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.

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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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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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