is a time where most people are participating in the behavior. Finally, the “laggards” in the population (the last to catch on) will slowly adopt the behavior. In order to ensure that the tipping point is met, it is helpful if early adopters are influential in the population of interest. This model is useful because it takes advantage of the herding phenomenon- as a public health professional, you do not have to worry about reaching every person (6). You only need to facilitate the population reaching the tipping point, or knock over the first domino. The Love Freely intervention employs this useful model in recruiting upperclassmen to participate in the women’s community first through monetary incentive. The influence of these women on campus will hopefully initiate the knocking over of the tipping point, and consequently spread the behavior of going to the center throughout the community of interest.
Anorexia nervosa and other eating disorders are a serious public health problem (8). Disordered eating patterns and progressed eating disorders seriously affect the lives of those who suffer from them and their loves ones. An intervention aimed at one of the root causes of eating disorders would help to prevent the onset or development of this serious disease (11,12). The Love Freely campaign marries propaganda outreach with a concrete community designed to empower University women. The design of this intervention satisfies the constructs of the Psychological Reactance Model, the Social Ecological Model, and the Diffusion of Innovations model.

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