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

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

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

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

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

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

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

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

The Three Frame Alignment Participation Pitfalls:

The BORC and Interpretation of Grievances (13)

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

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

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

The BORC and Dynamic Participation (13)

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

The BORC and Participation-Related Processes (13)

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

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

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

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

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

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

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

Analysis of the Three Participation Pitfalls and the BORC

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

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

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

The Intervention:

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

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

1. Frame Alignment and the Interpretation of Grievances:

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

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

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

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

2. Frame Alignment and Dynamic Participation

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

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

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

3. Frame Alignment and Participation-Related Processes

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

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

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

Conclusion:

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

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

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

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

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

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

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


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

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

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


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

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

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

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

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

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

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

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

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

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

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


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

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


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

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


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




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

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

Introduction

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

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

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

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

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

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

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

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


References
1 New York City Department of Health and Mental Hygiene. Are You Pouring on the Pounds? Health Bulletin, 2009.
2 Chan, Sewell. “New Targets in the Fat Fight: Soda and Juice.” New York Times. 01 September 2009. Web. 02 April 2010.
3 Prentice, Claire. “Anti-obesity as shocks New Yorkers.” BBC News. 07 October 2009. Web. 31 March 2010. http://news.bbc.co.uk/go/pr/fr/-/2/hi/americas/8281203.stm.
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5 Bay Area Nutrition and Physical Activity Collaborative. Getting the Soda Free Message. San Francisco, CA: Bay Area Nutrition and Physical Activity Collaborative. 2009. www.banpac.org.
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