“Scared Straight” To Juvenile Delinquency – Mary Kowal

Introduction
According to the Merriam-Webster Dictionary juvenile delinquency is “a violation of the law committed by a juvenile and not punishable by death or life imprisonment” (1). This definition encompasses a variety of actions and behaviors that are violations of the law and also ultimately affect health. Scared Straight Programs, jail tours, and similar programs bring attempt to scare “at-risk or delinquent children from a life of crime” (2). These programs that focus on deterrence and shock tactics are inherently flawed and are ineffective. A more reasonable and effective approach is implementing a program that addresses the motives and psychology of adolescent delinquents.
How is juvenile delinquency related to health? Violations of the law for youth include alcohol and drug use, use of firearms, and violence. These are actions and behaviors that can have a significant impact on health. From 1998-2008, 12% of violent crimes were committed by juveniles (3). Additionally, in 2008 21% of liquor law arrests involved juveniles along with 18% of sexual offense arrests, 18% of assault arrests, 15% of forcible rape arrests, 11% of drug abuse arrests, and 10% of arrests for murder involved juveniles (3). These numbers only reflect the numbers of teens being caught and arrested. Drugs, alcohol, and violence are a much wider problem. In the 2007 Youth Behavior Risk Survey, it was found that during the past 30 days 26% of teens binge drank and 29% rode with a drive who had been drinking (4). Additionally, 18% of students surveyed had carried a weapon in the 30 days prior to the survey and 35.5% of students had been in a physical fight in the year before the survey (5). The term “juvenile delinquency” readily correlates with teen health because of things like alcohol, drugs, and violence.
Scared Straight began in the 1970s as a program which inmates serving life terms in a New Jersey prison “scared” at risk youth and delinquents from lives of crime.2 The main objective of this program was deterrence by scare and shock tactics. Teens are brought into prisons through schools or parent initiative and then turned over to the prison guards for a “realistic” experience of prison life. Those in favor of the program (and others like it) believe that if teens experience this realistic view of life in prison they will be deterred from crime (2). However, many have published empirical evidence and data showing that Scared Straight and similar programs are ineffective. A 1982 evaluation found that 41% of Scared Straight attendees in New Jersey committed new offenses and only 11% from the control group (who did not attend the program) committed new offenses. Of eight other randomized trials analyzed, only one program was seen to have a positive result, though statistical insignificant. Overall these trials show that the Scared Straight program can actually increase the odds of juvenile delinquency (2). Despite their inefficentiveness, Scared Straight and other similar deterrence programs are still used in cities across the US today.
Critique 1: Negative Labeling
Labeling theory focuses on the formal and informal “application of stigmatization, deviant ‘labels’ or tags by society on some of its members” (6). This theory is widely used in criminology and sociology. Ronald Akers suggests that designating an individual as deviant or delinquent is not always determined by what s/he has done but rather who they are (6). This is problematic for “at-risk” teens who may come from troubled families or live in rough neighborhoods. While they might not be deviants, they may have a greater chance of being labeled as one simply because of circumstance. The symbolic interactionsim theory holds that those “…stigmatized as deviant are likely to take on a deviant self-identity and become more, rather than less deviant than if they had not been so labeled” (6). If the Scared Straight intervention is given to teens who are “at-risk” but not themselves delinquent, this can have the opposite intended effect. The program is showing them that prison is where they are headed and their life prospects are bleak.
Teens also feel powerless to resist labels applied to them by authority figures – teachers, administrators, and police and prison guards. Unable to fend off these labels, teens often integrate these negative labels into their own self-concept (7). With a negative label forced upon the, delinquency might become a self-fulfilling prophecy for teens that go through Scared Straight and similar programs. Although controversial this idea is very possible given that in randomized studies of both delinquents and non-delinquents, the experimental group that received the intervention did worse in follow-up actions (8). Even in less stressful or consequential settings, negative labels can lead to negative results for the subjects. After responding to a race prime question before taking the GRE verbal section, black participants scored worse than those who were not primed with a race label (9). It is reasonable to argue that a label as strong and as negative as “delinquent” or “deviant” may become self-fulfilling for the teens participating in Scared Straight or similar programs.
The negative labeling of teens in the Scared Straight Programs is one of its worst flaws. It harshly and deliberately labels teens as “delinquent” or “deviant” and expects that this will induce a behavior change. Moreover, authority figures and people in power apply these labels. By mentally and emotionally beating teens down with negative labels and stigmatization they may indeed feel they are doomed for a life of crime and substance abuse. Scared Straight offers no other options for them; it only shows them the negative side of who they assumed to become.
Critique 2: Scared Straight Is Likely to Provoke Negative Reactance
According to Jack Brehm’s psychological reactance theory, “people become motivationally aroused by a threat or elimination of a behavioral freedom” (10). They are then compelled to act in a way that restores that freedom. Reactance can occur in two ways: an individual can attempt to restore freedom by actions, or there can be an increase in the perceived attractiveness of the action or behavior being threatened. Likewise, it is also possible for individuals to attempt to regain a sense of control and freedom by exercising alternate freedoms than those specifically threatened (11). Although a freedom is not specifically being taken away by the Scared Straight programs, teens are told bluntly and harshly not to do certain behaviors. They are told it is not worth the prison time and consequences to do drugs, use alcohol, or commit violent crime. Teens may be motivated to restore their threatened freedom by engaging in illegal and harmful activities.
One factor in reactance is the explicitness of the message (9). This means the degree to which the message is clear about its intent. This factor can provoke reactions both ways, but usually tends to increase persuasion. In the case of Scared Straight, the message is very clear and as well as the intent of the message: delinquency will have serious consequences in your adult life and you should stop now or not even start delinquent behaviors. However, despite the clarity, it is possible in this scenario that even explicitness will not decrease reactance. The Scared Straight message is a firm “no” to alcohol, drugs, and violence. Teenagers may not care that the message is straightforward and unconcealed and instead choose to rebel against this threat to freedom regardless.
The second factor in reactance is dominance. This refers to the amount that the message reveals that the messenger can control the recipient (9). The greater the perceived dominance by the messenger, the greater the level of reactance will be in theory. Again the ideas of power and authority come into play. Scared Straight puts teens in a vulnerable position by showing then a realistic prison experience among prison guards and inmates. In interviews with participants done by James Finckenauer, they reported that the inmates and guards yelled, scared the participants “to death,” and that they were pushed and shoved (8). This shows the subordinate position of the teenagers in the intervention. Because of this decreased role and perhaps feeling of helplessness, teens may be motivated to act in a way that increases their sense of control and also protect their “freedoms.”
The last factor on reactance is the idea of reason. This is the idea that a justification is offered in support of the claim (9). The more reason given, the less reactance is the theory. A the time that Scared Straight began, the only types of prison visiting programs were for college students, and for educational purposes. The Scared Straight program had an entirely different agenda in mind (8). This program was and is about the shock value experience of prison life. As described in Finckenauer’s research, there is no education in the Scared Straight tours. Teenagers are given an experience, not a justification. A program so harsh with no lead up or follow up discussion can leave participants feeling angry or rebellious. Anecdotal evidence shows that many participants did not see how this program applied to them. For these reason, reactance to such tours and programs can be quite high.
Critique 3: Ignoring Motives and Circumstances
The final critique of Scared Straight and similar programs is that they focus on the outcome and not the motives. The programs solely aim to stop juvenile delinquency and scare teens out of illegal actions. However, there is a complex mix of motives and circumstances that lead teens to delinquency. The United Nations 2003 World Youth Report on Juvenile Delinquency notes that many programs to prevent youth crime and illegal activity are poor equipped to address these issues, or do not address them at all (12). Programs like Scared Straight fit into the category perfectly – there is no mention of the reasons behind of delinquency.
Families are a large factor in juvenile delinquency. Youth at risk for becoming delinquent are often raised and living in difficult circumstances. Parent alcoholism, poverty, lack of basic needs, broken families, and abusive home life are just a few of the factors influencing juvenile delinquency (12). Teens learn how to live and interact with society by observing family (13). Family environments can teach teens the wrong messages about interacting in society and what is acceptable behavior. Divorce is one sub factor that can promote an unhealthy family situation and teach dysfunctional behaviors to juveniles because of the lack of stability and concordance. Scared Straight is not a supportive environment in which to learn the “right” behaviors.
Socioeconomic status also plays a role in juvenile delinquency. Some argue that “antisocial behaviors have become entrenched norms within chronically impoverished inner-city environments, so that delinquency and criminality are now endemic facts of life” (13). Teens may feel as though they cannot change their circumstances, particularly if they see their families and neighbors in poor situations. Consumer standards and media pressure push teens to desire a lifestyle that is beyond their means (12). Those who feel that traditional and legal means of making income and advancement will not be successful to them turn to other activities like violent crime and drug dealing. Scared Straight and similar programs do nothing to address the motivations and desires of teens that may be precipitating their illegal and destructive behavior.
Finally, educational experiences factor into juvenile delinquency. Education is influential because it can “shape many youths’ sense of opportunity and self-worth” (13). If teens believe that their educational experience will help them excel, they are less prone to turning to illegal activities to earn money and freedom. However, “academic achievement is considered to be one of the principal stepping-stones toward success in American society” (13). Many teens do not have the opportunity for the same level of education as is required to succeed. Family and socioeconomic factors, as mentioned above, can also contribute to low educational achievement and poor encouragement from educators. Those who drop out of high school and have bad academic performance have higher incidence of delinquency (13).
Just from the examples of family, socioeconomic status, and education it is possible to see how programs such as Scared Straight effectively ignore the root causes of juvenile crime, alcohol use, and drug use.
Proposed Intervention
The proposed intervention does not focus simply on juvenile delinquency, crime and violence, and drug and alcohol use, but is more holistic in its approach to teenage problems and the causes of delinquency. Taking a broad approach to this topic can keep teens health both physically and mentally. The proposal is a based around a series of weekly workshop-style classes throughout junior and senior high school. It is important to begin an intervention early when most teens are not yet delinquent or experimenting with drugs and alcohol. The three overall goals are for teens to increased their decision-making skills and self-control, expand their knowledge of alcohol, drugs, and violence, and to give them concrete skills to use in everyday life.
Classes would be built into the normal weekly schedule for the students in participating schools. While this approach may be effective in a variety of settings, it might be most cost-effective in schools with a large number “at-risk” students. The intervention would be a universal program, meaning that all teens will attend this class regardless of “risk” status. It would be ideal to maintain the same instructor/facilitator as the students moved up in grade levels as this would provide continuity and stability. In addition, the classes would not be a complete top-down learning environment. It should be a non-threatening time for students to hear the instructor, each other, and themselves. At the beginning of the semester the instructor would review the goals of the class (see above) and ask for suggestions for specific workshops and conversation topics. Issues covered in each grade should be appropriate to that level and that stage of development and life.
The goal to increase decision-making skills and self-control can involve lessons, discussion, and practicing. Decisions should range from drugs and alcohol to decisions about life and school work. Some focal points can be narrowing down the real issues, listing one’s priorities, deciding who their decisions will affect, and attempt to project how one will feel at various points in the future from a decision (14). This can empower teens and pre-teens about decisions in their life.
The second goal is to expand knowledge of alcohol, drugs, violence, and crime and also the effects of these. Again these sessions should be a mix of instruction and discussion. Lessons about these topics should come from the instructor, but also the teens themselves. Groups should present on different topics regarding these actions and behaviors and their negative consequences. Facilitated discussions are also appropriate for these topics. This should be a time for confidential and candid discussion among the teens. Discussion topics can include issues related to drug and alcohol use, crime, violence, stereotypes, self-image, methods for quitting substances, and how these issues have touched their lives.
The final goal of this intervention is to give the teens tangible life skills. In addition to decision-making and self-control, there are other important life skills that can impact juvenile delinquency. Workshops can touch on topics to empower teens and give them a sense of control and hope for their future. Issues like study skills, essay writing, finding a part-time job, applying for college and financial aid, and how to cope with stress and peer pressure.
Defense 1: Avoids Negative Labeling and Supports Group Change
The universal approach to this intervention – having all students required to attend these classes – allows for the elimination of negative labeling and supports group change, unlike the Scared Straight programs.
As mentioned previously, there are detrimental effects to negative labeling, namely it can become a self-fulfilling prophecy. The universal approach of this intervention does not allow for negative labeling based on who participates, like the Scared Straight and similar programs. All teens are put in the same boat, receiving the same intervention and support equally. No one is labeled or seen as a delinquent. In fact, teens who go through this intervention can actually be labeled positively – as Resistors, as Successes, as Role Models. The attitude in the class should be one of empowerment and success – that these teens are going places. If other teachers at the school acknowledge this program and its goals, they too can be a part of the positive labeling of their students.
It is also important that the intervention is received among peers. The social network theory is a group-level model that says that behavior is determined by one’s social network. The implications are that the intervention should be delivered at the group level and if you can deliver it to the most connected person, you can influence the most people (9). This effect is shown by the Harvard smoking cessation study that diagrammed participants smoking cessation and their social connections. The diagrams showed how non-smokers and smokers clustered and how the relations change as people quit (15). This same concept can be loosely applied to this intervention. Since all the students in the school get the same intervention, you are likely to hit the key students who have major social connections. If the intervention is positive for them, they can influence a large group. The non-delinquents can potentially have an effect on the delinquents for the better. The idea of the social network theory is that imparting change is easier done on a group-level.
Defense 2: Gives Teens a Sense of Control
The proposed intervention gives teens both real control and a heightened illusion of control in their lives. This is an important counterpoint to the reactance that many juveniles may face when participating in the Scared Straight program.
The program gives the participants real control. They are encouraged to help select workshop topics, and to give presentations. Even facilitated discussion with the instructor posing questions and making suggestions, can make teens fee in control of he situation and avoid reactance (16). They are also given skills that allow them to better manage in life and school such as study habits and writing skills. These factors, combined with decision-making skills, can lead to teens making the decision not to use drugs and alcohol or to commit a crime. They have the knowledge and the tools to control part of their lives.
The factor also falls into line with the Illusion of Control Theory. This theory states that skill-related factors give people an expectancy of success that is “inappropriately higher than the objective probability would warrant” (17). Though theory this sounds negative, it does not have to be. Even if the participants are delinquent or have many risk factors for delinquency, they can be under the illusion of control. Perhaps odds are against them in terms of doing drugs, using alcohol, and committing violent acts. However, this program wants to instill the idea that they can in fact control their lives. Thinking about and practicing decision-making, having group discussions, and improving self-control all can create the illusion that these teens have the ability to control some aspects of their lives. By giving them this illusion of control, even when circumstances and statistics say they will fail, teens can take actual control and make the choice not to do illegal activities.
Defense 3: Addresses the motivations and circumstances
This proposed intervention has better chances of success because it addresses the motivations for juvenile delinquency and the factors that are behind it. The Juvenile Justice Panel’s report on the Interagency Panel on Juvenile Justice highlights successful crime-reduction programs in many countries that focus on the causal factors for juvenile delinquency: unstable home situations, school drop-out rates, skills training, and education (18). This intervention also targets the three critical factors in delinquency that the Scared Straight programs ignore: families, socioeconomic status, and education.
The intervention does not specifically address the role of broken families in juvenile delinquency, but it becomes a support system for the participants. The instructor will in theory stay with the same class of students as they complete the program. Having such a constant presence and mentor in their lives will provide teens with a sense of support and encouragement that they might not be receiving at home, as well as a positive role model. The classroom can also been seen a safe place for learning, expression, and conversation.
The proposed intervention also touches on the idea that socioeconomic status and education play a role in delinquency, as mentioned above. While nothing can change the circumstances in which the teens grew up, this program will allow them to see a successful future for themselves. After completion of the program, teens will have tools, skills, and resources to overcome obstacles they have in their lives. Learning to search for a part time job, to apply for college and financial aid, and to write a good essay gives teens tangible skills they can use to improve their lives. These skills will hopefully give teens another way to achieve their goals instead of delinquency.
Conclusion
When looking at the issue teen health in the United States, one must also look at the issue of juvenile delinquency including alcohol, drugs, and violence. The Scared Straight program and other like it attempt to resolve the issue of juvenile delinquency through deterrence and scare tactics. However, empirical evidence shows these programs are not working and actually increase delinquency. A better approach is a comprehensive intervention that targets all teens, avoids negative labeling, gives teens a sense of control, and addresses the root causes for juvenile delinquency.


References

1. Merriam-Webster. Merriam-Webster's Online Dictionary. . http://www.merriam-webster.com/netdict/juvenile%20delinquency. Updated 2010. Accessed 4/24, 2010.
2. Petrosino A, Turpin-Petrosino C, Buehler J. Scared Straight and Other Juvenile Awareness Programs for Preventing Juvenile Delinquency: A Systematic Review of the Randomized Experimental Evidence. The Annals of the American Academy of Politicial and Social Science. 2003. http://ann.sagepub.com/cgi/content/abstract/589/1/41.
3. Puzzanchera C. Juvenile Arrests 2008. Juvenile Justic Bulletin. 2009. www.ojp.usdoj.jov.ojjdp.
4. Centers for Disease Control and Prevention. Quick Stats: Underage Drinking. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/alcohol/quickstats/underage_drinking.htm. Updated 2008. Accessed 4/24, 2010.
5. Centers for Disease Control and Prevention. 2007 National Youth Risk Behavior Survey Overview. . 2007. http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbs07_us_overview.pdf.
6. Akers RL. Criminological Theories: Introduction, Evaluation, and Application. 3rd ed. Los Angeles: Roxbury Publishing Company; 2000.
7. Ray MC, Downs WR. An Empirical Test of Labeling Theory Using Longitudinal Data. Journal of Research in Crime and Delinquency. 1986. http://jrc.sagepub.com/cgi/content/abstract/23/2/169.
8. Finckenauer JO, Gavin P, W. Scared Straight: The Panacea Phenomenon Revisited. Prospect Heights, Illinois: Waveland Press, Inc; 1999.
9. Siegel M. SB721 Lecture: March 18, 2010. . 2010.
10. Brehm JW. Psychological Reactance: Theory and Application. Advances in Consumer Research. 1989;16. http://www.acrwebsite.org/volumes/display.asp?id=6883&print=1.
11. Dillard JP, Shen L. On the Natre of Reactance and its Role in Persuasive Health Communication. Communication Monographs. 2005;72(2). classweb.gmu.edu/gkreps/820/009.pdf.
12. United Nations. World Youth Report, 203: Juvenile Delinquency. . 2003. www.un.org/esa/socdev/unyin/documents/ch07.pdf.
13. Martin G. Juvenile Delinquency: Theories of Causation. In: Juvenile Justice: Process and Systems. Sage Publications, Inc; 2005. www.sagepub.com/upm-data/4880_Martin_Chapter_3_Juvenile_Delinquency.pdf.
14. Radical Parenting. Ten Ways to Teach Smart Decision-Making. Radical Parenting Web site. http://www.radicalparenting.com/2009/09/10/teaching-teens-to-make-good-decisions/. Updated 2009. Accessed 4/26, 2010.
15. Christakis NA, Fowler JH. The Collective Dynamics of Smoking in a Large Social Network. New England Journal of Medicine. 2008;358(21).
16. Skager RW. Why Youth Ignore Drug Education and Sanctions against Use: Individual Differences, Mismatched Strategies and Youth Friendly Alternatives. . . www.iirp.org/pdf/Bethlehem_2009.../Bethlehem_2009_Skager.pdf.
17. Langer EJ. The illusion of control. In: Kahneman D, Slovic P, Tversky A, eds. Judgement under uncertainty: Heuristics and biases. Cambridge, MA: Cambridge University Press; 1982.
18. Juvenile Justice Panel. Crime Prevention for Children: Developments and Good Practices. 2009. http://www.juvenilejusticepanel.com/resource/items/I/P/IPJJCCPCJSideEventReportApril09FINALVERSION.pdf.

Crash and Burn—A Critique of Anti-Tanning Public Service Announcements to Provide an Effective Melanoma Prevention Message-Susan Yanik

The haunting noises of clocks ticking, faint breathing and the sound of sizzling skin are some of the most provocative and memorable features of The Melanoma Foundation of New England’s video public service announcement titled “Tanning Is out, Your Skin Is In.” The ad features a young, white woman entering an indoor UV tanning bed lit like a carnival ride, and shows her skin beading with sweat, and the choppy shots of her body and the exterior of the tanning bed, which evokes a casket. Meanwhile, ominous statistics are flashed, stating the drastically increased risk of melanoma that results from indoor tanning, and the severity and growing threat of melanoma in teens and adults ages 15-29. The ad closes with the message “There is No Safe Tan—Tanning is Out, Your Skin Is In” [1]. If the purpose of this message was to nauseate and frighten viewers, this ad should be highly effective. However, it is clear that the Melanoma Foundation would want a multi-faceted advertisement, one that both discourages tanning and other risky behaviors, yet positively encourages safe sun practice, specifically sun-protection and early detection of melanoma. That said, the anti-tanning public service announcement by the Melanoma Foundation of New England (MFNE) and similar ones produced by the American Academy of Dermatology (AAD) [2] are flawed for a variety of reasons: the reliance on the Health Belief Model, a failure to target men and people of color, and it’s inability to deliver a positive message and practical solutions to combat the problem of melanoma.
To understand the need for effective sun protection messages, it is important to realize the dangers of early adulthood sun exposure and melanoma mortality. Melanoma is the most deadly form of skin cancer, and the most common form of cancer for Americans between the ages of 25-29 [3]. Melanoma is often fatal if allowed to spread, and approximately one American dies from melanoma every hour. However, if the melanoma is detected early, or before it spreads to the lymph nodes, the 5 year survival rate is about 99% [4]. Statistics from “Surveillance Epidemiology and End Results” (SEER) study from the National Cancer Institute state that the age adjusted incidence rate for melanoma was 20.1 cases per 100,000 men and women per year between 2003-2007 [5]. White men and women lead the annual incidence rates among the racial groups studied, with 29.7 per 100,000 men and 19.1 per 100,000 women, though blacks show about 1.0 incidence per 100,000 people, and incidences of melanoma among American Indians and Hispanics are about 3.9 per 100,000 people and 4.6 per 100,000 people, respectively. In addition, the trends in the rates of melanoma appear to be significantly increasing from 1975-2007 in men and women [6]. Studies have shown and overall worldwide increase in melanoma incidence, particularly in Australia and Western Europe, and often in the older male population in most countries [7]. Indeed, UV radiation is seen as a cause in at least 65% of melanoma cases [8] though other risk factors such as family history of melanoma, atypical mole syndrome (AMS) [9] and epigenetic factors, such as change in DNA methylation state [10] are proposed have a role in melanoma development.

Critique I: Use of the Health Belief Model

The anti-tanning public service announcements both serve to make viewers feel alarmed by the statistics presented and more aware of their vulnerability to melanoma. This design is part of the Heath Belief Model (HBM), used to explain and promote healthy, disease preventative behavior. The HBM was formulated in the 1950s by researchers from the U.S. Public Health Service, designed by breaking down health seeking behavior in four basic factors: 1) Perceived Susceptibility 2) Perceived Severity 3) Perceived Benefits of Taking an Action 4) Perceived barriers to taking an action [11]. The HBM has been in use since its creation, though over time various factors have been added to the model, such as “cues to action” (reformulated as the Social Learning Theory), and self-efficacy. The HBM was designed to confront the positive and negative forces in a person’s life, sway behaviors by encouraging steps away from negative decisions through emphasizing the perceived susceptibilities and seriousness of developing a condition in addition to the benefits of taking an action, while weighing the barriers to the action [12]. This model has been shown to be a relatively good predictor of individual level behaviors guided by an objective logical thought process [13].

While the model has been an effective tool in modeling behavior, its framework and attributes are not immune from criticism. The faults found in the HBM include its design as an individually-centered model, the assumption that health is a highly valued outcome among most people, its inability to account for spontaneous or irrational behaviors and reliance on likelihood and severity of beliefs as the only predictors of motivation [14]. Many studies have shown disadvantage of focusing on the individual, rather than the environment in model design, ignoring the social context and cultural norms of the society in which one functions [13, 15].Additionally, the HBM states that knowledge is considered to be gained only when an individual’s behavior has changed, which would fail to take into account the necessity for affective and cognitive portions of the learning process [16].
When the critiques of Health Belief Model are extended to the anti-tanning advertisements, many of the same problems still exist. The ads very effectively target two of the main HBM tenets, perceived susceptibility and severity, by describing the high incidence levels of deadly melanoma in the targeted age group. In the context of the model design, these are effective forces in pushing individuals away from a negative behavior towards a positive one. The trouble is, the positive benefits of not using a tanning bed are not explicitly stated. In addition, the perceived barriers to the behavior are also not mentioned in the public service announcements. While perhaps less applicable in a cessation message, barriers have been shown to be the most strongly associated variable in the model for sun protective practices, as shown in a study applying the HBM to relatives of melanoma patients [17]. Perhaps a more appropriate use of the HBM would be in a behavior adoption process, such as adoption of sun protective behaviors, whereby barriers to prevention and detection can be addressed.
Further addressing HBM use, an individually based anti-tanning model will appear less effective in a culture that praises tan skin, as shown by studies highlighting the importance of context and society on health behaviors [18]. Our current culture appears to place a high value on the appearance of tan skin, as evidenced by the approximately one million people visit who visit tanning beds on a given day [19], and about 28 million Americans have ever visited a tanning bed [20]. Sunbathing has been shown to be much more prevalent in adolescents whose social group, parents or friends also tan [21], a finding which may be harnessed in sunscreen adoption interventions.
Finally, the HBM is unable to account for spontaneous and irrational behaviors, including a spontaneous or infrequent desire to tan, which still may result in increased melanoma risk. People who tan for a special occasion or before going on vacation may not believe they are susceptible to an increased risk of melanoma, when a history of repeat (though potentially infrequent) sunburns and likeliness to burn is associated with developing melanoma as an adult [22, 23]. An example of irrational behavior is the finding that the majority of individuals who tan are those who have skin classified as “likely to burn”, but cite an appearance improvement as an impetus to tan [24].

Critique II: Failure to Target Men and Minorities

A meta-analysis examining 15 indoor tanning behavior studies in Europe and America found that girls are two to three times more likely to visit an indoor tanning bed than boys of the same age, and gender is a commonly controlled variable in studies of tanning bed users [21, 25]. A study reviewing melanoma epidemiology and trends found that in countries with high incidences of cutaneous melanoma, such as the US and Australia, the ratio of men and women developing melanoma is about equal, while in countries of low melanoma incidence, the rates of women diagnosed are higher than men [26]. Furthermore, the probability of men developing melanoma is 1:58, whereas the probability for women is 1:82, and men are approximately twice as likely to be diagnosed with melanoma between the ages of 60-79 [27]. A five year survival rate, calculated based upon relative survival in comparison to the general population showed a higher survival in women than men [6]. While melanoma development in men, especially in white men, is likely due to UV exposure, campaigns targeting UV exposure pathways other than tanning beds are needed to increase melanoma prevention and detection.
As previously stated, the melanoma incidence rates are higher for white men and women than Hispanic and Black minorities, but compared to Non-Hispanic whites, melanomas among minority populations are more likely to be detected at a later stage, and more metastatic, resulting in overall poorer health outcomes and decreased survival time [28]. Furthermore, the annual rate of increase among Hispanics in the US is 2.9%, nearly the same as the 3.0% increase seen in white non-Hispanics [6]. Many specific risk factors in non-white populations are still unknown, but research currently suggests that sun exposure may have less to do with melanoma in darker-skinned populations, due to the protective effects of increased skin melanin content, which is able to more efficiently scatter energy than lighter skin [29]. Additionally, high variation in DNA repair mechanisms within racial groups suggests the heterogeneous ability to control cellular mutations even within one race [30], while in vitro studies of melanocytes from blacks and whites showed that cellular melanin content can provide only partial protection from UV radiation [31]. Due to the different anatomical sites where primary melanoma tumors are found between minority populations and whites, in addition to potentially different exposure pathways to disease, melanoma has been seen as a heterogeneous cancer with potentially many underlying causes, one of which is UV radiation [29, 32].
However, as more studies are performed, understanding of behavioral and epidemiological risk factors for melanoma continues to increase. For example, it has been shown that African American men are four times as likely to develop melanoma than African American women [33], strikingly different than findings in whites. Additionally, a study of Hispanic high school students reported a perceived risk significantly lower than their white counterparts, and lower adherence to sun-protective behaviors [34], and Hispanics and blacks adults report full skin cancer screens less likely than non-Hispanic whites [35]. Together these findings suggest that the perceived risk for melanoma for Hispanics and blacks is lower among members in minority communities and health care providers.
Thus, because men and minorities are less likely to visit tanning beds, and because a large part of melanomas in minorities are found on areas of low sun-exposure, public service announcements focusing solely on the indoor tanning industry are flawed by missing a groups of people with increasing incidence rates of melanoma. By explicitly targeting the very specific demographic of tanning bed users (young, Caucasian women), the message may be lost on men and minorities, who arguably need the message as much as the white women. This failure to provide culturally and gender-specific messages about melanoma risk, prevention and detection is a major deficit in the anti-tanning melanoma prevention campaign.

Critique III: Failure to Promote Adoption of Preventative Behaviors and Melanoma Detection

In spite of previous sunscreen campaigns, and anti-tanning messages such the ones produced by the MFNE and AAD, one study showed that the rates of sunscreen usage among adolescents have only increased about 2% between the years of 1998-2004 [36], while melanoma incidences are increasing about 3% annually [6]. As previously discussed, the anti-tanning PSAs provide statistics to increase perceived risk and severity for their audience. Thus according to the message, the benefit to indoor tanning cessation is the potential to minimize mortality risk. While clearly important, it fails to remind viewers that there are other methods to decrease melanoma susceptibility, such use of sun screen and other sun protective practices, which should be utilized by all, not just indoor tanners.
Research shows that consistent sunscreen usage should be emphasized across genders and age groups. A study comparing daily sunscreen use with actual UV readings taken from personal monitoring devices found that women significantly applied sunscreen more frequently and on more high-risk days than males, while no difference was found in overall UV exposure between the genders [37]. The study also found that sunscreen was mainly used on days of high UV exposure, which is beneficial, but also implies that daily sunscreen use is may not be a common practice for many people. Sunscreen has been deemed an ideal sun protection measure, yet often times fail to protect against sunburn due to poor application practices [38], or sunscreen use before intentional suntan seeking behavior [39]. An effective melanoma prevention message ought to include encouragement not only for sun protective behaviors, such as use of protective clothing and limiting daytime sun exposure, but also include information on proper use of sunscreen.
Finally, the anti-tanning campaigns lack emphasis on early melanoma tumor detection and treatment, which are ultimately the most effective means in increasing survival time [40]. The ABCD mnemonic, a public health campaign developed in 1985 [41] is an effective tool used by both physicians and lay people in early detection of potential melanoma tumors and has since been augmented by the addition of “E” for evolving lesions [42]. However, physician performed or self performed skin evaluations are necessary to detect the tumors, though the exams are often unperformed by primary care physicians, due to lack of time or confidence in tumor diagnosis [43]. Approximately 24% of Caucasian adults in one study [44] performed a yearly self-skin evaluation, though this number is a far cry from ideal for a free, simple and life saving measure. A public service announcement attempting to decrease melanoma occurrence and increase survival time after diagnosis should surely mention sun protective behaviors and early detection practices, and the anti-tanning PSAs fail to do so.

Overview of Proposed Intervention: Advertising Theory

Tanning subgroups have been previously classified on the basis risk of developing melanoma after UV exposure, to better suit potential interventions [45]. For the purpose of this proposed intervention, three main groups at risk of melanoma will be targeted: the intentional tanners, the unintentionally exposed and the misinformed. The intervention will be guided by the principles used in the advertising theory. This model has been successfully used by marketers for decades, and is fit to replace the Health Behavior Model as a fresh way to appeal to the targeted groups, account for spontaneous decision making and effectively create a brand around healthy, protected skin. The foundations of the advertising theory lie in promises made to consumers, and assurance that the promises will be supported by the advertiser [46], or in this case, the melanoma prevention groups. The intervention builds upon the aforementioned flaws in the previous anti-tanning messages, and rather than addressing them in an outlined fashion, the intervention describes the new approaches needed for three distinct subgroups of the target population, and how this model enhances the former. The concept behind the proposed intervention lies on an overarching promise of healthy, beautiful and melanoma-free skin, and a disease free life. Instead creating a doom and gloom statistic-laden portrait of the tanning industry, the purpose of this intervention is to prevent melanoma by careful sun protection, and a behavioral shift away from tanning based on images of pure and natural beauty.

Intervention 1: Targeting Intentional Tanners

To maintain consistency with the originally anti-tanning messages, it is appropriate to focus on the same subgroup of people—those who intentionally tan and practice high-risk sun behaviors. Approximately 70% of the target audience would be Caucasian women in the 16-29 year old age group [47]. The intention is to brand the product of healthy, beautiful skin to these young girls, replacing the previous model of overly tanned skin. In public health branding, the relationship between consumer and public health sector is strongly valued [48], and in the proposed PSAs, the relationship between intentional tanner and the melanoma foundation should be more like one of mother-daughter or sister-sister, rather than a cold reading of didactic knowledge. The campaigns, which would be composed of a series of television and magazine ads would emphasize the true beauty that comes from natural skin. In this way, the campaign would also resemble the successful Green Movement in praising the natural, wholesome and peaceful [49]. These advertisements should feature photos and sketches of women of all skin tones, and relay the message that the most beautiful skin is healthy. The Skin Cancer Foundation provides a perfect example of a positive message with their “Go With Your Own Glow” campaign [50], using appealing images and endorsements by popular celebrities. A motto for this portion of the proposed intervention could read “Safe Skin is Sexy Skin”, in an effort to not only encourage protective behaviors, but also to attract the target audience to the ideals of beauty and appearance. Hopefully, with time and with enough social encouragement, the image of natural skin will be sold on the intentional tanners, and tanning bed use will become obsolete, especially in light of the added restrictions on tanning beds as recommended by the US FDA in March, 2010 [51]. This proposed intervention using advertising theory should be an improvement on the previous public service announcements constructed around the Health Belief Model through targeting of positive core values and lack of fear tactics in supporting the melanoma prevention message.

Intervention II: Targeting the Unintentionally Exposed

Selling sun safety to the general population, especially those who unknowingly experience UV radiation would be a huge step for the melanoma prevention program. Ideally, it would be advantageous to gather opinions from several groups at risk for melanoma, including adolescent males, adult males who appear to have the most rapidly increasing melanoma rates [6], and those who spend a large portion of their day outdoors. Ideally, these groups would provide feedback and elucidate the problems associated with sun protection and detection. The main intervention goal is to show sun protection as a current issue to maintain healthy skin in the present, rather than warn against the probability of future melanoma, which has reported as a barrier to motivation [45]. Not having feedback, it can be assumed that a main problem in sunscreen use arises from failure to apply adequate amount over a long enough time [38]. To counter the problem of sunscreen access, this section of the intervention would promote use of sunscreen in an affordable, easy to use and appealing vehicle. One possible idea would be to work with sunscreen manufacturers and produce sunscreen towelettes in age- and gender appropriate fragrances that can be purchased in a vending machine system at public beaches, outdoor concerts and festivals, where exposure to sun may be high. Also, to incorporate the core values of sexuality and attractiveness, the sunscreen adoption campaign could be advertised with pictures of adolescents applying sun screen to themselves and to others in a playful and engaging fashion. While this may not be the approach supported by family morality groups, it should definitely attract the attention of adolescent viewers. To target an older subset of the population, sunscreen use should still be emphasized in addition to advertisements showing fashionable sun protective clothing. It would be ideal for the melanoma foundation to partner with a clothing company to design appealing, wearable clothes that effectively block UV rays, and market them as sun-safe.
In this unintentionally exposed group, the message of detection is also extremely necessary. As mentioned in Critique III of the original intervention, rates of self-skin evaluations are not keeping pace with the melanoma incidence rate, and not helped by the failure of many primary care physicians in performing total body exams [43]. Therefore, a series of campaigns to promote self skin examinations (SSEs) are timely and could result in the detection of many pre-metastatic tumors. The American Academy of Dermatology coined the phrase “check your birthday suit on your birthday” [52], which is a clever and catchy message, though it does imply that checks should be performed only annually. It would be advantageous to design an advertisement extending the message of SSEs, and attempt to integrate them as part of a more frequent, monthly route, like paying rent and bills. Another example of a detection message could be targeted to people who spend recreation time outdoors, such as gardeners and golfers. One example of a slogan should show a picture of a gardener and state “If you leave no stone unturned, then why leave your skin unchecked?”

Intervention III: Dispel misconceptions and promote sun safe behavior in minority populations

Addressing a major criticism of the anti-tanning messages, culturally sensitive and specific messages are needed to dispel myths and provide African Americans and Hispanics with information regarding melanoma and preventative measures. As previously cited, Hispanic and black minorities have been shown to report a lower perceived risk of melanoma and are less likely to be screened for melanoma tumors at doctor’s office visits [34, 35]. The need for sun protective and early detection practices in minorities is more important than ever, with Hispanics becoming one of the fastest growing populations in the US [53], and in light with the increasing melanoma rates in the Hispanic populations [6]. An ideal campaign would be designed with feedback from members of the black and Hispanic communities, regarding approaches that are likely to appeal or repel the target audience. Without the input, a basic first step in designing melanoma prevention messages would use the format of embracing healthy natural skin, as shown in Intervention I. This proposed print/video public service announcement would show groups of people, including members of different ethnicities and genders, and promote the motto: “In all types of skin, healthy skin is the most beautiful.” This approach would target the core value of attractiveness and inclusion, and would help to raise awareness across racial groups. Furthermore, the unequal screen exams performed by physicians can be addressed with melanoma posters placed in doctor’s offices, reminding physicians to “Check all skin types at check-ins,” or a similar message to support total skin examinations in all patients. Finally, emphasis on culturally specific SSEs should be introduced, which would promote skin examinations of common anatomical tumor sites in darker skinned people, including arcral sites, such as feet and ankles. One static suggests that while 72% of melanomas are proximal the ankle in Caucasians, 90% are distal to the ankle in African-Americans [54]. Another potential intervention can show images of feet and stress the simplicity but importance in checking for potential tumors. These messages would be effective in dissolving misconceptions of no melanoma risk among minority populations, while giving a practical way to keep skin healthy.

References:

1. Melanoma Foundation of New England., Tanning Is Out, Your Skin Is In 2009. http://www.mfne.org/?page=mcpsas. Accessed 4/1/2010.
2. American Academy of Dermatology, Indoor Tanning is Out®, in Public Service Advertisements. 2010. http://www.aad.org/media/psa/index.html, accessed 4/1/2010/
3. American Academy of Dermatology Melanoma Fact Sheet. 2010 [cited 4/17/10]; Available from: http://www.aad.org/media/background/factsheets/fact_melanoma.html.
4. American Cancer Society., Cancer Facts and Figures. 2009: Atlanta, GA.
5. Altekruse, S. and e. al, SEER Cancer Statistics Review, 1975-2007. 2010 National Cancer Institute: Bethesda, MD.
6. SEER (2009) SEER Stat Fact Sheets--Melanoma of the Skin. Volume,
7. MacKie, R., et al., Melanoma incidence and mortality in Scotland 1979-2003. British Journal of Cancer, 2007. 96(11): p. 1772-1777.
8. Armstrong, B. and A. Kricker, How much melanoma is caused by sun exposure? . Melanoma Res., 1993: p. 395– 401
9. Haenssle, H.A., et al., Selection of patients for long-term surveillance with digital dermoscopy by assessment of melanoma risk factors. Arch Dermatol, 2010. 146(3): p. 257-64.
10. Rubinstein JC, et al., Genome-wide methylation and expression profiling identifies promoter characteristics affecting demethylation-induced gene up-regulation in melanoma. BMC Med Genomics, 2010 Feb(3): p. 4.
11. Edberg, M., Individual health behavior theories (Chapter 4), in Essentials of Health Behavior: Social and Behavioral Theory in Public Health. 2007, Jones and Bartlett Publishers: Sudbury, MA. p. 35-49.
12. Rosenstock, I., Historical Origins of the health belief model. Health Education Monographs, 1974. 2: p. 328-335.
13. Poss, J.E., Developing a new model for cross-cultural research: synthesizing the Health Belief Model and the Theory of Reasoned Action. ANS Adv Nurs Sci, 2001. 23(4): p. 1-15.
14. Salazar, M., Comparison of four behavioral theories. AAOHN Journal, 1991. 39: p. 128-135.
15. Choi, K.H., G.A. Yep, and E. Kumekawa, HIV prevention among Asian and Pacific Islander American men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Educ Prev, 1998. 10(3 Suppl): p. 19-30.
16. Thomas, L.W., A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. J Prof Nurs, 1995. 11(4): p. 246-52.
17. Manne, S., et al., Sun protection and skin surveillance practices among relatives of patients with malignant melanoma: prevalence and predictors. Prev Med, 2004. 39(1): p. 36-47.
18. Marks, D., Health Psychology in Context. Journal of Health Psychology, 1996. 1: p. 7-21.
19. Whitmore, S.E., et al., Tanning salon exposure and molecular alterations. J Am Acad Dermatol, 2001. 44(5): p. 775-80.
20. American Academy of Dermatology., Facts about Indoor Tanning, Press Kit
American Academy of Dermatology, Editor. 1997, Schaumburg, IL.
21. Lazovich, D., et al., Characteristics associated with use or intention to use indoor tanning among adolescents. Arch Pediatr Adolesc Med, 2004. 158(9): p. 918-24.
22. Holly, E.A., et al., Cutaneous melanoma in women. I. Exposure to sunlight, ability to tan, and other risk factors related to ultraviolet light. Am J Epidemiol, 1995. 141(10): p. 923-33.
23. Whiteman, D.C., C.A. Whiteman, and A.C. Green, Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes Control, 2001. 12(1): p. 69-82.
24. Pagoto, S.L. and J. Hillhouse, Not all tanners are created equal: implications of tanning subtypes for skin cancer prevention. Arch Dermatol, 2008. 144(11): p. 1505-8.
25. Lazovich, D. and J. Forster, Indoor tanning by adolescents: prevalence, practices and policies. Eur J Cancer, 2005. 41(1): p. 20-7.
26. Garbe, C. and U. Leiter, Melanoma epidemiology and trends. Clin Dermatol, 2009. 27(1): p. 3-9.
27. Dao, H., Jr. and R.A. Kazin, Gender differences in skin: a review of the literature. Gend Med, 2007. 4(4): p. 308-28.
28. Byrd, K.M., et al., Advanced presentation of melanoma in African Americans. J Am Acad Dermatol, 2004. 50(1): p. 21-4; discussion 142-3.
29. Rouhani, P., S. Hu, and R.S. Kirsner, Melanoma in Hispanic and black Americans. Cancer Control, 2008. 15(3): p. 248-53.
30. Tadokoro, T., et al., UV-induced DNA damage and melanin content in human skin differing in racial/ethnic origin. Faseb J, 2003. 17(9): p. 1177-9.
31. Yohn, J.J., M.B. Lyons, and D.A. Norris, Cultured human melanocytes from black and white donors have different sunlight and ultraviolet A radiation sensitivities. J Invest Dermatol, 1992. 99(4): p. 454-9.
32. Curtin, J.A., et al., Distinct sets of genetic alterations in melanoma. N Engl J Med, 2005. 353(20): p. 2135-47.
33. Bellows, C.F., et al., Melanoma in African-Americans: trends in biological behavior and clinical characteristics over two decades. J Surg Oncol, 2001. 78(1): p. 10-6.
34. Ma, F., et al., Skin cancer awareness and sun protection behaviors in white Hispanic and white non-Hispanic high school students in Miami, Florida. Arch Dermatol, 2007. 143(8): p. 983-8.
35. Saraiya, M., et al., Skin cancer screening among U.S. adults from 1992, 1998, and 2000 National Health Interview Surveys. Prev Med, 2004. 39(2): p. 308-14.
36. Cokkinides, V., et al., Trends in sunburns, sun protection practices, and attitudes toward sun exposure protection and tanning among US adolescents, 1998-2004. Pediatrics, 2006. 118(3): p. 853-64.
37. Thieden, E., et al., Sunscreen use related to UV exposure, age, sex, and occupation based on personal dosimeter readings and sun-exposure behavior diaries. Arch Dermatol, 2005. 141(8): p. 967-73.
38. Diffey, Sunscreens: expectation and realization. Photodermatology, Photoimmunology & Photomedicine, 2009. 25: p. 233-236
39. Autier, P., M. Boniol, and J.F. Dore, Sunscreen use and increased duration of intentional sun exposure: still a burning issue. Int J Cancer, 2007. 121(1): p. 1-5.
40. Betti R, et al., Factors of delay in the diagnosis of melanoma. Eur J Dermatol, 2003. Mar-Apr;13(2): p. 183-8.
41. Friedman, R.J., D.S. Rigel, and A.W. Kopf, Early detection of malignant melanoma: the role of physician examination and self-examination of the skin. CA Cancer J Clin, 1985. 35(3): p. 130-51.
42. Abbasi, N.R., et al., Early diagnosis of cutaneous melanoma: revisiting the ABCD criteria. Jama, 2004. 292(22): p. 2771-6.
43. Torrens, R. and B.A. Swan, Promoting prevention and early recognition of malignant melanoma. Dermatol Nurs, 2009. 21(3): p. 115-22; quiz 123.
44. Kasparian, N.A., J.K. McLoone, and B. Meiser, Skin cancer-related prevention and screening behaviors: a review of the literature. J Behav Med, 2009. 32(5): p. 406-28.
45. Pagoto, S.L., et al., Sun protection motivational stages and behavior: skin cancer risk profiles. Am J Health Behav, 2004. 28(6): p. 531-41.
46. Ogilvy, D., How to Build Great Campaigns (Ch. 5), in Confessions of an Advertising Man. 1964, Atheneum: New York. p. 89-103.
47. Swerdlow, A.J. and M.A. Weinstock, Do tanning lamps cause melanoma? An epidemiologic assessment. J Am Acad Dermatol, 1998. 38(1): p. 89-98.
48. Evans, W. and G. Hastings, Public Health Branding: Recognition, promise and delivery of healthy lifestyles (Chapter 1), in Public Health Branding: Applying Marketing Skills for Social Change. 2008, Oxford University Press: Oxford. p. 3-24.
49. Galtung, J., The Green Movement: A Socio-Historical Exploration. International Sociology, 1986. 1(1): p. 75-90.
50. Skin Cancer Foundation, Go With Your Own Glow. 2010 [cited; Available from: www.skincancer.org/go-with-your-own-glow/.
51. Skin Cancer Foundation, FDA Advisory Committee Meeting to Review Tanning Bed Regulations, in For the Media. 2010, Skin Cancer Foundation: New York, New York
52. American Academy of Dermatology, Be Sun Smart (R) 2010 [cited 2010; Available from: http://www.aad.org/public/sun/smart.html.
53. Hu, S., et al., UV radiation, latitude, and melanoma in US Hispanics and blacks. Arch Dermatol, 2004. 140(7): p. 819-24.
54. Wanebo, H.J., J. Woodruff, and J.G. Fortner, Malignant melanoma of the extremities: a clinicopathologic study using levels of invasion (microstage). Cancer, 1975. 35(3): p. 666-76.

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).
35. Salazar, M. K. Comparison of four behavioral theories: a literature review. AAOHN Journal 1991; 39(3):171-178.
36. The Center for Reproductive Rights. Breaking the silence: the global gag rule’s impact on unsafe abortion, 2003.
37. Thomas, L. W. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995; 11(4):246-252.
38. United States. Policy Statement of the United States of America At the United Nations International Conference on Population, 1984.
39. Unsafe Abortion: Global Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2003. World Health Organization, 2007.
40. Westoff, C. F. Contraceptive paths toward the reduction of unintended pregnancy. Family Planning Perspectives 1988; 21(1):4-13.

The National Organization Of Fetal Alcohol Syndrome And Its Responsibility To Focus On Prevention And Early Intervention-Lauren Goldberg

Birth defects occur in 1 out of every 33 babies born in the United States. Defects account for more than 20% of infant deaths. Seventy-percent of birth defects are from unknown causes, however, some such as those caused by Fetal Alcohol Syndrome (FAS) are preventable. FAS is caused by an alcohol –exposed pregnancy that results in mental retardation and neurodevelopmental disorders such as hyperactivity, distractibility, short attention span, poor judgment, impulsivity, poor social skills, and poor visual and auditory memory. Alcohol exposure directly causes these physical manifestations in addition to growth impairment and craniofacial abnormalities (1). Despite the fact that Fetal Alcohol Syndrome is 100% preventable, this birth defect affects 2 newborns per 1,000 live births in the United States.
FAS occurs more frequently in some populations and will not definitely occur in all fetus’ exposed to alcohol. A study on the permissive factors associated with FAS concluded that predisposing factors such as a mother’s socioeconomic status and culture, along with alcohol exposure, can increase a fetus’ vulnerability to developing Alcohol-Related Birth Defects (2). This phenomenon is evident in the fact that FAS rates were higher in inner-city women of low-socioeconomic status than those among Caucasian upper-middle women who are alcoholics. Since overall infant mortality rates are higher in women of low socioeconomic status, this study also concluded that permissive factors (e.g. ethnicity, SES) are more indicative of FAS development than biological factors. Additionally, factors such as poor nutrition status, tobacco use, and physical and psychological stress may also increase vulnerability to the development of FAS. These factors intensify fetal vulnerability to oxidative stress and free-radical induced cell damage, the two ways in which alcohol produces its teratogenic effects. Without fetal alcohol exposure, FAS does not occur. It is not enough to say alcohol exposure alone causes the development of FAS.
Not only is the incidence of FAS high, but the number of women consuming alcohol during pregnancy is high as well: 45.4% of women consume alcohol in their first trimester and 20.7% of women continue to drink even when they are aware of their pregnancy (3). Counsel against alcohol use is an effective way in which practitioners decrease these consumption rates. However, not all pregnant women seek help from practitioners. Since this disease is preventable, a national organization has been developed to combat it.

National Organization on Fetal Alcohol Syndrome

The National Organization on Fetal Alcohol Syndrome “is dedicated to eliminating birth defects caused by alcohol consumption during pregnancy and to improving the quality of life for those affected individuals and families (4).” With primary funding from the Centers for Disease Control and Prevention and the National Center on Birth Defects and Developmental Disabilities, it is the national voice for FAS prevention and advocacy. The approach of this particular organization is to educate addiction healthcare professionals on how to educate on both prevention and treatment strategies for FAS during prenatal and perinatal consultations. The organization gives workshops to parents on how to care for and nurture their child living with FAS. It also provides resources for women suffering from alcoholism who are pregnant or may become pregnant. The website also provides information about FAS like statistics and distribution materials. They also screen pregnant and non-pregnant women at select community health centers for alcoholism. Finally, this organization also brings together women who have consumed alcohol during pregnancy and may have a child or children living with FAS in a program called Birth Mother’s Network. The NOFAS helps create a positive environment for families but fails in other areas. Many communities may benefit from this type of approach but others need more tailored interventions (5). The NOFAS fails to target women who are at risk for an alcohol-exposed pregnancy prior to conception, relying on women to see out their clinics, and ignore the underlying causes of FAS.
The NOFAS also fails to target women who are most at risk before they conceive. Populations with the highest incidence of FAS are Native Alaskans, American Indians, and African Americans (6). These populations may not be living in a supportive environment that is conducive to change and need a strong presence from NOFAS. There are modifications that need to be made to this approach in order to reduce alcohol consumption during pregnancy and incidences of FAS.

Care is provided too late

A flaw in the NOFAS approach is that care is often provided too late in pregnancies to prevent FAS. The NOFAS relies heavily on the use of prenatal care to educate women on the risks of alcohol consumption during pregnancy and to screen for alcoholism in these women. However, irreversible damage has often already occurred by the time women seek care (7). While prenatal care and screenings are essential, for some women it may be too late to prevent a defect from occuring. The NOFAS must address the importance of initiating prenatal care during early pregnancy and even before conception. For example, 6.5% of African American women failed to receive or received late prenatal care and only 69.3% of American Indian women received early prenatal care (8). Furthermore, women who initiate prenatal care late in pregnancy are unlikely to show a change in substance abuse by delivery (9). NOFAS fails to initiate care early enough to prevent irreversible defects and cause a reduction in alcohol consumption.
Since 49% of all pregnancies in the United States are unplanned, many women are not aware that they are pregnant when consuming alcohol (10). Consequently, FAS might occur before she is even aware of the risk. If a woman who consistently drinks was not planning on conceiving and suddenly discovers she’s pregnant, breaking her habit immediately will be necessary and crucial. Unfortunately, eliminating alcohol addiction, along with other addictive behaviors, is often a time consuming process. The NOFAS does not foster preconception education which is crucial to the success of any program aimed at eliminating the incidence of FAS.
The NOFAS has built their intervention approach based on the Health Belief Model. According to this theory, women will be able to weigh the costs and benefits of drinking while pregnant after they seek help from a practitioner. Accordingly, NOFAS assumes that women will ultimately choose that the risks of drinking while pregnant outweigh the benefits. This theory however, fails to take into account the mother’s relationship with her environment and the biological implications that accompany addictive behavior. It cannot be assumed that alcohol consumption, a highly addictive behavior, will be stopped in enough time prevent FAS. Therefore, this emphasizes the need for NOFAS to educate these populations on the effects of coupling alcohol with unintended pregnancy before they engage in risky behavior. They also need to be given the option of testing themselves for pregnancy before they consume alcohol. This would help to instill awareness every time they drink. In addition, routine testing will allow them to know they are pregnant earlier than they might’ve realized otherwise. The earlier they know, the earlier they can seek prenatal care.
Women often perceive barriers to seeking prenatal care that cause late or lack of initiation. These barriers include lack of transportation, opinions of healthcare, partners’ opinions of healthcare, depression, fear of disclosure, and the fear of medical procedures (11). NOFAS must address these barriers in order to increase earlier initiation. However, motivating women to initiate prenatal care can also be a challenging.

Failure to seek out expectant mothers

Initiating prenatal care is a voluntary and beneficial process. In a study of urban black women, research found that unplanned pregnancies in this population were more likely to be accompanied by alcohol consumption and prenatal care initiation in the third trimester (12). Therefore, the NOFAS is presented with the difficult challenge of getting pregnant women into community health centers and getting them in early. A flaw in the NOFAS approach is that they wait for women to come to clinics on their own rather than actively trying to draw them in. The NOFAS fails to recognize there is little motivation for women to seek treatment early if it at all. In assuming that people are intrinsically motivated, the NOFAS effectively takes the Health Action Process Approach. This behavior change model is often used to predict whether or not a person will modify an unhealthy behavior or initiate a healthy behavior. An important component of the model is the idea that planning facilitates behavior change (11). The NOFAS unrealistically expects that women who have unplanned pregnancies with alcohol use will plan to seek prenatal care. The NOFAS cannot assume these women will plan to take action without offering an extrinsic motivating factor. If this were true, prenatal initiation would be higher and sooner in this population. Since it has been proven that women with unplanned pregnancies are less likely to receive prenatal care than those whose pregnancies were planned and neither population has perfect initiation rates, this stresses the need for the NOFAS to offer another motivating factor (13).

Failure to address underlying causes

Since women often initiate prenatal care after irreversible defects have already taken shape, there is a need for NOFAS to focus on the underlying causes of fetal alcohol exposure (14). A flaw in the NOFAS approach is that they do not attempt to eliminate the underlying causes of FAS. In the fifteen year period from 1990 or 2005 there has been no significant change in the prevalence of pregnant mothers who consume alcohol, therefore, the NOFAS has failed to eliminate the factors that cause an alcohol-exposed pregnancy (15). Educational campaigns have not reduced high levels of drinking during pregnancy. There is a need for the NOFAS to recognize that vulnerable populations such as Alaskan Natives, American Indians, and African Americans, need interventions related to lifestyle modifications. Currently, the focus is on alcohol abuse, but they fail to focus on the underlying problems that cause this behavior. It is estimated that 1 to 2% of women of childbearing age are binge drinking, sexually active, not using adequate protection have had multiple male sex partners in the past six months, have a history of physical abuse, have been treated for drug or alcohol problems, have been treated in a mental institution, and are less educated (16). These are underlying cause s for an alcohol-exposed pregnancy and FAS that the NOFAS has not addressed. These are also the causes that NOFAS fails to focus on. NOFAS should recognize that getting a mother to eliminate alcohol while she is pregnant does not eliminate the environment that may have caused her to drink the first place. NOFAS can prevent alcohol abuse before conception by channeling more of their resources toward empowering women and teaching them to not get involved in drug use, maintain safe relationships, be more sexually responsible, and stay in school. The NOFAS’ goal should be to help women adopt healthy behaviors to avoid risk of an alcohol exposed pregnancy. Primary prevention of FAS must include ways to eliminate these risks before conception (16).

Modifying the NOFAS approach to reducing the incidence of FAS

The NOFAS is a program designed to better the lives of children and families living with FAS and to prevent FAS in expectant mothers. This program must be expanded to include more primary prevention in the form of preconception awareness and interventions. The NOFAS must act more broadly in order to successfully decreased FAS incidence in Native Alaskan, American Indian, and African American populations. The NOFAS must also modify their prenatal initiation approach by creating incentives for expectant mothers.

Priming while purchasing

Women in vulnerable populations need to be reminded they could be pregnant each time they purchase alcohol. Pregnancy is usually not on a person’s mind when they walk into a liquor store. In order to reach women before they conceive, NOFAS needs to permeate their lives in an obvious way and emphasize the importance of early prenatal care initiation. A great way for NOFAS to make their message visible in the community is through local liquor stores. Each time a women purchases alcohol in a liquor store, she should be offered a pregnancy test. Even though she may not take the test, this primes her to think about the possibility she may be pregnant each time she purchases or consumes alcohol. There may come a day when she does accept the pregnancy test after repeated offers. Taking the test will allow her to know sooner than she normally would have. This gets women to think about just how risky alcohol exposed pregnancies really are, and will help them they are pregnancy sooner than later. This intervention will cause people in the community to engage in a discussion about such a seemingly strange occurrence at their local liquor store. If there are incentives to visit a prenatal clinic early in pregnancy, women will be more likely to visit very soon after a positive pregnancy test. It is also important to note that FAS does not only occur in babies with alcoholic mothers. Any amount of exposure can be harmful; therefore any women purchasing alcohol at a liquor store would be impacted (3). As a public health organization, the NOFAS needs to use a “cue” accompanying the purchase of alcohol in order to remind them of the risks associated with drinking while pregnant. Women will be able to develop an increased sensitivity to the purchase of alcohol each time they are offered a cue or in this case, a pregnancy test. Whether a women suspects she may be pregnant, or if she is already pregnant, this cue will force women of child-bearing age to associate purchasing alcohol with FAS (17). This intervention can help NOFAS bring women into their clinics sooner and before a defect has occurred.
It is also crucial to use this intervention as a way to eliminate any perceived women may have to initiating early prenatal care. As part of this intervention, each pregnancy test box will have written on it the services offered by NOFAS. These services will include prenatal care in addition to transportation to and from appointments, financial help to pay for visits, confidentiality on the part of the medical team, and painless medical care. Eliminating these barriers will also help women initiate prenatal care sooner.

Prenatal care initiation

Offering prenatal care is an important and essential service that NOFAS offers at community health centers. Without offering incentives to visit these clinics, NOFAS is running the risk of women seeing practitioners late in their pregnancies because of the aforementioned barriers. The fetus is most at risk for developing FAS in the first trimester of pregnancy (3). In unplanned pregnancies, initiating prenatal care often occurs in the third trimester. In order to get women at risk for an alcohol exposed pregnancy into their clinics, NOFAS needs to offer rewards that would benefit moms-to-be and actively draw them into clinics. An important of this intervention would be offering expectant mothers a free package of pampers every visit. After each trimester of consistent visits, expectant mothers would also receive a large gift such as a baby carriage or crib. Since this would be a costly intervention, NOFAS could partner with a major corporation such as Huggies®. These incentives could also get expectant mothers in the mindset of preparing for a newborn and may foster a maternal drive towards having a healthy baby and changing their risky habits. Expectant mothers will also have a positive attitude toward the prenatal care process and will therefore be more likely to make and follow-through with their appointments (18). Expectant mothers will be also be positively influenced by other mothers in the community who have also had positive outcomes from participation in this program. As a result, initiation prenatal care could become a norm in high-risk communities.
There are many psychosocial characteristics on the part of the mother that can affect the baby’s outcome (19). Therefore, the NOFAS must not only strive towards making the most from prenatal visits, but must also work to better the lives of expectant mothers. Initiation can be encouraged with referrals to food banks, stipends for continuing education, referrals to therapists, and help with employment. Regardless of the outcome after delivery, a healthier mom means a healthier baby. This would help NOFAS bring more women through the doors of the clinics. Additionally, the NOFAS can also strive to decrease the incidence of FAS on a more global level.

Preventing risk factors for an alcohol- exposed pregnancy

From an early age, women need to know they have the power to set goals and make decisions to achieve those goals. Young girls need to have role models and adult females they can learn from. The NOFAS needs to reach out to young teens living in vulnerable communities to help prevent them from engaging in risky behaviors associated with an alcohol exposed pregnancy. Empowering young girls and promoting healthy behaviors decreases the risks associated with an alcohol-exposed pregnancy. With this approach, the NOFAS will indirectly decrease their risks of having a child born with FAS. From eighth grade and throughout high school, young girls need hear first-hand accounts from women of what it’s like to be an alcoholic, or in an abusive relationship, or even what it’s like to have a child with FAS. These women would share the story of their struggles, make connections with young girls who need guidance, and encourage them to stay in school. In contrast, adolescent girls also need to learn from women who’ve set goals and achieved their dreams. They need to see women who’ve faced adversity and risen above it. Public health practitioners need to instill messages of empowerment and give young girls the self-efficacy they need to achieve goals. Students’ self-efficacy is linked to achievement goal orientation and self-regulation. Students who believe they can succeed will set goals and show more resilience when they encounter difficulties. This self-efficacy however, must grow from praise and the successful completion of smaller goals in a classroom setting. If students learn to overcome small obstacles and succeed in small ways, they will build the self-efficacy needed accomplish larger endeavors and to overcome larger tribulations (19). Girls will learn their decisions in the present can affect their future. By building stronger communities, NOFAS can indirectly decrease the incidence of FAS.
There is a great necessity to understand the types of environments women with alcohol-exposed pregnancies come from. Lack of both maternal and paternal education is also an important risk factor to consider (20). NOFAS must address this issue before they can see a marked decrease in alcohol consumption in pregnant women. They must use their time in the classroom to encourage young girls to finish high school and pursue higher education. With these guest speakers, the NOFAS can them what it’s like to succeed in life and what it is like to constantly struggle. The NOFAS’ mission should apply this broader approach to their interventions if they want to see better outcomes in their target populations and a decrease in the risk factors associated with an alcohol-exposed pregnancy. This type of primary prevention is a crucial component of any public health organization, including the NOFAS.

Looking towards the future

The NOFAS has a responsibility to all women, especially those of vulnerable populations, to expand the care they provide. They must recognize women need to be drawn into their clinics at the onset of pregnancy. The risks associated with an alcohol-exposed pregnancy are far too great not to act quickly. By eliminating some of the barriers to care the NOFAS will reach more women. The rewards and expanded services that go along with attending prenatal care will not only draw expectant mothers in, but will improve their quality of life. This will allow the NOFAS to have a “complete care” approach in which they will provide prenatal care and help provide a better life for a mother and her unborn child.
The NOFAS also has a responsibility to address the underlying causes of FAS if their goal is to decrease its prevalence in high-risk populations. They need to help empower women so they can live a life free of drugs, physical abuse, sexual promiscuity, and achieve higher education. The NOFAS will not only be decreasing the incidence of FAS but will provide guidance for young women in need of a supportive environment.
If NOFAS chooses to stand idle, this will mean thousands of new birth defects each year from a disease that is 100% preventable…thousands of newborn babies forced to bear the burden of a preventable disease for the rest of their lives.

References

1. Burd, L., Kerbeshian, J., Klug, M.G., & Martsolf, J.T. (2003). Diagnosis of FAS: A comparison of the Fetal Alcohol Syndrome Diagnostic Checklist and the Institute of Medicine Criteria for Fetal Alcohol Syndrome. [Electronic version] Neurotoxicology and Teratology, 25, 719-724.

2. Abel, E.L., & Hannigan, J.H. (1995). Maternal Risk Factors in Fetal Alcohol Syndrome: Provocative and Permissive Influences. [Electronic version] Journal of Neuraltoxicology and Teratology, 17, 44-462.

3. Donaldson, T., & Mitchell, K.T. (1999). Preventing fetal alcohol syndrome. [Electronic version] Journal of Pediatric Healthcare, 13, 87-89.

4. National Organization on Fetal Alcohol Syndrome. NOFAS. National Center on Birth Defects and Developmental Disabilities. http://www.nofas.org

5. Bolton, B., Cperich, Floyd, R.L., S., Ingersoll, K., Mullen, Nagaraja, J., Nettleman, M., Skarpness, B., Sobell, L., P., Sobell, M., Sternberg, K.v., Velasquez, M.M., and Project Choices Efficacy Study Group. (2007). Preventing Alcohol-Exposed Pregnancies: A Randomized Controlled Trial. [Electronic version] American Journal of Preventive Medicine, 32, 1-10.

6. May, P.A., & Gossage, J.P. Estimating the Prevalence of Fetal Alcohol Syndrome: A Summary. National Institute on Alcohol Abuse and Alcoholism. Retrieved from http://pubs.niaaa.nih.gov/publications/arh25-3/159-167.htm.

7. Chang, G., Haug, L.W., Mcnamara, T.K., & Orav, E.J. (2006). Brief intervention for prenatal alcohol use: The role of drinking goal selection. [Electronic version] Journal of Substance Abuse Treatment, 31, 419-424. Hastings-Tolsma, M., Park, J.H., & Vincent, D., (2007). Disparity in prenatal care among women of colour in the USA. [Electronic version] Midwifery, 23, 28-37.

8. Hastings-Tolsma, M., Park, J.H., & Vincent, D., (2007). Disparity in prenatal care among women of colour in the USA. [Electronic version] Midwifery, 23, 28-37.

9. Corse, S.J., & Smith, M. (1998). Reducing Substance Abuse During Pregnancy: Discriminating Among Levels of Response in a Prenatal Setting. [Electronic version] Journal of Substance Abuse Treatment, 15, 457-467.

10. James, S.A., Orr, S.T., & Reiter, J.P. (2008). Unintended Pregnancy and Prenatal Behaviors Among Urban, Black Women in Baltimore, Maryland: The Baltimore Preterm Birth Study. [Electronic version] Annals of Epidemiology, 18, 545-551.

11. Phillippi, J.C. (2009). Women's Perceptions of Access to Prenatal Care in the United States: A Literature Review. [Electronic version] Journal of Midwifery and Women’s Health, 54, 219-225.

12. Chow, S., & Mullan, B. (2009). Predicting food hygiene. An investigation of social factors and past behaviour in an extended model of the Health Action Process Approach. [Electronic version] Appetite, 54, 126-133

13. Eggleston, E. (2000). Unintended pregnancy and women’s use of prenatal care in Ecuador. [Electronic version] Social Science and Medicine, 51, 1011-1018.

14. McCormick, M.C., & Siegel, J.E. (2005). Recent evidence on the effectiveness of prenatal care. Ambulatory Pediatrics, 1, 321-325.

15. CDC. Alcohol Use Among Pregnant and Nonpregnant Women of Childbearing Age -United States, 1991--2005. MMWR 58(19);529-532.

16. Project CHOICES Research Group. (2002) Alcohol-exposed pregnancy: Characteristics associated with risk. [Electronic version] American Journal of Preventive Medicine, 23, 166-173.

17. Fishbein, M., & Yzer, M.C. n.d., Using Theory to Define Effective Health Behavior Interventions. http://www.stesapes.med.ulg.ac.be/Documents_electroniques/MET/MET-COM/ELE%20MET-COM%20A-8127.pdf.

18. Kanekar, A., & Sharma, M. (2007). Theory of Reasoned Action & Theory of Planned Behavior in alcohol and drug education. Retrived on 28 April 2010 from http://www.britannica.com/bps/additionalcontent/18/25057335/Theory-of-Reasoned-Action-ampTheory-of-Planned-Behavior-in-Alcohol-and-Drug-Education

19. Pajares, F., & Usher, E.L. (2006). Sources of academic and self-regulatory efficacy beliefs of entering middle school students. [Electronic version] Contemporary Educational Psychology, 31, 125-141.

20. Benz, B., Burd, L., Kerbesian, J., Klug, M.G., & Martsolf, J.T. (2003). A comparison of the effects of parental risk markers on pre- and perinatal variables in multiple patient cohorts with fetal alcohol syndrome, autism, Tourette syndrome, and sudden infant death syndrome: an enviromic analysis. [Electronic version] Neurotoxicology and Teratology, 25, 707-717.