A Critique of the Screen for Life Colorectal Cancer Screening Campaign – Jeremy Hetzel

Introduction
Colorectal cancer is the second leading cause of cancer-related death in the United States. In 2008, an estimated 148,000 individuals were diagnosed with colorectal cancer and 50,000 individuals died from colorectal cancer.(1) Colorectal cancer is also preventable through screening interventions such as fecal occult blood test, flexible sigmoidoscopy, and colonoscopy. The United States Preventive Services Task Force currently recommends these screening interventions for all men and women over the age of 50.(2) However, less than half of the US population has received proper screening.(3) Clearly, public health interventions are needed to encourage screening behavior and subsequently reduce cancer related morbidity and mortality. In this paper, an existing public health campaign, the Screen for Life campaign, will first be critiqued. A new campaign, the Polyp Man campaign, will then be proposed to improve upon the shortcomings of the Screen for Life campaign.
In 1999, the Screen for Life campaign was launched by the Center for Disease Control and Prevention, the Center for Medicare and Medicaid Services, and the National Cancer Institute. The campaign is based extensive literature reviews, informant interviews, focus groups, conversations with medical experts, and guidance from a professional communications firm. The goal of the campaign is to raise awareness for colorectal cancer screening among all Americans over the age of 50, with a special focus on African Americans, Hispanics, Alaska Natives, and Medicare beneficiaries. The campaign consists of public service announcements via television and radio, as well as posters, brochures, fact sheets, and print advertisements.(4)
The Screen for Life campaign is grounded theoretically in the Health Belief Model. Subsequently, it shares benefits and flaws common to all Health Belief Model campaigns. The Health Belief Model posits that behavior is motivated by the balance of four factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action. If the perceived benefits and susceptibility outweigh the perceived An individual weighs his perceptions of a behavior to formulate an intention regarding the behavior. The probability that the individual will act on his intention is dependent on the occurrence of an external event to motivate the action, known as a cue to action, and the individual’s belief in his ability to successfully change his behavior, known as self-efficacy(5; 6) The intention of the Screen for Life campaign is to alter individuals’ perceptions of colorectal cancer screening to minimize the perceived barriers and maximize the perceived benefits, severity, and susceptibility. The campaign also offers cues to action and attempts to increase individuals’ self-efficacy.
The campaign assumes sufficient causes
A fundamental assumption of the Screen for Life campaign is that insufficient knowledge of colorectal cancer and colorectal cancer screening causes a reduction in the probability that an individual will undergo screening. This assumption is well supported by previous studies. In a review of the literature, Subramanian and colleagues(7) found six studies that reported a statistically significant association between knowledge of prevention strategies and adherence to screening guidelines, and only one studied failed to find such an association.(8) Additionally, subjects who believed that screening was effective were more likely to undergo screening, and subjects with a fear of cancer or belief that cancer is incurable were less likely to undergo screening.(5; 9) The Screen for Life campaign subsequently aims to better the public’s knowledge of colorectal cancer screening, which it assumes will cause an increase in screening adherence.
The assumption of the Screen for Life campaign is flawed because it implicitly treats colorectal cancer screening knowledge as a sufficient cause of colorectal cancer screening adherence, when it is instead a component cause. This subtle yet important distinction is illustrated in Rothman’s heuristic model of causal inference,(10) which will be referred to here as the Causal Pie model. The basis of the Causal Pie model is that an outcome may be caused by the combined effect of many individual causes. Individual causes are named ‘composite causes’. Any combination of composite causes that results in an outcome is named a ‘sufficient cause’.
To demonstrate, three sufficient causes of colorectal cancer screening adherence will be defined. Sufficient Cause A is composed of colorectal cancer screening knowledge and physician recommendation. Sufficient Cause B is composed of colorectal cancer screening knowledge and socioeconomic status. Sufficient Cause C is composed of physician recommendation and socioeconomic status. In this example, perfectly educating the population of the benefits of colorectal cancer screening will result in increased adherence only if physician recommendation or a threshold socioeconomic status is also present. Adherence may also be increased by increasing physician recommendation and socioeconomic status without any increase in colorectal cancer screening knowledge. The important lesson is that increasing knowledge will complete a sufficient cause in some individuals but not all individuals.
There is reason to suspect that the population’s knowledge of colorectal cancer screening will reach a level where the causal component of knowledge will be satisfied for all individuals. Increasing the knowledge past this threshold will have no effect on adherence rates, since all non-adhering individuals will be lacking a different component cause. Jorgensen and colleagues admit that in 1998, when the four year formative focus group research for the Screen for Life campaign began, participants “showed a lack of knowledge and skepticism about the incidence of the disease, combined with discomfort discussing it”. During later years “participants were generally more aware of colorectal cancer and appeared more comfortable talking about the disease and the need for screening”.(4) This is evidence that the public awareness of colorectal cancer was already increasing prior to the launch of the campaign.
Many other component causes for colorectal cancer screening adherence have been identified. Physician recommendation of screening was always found to be associated with adherence in Subramanian and colleagues’ review of the literature.(7) In one study, subjects were 12 times more likely to comply with screening guidelines if recommended by their physician.(11) Other potential component causes include continuity of care, education, health insurance, sex, smoking, family history of colorectal cancer, and race.(12) Future campaigns could improve upon the Screen for Life campaign by targeting these additional component causes.
The campaign is urban-centric
Jorgensen and colleagues explicitly state that racial minorities were a target audience of the Screen for Life campaign. Televised, radio, and print media were tailored to African-American, Hispanic, and Native Alaskan sub-populations after extensive focus group research.(4) However, the campaign has been criticized for being urban-centric and ignoring rural populations. In a focus group study, Appalachian residents aged 50 years or more reported that the actors in the Screen for Life advertisements were too old, appeared less active and healthy than the study participants, and lacked simple eye-catching messages.(13)
Campo and colleagues conducted a series of studies in rural Appalachia to monitor the effectiveness of the Screen for Life campaign and assess discrepancies in the campaign aims and needs of individuals living in rural Appalachia.(13) Appalachia residents are particularly susceptible to reduced colorectal cancer screening adherence due to reduced access to health care facilities, economic vulnerability, and reduced health care coverage.(14) A quasiexperimental trial comparing the effect of the Screen for Life education materials to unexposed controls in Appalachia demonstrated that individuals exposed to the Screen for Life education materials were no more likely than the unexposed individuals to plan to undergo screening or to understand the risks of colorectal cancer and benefits of screening.(13) A survey of 905 individuals revealed that less than 50% could correctly identify the recommended age to begin colorectal screening surveillance, age 50. In a 2007 study of 356 individuals at a primary care facility in Boston, 74% correctly identified the recommended age to begin surveillance.(12)
The Screen for Life campaign is an evidence based public health campaign, however it is based on racially diverse yet regionally homogenous focus group research. The educational materials of the campaign were developed to appeal to urban individuals, however the campaign fails to address the complex interactions between cultural, sociopolitical, and economic conditions across the United States, especially in rural areas.(15)
The campaign assumes behavior follows intent
The failure of the Screen for Life campaign to modify the behavior of colorectal cancer screening in the Appalachian cohort is also illustrative of a third flaw common to all Health Belief Model Interventions: behavior does not follow from reasoned intent.(16) An assumption of the Screen for Life campaign, and all Health Belief Model campaigns, is that individuals intending to undergo screening actually will undergo screening. Although being exposed to the logical argument that colorectal cancer screening reduces the risk of morbidity and mortality, Appalachian residents reported being more concerned that the Screen for Life advertisements depicted subjects who did not look like Appalachians and used messages that were neither simple nor eye-catching.(13)
A study conducted by Vanderpool and colleagues provides anecdotal evidence that the increased awareness of colorectal cancer screening does not yield increased adherence. The study interviewed directors of the community based Appalachia Cancer Network, a National Cancer Institute funded special populations network created to address cancer disparities in Appalachia. The Appalachia Cancer Network was responsible for disseminating television, radio, and print media at the local community level. The authors concluded that the aims of the Screen for Life campaign were not well executed at the community level. The authors reported that the sentiments of the directors were summarized by the following quote, “Screen for Life is a great idea. It's good for national awareness, but it needs another level to actually impact CRC screening”.(17) The director acknowledges that the campaign succeeds at creating a national awareness of colorectal cancer screening, however this does not result in changed behavior at the local level. Further evidence for a lack of change in behavior resulting from the increased awareness is difficult to assess given a lack of longitudinal studies assessing both knowledge of screening and screening rates. However, the most recent estimates of screening adherence alone in the United States from the Behavioral Risk Factor Surveillance System. The overall adherence has risen slightly from 56.8% in 2004 to 60.8% in 2006.(18) While a 4% rise is a change in the right direction, it is unknown what proportion if any of the change is attributable to the Screen for Life campaign.
Conclusion
The Screen for Life campaign is a Health Belief Model based public health intervention. As such, it assumes that providing individuals with rational evidence in support of screening behavior will result in an increase in adherence behavior. Theory suggests that this logic is flawed, and anecdotal reports from the directors distributing the material suggest that there is a disconnect between national awareness and local adherence. Furthermore, the campaign is urban-centric, having been developed in urban focus groups, and fails to address the complex interactions between cultural, sociopolitical, and economic conditions in differing regions. Finally, by only addressing the knowledge deficit of colorectal cancer screening, the campaign focuses on only one component cause of screening adherence. Failure to incorporate other component causes into future public health interventions may result in stagnation of the screening rate.

Proposal for the Polyp Man Campaign
In 1999, the Screen for Life campaign was launched by the Center for Disease Control and Prevention, the Center for Medicare and Medicaid Services, and the National Cancer Institute, to improve screening adherence. Although based on substantial research, the campaign suffers fundamental flaws which are addressed in an accompanying article. Here, I propose an alternative campaign, named the Polyp Man campaign, which is a national and regional advertising campaign aimed multiple barriers to screening and sensitive to regional contextualization. Common to the advertisements is an anthropomorphized polyp attempting to interfere with the daily lives of hard working Americans, only to be squashed, allowing the Americans to return to their daily, jovial activities. The Polyp Man campaign is inspired from the American Cancer Society campaign of the same name, but much expanded in scope.4 A brief example of a Polyp Man advertisement is provided to facilitate discussion.
A family is sitting around the television watching the show Jeopardy! Included are a grandmother, grandfather, father, mother, young boy, and a toddler-aged girl sitting in a highchair. The family is laughing and carrying on. The Final Jeopardy music begins to play. A man in a polyp suit, Polyp Man, slowly waddles through the door towards the grandmother. He resembles Curly from the Three Stooges. The laughter softens as Polyp Man approaches the grandmother, and the laughter stops as he begins to pull the grandmother and her chair away from the family. The family begins glancing at each other nervously as the grandmother is pulled farther away. As the third to last note in the Final Jeopardy song sounds, the toddler-aged girl knocks Polyp Man on the head with a toy, resulting in a loud ‘boink’. Polyp Man reacts in a fashion similar to the Three Stooges and runs away, leaving the grandmother behind. The toddler girl giggles, and the family resumes laughing and carrying on. The commercial closes with Alex Trebek saying, “And the answer is, ‘Squash the polyp, contact your doctor or visit squashthepolyp.com’”.
Advertisement theory escapes the fallacy of reasoned intent
The Polyp Man campaign improves on one flaw of the Screen for Life campaign by its foundation in advertisement theory instead of the health belief model.(6) A fatal flaw of the health belief model is that behavior follows from reasoned intent.(16) The Polyp Man campaign will be instead modelled after the Y&R Creative Work Plan (the Plan), an advertisement theory which does not rely upon reasoned intention. The components of the Y&R Creative Plan are the following: Key Fact, Problem, Advertising Objective, and Creative Strategy. In the Polyp Man campaign, the Key Fact is that unmet component causes are preventing subjects from adhering to screening recommendations , and the Problem is that failure to adhere to screening guidelines increases morbidity and mortality from colorectal cancer. The Advertising Objective is to increase screening adherence. However, the Objective is achieved by a Creative Strategy, not an appeal to reason. The Creative Strategy has an additional four components. First, the Prospect Definition is a description of the target audience. Second, the Competition is the status quo of not adhering to screening guidelines. Third, the Promise is the best argument in favor of screening given the key fact. Finally, a Reason why the campaign will deliver the promise.(19; 20)
Importantly, the Y&R Creative Plan does not appeal to the reason of the target audience and is adaptable to varying component causes and regional audiences. An appeal to reason is avoided, because the Promise is not about the attributes of screening, such as reduction in mortality statistics or descriptions of social norms regarding colonoscopy. Instead, the Promise is about a benefit of screening, which in the introductory example is continued membership in an American family. However, the Promise may be modified to best appeal to varying target audiences. The Reason why is not an explicit explanation of how screening prevents CRC or why other individuals have chosen screening colonoscopy, it is a simple implication that people undergoing screening achieve the Promise. In the introductory example, the Reason was that the Polyp Man was dispatched by a toddler, which hints at the protective effect of removing polyps, but without any reference to medical terminology or invasive procedures. Finally, the Polyp Man campaign is sensitive to the psychological and cultural differences between regional audiences, which is lacking in the traditional health belief model.(15) Regional focus groups will allow for the creation of regional advertisements that address Key Facts and target audiences specific to a region.
Sensitivity to regional contextualization
Although racial minorities were explicitly stated as a target audience of the Screen for Life campaign,10 the campaign has been criticized for being urban-centric and ignoring rural populations.11 The educational materials of the campaign were developed to appeal to urban individuals and fail to address the complex interactions between cultural, sociopolitical, and economic conditions across the United States, especially in rural areas.(15)
The Polyp Man campaign will improve on the Screen for Life campaign by separating the national and regional advertisement campaign efforts. The national campaign will focus on the general US population, with a long term goal of changing screening behavior by socialization methods.(21) The regional campaigns will be more sensitive to the sociocultural context of local communities. These regional campaigns will be managed by local teams which will rely on focus groups to develop material optimized for the regional community. For example, Campo and colleagues conducted focus groups of Appalachian residents aged 50 years or more and reported that the actors in the Screen for Life advertisements were too old, appeared less active and healthy than the study participants, and lacked simple eye-catching messages.(13) The Polyp Man regional campaigns in Appalachia will employ young, active image in order to contextualize the campaign messages to Appalachia. Additionally, as described in the previous section, the regional campaigns will address Key Facts of the specific region.
Focus on multiple component causes
A third flaw of the Screen for Life campaign is its focus on a single component cause of colorectal cancer screening behavior, namely subject knowledge of colorectal cancer. The Polyp Man campaign will improve upon the Screen for Life campaign by specifically addressing multiple component causes that have been exposed in the literature. For example, Subramanian and colleagues identified physician recommendation as a consistent predictor of colorectal cancer screening among 44 reviewed studies.(7) In a cross-sectional study by Zapka and colleagues, subjects were 12 times more likely to comply with screening guidelines if recommended by their physician.(11) Thus one component of the Polyp Man campaign will be aimed at physicians through advertisement campaigns in medical journals, related websites, and professional conferences. The campaigns will use advertisement theory methods, discussed later in this paper, to encourage physicians to recommend screening to patients and to make physicians aware of physician-patient communication barriers such as personal health beliefs, power, listening ability, trust, directness, and racial or ethnic discordance.(22)
Individual patient level component causes will be addressed by national and regional advertisement campaigns. These campaigns will focus on barriers to screening identified in the literature such as continuity of care, education, health insurance, sex, smoking, family history of colorectal cancer, race,(12) dislike for blood tests, time off from work, and transportation.(23) A lack of knowledge of the risks of colorectal cancer remains a barrier to screening, Subramanian and colleagues(7) found significant associations between knowledge of prevention strategies and adherence to screening guidelines in all but one study reviewed.(8) Additionally, subjects who believed that screening was effective were more likely to undergo screening, and subjects with a fear of cancer or belief that cancer is incurable were less likely to undergo screening.(9; 24) Thus the Polyp Man campaign will collaborate with national and regional television networks to incorporate colorectal cancer educational segments into news programming. However, unlike the Screen for Life campaign, patient education will not be the sole aim of the Polyp Man campaign.
Conclusion
The Polyp Man campaign is a national and regional advertising campaign aimed at multiple barriers to screening and sensitive to regional contextualization. The campaign improves upon the traditional health belief model based Screen for Life campaign in three important ways. First, by employing advertising theory, the Polyp Man campaign escapes the fallacy of reasoned intent. Second, the campaign is sensitive to contextual differences in regional populations. Third, the campaign focuses on multiple component causes, increasing the likelihood that sufficient causes will be fulfilled and screening adherence increased. Colorectal cancer is a major cause of morbidity and mortality in the United States. Traditional public health interventions have not substantially increased screening adherence. The Polyp Man campaign is a non-traditional alternative that aims to reduce the burden of colorectal cancer.

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Foundations Of A New HIV Intervention Among Young Black MSM –Allan Welter

Introduction
Evidence shows that individual, interpersonal and community level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse considerably among MSM (men who have sex with men) (5, 6, 12). The individual-level component of an intervention is effective when modifying HIV-related knowledge, attitudes and beliefs held by MSM. Increasing perceived self-efficacy among MSM in relation to safer-sex behaviors is also crucial in the individual-level component of the intervention. The interpersonal-level component of an intervention is effective when aimed at changing knowledge, attitudes and beliefs about MSM in small groups of people. Group intervention among family members and close acquaintances of MSM is the main focus of the interpersonal-level. Finally, the community-level component of an intervention is effective in motivating and reinforcing behavior change among those who do not participate directly in the individual and interpersonal levels of the intervention (6).
A Hypothetical Alternate HIV-Intervention to the “Use a Condom Every Time” Campaign
New studies have shown that the annual increase of HIV among young black MSM is as high as 15% (3). In response, the public health department of Washington DC chose young Black MSM in metropolitan Washington DC as the key population of interest for a new culturally sensitive HIV intervention campaign running on individual, interpersonal, and community levels. The goal of this intervention was to increase rates of safer sex practices among young Black MSM.
Individual-Level Component of the Intervention for Young Black MSM:
To modify HIV-related knowledge, attitudes, and beliefs among young Black MSM, culturally sensitive advertisements were spread throughout the metropolitan DC area via brochures, dance clubs, radio stations, top40 podcasts, NPR, and common MSM-oriented websites. Advertisements promoted positive attitudes toward safer sex practices among young Black MSM. These attitudes were promoted through images of men participating in safer sex practices. Young black MSM couples were shown valuing safer-sex practices by saying slogans such as, “I love my Boo. Safer Sex is one way we Show our Love” (13). Men in the advertisements were young and relatable to young Black MSM in the metro DC area.
A general sense of well-being and perceived self-efficacy in relation to safer-sex practices were promoted through confidential private and group sessions in open, supportive environments. Sessions were held on weekdays and weekends and were conducted by trained professionals. These sessions ranged from safer-sex demonstrations to discussing difficulties associated with having sex with men and being a young Black man (5). Young Black MSM were recruited through social websites and after-school programs. Incentives such as food, public transportation tokens, and free passes into local 18+ and 21+ clubs were offered to increase turnout rates.
Interpersonal-Level Component of the Intervention:
To modify the knowledge, attitudes, and beliefs of young Black MSM among families and proxy contacts of young Black MSM (5), culturally sensitive messages were spread via brochures, the media, grocery stores, fast-food restaurants, the Internet, and any other accessible place. Respectful images showing families embracing MSM children were circulated. Individual MSM and MSM couples were shown everyday settings being welcomed, loved, and respected by family and friends. Culturally sensitive images were also circulated showing parents and close contacts of MSM playing active, respectful and positive roles in accepting a young Black MSM’s sexuality (6).
Through social networking, use of bulletins, media sources, and Internet advertisements, families and proxy contacts of MSM were actively recruited into the intervention. Incentives such as food, public transportation tokens, BP gasoline cards equal to the value of public transportation tokens, and $20 gift cards to whole foods with free delivery were offered to increase turnout rates. Sessions were offered on weekdays and weekends and were led by experts in this area of intervention. Counseling for families and proxy contacts were aimed at increasing open communication about sexuality with young Black MSM and transitioning to more positive attitudes relating to MSM persons. Support groups composed of multiple families and contacts were formed to help share experiences related to raising MSM children. Social networks supportive of gay children were introduced to families holding negative attitudes toward young Black MSM (5).
Community-Level Component of the Intervention:
A community intervention among young Black MSM was run on the national-level. Upon research, the campaign discovered that most young Black MSM considered safer-sex to be labeled as “good” and unsafe safe to be labeled as “bad” by the public. These beliefs were problematic for two reasons. First, there was a strong sense of masculinity among young Black MSM that corresponded with being “tough” and daring. Engaging in “bad” and unsafe sex could lead to a conscious or subconscious increase in perceptions of masculinity. Second, young Black MSM felt a sense of homophobia imposed upon them when told to use condoms. They felt heterosexuals imposed the belief that engaging in unsafe sex among MSM individuals is and will always be bad, regardless of any relationship circumstances (6). The campaign also discovered that definitions of “healthy” differed between public health officials and young Black MSM. Young Black MSM did not consider an HIV+ person unhealthy until they were diagnosed with AIDS. This potentially rises from high recognition between young Black MSM of effective HIV treatment (11). There were high levels of awareness of the high HIV infection rates among young Black MSM. This awareness may have led to the feeling infection as inevitable and therapy as painless. Low self-efficacy in relation to protecting oneself from HIV may be leading to higher rates of unsafe sex among young Black MSM.
The nationwide intervention used mass-media campaigns, taking advantage of the culturally sensitive data gained. Prime-time commercials, newspapers, popular magazines, websites commonly frequented by young Black MSM, NPR, and various radio stations transmitted the intervention. Advertisements portrayed HIV as sneaking into the body and hiding in an infected human’s DNA so the treatment could not touch the virus. This shifted the young Black MSM view of engaging in safer-sex as “good” to engaging in safer-sex as actively defending oneself against the sneaky and cowardly virus. It also challenged the notion of having only HIV as being in a healthy state because it made visible the fact that the virus lives inside the individual. To combat the perception of masculinity, advertisements showed young Black MSM protecting others from HIV through engaging in safer-sex practices, effectively associating masculinity with safer sex practices.
Peers of young Black MSM began delivering messages advocating for safer-sex practices. MSM oriented safer-sex demonstrations were made mandatory in public schools [through the wand of Barack Obama?], increasing the perceived self-efficacy relating to safer-sex among young Black MSM. To deconstruct homophobic undertones of safer-sex interventions, open dialogue relating to engaging in unprotected sex within monogamous MSM couples was encouraged. The term monogamous was emphasized, just as is true for heterosexual couples. Finally, role model stories of young Black MSM were distributed throughout the country over various forms of media in an attempt to increase a sense of value and well-being among young Black MSM.
Improvements of Proposed Intervention on the “Use a Condom Every Time” Campaign
Proposed Intervention Does not Run Only on the Individual Level:
One fundamental improvement of this intervention over the “Use a Condom Every Time” campaign is that it is not run merely on the individual level. Accounting for the group dynamic (4), this intervention will be able to shift behaviors of entire groups of young Black MSM rather than individual MSM (4). Essentially, people who do not participate in the intervention on the individual level are still influenced by the intervention through the cultural shift of attitudes related to safer-sex practices (5). The community and interpersonal proportions of this intervention attempt to shift HIV-related beliefs for entire groups rather than individuals.
Additionally, this intervention specifically addresses the wider social context affecting health related behaviors of individuals (4). Contextual issues are put forth regarding masculinity and unprotected sex among young Black MSM. Young Black MSM may have had unprotected sex to increase their sense of masculinity. This intervention used masculinity as a contextual tool of intervention, showing young Black MSM protecting others through safer-sex as masculine. This would not be possible in the “use a condom every time” campaign.
Homophobic Societal Undertones related to Condom Use are Eliminated:
MSM have “experienced hatred, abuse, and a lack of acceptance by their families, friends, communities, and society in general” (5, 6, 14). We have shown that these negative experiences, potentially leading self-destructive psychological natures, can result in MSM engaging in unprotected sex because it is dangerous (6, 14).
This intervention works on the interpersonal level to decrease homophobia among families, friends, and close contacts of MSM. This will hopefully lead to a decrease in self-destructive tendencies caused by homophobia. A potential decline their rates of unprotected anal sex may be observed as a result (14). Additionally, homophobia is addressed on the national level. Counter to the “use a condom every time” campaign, this intervention opens publicly accepted discussion among monogamous MSM couples to decide whether they want to use condoms in their relationship. In effect, the intervention removes society’s homophobic desire to dictate the behaviors of MSM through “always use a condom” campaigns. This allows MSM and the intervention to interact without the negative pretense of perceived homophobia. In circumstances such as these, MSM are less likely to be defensive and more likely to listen to the message being put forth by the campaign (5, 14). Intervening at the group and interpersonal level allows maximum efficiency in decreasing homophobic experiences of MSM individuals, leading to increases in safer-sex practices (12).
Health Not Assumed to be Highly Valued by most MSM:
The proposed intervention directly addresses the fact that the definition of “healthy” differs between young Black MSM and public health professionals. To get around this discrepancy in definitions, the intervention circulated images depicting HIV as deceptive and cowardly. This image of deception leads to young Black MSM acting in defense of their body, regardless of the definition of health.
MSM may hold a high value for not contracting HIV, but they may also have a low perception of self-efficacy in relation to engaging in safer sex. The new intervention addressed this potential low perceived self-efficacy for using a condom among young Black MSM, an aspect completely left behind by the “use a condom every time” campaign. Since the new intervention does not require that MSM use a condom every time, the pressure associated with having to use a condom in every sexual encounter for the rest of one’s life is diluted. Additionally, confidential group and private sessions were run that showed MSM how to engage in safer-sex practices. Role-playing was implemented to help MSM gain the strength and courage to insist to their partners that a condom be used if they feel it is necessary. Note that both individual and group level interventions were required to address the potential effects of low perceived self-efficacy relating to safer sex among young Black MSM.
Concluding Statement
The proposed intervention improves upon the “how to use a condom every time” campaign in three significant ways. First, this campaign is run on the individual and group level. While increasing perceived self-efficacy relating to safer-sex practices among young Black MSM, we are also shifting beliefs and behaviors of entire groups with relation to HIV (4, 12). Second, young Black MSM men do not perceive the intervention as homophobic. As a result, it is more likely for young Black MSM to take in messages of the intervention. The campaign also addresses homophobia through interventions among families and proxies of young Black MSM. Lower levels of homophobia among MSM proxies will lead to an increased sense of well-being. Young Black MSM will feel more valued and welcomed in everyday aspects of life, which can lead to decreased self-destructive actions and increases in the frequency of safer-sex practices. Finally, the proposed campaign improves on the “use a condom every time” campaign in that it does not assume “health” to be highly valued among most young Black MSM. Without this contextual assumption, the intervention was able to target factors that were truly related with low frequencies of safer-sex practices and intervene based on those factors.
Evidence shows that individual-level, interpersonal-level and community level HIV behavioral interventions are effective in reducing the odds of unprotected anal intercourse considerably among MSM (5, 12). It is crucial for all three components to be a part of the intervention. The community level component is necessary because it allows those who were not directly involved in the intervention to still be influenced by the intervention and because it analyzes health-related behaviors within the cultural context (4). The interpersonal level is essential because reduced levels of homophobia among proxies of MSM will lead to higher senses of well-being among MSM. This may correlate with decreases in self-destructive behavior, and potentially increases in safer-sex practices. Finally, the individual level component is essential because it provides HIV-related knowledge directly to individuals and increases individual perceived self-efficacy relating to safer-sex practices. Implementing all three components into an intervention significantly improves on the “use a condom every time” campaign, and will be effective in increasing the frequency of safer-sex practices within the target population.
REFERENCES:
1. Department of Health and Human Services. Basic Information. Centers for Disease Control and Prevention. http://www.cdc.gov/hiv/resources/qa/index.htm.
2. Sterk C. The health intervention project: HIV risk reduction among African American women drug users. Public Health Rep. 2002; 117(Suppl 1): S88–S95.
3. Brown D. HIV rate up 12 percent among young gay men: Steepest rise is in black males ages 13 to 24. (2008, June 27). The Washington Post, p. A14.
4. Edberg M. Essentials of health behavior: Social and behavioral theory in public health (pp 65-76). In: Edberg M, ed. Social, Cultural, and Environmental Theories (Part II). Sudbury, MA: Jones and Bartlett Publishers, 2007.
5. Choi K. H., Yep, G. A., & Kumekawa, E. HIV prevention among asian and pacific islander american men who have sex with men: A critical review of theoretical models and directions for future research. AIDS Education and Prevention. 1998; 10: 19-30.
6. Siegel M. The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (pp. 66-69). In: Siegel M, ed. Marketing Public Health: Strategies to promote social change. Sudbury MA: Jones and Bartlett Publishers, 2004.
7. The Complete HIV/AIDS Resource. HIV/AIDS Among Women. The Body. http://www.thebody.com/index/whatis/women_basics.html.
8. Huebner D. et al. The Impact of Internalized Homophobia on HIV Preventive Interventions. American Journal of Community Psychology 2002; 30(3):327-348.
9. Salazar K. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39(3):128-135.
10. S A. Bug Chasing: Why Some Men Want to Become HIV Positive. Associated Content: Information from the source. Published Nov 09, 2005. http://www.associatedcontent.com/article/13507/bug_chasing_why_some_men_want_to_become.html?singlepage=true&cat=5
11. Jaffe H, Valdiserri R, De Cock K. The Reemerging HIV/AIDS Epidemic in Men Who Have Sex With Men. JAMA Nov 28, 2007;298(20):2412-2414.
12. Herbst J, Beeker C, Mathew A, McNally T, Passin, W, Kay L, Crepaz N, Lyles C, Briss P, Chattopadhyay S, Johnson R. Effectiveness of Individual, Group, and Community-Level HIV Behavioral Risk-Reduction Interventions for Adult Men Who Have Sex with Men. American Journal of Preventive Medicine 2007; 32: S38-S67.
13. Gay Men’s Health Crisis. GMHC launches two new HIV awareness campaigns. New York City: Gay Men’s Health Crisis. Retrieved February 13, 2009, from GMHC: Press Web site: http://www.gmhc.org/about/releases/080319.html.
14. Huebner D, Davis M, Nemeroff C, Aiken L. The Impact of Internalized Homophobia on HIV Preventive Intervention. American Journal of Community Psychology 2002; 30:327.

Prenatal Breastfeeding Education: An Examination of Why Education Does Not Work In All Circumstances and a Proposed Intervention -Michelle O’Brien

As a maternal child health care provider and a public health practitioner, I am very interested in interventions aimed at increasing breastfeeding rates and longevity. At Boston Medical Center, a Baby Friendly hospital, we have many different interventions intended to impact breastfeeding rates. The Department of Pediatrics’ Adolescent Health Center Teen and Tot Program offers prenatal education classes for pregnant teenagers. The prenatal classes consist of a two hour session, once a week for ten weeks. The classes cover many important topics such as mind and body changes during pregnancy, common complications of pregnancy, family planning, child development, and newborn care. Breastfeeding is covered in one session, along with maternal nutrition, in the third week. The focus of the breastfeeding portion of the session is on the reasons to breastfeed, nutritional information about breastfeeding and resources to help with breastfeeding. There is no further mention of breastfeeding in the remaining seven weeks of classes. This is typical of most prenatal education classes as there is a lot to be covered in a short amount of time.
I will critique this intervention by focusing on the three most common mistakes made by healthcare professionals and health educators when creating and teaching prenatal breastfeeding education; over-reliance on the Health Belief Model, lack of focus on the needs of the intended audience and poor timing of the intervention.
Concept #1 - The Health Belief Model: “Breast is Best”
Many interventions in modern, Western medicine have a basis in the Health Belief Model. Doctors and other healthcare professionals use facts and data as the foundation of all that they do during their training years. They learn to trust knowledge and feel safe within the constructs of the Health Belief Model. Therefore, many of their interventions are linked to this model. However, there are many flaws with this theory, particularly when applied to the choice to breastfeed or formula feed.
Irrational behavior
The Health Belief Model is anchored in the belief that when presented with information about a desired behavior, the target audience will weigh the risks and benefits of adopting that behavior and make a rational choice. This has been proven to be untrue when applied to decision making regarding infant feeding (breast vs. formula). When questioned about the benefits of breast milk over formula, most women acknowledge the superiority of human milk over formula (1, 2). When asked specifically about the benefits of breast milk, the women are able to identify that breast milk has nutritional benefits over formula, that it can protect babies against disease, that breast milk is involved in both physical and psychological development of the child and that the act of breastfeeding creates a special bond between mother and child (1). In a study examining the reasons for infant feeding choices, this was true of both formula feeding and breastfeeding mothers. Women that had chosen to bottle feed acknowledged the advantages of breast milk over formula, although overall the difference between their ratings of breast milk over formula were smaller than for breastfeeding mothers (1). When looking at the decision making based on this information alone, it seems that prenatal education has been successful in educating the mothers on the benefits of breastfeeding but that this was not influential in the decision making in a large number of women. Another strategy used within the Health Belief Model when persuading women to breastfeed is an economic argument. Formula is very expensive when compared to breast milk. In the same study, women acknowledged the higher cost of formula but in women that chose to formula feed, the cost was not influential in their decision making (1). This is even more striking when you realize that the women sampled in this study were primarily low-income. One might even say it seems a bit irrational.
We are not all the same
Prenatal education as an intervention for breastfeeding assumes that all women will seek out information on breastfeeding. A sociodemographic difference in the women who attend childbirth preparation or prenatal education courses (3) has an impact on the overall effectiveness of this particular intervention, with poor minority women less likely to enroll in classes. For the women who do attend classes, use of the Health Belief Model assumes that they are all at the same level of education, have the same values and beliefs as each other and the health care providers and have the same support systems in place. Many prenatal education courses also assume that the baby is central to the decision regarding feeding methods. Research studies show that this is often not the case. There are other factors that supersede the needs of the baby; including perceived convenience of formula feeding over breastfeeding, feeling “tied down” with breastfeeding and pressures from family, significant others and friends to allow them to help feed the baby (1-2, 4). Women who are working or in school may not feel they have the time or a place to breastfeed or pump (1, 5). All these factors contribute to women rejecting the “facts” that they learn in the classes in making their infant feeding decisions.
Concept #2 - Know your audience: The teen mother
There are many studies that show that adolescents learn differently than adults and that their decision-making capacity is influenced by much different factors. In reference to breastfeeding, it is well known that teenagers are least likely to initiate breastfeeding and more likely to discontinue early (2, 4, 6-10). So breastfeeding interventions geared towards adolescents need to focus on the special needs and characteristics of their target audience.
Learning is boring
Most adolescent mothers are not interested in didactic education sessions. In order to keep their interest and attention, the educator needs to be creative. A program in Florida (11) utilized games to teach the adolescents about breastfeeding; a word search with common breastfeeding terms, “condom breasts” to demonstrate latch while also addressing safe sex issues, Breastfeeding Bingo and group activities such as “You Solve It” and Baby Boob Jeopardy. This adolescent-focused intervention showed a significant increase in breastfeeding initiation (65.1%) in comparison to girls who received “standard” breastfeeding education (14.6%). The typical prenatal education class is similar to a health class lecture. The teacher or educator imparts knowledge to the learner (adolescent mother) and allows time for questions at the end. More interactive learning is ideal in this age group particularly when addressing subjects that can be identified as embarrassing.
It’s Embarrassing
Adolescent mothers are more likely to cite embarrassment as the primary reason for not breastfeeding (2, 4). Prenatal education classes infrequently address the issues faced by adolescent mothers who are just becoming comfortable with the changes in their maturing bodies but do not yet have the mental maturity to assimilate breastfeeding and the purpose of breasts in infant feeding with their daily lives. When you add in the cultural context of sexuality and breasts found in this country (12), it is often too much for an immature mind to process without the proper support and guidance.
‘They” Don’t Want Me To
Not surprisingly, adolescent mothers are much more sensitive to the viewpoints of the people closest to them when making their infant feeding choices. The teens’ mothers are often the most influential in their decisions regarding infant feeding (2, 4) even if they don’t have a good relationship with their mother (2). Since most adolescent mothers still live with their parents, the maternal grandmother (of the infant) will shape her daughter’s decision based on her own experiences with breastfeeding and how involved she is with the care of the infant (ie Is she taking the “mother” role?) (2). If the mother’s mother will be assuming a large portion of the care duties (for instance, when the mother returns to school) she may be more likely to discourage the mother from breastfeeding so she can easily feed the infant with a bottle. The father of the baby also has significant influence on the decision of feeding method (2, 4). He may feel left out if the mother exclusively breastfeeds or may attach a sexual connotation to her breasts. A single two hour class on breastfeeding cannot even begin to address the influences of the mother (of the teen mother) and the father of the baby nor include them in any meaningful dialogue. As is common in individual based public health interventions, prenatal education classes do not always consider the greater context of the relationships and environment that the intended audience lives and works within.
Concept #3 - Timing is everything: Too little, too late
Finally, this intervention does not take into account the time needed to make a decision as complex as whether or not to breastfeed. A single two hour class does not do justice to the multitude of factors that play a part in each individual woman’s decision making process. As has been addressed in previous sections of this paper, pregnant teens are faced with many competing factors as well as dealing with pregnancy and impending motherhood. If an intervention truly intends to increase breastfeeding initiation, it needs to be more of a continuous ongoing intervention.
Most prenatal education classes take place in the seventh to eighth months of pregnancy. Studies have shown that in order to be effective breastfeeding interventions need to start much earlier (4, 11), perhaps even in schools before the teens are even pregnant (11). Breastfeeding presented in health class as a natural, normal way to feed your baby begins to lay the foundation for a different societal view of breastfeeding.
In summary, the Adolescent Center’s prenatal breastfeeding education intervention is less than ideal for many reasons. As demonstrated by the evidence cited, the decision whether to breastfeed or not is usually not a rational decision. Use of the Health Belief Model in breastfeeding promotion is misguided as it is in most public health intervention. Despite the fact the critiqued program is occurring within an Adolescent Center, they fail to consider the special needs of their population when approaching breastfeeding promotion. Innovative teaching methods are necessary to get the attention of the adolescent mind and the support people (mother, partner) need to be more integrated into the intervention beyond “inviting” them to attend classes. More thought should be put into the timing of breastfeeding interventions and collaborative efforts with the school systems should be explored.
A potential intervention that addresses the weaknesses of the Adolescent Center’s prenatal breastfeeding education class is one that I proposed in MC820 Planning and Program Development in Maternal and Child Health. This intervention combines several models of public health and healthcare interventions. The cornerstone of the intervention is an innovative model for prenatal care called CenteringPregnancy®. Developed by Sharon Schindler Rising, CNM, CenteringPregnancy® is group prenatal care which utilizes the power of self-empowerment and community to increase patient satisfaction, improve perinatal outcomes and increase breastfeeding rates (13, 14). A group of 10-12 women with similar due dates receive all their prenatal care in a group that is consistent throughout the nine months. Together the women teach and learn from each other, with guidance from a trained medical professional.
My intervention adds a hands-on breastfeeding education component to CenteringPregnancy® that starts at the very beginning of prenatal care, occurs at each visit and happens in the group setting. This breastfeeding education allows women to practice breastfeeding techniques with life size dolls and cloth breast models, visualize the size of a newborn’s stomach and discuss what to expect in the first couple days to weeks of breastfeeding. While there would be some teaching about the benefits of breast milk and why it is the ideal nutrition for newborns, this would not be the core of the breastfeeding education curriculum. A certified lactation consultant would participate in the design of the curriculum and would help the health care providers in demonstrating and problem solving with the women.
Previously, I discussed some of the limitations of other breastfeeding promotion interventions. This intervention directly addresses the weaknesses of the previous model; over-reliance on the Health Belief Model, lack of focus on the needs of the intended audience and poor timing of the intervention.
Concept #1 Redo - The Health Belief Model: “Breast is Best”
A skill based, hands on intervention does not rely on the concepts of the Health Belief Model. The Health Belief Model relies on presenting the target subject(s) with information and facts and trusting that these subjects will make rational decisions based on this information. The proposed intervention allows for the practice of techniques with props, while in a group setting where they can watch other women doing the same and learning from each other about what does and does not work. It gives women practical skills, not just facts. There is not so much a process of weighing the risks and benefits of the information gained as the achievement of skills that may or may not be utilized depending on the woman’s intentions regarding breastfeeding. By allowing the women to practice and consider the implications of breastfeeding beyond nutrition for the baby, it makes it more concrete and allows them to make a decision that works best for them. This type of learning has been found to be effective in several studies (15-18). And while this does have some foundation in Bandura’s Social Cognitive Theory (19), the limitations of this model are mitigated by the second portion of the intervention, the Centering® model.
The CenteringPregnancy® portion of the intervention uses social network theory. Social network theory describes the power that a group that is tied to each other in a social manner can influence and affect behavior of individuals in the group. By sharing an important time in their life with other women going through the same experience, the women involved in Centering® form strong relationships within the social network of the group. The healthcare provider participates as a member of the group, facilitating but not leading discussion or lecturing. So often the “answers” or proposed behavior changes are suggested by other members of the group and not necessarily by the authority figure of the healthcare provider. The type of group care in a Centering model is also contrary to the Health Belief Model because it is not a one size fits all approach. The conduct within the group is centered on every participant having an equal say, and while the care is done in a group, it is individualized for each woman. My proposed intervention would build on that. While the activities presented would be similar, each woman could choose to focus on what is most important to her and her needs.
Concept #2 Redo - Know your audience: The teen mother
Teenagers would be the ideal group of women for this intervention. First of all the hands-on, practical aspects of the intervention would appeal to many adolescents. It is often embarrassing for young women to talk about breasts, due to the sexualization of the breasts by our society. By getting comfortable with the cloth breasts and the baby models, teenage mothers are more likely to feel a little less embarrassed and self-conscious about trying breastfeeding when the time comes. As mentioned previously, it has been found that adolescents learn better when the information is presented in a creative or interactive way (11).
CenteringPregnancy® has been found to be very effective with adolescents (14). The model is aimed at empowering the women to take control of their health care and their bodies by allowing them to be actively involved in self care and other healthcare activities. This empowerment helps adolescent mothers have confidence in their decisions for themselves and their babies. The influence of the adolescent’s mother or the father of the baby on the young mother’s feeding decision lessens when she feels that she has control over her body and health. Many CenteringPregnancy® groups include support people in each session so they have the opportunity to hear the same information, hear what other fathers or grandmothers are saying about breastfeeding and bottle feeding.
The Centering® model has some elements of diffusion of innovation theory. Teens are very much influenced by leaders or innovators. Often they follow or imitate unhealthy or destructive behaviors. With CenteringPregnancy®, these young women see that it can be “cool” to take care of your body, to have respect for yourself and the decisions you make.
Concept #3 Redo - Timing is everything: Too little, too late
The proposed intervention would begin early in pregnancy. It would be a component of each group prenatal visit. Early introduction of breastfeeding interventions and support has been shown to be effective (4,11). By using the ideas presented in framing theory, breastfeeding preparation is reframed to become a part of normal prenatal care. By addressing breastfeeding and breastfeeding preparation at each prenatal visit, the concept becomes as normal and routine as a weight or blood pressure check. Because of the marketing of formula and even promotion of formula feeding by health care providers in this country, breastfeeding is often viewed as “extra” or something special that only some mothers do. Incorporating it into the usual prenatal routine helps send the message that breastfeeding is normal and natural.
Conclusion
While breastfeeding is not for everyone, more efforts need to be made in the clinical and public health arenas to better prepare women for breastfeeding, allow them the opportunity to experience the “process” of breastfeeding before the baby is born and normalize breastfeeding a natural and healthy choice for women and their babies. I propose that my intervention is just one way that this could be accomplished but does have the potential to work particularly well in a pregnant adolescent population.

REFERENCES
1. Zimmerman DJ, Guttman N. “Breast Is Best”: Knowledge Among Low- Income Mothers Is Not Enough. Journal of Human Lactation 2001; 17:14-19.
2. Morrison L, Reza A, Cardines K, Foutch- Chew K, Severance C. Determinants of Infant-Feeding Choice Among Young Women in Hilo, Hawaii. Healthcare for Women International 2008; 29(8):807-825.
3. Lu MC, Prentice J, Yu SM, Inkelas M, Lange MO, Halfon N. Childbirth Education Classes: Sociodemographic Disparities in Attendance and the Association of Attendance with Breastfeeding Initiation. Maternal and Child Health Journal 2003; 7(2):87-93.
4. Ineichen B, Pierce M, Lawrenson R. Teenage mothers as breastfeeders: attitudes and behaviour. Journal of Adolescence 1997; 20:505-509.
5. Johnston, ML, Esposito N. Barriers and Facilitators for Breastfeeding Among Working Women in the United States. JOGNN 2007; 36(1):9-20.
6. Hannon PR, Willis SK, Bishop-Townsend V, Martinez IM, Scrimshaw SC. African American and Latina Adolescent Mothers’ Infant Feeding Decisions and Breastfeeding Practices: A Qualitative Study. Journal of Adolescent Health 2000; 26:399-407.
7. Benson S. Adolescent mothers’ experience of parenting and breastfeeding:
A descriptive study. Breast Rev. 1996; 4:19-27.
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among adolescent mothers from northern Louisiana. J Am Diet Assoc.
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breastfeeding among WIC participants. Journal of Human Lactation 1997; 13:121-126.
10. Maehr J, Lizarraga J, Wingard D, Felice M. A comparative study of adolescent and adult mothers who intend to breastfeed. Journal of Adolescent Health 1993; 14:453-457.
11. Volpe EM, Bear M. Enhanced Breastfeeding Initiation in Adolescent Mothers Through the Breastfeeding Educated and Supported Teen (BEST) Club. Journal of Human Lactation 2000; 16(3):196-200.
12. Rodriguez-Garcia R, Frazier L. Cultural Paradoxes Relating to Sexuality and Breastfeeding. Journal of Human Lactation 1995; 11(2):11-115.
13. Massey Z, Schindler Rising S, Ickovics J. CenteringPregnancy Group Prenatal Care: Promoting Relationship-Centered Care. JOGNN 2006; 35(2): 286-294.
14. Grady MA, Bloom KC. Pregnancy Outcomes of Adolescents Enrolled in a CenteringPregnancy Program. Journal of Midwifery & Women’s Health 2004; 49(5): 412-420.
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17. Kistin N, Abramson R & Dublin P. Effect of peer counselors on breastfeeding initiation, exclusivity, and duration among low-income urban women. Journal of Human Lactation. 1990, 10(1):11-16.
18. Zimmerman DR. You can make a difference: Increasing breastfeeding rates in an inner city clinic. Journal of Human Lactation. 1999; 15:217-220.
19. Bandura A. Self-Efficacy: Toward a unifying theory of behavioral change. Psychological Review; 1977, 84:191-215.

The “Alcohol, Know Your Limits” PSAs and Binge Drinking: Helping People to Know Their Limits or Just Some Funny Commercials? – Jennifer Burda

Binge drinking is a popular topic in the public health world and on college campuses. However, the magnitude of this public health problem is not just concentrated in American college campuses. Many young people around the globe binge drink. This is also the case in the United Kingdom. Binge drinking is defined as excessive alcohol consumption which usually results in a blood alcohol concentration (BAC) of .08 grams percent or above. A BAC this high is often achieved during a short period of time, such as a woman consuming four drinks over the course of two hours (1). There are numerous health problems associated with binge drinking including unintentional injuries, alcohol poisoning, liver disease, and neurological damage (2). The European School Survey Project on Alcohol and Other Drugs shows 54% of youth in United Kingdom schools have had heavy episodic drinking within a 30 day period (3). The United Kingdom Home Office developed a public health ad campaign called “Alcohol, know your limits” in an attempt to curb binge drinking among young people within the country.
The “Alcohol, know your limits” campaign released several Public Service Announcements (PSAs) to convince youth to not overindulge on alcohol. One PSA features a young woman getting ready for a night out. In the process of getting ready, she rips her tights and top, vomits in the sink with her hair in the way, smudges her eye make-up, pours wine on a chair, breaks the heel off of her shoe, then leaves her home. The PSA ends with “You wouldn’t start a night like this so why end it this way?” (4). This PSA has a similar counterpart. In another PSA, a young man puts on clothes and rips them, goes to the refrigerator and wipes food on his shirt, urinates on the floor next to the toilet, puts an earring in and tears his ear, bangs his head against the door, then leaves his house with a bloody nose. The PSA ends with the same tagline “You wouldn’t start a night like this so why end it this way?” (5). The PSAs attempt to portray the characters as drunk before departing for the evening. The PSAs also demonstrate somewhat extreme examples of binge drinking behavior. However, these PSAs have not proven very successful and these campaign ads are overall flawed for three central reasons. These PSAs have not helped the campaign’s success because they do not take psychological reactance into account, do not address the social norms and culture surrounding binge drinking, and lastly fail because they assume people are rational and will choose to not binge drink because of the consequences.
No consideration for psychological reactance
To put it simply, the message of the “Alcohol, know your limits” PSAs is to not binge drink and portrays binge drinkers in a negative light. These PSAs assume young people will be turned off to binge drinking because of how the people are portrayed in the PSAs. However, the PSAs can have an opposite effect on the youthful targeted audience and cause them to revolt against this suggested restriction of freedom (ie being told not to binge drink) instead of embrace the message being sent.
Psychological reactance theory explains how people have an emotional reaction to threatened freedoms or attempts to control their behavior (6). If individuals perceive they are being manipulated, they will often react opposite to the persuader’s intent and reject doing the suggested activity (7). Psychological reactance occurs in four stages – first there is an understanding of the perceived freedom (in this case, ability to drink as much as one wants), then the perceived threat to freedom (being told not to over drink). This leads to a reactance (binge drinking) which thus ultimately restores the freedom in question (freedom to drink as much as one wants).
These particular PSAs were posted on YouTube which provides a comments field for people to remark on a clip. The following comment was posted by YouTube user Pwnagemonkey1 underneath the PSA portraying the girl getting ready for a night out:
fair enough, but dont try and tell people not to drink. People should be allowed to do whatever they want to themselves as long as its what they want, no matter the consequences. its a part of life, there would be no enjoying life if all you did was take no risks and be boring and sh** (4).
This comment demonstrates how this PSA resulted in psychological reactance. Instead of this YouTube user being inspired to not binge drink, he argues that people should have the freedom to do what they want regardless of the consequences.
Similar comments were posted under the YouTube PSA featuring the boy preparing to leave his apartment. One user wrote “This advert never fails to make me wanna go out and get sh**-faced.” Another user replied with “Yeah it just makes me want to go out on the trash! He really does look better at the end, no?!” (5). These comments explicitly demonstrate reactance and how people revolt and do the opposite of the intended message. The “Alcohol, know your limits” PSAs do not have the desired effect of persuading youth to not binge drink and in some cases, actually indirectly encourage them to binge because of psychological reactance.
A study was done examining the reactance of college students to messaging about flossing compared to binge drinking. Students behaved with rational planned behavior to the flossing message; they understood the healthful purpose of flossing which did not have any perceived infringements on their freedom. Binge drinking messaging was perceived very differently because there are social and commercial factors that promote binge drinking among young people. Therefore, the anti-binging message acts as a threat to perceived norms which causes a reactance (8). The “Alcohol, know your limits” PSAs experience a similar negative attitude and revolt since this message is also going against perceived social norms which young adults particularly value as they try to fit in with their peers. Youth negatively view messages that threaten their freedom or ability to fit in. If this ad campaign had taken psychological reactance into consideration, it would have been more successful.
Social norms and culture of binge drinking not addressed
As mentioned above in the discussion on psychological reactance, binge drinking is a social norm among youth and is not only accepted but expected. Norms are defined as patterns of beliefs and behaviors expected in certain situations and shared by a social group. Norms regulate social behavior (13). Social norms play a particularly important role among youth because they feel added pressure to fit in while they go through the stages of adolescence into adulthood. The “Alcohol, know your limits” PSAs do not address or use social norms or context. They only present negative examples of binge drinking instead of searching to change why or how binge drinking has become a social norm.
There are several socially based reasons for binge drinking which have helped it become normalized. Youth and young adults in the 15-17 age range in the United Kingdom drink because it allows them to express their views more easily, develop trust with friends, and explore sexual relations in what they perceive to be a less threatening context. Because of these reasons, alcohol is perceived as relaxing, an excuse for behavior, and provides an opportunity for bonding (14). These socially based reasons for binge drinking are perpetuated into social norms with the help of the media. Movies, television, and music display these supposed advantages to binge drinking. The media acts as a socialization tool and teaches people what to expect in certain situations (15). For example, the film “Animal House” has helped incoming college freshmen expect crazy fraternity parties with alcohol, as depicted in the movie.
The PSAs have not worked to change the social norms around drinking or address them. The campaign would have been much more successful if it had gone to the core of understanding why youth choose to drink and addressed those issues instead of simply presenting binge drinking in a negative light. The problem of binge drinking will not be solved if the root of the problem just continues to be masked – social norms and culture.
A study was done in South Wales which found the local community around the school embodied a culture of heavy drinking. This even impacted non-drinkers because many conversational topics revolved around alcohol (14). In addition to the results found in the South Wales community, the United Kingdom as a whole has been labeled for having a culture that embraces heavy drinking. Brits are known for their fond appreciation for pubs. Getting to the causal reason for binge drinking in the United Kingdom is key for a successful campaign. A study at Leeds University in the United Kingdom found that social context, beliefs, and morals should be considered when tailoring health promotions to hit a targeted young group (16). A much larger picture and framework needs to be considered for the public health campaign to be successful.
People see the consequences therefore do the behavior – not the case
The PSAs have a loose basis on the Health Belief Model (HBM) which is antiquated and has added to the PSAs’ flawed nature. HBM states people will take action against a disease (or in this case, follow the suggested protocol – not to binge drink) if they feel they have a high susceptibility to the disease/behavior (binge drinking), feel the effects of the disease/behavior are at least moderately severe, and taking action will reduce their susceptibility and the severity of the disease/behavior, and in general, be beneficial. People will choose to act if they do not have to overcome barriers, such as cost or pain (9). In other words, if the benefits outweigh the barriers, people will have an intention to take action and thus change their behavior (10).
The PSAs make it look like most young people are susceptible to binge drinking (ie the disease/negative health behavior in HBM) by choosing a seemingly normal young woman and man to represent society. The effects of binge drinking in the ads are moderately severe given the destructive nature of the two main characters. Their behavior indicates binge drinking leads to destruction of clothes and other personal items as well as poor judgment which can lead to pouring wine on a chair or urinating besides the toilet. The benefit to choosing not to binge drink is to avoid embarrassment by not doing these destructive behaviors. The PSAs do not highlight any specific barriers that need to be overcome in order to not binge drink. However as mentioned earlier, these PSAs are loosely based on HBM so they do not necessarily have all of its characteristics. Overall, the PSAs insinuate that because the severity and susceptibility of binge drinking is strong, people watching the PSAs should intend to want to and thus change their behavior, ie not binge drink.
HBM assumes people are rational and weigh their choices and options. However, this is not the case. The PSAs express this key characteristic of HBM. Even if the PSAs did experience some success in convincing people the binge drinking consequences are severe enough to not binge drink, this education does not automatically translate over to people changing their behavior. This is because humans are irrational (11). Weighing of costs and benefits and having an obvious logical outcome does not mean people will automatically do the suggested behavior.
There are two key reasons why people are irrational and are arguably predictably irrational in this case of binge drinking. People are irrational because of ownership – they put a high value on what they own. This does not just apply to physical items but to behavior as well. Habits, which include binge drinking, are particularly hard to change because people assume ownership of the habit. People focus on what they will lose as opposed to what they will gain. With binge drinking, people see the loss of having fun with friends and do not see the gain of living a safer lifestyle. People are also irrational because they lack self-control. They are lazy, procrastinate, and overall have less control over their actions than they think (12). Even though they may want to change their behavior, follow through is low because people lack will power.
The PSAs are faulty because they assume people will choose to change their behavior because of the negative effects of binge drinking portrayed in the PSA. However, this is not the case because people are not rational and do not make changes easily. If these points were considered in the “Alcohol, know your limits” PSAs, the campaign would have been more successful.
Conclusion
Binge drinking is a major public health problem in the United Kingdom and the country has developed a campaign to address the issue. However, its “Alcohol, know your limits” PSAs have not been very successful. Although the PSAs possess a degree of attraction for youth because of the humor in the PSAs, they are still largely flawed because they do not take certain social and behavioral science principles into account. The PSAs do not consider the possibility of psychological reactance to the messaging, nor do they highlight and address the social norms or context surrounding binge drinking. The PSAs also assume that because negative aspects of binge drinking are highlighted, people will be rational and not binge because of the consequences shown. Psychological reactance is the most important issue that needs to be immediately addressed since it can encourage binge drinking. The other two flaws simply make the PSAs ineffective. There is much room for improvement for these PSAs. By taking the social and behavioral science principles into account, the PSAs would be more successful and help curb binge drinking in the United Kingdom.
A new intervention
The “Alcohol, know your limits” campaign has room for improvement. In order for the Public Service Announcements (PSAs) associated with the campaign to be successful, they need to address psychological reactance, social norms and culture, as well as people’s irrational behavior. Incorporating these points into a new PSA will result in a stronger public health intervention to curb binge drinking in the United Kingdom.
The new PSA intervention is markedly different from the PSAs currently used in the “Alcohol, know your limits” campaign which depict a boy and girl getting ready for a night out but with insinuations that they binge drank before preparing for the evening and leaving their house. (4, 5) The new PSA does not use footage of young people who have already made the decision to drink and giving the message to not behave like them. Instead, it contains a happy, young, attractive couple spending their evening going out to dinner, sharing an inside joke, and enjoying themselves without binge drinking. The woman (Sarah) later that night reports to a friend how she had the opportunity to get to know her date and had fun versus her experiences meeting other men in bars in the past. Sarah then says she and her date are going rock climbing in the morning and a group of people should go and her friend agrees. The PSA then shows five people in a convertible on a beautiful, sunny morning on the open road heading towards the mountains. Once they arrive at their destination, they enjoy themselves and belay each other as they climb. They eventually reach the mountain’s peak, then sit down to enjoy lunch and admire the view. It ends with the tag line, “Don’t let alcohol give you limits.”
As seen in the new intervention described above, it advertises freedom and success as alternatives to binge drinking as suggested by the images of driving down the open road and reaching the summit of a mountain. The PSA is improved and addresses the “Alcohol, know your limits” campaign’s earlier problems because it contains positive role models, includes advertising theory which encompasses social context and beliefs, and has a replacement value for binge drinking.
Psychological Reactance – no longer an issue
Psychological reactance is a key concern in the original “Alcohol, know your limits” PSAs because they can actually cause more people to binge drink instead of prevent binge drinking. This is because people can have an emotional reaction when they feel they are being controlled or their freedom is in jeopardy (6). The original PSAs instruct the public to not binge drink, which could cause reactance. The new “Don’t let alcohol give you limits” PSA does not explicitly say to not binge drink, nor gives the impression the government is giving orders. Rather, the PSA provides positive role models who do not binge drink. Youth can aspire to become these models as they are happy, young, attractive, and enjoy life. Because binge drinking is not portrayed in an overtly negative light, the four stages of reactance cannot be completed. The second stage of reactance, which is the perceived threat to freedom, does not occur in the new PSA. The original PSAs’ YouTube comments indicate the viewers are more inclined to go out and binge drink after seeing the commercial - the new PSA avoids that because it does not contain a trigger to spark reactance.
The “Don’t let alcohol give you limits” PSA also does not go against perceived social norms of binge drinking per say by stating not to binge drink. Rather, it provides an alternative. The new PSA offers a sense of freedom by presenting a different lifestyle choice instead of restricting freedom and telling youth to not binge drink. Thereby this reduces the risk of reactance (6). However, the new PSA does contain characteristics to address the social norms and culture of binge drinking which not only have a role in addressing psychological reactance but also help get to the root of the binge drinking problem.
Advertising Theory – a Way to Address Social Norms and Culture of Binge Drinking
Binge drinking is often considered a normal social behavior for youth. The original PSAs do not address the social norms or context surrounding binge drinking in youth. Rather, they simply paint binge drinking in a negative light. Studies on British youth found youth binge drink for a variety of reasons which include the ability to express their views more easily, bond, and build trust with friends (14). These are core reasons why youth choose to binge drink. The “Don’t let alcohol give you limits” PSA addresses these particular reasons and tackles their context.
The new PSA shows the couple getting to know each other and being open without the assistance of alcohol. This is then reconfirmed when Sarah speaks to her friend about her preference to “really get to know someone” as opposed to the men she had met in bars. Being drunk is a fleeting state and not permanent – what matters is who a person is at all times, with and without alcohol. Sarah also bonded with her date as they laughed over dinner and shared an inside joke, which show that it is possible to be intimate with someone sans alcohol. The PSA demonstrates the motivating factors for youth binge drinking do not have to apply. People can build relationships without being intoxicated.
The new PSA also addresses the issue of building trust as seen in the clip of the friends belaying on the mountain. One must have total trust in your belay partner because your life is literally in his or her hands. Belaying is not an activity one can do while intoxicated. The friends in the new PSA build trust without the assistance of alcohol. Moreover, the PSA presents a different social norm – young, happy, attractive individuals having fun and enjoying life without alcohol. The PSA uses advertising theory to help perpetuate this norm.
Advertising theory is a key social and behavioral sciences model. It predicts how an intervention can reach and change a large group of people at the same time by using a universal appeal instead of addressing individual factors. Advertising theory is therefore comprised of attitude change theories as well (17). In advertising theory, people change their behavior or choose to follow the recommendation being given provided the ad has 4 key qualities: the ad makes a promise to the consumer, the concept being advertised has certain benefits, the benefits reinforce a core value the consumer holds dear, and the ad provides support to back up the claim being made.
In the “Don’t let alcohol give you limits” PSA, the promise being made in the ad is the ability to have fun without binge drinking. The subtle benefits to this include being able to get up early to rock climb (or participate in a different activity) and not have to worry about a hangover. Freedom and success are the core values addressed in the PSA. These core values are supported with visual images. For example, the convertible on the road with the top down is symbolic of freedom. The friends are successful because they reach the summit of the mountain and generally give off successful vibes given their happiness and attractiveness. The last scene of the PSA panning the view from the mountain also symbolizes freedom. The PSA presents youth with these two important core values which are achieved by not binge drinking and encourages the culture to not embrace heavy drinking.
In addition to the new PSA using advertising theory as a way to effectively address, understand, and change culture norms surrounding binge drinking, a partnership needs to be developed with the media. The media is responsible for educating the public on what to expect in certain social situations and is thus a socialization tool (15). Music, movies, and television show binge drinking as a common social norm. Partnering with the media and having an agreement to not actively promote binge drinking culture will reduce its normative appearance.
Consequences Do Not Necessarily Lead to Behavior - Embracing Irrationality
The “Alcohol, know your limits” PSAs’ loose basis on the Health Belief Model (HBM) adds to the campaign’s failure. The PSAs assume that because the susceptibility and severity of binge drinking were both portrayed as high in the ads, people will choose not to binge drink. However, desire to change does not necessarily lead to behavioral change. This is because people are irrational and do not follow linear, decision making processes (18). The PSAs also do not work because people lack self control and feel ownership over their habits. Habits are hard to break and people have risk aversion. In terms of changing behaviors, people will focus on what they will lose versus what they gain. Therefore, in order to solve this problem, the public needs to be presented with an alternative to binge drinking that seems worth the risk in order to break their habit. Risk aversion theory helps explain how this can work.
Risk aversion theory explains people will not gamble (whether it be their health, money, habit etc) if they feel the payoff or risk is not attractive (19). Therefore, when working to change people’s habits, the loss of the habit and/or payoff needs to be worth it for the individual. Successful behavioral interventions provide people with a large gain in place of their lost habit. A core value, like freedom, is an example of a worthy replacement of a lost habit. Advertising theory works particularly well to initiate this because it provides a big promise (in this case, freedom) to the audience and works to fill a void.
The new PSA uses advertising theory to tell people that they can attain freedom and success by not binge drinking. Not only does advertising assist with addressing social norms, but it helps with people’s irrational behavior as well. Freedom is the replacement value for the loss people experience by changing their habit. Instead of trying to scare people into changing their behavior and to not binge drink like in the old PSAs, the new PSA understands people are irrational and presents them with an alternative to their loss – freedom.
Conclusion
The proposed new PSA, “Don’t let alcohol give you limits” incorporates advertising theory and addresses where the “Alcohol, know your limits” PSAs fell short – particularly in addressing psychological reactance, social norms and culture, and irrational behavior. The new PSA creates the beginning for improved communication and binge drinking intervention among youth. More needs to be done to truly address binge drinking among youth in the United Kingdom, but the new PSA opens the door for developing more intricate interventions.
References
(1) National Institute of Alcohol Abuse and Alcoholism. NIAAA council approves definition of binge drinking. NIAAA Newsletter 2004; 3. http://pubs.niaaa.nih.gov/publications/Newsletter/winter2004/Newsletter_Number3.pdf.
(2) Centers for Disease Control and Prevention. Quick Stats Binge Drinking. Atlanta, GA: Centers for Disease Control and Prevention.
http://www.cdc.gov/alcohol/quickstats/binge_drinking.htm
(3) Andersson et tal. Alcohol and Drug Use Among European 17-18 Year Old Students. Data from the ESPAD Project. Stolkhom, Sweden: The Swedish Council for Information on Alcohol and Other Drugs (CAN) and the Pompidou Group at the Council of Europe, 2007. http://www.espad.org/keyresult-generator
(4) Alcohol Know Your Limits. Alcohol Know Your Limits – Binge Drinking Girl. June 16 2008. Online video clip. YouTube. http://www.youtube.com/watch?v=3jftfU30xJg.
(5) Alcohol You’re your Limts. Alcohol You’re your Limits – Binge Drinking Boy. June 16 2008. Online video clip. YouTube. http://www.youtube.com/watch?v=EuowE1SXNkA&feature=PlayList&p=38E9C4FB0390E743&playnext=1&playnext_from=PL&index=1.
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(7) Miller R. Mere Exposure, Psychological Reactance and Attitude Change. The Public Opinion Quarterly 1976; 40:229-233.
(8) Dillard JP, Shen L. On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs 2005; 72:144-168.
(9) Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
(10) Edberg M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett, 2007.
(11) Stein E. Can We Be Justified in Believing that Humans Are Irrational? Philosophy and Phenomenological Research 1997; 57:545-565.
(12) Dan Ariely. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: HarperCollins Publishers, 2008.
(13) Caboni et tal. Toward an Empirical Delineation of a Normative Structure for College Students. The Journal of Higher Education 2005; 76:519-544.
(14) Honess T, Seymour L, Webster R. The Social Contexts of Underage Drinking. London, England: Home Office. http://www.homeoffice.gov.uk/rds/pdfs/occ-drink.pdf
(15) DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.
(16) Carpenter et tal. After 'Unit 1421': An Exploratory Study Into Female Students' Attitudes and Behaviours Towards Binge Drinking at Leeds University. Journal of Public Health 2008; 30:8-13.
(17) Nan X, Faber R. Advertising Theory: Reconceptualizing the Building Blocks. Marketing Theory 2004; 4:7-30.
(18) Edberg M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett, 2007.
(19) O’Neill B. Risk Aversion in International Relations Theory. International Studies Quarterly 2001;45 617-640.

Heart Disease is the Leading Killer of Women - The Go Red Campaign’s Contribution – Susan Palmer

Introduction
What do you think of when you hear the term “heart disease”? Most admit to only thinking that it is the leading cause of death among men. Many do not know that heart disease is the leading cause of death among women as well. Heart disease includes any disorder affecting the heart’s ability to function properly. This term is defined by the International Classification of Diseases (ICD) and used by Center for Disease Control's (CDC) National Center for Health Statistics (NCHS), to include “acute rheumatic fever, chronic rheumatic heart disease, hypertensive heart disease, coronary heart disease, pulmonary heart disease, congestive heart failure, and any other heart condition or disease” (1). Heart disease is the leading cause of death for both men and women in the United States (US), and accounted for approximately 28% of the 1,244,123 deaths among women in 2002 (1-2). According to the CDC’s Division for Heart Disease and Stroke Prevention, “awareness of heart disease is the number one killer of women… only 13% of the women in [a] 2003 survey perceived heart disease as their greatest health problem” (1).
There is a surprising lack of public health campaigns currently in action for prevention of heart disease, especially considering the disease is the leading cause of death among women in the US. The American Heart Association (AHA), the largest voluntary health organization, has a mission to build healthier lives free of cardiovascular diseases and stroke (3). Their Go Red for women campaign launched as recently as February of 2004 and aimed to “educate women that heart disease is their leading cause of death” (4). Unfortunately, the campaign is not as recognizable as other public health intervention campaigns such as Lance Armstrong’s “LIVESTRONG” campaign for cance or Susan G. Komen’s “for the cure” for breast cancer campaign. The Go Red campaign incorporates a forgettable catch phrase and uses a red dress as their symbol, which is incidentally the same symbol for the National Heart, Lung, and Blood Institute (NHLBI) Heart Truth campaign. In a study of 81% of women reporting they had heard about heart disease within the past 12 months, only 23% of those women had “seen, heard, or read any information about the ‘red dress’ symbol” (5). Oddly, the AHA does not have the campaign advertised on their main webpage and it takes a bit of searching to find a link to the Go Red campaign. The Go Red campaign is seemingly just a slogan suggesting that women wear red to show their support for the fight against heart disease. But it is not clear how that “fight” is being employed. How is wearing red really going to get the word out there that heart disease is the number one killer of women? The failure of this public health campaign contributes to lack of awareness of heart disease among women.
A Flawed Foundation
One major flaw of the campaign is that it seems to have been designed upon the Health Behavior Model (HBM). Based on the HBM, the campaign assumes that a woman will rationally consider her susceptibility to heart disease and the severity of heart disease if action is not taken (6-8). The campaign attempts to educate the possible risks and severity of heart disease if left untreated by providing heart disease statistics and literature on their website. It is assumed that if a woman perceives a high risk and severity of heart disease, she will then contemplate the benefits and barriers to a proposed action. The campaign’s aim is to empower women to the benefits of talking to their doctor about heart disease. By providing a “Go Red Heart CheckUp” on their website, the AHA is providing a forum upon which women can check their heart disease risk online and then print the results to bring to their next visit to the doctor. The idea here was to show women that the costs of assessing heart disease are low and access to information is plentiful, and thus the barriers are low. Upon determining that the benefits are high and the barriers are low, the campaign assumes a woman will move forward with intent to lower her heart disease risk.
In theory, this campaign would educate and persuade a woman to take preventative action against heart disease. However, few studies have evaluated whether perceived susceptibility to heart disease is associated with action to lower that risk (5). The campaign does not account for the social and environmental factors that influence a woman’s decision, such as language barriers, and lack of access to a computer or internet to utilize their website (6-8). It also does not account for those who lack access to healthcare because they do not have health insurance or do not live within close proximity to a hospital or doctors office. Additionally, the campaign does not have motivational measures in place. For example, a woman may have heard of the Go Red campaign, accessed the website, decided to assess her risk of heart disease using the “Go Red Heart CheckUp,” and found that she was indeed at risk for heart disease. When prompted at the end of the “CheckUp” to print the information out to bring to her doctor, she did so intending to schedule a visit. However, as in most cases, her doctor could only schedule her for a visit 2-3 months later, and during that lapse in time between the intention and the action, the woman decides it is not as important as originally thought, or she has a scheduling conflict, and cancels her appointment. The woman is not motivated to see her doctor or address her risk of heart disease and six months later she has a heart attack. The campaign has failed its mission.
Undermining the Call to Action
The Go Red campaign encourages awareness through informational education, but lacks tools to promote self-efficacy. Self-efficacy in this case is a woman’s belief that she can perform a certain behavior (6-8). Specifically that would mean taking steps to preventing heart disease by lowering her risks. This campaign does not translate the message into real world action to prevent heart disease. The idea of “action” for this campaign is to wear red and be educated on heart disease risks. In reality, action should be promoted not only as a chat with your doctor about your risks, but by getting involved in exercise programs or smoking cessation classes to lower risks. A 2006 study reported that women who expressed self-efficacy believed their actions could impact their risk of heart disease (5). These women were more likely to take part in physical activity and to have lost weight in the previous year (5). The study also reports that the five most common motivators for taking action to lower their risk were 1) wanting to improve health, 2) wanting to feel better, 3) wanting to live longer, 4) wanting to avoid taking medications, and 5) did it for their family (5). So it seems that there is not a lack of “wanting” to be healthy, and that the real problem may be that women are not provided with the tools to help them take action.
The Go Red campaign’s attempt to advocate action includes long “to-do” lists of ways to decrease the risk of heart disease. Such lists include “make easy lifestyle changes,” “tips for women at work,” “tips for moms on the go,” “tips for traveling for work/play,” “love your heart: relaxation tips,” with each list containing at least five actions (4). While providing helpful tips for heart-friendly activities is a step in the right direction, long “to-do” lists may prove to be more overwhelming than anything else. Tools to promote self-efficacy by showing her how to take action are not provided.
In most cases, an individual who learns a behavior by observing others and builds the skills to do that behavior will be more likely to do that behavior, especially if they believe that the behavior will lead to a positive outcome. Simply providing lists of heart-healthy activities is not enough to promote self-efficacy. Women need to feel as if they can be successful and will receive positive reinforcement for engaging in these activities. Offering AHA sponsored activities such as free heart disease risk assessment, physical activity classes, and heart-healthy nutrition seminars may help build self-efficacy. By providing women with the skills and motivation, as well as interaction with others who have heart disease risks, it will motivate them into action. Without provision of self-efficacy tools, women will feel helpless despite their “want” to take action to reduce heart disease risks. The campaign has failed its mission.
Missing the Target
Despite the reality that heart disease is the leading cause of death among women in the US, a survey conducted by the AHA in 1997 indicated that 62% of women believe cancer is the greatest health threat for women (9). Since that survey was taken, and new public health interventions have been implemented, an increase in awareness of heart disease risk has been documented (2, 5, 9, 10, 11). However, it remains inconclusive whether greater awareness has led to increased preventative actions among women (5). The Go Red campaign may only be targeting women who already perceive themselves as having a high risk of heart disease, and not those that are unaware of their risk. A study run by the AHA found that awareness was significantly greater among those who perceive themselves as having a high to moderate risk compared to those at low risk (5).
The CDC reported in 2002 that age-adjusted death rates for heart disease were higher among African American women (169.7 per 100,000) than among Caucasian women (131.2 per 100,000) (12). A 2006 study reported that racial and ethnic minorities, such as African-American women, were less likely than whites to be aware of their heart disease risk (5). Of those who were aware of a risk, minorities were more likely than whites to underestimate their risk (5). The Go Red campaign uses television, print, radio, internet, and billboards to advertise the campaign. However, the number of advertisements is limited and they fail to target African American women, who are the highest risk group. Print advertisements in newspapers and magazines are most inclusive of African-Americans. In these ads, a picture of an African-American woman is used in tandem with the Go Red slogan and message to “Go Red in Your Own Fashion” (4). However, of women aware of heart disease information, more Caucasian women (46%) reported magazines as their source of information, compared to 28% of African-American women. The Go Red campaign does not use television, radio, or billboards to target the African-American group and only use Caucasian women in the advertisements (with a Hispanic radio version available dubbed in Spanish) (4). These forums should not be discounted by the Go Red campaign and may contribute to the lack of awareness among African-American women.
A 2000 study reported that less than 20% of African-American women mentioned that they were well informed about heart disease (10). When asked to list warning signs of heart attack, less African-American women than Caucasian women correctly identified chest pain, shortness of breath, pain in the arm, chest tightness, and nausea (10). For a public health campaign designed to raise heart disease awareness among all women, Go Red seems to mostly reach Caucasian women, and not the highest at risk group of African-American women. The campaign has failed its mission.
Conclusion
The AHA’s Go Red campaign’s mission to spread awareness that heart disease is the leading cause of death among women has failed. For one, the campaign’s foundation has cracked under the pressure of the HBM’s lack of consideration for irrational behavior. Social and environmental factors that influence a woman’s decision are not accounted for and contribute to the campaign’s failure to educate women. The campaign lacks the tools necessary to empower women to believe their actions could impact their risk of heart disease. Instead of only promoting the wardrobe choice of wearing red, the campaign should provide resources for women to join exercise programs or smoking cessation classes to lower heart disease risks. Additionally, the campaign contributes to the lack of awareness among African-American women by not targeting this high risk group in their campaign efforts. These awareness and preventive action gaps in the Go Red campaign contribute to preventable heart disease among women in the US and must be amended before more lives are lost.
Counter-Proposal to the Go Red Campaign for Heart Disease among Women
Introduction
Improvements must be made to the current approach implemented by the Go Red campaign, whose mission to spread awareness and prevent heart disease among women is failing. An alternative campaign will attempt to remedy the major flaws of that approach and feature a new design to support a shift towards empowerment. The new design will remove the Health Behavior Model (HBM) from the foundation and instead consider social and environmental factors, implement tools empowering women into action, and target African-American women, the most at risk group affected by heart disease.
The new public health campaign proposed will promote heart disease awareness through organized walk/run/bike events in all major cities throughout the year, focusing on team participation and fundraising efforts. Participants will have the option of signing up individually or with a “team,” and to raise a minimum amount of money by the day of the event. The funds raised will go towards heart disease advocacy efforts. This campaign is modeled after two of the most renowned public health campaigns, the Susan G. Komen breast cancer Race for the Cure and the Lance Armstrong LIVESTRONG for cancer. Both campaigns heavily promote advocacy for cancer awareness through physical activity and fundraising events such as walk/run or bike races. The new campaign will frequently advertise the events using various media including television, radio, internet, billboards, and magazines. Paired with popular sponsor involvement (New Balance, Nike, Powerade, etc.), the cause will be able to reach a wide audience. In addition to promoting physical activity on the day of the event, the sponsors will provide free local heart disease risk assessments/screenings, heart healthy physical activities and nutritional seminars throughout the year in effort to provide women with the tools to live healthy lifestyles and stay motivated.
Building a Strong Foundation
The HBM is a weak foundation upon which to design a public health campaign because it does not take into account all factors that influence an individual’s decision on whether or not to do a behavior. Upon studying the HBM, researchers have reported that despite various preventative measures provided free or at low cost, people fail to take advantage of early detection (7). This new heart disease awareness campaign aims to take advantage of alternative health models which are based on the theory that behavior is irrational, people are influenced by expectations, have difficulty with self control, and place a high value on ownership.
The new campaign will be based upon the Social Network Theory (SNT), the main premise being that groups of people change together. The relationships that people have with each other, such as families, work groups, or other social groups, influence each others’ beliefs and behavior (6). People exist in social networks and change as social networks, not only as individuals. This campaign strives to work with this theory to provide women at risk for heart disease the tools to build a heart disease social network. This social network will be the forum upon which they become empowered by each other to address the disease in a proactive manner.
Specifically, a woman at risk or who already has heart disease will become a member of an event team working together to improve their physical, nutritional, and emotional health in tandem with promoting awareness. Team members involved in working towards the walk/run/bike event will recruit others into the team (or “network”). Whereas the SNT typically identifies small networks to disseminate information, the new campaign builds upon the theory to appeal to a larger population. An article assessing the dynamics of a large social network on smoking cessation, describes how people seemed to be under the “collective pressure” within networks to quit smoking (13). This can also be applied to promoting healthy behavior such as heart healthy physical activity.
While the campaign may start with one person deciding to join a heart disease awareness event, that one person can recruit others to become a member of their “team,” thus spreading awareness to others (6, 13). Where the Go Red campaign was hitting barriers, the new campaign’s efforts would not be negatively impacted by lack of access to a computer or internet, or lack of access to healthcare, since the events would be locally available to all participants. Motivational measures would be in place and awareness of heart disease among women would spread.
A Time to Act
The Go Red campaign failed to translate their message into action by only advocating education on heart disease risks and wearing the color red. The new campaign aims to provide women with the tools needed to promote self-efficacy. Women have reported the intent to participate in healthy behavior, but they need to believe they can lower their risk of heart disease, and be shown how to do that (5). The new campaign offers events to get people participating in heart disease awareness activities.
Sponsored activities such as free heart disease risk assessment, physical activity classes, and heart-healthy nutrition seminars will help raise awareness and build self-efficacy. Encouraging women and their teams to not only participate in a local walk/run/bike event, but also to participate in free health activities will motivate life-long healthy behavior. The most important factor in the decision to do a behavior is the idea of “self-efficacy” where the individual has self-confidence in the ability to do that behavior. This new campaign will encourage women to participate in an event that is heart healthy, offers encouragement through a team atmosphere, and aids in holding participants accountable through fundraising efforts.
The “team” factor will not only be the primary motivator on the day of the event, but will also be a source of continuous support during the time leading up to the event. Participants will be more likely to adhere to a physical and nutritional regime if they have others (their team) to report to (13). Raising money will also keep participants accountable to sticking with the event. By asking people to donate to their event, they are much less likely to drop out, and more likely to stay motivated. Involvement in this campaign creates a sense of community where everyone is working together to get healthy and raise awareness for heart disease. The belief that the campaign will lead to a positive outcome will reinforce life-long healthy behavior and participation in heart-disease awareness efforts.
Tailoring the Message
Many women report that they believe they are most at risk for breast cancer, which infers that the Go Red campaign has failed to deliver their message (9). Specifically, African-American women who are most at risk of heart disease have reported not being well informed about heart disease risks (10). The new campaign aims to reach a wider audience, particularly African-American women. Heart disease awareness walk/run/bike events will be held in or within close proximity to major cities, targeting the areas with a high African-American population. Additionally, free local heart disease risk assessments/screenings, heart healthy physical activities and nutritional seminars will be available throughout the year in effort to provide women with the tools to live healthy lifestyles and stay motivated at no cost to them. A 2006 study found that friends and/or relatives were more influential in motivating preventive action in nonwhites than whites (5). This finding is supported by the new campaign’s team participation design, predicting that team members, in particular African-Americans, will help support each other’s efforts towards heart healthy behavior.
All events will be heavily promoted using television, radio, internet, newspapers, magazines, and billboards. Advertisements will include versions specific to Caucasian, African-American, and Hispanic women so that the target audience(s) can personally identify with the message. In a 2003 study, 41% of African-American women reported television as the most common provider of healthcare information (2). Based on this information, a higher concentration of advertisements tailored towards African-American women should be broadcast on television. By simply increasing the frequency, circulation, and tailoring of advertisements to African-American women, the campaign should reach more people and increase awareness of heart disease.
Conclusion
The new public health campaign proposed will promote heart disease awareness through organized physical activity events in all major cities throughout the year, focusing on team participation and fundraising efforts. The new design will be supported by the SNT, concentrating on the relationships that people have with each other and the positive influence of social networks. Tools such as free local heart disease risk assessments, heart healthy physical activities, and nutritional seminars will be made available, empowering women into action. Advertisements tailored to African-American women will reach a larger number of those most at risk of heart disease. The combined effort of all three aspects of the new public health campaign will expand its reach more women at risk and hopefully motivate those women into action. REFERENCES
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