Failure of the DoD’s ‘Real Warriors’ Campaign: Our Heroes War at Home – Carly Milliren

Introduction

“The [U.S. military] faces a battle over the life and death of its soldiers. The battle is not being waged in Iraq and Afghanistan, but in the minds and tortured souls of soldiers contemplating suicide [and suffering from mental illness]” (1). Mental illness and suicide have been long-standing issues in the U.S. military, but rates have been steadily increasing since the beginning of the wars in Afghanistan and Iraq with 2009 military suicide rates the worst since recordkeeping began in 1980. For every completed suicide in the military, there are five attempted suicides, taking a large toll on the mental health of our armed forces (2). Suicides in the military have reached epidemic levels, with approximately 120 a week according to a recent study (3).

The stigma surrounding mental illness is present throughout our society, but it is even more pervasive in the military. In a New York Times blog article from last year, Defense Secretary Robert Gates recognizes the stigma associated with seeking help for mental health issues in the military as well as the need to inform soldiers and veterans of the resources and support available to them (4). Suicide and mental illness are scary, even taboo subjects, but the even scarier fact is that this continues to happen on a daily basis as people do not seek help. Studies have shown that by decreasing the stigma associated with mental illness, people suffering from these illnesses have improved self-esteem. Reducing stigma associated with mental illness not only improves self-esteem but also increases care-seeking behavior (5).

Statistics are meaningful to assess the absolute effects of suicide and mental illness on our military, but individuals get lost in this sea of numbers. Anecdotal evidence is just as powerful, if not more so, in assessing the tangible toll that perceived barriers or lack of access to mental health care can have on soldiers, their families, and the military as a whole. Having recently had a first-hand experience with the suicide attempt of an active-duty soldier very close to me, I am very aware of the stigma attached to seeking help for a mental illness in the military until a situation has reached its boiling point and a person is literally in crisis.

In order to combat the stigma associated with seeking treatment and help for mental illness, the U.S. Department of Defense launched the ‘Real Warriors’ campaign in 2009. This multimedia education campaign encourages service members, veterans, and families to increase both awareness and use of psychological health care and associated resources. Real Warriors attempts to remove barriers often preventing service members from obtaining mental health treatment by providing information to soldiers as well as their families and employers on how to encourage them to get the help they need when they return home from deployment or reintegrate into civilian life. This campaign uses an array of communication and social networking tools including radio and TV public service announcements, posters, an interactive Web site, Facebook, Twitter, and other outlets. Included in these materials are personal stories of real service members who have sought treatment and are maintaining successful careers, both military and civilian. Resources and support for improved mental health and treatment of psychological concerns are also included. By stripping the stigma, this campaign hopes to encourage soldiers to get treated for mental illness in the same way that they would get treated for physical wounds (6, 7).

This campaign is great in providing a litany of mental health resources, however it falls flat in accomplishing its goal of stripping the stigma away from seeking help for mental health issues. The evidence that this campaign has done little to increase usage of mental health services and decrease rates of suicide is clear and convincing; it is written in the blood of our soldiers who have taken their own lives because they did not get the help they so desperately needed. The following presents my individual critiques of the campaign, followed by recommendations to improve the campaign to overcome these issues. By tweaking this campaign a bit it could hopefully reach its target audience more effectively in order to accomplish the ultimate goal of increasing utilization of mental health services in the military and simultaneously decreasing suicide.

Critique: Reinforcing the Macho Ideal

The military is its own culture and a macho ideal is central to this culture. It is also a male-centric culture in which power, manliness and courage trump sensitivity and acceptance. Seeking help for mental illness is considered cowardly and unmanly, in a way admitting defeat and weakness. Perceived consequences of seeking care by service members include being shunned by other members of the unit, including superiors, and even more severe consequences such as being discharged (3, 8). Instead of eliminating this macho ideal as a means of breaking down the stigma, the Real Warriors campaign actually glorifies and reinforces it.

The campaign materials including posters and the website contain pictures of soldiers in uniform toting guns – the quintessential macho personification – with the caption “Reaching Out Makes a Real Difference.” These stock photos may as well be ads to join the military, not combat the stigma surrounding mental illness. In addition, these pictures are harsh and masculine, and for the most part contain only images of male soldiers, and mainly only white men (6). Women and minorities in the military suffer from mental illness as well and the materials should be targeted toward these groups too (3).

Even the name of the campaign and the associated slogans reinforce this macho ideal presenting a case of public health branding gone wrong. Branding is an extremely useful way of inspiring interest in a public health activity or intervention (9). The materials echo the catch phrase of the campaign “Real Warriors. Real Battles. Real Strength.” This plays into the military culture, but in such a way that it emphasizes masculinity and brute strength, not the courage to come forward and seek treatment for a mental illness. The message that the slogan is trying to get across that seeking help for a mental illness is a sign of strength is blurred by the overarching suggestion of a masculine, warrior ideal. There is a distinctive difference between the term ‘warrior’ and the term ‘soldier;’ one which implies a permanent duty to make war. “Once a warrior, ALWAYS a warrior and […] warriors are bred, groomed educated and disciplined to conduct one and only one activity: making war. A soldier, I think, when not needed, returns to civilian life. But a Warrior?” (3). A soldier is not necessarily a warrior. Warriors are defined and identified by the battles in which they fight, and labeling those who come forward to be treated for a mental illness as ‘warriors’ is a permanent label from which one may never escape. In addition, soldiers who are suffering from mental illnesses which have no connection to their experiences in combat may not see themselves as warriors and thus may not choose to get help or use the resources available in this campaign.

Intervention: Take the Macho Out of Military

Instead of reinforcing this macho ideal, any campaign designed to promote increased awareness and utilization of psychological health services to improve the mental health and wellbeing of our military should break down this ideal and change the overall attitude toward seeking out mental health services. There are ways to positively brand this campaign without reinforcing the macho military ideal.

It is important to use the military culture to our advantage when designing a campaign to target service members, but using harsh images of battle goes a bit too far in trying to capture that feeling. The images used for this campaign should be softened, not necessarily feminized, but less harsh. I think just taking the automatic weapons out of the pictures would go a long way. If the message is that you don’t have to be a macho manly-man all the time and admitting mental illness is a sign of strength, get rid of the guns.

As for taking the machismo overtones out of the name of the campaign would strip the permanence from the title of ‘warrior.’ Although mental illness is permanent and must be treated for a lifetime, it is important to connote an ability to return to a normal life, a civilian life if a soldier chooses to do so (3). Soldiers can return to this life bearing scars both visible and invisible, without taking on a negatively associated label to go with them. Replacing the term ‘warrior’ in the name with the word ‘soldier’ is a small but significant change that can change the connotation of the name entirely while still maintaining the ultimate goal. Any soldier can be encouraged to get treatment, not just those who are suffering from the effects of combat stress. These changes soften the campaign just enough to still reach the target audience while teaching service members that it is OK to forgo the traditional manly ideal to get help for a mental illness.

Critique: Too Much Information in the Wrong Places?

The Real Warriors campaign website contains separate pages for active duty service members, members of the national guard and reserve, veterans, families, and health professionals with links to resources in order to get help for oneself, a family member, or friend. These pages list the signs and symptoms of PTSD or traumatic brain injury, what to expect before, after, and during a deployment, and what seems like an exhaustive number of resources to help in finding treatment including the phone numbers for the National Suicide Prevention Lifeline. There are also links to personal stories of soldiers who sought help for their mental illness, which may actually be this campaign’s best tool. Although this site contains a vast amount of resources, it almost seems like too much information that could also be found in other places and it is unclear how useful it is to simply provide an outlet to find links to resources in a single website (6). I

The better question than whether or not the materials are useful is whether people are actually using them. It does not really matter whether the resources are there if no one seeks them out. This campaign makes use of a wide variety of media outlets, which is a strength in providing information to a large and diverse group of people. Social networking sites including Facebook and Twitter bring news and information to the target audience, but it is difficult to determine if this audience is really being reached. Social networking can be a very powerful tool, both in traditional social networks of person-to-person contact and influence, but also in today’s world of social networks in which it seems that we are more connected than ever, just more remotely. Social networking can be used to spread information as well as change behaviors by spreading diverse phenomena through networks (10). Social networking media outlets like Facebook, Twitter, and MySpace are currently used by the Centers for Disease Control and Prevention to provide information and resources to the public regarding a variety of topics including H1N1 swine flu and the recent peanut product recalls, demonstrating the far-reaching power of social media for public health (11).

Interestingly, the Real Warriors Facebook page (which can be found at http://www/. Facebook.com/realwarriors) contains almost hourly updates with only rare instances of anyone actually taking notice and providing feedback. In fact, most of the few comments left on the page are something to the effect of “Maybe if we ended the war, this wouldn’t be such a problem,” which is clearly mocking the underpinnings of the entire campaign (12). The main campaign website also contains a ‘Twitter monitor’ for those who either do not have Twitter (I admit, I am the last person in my demographic to not have Twitter but I fail to see the need for a streaming update of everyone’s life; suffice to say I did not sign up to follow the campaign’s ‘tweets’) or do not want to follow the campaign via this method. However, it seems that bird has flatlined, with absolutely no updates in the monitor which makes it seem that maybe this page of the site is underused (6). Heading over to the actual Twitter site (which can be found at http://www.twitter.com/realwarriors) gives the same set of stories presented on the Facebook page, and again next to nothing in terms of feedback, despite having over 1,700 followers (13). In asking a few friends of mine who are current service members, veterans, or family members it seems that there is little knowledge of this campaign even among the very people it is trying to reach. None of the handful of people I asked had ever heard of the campaign and these are people exposed to the military life on a daily basis. From this information, it can only be concluded that try as it might, this campaign is simply not increasing awareness of mental health issues and resources simply because it is not being utilized. It would be interesting to know the number of visits to the website daily, but unfortunately this information was not available.

Intervention: Use Leadership to Your Advantage

Maybe Real Warriors use of social networking outlets is not putting information in the wrong places, it is just that this information could be communicated more effectively through these outlets. The website as well as social media are great, almost essential resources in today’s society. But how do we get the most out of them? Strong leadership is one of the military’s greatest assets and one which could certainly be advantageous in trying to communicate information and create a paradigm shift in thinking about mental health (3, 8).

In society at large, the use of strong leaders or celebrity advocates to promote healthy behaviors or screening for diseases have been extremely successful. For example, after then NBC’s “Today Show” anchor Katie Couric underwent a colonoscopy on live TV in 2000 to raise awareness of screening for colorectal cancer, the number of Americans who chose to get a colonoscopy jumped by more than 20 percent. Couric’s brave move in getting an uncomfortable and embarrassing exam on live television had a very positive effect on reducing stigma and fear of getting a colonoscopy (3).

By coupling this kind of advocacy of military leaders with the existing social media outlets used by Real Warriors, this campaign could reach more of our silently suffering soldiers and inspire real change. High-ranking generals and officers should be encouraged to speak out about their experiences with mental illness. These individuals are role models and should be utilized in breaking down the stigma surrounding mental illness. It is not just junior-ranking soldiers who suffer from mental illness, it may be any soldier. Leaders should demonstrate that getting help for a mental illness is a sign of courage, not weakness. Including the stories of these influential individuals in the website materials as well as Facebook and Twitter could have real power to inspire. People may be more likely to seek help if they realize that even these high-ranking officials have gotten help.

Critique: Passivity Requiring Rational Action

Both in the military and out, people with mental illness generally do not seek help until they are in crisis and contemplating harming themselves or someone else. Military mental health services are chronically underused and even when they are utilized it is rarely for early diagnosis and intervention. People seek out help only when they have no where else to turn. Active-duty soldiers suffer notoriously low rates of perceived need for mental health services (14). Unfortunately, Real Warriors does little to change this trend in care-seeking behavior and perception.

This campaign is passive, requiring service members or their family and friends to actively seek out information which may never actually translate into getting help. Just like handing out pamphlets about the dangers of smoking does not make people quit, providing a website with information about mental health resources will not make people seek out help in crisis or not.

A major flaw of this campaign’s design is its use of the Health Belief Model as a means of educating its target audience. The motivations of perceived susceptibility to mental illness or suicide, perceived severity of suffering from a mental illness, perceived benefits of being treated, and perceived barriers in the form of stigma feed into this model (15). The campaign is mainly targeting this latter aspect by removing the associated stigma, however use of this model assumes that thoughts are rational and always lead to action. This assumes that supplying people with enough information will force some realization and a desire to seek help, however knowledge does not always translate into action. The behavior itself that this campaign is trying to change, mainly suicide, is itself not rational, in fact it is one of the most irrational and impulsive acts one could even imagine. In the midst of a mental health crisis rational thoughts or actions may not even be in the realm of possibility. So how could we model the most irrational act with a theory designed to address rational behavior? The answer is we can’t, and we shouldn’t.

Intervention: Educate, Educate, Educate, but Most Importantly Help

The Real Warriors campaign may have been designed to better educate soldiers and their families of the stressors of the military life and resulting or exacerbated mental health issues, but this campaign suffers in its passive attempts to get people to seek out care. A more active approach to breaking down the stigma surrounding mental health and the barriers to seeking care would likely result in better outcomes in the form of fewer suicides and attempted suicides. As public health practitioners, we must design our campaigns in such a way that they target the people they are intended to help while getting at the core issue – that is behavior – in order to promote meaningful and healthy change from a bottom-up fashion. Education is only the first step in promoting mental health and decreasing the incidence of suicide in the military.

At Fort Campbell, Kentucky there has been a concerted and active effort to change the way soldiers think about mental health, from a weakness to a very real and ever-present part of the military life that should be dealt with instead of suffering in silence. A major part of this effort was educating leaders and Army doctors to be proactive about detect signs of trouble in their soldiers, before things reach a boiling point and escalate into suicide. Intense surveillance efforts in the form of monitoring data about substance abuse, issues with the law, etc. which may be trouble signs have also been stepped up in order to recognize problem areas before they get worse. One of the most important aspects of this program has been a shift to giving soldiers an outlet to facilitate one-on-one conversations with their superiors about how to think positively, become more self-aware, and deal with stress. So far these targeted efforts seem to be working by both making soldiers more aware of the resources that are there to help, but also by making them more likely to open up, combating the underlying stigma and having a real effect (8).

So what can we learn from Ft. Campbell? A proactive approach is much more productive than a passive or reactive approach for one thing, especially when promoting earlier care-seeking for mental health issues. For another, we cannot react to suicide by treating it like a rational act; by looking out for early warning signs of mental issues, it may be easier to detect and stop before a soldier is even contemplating suicide. In the past few years, the Department of Defense has implemented a population-wide mental health screening program for soldiers returning from Iraq and Afghanistan but people continue to fall through the cracks of this, or fail to get the continuity of care necessary (16). There must be some middle ground between the Real Warriors passivity and this mass screening program in order to encourage soldiers to get the help they need. A lesson can be learned from Ft. Campbell in that one-on-one conversations can go a long way. Coupling these conversations with the goals of the Real Warriors campaign to educate and inform would go a long way in accomplishing these goals. Perhaps platoon leaders, non-commissioned officers, and other superiors should be educated of the goals and resources available through the Real Warriors campaign, in particular the personal stories which can be found on the website. These stories represent the ideals of the campaign while also providing a means of connection with others who have been in a similar situation. These resources could be a jumping-off point for introspection about the brevity of a soldier’s own situation, perhaps making him/her realize that seeking help is a sign of strength instead of weakness.

Conclusion

The Real Warriors campaign is a great outlet of resources for service members and their families to find information about getting help with a mental illness, however this campaign falls flat in actually reaching its target audience and breaking down the stigma surrounding mental health care. By softening the image of the campaign, it will be better able to reach people in need by not reinforcing the macho ideal of the military culture which perpetuates the stigma associated with seeking help for a mental illness. Expanding upon the use of social media by using the military’s strong leadership hierarchy to this campaign’s advantage would also perhaps make more people take notice and inspire change. Lastly, coupling this education only campaign with more proactive mental health awareness and treatment campaigns such as the one happening at Ft. Campbell would go a long way in fostering positive conversations and introspection among soldiers who are suffering silently from a mental illness. From the high rates of suicide in the military, it is clear that something must be done to help our soldiers who are still waging deadly battles even at home.

REFERENCES

1. Hsia T. A Matter of Life and Death: Suicides in the Army. At War Blog 2010. http://atwar.blogs.nytimes.com/2010/03/26/a-matter-of-life-and-death-suicides-in-the-army/

2. Coogan J. Suicide claims more US military lives than Afghan war. World Socialist Web Site, 2010. http://www.wsws.org/articles/2010/jan2010/suic-j06.shtml.

3. Coleman P. War Trauma Is an Admission of Weakness in ‘Macho’ Army Culture: Army studies say one in three soldiers will return from Iraq with significant mental health problems, but the system isn’t there to help them. AlterNet 2008. http://www.alternet.org/world/79130/?page=entire.

4. Shanker T. Combating the Stigma of Psychological Injuries. At War Blog 2009. http://atwar.blogs.nytimes.com/2009/10/26/combating-the-stigma-of-psychological-injuries/.

5. Link B., E. Struening, S. Neese-Todd, S. Asmussen, and J. C. Phelan. Stima as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People With Mental Illness. Pshychiatric Services 2001; 52: 1621-6.

6. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). Real Warriors. Arlington, VA: Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. http://www.realwarriors.net/.

7. Wilson E. ‘Real Warrior’ Describes Post-traumatic Stress. U.S. Department of Defense American Forces Press Service 2010. http://www.defense/.gov/news/newsarticle.aspx?id=57454.

8. Hall K. U.S. army base tries to stop soldier suicides. USA Today. 2010. http://www.usatoday.com/news/military/2010-04-24-army-suicides_N.htm?csp=34.

9. Blitstein J., W. D. Evans, and D. L. Driscoll. What is a public health brand? (pp. 25-41). In: Evans W. D. and G. Hastings, eds. Public Health Branding: Applying Marketing for Social Change. New York, NY: Oxford University Press Inc., 2008.

10. Christakis N. and J. Fowler. The Collective Dynamics of Smoking in a Large Social Network. NEJM 2008; 358: 2249-58

11. Centers for Disease Control and Prevention. Social Media at CDC. Atlanta, GA: Centers for Disease Control and Prevention, 2010. http://www.cdc.gov/socialmedia/

12. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). Real Warriors Facebook Page. Facebook. http://www.facebook.com/realwarriors.

13. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). Real Warriors Twitter Page. Twitter. http://twitter.com/realwarriors.

14. Sareen J., B. S. Belik, M. Stein, and G. Asmundson. Correlates of Perceived Need for Mental Health Care Among Active Military Personnel. Psychiatric Services 2010; 61: 50-7.

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

16. Hoge C., J. Auchterlonie, and C. Millken. Mental Health Problems, Use of Mental Health Services, and Attrition From Military Service After Returning From Deployment to Iraq or Afghanistan. JAMA 2006; 295:1023-32.

American Foundation for Suicide Prevention Campaigns: a Critique and Alternative use of Stigma Theory- Kerri Barton

Several suicide prevention campaigns have been developed over the past decade by the American Foundation for Suicide Prevention (AFSP) that attempt to solve the complicated and sensitive problem of suicide through the use of television, radio, and billboard advertisements promoting suicide awareness. However, instead of using more recent and effective interventions such as the Stigma Theory, the campaigns push facts onto their audience and fail in their use of the Advertising Theory.

According to the American Foundation for Suicide Prevention, 33,000 people die from suicide each year in the United States (1). Overall, it is the 11^th leading cause of death in the US, and the 4^th leading cause of death among adults between 18 and 65 (1). Among 15-24 year-olds, suicide is the third leading cause of death, following unintended injuries and homicide (1). It is estimated that 90 Americans take their own life everyday, and about 2,300 more attempt to do so (1). However, suicide is a preventable cause of death, as it has been reported that about 90 percent of all people who die by suicide have a diagnosable psychiatric disorder at their time of death (1).

These rates are obviously alarming, and have prompted the American Foundation for Suicide Prevention and several other agencies to implement interventions to reduce this rapidly increasing problem. The campaign created by AFSP projects its message through television, radio, and billboard advertisements (2). The television and radio advertisements, which began in 2000, target an adolescent audience, telling them “don’t keep suicide a secret” (2). The billboards, which can currently be seen in Minnesota and Nebraska, are targeted toward an older audience and instruct highway drivers who are depressed to seek treatment (3). Even though this campaign has several positive aspects, it relies too much on facts, it inefficiently uses advertising in the media, and it targets the wrong audience. The following critique will discuss these three failures and give an alternative approach that may be more effective.

Campaign Critique

An all too common failure of suicide prevention interventions is the frequent use of facts and statistics in advertisements and curriculum-based programs (4). The AFSP campaign is no exception. Three of their billboards contain a list of the number of deaths from suicide, DWI/DUI, and homicide in Minnesota, Washington, and Ohio (3). These billboards are most likely on the side of a highway or busy street, and it would probably be very difficult for a driver going 60 miles per hour to read a list of statistics. How then, could these advertisements reach out to people in need of help? All of the billboard ads urge readers to visit the campaign website: www.depressioncanbefatal.org, which is a very simple website containing a few statistics about clinical depression and a questionnaire that helps to screen for depression (3). A study done in 1991 by Shaffer et al. evaluated the effectiveness of three suicide prevention campaigns among students in the US, and found that “the majority of the students who attended the programs were fairly knowledgeable about suicide before program participation, and most held favorable attitudes toward help seeking” (4). Thus, it is apparent that most who are at risk for depression already know they are at risk for suicide since they probably already have contemplated doing so, and do not need more facts pushed at them about their condition. What they really need is professional help and a push to seek such treatment.

In addition to the billboards, the television and radio advertisements urge viewers and listeners to visit the AFSP website homepage, which is completely lackluster and does not contain any other resources someone can seek help from (1). The National Suicide Prevention Lifeline is listed toward the bottom of the homepage, and you can find it if you look hard enough (1). If someone felt that they were seriously depressed or contemplating committing suicide, they would have a difficult time finding help on this website. They would merely find the latest projects and promotions by AFSP, and clicking on their links on the left side of the page would lead them to more facts and the ability to watch the commercials again (1). The WHO reports several factors that lead an individual to suicide (9). There are usually multiple and complex factors that all combine to result in an individual committing the act (9). Thus, suicide should not be reported in a simplistic way, as it is in this campaign. Suicide is never the result of a single factor or event. Mental illness and impulsiveness each play an important role (9).

Besides this, it has been proven in past attempts at adolescent public health interventions that the opposite affect may occur in this age group (6). An evaluation by Hornik, et al of the National Youth Anti-Drug Media Campaign observed that antidrug advertising was conveying a message that drug use was commonplace among youths (6). Thus, the target audience who saw the ads believed the only way they could fit in was to smoke marijuana like all of their peers are doing (6). The same effect is likely to occur among adolescents with thoughts of depression or suicide. If they see an advertisement telling them about the thousands of suicides that take place every year, they may be more inclined to take this option and “follow the trend.” The WHO’s article on preventing suicide reports that specific groups in the population such as young people suffering from depression are even more vulnerable to imitating suicide behaviors of others (9).

A second flaw of the campaigns by AFSP is the audience chosen to be targeted in the television and radio advertisements. Essentially the purpose of these advertising campaigns is to prevent suicide among adolescents. Their commercials are currently airing in 85 markets nationwide, reaching about 88 million television viewers (2). The message of each commercial is that “Suicide Shouldn’t Be A Secret” and features adolescents telling stories about friends they lost to suicide and instructing viewers to “tell someone” if someone they know is thinking about committing suicide (2). Thus, the target audience of these commercials is not even those thinking about committing suicide themselves, but rather their peers.

More evidence needs to be found as to whether targeting the peers of those at risk for suicide is more beneficial than targeting the suicidal teenagers themselves. It is rare to see an anti-smoking or anti-drug use campaign targeting peers of teenagers who smoke or do drugs instead of the teenagers performing the risky behaviors themselves. A public health report from the Centers for Disease Control and prevention stated that “recent research has shown that mass media campaigns can be effective in preventing smoking among youth if the messages are based on appropriate educational objectives and communicated with sufficient reach, frequency, and duration to high-risk youths” (7). They do not say that targeting the friends of those who smoke will be an effective mass media campaign. Instead, it is important to reach the high-risk group in order to intervene effectively. In addition, the National Institute of Mental Health suggests that research helps determine which factors of programs can be customized to help prevent suicide in specific groups of people and before being put into effect, prevention interventions should be tested through research to evaluate their effectiveness (8).

A recent teen suicide prevention campaign created by the Substance Abuse and Mental Health Services Administration (SAMHSA) called “We Can Help Us” focuses on changing the thoughts of young people contemplating suicide (10). The initiative actually empowers adolescents that they can help themselves, and there are many others just like them who have been in their situation and survived to tell others about it (10). The campaign website contains several personal stories from teenagers who have been clinically depressed or attempted suicide (10). In most of the stories, the teens did not seek help until things began to get out of control, or when they were so close to killing themselves it scared them into seeing a doctor about their problem (10). Many of them felt embarrassed about their condition and were too ashamed to seek help (10). Thus, the AFSP messages may not be helpful in many situations if those who are thinking about ending their life are not even seeking help from others or speaking about their feelings outwardly.

A third major flaw of the AFSP campaign is its failed use of advertising theory for a public health intervention. An article by Evans and Hastings focuses on public health branding and reports that “brands, recognition of brands, and the relationship between brand and consumer are essential to marketing and largely explain the tremendous success of product advertising and the growth of the global consumer economy…” (11). They define brands as a collection of associations tied to a specific name, mark, or symbol representing the product or service (11). Thus, in order to have a successful public health campaign and to effectively “sell” the product of interest (suicide prevention), the program should contain a recognizable image associated with it. The campaign should be marketed across several media outlets (i.e. television, radio, print ads, and the internet) and contain the same message and image throughout. Even though the AFSP campaign does use several different media outlets to convey their message, including television, radio, print ads, and the internet, it fails to have a recognizable image that reaches the target audience across a large population.

One of the most famous and successful marketing campaigns in the US is Nike. Their trademark “swoosh” is highly recognizable in American culture (13). Even more relevant is the largely successful “Truth” campaign, which intended to reduce the prevalence of smoking among adolescents (14). This campaign targeted teens across several media outlets, including television, radio, MySpace, YouTube, and Facebook. It empowered teens with the ability to rebel against tobacco executives by not smoking, and, according to an article by Hicks, “(a) study found that since 1998 the percentage of youth using tobacco in the past 30 days had declined by 7.4 percentage points… in middle school and 4.8 percentage points… in high school” (15). The campaign had such a powerful “brand image” that they are still selling apparel and other merchandise associated with the campaign. Even though the television advertisements have been taken off the air, the campaign website is still available for viewing (14). It is apparent that the AFSP program has not been able to reach this level of notoriety among its audience yet. The television advertisements do not promote a specific brand, symbol, or recognizable image one can associate with suicide prevention. There is also no connection between the colors, images, and people portrayed on television, the billboards, and their website.

Besides lacking a “brand image,” the campaign overall fails to have an effective “shock factor” that would essentially lead to change. The billboards displayed are targeted mainly toward adults and those who frequently drive on highways in Minneapolis and Nebraska (3). They are yellow and blue in color, and project these messages: “Depression: #1 Cause of Suicide,” “Prevent Suicide, See your Doctor,” and “Ohio Deaths 2004: Suicide 1319, DWI/DUI 495, Homicide 492” (3). Two of the billboards show a black and white photo of a person who died from suicide, but their deaths are dated in the 80s and 90s (3). An article on Wikipedia discusses the aspects of an effective billboard: “they have to be readable in a very short time because they are usually read while being passed at high speeds. Thus there are usually only a few words, in large print, and a humorous or arresting image in brilliant color” (12). Three of these billboards that list the number of deaths associated with suicide and other causes are much too difficult to read at high speeds. They also lack a captivating or shocking image to leave an impression on their audience. Calvin Klein is notorious for having shocking billboard advertisements that show models barely clothed engaging in risqué positions (16). The billboards usually do not even contain any words at all except for “Calvin Klein,” but the posters are very eye-catching and successful, as it appears in Times Square in New York City. It is unlikely that the billboard advertisements created by AFSP will be in Times Square any time soon.

Besides the billboards, the television commercials also lack a “shock factor” to captivate their audience. An advertisement promoting breast cancer awareness created by ReThink Breast Cancer shows a woman’s breasts throughout the entire commercial (17). Although somewhat controversial, the commercial is has reached a wide audience and has over 800,000 hits on YouTube (18). The “truth” campaign also had several shocking facts and images on their commercials, one of which included stacking body bags of the number of people who die annually from smoking outside of a large tobacco company (14). The AFSP commercials fail to captivate their audience with such imagery.

Creating an Effective Intervention

In response to the flaws that have been pointed out above, there is hope for an effective suicide prevention program. A 1993 article in American Psychologist looks at several approaches to suicide prevention efforts. They conclude that there are several more efficient and effective strategies to try to solve this problem (5). Garland, et al suggests implementing primary prevention programs, suicide prevention education for professionals, education and policy formation on firearm management, education of media professionals about the social “herd mentality” in adolescent suicide, more efficient identification and treatment of at-risk youth, and crisis intervention and post-intervention programs (5). In addition to these alternate approaches to creating a public health intervention aimed at suicide prevention includes that of the use of Stigma Theory.

An article in the International Encyclopedia of Public Health conveys that stigma is an omnipresent force that can have severe consequences and may even reduce the life opportunities of those being affected by it (19). Stigma results from a collection of internal psychological processes at the individual level, interpersonal social interactions between individuals and groups, and even larger impacts from the level of culture and politics (19). A news article from the United States Department of Defense explains how stigma associated with mental illness is the biggest block mental health practitioners are forced to encounter in helping patients in need, reducing suicide rates, and improving the military force (20).

According to the National Institute of Mental Health, more than 90 percent of those who die by suicide have depression, other mental health disorders such as bipolar disorder, or they have a substance-abuse problem often in combination with a mental health disorder (8). According to Johns Hopkins University psychiatrist Dr. Kay Redfield Jamison, "We have good treatments for the major psychiatric illnesses. What's difficult is getting people to recognize that they have a problem ... and to set aside the stigma or work around it" (20). An article in Clinical Psychology: Science and Practice discusses mental health stigma and demonstrates the connection between stigma signals, stereotypes, and behaviors in a comprehensive diagram, as shown in figure 1 (21).

Fig. 1: The relationship between discriminative stimuli and subsequent behavior

Clinical Psychology: Science and Practice 2006

The article argues that this model can be used to better understand the stigma around mental health (21). One of the most important descriptive stimuli involved with mental illness is that of labeling. According to labeling theory, those who are termed mentally ill, or those who are known to be labeled as such (i.e. being observed coming out of a psychiatrist's office), are subjected to stigma and the negative effects that result (21). A study found that those who were labeled "mentally ill" in the public had lower incomes than an equally impaired group without labels (21). The labels given to individuals with a mental illness in our society are a significant hindrance to those who need professional help. Because of this, many individuals may feel that going to see a psychologist or counselor as a bad thing, and not go at all. Many tend to consider what their friends or family would think of them if they revealed that they were going to see a psychiatrist or psychologist for their mental disorder, and sometimes the thought of being called “crazy” will prevent them from getting the treatment they need. In addition to labeling, many of the symptoms that are associated with mental illnesses, such as inappropriate or bizarre behavior, language impairment or irregularity, and talking to oneself out loud are another set of signals that may result in additional stigma toward mentally ill and may frighten the public (21). They also lead to stereotypes of dangerousness and social ostracizing, as demonstrated in Figure 1. Research has shown that these kind of behaviors and symptoms tend to produce an even greater stigma effect than that associated with labeling alone (21). All of these factors will lead to an individual with a mental illness to feel discriminated against, rejected from society, and maybe even hopeless. They may even feel that they do not want to burden their friends, families, or a doctor with their problems.

The main stigma associated with clinical depression is the corresponding treatment. Taking anti-depressant medication has a stigma attached to it that the person is reliant on their “crazy pills.” A British woman reports: “Well I'm too worried about telling people I'm on medication. There are very, very few people that I talk about the ECT to...because it does feel...well I don't really want to talk about it because I hate it and it's horrible and also I feel there is big stigma attached and if they hear about that they'd think I was really mad” (23). In addition, a 43 year old British man reported refusing treatment at a hospital because of the stigma associated with depression: “I regret not going to the hospital. I listened to too many people and I suddenly thought I am going to be labeled a loony. I wasn't aware obviously because it hadn't happened to me before so I was...yes it did stop me from going there” (23).

Thus, a successful public health intervention would be one that promotes positivity around seeking professional help for a mental illness and one that reduces the stigma associated with the act. The CDC reports that in 2006, 15.7% of Americans reported being diagnosed with clinical depression by a healthcare provider at least once in their lifetime, and many more go undiagnosed (22). This is a high prevalence in the population that should be disclosed to those who feel alone in their illness. A campaign that promotes this idea that there are several others who face the same day-to-day challenges and that there are several resources available for those in need is likely to succeed. A 40 year old woman with depression reports: “First of all I was relieved, the first time I saw the psychiatrist I talked to him for three hours. To have someone say that what I was feeling was not that unusual. I thought I was the only person in the world who felt like that” (23).

Looking to the successful campaigns mentioned above such as the “truth” campaign, Nike, and “ReThink Breast Cancer,” it would be effective to create an anti-suicide campaign that creates a brand image for itself and one that reaches across several media outlets, including television, radio, print ads, and many internet websites such as Facebook, Twitter, and YouTube. The campaign should create a positive slogan, such as “get help, stay alive,” or “choose life.” A brand image can be created by using the same font, colors, and characters in all forms of advertising. The focus of television commercials should be to educate the public about the prevalence of depression among adults and teenagers alike, and that no one is alone in their mental illness. The commercial should direct viewers to a website that contains resources for those who are depressed or thinking about committing suicide, and also for the general public to learn about their peers who are suffering silently. The campaign website should be colorful, inviting, and captivating to a wide audience, including young people. There should be real stories from those who suffer from a mental illness and how they decided to seek help and get treatment. It is important to empower the people suffering with the tools to help themselves. This will give them confidence that they can get better and will seek the treatment they need. In order to reach a wide audience across the nation, projecting the campaign on Facebook, Twitter, and YouTube is important. Facebook is a very important outlet for young people, and creating a captivating webpage here would be effective. In addition, Twitter and YouTube are also popular, and would probably reach an older audience at the same time. An additional media outlet to project the campaign could be through podcasts, which can contain a series of educational videos and audio that include teaching positive “self-talk” and empowering messages.

It is very important that the program is positive and projects a “choose life” message or a positive image around mental illness. Empowering the public to change and help themselves would lead to more positive outcomes instead of instilling fear and anxiety within them. Endorsing advertisements that show or describe gruesome suicides may lead to the opposite effect of what’s desired, as described earlier about suicide imitation (5).

To conclude, the American Foundation for Suicide Prevention’s campaigns, which can be found on television, radio, and billboards, fail to meet the needs of controlling the national suicide epidemic. Although it makes a commendable effort to promote suicide awareness, it is too fact-based, targets the wrong audience, and fails to use advertising effectively. An alternative solution to solving the problem of suicide would be to recognize and decrease the stigma associated with mental illness and its increasing impact on suicide. Empowering those in need with the tools to help themselves and increasing public acceptance and awareness of this problem will lead to a decrease in this horrible national tragedy.

REFERENCES

1- American Foundation for Suicide Prevention. Facts and Figures. American Foundation for Suicide Prevention, 2006. April 2010. http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_id=04EA1254-BD31-1FA3-C549D77E6CA6AA37.

2- American Foundation for Suicide Prevention. Teen Suicide Prevention Campaign. American Foundation for Suicide Prevention, 2010. April

2010. http://www.afsp.org/index.cfm?page_id=056954D8-0D84-0DD0

4984862095B0D073.

3- American Foundation for Suicide Prevention. You Saw One of Our Billboards? 2010. American Foundation for Suicide Prevention. April 2010. www.depressioncanbefatal.org.

4- Shaffer D, et al. The impact of curriculum- based suicide prevention programs for teenagers. Journal of the American Academy of Child and Adolescent Psychiatry 1991; 4: 588-596.

5- Garland, A and Edward Zigler. Adolescent Suicide Prevention: Current Research and Social Policy Implications. American Psychologist 1993; 48: 169-182.

6- Hornik R, Jacobson 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: 2229-2236.

7- McKenna J, Williams K. Creating Effective Tobacco Counteradvertisements: Lessons from a Failed Campaign Directed at Teenagers. Centers for Disease Control Public Health Reports 1993; 106: 85-89.

8- “Suicide in the US: Statistics and Prevention.” National Institute of Mental

Health. 2010. National Institute of Mental Health, 2009. April 2010.

9- Preventing Suicide: A Resource for Media Professionals. Geneva, Switzerland: World Health Organization: Department of Mental Health and Substance Abuse, 2008. Print.

10- Inspire USA Foundation, 2010. Web. April 2010. www.reachout.com.

11- Evans WD, Hastings. Public health branding: Recognition, promise, and delivery of healthy lifestyles (Chapter 1). In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press, 2008, pp. 2-24.

12- Wikipedia, 2010. Billboard. April 2010. http://en.wikipedia.org/wiki/Billboard.

13- Nike, 2010. Web. April 2010. www.nike.com.

14- The Truth Campaign, 2010. Web. April 2010. www.thetruth.com.

15- Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.

16- Calvin Klein, 2010. Web. April 2010. www.calvinklein.com.

17- Re Think Breast Cancer, 2003. Web. April 2010. www.rethinkbreastcancer.com.

18- YouTube, 2009. Save the Boobs. April 2010. http://www.youtube.com/watch?v=8tkB264wZZk

19- Yang LH, Cho SH, Kleinman A. Stigma of Mental Illness. International Encyclopedia of Public Health 2008; 219-230.

20- Rhem KT, Sgt. “Reducing Stigma of Mental Illnesses Could Reduce Suicides.” American Forces Press Service 8 May 2000. Web.

21- Corrigan PW. Mental Health Stigma as Social Attribution. Clinical Psychology: Science and Practice 2006; 7: 48-67.

22-Centers for Disease Control. Anxiety and Depression 2009. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/Features/dsBRFSSDepressionAnxiety/.

23-Dinos S, Stevens S, Serfaty M, Weich S, King M. Stigma: the feelings and experiences of 46 people with mental illness. The British Journal of Psychology 2004; 184: 176-181.

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.

REFERENCES

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13. Yamamiya Y, Cash TF, Melnyk SE, Posavac HD, Posavac SS. Women’s exposure to thin-and-beautiful media images: body internalization and impact-reduction interventions. Body Image.2005;2:74-80.