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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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














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

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

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

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

5 U.S. Department of Health and Human Services. Minority Women’s Health, Breast Cancer. http://www.womenshealth.gov/minority/africanamerican/bc.cfm.

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

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

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

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

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

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

12 US Census Bureau. Computer and Internet Use in the United States. Washington, DC: U.S. Department of Commerce. http://www.census.gov/prod/2005pubs/p23-208.pdf.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

27 Cleveland Clinic. Breast Cancer in Young Women. http://my.clevelandclinic.org/disorders/breast_cancer/hic_breast_cancer_in_young_women.aspx.

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

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

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

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

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

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

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

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

The Failure Of The Shape Up Somerville Program To Adequately Address Children’s Healthy Behaviors Outside Of School

Introduction

“Shape Up Somerville: Eat Smart. Play Hard.” was a three year long program that began in 2002 aimed to lower the body mass index of early elementary school children in the city of Somerville, Massachusetts. This program was comprised of a number of interventions geared towards promoting healthy eating and exercise behaviors in these children before, during, and after school. Although this program succeeded in lowering children’s body mass index after the first year of implementation (4), it failed to adequately address children’s unhealthy habits outside of school. A recent research study found that “Hedonic factors, rather than reasoned judgments, may help drive children's intentions” (6). These hedonic factors reinforce the importance of addressing children’s eating and exercise behaviors outside of the school setting. This all-encompassing approach is crucial to long term success in the promotion of healthy behavior promotion in children.

Children spend five days a week, nine months out of the year in school and may only consume one meal at school during the school day. This is one meal out of three a day that can be directly impacted by the school’s healthier food interventions. Also, only about 60% of the Somerville study population participated in receiving a school lunch; leaving 40% that would not benefit from an in-school healthy food intervention (6). It is therefore critical that the Shape Up Somerville program consist of multiple comprehensive interventions aimed at addressing children’s healthy eating and exercise behaviors outside of school. The interventions that were initiated outside of the school setting were inadequate and did not address children’s access to healthier foods, target the children’s families appropriately in disseminating information about healthy interventions, or accurately target lower activity level improvements in children.

Addressing Children’s Accessibility to Healthier Foods Outside of School

The Shape Up Somerville program does not address the population’s access to healthier foods, notably this population’s financial and geographical barriers. A previous study examining the link between parents and their ability to change their children’s obesity status has shown that families with a higher income level are more likely to adhere to healthy behaviors (8). Fresh produce and healthy food products are traditionally more expensive than processed foods with lower nutritional value (10), so it is expected that lower income families will have problems purchasing healthy foods. The median household income of this study population was around $42,000 with approximately 13% of the families living below the poverty level (4). The study population was comprised of low to middle income families, thus a significant financial barrier is in place that prevents these families from being able to purchase healthy foods. No interventions were put in place in the Shape Up Somerville program to address these financial barriers.

Parent outreach and education was the only out of school intervention implemented as a means to boost healthier eating behaviors. The idea of educating parents about healthy eating follows the Health Belief Model. This model finds that once individuals are educated on the benefits and importance of a healthy behavior, they will adhere to the healthy behavior. Individuals, in fact, may be educated on a healthy behavior, but may not choose to engage in the healthy behavior. A study assessing environmental contributions to obesity found that telling individuals to eat healthier without addressing their current food supply as seen in parent outreach and education will only result in limited success (11). A list of restaurants adhering to the “Shape Up Somerville” health campaign was also developed as a part of this program, but for families who are struggling financially, this information is irrelevant due to the cost associated with eating at restaurants.

Being located in an urban area, these families also have geographical barriers in place to prevent them from eating healthy. As noted earlier, Somerville is a predominantly low to middle class income area and grocery stores in higher income areas are likely to have more nutritious foods than grocery stores in lower income areas (7). There may not be grocery stores with healthy foods within walking distance or within a comfortable public transportation distance. With financial barriers already in place to prevent families from eating healthfully, it is unlikely that these families have cars that they can use to drive to grocery stores that have fresh produce and/or natural food products. In a New England Cable News video clip describing the Shape Up Somerville program and its increase of fruits and vegetables within the school, Mary Jo McLarny, director of Somerville Food Services, discussed the success of the program within the school and stated that they had to “… teach children what these fruits and veggies are because they don’t have the opportunity to eat them at home” (13). It is unfortunate that public officials who are involved with the Shape Up Somerville program are aware that children cannot receive healthy foods such as fresh fruits and vegetables at home and do nothing to address this deficiency. It weakens children’s self-efficacy when they have access to fruits and vegetables in the school setting and are educated about eating healthy, but are then unable to eat the same healthy foods and implement what they have been taught about eating healthfully when they are at home. This also puts parents in an awkward, and potentially shameful, situation because they may be forced to explain to their children why they are unable to eat as healthfully at home as they do in school. As part of the Shape Up Somerville program, children went on field trips to organic farms to learn more about fruits and vegetables. These trips were counterproductive in that children were exposed to fresh produce and its benefits, while there is limited or no access to healthy produce at home.

Insufficient Healthy Eating and Exercise Information Dissemination to Children’s Families

This program does not accurately target its audience; moreover its intervention to disseminate information to families on how to develop healthier eating and exercise habits is fundamentally flawed. It is helpful for healthy interventions to focus on parental behaviors because parents determine the diet and physical activity practices of their children (12). It is also likely that parents need assistance with healthy behavior adaptation when their children need help” (8). The interventions used in the Shape Up Somerville program to educate parents on healthy eating and exercise habits disseminated instructive documents online, provided information through a bi-monthly newsletter, and discussed healthy behavior changes through in-person parent nutrition forums. Online information and in-person parent nutrition forums are not likely to help families with financial barriers because these families may not have the luxury of a computer and internet connection at home or they may not be able to spend time outside work or family to attend an in-person forum. These interventions also did not take the cultural diversity of the study population into account.

The Principal Investigator admits that “Given the ethnic diversity, different languages spoken….we were not able to gain consent for all eligible children in the three communities” (4). Despite recruiting a study population that admittedly does not mimic the ethnic diversity within the city of Somerville, one third of the families involved in the Shape Up Somerville program did not speak English at home (4). There was an understanding at the beginning of the study that diverse cultures were present in the study population and efforts were initially made to engage these populations. At the beginning of the program, parents were sent a pre-intervention questionnaire to fill out that was translated into Spanish, Portuguese, or Haitian-Creole when appropriate. (4) A research study that focused on healthy interventions in minority populations found that healthy eating and exercise interventions “…may be particularly critical for African Americans and Hispanics, a relatively neglected and greatly expanding sector of the population” (5). These minority populations are therefore important to keep in mind while generating healthy eating and exercise materials for families. The educational materials available online included various types of information such as tips on how to grocery shop for healthy foods and how to develop a family plan for a healthier future. Unfortunately these online documents and the bi-monthly parent newsletter were only provided in English and thus did not educate parents who may not speak English fluently. The parent nutrition forums that were offered did not appear to be offered in multiple languages and thus would also only help parents who speak fluent English. The healthy eating information provided in these documents focuses on healthy American foods, which may not be the staple food within a child’s home. Providing information on how to eat healthfully within a cuisine that is not consumed in a family’s household is much less likely to result in a healthy food modification. For example, the “Healthy Snack Guide” focuses on snacks low in sugar, fat, and sodium (2), which is contrary to some of the cuisines represented in the cultures of Somerville. One example is Haitian cuisine, which consists of foods that are traditionally high in carbohydrates and fat (9). The development of a healthy eating plan must take the various ethnicities of Somerville and their traditional cuisines into account. This will ensure that families will see the healthy eating plan as a viable alternative because the plan will encompass the families’ culture and traditions.

Targeting Low Activity Level Improvements Outside of School

This program does not accurately target low activity level improvements outside of school. The only intervention developed to address low activity levels in these children outside of school was through a Walk to School campaign. Somerville is a relatively population dense urban area with two major highways running through the city. It also contains multiple subway stations and bus stops. The children enrolled in this program are in Grades 1-3 and are therefore between 5 and 10 years of age, which is a young age to be walking to and from school regardless of adult supervision. Safe routes for children to use to walk to school were developed, but the criteria used to determine safety were not delineated. One could argue that the safe routes were deemed safe because they include pedestrian signage or painted crosswalks at road intersections. These routes may not take into account areas that are known to have large volumes of vehicular traffic or higher crime rates. A child’s safety and security is much more important than the limited exercise that would be received through walking to and from school.

Parents in urban areas have reported that they “…prefer having their children watch television at home rather than play outside unattended because parents are then able to complete their chores while keeping an eye on their children” (3). No out of school interventions to address low activity levels within the home were created as a part of this program, which further fails to engage this target urban population. A recent study found that girls of all races and non-Hispanic blacks are most likely to have low activity levels and high levels of watching television (1). This subpopulation would benefit from additional incentives and there are no aspects of this program that seek to cater to this population in need.

Conclusion

By concentrating the majority of its healthy eating and exercise interventions within the school environment, the Shape Up Somerville program compromised its level of effectiveness. Increased interventions outside of school, along with more substantive contact with children’s parents and families, would have resulted in a higher success rate of reducing obesity within the study population. The out of school interventions also do not taken the ethnic diversity of the city of Somerville into account, which also impeded the program’s success. Addressing all aspects of a child’s environment is crucial in promoting a healthy behavior change.

Addressing The Failure Of The Shape Up Somerville Program To Adequately Address Children’s Healthy Behaviors Outside Of School

Introduction

The Shape Up Somerville program was successful in teaching children within the school setting to employ healthy behavior changes such as eating fruits and vegetables and exercising, but failed to initiate successful healthy behavior change programs outside of the school setting. Although school is an ideal place to affect healthy behavior changes in children, settings outside of school can also be effective in employing healthy behavior change (3).

A successful healthy behavior change program outside of the school setting must take the surrounding community into account. There are social, cultural, and geographical aspects of a community that must be reviewed in order to develop a successful healthy behavior change program. These various aspects of a community have been addressed in the following revised Shape Up Somerville program. This program ensures that children have access to healthy foods outside of the school setting, children’s families are educated in a culturally sensitive manner, and children are given a wider range of options to exercise outside of the school setting.

Addressing Children’s Accessibility to Healthier Foods Outside of School

Food prices affect the way a family will conduct their grocery shopping, i.e. food that is cheaper, although nutritionally poor, is more likely to be purchased than food that is more expensive and healthier (3). Consequentially, families with economic hardships are at a disadvantage because they are more likely to purchase cheaper nutritionally inadequate food. The city of Somerville contains a large amount of low and middle-income families (4), which need to be taken into account in the revised Shape Up Somerville program in terms of getting children to eat healthier. This financial barrier will be reduced by giving economically disadvantaged families access to no-cost or low-cost healthier foods through organic produce deliveries or organic farms.

Boston Organics is a company that delivers organic locally-focused produce to the Boston area on a weekly or bi-weekly basis (14). As part of the revised Shape Up Somerville program, economically disadvantaged families would receive the organic produce delivery at reduced or no cost, which would improve families’ access to fresh produce. Boston Organics supports local produce and by participating in this program, they would also support local communities and be able to advertise their charitable campaign. By drawing attention to one of the many hardships that economically disadvantaged families face, Boston Organics is setting the agenda to help neighborhoods in need of access to fresh produce.

As part of the original Shape Up Somerville program, children were sent on field trips to organic farms to be educated on the different types of fruits and vegetables and how fruits and vegetables are grown. This field trip would be expanded to include children bringing home some of the fruits and vegetables at a reduced cost or at no cost to improve family access to fresh produce. The organic farms could provide this produce by giving fruits and vegetables that are good, but perhaps smaller in size or closer to expiration and thus not profitable to sell. These farms could market their charitable giving to further set the agenda of providing healthy foods to families in need, like Boston Organics. Giving families increased access to fresh produce is not guaranteed to employ a healthy behavior change; however the children receiving and eating fresh produce within the school setting will generate a social norm of eating fruits and vegetables. This social norm will influence children’s parents and families to eat and cook with fruits and vegetables within the home.

The original program generated a list of restaurants within the area that carry healthy dishes. Eating at these restaurants is considered out of reach for many of the low to middle income families who cannot afford to eat out. These restaurants would employ time periods and days (for example. Tuesdays between 6:00 and 8:00 pm) where prices are reduced so that families with a lower income are able to afford a healthy meal outside of the home. The restaurants could choose this date and time based on their internal food deliveries so that food that would normally spoil and go to waste is instead sold and eaten on the reduced price night. The restaurant will also garner increased business on the reduced price night than it would during the same time period without the price reduction. The reduced price night implementation would not stigmatize economically disadvantaged families because they would not be singled out for their lower economic status.

A major geographic barrier that children’s families face is grocery stores with limited fresh produce near the families’ homes or fresh produce available at grocery stores that are outside of walking distance or comfortable public transportation distance. A solution to this geographical barrier involves recruiting farmer’s markets to neighborhoods in need. Farmer’s markets traditionally sell fruits and vegetables at a lower cost than grocery stores, which improves financial accessibility of fresh produce to lower-income families. A program would also be established to provide periodic weekend busing to healthy grocery stores to improve geographic as well as financial barriers to children and their families. Children and their families will have an increased sense of self-efficacy with these interventions in place because eating healthy will not occur only within the school and will no longer be out of reach outside of the school.

Healthy Eating and Exercise Information Dissemination to Children’s Families

Currently there is more information disseminated by the media regarding overeating and eating poorly than there is about portion control and eating healthy foods (7). Although children have been educated about eating healthy and exercising within the school setting, they are unable to control their household’s healthy eating and exercise habits. The previous Shape Up Somerville program disseminated educational information about eating healthy within the American cuisine in English via newsletters and websites. Children’s families should be educated about eating healthy in a language that they can understand and in a manner that is consistent with the traditional cuisine served in their home. The revised Shape Up Somerville program caters to a broader audience of families through culturally sensitivity and increased modes of communication.

Information about eating healthy and exercising will be disseminated in some of the major languages spoken in the area of Somerville beyond English, namely Spanish, Portuguese, and Haitian-Creole (4). Individuals within the communities who are bilingual will be recruited to translate this information to assure that the translation is done in an understandable layman’s term format and as a method to reduce costs. For those who do not have internet access within the home, the online newsletter information that is translated into the appropriate language will be disseminated at school and brought home by the child in paper format.

The in-person nutritional forums that were taking place will involve interpreters, who would be members of the community, to serve as interpreters for the forums. Initially, a wide range of families within the community will be sampled to ensure that individuals who speak different languages within the community would attend the in-person nutrition forums. The forums may prove not to be beneficial to this population, who may be busy with work and home life responsibilities.

In order to address the different cuisines eaten by the study population, the respective cultural communities will work with students studying dietetics to develop healthier recipes that adhere to a family’s cultural cuisine. Students from nearby colleges pursuing a degree in nutrition would be tapped as a resource to help develop healthier recipes. The use of students would keep costs down, while ensuring a level of nutritional specialization. This collaboration would also prove helpful to the student and would be incorporated with his/her coursework. With this intervention in place, future dietitians will be sensitive to an individual’s culture and traditional cuisine in their nutritional advice and consultation.

Targeting Low Activity Level Improvements Outside of School

The previous Shape Up Somerville’s program to address low activity levels outside of school through a walk to school program is insufficient because it compromises the safety of the children. The revised program employs other means of exercise outside of school to ensure that low activity levels are targeted and alleviated.

Different means of exercise can occur within the home or in an after school program.

Video game play involving movement and significant caloric expenditure has recently come to the forefront in U.S. media. Two video game methods that are known for their aerobic abilities include the use of the Wii console and the video game Dance Dance Revolution. The Wii console and controllers are developed in a dynamic way that encourages player movement, instead of traditional video game controllers that limit a player’s movement to use of the hands only. There are numerous games for the Wii that promote physical activity such as tennis, basketball, and a game called the Wii fit that showcases activities such as yoga and skiing. Dance Dance Revolution is a game that is based on a player jumping on a board of four arrows in tune with the sounds and movements emitted through the speakers and on screen, ensuring a formidable workout. These consoles and games would be donated from the companies who developed them, sell them, or from members of the community who no longer use them.

A recent study finds that “Children who are approaching adolescence, girls, and non-Hispanic blacks are most likely to have low levels of active play and high screen time” (1). An afterschool program has previously been developed that targets these populations in the form of a Latino dance class. This class, called Dance for Health, was originally developed in California as a 12 week program for the seventh grade population (5). The dance class was offered in place of physical education during the school day and was successful in lowering BMI and heart rate among participants (5). This class would be offered after school in the context of the Shape Up Somerville program after school, on weekends, and/or both. Dance class is a method of packaging exercise as a fun way to spend time with friends along with the side benefit of caloric expenditure.

Conclusion

Addressing healthy behavior change outside of the school setting will reinforce the aims of the Shape Up Somerville program and make the program more effective. By taking into account previously neglected aspects of the children’s community such as geography, culture, and socio-economic status, a successful healthy behavior change program can be implemented. The Shape Up Somerville program can now fully encourage participants to “Act Right, Play Hard.”

References

1. Anderson SE, Economos CD, Must A. Sociodemographic and weight status characteristics in relation to physical activity and screen time in US Children ages 4-11 years. BMC Public Health. 2008 Oct 22;8: 366.
2. Children in Balance. Tufts University. 2008. .
3. Dehghan M, Akhtar-Danesh N, Merchant AT. Childhood obesity, prevalence and prevention. Nutrition Journal. 2005; 4: 24.
4. Economos C, Hyatt R, Goldberg J, Must A, Naumova E, Collins J, Nelson M. A community-based environmental change intervention reduces BMI z-score in children: Shape Up Somerville first year results. Obesity. 2007; 15: 1325-1326.
5. Flores R. Dance for health: improving fitness in African American and Hispanic adolescents. Public Health Report. 1995; 110:189 –93.
6. Folta SC, Bell R, Economos C, Landers, S and Goldberg JP. Psychosocial factors associated with young elementary school children's intention to consume legumes: a test of the theory of reasoned action. American Journal of Health Promotion. 21:13-15, 2006.
7. French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annual Review in Public Health. 2001;22:309 –35.
8. Golan MW, Apter A, Fainaru M. Parents as the exclusive agents of change in the treatment of childhood obesity. American Journal of Clinical Nutrition. 1998;67: 1130 –5.
9. Haiti Directory. Com. .
10. Healthy food getting more expensive: study. Reuters. 2 January 2008.
11. Hill JO, Peters JC. Environmental contributions to the obesity epidemic. Science. 1998;280:1371–4.
12. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1990-2000. Journal of the American Medical Association. 288:1728 –32.
13. Shape Up Somerville: NECN - Call to Revolution. March 22, 2008. Online video clip. Youtube.com. April 1, 2009. .

Boston Organics. http://www.bostonorganics.com/index.html.

The Funding that has Fueled an Ineffective Intervention-Isadora Nogueira

Intervention: The President’s Emergency Plan For AIDS Relief (PEPFAR) and the Official AB Policy in Uganda

Although a public health intervention’s purpose is for societal improvement, it may be ineffective end harmful if not implemented adequately. In 2004, the Bush administration approved its plan for AIDS relief in Africa- the Presidents Emergency Plan for AIDS Relief (PEPFAR). PEPFAR provides a total of fifteen billion dollars within a five-year period to fourteen African and Caribbean countries. The White House will give $6 billion this year for global AIDS. However one of the requirements for the country receiving the funding is that one third of the overall prevention budget and two thirds of the behavioral prevention budget be spent on abstinence/being faithful (AB) programming. Not only does it dictate that thirty-three percent of the funding go to abstinence-until marriage programs, it limits condom-distribution to “high risk” groups and does not allow the funding to be spent on sex workers (1). In Uganda, with the PEPFAR funding, the government established an official “AB” policy in 2004, undermining the previous ABC policy which included promoting condom (C) usage. Before the AB policy, HIV activists in Uganda had spent the last two decades trying to normalize condom usage. PEPFAR’s guidelines for funding, which has fueled the official AB policy is ineffective and may do the opposite of its intended purpose: to decrease the spread of HIV. The past couple of years HIV in Uganda has actually increased (2). PEPFAR is ineffective because it places too much emphasis on internal characteristics of the individual. Furthermore, it does not universally address all the groups in the community while increasing the stigma on those who become infected. Lastly, it does not take into account the cultural behaviors prevalent in the community.

The AB plan heavily emphasizes internal characteristics, failing to take into account external factors.
Abstinence and Be Faithful policies emphasizes self-control and will-power of the individual. Albert Bandura’s Social Cognitive Theory (SCT) addresses the interplaying factors of behavior- the individual characteristics, environmental factors, and interactive process between the individual and social/environmental cues (3). Using the SCT, the AB method fails to consider the variety of other factors that affect behavior, and only emphasizes the internal characteristics such as behavioral capability, expectations, and self-control. However, solely addressing these characteristics is not enough. Even if the individual has the intention to avoid sexual intercourse, it may not necessarily translate into action, for we are influenced by much more than our own characteristics but by those around us. Furthermore, even excluding the environmental and social influence, sticking to the AB policy is difficult nonetheless. According to past research and interventions, abstinence is tough and even people who swear by it have a hard time sticking with it (4). Ninety-five percent of the American population has premarital sex (5). In the study Promising the future: virginity pledges and first intercourse, teens who pledged not to have premarital sex were followed over the period of six years. Sixty percent of these teens had broken their vow, which supports the notion that intention does not translate into behavior. Furthermore these teens who pledged to refrain from sexual intercourse until marriage were more likely to engage in oral and anal intercourse and less likely to use condoms compared to non-pledging teens (6). In the United States, the abstinence approach has been ineffective in twelve different states(2).

Not only has the abstinence approach been ineffective in other countries, it also goes against empirical evidence on what has been effective in Uganda. In the last decade, HIV incidence in Uganda has decreased due to comprehensive preventative efforts. The AIDS prevention campaign which was initiated in 1982 has been credited with helping decrease HIV prevalence from around 15% in the early 1990s to around 5% in 2001. This first AIDS prevention campaign was called the ABC approach - encouraging sexual Abstinence until marriage; advising the sexually active individuals to Be faithful to one partner; and advising Condom use (7). The ABC approach was effective because it took into account the possibility of the individual being affected by others around him, considering the overall social and physical environment, where it is common to have sexual intercourse before marriage. The individual may be influenced by modeling, the behavior of others and by positive or negative reinforcements from that behavior. Since the adolescent or adult are not completely resistant to societal influence, a public health intervention must include a preventative method that takes these factors into account. Hence encouraging condom usage and increasing their availability are key for HIV prevention. The number of condoms delivered and promoted by international groups rose from 1.5 million in 1992 to nearly 10 million in 1996. Within the last decade the C for condom in ABC has been removed. Uganda did not implement abstinence education on a large scale until the United States began promoting these programs internationally around 2001. During the 2000-2005 period when the PEPFAR was passed the HIV prevalence has increased to 5.4% and continues to increase since the shift to abstinence interventions were made. There are currently 940,000 people currently living with HIV in Uganda (8). Health policies in Uganda should be dictated by what has been effective in the past, which should address more than just individual characteristics, but external factors and the interactive process between the social/environmental cues and the individual.

The AB policy is not completely effective, increases stigmatization of HIV, and discriminates against certain groups.
Even if the individual is able to stick to the AB program, it does not guarantee that he or she will not be infected by the HIV virus. Abstinence does not protect faithful couples if one is already infected, married couples who have sexual intercourse outside of the marriage, rape victims, injecting drug used, sex workers and people who are already infected. And since in the AB policy, the person is expected to wait until marriage to have sexual intercourse, it assumes that everyone has the intention and capability of getting married, which is discriminatory and excludes certain groups of people. Homosexuals are not by law permitted to get married, so how does abstinence until marriage apply to the gay population? The abstinence policy also discriminates against sex workers, in which the person makes their living off of sexual intercourse. Those who support their families by this profession will most likely not follow the abstinence policy (2). The AB approach has also contributed to increase in stigma on those infected with HIV. The Behavior Change Communications (BCC) theory is an approach developed primarily in the global health context integrates several behavioral change theories ranging from Diffusions of Innovations to Social marketing theory. The BCC has been widely used in designing HIV interventions. One of the major goals of a BCC program are to reduce stigma and discrimination, an important characteristic of what makes a public health intervention effective (3). The AB policy does the opposite, and actually increases stigma and discrimination related to AIDS. Solely promoting messages that advocate abstinence and partner reduction stigmatizes and demoralizes those who do become infected. The message that for the person to prevent infection, he or she must resist temptations and maintain fortitude puts an overwhelming pressure on the individual and demoralizes him if he does become infected. And in countries where 90% of the population does not know their HIV status, how does one identify and avoid sexual interaction with those who are infected and those who are not (2)? Furthermore, for those who know of their HIV positive status, is he expected to not have any sexual interactions with anyone for the rest of their lives? Abstinence would promote that no one should have sexual encounters with the HIV positive person, an extremely demoralizing stigmatization to carry throughout life if the person is the one who is infected. The overemphasis on abstinence and faithful relationships increases stigma and discrimination on those who become HIV positive, precludes certain groups of people, and is not completely effective in certain cases.

Also, the program does not target all populations equally which furthers
contributes to the stigma. In terms of testing for HIV, instead of having widespread testing, the program heavily promotes couples getting married to be tested rather than encouraging universal testing. Also, the Ugandan government does not address the gay, lesbian, and transgendered community in any kind of AIDS prevention service, and therefore discriminates against specific groups. It also does not provide AIDS prevention service or education to sex workers. Sex workers should be a priority target due to the high risk of contracting and spreading the HIV virus, however the government does not acknowledges this fact. Furthermore, the United States only provides funding for countries that sign a contract saying the money for HIV prevention will not be spent on sex workers, therefore supporting this kind of exclusion and contributing the spread of the HIV virus. To reiterate, in the AB policy, condoms are only do be given to “high-risk” groups. However two extremely high risk groups are the gay community and sex workers, yet they are treated as if they did not exist. Currently in Uganda, the newly diagnosed HIV cases are being seen with greater intensity in married women, which is not an expected high risk group. Therefore if condoms are to be given out, they must be made available to everyone and not just certain groups that are considered “high risk”. The funding for the AB plan does not address all populations equally, for it literally excludes certain groups from being included in the funding. And since the AB plan is not applicable to everyone, it is discriminatory intervention.

The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture
The AB plan fails to take into account the overall culture in Uganda, disregarding common behaviors and cognition prevalent in the community. According to cultural anthropologists, there is a strong connection between culture and personality and its expression as behavior. Using the Anthropological approach, the public health specialist would focus on the health behavior prevalent in the community and relate it to a larger context. In Uganda, the estimated age girls have their first sexual experience is 16.7 years for girls and 18.8 for boys as of 2001(9). According to the Uganda AIDS Commission, “Ugandan youth begin sexual activity at fairly young ages and with little sexuality information.”13. With a large population of adolescents starting sexual intercourse at a relatively young age and before marriage, the abstinence policy would be hard to push in this sort of community. A public health interventionist who uses the anthropological approach would most likely consider alternatives to address the AIDS epidemic in this community. Furthermore, one fifth of marriages are polygynous, which increases the chances the HIV transmittance if one of the people already have the virus or are unfaithful. Women also marry at a much younger age usually with men who have already been sexually active for several years and who may not have used a condom in the past. In marriages, Forty percent of women experience domestic violence. In the majority of the marriages, the woman is expected to have sex whenever the husband demands it, and the chances of her convincing the husband to use a condom are much lower than with a man who she is not married to(2). The women in the Ugandan community, based on their culture, most likely do not perceive they have power over the man in remaining abstinent and demanding condom usage. The AB plan takes away from the importance of the condom and reinforces the husband’s behavior of failing to use a condom and discourages more women to demand condom. It contributes to stigmatization of condom by denormalizing its usage. In Uganda, the overall belief of the community is that condom does protect against HIV but the AB plan is minimizing the protective power of condom usage (2). Consequently less people are using condoms and more people are infected each day. The Anthropological approach would take into account these overall behaviors and make sure the health intervention fits into the cultural behaviors.

In the Anthropological model, the culture’s cognition of health and disease are important determinants of behavior. The problem with the AB policy is that it is withholding critical information about condom protection without explaining the possible risks associated with abstinence until marriage (10). Therefore the AB policy impacts the cognition in the community, but in a negative way. The AB program was implemented in halls and classrooms of primary and secondary schools across Uganda. Although the Ugandan government had initially said that condom usage would continue to be promoted, it did not maintain this position, for according to them, it conflicts with the abstinence promotion. Out of the funding the United States is giving to Uganda, 3 million is given to a program called te Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY), which provides abstinence-until-marriage through assemblies, youth rallies, classroom activities. Inclusion of objective health information with images depicting ejaculation, body changes during puberty, the effectiveness of condoms, and proper cleaning of the foreskin were vetoed from being shown in the educational materials. The materials also includes some false statements about condom usage, minimizing their protective value and emphasizing overall religouss values (2). If the individual makes decisions based on cognition but the cognition turn out to be false, the individuals actions may be of great damage to himself and to those around him. The Ugandan government must promote honest messages and not withhold information in order for people make decisions based on truths rather than faulty information.

Uganda needs to maintain what has been effective in the past based on empirical data and not change solely based on funding requirements set by the United States. The AB program does not address alternatives to abstinence or provide preventative education that includes other contraceptive methods. Improved contraceptive use is responsible for 86 percent of the decline in the U.S. adolescent pregnancy rate between 1995 and 2002 (12). Uganda must reduce HIV by promoting effective behavioral strategies - which includes condom usage. It must make condoms available and affordable throughout the country. It must have HIV testing not only for married but for everyone. Finally, it must not discriminate against the gay community and sex workers, which right now are excluded from their HIV programs. The program must reach individuals of all educational levels, social economic backgrounds, genders. It must take into account cultural factors, statistics on what has been effective in the past in Uganda and in other countries.

The AB policy has shown to be ineffective on many levels. The AB policy places too much emphasis on individual factors, is not completely effective while contributing to stigmatization, and does not address behaviors prevalent in the culture. An effective HIV intervention in Uganda should not ignore empirical data and be based off of religious principles. Public health interventions should be effective and have the purpose to contribute to the well-being of the community.

Counter Intervention

Solution to: “The AB plan heavily emphasizes internal characteristics, failing to take into account external factors that impact behavior”
To decrease the emphasis on the internal characteristics, an intervention should promote alternatives to preventing HIV that go beyond being faithful or abstinent. To address the flaws of the AB plan, I propose reverting back to the ABC approach in Uganda, where “C” stands for condom usage. An intervention that focuses on promotion of condom usage, if implemented appropriately could address factors that go beyond the individual level. Although both the AB plan and the ABC plan to an extent rely on “internal” characteristics of the individual(e.g willpower), it has been consistently supported that remaining abstinent is significantly more difficult for the individual compared to condom usage (13). Albert Bandura’s Social Cognitive Theory (SCT) addresses the interplaying factors of behavior- the individual characteristics, environmental factors, and interactive process between the individual and social/environmental cues (14). An effective intervention would apply the SCT at some level. To address environmental factors that affect HIV infection, one would consider societal and social influences on the individual. Although condom usage still relies on the individual’s “internal” characteristic, if it is heavily promoted and widely available, the social and physical environment may be framed to help the individual make the decision to wear condoms. The intervention would educate in schools, health clinics, work-places, and throughout the community by lecturing about condom usage and HIV protection. Along would promoting their usage, condoms must be widely distributed and available. Condom usage must be encouraged by community leaders, whether it is in schools or in health clinics. By having community leaders and health workers, and other well-respected individuals advocate condom usage, the rest of the community may model their behavior. School programs could have individuals with HIV as spokespersons to tell their stories in order for the students to vicariously learn through them. Condom usage must be normalized and through behavior modeling within their social groups, a greater number of individuals will chose to use a condom or demand that the partner uses one. If there are a significant number of positive messages associated with condom usage, seeing the message would make someone who uses condoms positively reinforced to continue using them. Workshops should be incorporated in the health intervention in order to promote self-efficacy. It is important for schools to communicate with parents as well to gain their support in encouraging their children to protect themselves and to be good role-models by promoting safe-sex practices. Using the SCT model, not only would the internal characteristics, but the external characteristics would be addressed. There are endless interventions that could be done applying the SCT, but promoting condom usage, increasing its accessibility, and educating about the importance of condoms would make the physical and social environment more condom-friendly. With this, the external environment is more positively shaped to help the individual make the right decision.

Solution to: “The AB policy is not completely effective, increases stigmatization of HIV, and discriminates against certain groups.”
The second flaw of the AB approach is that it has shown to not be effective in the past within Uganda and in other countries. The new intervention would be based on facts of what has been effective in the past. The AB policy is not completely effective, for it ignores data that supports the fact that the AB policy generally does not work in preventing the spread of HIV. During the 2000-2005 period when the PEPFAR was passed the HIV prevalence has increased to 5.4% and continues to increase since the shift to abstinence interventions were made. There are currently 940,000 people currently living with HIV in Uganda (15). A public health interventionist who seeks to carry out an effective intervention must be aware of what has been effective in the past within that specific community and perhaps beyond it. Prior to the recent increase in HIV, there was a steady decline in HIV due to the public health intervention that implemented the ABC (Abstincence, Be-faithful-Condom) approach. The AIDS prevention campaign which was initiated in 1982 has been credited with helping decrease HIV prevalence from around 15% in the early 1990s to around 5% in 2001. The program included widespread availability and distribution of condoms, increasing the normalization of its usage and decreasing the spread of the virus. The number of condoms delivered and promoted by international groups rose from 1.5 million in 1992 to nearly 10 million in 1996 (16). The ABC program has been effective, while the abstinence approach has been ineffective not only in Uganda, but in many several other places including the United States. A public health interventionist would look at past data and evaluate the effectiveness of different programs. Clearly, the ABC approach is what has been effective in Uganda while the AB approach has been ineffective and therefore the ABC approach is clearly what should be implemented.

Furthermore, the AB approach increases stigmatization of those infected with HIV and discriminates against certain groups of people by not providing preventative services. The new program would decrease stigmatization of HIV and would target the entire community, rather than focusing on specific groups. A program that would prevent the increase of stigmatization of HIV would provide alternatives to abstinence and being faithful, for neither protect if the person already has HIV. An effected intervention would consider the fact that abstinence until marriage and being faithful would not prevent the virus from spreading if the person is already an HIV carrier. If it is known that the person has HIV, most likely no one will want to marry or have any kind of sexual relations with the person, feeding on to the stigmatization of HIV. An effective program would focus on how condom usage protects the spread, and therefore the person with HIV would not carry such a heavy stigma. Furthermore, a significant number of people with HIV are unaware they carry the virus, and therefore only through condom usage can it be certain that the virus will not spread. The public health intervention would promote widespread HIV testing rather than promoting only couple that are getting married to be tested. It would promote condom usage to the entire population, rather than to high-risk groups. Unlike the current approach in Uganda, the new public health intervention would not discriminate against certain groups of people (17). An effective intervention should target all segments of the population, despite social class, gender, ethnicity, occupation, and sexual preference. The gay, lesbian, and transgendered community would be included in AIDS prevention service. The new intervention would also provide AIDS prevention service or education for sex workers. Sex workers should be a priority target due to the high risk of contracting and spreading the HIV virus, The public health practitioner knows it is unwise to ignore one specific group not only because it us inhumane, but for the well-being of all the other groups as well. HIV will spread between the groups, therefore neglecting to target one group may actually harm all of the others. The program must decrease the stigma of HIV by focusing on condom promotion and it much reach individuals of all educational levels, social economic backgrounds, genders in order to be completely effective.

Solution to: “The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture”
The new intervention would consider Anthropological factors upheld in the community. The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture. Using the Anthropological approach, the public health specialist would focus on the health behavior prevalent in the community and relate it to a larger context (18). Since a large part of the community starts sexual intercourse at a young age, safe sex practices must be advocated to the youth, in school settings. Furthermore, the high prevalence of polygomous relationships and marriages fuel the need to invest in contraceptive education as opposed to abstinence, and further supports the need for widespread distribution of condoms(19). The normalization of condoms must occur in order to decrease stigmatization, which will occur once promotion and access to condom is available. Women must be empowered to demand condom usage through community education and workshops. The protective power of the condom must be advocated in order for the belief that it will prevent HIV infection become more widespread. Although the majority of the population is aware that condoms may protect against HIV, the AB plan is fueling the belief that it can be ineffective. The school programs must send out a clear message about the protective power of the condom, rather than focusing on other alternatives such as abstinence. The programs must teach factual, and comprehensive information regarding HIV and condom usage, without imposing any kinds of religious values. The information must not leave out pictures or figures that would be helpful for the students to understand the HIV virus and its transmittance. The intervention would educate using facts about condom usage taking into account community behaviors and cognition prevalent in the community.

As opposed to the AB policy, the ABC public health intervention would be effective if implemented appropriately. It addresses external factors rather than emphasizing internal characteristics. It decreases the stigma individuals with HIV carry. It is encompassing and target all within the population. It considers prevalent cognition and behaviors entrenched in the Ugandan community. More importantly, it has been proven effective in the past within the same community and therefore must be reimplemented in order to reverse the damages the AB intervention has caused.





References

1) Health Gap Global Access Project. 2009. President’s Emergency Plan for AIDS Relief (PEPFAR). Retrived from http://www.healthgap.org/camp/pepfar.html April 2009

2) Human Right’s Watch.2009 The Less They Know, the Better Abstinence-Only HIV/AIDS Programs in Uganda. Retrieved from http://www.genderhealth.org/pubs/HRWuganda0305.pdf . April 2009.

3) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.

4) Advocates for Youth. 2009. Abstinence-Only-Until-Marriage Programs: Ineffective, Unethical, and Poor Public Health. Retrieved from
http://www.advocatesforyouth.org/PUBLICATIONS/policybrief/pbabonly.html. April 2009.

5) Finer L. Trends in premarital sex in the United States, 1954-2003. Public Health Reports, 2007; 23: 73.
6) Bearman PS, Brückner H. Promising the future: virginity pledges and first intercourse. American Journal of Sociology 2001; 106:859-912.
7)The American Prospect. 2008. How Bush's AIDS Program is Failing Africans. Retrieved from
http://www.prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans. April 2009

8)Avert. 2008. HIV and AIDS in Uganda. Retrieved from avert.org/aidsuganda.htm. April 2009.

9) Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. UgandaBureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.

10)Uganda AIDS Commission. 2001. “National Young People HIV/AIDS Communication Program for Young People: Concept Paper”. Retrieved from http://www.aidsuganda.org/pdf/piacy_doc.pdf. April 2008

11) Health Gap Global Access Project. 2005. 10 Months and Counting: The Condom Crisis in Uganda. 2005. Retrieved from http://www.healthgap.org/press_releases/05/082905_HGAP_Uganda_call_transcript.html, April 2009.
12) Santelli, Julia.and Laura Lingberg. Explaining Recent Declines in Adolescent Pregnancy in the United States: the Contribution of Abstinence and Improved Contraceptive Use
Am J Public Health. 2007;97(1):150-156



13) Advocates for Youth. 2009. Abstinence-Only-Until-Marriage Programs: Ineffective, Unethical, and Poor Public Health. Retrieved from
http://www.advocatesforyouth.org/PUBLICATIONS/policybrief/pbabonly.html. April 2009.


14) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.

15) Avert. 2008. HIV and AIDS in Uganda. Retrieved from avert.org/aidsuganda.htm. April 2009.

16) Uganda AIDS Commission. 2001. “National Young People HIV/AIDS Communication Program for Young People: Concept Paper”. Retrieved from http://www.aidsuganda.org/pdf/piacy_doc.pdf. April 2008

17) The American Prospect. 2008. How Bush's AIDS Program is Failing Africans. Retrieved from http://www.prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans. April 2009

18) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.

19)Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. UgandaBureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.

Successful Miscommunication: A Critical Review of the Peace of Mind Campaign -Matthew Hanlon

Introduction
In an effort to combat high rates of unhealthy sexual behaviors and negative outcomes of those behaviors the Health Promotion Agency, a public health organization in Ireland, launched a campaign in Northern Ireland. This initiative named "The Peace of Mind Campaign," focused on increasing knowledge of existing sexual health issues facing the Northern Ireland population aged between eighteen and thirty years. The campaign began its efforts in 1993, with a poster campaign that was received very well, but not directly followed up upon. It was not until 1997 that a new poster campaign was launched. These posters were targeted primarily university students at first, as they were used as a test group. Advertisements addressing transmission of chlamydia, getting regular STD tests and to a lesser extent condom use were placed in and around university campuses and surrounding pubs. Studies were then conducted in order to measure awareness of the poster advertisements in the target population. It was found that approximately two thirds of the population was aware of the advertisements and their message.
Based on the findings of the awareness study the in December of 2000 the intervention was expanded to include information leaflets, fact sheets and other forms of print media as well as other locations not directly associated with university students. However, it is important to note that the target age group was not expanded at this time. As the campaign progressed posters were changed regularly with about one year between new iterations. By 2004 fourteen different posters had been created and used in the campaign. Keeping in line with the strategy of varying how the safe sex message was delivered in April of 2007 the Health Promotion Agency began launching radio and television advertisements in Northern Ireland as well (10).
HBM and the Peace of Mind Campaign
This intervention, as has been stated previously, is an educational campaign based on the dissemination of information and subsequent awareness of sexual health issues faced by the population being targeted. It is worth noting that content of the print media contained within this campaign can be divide into two main classes. The first class is information aimed at increasing the population's view of benefits derived from safe sex behaviors. This is achieved by enlarging the population's view of its susceptibility to and the severity of the negative health outcomes associated with sexual behaviors, such as unwanted pregnancy, chlamydia, HIV or other STDs. The second class of information deals with providing specific knowledge about sexual health clinics or where to get further information on sexual health issues. This type of information can be seen as material aimed at reducing the perceived barriers to gaining information about and practicing health conscious sexual behaviors. These two factors, perceived susceptibility and perceived barriers are major components of a popular model for public health interventions known as the Health Belief Model (HBM). The HBM asserts that perceived benefits and perceived barriers are in opposition of each other, and that in order for someone to develop an intention to perform a health behavior the perceived benefits must overcome the perceived barriers (3).
The HBM can be very useful at the beginning stages of a public health intervention. It provides direction and focal points for disseminating information to the target population. There are a number of people that do and will respond to the strategy outlined by the HBM early on in the intervention. Often times there can be a change in a significant portion of the population when a campaign based on the HBM is instituted. However, it is important to note that the entire population does not respond the same way as this smaller group that is fast to develop safe sex habits. There are a few explanations for this occurrence. One is that the people who are fast to pick up condom use and other safe sex habits are different from the rest of the population regarding health conscious behaviors. Due to variables not shared by the rest of the population this group of people readily makes behavior changes when they are given health information they did not previously have. The second explanation is that the educational information presented in the intervention are more salient with the first group and have simply not reached the others who have yet to develop the safe sex habits being promoted. Each of these explanations results in a very different view of the HBM's impact as an intervention model.
Failure of the HBM
When viewing "The Peace of Mind Campaign" through the lens of the HBM it seems to be a rousing success when 67% of subjects in the study evaluating awareness of the campaign responded they knew of the posters and that they recalled the message(10). This is especially true if it is believed that the reason the HBM may be unsuccessful is not because of different groups' response to health information, but whether or not they retained the information given to them. However, this is also based on the assumption that health behaviors in general and, more specifically, sexual health behaviors do follow the HBM, which has been shown to not be the case. In a study where the predictive powers of the HBM was compared to other health behavior models it was shown that the HBM accounted for less variance in diet, exercise and smoking behaviors than did the theory of reasoned action or theory or planned behavior (5). In addition, a later study based on a quantitative review of many preexisting studies it was shown that the HBM was lacking in predictive powers, which was then attributed to its focusing only on factors predisposing people to a behavior (4). Because of these studies it can then be concluded that the HBM functions through the first explanation given for why the HBM does not reach an entire population: there are different groups within a population with different dispositions towards adopting a health behavior. As such this entire campaign is fundamentally flawed because it is based on faulty assumptions made by the HBM and how it is applied to target populations.
Lack of Aim in Addressing Relevant Populations
Another major flaw with this campaign is the target population for the intervention. This intervention was an educational campaign focused on creating awareness of sexual health so that people would then subsequently change their behaviors to conform with their new knowledge. In addition, as stated earlier "The Peace of Mind Campaign" targeted adults of ages eighteen to thirty years. Although there is nothing inherently wrong with targeting a safe sex intervention to that age group, it was a mistake in this particular intervention to place that specific age restriction on the campaign. There is reasoning based on both psychological theories and empirical data collected directly in relation to this campaign that gives credence to an age restriction of eighteen to thirty years being a mistake.
As stated earlier, interventions of this type do have an effect on some members of the population, but there still remains a large proportion that does not change their preexisting behaviors. One possible explanation for this occurrence comes from an extension of the endowment effect. The endowment effect states that people will place higher value upon an item that they have ownership of in comparison to a similar item that they do not own (7). This can be interpreted to mean that owning something has an inherent value to a person and that value is substantially higher than the innate value of that item. It is therefore very easy to infer that people who do not readily change their behaviors to safe sex practices as prescribed by "The Peace of Mind Campaign" feel ownership of their preexisting behaviors. Also, the value members of the target population place on that sense of ownership is substantially higher than what they feel the will receive in return for ceasing their current behaviors.
In order to effectively change the sexual behaviors of those living in Northern Ireland the sense of ownership stemming from the endowment effect must be circumvented. Classical conditioning theory shows that behaviors become more ingrained over time and repetition. The more often, longer duration and amount of reinforcement received from a behavior performed the more ingrained that behavior becomes (6). Thus in order to circumvent that sense of ownership that develops from an ingrained behavior it would be ideal to create a change before or in the early stages of behavior conditioning. Research done by the Health Promotion Agency, the same organization responsible for "The Peace of Mind Campaign," shows that approximately 90% of females and 80% of males between the ages of twelve and fifteen years old are sexually active. Based on this research the target audience of the intervention should have used age twelve as the lower bound for the target population. By educating the population early on it is easier to effect change as behaviors are not yet ingrained and individuals do not possess a sense of ownership yet. Also, it is considerably more likely that by targeting a younger population that early sexual behaviors will be health conscious and will continue into the future due to the processes described by conditioning theory and the endowment effect.
Breakdown in Communication
Borrowing from the endowment effect again another issue can be raised with "The Peace of Mind Campaign." In this instance the issue is not with the delivery of the message, but rather the message itself. The posters used in the promotion of health information this intervention is based around may actually be counterproductive to the end goal. A specific example is one poster used in May of 2004 to educate that chlamydia may not present with any noticeable symptoms. The poster reads "You could be looking at someone with chlamydia." This message is written upon a mirrored background so that whoever is reading it should see their own reflection. This one poster is sending the wrong message, according to three different theories explaining behavior. The first, as was mentioned, is the endowment effect. This poster goes against what you would expect to see if the endowment effect was considered because the poster is threatening a person's sense of ownership of health. People place value on being healthy and this poster in a sense attempts to purchase that belief in exchange for either proof of health or proof of illness. This is not an exchange that would seem worthwhile to a person who believes that he is in fact healthy.
The second theory this poster seems counter to is psychological reactance theory. The basics of reactance theory can be explained as follows. When people perceive a threat to their freedom they will often overexercise that freedom in order to prove that they still hold control over the situation. This can manifest in one or both of two possible ways: behavior or attitude. When a person perceives a behavioral freedom is threatened reactance to threat will motivate the person to further participate in that behavior. Also, if a person feels a particular attitude is being forcible impressed upon them he will most likely take up the opposite attitude in order to assert his freedom (2). This outcome can occur in this situation, as there is a threat being made to a person's freedom from illness and his sexual freedom. A behavioral reaction predicted by this theory would be that a person would not get tested. By making a conscious choice not to get tested a person can reassert their control over being healthy or sick and maintain their sexual freedom. Having an asymptomatic illness allows this choice as the only way to "become" ill is to actually get tested, thus allowing a person to create their own state of health or illness.
Creation of categories based on the physical status of a person leads to the third theory that this poster opposes: labeling theory. This theory asserts that when an individual is labeled as part of a group they will begin to conform to what that label would expect of them (1). There are two different ways under labeling theory that this poster is counterproductive to the goal of promoting safe sex. The first is that poster labels all people, regardless of their true situation, as being at risk for chlamydia. This is a dangerous label to apply to both those at risk and those not at risk as for either group it promotes sexual risk taking in regards for chlamydia. As per labeling theory people or either risk group may be given motivation, they would not have had otherwise, to attempt to live up to the label of being at risk for chlamydia by participating in risky sexual behaviors such as intercourse without condoms. This increases the the level of risk for those already at risk for chlamydia or other negative outcomes of unsafe sexual behavior, and creates risk for those that had a minimal amount beforehand.
The second aspect of labeling theory this poster is set against has to do with stigmatization. Because chlamydia can be asymptomatic the only way to be certain of a person's infection status would by medical testing. However, those who get tested can be labeled quite negatively as being at high risk or even worse actually having the disease. This creates a stigma that is associated with the act of being tested(8). People, regardless of their actual risk or infection status, fear being labeled as having the disease simply because they do get tested. This stigma in turn discourages people from seeking medical tests to determine their infection status. A public health intervention should seed to discourage stigmas around being tested instead of promoting them. This poster unfortunately promotes stigmatization of those seeking medical tests and in fact goes against its own goal.
Evaluation of The Peace of Mind Campaign's Effectiveness
Although as stated earlier the Health Promotion Agency cited a study in which 67% of respondents were aware of their campaign, it was by no means a massive success. What this study of the effects of the intervention showed was that people were aware of the intervention's message. In terms of getting the message and information "The Peace of Mind Campaign" was presenting to the public the intervention was moderately successful. Reaching two thirds of the target population is a very large step in the correct direction for a public health intervention. However, reaching the target population in itself does not mean that the message received was effective.
There may have been a portion of the population, as earlier stated, that responded to the health education approach used by this intervention. However, it is highly unlikely that this intervention had any appreciable effect on increasing sexual health behaviors and subsequently decreasing infection rates of sexually transmitted disease beyond those that were reached easily and early on in the intervention. Incidence data for sexually transmitted disease collected by genitourinary medicine clinics in the United Kingdom support this claim. Between the years of 1998 and 2007 chlamydia rates have increased 2.5 times and total diagnoses of any sexually transmitted disease has increased 1.63 times. This data shows it is absolutely vital that public health interventions be rethought. There is a vast body of research that exists and can be applied to campaigns promoting any number of health behaviors, that is not being used to its fullest potential. By tapping into resources not traditionally used by public health agencies interventions can become massively more effective. If new approaches are not used there will just be more interventions like "The Peace of Mind Campaign" that span decades, but only accomplish wasting funding and effort.
Possibilities for Future Interventions
The "Peace of Mind Campaign" instituted in Northern Ireland by the Health Promotion Agency in order to improve the rate of safe sex behaviors was not nearly as effective as it could have been, due to a number of flaws in its design (10). Some flaws existed in the very foundation of the intervention others came about later on and were introduced at a later stage. Regardless of where these flaws were found they detracted from the overall effectiveness of the "Peace of Mind Campaign," which is an unfortunate occurrence as promotion of safe sex behaviors is an important public health goal. However, the "Peace of Mind Campaign" was not a total loss as in addition to its flaws it had some effective strategies as well and because of this can be used as a comparison point for future plans for safe sex interventions. By judging what was effective and what was not about the "Peace of Mind Campaign" an intervention that is significantly more effective as a whole can be designed.
Choosing the Proper Model
The first flaw with the "Peace of Mind Campaign" that was discussed was its reliance on an ineffective behavior model, the Health Belief Model. Therefore, a new intervention would have to diverge from using this model as a basis for planning the intervention. One possible approach would be to create an intervention based on a combination of social expectations theory (SET) and social network theory (SNT). Social Expectations Theory explains behavior which may at first seem to be an individual choice, like condom use, is in fact a social behavior (11). As such, safe sex practices are largely a result of conformity to the expectations of the larger group of which a person is a member. Social network theory also deals with people as being influenced largely by their peers. Under SNT people do not exist as individuals but rather as part of a great social amalgam. Because of this view SNT asserts that behavior change does not occur on the individual level, but rather on the group level and that in order to affect behavior change it must be group focused rather than individually focused (12).
By using group level models instead of the HBM the issue of individual differences between people influencing the effectiveness of the intervention is decreased. Whereas there may exist a strong degree of heterogeneity between individuals, there is much higher degree of homogeneity between groups. This is an important concept for a number of reasons. The first reason, it allows a more focused campaign in terms of how the intervention appeals to an individual. Rather than making hundreds of posters that are designed to appeal individually to people, only a few posters need to be made provided they are designed to appeal on a group level. Another reason is that within a population there are those with different levels of safe sex behaviors. By using a group centric approach this difference does not matter, as changing the group dynamic will reinforce behaviors in people that already practice safe sex, and cause a shift towards safe sex behaviors for people that are not yet there. Therefore, by targeting groups, instead of individuals, it is much more likely that an intervention will be effective for a large proportion of the population rather than a small subsection.
Individual Behaviors Change on a Group Level
Also, using a group centric model as the base for this intervention helps in addressing the second major flaw of the original "Peace of Mind Campaign": its failure to address problems facing the intervention stemming from endowment theory and classical conditioning. As stated earlier, when these two theories are applied to sexual behaviors they show that people are unwilling to make changes because of the intrinsic value of ownership and the level of conditioning they have with respect to that behavior. By using a model that promotes group change for the basis of the intervention it helps alleviate both of these issues. People are more likely to change a behavior they value if they believe they will gain something of equal or greater value. A group level model directly effects this exchange. As the social group a person belongs to shifts, they will be forced to alter their behavior in order to maintain their place in the social hierarchy. In a sense people are exchanging individual behaviors for a sense of social belonging (7). Also, affecting a change in a social network helps to lessen conditioning people have towards sexual behaviors. Changes in social networks result in a break down of cues for the conditioned response a person has towards a behavior (6). If a large enough change can be created then there will be removal of many, if not all, of the social cues that trigger unsafe sexual behavior.
Focusing on the Message
The issues addressed so far have only dealt with the general concepts of a public health intervention without going into the specifics, such as the method of interacting with the public. The "Peace of Mind Campaign" used mainly print media, such as posters and leaflets to reach the target population. This proved to be effective in just terms of exposure in that 60% of people interviewed in a study by the HPA recalled the content of the posters (10). Therefore it seems print was a good media for gaining exposure in the target population. However, the "Peace of Mind Campaign" had problems, not in exposure, but rather in terms of the content of the posters it presented.
One such poster with lackluster content was already discussed in great detail. The major issues with this poster being that it went against what would be expected from an intervention that consulted endowment theory, psychological reactance theory or labeling theory. Therefore it would make sense to design a poster that incorporated the major tenets of these theories rather than disregarding them. The first concept to be included in this poster would come from endowment theory: the poster should somehow offer something of equal or greater value than the behavior being targeted. Psychological reactance theory states that the poster should not threaten the sense of freedom a person possesses, otherwise they will rebel against the message presented (2). Labeling theory states people will conform to a label placed upon them, so the poster should place a positive label on people.
One example of a poster that meets these requirements is as follows: The main picture on the poster is of a couple sitting at the bar talking. The people in the poster are fairly representative of the target population. There is a main caption that reads "It's not about getting lucky tonight, it's about being prepared for the night. Know where you're going, and bring a condom with you." In this poster an exchange is being offered, for a change in sexual behaviors. The message implies that by using a condom it will make a person more sexually attractive because it's "not about getting lucky." This is an exchange that gives a person something of value for giving up their previous behavior. Also, by using a couple representative of the target population it creates a sense of identification for the recipient of the message which limits psychological reactance to threatened freedoms (2). Finally this poster creates a positive label for condom users, without the co-creation of a negative one for non-condom users. "Know where you're going" implies a sense of purpose, direction and confidence. These are all positive traits that people will aspire to have that according the poster condom users have. Therefore if the poster is salient enough people will attempt to take on the label of being a condom user in order to gain these traits that come with it (1).
Synthesizing an Effective Approach
After analysis of the shortcomings of "Peace of Mind Campaign" and their comparison to other approaches described a general understanding of what an effective public health intervention would require can be reached. The first step in an effective intervention is to choose a model that works to base the intervention upon. Group level models have distinct advantages over individual level ones that make them much more useful in this setting. By using a group level model it allows interventions to focus on the issue at hand in a homogeneous population rather than getting bogged down by trying to determine how best to influence a conglomeration of heterogeneous individuals. Also, group level models confer the added advantage of creating a new set of social norms. This is aids in the second step of creating a successful intervention: people must feel they are benefiting from making the behavior change proscribed by the intervention. Changing social norms is an advantage in reaching this second step. People will exchange their negative behavior for these new norms because they gain a sense of group belonging as replacement for their lost behavior. The third step is to make sure the message of the intervention is salient and coercive to the public. Three cognitive theories were used in creating the poster in described as a replacement for the one that came from the "Peace of Mind Campaign." However, there are countless useful cognitive theories that can be applied as well. It falls to public health officials to carefully design interventions so that they meet these criteria. If this is done, there will be more successful interventions that occur.

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