A Critique of the Fruits and Veggies: More Matters Campaign- Tiffany Chua

Introduction
Infectious diseases have been replaced by chronic diseases as the major contributors to mortality in the United States (1). Cardiovascular disease is at the top of the list (1). It is largely considered a preventable disease and, because of this, has been the topic of many epidemiologic studies (1-4). Nutrition studies have investigated the effect of diet on cardiovascular disease and have found an inverse relationship between fruit and vegetable intake and cardiovascular disease (2-4). Along with the heightened focus on diet and nutrition, researchers have noticed the growing obesity rates in the United States, especially in children (5,6). As researchers have accumulated evidence supporting the protective effect of a healthy diet on such problems as cardiovascular disease and obesity, public health practitioners have designed programs to help fight these diseases. This critique will discuss a public health intervention that has attempted to improve people’s health by encouraging consumption of more fruits and vegetables. However, it is unlikely that the program will be able to realize its goals due to innate flaws in its design.

Fruits and Veggies: More Matters
Fruits and Veggies: More Matters is a public health intervention program that is run by the Centers for Disease Control and Prevention (CDC), Produce for Better Health (PBH), and several other entities including industry and nonprofit organizations (7). It launched on March 19, 2007 as part of the National Fruit and Vegetable Program and replaced the 5 A Day program under the National Fruit & Vegetable for Better Health (7). The 5 A Day program had been in effect since 1988, but in 2005 the Dietary Guidelines for Americans published a report that increased the recommended daily servings of fruits and vegetables from 5 servings to 5-13 servings (8,9). The mission of the Fruits and Veggies: More Matters program is to encourage people to eat more fruits and vegetables through awareness and education (7). An interactive website is available at www.fruitsandveggiesmatter.gov (7). The website includes a program that helps people calculate their personalized fruit and vegetable needs based on one’s age, sex, and activity level. There are printable resources such as recipes and tips for eating healthy that attempt to help people incorporate more fruits and vegetables into their daily meals. Links to other websites that promote healthy eating are provided as well.

The Health Belief Model
The failures of this public health intervention stem mainly from its basis upon the Health Belief Model (HBM). The HBM was the first model that was developed to explain behavior change (10). In brief, it proposes that a person’s decision to change a health behavior is dependent upon whether the perceived benefits outweigh the perceived costs (10). Although there are several weaknesses of the model, it is frequently used to design public health interventions. Additional details of this traditional model have been described previously, however the relevant aspects to this critique will be highlighted again.

Three major pitfalls of this public health intervention are related to three negative aspects of the health belief model. One negative aspect is the HBM’s exclusion of social and environmental factors. A second negative aspect is one that the HBM has in common with other traditional social behavior models - it is designed to address behavior change on an individual level. A third negative aspect is arguably one of the strongest negatives of the HBM – it assumes that people behave rationally.

Ignores Socioeconomic Factors that Affect Access
The Fruits and Veggies: More Matters program promotes a nutritious diet, but does not address any social or environmental factors that could prevent people from eating nutritiously. The program’s website includes a plethora of information, from the nutritional content of a wide variety of different fruits and vegetables to different ways to incorporate more fruits and vegetables in a diet. However, all of this useful information is available mainly to those who have a computer and internet access as well as the motivation to visit the website. Studies have shown that the demographic population in the United States that is least likely to eat sufficient amounts of fruits and vegetables are those with the lowest household income levels (11). These families are probably also the least likely to have internet access much less their own computer.

If economically disadvantaged people do manage to access the website and are interested in eating more fruits and vegetables, they may not be able to buy the fruits and vegetables that the website suggests for two reasons: due to the lack of supermarkets in their neighborhood that carry high quality, fresh produce or due to the financial inability to afford high prices of fresh produce. In general, large supermarkets tend to have a wider selection of produce that is more reasonably priced when compared to small grocery or convenience stores (11). Studies have shown that there are fewer large supermarkets in areas with greater populations of low-socioeconomic families and that high price is a major reason why low-income families choose not to eat fresh fruits and vegetables (11-13). These are critical issues, because people will not be able to take advantage of the information provided by the program if they cannot find a market from which to buy fresh fruits and vegetables or if they cannot afford to buy those fresh fruits and vegetables for their family. The program does not address the fact that fresh fruits and vegetables cost more than processed and fast food, nor does it address the additional inconvenience that may accompany more frequent trips to the supermarket.

These social and environmental factors are significant forces that may work against a person’s ability to adhere to the advice of the Fruits and Veggies: More Matters program. Additionally, the program may fail to reach the very population that needs the most encouragement by heavily relying on their website to educate people. These failures were demonstrated in a study that analyzed the success of the HBM in increasing fruit and vegetable consumption in urban black men, a low socioeconomic status population at increased risk of cardiovascular disease (14).

Targets Individual Adults
The Fruits and Veggies: More Matters program should reach out to both adults and children. With the increasing utilization of computers in children’s education, children have been spending more of their time on the Internet (15). However, the Fruits and Veggies: More Matters website is geared towards adult education. In one sense this is beneficial since studies have shown that there is a significant correlation between a mother’s nutrition knowledge and their child’s nutrition knowledge. This is mostly due to the fact that mothers are their children’s primary care givers and play a major role in shaping their eating habits (16). This serves as evidence to support ensuring that accurate knowledge is readily available to children’s parents to take advantage of this strong, positive relationship.
In another sense, it would be prudent to ensure that children, whose parents do not play a role in encouraging their children to develop healthy eating habits, are given the chance to learn about the nutritional benefits of fruits and vegetables for themselves. One reason why this is so important is because childhood and adolescence are crucial times during which children develop habits that will influence their health behavior throughout adulthood (17). As previously discussed, this development of a healthy diet into adulthood may have long-run beneficial health effects with respect to cardiovascular disease.

In addition to excluding children as part of their target population, the program addresses health behavior change on an individual level. As we have learned from Dr. Michael Siegel’s lectures, the program could be more effective and efficient if it were designed to address behavior change on a group level. The benefits from such an approach would not only be reaped by the individuals who adopt healthier eating habits, but also by society as a whole. The costs related to cardiovascular disease in the United States are expected to exceed $475 billion in 2009 (18). Since fruit and vegetable consumption has been shown to be negatively related to cardiovascular disease as well as obesity (5,6), health care costs associated with these diseases could potentially decrease substantially.

Disregards Irrational Behavior
The Fruits and Veggies: More Matters program assumes that people behave rationally. It believes that simply telling consumers that fruits and vegetables are healthier and that they potentially prevent various diseases will result in their making the choice to seek out and purchase fresh fruits and vegetables. This, however, is not the case with most people. As we have learned from Dr. Siegel, even if people intend to follow through with the behavior – in this case buying fresh fruits and vegetables – it still does not mean that the behavior change will occur.
Studies have shown that even when people are aware of the nutritional content of fruits and vegetables and the positive health effects a nutritious diet can have, they still do not change their eating habits. In children, this relationship has been observed mostly due to the fact they have trouble perceiving the future and thus the relevance of fruits and vegetables to disease prevention (19). In a population of adult black men, perceived health benefits were not associated with fruit and vegetable consumption either (14). Another study investigating the influences on eating habits in adults, taste was the top predictor of what people chose to eat, followed by cost. Only in those people that the study categorized as members of a “health lifestyle cluster” was importance of nutrition a predictor of eating healthful foods (19). Thus, by attempting to promote healthful eating based on benefits from disease prevention, the Fruits and Veggies: More Matters program may only be influencing the decisions of those people who are already attuned to living a healthy lifestyle.

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The Fruits and Veggies: More Matters program is a national public health initiative that promotes the benefits of fruit and vegetable consumption, but suffers from three flaws that may prevent it from reaching its goals. It does not address socioeconomic factors that influence fruit and vegetable consumption. It also fails to appeal to children, and falls into the all-too-familiar trap of assuming that people behave rationally.

Being supported by a wide variety of institutions, including the government, industry and nonprofit organizations, the program possesses great potential to reach its goals due to its access to financial and political resources through its contributors. These advantages put the well-intentioned program in a position to create positive change in the American population.
Having been launched a little more than 2 years ago, the program has been re-evaluated at a critical time. There is little question about the growing obesity problem in the United States. A program could have a big impact in the lives of adults, but most especially in the generation of current youths who are still in the position to adopt healthy eating behaviors. In order for this program to effectively improve people’s nutrition across all ages and levels of socioeconomic status, changes will need to be made to improve upon the three critical flaws.
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These three critical flaws can be addressed by structuring the design 0f the Fruits and Veggies: More Matters program around the Social Marketing Theory (SMT), including aspects of the Advertising Theory (AT), and the Social Expectations Theory (SET). These are population-level models that are ideal for addressing a wide-spread issue like fruit and vegetable consumption. The improvements that should be made include enacting policies that impose restrictions on supermarkets, implementing school programs, and incorporating media advertisement to promote the program.

Increase Access
A solution which takes social and environmental factors into account has two parts: increased access to education and increased access to fruits and vegetables. The problem with heavily relying on a website to educate people is its assumption that its target population has access to a computer and the Internet. Even fliers distributed at the grocery store do not address this problem since people first have to get to the grocery store in order to see the fliers. Instead of waiting for people to come to the information, the information should come to the people. This can be achieved through mailed pamphlets. Pamphlets should minimize the amount of text and maximize the use of charts and pictures to make them attention-grabbing. They will provide exposure to the benefits of eating more fruits and vegetables, the costs involved with eating more fruit and vegetables, and ways to access them.

The solution to the second part of the access problem adheres to the SET and focuses on changing current social norms, wealth and inconvenience, around fruit and vegetable consumption among the low-income population to affordability and accessibility. Two policy changes can help achieve this goal: one to increase physical access to large-scale supermarkets and one to increase financial access to fresh fruits and vegetables. Supermarkets should be required to locate their stores so that the average income level in the regions of all their stores within a state must not exceed a specified maximum. This would require them to locate their stores in lower income areas that they normally would avoid.

The second part of this policy change proposes a tax on so-called junk food due to their lack of nutritional content. The taxes will subsidize the cost of fresh fruits and vegetables to lower the price of healthy produce in relation to junk food and make nutritious diets financially feasible to low-income populations. Industries affected by these policies will be adverse to these proposals. There will likely be heated discussion concerning which foods to consider junk food and thus liable to the tax. Thorough research will need to be conducted to determine a minimum nutritional content for certain foods. Supporting institutions behind the program will need to harness their political influence to compete against lobbyists that may dispute these policy changes.

Target Children in Addition to Mothers
Policy change, in addition to education, should be used to include children in the target population. The main reasoning behind the original program’s focus on mothers is because, for the most part, they are responsible for buying the family’s groceries and preparing the meals. However, the program should directly target children in addition to mothers so as not to rely on mothers to instill nutrition values. Some mothers may not provide their children with the environment or resources conducive to developing nutritious eating habits. This should not prevent the children of these mothers from having the same opportunity to learn about nutrition as other children.

A Fruits and Veggies: More Matters educational program should be developed and implemented in schools for first through eighth graders. In an article that reviewed the successfulness of obesity interventions based on several different theoretical models, population-level interventions that were tailored to specific groups were the most successful (20). School programs containing two key components will certainly achieve this goal. One component is interactive classroom learning. The Fruits and Veggies: More Matters program should not take the form of another lecture to which children must passively listen. The same article that reviewed obesity interventions found that interactive intervention is more successful than its counterpart; therefore the program should use hands-on activities to teach kids about healthy eating habits (20).

In accordance with the “four Ps” of the SMT, formative research should be done among the different age groups since a six-year-old in first grade will respond to an activity differently than a thirteen-year old in eighth grade. This research should illuminate how one can benefit from changing his/her eating habits, what costs are involved in changing eating habits, and the best ways to gain access to fresh produce. The second component of this educational program is requiring school lunch programs to provide multiple fresh fruit and vegetable options. Provision of these options will give children who eat school lunches the opportunity to choose, and thus practice, actually making healthful decisions.

One may ask where the program plans to get the financial resources to implement this educational program and policy change. Since these changes will only apply to public schools, a portion of school budgets that state governments allocate to public schools will need to be used for this program. Additionally, funding from the health care sector will be sought as Fruits and Veggies: More Matters is a heath promotion program that will result in cost savings in the long-run due to prevention of chronic diseases associated with obesity.

Appeal to People’s Emotions
The solution to the third critique of the Fruits and Veggies: More Matters program utilizes the AT. People’s irrational behavior concerning their food choices should be addressed in ways similar to those that conventional industries use to market their products. In a paper highlighting use of advertisements to promote conventional consumer products, successful advertisements have utilized the emotions of the consumer to help sell their goods (21). There is no reason why public health intervention should not adopt the same tactic for promoting health behavior change. The way that the Fruits and Veggies: More Matters program should achieve this is by creating a brand, a slogan, and a promise. The brand will be a set of values that appeal to both youths and mothers, including physical attractiveness and carefree fun. Commercials, billboards, and magazine spreads will feature a young, attractive woman. She will be doing something as simple as posing on a beach. A fresh fruit or vegetable will appear in her hand or beside her, but not as the focus of the advertisement. The slogan will read “You are what you eat.” The promise of being beautiful and carefree will resonate with youths and young mothers alike. The slogan will brand the program by associating it with physical attractiveness. In a sizeable portion of the advertisements certain celebrities such as musicians and actors will be used to tie the program in with mainstream values. These advertisements will promise consumers that they can look and feel attractive if they eat nutritious fruits and vegetables.

One criticism of this solution highlights the issue of finances. Instead of being funded by the government, these media advertisements will have to be paid for with money from the program’s contributors – more specifically, the industry groups that have deeper pockets than the non-profit or government organizations. Although they will be expensive, these advertisements represent a significant component of the program.

Conclusion
The Fruits and Veggies: More Matters program should be structured around the Social Marketing Theory and include elements from the Advertising Theory and Social Expectations Theory. Implementing policy change is an effective and efficient way to create behavior change on the population level. Modeling advertisements after successful tactics used in conventional product promotion will help the program appeal to the emotional side of the predictably irrational population. Incorporation of all the changes discussed in this paper will help the Fruits and Veggies: More Matters program become a strong public health intervention that will improve the health and wellness of our current population as well as of future generations.

REFERENCES
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A Social Sciences Revision of Help for Today, Hope for Tomorrow – Jennifer Stedman

Breast cancer is one of the leading causes of death in women. Unfortunately, even with this knowledge, not enough women are proactive in their health and having regular mammogram screenings. Often, those who are getting screened are not even the target population. One program trying to promote breast cancer awareness and early detection is The National Breast Cancer Foundation (1). For several reasons, The National Breast Cancer Foundation falls short and does not have an effective campaign. The first shortcoming comes directly from the mission of the program. The second is a result of their partnership with Self magazine. Lastly, they have an ineffective Casual Up program.

MISSION
The mission of The National Breast Cancer Foundation has two objectives: first is education about breast cancer and second is provision of mammograms to those women in need. To accomplish this mission, they have laid out three means to reach the target, at risk population. One method is their Beyond the Shock educational video. The video is actually a tutorial of slides, covering thirteen overview topics, taking approximately forty-five minutes to watch. One of the first topics covered is the Risk Factors for breast cancer. The slide mentions that non-Hispanic Caucasian women are at higher risk than African – American women (2). This is a true statement, however it fails to mention that African – American women have the highest mortality rates out of any ethnic or racial group (3). This happens because African – American women tend to have their breast cancer diagnosed at later, more advanced stages when it has metastasized and there are fewer treatment options (4). Reasons for later diagnosis and treatment are a result of a few social factors including lack of health insurance, no follow up on abnormal tests or a belief that mammograms are not necessary (5). Issues such as this need to be address in the public health field, especially in visible campaigns such as The National Breast Cancer Foundation, however are often over looked and therefore reinforced within the African – American community.

In addition to neglecting African – American women, the video also leaves out the Latino women community. Like the African – American women, Latino women experience more aggressive types of breast cancer, which results in difficult treatment and higher mortality rates. Breast cancer is the leading cause of cancer – related death in this population. It is speculated that environmental factors such as working on farms may be a cause of increased rate (6), as well as social factors such as low-income status affecting their means of receiving appropriate health care (7). Therefore, even though the incidence and mortality rates of breast cancer are lower in Hispanic women when compared to non-Hispanic Caucasian and African – American women, they have their own unique issues needing to be addressed.

The National Breast Cancer Foundation also tries to portray its mission through endorsement. This can be seen on the homepage of their website with a video message from Dr. Phil front and center encouraging women to go for yearly mammograms (8). Even though the Dr. Phil television show receives high viewer ratings, the use of Dr. Phil as a spokes person severely limits the target audience. When looking at the demographics of those who watch the Dr. Phil show, the age and gender are appropriate with 66% female, 38% between the ages of 35 – 49 years old and 30% at least 50 years old. However, the viewers are also 88% Caucasian (9), which is the population of least concern for under utilization for mammogram screenings (10).
The National Breast Cancer Foundation also promotes their mission through the use of an online community. Both women and men of any age can register; identify themselves as a patient, survivor, supporter, or provider; find support or ask questions; and they can share their stories (11). Having the main forum for support and information through an online resource also selectively targets a specific population, which is non-Hispanic Caucasian. Within this group, 59.9% have internet access. This is drastically reduced for African – Americans and Hispanics who both only have 36.0% of their population with access to the internet (12).

The use of and access to the internet is also segregated according to socioeconomic status. Within those with a higher socioeconomic status, approximately 60% will have access, whereas approximately 12% within the lower group will have access (13). The same trend can be see between socioeconomic status and those who go for mammogram screenings. Women with household earnings greater than $50,000 had 82.5% report having a mammogram within the past two years; conversely, women with house hold earnings less than $15,000 reported that 68.4% had received a mammogram within the past two year (14). This demonstrate the need for new ways to promote education and support to communities such as African – American and Hispanic women who are not being reached through the current means.

PARTNERSHIP WITH SELF MAGAZINE
In an effort to reach more women and cover a wider domain of breast cancer topics, The National Breast Cancer Foundation partnered with Self magazine. The purpose is to allow those registered with The National Breast Cancer Foundation to have greater access to health information, how to donate to charity and how to make sure their money is well spent (15). This collaboration is, in theory, a great idea; Self magazine and Self.com are great resources for women to learn about having a proper diet, appropriate exercise regimes and other self improvement lessons. However, upon clicking the link to access the Self.com website or looking at the cover of the magazine, every image is one of a young, healthy non-Hispanic Caucasian woman (16). These images reflect Self’s ideal reader:
You're an active, educated, sophisticated woman who yearns to improve the quality of your life. You're interested in health, nutrition, money management, the mind-body-spirit connection, culture, fashion, psychology, fitness and the environment. If that describes you, then this is the magazine that will help you develop your untapped potential (17).

There is a narrow group who can identify with a statement such as this. When promoting breast cancer awareness, the target audience should be broad and encompassing, very different from this campaign. As mentioned before, it is the African – American and Hispanic women who are in greatest need for an intervention. If they were to come across this promotion, the majority would feel it does not apply to them. The prominent reason for failing to reach this group is because the campaign violates McGuire’s Communication / Persuasion Matrix, which focuses on the source, message and channel factors as a means of effectively reaching a group (18). The source refers to whom the message is coming from. The message reflects the core values being presented. The channel is the means of reaching the audience. As demonstrated in viewing the website and reading the description of the ideal reader of Self, the source of the message comes from non-Hispanic Caucasian women of higher socioeconomic status who are fashionable, educated and healthy. The core values of the message include nutrition, money – management and the environment. The channel of the message is through access to the internet or subscription to the magazine. It is clearly visible as to why African – American and Hispanic women cannot identify with the source of the message from Self magazine and The National Breast Cancer Foundation, no one looks like they do. Why would they feel this program would help them when the message is coming from a group visibly different than them? The core values of the message do not associate with the values of African – American or Hispanic women. The traditional values, which are held by African – American women, include communalism, such as the family and child centered, and spirituality (19), none of which can be found in the message from Self magazine. Within the values of Hispanic culture, the family is at the forefront and the mother is responsible for the home (20). These responsibilities become their focus and prominently include cooking and cleaning. Nutrition would fit within the values of the Hispanic woman, however because money – management and the environment are so far out of the scope of their daily lives that the connection will be lost. Lastly, the means to gain access to the benefits of Self are limiting. As previously mentioned, the women who are able to go online and login to the Self.com network (or The National Breast Cancer Foundation website) are those who are non-Hispanic Caucasian women in a higher socioeconomic bracket. This group is already going for regular mammogram screenings and living a generally healthier life-style. The women excluded from access are the African – American and Hispanic women, the group in need of screenings and healthier life-style information.

CASUAL UP
The last initiative of The National Breast Cancer Foundation is Casual Up. This program is designed to take “casual Fridays” in the work environment to raise money and awareness for breast cancer. It refers to casual Fridays as a time to boost employee morale and serve as a function to “increase education about the benefits of early detection and provide mammograms for those in need” (21). Casual Fridays have also become part of the norm for today’s youth, therefore campaigns involving this dress down day are automatically targeted to the young-professionals in our country (22). As a result, even though this campaign is beneficial for employers to take part in for the tax deductions and at the same time raise money for mammograms, the awareness is going towards the wrong demographic. Studies have shown that mammograms are on the rise in young professional women. Campaigns are now drawing attention through the use of young, healthy models promoting early detection (23). It can be understood why campaigns such as Casual Up are having an impact on young women when recent news headlines and medical websites covered Christina Applegate’s diagnoses of breast cancer at age 36 and her decision to have a double mastectomy (24, 25, 26). An occurrence such as Ms. Applegate’s is rare though and often cannot be prevented through screenings at a young age. Only 5% of all breast cancers occur in women under 40 years of age. Those that do occur in younger women are more difficult to detect as their breast tissue is much more dense (27). As a result, it is recommended that women under the age of 40 do not go for mammograms, but instead take part in regular self-breast examination (28). Therefore, despite a creative method, aimed at reaching a broader population, Casual Up may have greater shortcomings than benefits. The goal of raising money to provide mammograms to those in need is definitely needed. Regrettably, the group receiving their message from the campaign is already going for mammograms at too early of an age and should have its efforts focused elsewhere.

The National Breast Cancer Foundation, whose motto is “Help for Today, Hope for Tomorrow,” has great intentions of raising awareness and education in breast cancer and also providing a means of mammograms to women in need. Unfortunately, this message only reaches one, specific population and it fails to reach those women truly in need. The primary methods of execution through their Beyond the Shock video, early detection message from Dr. Phil and on-line community forum are only reaching women of high socioeconomic status who are non-Hispanic Caucasian. Similarly, their effort to reach more women and promote healthier life-styles through a partnership with Self magazine again leaves out African – American and Hispanic women who are in greater need of public health interventions for breast cancer. Finally, the Casual Up campaign, put on by The National Breast Cancer Foundation, has a target audience of women who are under 40 and already, unnecessarily going to mammogram screenings. If The National Breast Cancer Foundation were to look at their methods of spreading awareness through Multi – Level research, the flaws currently in place would become clear to them and allow for the development of more effective and diverse programs. Their programs rely on individual – level models, with the belief that providing information will compel women into action. It does not acknowledge the reasons certain groups, such as African – American and Hispanic women, have more aggressive tumors and high mortality rates when they are at lower risk. The multi – level model would demonstrate information such as lack of access to health care, lack of access to the internet, or even lack of a spokes person who this audience can identify with. The National Breast Cancer Foundation has the potential to be an essential tool of helping women; it just needs a new mode of reaching those who need their help.

The attempts and failings of public health interventions, such as The National Breast Cancer Foundation, give cause for a new perspective to be employed in order to find a solution. The NBCF has specific shortcoming with their implementation of a few programs, including the mission of the foundation, their partnership with Self magazine, and their Casual Up program. The primary issues resulting from these ineffective campaigns are 1) targeting non-Hispanic Caucasian women and neglecting African – American women, who have the highest mortality rates from breast cancer, 2) delivering a message through an inappropriate source, where the viewers cannot relate, and 3) reaching a subset of women who are too young and therefore preventive mammograms are non necessary and ineffective for.
Intervention

A new intervention that promotes breast cancer screenings, especially for African – American women, needs to be developed. This intervention should be based on the Social Sciences in order to capture the underlying causes of discrepancy regarding the preventive measures used, and mortality rates occurring, for African – American women. An effective intervention would be similar to the Pepsi My Generation commercials. This works by displaying images reflective of a certain group. In the Pepsi commercial, the images spanned from the early 1900’s through to the 1980s, capturing images of youth, rebellion and communality. At the end of the commercial, the message of “Every generation refreshes the world, now it’s your turn. Pepsi. Refresheverything.com” (29) appears, providing the viewers with information bringing them together. This campaign works through Social Marketing Theory. The important concept behind the theory is market segmentation, which divides the population into significant subgroups in order to successfully delivery their message (30). The reason this is an effective campaign tool is because it allows the targeted subgroup to feel like they are part of something bigger than themselves; it is something they can associate with, feel an emotional connection to and remind them of the times when they were young, rebellious and connected to others because of these commonalities, which are values that are important to and resonant with most people.

By drawing on the methods used in the Pepsi My Generation commercial, a revised approach can be made in promoting preventive mammograms in an appropriate group of women. Similar to Pepsi, the commercial would have images and music reflective of an older population of women. The targeted women would be about forty years old as it has been shown that a women’s risk of developing breast cancer does not become significant until she is forty years old and that is the recommended age to start going for regular mammograms (31). Therefore, to capture the times of youth for women aged 40 through 85, the images should come from 1940s through the mid 1980s. The images should be reflective of all women, with some emphasis on African – American women, coming together, having fun, and being empowered. The end of the commercial would have a message, like Pepsi, telling women to band together, to hold on to the ideals of their youth and to go for their yearly mammograms. The commercial would then have a website to go to or a phone number to call for more information. By giving them the next step in action, it is more likely to “hook” the audience and be successful.

Having a television commercial is the most common means of reaching the population. Having ads in magazines is also widely used. An advertisement with one of the images displayed in the commercial and the message written on it would also be beneficial to the campaign. A specific magazine that should be utilized is Essence magazine (33) in order to target the African – American women. The reason this magazine has been chosen is because it was an effective tool in recruiting a large population of women to participate in the Black Women’s’ Health Study (32). By choosing this magazine, along with others to target specific groups of women, the campaign should successfully promote it’s message.

Becoming Inclusive
The first criticism of the NBCF program was the way it solely targeted non-Hispanic Caucasian women. This is a substantial problem as the women with the highest mortality rates are African – American women. Having a campaign promoting breast cancer awareness, but not including African – American women in the campaign is a form of institutionalized racism. The revised campaign, based on marketing theory from the social sciences, does not fall into the trap of excluding any groups, specifically African – American women. By utilizing resources such as Essence magazine, which already reaches out and connects with the target population, the campaign is able to get through to these women. Essence magazine is committed to understanding its audience and as a result commissioned a study to define the micro-demographics among black women (34). The study is designed to help effectively advertise for products sold to black women; however the ways the advertisements are designed should also be applied to public health campaigns. The six mini-demographics described represent different values and ideals that are held by different percentages of African – American women. By knowing what values to appeal to the more likely it is that the campaign will be successful, whether for a product or for public health.

Promoting with an appropriate source
The second criticism of the NBCF program was the delivery of their message from an inappropriate source. The messengers were only white women and therefore the African – American women, who are at the greatest risk for mortality from breast cancer, cannot relate to the message. This violates McGuire’s communication / persuasion matrix from the social sciences communications theory (35). This revised approach does not violate the communication / persuasion matrix through the images it displays of all types of women through the generations. The message is coming from someone who resembles the viewer, no matter her background. Every woman has a history and every woman has been a youth. Therefore, by capturing images of different women through out the designated time periods, this becomes an inclusive campaign for the target audience.

Reaching an older age group
The third criticism of the NBCF was due to the programs reaching an audience who should not yet be going for mammograms because they are still too young. The young audience occurred as a result of the Casual UP promotion in the work place. Attracting a younger population should not be an issue for the social science based intervention. By using images that only pertain to the target group’s youth, the images would not apply to younger women and therefore would not appeal to them in the same way. They might find the commercial or magazine ad interesting, but they will not feel the connection with it that the intended group of women, ages 40 and up, will feel. The intended group will have lived through the images shown and experienced the emotions associated with it. This should also be effective as it takes advantage of the social science’s framing theory which centers the message on the core values of the viewer in order to make it appealing (36). For this campaign, the values are reflective of the women’s youth and empowerment. This should trigger a connection to the commercial through shared experiences and subsequently should have positive results influencing these women to engage in preventive mammograms.
The methodology of the revised campaign should be effective in promoting preventive mammography to all women, but especially African – American women. The design of the campaign is group – level, rather than individual – level. This means it acknowledges that groups are different than a simple collection of individuals; it allows for groups of individuals to be effected at the same time; it accounts that behavioral decisions are dynamic and that people can change their mind instantaneously; and it acknowledges that behavior is irrational, not planned or reasoned.

This intervention does have limitations. It does not take into account funding for a campaign such as this. Perhaps if this were to be implemented by an existing program, the funding would be available. An ideal program to do this would be the Susan G. Komen Circle of Promise, which is designed to engage African – American women in their fight against breast cancer (37). Another limitation involves the higher – level factors that might also be preventing African – American women from participating in preventive mammography. One factor that may cause this is a distrust of the medical field within the community. This campaign does not account for this high – level factor, however by focusing on this group and finding a way to connect to these women, I believe it truly is a step in the right direction. Perhaps a pilot campaign should be tested on a group of African – American women to determine how they react and if it might be effective.














References
REFERENCES
1 The National Breast Cancer Foundation. http://www.nationalbreastcancer.org/default.aspx.

2 Beyond The Shock: A step-by-step guide to understanding breast cancer. http://www.nationalbreastcancer.org/About-Breast-Cancer/Beyond-The-Shock.aspx.

3 Breast Cancer Fund, Prevention Starts Here Eliminating the Environmental Causes of Breast Cancer. Breast Cancer Incidence and Mortality by Race and Ethnicity. San Francisco, CA: Breast Cancer Fund. http://www.breastcancerfund.org/site/pp.asp?c=kwKXLdPaE&b=84427.

4 Health Day, News for Healthier Living. Black Women at Higher Risk for More Aggressive Breast Tumors. ScoutNews, LLC. http://healthday.com/Article.asp?AID=625376.

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6 Breast Cancer Fund, Prevention Starts Here Eliminating the Environmental Causes of Breast Cancer. Breast Cancer Incidence and Mortality by Race and Ethnicity. San Francisco, CA: Breast Cancer Fund. http://www.breastcancerfund.org/site/pp.asp?c=kwKXLdPaE&b=84427.

7 Women Caring for Women. Latinas: Breast and Cervical Cancer. CharityAdvantage.com. http://www.latinabca.org/LatinasBreastandCervi.asp.

8 The National Breast Cancer Foundation. http://www.nationalbreastcancer.org/default.aspx.

9 QuantCast. Dr. Phil. Quantified Publisher Program. http://www.quantcast.com/drphil.com.

10 Callee, E. et al. Demographic Predictors of Mammography and Pap Smear Screening in US Women. American Cancer Society 1993; 83: 53-60. http://www.ncbi.nlm.nih.gov/pubmed/8417607.

11 National Breast Cancer Foundation. Join My NBCF. http://community.nationalbreastcancer.org/.

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13 National Telecommunications and Information Administration. Falling Through the Net: Defining the Digital Divide. US Department of Congress, http://www.ntia.doc.gov/NTIAHOME/FTTN99/part2.html.

14 Centers for Disease Control and Prevention. Breast Cancer Screening and Socioeconomic Status --- 35 Metropolitan Areas, 2000 and 2002. Atlanta, GA: Morbidity and Mortality Weekly Report, 2005. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5439a2.htm.

15 National Breast Cancer Foundation. News Releases. http://www.nationalbreastcancer.org/About-NBCF/Media-Room/News-Releases.aspx.

16 Self. New York, NY. Conde Nast Publications Inc. http://www.self.com/.

17 Magazine Agent. Self. http://www.magazine-agent.com/self/magazine.

18 Kreuter, M. et al. The Role of Culture in Health Communication. Annual Review of Public Health 2004; 25: 439 – 455. http://arjournals.annualreviews.org/doi/abs/10.1146/annurev.publhealth.25.101802.123000.

19 University of Oregon. African Americans. http://darkwing.uoregon.edu/~gnhall/psyc459/africanam.html.

20 The Ohio State University. Understanding the Hispanic Culture. Columbus, OH. Family and Consumer Sciences. http://ohioline.osu.edu/hyg-fact/5000/5237.html.

21 National Breast Cancer Foundation. Casual Up. http://casualup.org/.

22 Meredith, G., Schewe, C. and Karlovich, J. Defining Markets, Defining Moments, America’s 7 Generational Cohorts, Their Shared Experiences, and Why Businesses Should Care. http://booklocker.com/pdf/2780s.pdf.

23 Kolata, G. IDEAS & TRENDS; Mammography Campaigns Draw In the Young and Healthy. The New York Times, 1993. http://www.nytimes.com/1993/01/10/weekinreview/ideas-trends-mammography-campaigns-draw-in-the-young-and-healthy.html?sec=health.

24 CNN. Christina Applegate: Why I Had a Double Mastectomy. http://www.cnn.com/2008/LIVING/10/14/o.christina.applegate.double.mastectomy/index.html.

25 WebMD. Christina Applegate’s Mastectomy: FAQ. http://www.webmd.com/breast-cancer/news/20080820/christina-applegates-mastectomy-faq.

26 abc NEWS. Exclusive: Appleate Underwent Breast Removal to Stop Cancer. http://abcnews.go.com/GMA/story?id=5606034.

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28 Author, Unknown. Young Women ‘Shouldn’t Seek Mammograms.’ The Sydney Morning Herald, 2008. http://news.smh.com.au/national/young-women-shouldnt-seek-mammograms-20081027-599b.html

29 NCCNeon. Pepsi My Generation Spot. http://www.youtube.com/watch?v=MFAF-bR6Y0o

30 Edberg, M. Essentials of Health Behavior, Social and Behavioral Theory in Public Health. Surbury, MA. 2007. (60-61)

31 Méndez, Jane. Boston University School of Medicine. April 15, 2009.

32 Essence Magazine
http://www.essence.com/

33 Cozier, Yvette. Boston University School of Public Health. February 25, 2009.

34Author, Unknown. Study identifies 6 micro-demographics among black women. Tapestry cultural threads of success. Rochester Hills, MI. 2006 http://www.mbcglobal.org/News2006-10-31-EthnicBeauty.html

35 Kreuter, M. et al. The Role of Culture in Health Communication. Annual Review of Public Health 2004; 25: 439 – 455. http://arjournals.annualreviews.org/doi/abs/10.1146/annurev.publhealth.25.101802.123000.
36 Jablin, F., Putnam, L. Framing (88-89) in The New Handbook of Organizational Communication. http://books.google.com/books?id=6fumvnF6BsEC&pg=PA88&lpg=PA88&dq=framing+theory+fairhurst+%26+sarr&source=bl&ots=E1NwqY7L3y&sig=fCDWKc01sSt0hARfRtEHljHcp4s&hl=en&ei=cw_6SYvJKYyeM9GGqa0E&sa=X&oi=book_result&ct=result&resnum=7
37 Susan G. Komen Circle of Promise
http://www.circleofpromise.org/

Failure of the “Above the Influence” Campaign-Grace Yang

Introduction
Despite the efforts of various anti-drug campaigns, there has been no change in the prevalence of youth drug use from 2005 to 2007 (1). The National Youth Anti-Drug Media Campaign attempted to combat youth drug use through its Above the Influence (ATI) initiative. This intervention uses TV, radio, print, and Web-based advertising to prevent and reduce youth drug use. ATI fails to accomplish its goal of reducing youth drug-use because it neglects social factors that are involved in youth behavior, disregards effective marketing strategies, and stigmatizes youth who use drugs.

An ATI advertisement that is entitled “Dog” shows a scenario where a young girl is in the kitchen and she hears someone call her name. She turns around and sees that it is her dog that is talking to her. Her dog expresses his disappointment in the fact that she smokes marijuana. In response to what her dog has said, the young girl looks like she feels overwhelmed with guilt because she failed to meet the expectations of her dog.

Another ATI commercial is called “Pony.” The advertisement shows three teenage boys walking in a field towards a horse. One teenager approaches the horse, pulls its tail, and gets kicked in the shin. The second boy does the same. The third teenager sees the pain that the other two are in and walks away as the adult narrator says, “You know a bad idea when you see one. Live above weed.”
The final example of an ATI advertisement is called “Achievements.” The commercial shows various happy teenagers saying things about themselves that they are proud of. However, they are actually things that people would normally be ashamed to admit. One teenager says that she received straight D’s. Another says that she made her mother cry. A different teenager says that he stole from his younger sister.

The ATI intervention wastes scarce resources by designing and implementing a campaign that fails on many levels. First, the campaign neglects to address social factors that influence health-related behavior. Second, it fails to use marketing techniques to induce behavioral change. Finally, it stigmatizes youth, creating another barrier to drug-free behavior. This paper will discuss these three aspects that result in the campaign’s failure.

Above the Influence Disregards Social Norms, Expectations, and Networks
The ATI campaign fails to change behavior because its advertisements do not address the importance of social norms, expectations, or networks. The behavior of large groups can be changed by understanding these important influences. This is especially true for adolescents. However, ATI fails to address behavior from these social perspectives, resulting in a weak and ineffective campaign.

Interventions must account for social norms, particularly when dealing with youth. Social norms are general rules that are understood and observed by a given group, community, or society (2). These include simple concepts that do not have severe consequences if people deviate from them, such as washing hands after using the bathroom. Other norms are more serious in nature, resulting in grave repercussions if broken, such as not driving while under the influence of drugs or alcohol. Whether these rules are perceived as trivial or serious, social norms play a large role in people’s behavior. The norms of peers are especially important to youth. For example, adolescents are also more likely to use condoms if they believe that their peers use them (3). This shows that the normative behavior of peers influence the boundaries for acceptable behavior rather than individual beliefs and attitudes. Therefore, if public health campaigns change the perceived social norms regarding a certain behavior, their effectiveness would substantially increase. However, ATI disregards the impact that peer behaviors have on individual adolescent behavior.

Another important social influence is social expectations, which is defined as whether an individual’s social groups of influence approve or disapprove a behavior (3). The expectations of peers have been shown to greatly affect health-related behaviors. For example, youth who associated with deviant peers were more likely to be delinquent themselves and use drugs (4). Also, peer perceptions more strongly affected sexual behavior than parental monitoring (3). It is clear that the opinions of peers have a large influence on the behaviors of youth. Despite these findings, ATI rejects the importance of peer approval or disapproval and consequently fails to change youth drug-use behavior.

The ATI media campaign also fails to focus on social networks and its influence on behavior. Social networks are comprised of individuals who influence one another, such as family, friends, or co-workers. The nature of the relationships between people in social networks can have a great impact on the way that people behave. Each person in a social network has a particular role to fill when in a group setting (2). These roles are specific parts that people play when involved in group activities. For example, mothers, fathers, and children all play distinct roles in a family. Similarly, peers play a particular role in an adolescent’s social network. Certain roles are more influential than others, especially regarding health-related behaviors. Peer influence is a significant predictor of adolescent smoking, whereas parental influence has little effect (5). Moreover, the finding that condom use typically declines with age except among youth who perceive that most of their friends use condoms illustrates the powerful role that peer behavior can have on risk-reducing behavior (3).

Conducting formative research, which is research that is conducted before a program is designed and implemented, is an essential tool for creating an effective campaign. The roles of different people in the lives of youth must be researched prior to developing a campaign to better understand which social groups that have a greatest amount of influence. The developers of Florida’s anti-smoking campaign called “Truth” spent months researching and interviewing youth (6). This is one of the key elements that contributed to the success of the campaign. ATI clearly did not conduct enough formative research with youth because it fails to take into consideration the influential role of peers.

When addressing social norms and expectations, it is important to focus on the beliefs and opinions of individuals, rather than non-human beings. Similarly, an individual’s social network consists of people, not animals. Twenty five percent of the current ATI advertisements depict a conversation regarding drug use between an individual and a non-human character. The ATI advertisement called “Dog” is an example of the campaign’s ignorance of the social factors that influence their target population. The scenario depicted in the advertisement is unrealistic and likely to have no effect on drug use, or more likely to have unintended consequences (i.e., increase the probability that adolescents will try or continue to use illicit drugs) (7). Failing to highlight the importance of social factors in decision making results in an ineffective or even counter effective intervention.

Above the Influence Fails to Market Anti-Drug Behavior to Youth
The ATI campaign fails to utilize key components of social marketing to appeal to adolescents. Marketing is a process in which two or more parties each have something to exchange. On one side of the exchange is the party that promotes and sells a product. On the other side are consumers who pay a price to buy the product (8). Marketing is a novel strategy that should be utilized in public health interventions aimed at behavior change. In order to successfully market a product, formative research must be conducted to better understand the targets population’s preferences and needs (9,10). The developers of the ATI campaign failed to thoroughly understand which benefits the target audience values the most. Therefore, they were unsuccessful in creating a desirable product that provides those benefits.

One of the key elements of marketing is the product, which refers to the behavior that is being promoted (8). Product also refers to the benefits associated with the behavior (10). ATI fails to present anti-drug behavior as a product. Rather, it merely presents it as a means for healthier living. Packaging health-related behavior as a valued product that the target population is willing to purchase is a more effective way to induce behavioral change (11).

Price is another key element of marketing. This refers to the costs of adopting a certain behavior. Even in a voluntary exchange, there is a price for a new behavior (9). Price often entails intangible costs, such as embarrassment and decreased pleasure associated with denying drug use. There is also a psychological cost related to change, especially when altering habits. ATI ignores the sacrifices that teenagers make when they decide to be drug-free. These sacrifices include being alienated and losing friends. A constricted social network can be a serious cost to adolescents, but ATI fails to address these costs, rendering the campaign ineffective.

Another aspect of marketing that makes it such a successful strategy is that it puts the decision making in the hands of the consumers. This is especially relevant when the target population is youth because freedom and autonomy are core values that they highly regard. Formative research shows that youth do not want to be told what to do (6). They want to make their own decisions and any threats to their independence is likely to result in rebellion. The success of Florida’s anti-smoking campaign, called “Truth,” is attributed largely to the fact that it marketed anti-smoking behavior as a desirable product. But it was also successful because it had a message other than “don’t.” The goal of marketing is to influence a target population, while allowing them to voluntarily adopt the health behavior that is promoted. What makes marketing so powerful is that the population is in full control of the decision making process. Rather than trying to sell a certain behavior change to youth, ATI advertisements tell them to adopt it. They remove the element of freedom, which is an ineffective way to influence adolescents. For example, the Partnership for a Drug Free America produced anti-drug public service announcements with “just say no” messages, which had a negative effect on drug use (7). The ATI commercial called “Pony” is an advertisement that would result in a similar negative reaction in youth. The tone of this message is one of authority, which is likely to evoke a rebellious response in teenagers in an attempt to preserve their autonomy. The commercial has the potential to cause youth to try drugs in an act of rebellion because the advertisement essentially tells them not to use drugs because it is a bad idea. This demonstrates the ineffectiveness of telling youth what to do, as opposed to providing them with tools and allowing them to make the decision on their own.

The Above the Influence campaign fails to provide youth with new information and allow them to utilize the information that is presented to make their own decisions. Marketing is a proven way to induce behavioral change by allowing target populations to make healthier decisions on their own. This strategy is especially effective on youth because autonomy is so important to them. However, ATI disregards the power of marketing and the value that youth place on autonomy, thereby creating a fruitless campaign.

Above the Influence Stigmatizes Youth for Their Drug Use
ATI overlooks the negative impact that stigmatizing youth has on their behavior. Negatively labeling youth for their drug use is counterproductive because it creates a barrier for behavioral change. Even when youth had different opinions about smoking, there was an overwhelming consensus regarding their abhorrence for anti-tobacco efforts that pass judgment on tobacco users (6). This shows that ATI is not only ineffective, but counterproductive in their efforts to decrease youth drug use. Youth’s strong aversion to stigmatization makes them more likely to continue or start a behavior, rather than prevent or change an existing behavior, in response to negative labeling. Therefore, ATI fails in its attempt to change behavior by utilizing stigmatization.

The ATI intervention is also counterproductive because of the negative emotional effects that stigma has on vulnerable populations. In the context of ATI, vulnerable populations include youth who already use drugs. The effect of stigma on people with mental illnesses highlights the detrimental effect of stigma. One of the most adverse effects of the stigma of mental illness is that it leads many afflicted with such illnesses to believe that they are failures or have little to be proud of. A fear of rejection by others can have serious negative consequences, such as more constricted social networks, poorer life satisfaction, and unemployment. As a result, self-esteem is negatively affected and many people with mental illnesses conclude that they are less capable than others (12). Moreover, stigma is a barrier for individuals with depression to adhere to treatment regimens. Compliance with antidepressant drug therapy is predicted by levels of perceived stigma (13). Individuals with mental illness experience such high levels of social stigma that the Surgeon General emphasizes the importance of reducing stigma as a barrier to improved health outcomes (12). The influence of stigma is so strong that it diminishes self esteem and outweighs the therapeutic value of taking medication. For these reasons, ATI’s use of stigmatization is counterproductive in their attempt to prevent and stop youth drug use.

Stigma is also a reason that people fail to disclose their HIV-positive status. There are salubrious advantages of disclosing one’s HIV-positive status. First, an individual who is HIV positive can reduce potential infections of sexual partners, consequently preventing the spread of the virus, by disclosing their HIV positive status (14). Second, disclosure is also a means to receive social support to facilitate coping with the disease process (15). However, disclosure can also lead to stigma and shame (16). The traumatizing power of stigma associated with HIV overrides the healthy effects of disclosure (17). Clearly, stigma has a strong influence on health behavior. Despite the advantages of disclosing one’s HIV-positive status, the fear of stigma is so overpowering that it negates the benefits of disclosure.

The ATI campaign’s attempt to prevent and reduce drug use is futile because it utilizes stigmatization to reach this goal. Stigma is shown to have detrimental effects in people who have mental illnesses and are HIV-positive. Stigma causes those with mental illnesses to feel less worthy than others, exacerbating their condition. It also prevents people with depression from adhering to their medication regimen. Lastly, stigma creates barriers for people who are HIV-positive to make healthier decisions for themselves. Another example of stigmatization is seen in the ATI “Achievements” advertisement, which negatively labels youth who use drugs as poor students, cruel to their parents, and deceitful to younger siblings who look up to them. Stigmatizing youth for their drug use will only lower their value of self-worth, creating further barriers to behavior change. This use of stigmatization is detrimental to the campaign’s goals of reducing youth drug use.

Conclusion
The ATI campaign fails in its attempt to prevent and reduce youth drug use because it overlooks key components for successful behavior change. The campaign disregards key social factors that influence health-related behavior. It also fails to use marketing strategies to sell drug-free behavior to youth. Rather, it poses a threat to their autonomy by dictating their decisions. Lastly, the content of the messages is counterproductive because it stigmatizes youth, which creates a barrier to behavior modification. Media campaigns are promising means to induce large scale behavioral changes. However, the ATI campaign fails to take advantage of the potential that the mass media has to influence healthier behaviors in youth. ATI dismisses the growing evidence in the literature from various fields that provides strategies for effective interventions. Consequently, it misuses valuable resources to create an intervention that fails on multiple levels.

“Unhooked”: Counter-Proposal to the “Above the Influence” Campaign

Unhooked: Alternative Anti-Drug Intervention
The Above the Influence (ATI) campaign attempts to prevent and reduce youth drug-use. However, it fails on many levels because it does not address important influential social factors, neglects effective marketing strategies, and stigmatizes youth who use drugs. This paper proposes a novel intervention, called Unhooked, to counter the failings of ATI.

Unhooked is a web-based campaign that addresses adolescent drug use from a social and behavioral science perspective. This intervention is superior to ATI for three reasons. First, it approaches behavior from a social context by incorporating the influence of peer groups. Second, the intervention utilizes marketing strategies to promote drug-free behavior as a desirable product. In order to effectively advertise and promote the product, it takes advantage of various media outlets frequently used by youth, such as Facebook, MySpace, and YouTube. Third, the content presented in the intervention is thoughtfully developed in order to avoid stigmatization.

This campaign is comprised of five main components: (1) web groups, (2) a media library, (3) gear, (4) fact sheets, (5) and forums. Web groups are online “clubs” that are led by peer leaders of the target population. Peer leaders are youth who demonstrate leadership skills and have a significant influence over the target population. Leaders create a web group for each of their schools in order to serve as a community of support for those who want to be drug-free. This creates a special social network of youth who are committed to being drug-free. The Unhooked media library consists of videos and commercials created by youth and advertising professionals to decrease the allure of drug use. Commercial topics include the difficulties of saying no to drugs and the social consequences of doing so. Gear is an essential component of the intervention because it facilitates the promotion of drug-free behavior by creating a brand that is easily identified and consequently desired by youth. Lastly, the educational element, comprised of fact sheets and an educational forum, provides youth with information about drug use so that they can make an informed decision about their behavior.

Unhooked Addresses Social Influences Associated with Youth Drug Use
The Unhooked campaign incorporates peer norms and expectations because social factors play important roles in youth behavior. The influence of peers is one of the most prevalent risk factors for early onset or increased substance use during adolescence (18). A key strength of the Unhooked intervention is that it addresses peer norms, a powerful influence on adolescent health-related behavior. Norms that encourage drug use result in greater rates of youth substance use (19). Expectations, which encourage or discourage drug use, also influence adolescent substance use. When teenagers’ peers use drugs and expectations for drug-use increase, teens are more likely to use drugs (20,21). For these reasons, it is necessary to acknowledge the effect of social norms and expectations on youth behavior and address drug use with this phenomenon in mind.

Web groups are a means to create social norms and expectations that deter adolescents from using drugs. They also provide a social network for youth who are already drug-free or would like to be drug-free. Having peer leaders create these groups is an effective strategy to reduce drug use because smoking prevention programs led by peers were successful in reducing adolescent smoking onset rates (22). School health education programs led by peers were as effective or more effective than programs led by adult leaders (23). Peer leaders who advocate for drug-free behavior change social norms and expectations that encourage and accept drug use to those that discourage it. This creates a shift in the perceived normative behavior of youth and provides a network of support for youth who would like to be drug-free. Therefore, web groups led by peers are effective means of compelling youth to change their behavior.

Unhooked Markets Anti-Drug Behavior
Marketing has been used in various fields for decades as a powerful tool to evoke behavioral change. However, public health professionals have yet to incorporate this effective strategy into their interventions. Unlike ATI, Unhooked uses components of marketing to reach its target population. Adolescents are often the target of advertising and marketing efforts because they are easily persuaded and influenced by their messages (24). Youth who were exposed to more alcohol advertisements consumed higher amounts of alcohol on average than those who saw fewer advertisements. Youth in high advertisement environments also increased their alcohol consumption into their late 20’s, while alcohol consumption for youth in low advertisement environments leveled off (25). This illustrates the persuasive and lasting effects of marketing on health-related behaviors.

Marketing is a prevailing force on youth behavior. For this reason, Unhooked integrates marketing strategies into its anti-drug campaign. This intervention uses the internet to disseminate media messages about drug-use. The videos and commercials can be easily accessed on the Unhooked website, and on social networking websites that youth frequently use, namely Facebook, MySpace, and YouTube. The Unhooked media library is created by youth so that drug-free behavior is advocated from the perspective of peers, rather than adults. This minimizes any negative reactions that youth may have against authority and decreases the likelihood of unintended consequences, such as rebellious drug use. The media clips demonstrate the costs of adopting a drug-free lifestyle, such as potential alienation from friends who use drugs. The videos and advertisements show that although youth may lose friends in their social network, there are still countless youth who commend and support their decision to reject drugs.

Unhooked also promotes healthy drug-free behavior through its line of various gear, including bracelets, notebooks, and t-shirts. Unhooked takes advantage of branding, a strategy that creates a set of positive associations with a product. The LIVESTRONG Global Cancer Campaign is a well-recognized campaign that has effectively used gear to brand their efforts for cancer control. Using gear as promotional items marked with the Unhooked logo creates a positive relationship with youth, which results in brand awareness and preference (24). This often leads to brand loyalty, which leads them to desire the product of drug-free behavior. This is a clever tool used by the marketing industry that should also be used in public health interventions.

Unhooked Incorporates Non-Stigmatizing Content
Interventions with stigmatizing content are counter-productive because stigma creates barriers to behavior change. Stigma precludes those living with depression and a positive HIV status from engaging in healthy behavior (11-16). Similarly, the stigma of being overweight and focusing on negative body images deters some youth from losing weight (26). Formative research conducted with youth show that rather than being judged for their behavior, youth want facts to make their own decisions (6). Therefore, it is important that public health professionals pay close attention to the content of their intervention’s message.

Unhooked uses caution when creating the messages that are conveyed to youth about drug use. It is essential that the tone is non-judgmental and the message does not contain stigmatizing content. Because youth are prone to negatively react to stigma, the Unhooked website refrains from incorporating negative labeling into the content of its intervention. This is accomplished by staff members who regulate and remove stigmatizing content that may be posted on the website by the public. This is done strictly to uphold the positive and safe online environment that Unhooked creates for youth. Instead of using to stigma to try to effect behavioral change, Unhooked provides youth with educational tools to receive information and advice about drugs. The website has fact sheets about various illicit drugs and the effects of drug use. There is also an educational forum where youth can ask health professionals any questions they may have about substance use. If there are any question about drugs or behaviors that the fact sheets do not answer, youth are welcome to ask health care providers for additional information. An advantage of using the forum to inquire about the consequences of drug use is that youth can remain anonymous when posting questions to minimize any feelings of stigmatization from peers or the online community.

Conclusion
Youth drug-use is an individual and societal level problem that must be confronted with innovative strategies. Unhooked is a novel alternative to ATI, which fails to decrease rates of risky youth behavior. Unhooked addresses the three key failures of the ATI campaign. First, it addresses the social influences that impact youth behavior by facilitating web-based social networking. Second, it uses marketing techniques to sell drug-free behavior as a desirable product by using media and gear as promotional tools. Third, it contains non-stigmatizing content that informs youth about drug use so that they can make an educated decision on their own. Understanding the target population is a primary strength of the Unhooked intervention, which is based on social and behavioral theory. In order to decrease the prevalence of youth drug-use, it is necessary to stop wasting resources on ATI and implement Unhooked.

REFERENCES

1. Youth Risk Behavior Survey (YRBS). Available from URL: http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbs07_us_drug_use_trend.pdf. Accessed on April 24, 2009.

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3. Romer D, Black M, Ricardo I, Feigelman S, Kaljee L, Galbraith J, et al. Social Influences on the Sexual Behavior of Youth at Risk for HIV Exposure. American Journal of Public Health June 1994; 84(6):977-985.

4. Elliot DS, Huizinga D, Ageton SS. Explaining Delinquency and Drug Use. National Institute of Justice 1982; 1-190.

5. Wang MQ, Fitzhugh EC, Westerfield C, Eddy JM. Family and Peer Influences on Smoking Behavior Among American Adolescents: An Age Trend. Journal of Adolescent Health 1995; 16:200-203.

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

7. Fishbein M, Hall-Jamieson K, Zimmer E, von Haeften I, Nabi R. Avoiding the Boomerang: Testing the Relative Effectiveness of Antidrug Public Service Announcements Before a National Campaign. American Journal of Public Health 2002; 92(2):238-245.

8. Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury: Jones and Bartlett Publishers; 2007

9. Kotler P, Zaltman G. Social Marketing: An Approach to Planned Social Change. Journal of Marketing. July 1971; 35:3-12.

10. Ling JC, Franklin BA, Lindsteadt JF, Gearon, SA. Social Marketing: Its Place in Public Health. Annual Reviews 1992; 13:341-362.

11. Grier S, Bryant CA. Social Marketing in Public Health. Annu Rev Public Health 2005; 26:319-339.

12. US Department of Health and Human Services: Mental Health: A report of the Surgeon General. Rockville, Md, Center for Mental Health Services, 1999.


13. Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, Friedman SJ, Meyers BS. Stigma as a Barrier to Recovery: Perceived Stigma and Patient-Rated Severity of Illness as Predictors of Antidepressant Drug Adherence. Psychiatr Serv 2001; 52:1615-1620.

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15. Serovich J. A test of two disclosure theories. AIDS Educ Prev 2001; 13:355-364.

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18. Griffin KW, Botvin GJ, Nichols TR, Doyle MM. Effectiveness of a Universal Drug Abuse Prevention Approach for Youth at High Risk for Substance Use Initiation. Preventive Medicine 2003; 37:1-7.

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24. Story M, French S. Food Advertising and Marketing Directed at Children and Adolescents in the US. International Journal of Behavioral Nutrition and Physical Activity 2004; 1:1-17.

25. Snyder LB, Milici FF, Slater M, Sun H, Strizhakova Y. Effects of Alcohol Advertising Exposure on Drinking Among Youth. Arch Pediatr Adolesc Med 2006; 160:18-24.

26. Allon N. Self-perceptions of the stigma of overweight in relationship to weight-losing patterns. American Journal of Clinical Nutrition 1979; 32:470-480.

Winning the War against STIs: Why Public Health Interventions have failed to reduce STI rates among Adolescents- Oluwakemi Olukoya

Sexually transmitted diseases (STDs) remain a major public health problem in the United States. The CDC estimates that approximately 19 million new infections occur each year and almost half of the infections occur among young people 15-24 years of age. Though several public health campaigns have been conducted to curb the spread of sexually transmitted diseases (STD) among adolescents, the rate of STDs continues to soar. The failure of these campaigns can be linked to their reliance on traditional health behavior models which have limited ability to change behavior. The traditional health models are limited by their individualistic approach to change behaviors and by their assumption that individuals have mastery and control over decision making and behavior change.

An example of a public health campaign which is based on traditional health behavior models is the It’s Your (Sex) Life (IYSL) national campaign. IYSL is an ongoing partnership of MTV and the Kaiser Family Foundation to help young people make responsible decisions about their sexual health (1). IYSL campaign has distinguished itself from other public health campaigns by winning the Emmy and Peabody award for public information campaign on HIV/AIDS, other sexually transmitted diseases and related sexual health issues. In addition, the recent extension of IYSL partnership with Planned Parenthood Federation of America to promote the GYT (Get Yourself Tested) campaign- aimed at removing the taboos surrounding STD testing- through celebrities seems promising. Despite the above strengths of the IYSL campaign, its’ message, based on traditional health behavior change models (Health Belief Model and Social Learning Theory), has limited ability to change adolescents risky sexual behaviors to preventive behaviors. This article critically reviews the It’s Your (Sex) Life national campaign and presents three arguments which explain the limitations of the IYSL from the perspective of social and behavioral sciences.

I.) Health Belief Model
By using the Health Belief Model, It’s Your (Sex) Life campaign presumes that by promoting ads which emphasize on the consequences and statistics of sexually transmitted diseases, an individual will perceive his susceptibility to acquiring STD and perceive the severity of STD on his life; thus he would rationally weigh the benefits of not engaging in risky sexual behaviors to barriers which leads to intention and safe sex practices. For example, one ad featured a lady instructing a “teenage girl” to break up immediately with her boyfriend who refused to use a condom because she is at risk of contracting HIV.

Though the ad provides factual information, studies have shown that early prevention efforts that involved providing factual information about HIV/AIDS to promote safer sexual practices among adolescents and young adults were not strongly correlated with preventive behaviors(2). Thus, knowledge is necessary but not sufficient for HIV/AIDS risk reduction (2; 3). In addition, findings from various studies(4) that applied the HBM to promote preventive sexual behaviors among heterosexual college students have been inconsistent and provided only partial support for the model. Overall, perceived barriers (to condom use) received the most consistent support as a significant predictor of engaging in preventive behaviors (5). The fact that the extension components of the HBM did not significantly increase the prediction of condom use among college students may reflect the limitations of the HBM in promoting protective behaviors (5).

Furthermore, there is a wider social context within which individuals must circulate such as families and communities, which in turn affect the individuals’ decisions and behavior. HBM does not account for such social and environmental factors. (6) The HBM focus on individual-level factors and its’ reliance on the individual’s ability to make rational decisions and develop intention (7) to engage in protective behaviors constitute a major weakness of this approach. Intention does not always lead to behavior and human actions are mostly irrational. Also, HBM does not take into account the spontaneous activity that characterizes much of human behavior (7)

II.) Self-efficacy versus Self-control
IYSL draws from SLT by promoting self-efficacy. The IYSL campaign assumes that by instructing adolescents to take charge of their sex life by being in control and making smart choices, adolescents will be empowered and thus develop self-efficacy to practice safer sex. However, this assumption is false because individuals lack self-control over their actions due to other influences.

Studies indicate that patterns of social cognitive development in adolescence vary as a function of the content under consideration and the emotional and social context in which the reasoning occurs (8). Adolescents’ reasoning about real-life problems is not as advanced as their reasoning about hypothetical dilemmas (9) (e.g. a female practicing negotiation of condom use in a non-aroused state versus an aroused state). Adolescents’ when faced with a logical argument are more likely to accept faulty reasoning or shaky evidence when they agree with the substance of the argument than when they do not. (10-11). In other words, adolescents’ social reasoning, like that of adults, is influenced not only by their basic intellectual abilities, but by their desires, motives and interests (12).

Behavioral data have made it appear as though adolescents are poor decision-makers (i.e. their high-rates of participation in dangerous activities, automobile accidents, drug use and unprotected sex) however, there is substantial evidence that adolescents engage in dangerous activities despite knowing and understanding the risks involved (13-15). Thus, in real-life situations, adolescents do not simply rationally weigh the relative risks and consequences of their behavior – their actions are largely influenced by feelings and social influences (16). In addition, research has shown that sexual motivation can distort judgments on the risk of contracting sexually transmitted disease (17). Results from a study suggests that arousal does not change an individual’s general knowledge about the risks of unprotected sex, but when it comes to concrete steps involving condoms, sexual arousal changes one’s perceptions of the tradeoffs between benefits and disadvantages in a fashion that decreases the tendency to use them. (18)

III.) Social Determinants
IYSL campaign fails to account for diverse array of factors influencing adolescents’ risk taking behavior (Figure 1). Such factors include familial characteristics such as parental support, peer influence, school environment, community, socioeconomic status, racial disparities and societal factors such as media exposure (19). IYSL campaign may have no influence on adolescents who do not belong to a stable and supportive family system. Families provide role models, shape sexual attitudes, set standards for sexual conduct, control and monitor adolescents’ behaviors. Parental monitoring is associated with older ages of sexual initiation, smaller numbers of sexual partners and more consistent contraceptive use, all of which suggest lower STD risk (20). Thus how will the IYSL campaign account for teenagers, particularly homeless teens, who do not have family support and are predisposed to engage in risky behaviors?

In addition, though IYSL campaign used teenagers to promote its’ message to other teens, the campaign failed to recognize the power of group dynamics in shaping an adolescent decision with regards to which norms to abide to. Peer norms surrounding sexual behaviors and condom use have been shown to be major influences on both risky and protective sexual behavior. When adolescents perceive that friends and similar-aged teens engage in risky sexual behavior, even if their perception is skewed, then they are more likely to adopt those same behaviors (19). IYSL campaign needs to be more strategic in using teenagers in its’ ads in promoting safe sex practices rather than showing teenagers who are willing to adopt condom use because of the consequences of acquiring STDs.

The IYSL campaign failed to take full advantage of the effect of school environment on sexual risk taking behaviors. In one ad, a Professor told a group students that “there is hardly any healthy sexual relations…… they should learn to stop and have a conversation” about sex. Through this ad, IYSL campaign assumes that students have self-control and schools are a good place to let adolescents know they can take charge of their sex life. Though schools play a vital role in sex education, how does IYSL account for other aspects of school social environment associated with risky sexual behaviors? School structural attributes affect norms and attitudes about dating practices and sexual behaviors (21). Studies of the effects of school characteristics on sexual risk-taking behaviors found that racial composition and school type (public or private) are associated with age at first intercourse and number of sexual partners (22). Compared to private schools, teenagers in public schools have a higher STD risk. (21-22).

In addition, IYSL campaign failed to take into consideration racial differences in an ad which lead to counterproductive responses from adolescents. In the commercial, a white teenage girl refused to have sex with a black teenage boy because he did not have a condom to use. Though the ad was trying to tell adolescent females to be firm in their decision of practicing safe sex, the public interpreted it as her being a racist as illustrated by several comments on You Tube. This commercial also failed to use effective communication principles by ensuring a similar group was used as the source of message to the receiving group. The media plays a significant role in socialization of adolescents and therefore impacts their sexual risk and protective behavior. For example, studies have found that greater exposure to rap music videos and X-rated movies were associated with having multiple sex partners, more frequent sexual intercourse, and testing positive for an STD (23, 24). It is ironic that MTV, partners of IYSL campaign, hopes to promote protective sexual behaviors while they show more of music videos promoting sexual activity.

Overall, we cannot hope to optimize changes in adolescents’ sexual behavior without addressing the broad range of factors that influence adolescents’ decision-making process and, in turn, their likelihood of engaging in risky sexual behavior (24).


COnclusion
In order to achieve greater success, “It’s Your (Sex) Life” campaign must move beyond the traditional health behavior models- focused on individual level factors. Merely examining individual-level determinants in isolation provides a limited perspective on a complex issue and, furthermore, precludes a more in-depth understanding of how higher-level variables (e.g., family, peers, school, community, and society) may be independently associated with STD risk behaviors in the presence of other individual-level factors (19). Thus, while efficacious in promoting the adoption of STD/HIV-preventive behaviors in the near-term, individual-level interventions appear to be insufficient in sustaining newly adopted preventive behavior changes over protracted periods of time (19). What is needed is a complementary approach that addresses these multiple spheres of influence and adopts alternative health behavior change models capable of changing people’s behavior en masse to the desired or protective health behavior.

Section 2
To address the problem of rising STD’s rates among adolescents, I propose an intervention/strategy that promotes condom use at a group level by utilizing the following alternative health behavior models: marketing (social marketing) and framing theories.

Marketing is defined by the American Marketing Association as the activity, set of institutions, and processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society at large. Social marketing is the systematic application of marketing strategies along with other concepts and techniques to achieve specific behavioral goals for a social good. Social marketing seeks to influence social behaviors and to benefit the target audience, the general society and not the marketer.(26)
The defining features of social marketing emanate from marketing’s conceptual framework and includes exchange theory, audience segmentation, competition, “the marketing mix,” consumer orientation and continuous monitoring. (27)
Framing comes from cognitive science, which defines a frame as a conceptual structure involved with thinking.(28) Frames are a composition of elements—visuals, values, stereotypes, messengers— which together trigger an existing idea. Frames tell us what a communication message is about. They signal to us what to pay attention to (and what not to), and they set up a pattern of reasoning that influences decision. Framing, therefore, is a translation process between incoming information and the pictures in our heads (29)

Intervention: Ignite Campaign- bringing out the fire in you

This intervention builds on the growing evidence which indicate that promoting pleasure in condom use, alongside safer sex messaging, can increase the consistent use of condoms and the practice of safer sex.(30) Ignite campaign aims to reduce STD’s rate by increasing the consistent use of condoms among sexually active adolescents. It aims to achieve this by reframing the use of condoms as being pleasurable rather than a just a protection “tool” from sexually transmitted diseases; also by using effective marketing strategies to spread its’ message.

Components of the Intervention

1) Form partnership with a condom manufacturing company in order to make Ignite pleasure condoms.

2) Use strategic adverts to reframe condoms as being pleasurable. I created two commercials which use pleasurable activities (dancing, and going to the beach) to appeal to core values (such as attractiveness, pleasure, vitality, sex) which adolescents value more than health.


Commercial One:
Several teens are gathered in an arena to watch a Salsa dance competition (illustrated by showing contestants (adolescents) with their partners (male and female) wearing salsa dance costumes)
Scene: Presenter of the show: Let’s welcome our final contestants for the night
(The crowd cheers)
Two teams come on stage and as the salsa music plays both teams start dancing.
Team 2: The female partner suddenly stops dancing…..she tells her partner “I can’t continue dancing…..my wrist hurts severely”. Her partner smiles and brings out a pack of Ignite condom (she smiles), he opens the condom pack and ties it around her wrist. Immediately vibrant salsa music plays, team 2 does amazing dance steps and wins the competition. At the end of the commercial, Ignite condom- bringing out the fire in you is displayed.

Commercial two:
Four teenage boys sitting on the beach suddenly get excited when four attractive females walk up to them. The boys stare so hard that “fire” comes out of their eyes. Each of the girls show the boys a box of ignite condom…..strangely the boxes become “alive”, grow so big and each female enters the box. Happily each boy grasps one Ignite condom box.

The two commercials use the power of visual imagery to frame the message. Imagery in brand marketing helps to create the external ideal (e.g. a figure, image or symbol that embodies socially desirable characteristics). Thus an individual will aspire to close the gap between his or her own self image and the idealized external image (e.g. Ignite condom brands).

3) Spread the message via a multi-channel approach by using a combination of traditional media channels, including TV, radio, print (billboards, celebrity, sports and other youth magazines), and new media such as internet websites (blogs, download materials, videos, games, celebrity and Ignites’ own website), E-mail services, Social networks (Facebook, Myspace), Youtube, Desktop agents, mobile phone texting and placing ads on other hand held computing devices.

4) Organize community based events such as concerts, cultural festivals, fairs where free Ignite condoms can be distributed. Distribution can be extended to recreational centers, school health centers, summer camps, hair salons etc. Flyers that have the logo of Ignite and the picture of the star couple in the Salsa dance ad will be distributed. Also, members of the community will be engaged in advocacy for the provision of sufficient resources (e.g. comprehensive adolescent health centers) for adolescent health.

5) Regular evaluation of the campaign to gauge the responses of the target audience to all aspects of the intervention, from the broad marketing strategy to specific messages and materials.

Argument: Why the Ignite campaign is better than It’s Your (Sex) Life campaign
1.) Strength of the alternative health theories over the health belief model
Unlike the HBM that relies completely on individual level factors to change behavior, the alternative health models utilize the group phenomenon to change people’s behaviors en masse. Groups are not just a collection of individuals; they have certain characteristics which individuals tend to adopt. For example, though an adolescent may not want to engage in risky sexual behaviors, when he/she perceives that friends and similar-aged teens engage in risky sexual behavior, then he/she is more likely to adopt those same behaviors (19). The alternative health theories do not focus on predicting individual behavior rather they take advantage of the predictable group “mentality” (the herd mentality) to change an entire group at the same time. The Ignite campaign uses effectively two alternate health theories (Framing and Marketing) which have been proven to yield desirable results in the commercial and political sector. There is substantial evidence that social marketing is effective in changing health behaviors on a population level (31). The VERB campaign, It’s what you do, promoted by the CDC is a good example of how social marketing can change health behavior at a group level. Marketing alters the environment to make the recommended health behavior more advantageous than the unhealthy behavior it is designed to replace (27).

The Ignite campaign uses the framing theory to appeal to other core values (sex, attractiveness, pleasure) more compelling to adolescents than health as used by the IYSL and other public health campaigns. Framing an issue on core values more important to individuals (level 1) is vital because they are the ones that connect to individuals in the deepest way (29) which can trigger the ‘jolt’ necessary for instantaneous behavior change. According to Lakoff (1996), people’s support or rejection of an issue will largely be determined by whether they can identify and connect with the Level 1 values rather than the minute details of issues (e.g. statistics of sexually transmitted diseases) which may “crowd’ level 1 core values and make the campaign message ineffective. The national Truth campaign used the framing theory to appeal to the rebellious core value of adolescents. By successfully framing non-smoking as being rebellious and promoting a teen focused “counter marketing” brand, Truth campaign was able to account for 22 percent of the decline in adolescent smoking prevalence from 25.3% to 18.0% from 200-2002. (32)



2.) Self control
Unlike the IYSL campaign which assumes that adolescents have self control over their actions and can take charge of their sex life, the Ignite campaign takes cognizance of the fact that people have difficulty with self control and their social reasoning is influenced not only by their basic intellectual abilities, but by their desires, motives and interests (12). In addition, the alternative health models used in the Ignite campaign take advantage of the fact that human behavior is influenced by expectations, predictably irrational and not planned. For example, there are “seasons” in the stock market when investors (skilled and unskilled) “rush” to buy a particular stock at unreasonable high prices because such companies have strategically raised the expectations of consumers (via branding, framing and marketing theories) and taken advantage of the predictable irrational “herd” mentality. Similarly, by successfully associating the Ignite condom brands with the core values (sex, attractiveness and pleasure) that appeal to adolescents, the Ignite campaign can take advantage of adolescents lack of self control (which contributes to risky behaviors) and predictable irrational behavior in order to increase the use of Ignite condoms. Trust campaign, conducted by the U.S.-based Population Services International (PSI) promoted an HIV/AIDS prevention social marketing campaign that was effective in reaching adolescents and young adults in Kenya. The Trust campaign promoted the social desirability of condom use by making condom use seem cool. Studies show that the campaign increased adolescents and young adult awareness of the Trust condom brand and increased condom use among those with repeated exposure to the brand. (33)

It is important to note that while the commercial marketing strategies benefit the marketer, the social marketing strategy used by Ignite campaign benefits the target audience and the society at large by reducing STD rates and its consequences. In addition, by actually making pleasurable condom packs, Ignite campaign is not deceiving the target audience.

3.) Social Determinants



Though the Ignite campaign may not be able to address all the societal factors that influence adolescents’ behaviors, it offers a more comprehensive approach for addressing these factors than the IYSL campaign. Firstly, because adolescents are increasingly less subject to parental influence and more subject to peer and media influence (31), there is a dire need for public health professionals to promote media campaigns that can influence adolescents. Campaigns that appeal to the core values of adolescents are more influential than campaigns which emphasize on the negative consequences of acquiring STD’s. The use of negative messaging (“don’t do this behavior”) counters the rebellious core value of adolescents. Adolescents rebel against external restrictions on their independence and self-control (31), thus they develop opposing reactions to negative — “don’t do it” —messages. For example adolescent boys who associate displeasure strongly with condom use are likely to rebel against outside forces who try to “impose” condom use on them without offering them an immediate, tangible, gratifying and valuable exchange that will not make them feel a loss. Thus by reframing condom use as pleasurable and using ads that do not counter the rebellious nature of adolescents and appeals to their other core values (pleasure, attractiveness, sex), the Ignite campaign has superiority in using the media to influence adolescents’ behaviors than the IYSL campaign. The success of the Trust campaign in increasing condom use by framing condom use as being cool, illustrates the power of branded messages that convey positive behavioral alternatives for young people (33).

Secondly, through the extensive use of multi-channels by the Ignite campaign, the campaign is capable of fighting the “battle” against other media and marketing exposures that can promote risky health behaviors. The VERB campaign, It’s what you do, is an excellent example of a public health campaign that used several multi channels to reach its target population. The VERB advertising and promotions reached “tweens” in their homes, schools, and in their communities. The primary vehicle was paid advertising in the general market and in ethnic media channels. The VERB made use of TV, radio channels, print advertising in dozens of youth publications, websites, social networks (Facebook, MySpace) and other media agents such as text messages. Evaluation of the VERB campaign showed that as these same children became more aware of VERB, they engaged in more free-time physical activity sessions. The average 9-to 10-year old youth who were aware of VERB engaged in 34 percent more free-time physical activity sessions per week than did 9- to 10-year-old youths who were unaware of the campaign. (31)

Thirdly, the Ignite campaign also offers a comprehensive approach to promoting preventive behaviors through its outreach to the communities and school based centers. In addition, by involving community members in advocacy for provision of comprehensive adolescent centers, the Ignite campaign takes advantage of the “power” of social marketing in affecting policy makers through the media to frame public debate in support of enacting health policies; thus by influencing policy makers, they can address the broader social and environmental determinants of health (27).

Conclusion
The alternative health behavior models (Framing and Social Marketing Theories) used by the Ignite campaign have the potential to promote preventive sexual behaviors among adolescents; and thus reduce STD rates. Public health professionals need to abandon the “myth” that using such strategies to promote healthy behaviors is manipulative and unethical. It is time for public health campaigns/interventions to look beyond the traditional health models which have failed to curb STD rates among adolescents. The Ignite campaign provides a strong model that can be used to win the war against sexually transmitted diseases.

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Informational Approaches Targeted to Promote Physical Activity- the Breakdown and Futility for Our Obese Population- Julie O’Shea

Introduction

A sedentary lifestyle or lack of physical activity contributes overwhelmingly to an individual’s risk of disease which has burdened our healthcare system. The lack of physical activity has been demonstrated to be a contributing cause of the obesity epidemic and may contribute to a decreased quality of health in the public [1, 2]. In the United States, heart disease and stroke have been the first and third causes of death for decades [3]. Also in the US, only 25% of adults report performing the recommended activity level (i.e. 30 minutes of moderate or intense activity on 5 or more days), despite the public’s general knowledge in the benefits of regular physical activity [4]. It has been shown that an increase in physical activity level may decrease coronary disease mortality by 5% suggested by a theoretical estimate of the US public health burden [5]. Additionally, physical inactivity is a factor and associated risk with some cancers [6]. Finally, the initiative from the US government, Healthy People 2010 has ranked physical activity as a leading health indicator [4]. Despite the knowledge of the importance of physical activity, public health initiatives directed at this issue continue to fall short in their impact and effectiveness.

Consideration of the Health Belief Model

Applying the health belief model, most approaches have utilized the notion that by providing health information for risk reduction of disease, people will be motivated to increase their physical activity and change their behavior [7]. This frequently does not occur. The Stanford Five City project is an example of a community based informational campaign that has been shown to be ineffective for this reason [8]. The use of the Health Belief Model, poor framing and lack of knowledge of environmental factors contributed to the failure of this community approach.

The Stanford five City project was a community health education program for improving the knowledge, attitudes and behaviors toward physical activity targeting the residents of 2 communities of California [9]. The dissemination of information promoting the benefits of physical activity was included in the intervention in a stepwise fashion over 6 years. Other parts of the intervention included news column, workshops, organized events, media such as TV segments and worksite and school based education programs. The benefits of regular physical activity communicated via educational messages were the key integral motivating factor this intervention was dependent on [8].

This intervention, which has taken its cue from the traditional Health Belief Model, is flawed on this level. The educational programs of the Stanford Five city project have been outlined in the tenets of the Health belief model. That is, if you provide the information of perceived susceptibility and severity of diseases due to sedentary lifestyle, the people in the community exposed to this message will change their behavior. It assumes the individual will have a rational weighing of the message of risk with physical inactivity and thus change their behavior from the intention they have formulated [7]. This idea is based on people making rational health choices and does not account for multilevel variables at play in the people’s lives that may or may not be altered. The barriers of incorporating exercise are not addressed in this intervention. A person’s time commitments to work, family and care giving are not accounted for or resource availability. The way the information was provided to these communities was based on the health belief model of severity and susceptibility. The education of the public was directed on the individual level. Although the campaign delivered the message on varied channels, it did not account for the environmental variables that could impact the individual’s ability to increase their physical activity. The complex behavior of incorporating physical activity into one’ lifestyle was not taken into account in this campaign [10].

Consideration of Framing and Marketing Techniques

The campaign used the benefits of physical activity and the promotion of health as the core value of the campaign. The interventions were not framed in a deep core value to get the topic of physical activity on the agenda of this population. The way in which the community viewed the behavior of exercise can be impacted greatly by framing through mass media images [11]. This campaign framed physical activity in a value of only health promotion and not surprising the public was not impacted greatly by the intervention [12].

There is a wealth of data that demonstrates the effectiveness of utilizing marketing theory and branding [13]. Consumer research regarding the population to motivate behavior change was not adequately performed in the Stanford Five City Project. This was evidenced by the lack of awareness to utilize framing, agenda setting and marketing techniques.

The framing and presentation of information in the mass media, which is inevitably part of any community wide campaign, can actually systematically effect and impact how the recipients understand the information presented [14]. There is no indication that any mass media research was undertaken or performed to frame the health information in a meaningful way in this intervention. When the community was receiving the health information through the various outlets, there was no dramatic heart wrenching or deeply touching aspect of the campaign that hit people where it matters. The health information was not framed in a compelling way in this campaign. When a person’s heart or soul is impacted, behavior can change. Although in the public health domain in the past, we have not discussed the heart and soul of the public. Advertising has been changing the way consumers purchase by these techniques for decades [11]. I argue that when the community wide campaigns adopt a more compelling and soul touching script of a core value of family, freedom or sex, only then will the population adopt health promoting behaviors such as increasing physical activity.

The Stanford Five project in the early 1980s did little to determine how to alter the people’s behavior. The research that was performed was not integrated in a multilevel system to determine other variables and factors that were preventing the participation of community members.

Consideration of the Environment

The health education intervention occurred in the two communities of Modesto and San Luis Obispo. The intervention did not include a multilevel analysis of contributing factors which discourage physical activity such as availability of a public park or trail system in these communities. Neighborhood features that do not encourage physical activity have been shown to consistently demonstrate an increase body mass index among residents of those neighborhoods [15]. The Stanford Five Project did not put on the agenda sidewalk or park renovation in their intervention. Without access or availability to a park or playground, families are limited in their ability to incorporate physical activity into their lives. In addition, active commuting to school can be an overlooked source for youngster’s activity [16]. The proximity of public parks to residential communities has been associated with physical activity. Parks are common places to exercise and park use and proximity to the park can be predictors of exercise level of the individual [17].

How one interacts with their built environment and the impact of one’s place can directly impact a person’s health [18]. How livable the community is for the population, the availability for walking and bicycling paths and neighborhood design can all impact health promotion [19]. The Stanford Five Project, although determined the community’s attitude toward physical activity with questionnaires, it did not analyze or begin to look at the level of the environment. Whether traffic, lighting or sidewalk maintenance had at all been examined, these urban design factors can be an influencing variable on the physical activity level of the population [20]. In a study by Craig, when university education, income and poverty levels were controlled for, the environment score, which included features of the neighborhood including routes, transportation, visual aspects, safety and crime, was positively associated with walking to work [21]. The environmental barriers to walking were not considered as potentially threatening to physical activity in Modesto and San Luis Obispo in the intervention discussed.

Conclusion

This campaign based off a health belief model approach, framing the behavior change in only a health promotion value and not examining the built environment and other environmental factors has contributed to its woeful results in attempting to improve the physical activity level of the population in these 2 Californian cities. The recent highly publicized increase in obesity rates and health care costs, although have put physical inactivity on the agenda, has not dramatically shifted the approach of what was performed over 20 years ago. Our profession must be innovative in their design and execution of a more compelling way to change the lifestyle of the population to improve physical activity rates. The approach of increasing physical activity in our culture must include policy of environmental approaches, outreach on a more compelling level framed in a way to have impact and must evolve from a health belief model of providing the information and falsely thinking people will change. The Stanford Five City Project took place in the early part of the 1980’s, it is a good warning for a more refined approach to take public health intervention to the next level to produce results and improve the health of the community. Our nation’s population lives in a high risk environment which the public health community must not ignore.

Written Assignment #4

Get Moving or Get Trapped Campaign

Introduction

As discussed, the Stanford Five City Project campaign, a community based informational approach campaign to increase physical activity, has been inadequate and ineffective. The following proposal could solve the previous flaws in the Stanford Five City Project and impact the public’s inactivity and improve the health and wellness of the community. My proposed intervention, ‘Get Moving or Get Trapped’, will be described and could unburden our system with the complications of diseases associated with physical inactivity.

This campaign will be different in a variety of ways. The ‘Get Moving or Get Trapped’ campaign will be modeled on the Diffusion of Innovation Theory rather than the Health Belief Model. The information to increase physical activity will be communicated over time throughout the social system. [22] Various revered members of the community will be delivering the message to increase physical activity for the diffusion to occur more rapidly and most efficiently. The program will not use good health as the core value, but freedom. It will frame physical inactivity as a form of prison, using ad campaigns and propaganda to change people’s perception of how they view walking and biking. This will be combined with a dramatic change in public policy and infrastructure and urban development. Urban planning will be incorporated into the campaign. The community will be beautified with parks, walking and biking paths and a reliable transit system to increase commutes without vehicle use. The mass media approach, diffusing the idea of increasing physical activity via community members, framed in a new way using mass advertising and the change in the built environment combined, will allow for the public to adopt the lifestyle change of increasing activity through walking and biking and be an effective alternative intervention.

Addressing the flaw of the Health Belief Model

The program will not be based on the Health Belief Model, but an alternative model, the Diffusion of Innovation theory. This model allows for a process by which the intervention will be communicated over time through various modes to the public. [22] It will be a social change among members of the public. The message of increasing physical activity will be delivered by high profile members of the community, who are considered a highly credible source. Typically when television ad campaigns are from a trusted source those members of the society are used as an agent for change. [23] In the ‘Get Moving or Get Trapped’ campaign multiple people will participate in the ad campaign on various channels to deliver the message of walking to destinations, increasing activity and changing their physical activity. The information will be diffused to the public and disseminated with this message in a continually reinforcing way.

The message of increasing physical activity delivered by these trusted individuals can be a very efficient jump start to any public health initiative. When a small subset of the population begins to adopt the behavior and increase their activity by walking, the initiative can spread quickly through the social network. [24] This efficiency can be dramatic since opinion leaders in the community can influence the majority of the public and facilitate rapid behavior change through the diffusion process. [25] In my intervention celebrities, community leaders and positive newsworthy individuals will be utilized to deliver the message to increase physical activity. The idea of walking to work, school or errands will be the main message to increase activity. This idea will be diffused rapidly by the opinion leaders since it will be considered better than sitting in your car in traffic. The alternative innovation will appeal to people and be considered a better idea which has shown to increase diffusion of a behavior. [25] The public will therefore increase their level of activity.

Addressing the flaw of Framing and Marketing Techniques

As the message of increased walking will be diffused via the ad campaigns there will be a mass media approach that frames the increase in physical activity not in a value of health, but freedom and alternative lifestyle. The commercials’ will frame driving, being stuck in traffic as being in a prison, a prison of your mind, body and spirit. Walking and/or biking to work, school or the store will be portrayed as a way to exercise your right to be free, your right as an American. The ads will show that sitting in our car is a form of oppression, a way to be trapped. The ‘Get moving or Get Trapped’ campaign will use the framing theory to change how physical activity is viewed which will impact the community. [11]

When the TV stations and radio stations begin to flood the airwaves with this campaign, people will begin to walk to work and school and increase their physical activity without thinking of their health, but their freedom. Their desire to not be trapped, not be stuck, stuck in the car or stuck in a body, will compel and motivate them to incorporate walking into their everyday life. It will become habitual and be adopted as a lifestyle change.

Addressing the flaw of the Environment

As this diffusion of this idea to walk/bike is rapidly catching on, along with the framing of walking as a way to exercise your freedom, the community environment will be examined and modified. In this intervention, ‘Get Moving or Get Trapped’, the community will be studied and areas of improvement will be targeted. Available evidence has demonstrated that if the built environment promotes biking and walking it will help create more active healthier individuals. [26] The access to bike paths, walking trails and recreational facilities has been associated with increases in physical activity levels. [27] The urban design of the neighborhood in the community can impact and influence how active the population will be. [21] In our proposed intervention a task force will study the community and perform focused research on traffic, safety, lighting, sidewalk availability and aesthetic of routes. After this information is gathered, any area without sidewalks or appropriate lighting will be redeveloped for more pedestrian traffic. If safety was determined to be an issue this will be targeted for community development with an increase in police activity patrols on foot and bike. A trail system which will link residential neighborhoods to shopping districts, office parks and any public transportation system available will be implemented.

Additionally a beautification program will be part of the ‘Get Moving or Get Trapped’ campaign. Flowers and trees will be planted in public areas to increase people’s desire to walk and enjoy their environment. The community will want to walk to be part of the growing group of individuals who are using the new sidewalks, benefitting from the changing community aesthetics and therefore their physical activity will increase. The feeling of belonging to a community can motivate individuals to have pride in their neighborhood.

Conclusion

This alternative intervention has addressed the flaws in the previous campaign in a skillful and productive manner. By taking advantage of the diffusion of innovation theory, the idea of changing physical inactivity will catch on like wildfire, especially with the advantage of key opinion leaders in the community. By framing the ad campaign in a value of freedom and not health, the desire to be free and not a prisoner will be more compelling then changing their physical activity for health reasons. Finally, by orchestrating changes to address deficits in the built environment, which detract from walking and biking, the public will change their physical activity level in dramatic ways. As described, the ‘Get Moving or Get Trapped’ campaign could impact a community in a powerful way to shift and alter lifestyles to incorporate walking as a way to increase physical activity and ultimately improve the community’s health.

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Food for Thought: How Public Health has Failed to Combat Obesity – Aanchal Sharma

Oftentimes, small issues that remain untreated can escalate into large scale problems. This is the case with obesity, defined as having a body mass index (BMI) of 30 kg/m² or higher (12). Obesity has now become an epidemic in the United States, where approximately seventy million Americans are obese and more than one in three of all adults and one in five of all children are overweight (3). Many intervention programs have been launched to deal with this public health issue. A number of the programs are aimed at improving the nutritional health of young children so that they will maintain a healthy diet into adulthood. Among these interventions is the implementation of a weight report card system for schoolchildren. This intervention has been proposed in different forms in various states and has met with mixed emotions from both parents and children.

The Weight Report Card

The general concept of the weight report card is to keep parents informed about the nutritional status of their children and to help them teach their children about proper eating habits so that obesity does not becomes an issue. The way the weight report card works is that the school measures the weight and height of all the students and then uses these measurements to calculate their BMI. The BMI is then scaled against what is considered underweight, healthy, overweight, or obese and these finding are sent home to parents just like an academic report card (4). While the goal of the weight report card is similar that of most public health interventions – to stimulate a change in the behavior of both parents and children – it has not been documented to have achieved such success (16). Nevertheless, the weight report cards did increase awareness among parents about the health of their children. The lack of success of the weight report card intervention program can be attributed to issues with stimulating an intention to change behavior, self-efficacy, and framing. Each of these factors has a key impact on how people with react to the intervention and whether or not they will be influenced enough to change their behavior.

Critique 1: The Inability to Create an Intention to Change Behavior

The weight report card does not create an intention to change behavior. Intention to carry out an action or behavior is an important component of the traditional health behavior models (15). Though intention does not always lead to the execution of a behavior, the existence of intention is necessary to have some sort of desire to change a behavior. The weight report cards are intended to stimulate a change in behavior that will lead to healthier lifestyles for children (16). However, by just pointing out the children who are overweight and obese, there is no true motivation to improve health. Furthermore, in cases where programs are offered to the children and the families of the children who have higher BMIs, there is a lack of intention for families to get involved because of the stigma that is associated with these programs. If the school were to offer to all of the schoolchildren a program that would have components aimed at increasing physical fitness and improving eating patterns, children and their families would be more inclined to get involved since the programs would be associated with healthier lifestyles, rather than only helping those who are obese or at risk (6).

In Wyoming, the school district that distributed weight report cards also offered students and their families an opportunity to get involved in a program called the Healthy Kids Club, which included a weekly exercise regime. Rather than having the intention to change their behavior and have their families become more physically active, parents of the children who were offered this program due to their high BMI were offended and outraged. They did not want to subject themselves or their children to a program that implied that their family was incapable of taking care of themselves and of making healthy decisions (6).

In Arkansas, the weight report cards do offer suggestions on ways to improve the quality of health, but there are not concrete examples being offered to parents (2). There is no acknowledgement of the fact that the problem may also be due to parents who are unaware of how to go about changing the behavior of their children. In some cases, parents may realize that there is a problem, but may not know how to approach the situation or may need help in finding a solution. Thus, it is essential to incorporate a component of common ways to improve the nutritional health of individual and this can even be presented through informational sessions at local schools or community centers. These sessions should be offered to any parents who may be interested in the issue and during these sessions, the parents can be informed of ways to motivate their children to be more physically active and improve the quality of their health. The addition of these components into the weight report card program could help create the intention necessary to change behavior among the target population.

Critique 2: The Concept of Self-Efficacy

Many of the traditional health behavior models include the concept of self-efficacy. Self-efficacy can be understood as an individual’s belief as to whether or not he or she can carry out an action or behavior (15). In the case of the weight report cards, it seems as if the intervention completely disregarded the concept of self-efficacy. By pointing out children who are overweight or obese, the intervention creates a division between the children. This can really have a negative effect on the self-esteem of the children who may be more at risk for obesity as compared to their classmates. This can also result in reduced self-efficacy among the children who are more overweight as they may become increasingly self-conscious and place greater blame on themselves for their physical condition. Thus, they may not feel like they are capable of doing anything to improve their physical health or may not be motivated to change their behavior due to the lack of positive reinforcement from the intervention program. In addition to this, children may be more prone to develop unhealthy eating habits or eating disorders due to the stigma that is associated with getting a high BMI on their weight report card (26).

Self-efficacy is an essential mediating mechanism in enhancing the understanding of the treatment of those who are overweight and obese (27). Research that assessed the importance of self-efficacy has shown that treatment programs for weight are incomplete without this component of the model (4). Weight loss can only be achieved when an individual makes an effort and feels like he or she can achieve successful results by altering eating patterns and increasing physical activity. Personal health care and management requires a drive that comes from within the individual, which includes a desire to change behavior and the confidence that he or she is capable of changing the behavior. Self-efficacy has a great impact on self-management and is a key component on one’s initiative to change behavior and promote healthy living (7). Thus, without the component of self-efficacy, it becomes difficult to implement a program to successfully help with the obesity epidemic.

Critique 3: Framing Obese Children as Failures

One alternative model for public health intervention is the framing theory. The framing theory is based on the principle that if you frame something the right way, you can change the mentality of a group and influence a change in behavior by appealing to the core values of a group (15). Proponents of the weight report card program may argue that they are trying to appeal to the value of good health; however, there is a stigma attached to a report card. A bad grade on a report card can really harm the self-esteem of children and may make them feel like failures. The weight report card does not take external factors into consideration. It implies that it is the child’s fault that he or she is overweight or obese. Like self-efficacy, self-esteem is a key factor to consider when assessing weight report cards (19). Obese children with decreasing levels of self-esteem demonstrate emotional problems and engage in high-risk behaviors, such as smoking or consuming alcohol (28). They are generally more disengaged and tend to exhibit signs of sadness, loneliness, and even depression. Research has also shown that middle school females who perceive themselves as overweight are significantly more likely to be associated with suicidal thoughts and actions, and for middle school males, perceptions of being underweight or overweight were significantly linked to suicidal thoughts and actions (29). If the weight report cards are issued in schools and boys and girls are being told that they are overweight or obese, there is a direct negative effect on their mental health and self-esteem. Thus, the weight report cards need to be reconstructed so that they are not as harmful to the self-esteem of schoolchildren.

Generally, school grades are meant to reflect the caliber of a student’s performance in class and are an assessment of their ability to do well both in class and on exams. Similarly, the weight grade can be associated with poor eating habits and lack of physical activity, framing the problem as a result of poor performance on the part of the child. This may be the case for some children; however, there are often biological issues that can result in higher BMIs for certain children, such as slower metabolism or a problem with the stomach, liver, or kidneys. Furthermore, BMI does not take body composition into consideration and therefore can misclassify someone who is healthy with greater muscle mass as overweight. The American Academy of Pediatrics conducted a study that shows that if one parent is obese, the odds ratio is approximately three times the normal risk for that child to become obese in adulthood. If both parents are obese, the risk increases to ten times the normal risk (20). The weight report cards do not account for these issues. Thus, the way the intervention is framed does not have a sympathetic tone; instead, it is rather critical and places the blame on the individual and his or her family and lifestyle.

Framing interventions in a particular way has a direct impact on the emotional response of an individual to the information being presented (13). The emotional response of an individual will influence how they will approach the intervention and whether or not they will be open to the information being presented to them. It is also important to frame the issue of obesity in terms of external environmental and societal factors in addition to the personal factors that the weight report card focuses on (14). For example, availability of healthy foods and socioeconomic status may be linked with why certain communities have a greater percentage of overweight and obese people. Each of these aspects of framing can make a great difference in the success rate of the intervention program.

Food for Thought: Where Do We Go from Here?

Even though the weight report cards are not the key intervention to help reduce obesity among schoolchildren in the United States, it still has strong elements that can be further developed to create a more effective public health program. The weight report card was effective in creating raised awareness about the issue of obesity (16, 19). This is a key aspect to creating interventions that will have successful results. Increasing awareness about an issue increases the perceived susceptibility and perceived severity of an individual towards a problem (15). However, this is not enough to create an intention to change behavior.

A better suited intervention program would stem off of the idea of using school as a medium for assessing the health of the children. Instead of alienating children who have a BMI that categorizes them as overweight or obese, the school administration should educate all the children about the importance of proper eating habits and physical fitness. Classroom presentations, healthier lunch options, and more physical activities for children to participate in are all components of making the school environment more conducive towards providing children with outlets for improving the quality of their health (25). By educating children about how they can better take care of themselves and improve their own health, there will be less of a stigmatization towards children who may be at risk for obesity and there will be more positive reinforcement to encourage children to change their behaviors.

The weight report card allows public health officials to realize how physical health is a sensitive topic that needs to be dealt with using discretion. Placing blame and framing the problem in a way that makes people feel guilty will only result in disheartened or angered individuals. Society and media is obsessed with body image and there is a constant emphasis placed on being skinny and how that is associated with beauty. Schoolchildren are aware of this image and are able to draw correlations between weight and lifestyle. Thus, telling children that they are overweight is not enough to stimulate the change in behavior that will lead to weight loss. The interventions laid out by public health officials should focus more on providing solutions rather than pointing out who is at need for the most help, especially since schoolchildren are probably aware of their health status in terms of weight. Such solutions can include programs that focus on better eating patterns and ways to increase physical activity to promote healthy lifestyles. By teaching children about how to adequately take care of themselves and how to make healthy choices, public health officials can lower the incidence of obesity among this population as they get older and eventually diminish this epidemic from the American population.

The LEAP Ahead Program: Live Happily, Eat Healthily, Actively Learn, and be Physically Fit

An intervention that would help reduce the incidence of childhood obesity would be a program that addresses the issue, while constructively motivating children to live healthily. The LEAP Ahead program is meant to motivate children to maintain healthy lifestyles without feeling uncomfortable and ostracized. The various components of the program address public health issues, while incorporating social and environmental factors. Furthermore, when working with children, it is essential to make the program appealing in terms of enjoyment and simplicity. The LEAP Ahead program has components that include multiple areas of the school and range from classroom lessons and exercises to more rigorous physical education programs and more nutritious meal options in the cafeterias. Similar to the LEAP Ahead program is the Planet Health Intervention, which was successfully applied in school settings and provides evidence that school-based approaches are effective in preventing or reducing obesity among schoolchildren (30). The LEAP Ahead Program is meant to be implemented at the school level so that its components fit into the academic curriculum and the physical education and recreational departments. This intervention is intended to enhance the school environment and make it more conducive to healthy living.

Live Happily: Promoting Self-Efficacy

The Live Happily part of the intervention promotes positive self images and boosts the self-esteem of young children. As a supplement to the academic curriculum in the schools, this program will have students do leadership building workshops, teamwork exercises, and personal discovery projects. Each week, teachers will dedicate one part of their lesson to working with their students and helping them build up character and self-esteem. Activities will include creative writing, leadership seminars, and trust building games. Health models look at communities as experts and in this case, it is the schoolchildren that understand what appeals to them and what influences their decisions (15). Giving them the right to make their own decisions and engage in the LEAP Ahead program with their peers will lead to a higher percentage of schoolchildren making positive decisions to change their behavior. A result of this part of the intervention will be the creation of self-efficacy among the schoolchildren.

Promoting a positive self image and creating self-efficacy among schoolchildren is a key component of this intervention because it is the foundation required to motivate a change in behavior (27). Empowering young children and making them feel like they have the ability to make positive health decisions makes the other components of this intervention more feasible. With self-efficacy in place, schoolchildren can make decisions about improving their dietary intake and physical fitness (4). They will feel empowered and realize that they are capable of taking on challenges and living happy and healthy lives.

Eat Healthily: Framing Obesity in a Way that Stimulates Balanced Diets

Using the school lunch program, the Eat Healthily component of the intervention can have the school cafeterias offer well balanced meals to the students during lunch time. One major component of this will be to eliminate sugar sweetened beverages from the menu, especially since significant data suggests that these drinks are linked to obesity in children (33). Instead, there can be an increased emphasis on offering high quality food that is both appetizing and nutritious. Students will be each asked to keep a food journal, students will record what they eat and when both during and outside the school day. Based on the nutritional value and the appropriate quantity, which would be determined off the daily 2,000 calorie diet, students will receive points for healthy eating. The scoring will range from 0-5000 calories. Points will not be given and may even be deducted for students with too few or too many calories. At the end of each month, any student with a score between 1500-2500 will receive a prize as well as a commendation from the principal. Students consistently performing well will be given a special award at the end of the academic year.

This intervention frames obesity as a challenge. Students are challenged to eat healthy food and no child is framed to be a failure if they do not have the recommended calorie intake. Instead, they are invited to participate in the challenge the following month. Since the target population is schoolchildren, the intervention is framed in a way that they will be receptive to. Most children are inspired by challenges and become competitive when asked to complete a task with their peers (30). Unlike the Weight Report Cards, this LEAP Ahead intervention is aimed at empowering children without explicitly segregating children by weight. This is a key issue as weight discrimination has been noted to be as harmful as racial discrimination among individuals (34). Racism has implications of causing disparities in health care and causes stress among individuals that lead to more complicated medical issues (42). Similarly, the stigma and stress associated with weight discrimination can lead to a faster onset of weight related health disorders as well as more sever cases of obesity.

Actively Learn: Create an Intention to Change Behavior

The way interventions can create an intention to change behavior is by addressing the perceived susceptibility and perceived severity related to a behavior that is meant to be changed (15). For children, perceived susceptibility may not be as apparent since they may not be aware of the health issues associated with poor diet and obesity. It is essential to educate schoolchildren about risks associated with unhealthy eating patterns and lack of exercise. By going over the health risks and impairments associated with obesity, schoolchildren will be more inclined to want to take care of themselves since they will better understand the perceived severity associated with unhealthy lifestyles. As a result, they will be more receptive toward the LEAP Ahead program, which provides the dietary and physical activity aspects that will be emphasized in this part of the intervention. The Actively Learn part of the intervention will become a component of the health studies already built into the curriculum. Teachers will go over what it means to be obese and how students can avoid this health issue and maintain healthy lives.

Oftentimes, television is a method used by public health interventions to target youth and adolescent populations (38). However, it is very difficult to create an intention to change the behavior of watching television to becoming more active by simply airing something on the television for a few seconds (39). Instead, interventions created to target obesity must be consistent with the core values of being healthy and should provide visible and tangible alternatives to the sedentary lifestyle adopted by a majority of American youth. Evidence of this is provided by the Eat Well and Keep Moving Program, which effectively improved the dietary intake and reduced the amount of television watched by schoolchildren (40). The LEAP Ahead program incorporates this educational component of the program to not only raise awareness, but to also provide ready to use solutions to the problem.

Be Physically Fit: Framing Obesity in a Way that Stimulates Exercise

One of the major goals of the LEAP Ahead program is to make schoolchildren physically fit. The Be Physically Fit component of the intervention is meant to go hand in hand with the physical education department in the school. The school will be asked to implement a fitness program that consists of fun activities that target the major body systems, such as games that promote cardiovascular exercises. The activities will be varied and offered in random orders so that they keep the schoolchildren engaged and allow them to have fun while exercising. Unlike the Weight Report Cards, which created programs just for the obese children, the LEAP Ahead intervention offers this program to all of the students and is inclusive of all children. Thus, obesity is not being framed as problem for only a fraction of the children; instead, obesity is framed as a problem that everyone may be at risk for if they do not participate in exercises to improve their fitness.

Having this intervention in a school based setting allows students to embrace the program in a setting they are familiar with. When dealing with weight, framing this issue is very important. Since the topic is highly sensitive, it must be portrayed in a way that is respectful of emotions; if not, it can lead to unhealthy and disordered eating patterns among children. A study done by the Division of Adolescent and Young Adult Medicine at the Children's Hospital in Boston provided evidence that school-based interventions can both prevent obesity and reduce the incidence of eating disorders (38). In addition to this, making the intervention become part of the school day as a supplement to either recess or physical education reduces stigma attached to participating in fitness routines; instead, it transforms into something fun that schoolchildren want to engage in with their friends.

Weight Report Cards vs. LEAP Ahead

Although Weight Report Cards and LEAP Ahead are both interventions that are school-based and aimed at preventing obesity, they have key differences in their layout and implementation. Many of the successful behavior change models in public health have the component of self-efficacy (15). Studies have also shown that self-efficacy is needed to ensure the success of weight loss and healthy lifestyle programs (4). The LEAP Ahead program makes schoolchildren feel like they are capable to make choices that will lead to healthy lifestyles. Further, the promotion of self-efficacy is essential for the other components of the program, while require the student to make the right choices and take on the challenge to be healthy and physically fit. In addition to this, behavior change models state that there must be an intention to change before an individual changes his/her behavior. Also, other models show how social factors also impact whether or not an action will be carried out (15). Unlike the Weight Report Cards, the LEAP Ahead program goes beyond singling out obese children and challenges all of the students to excel in each of the components of the intervention without attaching any stigma to the participants. Finally, the Weight Report Cards had a major flaw as framing the problem of obesity as the individual’s fault and making the obese children feel like failures (5). The LEAP Ahead program frames obesity as a problem that all of the schoolchildren are challenged to overcome by eating balanced diets, exercising regularly, and making healthy life decisions. Thus, with each of these improvements, the LEAP Ahead program is expected to have a greater success rate than the Weight Report Cards.

Conclusion

The problem of obesity affects people of all ages throughout the United States. There have been many interventions laid out to combat this problem. However, many of these interventions have not proven to be successful due to limitations in their layouts. Thus, new interventions must be constructed that take social and environmental factors into consideration and create programs that motivate participation among communities. The Weight Report Cards made an effort to reduce the incidence of obesity; however, due to its drawbacks, namely failing to take social theories into consideration, it was not a successful intervention. The LEAP Ahead program addresses all of these shortcomings and is structured so that schoolchildren become empowered to make healthy life decisions. Similar multi-faceted school-based interventions are feasible for implementation in public schools can lead to increased awareness and can reduce the cases of obesity (35).
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Why the Shape up Somerville community intervention to decrease childhood obesity is flawed - Andrea Crete

A Massachusetts, community-based, environmental change intervention called “Shape up Somerville” (SUS) intended to prevent obesity in culturally diverse, early elementary school children. This program was designed by researchers from the Friedman School of Nutrition Science and Policy at Tufts University and the Tufts University School of Medicine in collaboration with the Somerville community(1).

This program used a range of initiatives designed to provide and promote healthy eating options at local restaurants and in the elementary school cafeteria, and physical activity among the elementary school-aged children in Somerville, MA. The elementary school cafeteria offered healthier foods, developed more healthful recipes, and promoted the consumption of new foods through interactive education programs. New after school curriculum involved creative cooking classes, yoga, games, and field trips to farms to teach the children how food is grown and to appreciate where it comes from. New in class curriculum included daily “cool moves” sessions, weekly nutrition and physical activity lessons, and fun and healthy giveaways. Not only was the elementary school intimately involved in the program, but the parents of the children and Somerville community participated as well. Parents were encouraged to get involved in the after school and community events. Forums were made and sent to the different language communities in Somerville along with news letters containing healthy tips, fitness contests, and coupons for healthy foods. The local restaurants also collaborated with the program by developing an “SUS” stamp of approval indicating that the restaurant offers healthy menu options (1).

A BMI-z-score was used as a measure to report weight gain or loss during this one year program. The results of this program were a one pound reduction in weight gain on average over eight months for an eight year old child (1).

This paper will provide three arguments as to why this intervention is flawed.

Argument 1. BMI-z-score cards lower self esteem, label children, and increase BMI.

It is believed that childhood obesity is strongly associated with psychosocial morbidity. Psychosocial effects of obese children can include social isolation, discrimination, and peer problems. This can lead to increased rates of sadness, lower self esteem, loneliness, and nervousness by adolescence (2). A stronger association between body fat and self esteem is generally reported when body esteem or body image is the primary aspect of self esteem being measured (2).

This may be the case with using BMI-z-scores in the elementary children. The scores place children in categories of normal (non overweight), overweight or obese. Longitudinal studies have shown greater decreases in self esteem for obese children than non obese (2).

In the study done by Hesketh et.al, a temporal relationship was shown between self esteem and BMI in a cohort of young children tracked for three years from early to late elementary school. At the beginning of the study and at the end, children’s height and weight were measured. BMI was calculated and transformed to z-scores. Parents of the children completed a self esteem scale at the beginning and end of the study for the children. Low self esteem scores were defined as those falling below the 15^th percentile (2).

Results of the self esteem scores and BMI indicated that higher BMI scores (at the beginning of the study) predicted poorer self esteem scores at the end of the study. Children classified as overweight or obese in the beginning had lower self esteem scores at the end of the study. Self esteem and BMI are clearly related. BMI may play an important role in the development of lower self esteem experienced by many overweight and obese elementary school children placing them at risk for psychosocial effects.

According to the Stigma or “labeling” theory in public health, if these elementary school children are labeled as obese or overweight according to their BMI z-scores, the children will actually change their behavior to fit their label. This stigma becomes a barrier to behavior change thereby increasing BMI and contributing to the childhood obesity epidemic.

Argument 2. Other causes of childhood obesity are ignored.

Using the health belief model by providing and promoting these two environmental and community changes it is assumed the children will make the decision to eat healthy and exercise. Especially when their BMI z-score indicates they are overweight or obese. This gives the child a perceived susceptibility that they are at risk and the decision to make a healthful change will follow. The health belief model has proved ineffective in many public health interventions.

The Shape up Somerville intervention only incorporates diet and physical activity as a means to lower BMI among the elementary school children in the community. According to Robinson, most prevention programs that specifically aim to reduce fat and energy intake and increase physical activity have been ineffective at changing body fatness (3).

Television viewing has been speculated to be one of the causes of obesity among children. American children spend more hours watching television and playing video games than they do anything else besides sleep. This may lead to reduced physical activity and increased dietary energy intake either as a result of television food advertisements or during viewing (3).

Robinson developed an intervention designed to decrease media use alone without promoting active behaviors as replacements. The intervention, based on Bandura’s social cognitive theory, incorporated self monitoring lessons for the elementary children to report on regarding total television, and video game use to reduce the time spent in these activities. Lessons were followed by a television turnoff, where the children were challenged to watch no television, video tapes, or video games for ten days. The children were also asked to report the amount of food they ate during the day, and while watching television. BMI was measured at the beginning of the study and at the end to determine body fat loss or gain from the intervention (3).

Robinson found that compared with controls, children in the intervention group significantly reduced the number of meals they reportedly ate in front of the television. Compared with controls, the children in the intervention also had statistically significant decreases in BMI, triceps skinfold thickness, waist circumference, and waist to hip ratio. Robinson concluded that reducing television, video tape and video game use may be a promising, population based approach to prevent childhood obesity (3).

If SUS changes the environment the children live in by promoting physical activity and healthful food options, other factors including behavioral changes (tv viewing and video games) need to change as well. Children’s BMI may still increase if television watching and video games are not reduced.

Argument 3. Social Inequalities of obese children and their families in the community are ignored.

The Institute of Medicine reported that on assessing progress in childhood obesity prevention, some risk factors are relatively everywhere across all settings, but more concentrated in low-income communities of color (4). In schools, participation among female, racial/ethnic minority and lower income students are low for varsity and intramural sports. School SES and racial/ethnic composition are inversely correlated with BMI even after controlling for individual race/ethnicity and SES (4).

Crime rates and perceptions of danger are higher in low income neighborhoods. Unsafe neighborhoods do not attract walking to school and playing outdoors after school, at home, or in parks. This not only displaces physical activity among children, but also promotes increases in television viewing and video games. Lower income families with a high cost for housing and other living expenses may have little money left over to buy healthful foods thereby relying on inexpensive, but high calorie foods. Isolated environmental changes cannot be expected to break longstanding eating and physical activity patterns among populations undergoing ecologic stress who have adapted to their circumstances (4). The African American ethnicity for example incorporates high fat and high calorie “soul foods” into their diet as a positive connotation to help define their culture. Health advice coming from the majority culture may not be met with trust, generalizing from past experiences with discrimination (4). The SUS intervention may not reach the lower SES families of some obese children. Nothing in the intervention addressed how these families would be integrated into the program. The intervention to improve diet and increase physical activity in Somerville may be too weak or insufficiently focused to have an affect on the obesity epidemic in African American, Latino or Native American children.

In conclusion, the Shape up Somerville intervention to decrease childhood obesity by promoting a healthful diet and physical activity rich environment fails to address issues that may be contributing to the obesity epidemic of children. Using BMI z-scores have shown to cause low self esteem among some children who are labeled as obese or overweight, and have increased their BMI as a result.

Behavioral/life style changes such as watching less television and playing less video games have shown to decrease BMI and also decrease food consumption. The SUS intervention only strives to increase healthful food consumption and physical activity, failing to address these other causes of obesity including the lower SES families and how to incorporate them into the intervention.

Counter Proposals for the Shape Up Somerville Community Intervention –

Andrea Crete

The Shape Up Somerville intervention to decrease childhood obesity by promoting a healthful diet and increasing physical activity fails to address other issues that may be contributing to the obesity epidemic of children. Using BMI scores to label children as obese or non obese; solely focusing on diet and exercise; and failing to incorporate lower SES families; are some of the flaws that are addressed in this paper. This paper will discuss a new intervention that improves upon the Shape Up Somerville Intervention by developing counter proposals for the flaws mentioned in the previous paper.

Counter Proposal for Argument 1.

Studies have shown that children’s BMI can actually increase based on their scores. A BMI that labels a child as obese lowers that child’s self esteem which can eventually lead to an increase in BMI over the years to come. Self esteem and BMI are clearly related. BMI may play an important role in the development of lower self esteem experienced by many overweight and obese children, placing them at risk for psychosocial effects (2). Although BMI is a measurement currently used for assessing the growth of children, it is only a rough estimate of risk for overweight. For an individual child, BMI is likely to change over time in regards to changes in height and weight as the child’s muscle mass and stage of puberty change accordingly. There are also some children who have a high BMI that are actually not at risk of having too much body fat, while others with lower BMI have more body fat and are at risk. BMI can also give a false positive reading for obesity for some children with a high BMI that do not have high body fat (6). These are some of the inaccuracies of BMI scores.

I propose that the Somerville intervention dismiss the idea of using BMI to label a child as obese or non obese, putting them in a category that is subjected to lowering self esteem and hence defeating the purpose of lowering BMI. Developing an intervention that focuses on the importance of physical activity and healthy eating to lose weight and be healthier will be more effective in lowering BMI. Instead of using BMI as a means to measure weight loss and program effectiveness, I suggest that children’s weight be measured using a scale in the nurses’ office. The child’s weight can be measured twice a month for the length of the intervention. The weight loss or gained can be reported to the parents. Rewards are given for child participation in the program, not whether they lost weight or not.

This improvement avoids stigma or “labeling” theory commonly used in public health and in the Somerville intervention by using BMI scores and categories.

Counter Proposal for Argument 2.

The Shape up Somerville Intervention only incorporates diet and physical activity as a means to lower BMI among the elementary school children in the community. Programs and interventions that primarily aim to reduce fat and energy intake and increase physical activity have been ineffective at changing body fatness (3). Due to the fact that American children spend many hours watching television and playing video games, this may lead to reduced physical activity and increased dietary energy intake either as a result of television food advertisements or during viewing (3). I propose that parents of the children in the Shape Up Somerville intervention monitor and reduce the amount of television used (tv watched and video games played) to further increase the effectiveness of the intervention. Community and after school activities would aim to increase children and parent participation to limit the time children spend home with the television.

Interventions have been developed to decrease media use alone without promoting physical activity as a replacement. These studies have shown that reducing television, video tape, and video game use may be a promising, population based approach to prevent childhood obesity (3).

Counter Proposal for Argument 3.

The Shape Up Somerville intervention may not be effective in reaching the lower SES families in some obese children. Nothing in the intervention addressed how these families would be integrated into the program. Studies have shown that crime rates and individual perceptions of danger are higher in low income neighborhoods. Families that have a lower SES and a higher cost of living tend to buy less healthful foods which are lower in cost. Unsafe neighborhoods deter walking to school and playing outdoors or in parks. This increases television viewing and video games among children (4). Numerous studies have associated lower SES with poorer health. Neighborhood stressors such as exposure to violence and the physical condition of the neighborhood are also linked to SES and may affect physical health (5). Social networks in a neighborhood may define the level of trust and norms of cooperation and behavior thus also relating to both SES and health. Childhood health problems such as obesity have been documented as related to low SES (5).

I propose neighborhood activities be designed to get the different neighborhoods involved including the lower SES and work together. A feeling of being part of the community may increase moral in lower SES neighborhoods. I would develop a program that would make unsafe neighborhoods safer by setting up neighborhood committee’s that would work together in assessing their neighborhoods’ needs and improvements. Residents in the neighborhoods can collaborate to make improvements, do some landscaping/gardening to make the appearance better, help those in need with fixing up homes and yards, and developing activities for the children to do outdoors to increase physical fitness.

This would ideally change the perceptions of the neighborhoods being unsafe and promote activities outdoors, potentially decreasing child obesity among lower SES families.

Conclusion

Using a scale to measure children’s weight bi-monthly is a more effective way of lowering BMI in children as opposed to using BMI z scores which can lead to lowered self esteem and an actual increase in BMI. Decreasing the amount of television viewed and video games played along with increasing physical fitness and healthful eating can also decrease body fat in children. Lower SES families and neighborhoods need to be involved in community events and activities. Making neighborhoods safer, cleaner and unified may help change some of the negative perspectives residents have about their neighborhoods and increase child outdoor activities in those neighborhoods. An intervention that incorporates the above would be a more effective approach to decreasing childhood obesity.

References:

1) Fennelly, Christine. Childhood Obesity Intervention Shows Promising Results. Tufts University, Health Sciences. May 10, 2007.

2) Hesketh et.al. Body mass index and parent-reported self esteem in elementary school children: evidence for a causal relationship. International Journal of Obesity (2004) 28, 1233-1237.

3) Robinson, N. Thomas. Reducing Children’s Television Viewing to Prevent Obesity. JAMA, October 27, 1999-vol 282. No. 16, 1561-1566.

4) Yancey, K. Antronette et.al. Bridging the Gap: Understanding the Structure of Social Inequalities in Childhood Obesity. American Journal of Preventive Medicine (2007); 33 (4S) S172-S174.

5) Chen, Edith and Peterson, Laurel. Neighborhood, Family, and Subjective Socioeconomic Status: How Do They Relate to Adolescent Health? Healthy Psychology (2006); vol. 25 No. 6, 704-714

6) Crawford et.al. Weighing the Risks and Benefits of BMI Reporting in the School Setting. Center for Weight and Health. http://nature.berkeley.edu/cwh/PDFs/BMI_report_cards.pdf