Trytostop.org Tries Too Hard And Not At All - Jasmine Lopez

Approximately 10,000 smokers and second hand victims die annually in the state of Massachusetts, and billions of dollars are exhausted on smoking-related health care needs (1). The Make Smoking History Campaign and the Massachusetts Department of Health acknowledge these health and economic impacts of cigarette smoking in the state. “Quitting smoking is hard, but you can do it. You can win the Fight 4 Your Life (2).” The trytostop.org website makes these claims throughout its pages, but this cyber intervention is likely being passed by many smokers because of its flaws.

The site is like a large warehouse of tips, video clips, statistics, questions and more. A potential quitter must find his way through the halls, rooms, stairways and levels of the warehouse with only an idea of what his final destination might look like. This is not an intervention for everyone.

In this critique I will focus on the Quit Wizard which is a part of the trytostop.org campaign (3). It is an internet based support intended to guide smokers who would like to quit become nonsmokers. Its content and method of behavior change provide little guidance, discipline or encouragement to smokers who are thinking about quitting. This intervention is based on the Transtheoretical Model of Behavior Change (TTM), which is a model of behavior change in which individuals seeking to complete a change will progress or digress through five stages. That movement depends upon the process of change which includes catalysts to motivate individuals to progress (4).

The Quit Wizard is flawed in its assumption that individuals who start the program will have high levels of self efficiency to get them through the six stages. In addition, it does not clearly assign which stage an individual begins the intervention or when movement is appropriate; forward or backwards. Finally, Quit Works presents weak and contradictory messages; “Make Smoking History” and “Try to Stop.”

Too Little Motivation

Individuals procrastinate. They set goals and struggle to follow through. It is an issue of self control (5). Ariely demonstrates the need for some authority in meeting deadlines. He conducted an experiment in his classes to explore the effect of deadlines on goal attainment. One class set their own deadlines throughout a semester. A second class had some guidelines in setting deadlines, and the third class had to follow the deadlines set by the professor. Ariely concluded that the class with the most flexibility had the lowest scores and the class that had no flexibility had the highest scores. Ariely also included penalties for late work and found that factor to have some effect on the outcome as well.

Ariely presents evidence that individuals need motivation in order to complete tasks; even if it is in the form of penalties. Quit Works does not motivate smokers to choose an attainable quit date or deadline. Smokers set their own date and Quit Wizard records it on a calendar. This date can be the next day or the following year. Upon return to the site, smokers may change their quit date to be sooner or later, and it has been determined that smokers will change their minds about quitting often (6). The site does not impose a firm deadline on smokers; they may adjust the quit date everyday if they so choose.

The tone of the text and tips to keep smokers on the path to quitting are not authoritative or encouraging. In fact, smokers may click through pages and messages without reading any of the content. Quit Works relies on the self efficacy of smokers to get through the intervention. This intervention assumes that site users have high level of self efficacy and therefore sufficient motivation to carry out all of the prompts and suggestions. This will not be the case, however, as the Transtheoretic Model recognizes that individuals need tailored interventions. In order to quit smoking with this intervention, individuals must expect that they can complete each task presented and attain the expected outcome (7). Quit Works presents tasks at every level, but does not offer incentives to motivate smokers to complete the tasks.

The absence of instant gratification and an unstable belief in one’s ability to complete a goal set individuals up for a long experience within the stages; possibly a to complete standstill that is never approached again. There is no element of reward or punishment in the intervention (8). The Transtheoretic Model allows individuals to move between stages in a forward or backward direction for as long as it takes the individual to complete the intervention (8, 9). Quit Works fails to keep motivation and self efficacy elevated.

Too Much To Navigate

Another flaw of this intervention is that site users are presented with too much information. Using education as a tool to create change is ineffective by itself. Providing an excess amount of information does not change that. This website has dozens of tabs and hyperlinks. There is so much information available on this website that it is easy for potential quitters to become overwhelmed. So overwhelmed that they might reach for a cigarette before they find their way to the Quit Wizard; where they will encounter many more tabs and links! There are tabs along the vertical and horizontal edges of each page.

Quit Wizard follows the Transtheoretic Model of Behavior Change which is based on movement through five stages: precontemplation, contemplation, preparation, action and maintenance (9, 10). Quit Works’ corresponding stages are: Taking a Look, Getting Ready, Counting Down, Early Days, Making Progress, Becoming a Nonsmoker. There is no guidance through the site or the stages. In addition, the intervention lacks the processes of change that sift smokers to appropriate base stage and then on toward the final stage or back to a previous stage (11).

The Transtheoretic Model is a strong model of behavior change because of its ability to mold to the individual. In other words, individuals may begin an intervention at any stage and fluctuate through the stages until the behavior change occurs. However, Quit Works does not personalize the starting point. Moreover, it does not adapt the individual’s movement through the stages. The site tracks the sections that are completed by the individual, but does not change content to reflect the individual’s return to that stage. It is easy for site users to skip through the sections and become lost.

Too Passive

The campaign title alone demonstrates how passive the Quit Wizard and other site content are. The message is to “Try” to Stop. This implies that it is acceptable for smokers to visit the site, read the intro to the Quit Wizard and move on; another failed attempt at breaking the habit. The message does not invite smokers to consider their optimal level of self efficacy, nor does it attract smokers to be a part of the intervention. Without such a pull, smokers will miss out on the quit attempt. Quit Wizard recognized that some individuals may respond better to personal assistance so it presents information about a phone line. Again, this information is barely suggested. It is up to the individual to recognize the need and take action.

The intervention is uninvolved in the quitting process. It is dry and unpleasant. The sections have checklists and tips that are easily forgettable. There is an “emergency” button should the individual crave or smoke a cigarette during the intervention. The Quit Wizard makes some suggestions for both the emergency craving and smoking scenarios. Such as drink a glass of water, tell yourself “No smoking!,” and repeat the phrase: “Just don’t smoke.” However, should the individual find himself in that emergency again, he will receive the same advice from Quit Wizard. This would be an appropriate situation for a reward or consequence, however, the Quit Wizard does not include these in the intervention.

Quit Wizard Summary

Quit Wizard is a flawed intervention based on the Transtheoretic Model and aimed at helping smokers become nonsmokers. It is hidden in a website overflowing with information. Smokers who open the webpage at all must then click their way through the site to make it to Quit Wizard. They are then linked into a six stage, impersonal, multi-part program. It has repetitive sections and long check lists. This adds to the lack of motivation, as progress through the stages could serve as a type of gratification or reward and improve self efficacy. Quit Wizard does not incorporate rewards or consequences to help smokers move through the stages. This program is ineffective in helping smokers who need an extra push or regular guidance to meet their goals. The flexible calendar and dull suggestions will not accomplish that. Quit Wizard tries to help smokers but falls short in these areas. Moreover, it is based on the Transtheoretic Model of Behavior which has been criticized in studies for being weak in defining its stages and lacking incentives. Quit Wizard may help many “Try to Stop” but it will not “Make Smoking History” in Massachusetts.

Counter Proposal to Trytostop.org Quit Wizard

The Quit Wizard on trytostop.org has three flaws that my intervention does not. First, it assumes that individuals have a high level of self efficacy. Second, it does not individualize the baseline stage or determine when stage movement is necessary. Third, it presents weak and contradictory messages. I propose the implementation of a different kind of Quit Wizard. This cyber intervention, Butt In, would provide the motivation, guidance and encouragement throughout the quitting process that trytostop.org is missing. It would be accessed as an application through social networking sites Facebook and Myspace. Butt In incorporates elements from some social behavior models discussed in SB 721: Transtheoretical Model of Behavior Change, Framing Theory, Marketing Theory, Self Control, and Social Network Theory.

Butt In to Back Up Low Self-Efficacy

Butt In pulls elements from both individual and group focused interventions to create a program that is effective whether the smoker quits alone or with other smokers. Quit Works assumed that all participants have a high level of self-efficacy. Butt In utilizes a combination of group-focused and individual-focused social behavior theories to account for the fact that some participants will not have strong levels of self-efficacy. Incorporation of the group-focused Social Network Theory is the main method used to account for participants’ low self-efficacy.

Research shows that individuals behave differently when they are in groups, and that closely related groups of people (relatives, coworkers, friends) often quit smoking together(12). In fact, Christakis and Fowler studied networks of 12,067 individuals from the Framingham cohort and found that smoking cessation by a sibling decreased a person’s chances of smoking by 25%; by a friend, 36%; and by a coworker, 34%. Furthermore, they determined that decisions to quit smoking “reflect choices made by groups of people connected to each other both directly and indirectly at up to three degrees of separation. People appeared to act under collective pressures within niches in the network” (12). These findings are in line with the premise of the Social Network Theory(13).

With more and more communication and interaction between these groups via social websites as opposed to in person(14), Facebook and Myspace are the most appropriate places to implement Butt In. Moreover, these media are available 24/7 to smokers with internet or mobile phone access. So smokers can rely upon Butt In throughout their entire quitting experience. This is a motivational aspect of the intervention that trytostop.org lacked.

The individual-based theory of Self Control essentially claims that people procrastinate. Individuals do not often do what they set out to do. This is indicative of the spontaneous changes in behavior that individuals constantly make(8). The calendar, reminder emails, regular updates, and progress widget components will keep individuals on track.

Butt In will include another motivational component: ownership. In order to change behavior, we must offer some significant, tangible exchange or reward(5, 16). Participants who progress through the stages of Butt In will be rewarded with access to new social networks, popular widgets (15), and encouraging praise from individuals within their network. The use of widgets to calculate dollar savings attributed to quitting smoking is a way to provide some tangible benefit to the behavior change.

Butt Out of One Stage and Into the Next

The Transtheoretical Model of Behavior Change is typically used in smoking cessation interventions because its framework allows individuals to personalize their quitting experience(17); the same reason it is employed as the basic theory for Butt In. The aim of Butt In, however, is to guide participants to their endpoint with as few relapses as possible. It will individualize each participant’s baseline stage according a pre-start assessment and attempt to recognize the processes of change that transfer participants from one stage to another(4). Some of these processes are dramatic relief, social liberation, self reevaluation, and reinforcement management.

At the start of Butt In, a participant a completes and submits a short assessment that is reviewed by a professional who determines that person’s base stage. This occurs live via an online chat with the professional. Like the Quit Wizard, the participant will then be prompted to log goals and smoking habits on his/her profile. The difference here is that the baseline stage will actually be individualized and the participant will have guidance towards the action and maintenance stages of TTM.

The processes of change are the pathways through the TTM stages, yet some are difficult to recognize. Ideally, the accessibility of Butt In and the culture of its medium will allow for better recognition of the participants’ progress. Myspace and Facebook are about sharing up to the date news about personal accomplishments, challenges and activities. The intervention will call for brief, routine status updates on the participants’ quitting successes and drawbacks. Theses updates, like the initial assessment, will be evaluated by professionals, and summary details will be posted on the participants’ profiles so that their peers may add encouraging comments and advice.

Butt In Now

While Quit Works is tied to a passive message “try to stop,” Butt In sends a stronger message through framing and marketing strategies. It is framed in a positive and assertive tone that invites smokers to at least explore the intervention and share their quitting experience. It has an attractive and fun feel that appeals to the compelling values of youth and freedom. The use of virtual networking sites is a way of branding the intervention as a popular thing to do with friends, family and coworkers. The message is to quit and help your network become smoke-free too. An individual may be invited to join Butt In and then invite dozens of his/her online friends to join too. This adds to the individualized feel while promoting a social strategy.

Conclusion

We will not see a flawless intervention for smoking cessation; each approach will affect a specific audience and have its set backs. Butt In is an intervention for smokers who utilize social networking sites, and it is focused on motivation, guidance, and encouragement. These are three areas in which Quit Works needs improvement. Quit Works tries too hard to provide a large amount of information to smokers following an individual-based theory of behavior change. However, the information is not individualized and smokers get lost in the text. Butt In has live, personalized information from health professionals, electronic mechanisms to track appropriate movement through TTM stages, and instant connection with peers who can view progress made by the participants and add support. This counter-proposal takes one strong model of behavior change (TTM), and partners it with the Social Network Theory, another model that has been studied and deemed a strong base for smoking cessation interventions. Butt In is also supported by the benefits of Framing and Marketing Theory, and Ownership. These are implemented to keep smokers on the track to smoking cessation. For those who nonetheless relapse, the TTM foundation allows them to review their progress and get back on track at an appropriate stage.

References

1. Massachusetts Department of Public Health. Annual Report of the Massachusetts Tobacco Control Program Fiscal Year 2007. MA: Massachusetts Tobacco Control Program, 2007.

2. Massachusetts Department of Public Health. Make Smoking History. MA: Massachusetts Tobacco Control Program. http://makesmokinghistory.org/fight-for-your-life/index.html

3. Massachusetts Department of Public Health. Quit Wizard. MA: Massachusetts Tobacco Control Program. http://quitwizard.makesmokinghistory.org/

4. Cancer Prevention Research Center. Summary Overview of the Transtheoretical Model. Kingstown, RI: University of Rhode Island. http://www.uri.edu/research/cprc/transtheoretical.htm

5. Ariely, Dan. The Problem of Procrastination and Self-Control: Why We Can’t Make Ourselves Do What We Want to Do (pp. 109-126). In: Ariely, Dan. Predictably Irrational. New York, NY: 2008.

6. Werner, J., Lovering, A., & Herzog, T. (2004, February). Measuring time frames for intentions to quit smoking. Paper presented at the Annual Meeting of the Society for Research on Nicotine and Tobacco, Phoenix, AZ.

7. Salazar, Mary Kathryn. Comparison of Four Behavior Theories: A Literature Review. AAOHN Journal. 1991; 39(3): 128-135.

8. Society for the Study of Addiction. Time for a change: putting the Transtheoretical (Stages of Change) Model to Rest. London: University College London Department of Epidemiology, 2005.

9. Kim, Joseph. Smoking Behavior and the transtheoretical Model of the Stages of Change. BioPsychoSocial Health. Jan 25, 2009. http://brainblogger.com/2009/01/25/smoking-behavior-and-the-transtheoretical-model-of-the-stages-of-change/

10. Baum, Andrew. Transtheoretical Model of Behavior Change (pp. 181). In: Baum, Andrew. Cambridge Handbook of Psychology, Health and Medicine. Cambridge, MA: Cambridge University Press, 1997.

11. Aveyard, Paul et al. The effect of Transtheoretical Model based interventions on smoking cessation Social Science & Medicine. 2009; 68(3): 397-403.

12. Christakis, Nicholas A.,, Fowler, James H. The Collective Dynamics of Smoking in a Large Social Network. New England Journal of Medicine. Volume 358:2249-2258. May 22, 2008. Number 21.

13. Northeastern University. Current Research in Social Network Theory. Boston, MA: Northeastern University College of Computer Science. http://www.ccs.neu.edu/home/perrolle/archive/Ethier-SocialNetworks.html

14. CNN Technology. All in the Facebook family: older generations join social networks. CNN, 2009.

15. Tech Terms. Computer Dictionary. 2006. www.techterms.com

16. Health Education Through Extension Program. Monitor Your Progress and Reward Success. KY: University of Kentucky. www.ca.uky.edu/HEEL

17. Bridle, C. et al. Systematic review of the effectiveness of health behavior interventions based on the Tran theoretical model. Psychology and Health. 2005; 20(3): 283-301.

The Fight Against Teen Pregnancy in the U.S.: A Critique of Abstinence-Only Sex Education Based on Social and Behavioral Theory - Karen Campbell

The United States has the highest rates of teen pregnancy and births in the developed countries (2). Thirty-four percent of women become pregnant at least once before the age of 20, which averages 820,000 pregnancies a year (10). Eight out of ten of these events are unintended and 79 percent are to unmarried teens (10). Although the amount of teen pregnancy has decreased since 1991 when incidences of teen pregnancy was at the highest peak since 1980, the decline in events began another incline in 1996, making this an issue that still needs the implementation of an effective intervention. (5)
Bearing a child as a teen can have negative affects on the child, mother, and father (2). Teen mothers are less likely to complete high school and more likely to live in poverty (6). These mothers are less likely to receive prenatal care and gain appropriate weight which heightens the risk for birth defects (6).
Under the Bush Administration, federal funding for abstinence-only, or abstinence until marriage programs rose significantly with the hope to decrease teen pregnancy as well as other negative outcomes of risky sexual behavior. The goal of these programs is to target premarital sex as the causal behavior for unintended teen pregnancy among other negative outcomes that correspond with sexual activity. The federal government spent approximately $170 million in 2005 towards abstinence based programs, which is more than twice the amount spent in 2001 (14). These programs focus on an “exclusive purpose of teaching the social, psychological, and health gains” by abstaining from sexual activity and that abstinence outside of marriage is the “accepted standard for all school aged children” (13). However, a focus on strictly teaching abstinence can be dangerous when it is presented as the sole choice and where health information on other choices is restricted (11). Theoretically abstinence is the most protective form of contraception however in actual practice abstinence often fails to protect against teen pregnancy (11).
Although risky sexual behavior can have many negative outcomes, it is important to teach adolescents ways in which to protect themselves if the teen chooses not to be abstinent. In European countries, the rates of sexual activity are very similar to that in the United States; however the US has a much higher rate of teenagers who become pregnant (2). Due to the severity of teen pregnancy rates in the US, abstinence based programs need to be revisited in order to present a more effective intervention. This paper will critically analyze the failure of abstinence-only sex education programs in the US by examining the use of fear tactics in a public health intervention, the focus on the individual as opposed to a multilevel based model, and the issue of social norms and the negative stigma on the open communication of sexually based questions and concerns in adolescents.
The Health Belief Model and the use of Fear tactics in a Public Health Intervention

Abstinence based education curricula mirrors traditional public health models such as the Health Belief Model. The main focus of abstinence programs is to highlight the health gains by abstaining from sexual activity outside of marriage by teaching the harmful psychological and physical effects of having sex (10). The goal of this program is to lower risky sexual behavior which can lead to teen pregnancy and other negative outcomes such as sexually transmitted infections. The emphasis on negative consequences of sexual behavior can be identified as a factor in a conceptual model such as the Health Belief Model.
The Health Belief Model is based on the individual cognitively analyzing the perceived susceptibility, severity, benefits, and barriers of an action (9). The emphasis of the negative outcomes of sexual activity before marriage can be benchmarked into the weighing of perceived severity and perceived susceptibility in the Health Belief Model. For example, according to Representative Henry Waxman’s analysis of these education curricula, one program teaches that a pregnancy occurs one out of every seven times a couple engages in sexual behavior with the use of a condom (14). This statement emphasizes the degree to which the individual feels that they will be at risk for the health outcome or in this case, pregnancy. Another program highlighted by Waxman includes in the curriculum that in heterosexual sex, the popular claim that condoms help prevent the spread of Sexually Transmitted Infections is not supported by data and that condoms fail to prevent HIV approximately 31% of the time (14). The above information translates to the individual that despite using contraception such as a condom, they are still at high risk for negative outcomes.
Another factor that is present in the Health Belief Model and is included in abstinence-only programs is perceived severity. For example, one curriculum states that 5% to 10% of women who have legal abortions become sterile and that “premature birth, a major cause of mental retardation, is increased following the abortion of a first pregnancy” (14). This lesson emphasizes the severity of pre-marital sex to the individual. I would also argue that the lesson from these negative teachings highlights the perceived benefits of abstinence. All programs are required to include that abstaining from sexual activity will bring many health benefits as it is the only option to prevent pregnancy and other negative health outcomes such as Sexually Transmitted Infections that are highlighted (10).
Not only do the above lessons contain false, misleading, and distorted information about reproductive health (14), this curriculum focuses on fear tactics to encourage youth to not engage in pre-marital sex. Behavioral theory suggests that fear-arousing messages can be ineffective (3). In a systematic review of randomized controlled trials on unintended pregnancies, adolescents were interviewed regarding their suggestions on how to improve sex education programs (7). This feedback on the current curriculum even included that sex education should be more positive with less of an emphasis on scare tactics (7). The goal of using a model such as the Health Belief Model would be that with the knowledge of the perceived severity, perceived susceptibility, and perceived benefits of abstinence will allow the individual to make a rational decision to not have premarital sex. The use of scare tactics is based on the assumption that individuals will change their behavior based on the portrayal of a negative outcome (6). This line of thinking correlates with the basic view of the Health Belief Model that behavior is based on a rational decision making process. This is not always the case. Many experts have come to the conclusion that programs that rely on fear tactics are “difficult to execute and rarely succeed” (6). It is further argued that risky behavior can often be attractive to adolescents which will then actually attract this age group to a behavior (in this case, premarital sex), therefore making the behavior more difficult to change (6). Extending even more upon the point that scare tactics may only be increasing the behavior of premarital sex, because the emphasis is only focused on negative knowledge and a measured concept, these programs than contribute to the limited understanding (12) of sexual behavior in adolescents. Therefore, if the individual is in fact attracted to the idea of a risky behavior (premarital sex), they will not have the knowledge regarding the efficacy of contraception use while engaging in sexual activity.
The Focus on the Individual and the Linear Correlation Between Intention and Behavior

Abstinence-only programs focus on the rational decision making of the individual. The curriculum is designed to provide information for the student so they can weigh the benefits and barriers of participating in pre-marital sex. This information (if valid) can be beneficial; however there are many limitations that can be attributed to this model of intervention as it only focuses on the individual.
A strong limitation is that there is no consideration of attitudes, beliefs and emotion (9). For example, when in a state of arousal, because of the strong emotional and physical energy, the rational teachings of “just saying no” usually do not apply (1). At this point, emotion will have a stronger effect on behavior then any planned intention regardless of the dangers that apply (1). In order to address the physical state of arousal, education should focus on methods on how to deal with emotions that occur during arousal, and not just walking away from them (1).
In addition, this model of intervention does not consider any factors that can be attributed to the community or the environment (9). Many factors have an effect on the individual, and these factors are crucial to include in a public health intervention. For example, Mark Edberg highlights that “given the broad and often complex relationship among school, family, and community, the potential kinds of useful information are diverse” (9). As abstinence-only programs currently only incorporate the decision making process of the individual, many beneficial factors are ignored. Issues such as social norms in the community, the environment, race, gender, class size and drug use are all issues that have an effect on adolescent behavior (9). Specifically in terms of drug use, studies have shown that programs that reach out to also prevent drug abuse along with social resistance skills have been successful (7).
Another issue with the Health Belief Model is that there is a direct correlation between intention and behavior. The abstinence-only model follows the linear decision making path that if the individual has enough information regarding the negative outcome and high susceptibility of these outcomes while engaging in premarital sex and understands the benefits of not having premarital sex, then they will have no intention of participating in this behavior, and therefore chose to be abstinent. This assumes that behavior is always planned. The assumption of planned behavior is apparent in the mechanistic, linear format of this particular model (9). The presence of habit and emotion are not incorporated, as there is the assumption that there is a linear thought process involved in each decision (9). This again does not account for any outside factors from the environment, community, or even emotion that can affect a behavior.

The Affect of Negative Stigma on Social Norms
As highlighted earlier as an issue that can affect an individual’s behavior, social norms are a very important factor in planning a health intervention. Edberg defines social norms as “customary codes of behavior in a group or culture” (9). These norms can vary in many different settings, so it is important to adjust specific programs to fit the needs of the target community. An example of a social norm in a community may be that you do not disrespect your elders. This is a guide on how to behave (not respecting your elders), as well as an affirmation of the route from where the social norm comes from (that it is not right to disrespect your elders) (9). In addition to social norms existing in a community, stigmas can also exist. Unlike social norms, stigmas are not defined rules, but negative actions that are considered “disgraceful” (8) in that community. Stigma can be associated with a negative label upon a certain behavior.
The negative emphasis that is being put on sexual activity by abstinence only programs aid in creating a social norm as well as a negative stigma in that community. Both stigma and social norms need to be considered in creating an intervention to a certain community; however both of these unique factors are not included in abstinence-only based programs. For example, if adolescents are repeatedly taught that sex in wrong, this creates a negative stigma towards those who participate in premarital sex. It also creates a barrier to communication regarding sexual issues, in which it is a social norm to not discuss sexual issues.
The lack of communication regarding sexual issues poses a serious threat to sexual health. In an investigation observing abstinent girls in an urban setting, there was a significant finding that open communication between mothers and daughters regarding sex had a strong influence on the adolescents choosing to stay abstinent (3). If abstinence based programs continue to rely on fear tactics alone, then the valuable resource of open sexual communication may not only be lost, but also develop into a social norm that this subject should not be openly discussed.
Another social norm that abstinence-only programs incorporate is stereotyping gender roles. Many curricula often incorporate the roles of men and women in successful relationships by defining that women need financial support, and men need domestic support (14). Another program states that women care less about their achievements and should judge their success on their relationships, while men judge their success on achievements (14). Another program includes that men are “sexually aggressive and lack deep emotions”, while women need affection and conversation (14). This line of teaching proposes a social norm that women are weaker, and need male support. This may also place a negative stigma upon girls that tend to be more independent, and men that tend to be more emotional.
Including any form of lesson that suggests women should be dependent on men is also very dangerous. In the same investigation observing abstinent girls in an urban setting, there were also significant findings that an emphasis on future achievements, independency and choices had a strong influence on the adolescents choosing to stay abstinent (3).
Conclusion:
Abstinence-only sex education was put into place to decrease teen pregnancy and other issues associated with risky sexual behavior. The program identifies pre-marital sex as the main cause of these issues as well as incorporates modeling traditional heterosexual relationships as an example of an acceptable lifestyle. Unfortunately, the execution of this intervention uses techniques that are ineffective.
The use of scare tactics and the extreme focus on premarital sex as an unacceptable and harmful behavior is not only an unsuccessful method of intervention, but also uses false information as statistical fact. As stated before, facts such as a pregnancy occurs one out of every seven times a couple engages in sexual behavior with the use of a condom, that “5% to 10% of women who have legal abortions become sterile,” and that “premature birth, a major cause of mental retardation, is increased following the abortion of a first pregnancy” are included in abstinence-only curricula (14). According to obstetrics textbooks, fertility is not altered by abortion and no results have been shown to have an on effect low birth weight in later pregnancies (14). Also, in terms of condom use, failure rates for perfect use are 2-3%, and for typical use it is 15% (14). It can be argued, that if more attention is focused on teaching students how to correctly use contraception methods, then the failure rates would decrease. Currently, there are no abstinence-only programs that provide information on how to choose an appropriate method of birth control, and use it effectively (14).
The extreme focus on the individual also weakens the intervention. There is no focus on outside factors such as gender, race, socioeconomic status and social norms, which are all factors that have an effect on human behavior. Factors such as social norms can cause an individual’s decision making process to be irrational, and this specific program only focuses on a rational decision making process. This program also teaches social norms that enforce traditional stereotypes; such as women are weaker than men, in the curriculum (14). This type of lesson does not only force a certain view of traditional relationships on individuals it may not apply to, but it also can work against the actual message of abstaining from sex before marriage. Studies have shown that girls who are more independent and value their choices and futures are more likely to choose abstinence than other girls (3).
The issue of teen pregnancy in the US is severe, and needs to be addressed. Unfortunately, abstinence-only sex education is ineffective, and is forced on millions of adolescents each year (14). In order to create an intervention that will produce a positive outcome, many modifications to the current curriculum need to be addressed. Although abstinence in theory is the best method of contraception, it is important to teach abstinence in addition to other methods of birth control and how to protect oneself against unplanned pregnancy. Other factors such as future planning, self confidence, emotions, and alcohol and drug prevention need to be incorporated as well. Each program must also focus on more than just the individual, and also be modified to fit the social norms of the community that it is reaching out to. Finally, the extreme negative emphasis on premarital sex needs to be eliminated. In the event that an adolescent is not abstinent, it is essential to sexual health that they know how to not only use an appropriate method of contraception, but know how to discuss these options with their partner. Open communication about sexual issues is essential, and needs to be accepted.
The Fight Against Teen Pregnancy in the United States: A Proposal to transform Abstinence-Only Sex Education Based on Social and Behavioral Theory

In order to see positive results in a Public Health campaign regarding the rates of teen pregnancy in the US, many changes need to be made to the current abstinence- only based curriculum. As highlighted in the previous critique, methods such as fear tactics, focusing on the individual, and creating negative social norms has not only hindered the effort to lower teen pregnancy rates, it has actually contradicted the teachings of abstinence. For example, by using fear tactics as a method of teaching this emphasizes that the target behavior is unacceptable. Risky behavior can often be attractive to adolescents which will then attract this age group to a behavior (in this case, premarital sex), therefore making the behavior more difficult to change (6). In order to create a program that will yield positive effects, education in schools must be altered to eliminate the use of fear tactics, a strict focus on the individual, and the creation of negative social norms.
We first must build a health education program that is mandated in schools and includes all aspects attributed to sexual health. Currently, 21 states do not require sexual education in public schools, including the State of Massachusetts (20). Health education should be required, and should also start at an early age. The average age of sexual initiation is 13.8 years (15), so it is crucial that this curriculum be initiated before the participants initiate sexual intercourse. This health program in schools should be year round and should start as soon as the child begins schooling. Specific issues that can affect sexual health such as alcohol consumption, future planning, communication, and contraception should be addressed in addition to biological functionality of the reproductive system. In order to take the necessary steps to prevent teen pregnancy the abstinence-only curriculum needs to be revised. This proposal will define ways to educate youth in a health education class that occurs yearly from age 5-18. This will focus specifically on sexual issues and contraception use and opening the lines of communication in a multilevel model by eliminating the use of fear tactics, individually based models, and the creation of negative social norms that currently exist in abstinence-only programs.
Education of all Methods of Contraception, including Abstinence (age 10-18):

Abstinence in theory is the best method of contraception, and should be included while teaching methods of contraception. However, if the adolescent chooses to engage in sexual activity, all methods of contraception should be taught so that the individual is fully educated on how to protect themselves accordingly. As teens that use condoms at first sexual intercourse are 20 times more likely to use protection in future sexual acts and the average age for sexual initiation is 13.8 years (15), contraception education should be initiated at age 10. This will allow adolescents who do engage in sexual intercourse at an early age to have the tools to properly administer their preferred method of contraception, and will increase the likelihood that they will continue to use methods of protection.
Starting at age 10, students will begin receiving education in health class with an exclusive focus on contraception methods including the correct efficacy rates, and how to use each method. All classes will need to incorporate statistical evidence and percentages (such as thirty-four percent of women become pregnant at least once before the age of 20, and 79 percent are to unmarried teens (10)), ways in which infections can be prevented (such as using different methods of contraception), and how to administer contraceptives along with efficacy rates.
All methods of contraceptives should also be brought to class so that students can learn what they look like, and how to recognize each method. In an investigation that surveyed 1,373 British teens, many teens that had engaged in sexual activity stated that they had used a condom, however either administered the condom after intercourse had already initiated, or removed the condom before intercourse was complete (16). This is not only an unsuccessful method of protection but “the reduced effectiveness of condoms as a method of sexually transmitted disease prevention when used incorrectly may result in users losing confidence in what should be a highly effective method (16).”
The basic format of the abstinence-only education based solely on the Health Belief Model does address the benefits of abstinence; however the use of fear tactics and negative emphasis does not allow the student to be educated on all options. Adolescents who do chose to become sexually active will not have the appropriate tools to stay protected against unwanted pregnancy and sexually transmitted infections. Not only can this lack of education have negative outcomes like unwanted pregnancies, but the loss of confidence in what should be a highly effective method can then affect the choices that the individual makes in future sexual acts (16).
Taking the Focus off of the Individual and Incorporating Irrational Factors (age 5-18)

Abstinence-only programs focus on the rational decision making of the individual, however, decision making is not always rational. Many factors such as emotion, attitudes, the community, and the environment can all interrupt the line between intention and behavior (9) and these factors are not included in the abstinence-only curriculum. In order to design a program that does not rely on rational decisions, each school year will begin with an evaluation of the community.
As Mark Edberg highlights, “given the broad and often complex relationship among school, family, and community, the potential kinds of useful information are diverse” (9). As issues such as social norms in the community, the environment, race, gender and class size can affect adolescent behavior (9) these factors need to be evaluated on a yearly basis so that issues that are specific to that community can be incorporated. For example, one of the most prevalent risks associated with drug and alcohol use in teens is engaging in risky sexual behavior (19). As this is a known risk factor of unprotected sex, the levels of alcohol and drug use in the specific community can be evaluated. The severity of this issue can then be incorporated into the health curriculum. The same method can be applied to other factors that may be prevalent in the community that need to be addressed.
Emotion and biological functionality are also important factors that are not addressed in abstinence based programs. Arousal, peer pressure, and curiosity are all emotions that may not be present when rationally thinking about engaging in sexual activity, however can arise in other situations. In order to address these emotions and physical states, the health curriculum must include methods on how to address emotions, and alternative methods of dealing with them as opposed to acting on impulse. For example, addressing the existence of arousal should be tied together with contraception education so that adolescents understand that if you are in a state of arousal, and are about to engage in any type of sexual activity, it is important to be prepared with the choice method of contraception, and understand the emotions that will be present.
It is important to include the functionality of reproductive organs as well in teaching emotion. Arousal for example, can be taught as an emotion; however it is important for the adolescent to fully understand the physicality of sexual acts. Sex education needs to start when a child begins to have curiosity about his or her body which starts at a very young age (18). Incorporating different organs and their roles in the body should start at age 5 and continue through age 18. Starting with explaining the presence of different body parts at a young age, as well as encouraging young children to ask questions regarding their curiosity is important so that the child does not learn at an early age that it is not appropriate to ask questions regarding this topic. Sexual development such as puberty should then be incorporated and eventually sexual health (i.e. self breast exams, STI Information, the importance of getting checked for STI’s etc). One way to monitor specific topics that need to be addressed is by including surveying each class during the yearly community review. The survey will inquire what type of topics the student wishes to learn next year, and if they have any specific questions that they would like to have addressed. These questions can help to evaluate where these groups of students are in their sexual development, and then be incorporated into the curriculum.
Opening the lines of communication (age 5-18)
Open lines of communication between adolescents and parents is extremely important. According to the Centers for Disease Control and Prevention (15), findings from a collection of interviews with 372 sexually active adolescents in New York, Alabama, and Puerto Rico established that parent-adolescent discussions about condom use before the initiation of sexual intercourse greatly increased the percentage of adolescents who used condoms for their first intercourse (15). Adolescents who did choose to use condoms at first intercourse were also 20 times more likely to use condoms in subsequent acts (15).
Currently, the negative emphasis that is being put on sexual activity by abstinence-only programs is creating a social norm as well as a negative stigma in that community that can hinder communication lines between adolescents, their teachers, parents and peers. Lifting the extreme negative emphasis on intercourse will help to change the social norm in the community that sexual activity is not appropriate to discuss; however open communication regarding sexual issues needs to be a prominent theme in school education.
Healthy relationship and communication training needs to be incorporated into the curriculum. It is important that adolescents understand how to communicate with their partners about their own needs, as well as with their peers, and parents. Included in communication and healthy relationship training, self confidence should be emphasized. It is important that students learn to build healthy relationships with not only their peers, partners, and parents, but also with themselves. All students should receive training on the values of future achievements, independency and choices as the importance of these factors can yield significant results on the individual making healthy choices (3).
Opening lines of communications with adolescents and their parents can be difficult but it is important that the student has a relationship with an adult that they feel that they can trust. In order to open up these lines of communication, each year the student will need to interview and adult of their choice on the topics learned in class. This will help the adolescent learn how to communicate with adults about sexual and health topics, as well as build a relationship with this contact. The strength of this relationship is crucial so that if the student ever has questions, or needs to talk to someone about sexual issues, they have confidence that there is someone they can go to.
Conclusion
Abstinence-only sex education was put into place to decrease teen pregnancy, however the intention of education in general is to prepare youth with the skills they need for the future (17). Fear based abstinence teaching not only is not helpful to youth after the age of 18, but it also does not incorporate information based teaching so that students can apply the information later in life (17). This method also does not take into consideration community factors which have a strong impact on behavior. For example, abstinence-based programs enforce that unmarried people should remain abstinent, but this does not take into account the fact that the median age of first marriage is continually rising (17).
In order to see positive results on the fight against teen pregnancy, a program must be designed that starts at an early age and continues until the student graduates. Students must be educated on all methods of contraception, as well as the reproductive system. Multilevel factors such as the community and the environment must be incorporated so that the program can successfully relate and apply to the participants. Evaluating the community issues on a yearly basis is essential because if there are existent factors that are not addressed, the intervention may not have any positive effect. Finally, communication regarding sexual issues between students, teachers, peers, partners and adults must be accepted. It is essential that students feel that they can talk about issues, and develop communication skills that allow them to address their own needs. With these established skills, students should be able to make healthy decisions with future goals in mind as they leave schooling and move into the working world or higher level education.










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"Small Steps: Limited Rewards" - The Failure of the National Diabetes Education Program's Diabetes Prevention Program Sharon Touw

According to data from the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey, in 2003, 23.6 million people in the United States had diabetes. In adults, type 2 diabetes accounts for 90 to 95% of all new cases of diabetes, so this paper will focus on this form of diabetes which is characterized by a gradually increasing resistance to insulin until the pancreas is no longer able to produce it. (1,2) According to data from the NHANES III, 9.7% of the US population, aged 40-74, had impaired fasting glucose (abnormally high glucose levels after fasting) and 15.6% had impaired glucose tolerance (abnormally high glucose levels after a two hour glucose tolerance test. (1) A person having one or both of these conditions is considered to have prediabetes, meaning that their glucose levels are high, but not high enough to be characterized as diabetic. Individuals with prediabetes are 5 to 15 times more likely to develop diabetes type 2. (3)
Diabetes is a long-term, chronic disease that requires extensive self-management and provider involvement in clinical care. The costs on the health care system, the family, the community and the individual can be devastating, so it is a worthwhile endeavor to try to prevent or delay the onset of diabetes. In 2007, diabetes cost the United States 174 billion dollars in direct medical costs and 58 million dollars in indirect costs such as disability, premature mortality and work loss. (2) Several randomized trials have shown that modest behavior modification can delay or even prevent the onset of type 2 diabetes when individuals make minor adjustments to their diet and moderately increase their activity level. (4-6)
Recognizing this, the National Diabetes Education Program (NDEP), a partnership of the Centers for Disease Control in partnership with the National Institutes of Health and other organizations, established the “Small Steps: Big Rewards” program to educate individuals at risk of developing diabetes. (7) The "Small Steps” program is trying to convey a message of hope that modest changes in diet and exercise can prevent or delay the onset of diabetes. Their core message is that with a small amount of effort and minimal behavior modification, people who have prediabetes, a family history of diabetes, BMIs characterized as overweight or obese, or other risk factors are capable of preventing or delaying the onset of diabetes. The program encourages people to walk or participate in other moderate physical activity for 30 minutes a day. The campaign also promotes healthier eating habits, such as eating fast food, choosing healthier fast food options, consuming more fruits and vegetables, eating smaller portions and avoiding fried foods. Their hope is that cumulatively these minor changes will have a major impact on the health of the individual resulting in weight loss, since elevated BMI is one of the strongest predictors of diabetes. (8) The "Small Steps" program encourages individuals to lose 5-10% of their body weight, which they deem an attainable goal.
The program is also trying to empower people and build their self-efficacy. It drives home the message that you as an individual are in control of your body. Genetic and other risk factors play a role, but ultimately, you need to take charge of your health and prevent the onset of diabetes. Messages include "Get Real. You don't have to knock yourself out to prevent diabetes." Another message aimed at older people states, "It's not too late to prevent diabetes." The Game Plan campaign provides educational and planning materials such as calories and activity trackers for individualized "game plans" for diabetes prevention. (7) Although the posters use different imagery and themes, the message stays the same – namely, you are in control of whether you develop diabetes and that by taking small, manageable steps, you can achieve better health.
The “Small Steps” campaign targets the groups at higher risk for developing diabetes, namely older Americans, African Americans, American Indians and Native Alaskans, Asian Americans and Hispanic Americans since diabetes disproportionately affects these groups. According to the Office of Minority Health, African Americans are 1.9 times more likely to be diagnosed with diabetes, American Indians and Native Alaskans are 2.3 times more likely and Hispanic Americans are 1.5 times more likely than non-Hispanic Whites in the same age group. (9)
The National Diabetes Education Prevention's campaign "Small Steps: Big Rewards" campaign will fail for three major reasons. First, they have based their intervention largely on the health belief model and the theory of planned behavior, ignoring some of the basic tenets that characterize human behavior. By focusing their strategy on individual-level risk factors, they did not contextualize these factors in the social and physical or built environments of the individuals. They also did not consider the challenges of building self-efficacy in a marginalized and disempowered community. Second, the “Small Steps” campaign does not recognize the challenges to participating 3o minutes of physical activity faced by the residents of many neighborhoods and communities. Third, the “Small Steps” intervention does not take into account that many low income neighborhoods lack access to nutritious, high quality food in low SES neighborhoods.
Laying the Foundation on the Individual-Based Models of Behavior Change
The NDEP's "Small Steps: Big Rewards" campaign is based on individual level models of behavior change. Specifically, it incorporates elements of the theory of planned behavior and the health belief model. The Theory of Planned Behavior developed by Icek Ajzen requires the individual to rationally weigh their personal behavioral beliefs, with normative beliefs, how they think their family and friends perceive the behavior and the importance of this perception. Additionally, the individual must have enough "perceived behavioral control;" namely, they must feel that they have both the ability and strength to make the behavioral change. (10)
The "Small Steps Big Rewards" includes each of these elements. It presents positive images about exercise and diet to try and impact a person's personal behavioral beliefs. It incorporates images of family members, spouses, children and grandchildren, to remind people of the importance of staying healthy for those who love them and depend on them. Finally, the “Small Steps” campaign is trying to build a foundation of self-efficacy or perceived behavioral control. It emphasizes repeatedly that only minimal action — "small steps" are necessary to garnish large rewards. The goal is to both influence a person's beliefs about the behavior and to help build the perceived behavioral control or self-efficacy needed to take on the challenge of losing weight.
The "Small Steps" campaign also brings in some elements of the health belief model. They present the benefits of adopting diet and exercise modifications and try to present these modifications as being easy to achieve and minimize barriers to achieving minor weight loss and other health goals.
Though the premise of the "Small Steps" campaign isn't wrong, it unfortunately fails to move beyond the individual level theories and is thus not very useful in effecting behavior change. Diabetes is a problem that is plaguing entire communities, and the focus on individual behaviors ignores the fact that the individual makes decisions and operates in a larger social and environmental context.
The “Small Steps” campaign did not leave room for irrational behavior. It makes the assumption that by presenting clear information and “simple” ways to change behaviors, that people would make the rational choice, especially to avoid the pain, suffering and complications of diabetes. Unfortunately, humans often make irrational decisions. This is especially the case in food consumption where external factor such as the eating behaviors of others or the amount of people present at meal have been shown to influence consumption. (11, 12) Furthermore, people do not even recognize that these external factors play a large role in their consumption patterns. (13) The "Small Steps" campaign also does not recognize the macro-level factors such as food prices, food trends (eating more meals outside the home and larger portions), advertising, and the increased consumption of soft drinks. (14) An individual's food habits have been steeped in American culture, and it will take more than a colorful poster or ad to change behavior that is so entrenched in the daily routine.
The “Small Steps” campaign did not account for the fact that people do not gain weight as individuals, but as groups. Using data from the Framingham Heart Study, Christakis and Fowler showed that a person had a 57 percent greater chance of becoming obese in a certain time period if she or he had a friend who became obese in this period. If one spouse became obese, the likelihood that the other spouse would become obese increased by 37 percent. (15) Since individuals are adopting unhealthy behaviors as a group, then successful interventions need to be targeted at the level of the family, neighborhood and community to truly tackle the roots of the obesity and diabetes epidemics.
Although the “Small Steps” campaign incorporates self-efficacy as a necessary component to translate a behavioral intention into action, the campaign did not take into account that their upbeat messages may not be enough to counter the lack of empowerment and felt by many in lower SES groups when faced with something as daunting as obesity and diabetes. A New York Times piece exposes the situation in East Harlem where people are dying of diabetes at twice the rate of people of people in the entire City. New York City already has a high prevalence rate of diabetes with one in 8 people having received a diagnosis. One of the people profiled in the article sums it up well by saying, "Around here if you make it to 40, you think, hey, I'm lucky, I made it to 40. You have to understand, the philosophy out her is we're going to die from something." Amongst those interviewed for the article, there was a prevailing attitude of despair and discouragement when looking at the diabetes in their own lives and in their communities. (16) Communities such as East Harlem where there is lack of engagement in the political process and less vehicles for community engagement are powerless in the face of such a daunting disease as diabetes. Disempowerment and powerlessness over disease has been shown to be a broad-based risk factor for disease (17)
Taking care of one's health often takes a place on the back burner in comparison with other more pressing concerns such as day-to-day survival, taking care of children and grandchildren, youth violence and drugs. Maslow’s Hierarchy of Needs can be used as evidence for the failure of the “Small Steps” campaign, especially among low SES communities. According to Abraham Maslow, people have a hierarchy of needs with physiological needs such as air, food and water, forming the basis of the pyramid, followed by safety/security needs. Before an individual can nurture needs related to esteem and self-actualization (which is where optimal or improved health might fall), s/he needs to feel that the basic physiological and safety needs have been met. (18) Since the “Small Steps” campaign is focused on fulfilling a higher level need, it does not work for many who are facing food and housing insecurity, violence or other more pressing problems.
Finally, a danger of focusing on individual level risk factors is that you take the risk of stigmatizing the individual, namely that a person develops diabetes because they are fat, lazy and don't care about their health. If interventions fail to look beyond the individual level risk factors, they are at risk of stigmatizing a group of people who are already struggling with a complex, time-consuming, and challenging disease.
30 Minutes of Daily Physical Activity – Not Such a Small Step
The physical environment in which a person lives, works, studies, shops, eats, and exercises, sometimes known as the built environment, may have a tremendous influence on individual risk factors. The CDC defines the built environment as "the buildings, roads, utilities, homes, fixtures, parks and all other man-made entities that form the physical characteristics of a community." (19) The built environment has always been of interest to urban planners, but in the past decade, it has become of more interest to the public health practitioner. There have been several studies that have looked at BMI, reported physical activity and its association with access to playgrounds, community centers or other places for recreation activity. (14, 20, 21) Gordon-Larsen et al. looked at the availability of recreational, facilities with in different census blocks and its association with physical activity and BMI in adolescents. They found that blocks with low SES groups and blocks composed of largely minority groups had fewer recreational facilities with many having no access to facility within 5 miles. The lack of recreational facilities was positively associated with less physical activity among the adolescents, more overweight and obese adolescents and an increased risk for developing type 2 diabetes. (21)
The study did not evaluate if the recreational areas were considered safe and if parents felt that children could walk to and from facilities safely, other important factors in the built environment. Public health practitioners need to evaluate the perceived safety of the environments in which people live. Parents may prefer that their children be home watching televisions and playing video games, safe and accounted for, rather than out engaging in their 30 minutes of physical activity as advocated by the "Small Steps" campaign. It's obvious that the designers did not take into account the environments in which many of those at risk of developing diabetes are living. The intervention was aimed at those individuals living in safe neighborhoods with access to adequate recreation facilities.
Evaluating Food Options and Costs
The "Small Steps" campaign also advises individuals to eat more fruits and vegetables, prepare more foods at home and to avoid high fat fried foods – all worthy and appropriate things to do in the effort to reduce the risk of developing diabetes. However, the campaign does not take into account the fact that the very people they are targeting may not have access or the availability to take these "small steps." For some, these steps may be a monumental task.
The businesses located in a neighborhood may not allow for individuals to comply with the dietary recommendations of their doctors or campaigns such as “Small Steps.” Researchers have begun to conduct neighborhood level analyses about what types of food-related businesses are available in particular neighborhoods. Neighborhoods characterized as lower SES often do not have stores that stock the types of foods that are recommended for diabetics, specifically, high fiber or low carbohydrate bread; fresh fruits; fresh green vegetables or tomatoes; low fat or skim milk; and diet soda.. Horwitz et al. conducted food availability surveys comparing East Harlem to the Upper East Side, two vastly different neighborhoods in New York City. In 1998, East Harlem’s population was 40% Black, 50% Hispanic and had a median household income of $21, 295. On the other hand, the Upper East Side’s population was 2% Black, 4% Hispanic and had an average median income of $74,130. The study showed that Upper East Side stores were 3.2 times more likely than East Harlem stores to stock all recommended food items. (22) Another interesting study looked at the food environment and its impact on residents' diets and found that only 8% of Black American lived in a census tract with at least one supermarket. For Black Americans, the presence of a supermarket was associated with increase intake of fruits and vegetables. (23) People may want to comply with the recommended daily servings of vegetables and other healthy foods, but may not have access to the stores that sells fruits and vegetables.
Other studies have looked at the number of fast food restaurants in different neighborhoods. A study by Block et al. looked at the geographic location of fast food restaurants and the socioeconomic characteristics of neighborhoods within New Orleans. They found that there were 2.4 fast food restaurants per square mile in predominantly Black neighborhoods in comparison with 1.5 in predominantly White neighborhoods. (24) Other studies have been carried out in different cities with similar results. (25) The “Small Steps” campaign’s colorful images of fruits and vegetables and inspirational messages do not alleviate the problems associated with lack of food choices and the ready access to unhealthy options that plague many lower SES neighborhoods.
It is also useful to look at the transportation in a neighborhood and the methods of transportation that are available for people to do their shopping. If the supermarket is in another neighborhood, is it worth the time, money and energy to take a bus or two to buy food to prepare a home-cooked meal? Does a busy mother or caretaker even have the time?
Fresh foods and vegetables are also more expensive and a person on a fixed income may not have enough resources to purchase them. Energy dense foods have been shown to be associated with lower costs, and these foods have been linked to over consumption. Families facing food insecurity often face problems with obesity as they choose processed food, and products with refined flours and sugars in order to be able to purchase enough food for the entire family. (26) The “Small Steps” campaign’s admonitions to eat fresh fruits and vegetables are competing with powerful forces of poverty and the price structures of food products that do not support healthy eating.
The “Small Steps” campaign did not look at the landscape in which people make their food choices and the money would have been better spent working to transform the built environment and encourage new types of businesses in the communities affected by diabetes.
Counter Proposal – Community Gardens: Growing Food and People
Community gardens are a viable option to combat diabetes and other chronic diseases since they do not seek to effect behavior change one individual at a time, rather, they are seeking to transform an entire community. The community garden movement began in the late 1960’s and early 1970’s when activists sought to fight urban blight by revitalizing vacant lots, often home to drug dealing and other illegal activities. Community gardens exist in urban, suburban, and rural areas, though they have thrived in urban areas especially in larger cities in the United States and Canada (27) Community gardens differ from private gardens in that they operate in the public domain to some degree in terms of the ownership, access and democratic control of the space. (28) Community gardens involve shared responsibility for common areas, work days where gardeners collaborate on larger projects and foster daily interaction as people tend their plots.
A community garden with a greenhouse, community kitchen/classroom, playground, and ideally staff members could have a tremendous impact in the fight against diabetes and other chronic health problems such as obesity, cardiovascular disease and mental health issues. The community garden, especially in urban environments, addresses problems related to the built environment, such as the lack of recreational facilities and safe places to exercise, while promoting community development and social cohesion. The kitchen could serve as a meeting place and a classroom where community members could eat and learn from each other as well as engage in more structured educational activities related to health promotion. Once the environmental issues were being addressed, the community would be more receptive to these types of educational and health promotion interventions. (29) Health promotion would be more effective in a community forum and with hands on activities rather than with messages on buses, billboards and PSAs on the radio. The same message of making healthier food choices and getting more exercise that has gotten limited results from the “Small Steps” campaign would yield positive results if it were crafted in the context of a community garden/kitchen which gave people the opportunity to share, interact and change their behavior as a community.
Community Gardening - Growing Community and Promoting Health
Community gardens provide a venue for neighbors to get together and form social connections. Not only are they places where people can have daily social interaction, they are often the sites of community events, such as festivals, potluck suppers, theatre, music and art events, etc. (27) Wakefield et al. interviewed gardeners in South-East Toronto and found that the gardeners felt that the gardens were beneficial to the community. They were viewed to be improving relationships and increasing community pride. (30) There was also evidence that the increased pride and ownership due to the community gardens led to less littering and to the perception that the community was cleaner and safer. (27, 30,31,33) Community gardens foster social interaction and build social networks, which in turn cultivates the organizational capacity of the community.
Additionally, in several studies, community garden were seen as mechanisms for broader community development since they build leadership skills and empower residents to be advocates for themselves and their communities. (27, 30,31) The gardeners start off sharing thoughts about gardening and food, working together, and sharing seeds, tools and cultural practices. The social cohesion built by these informal interactions often serves as a springboard for discussion about and action on other non-garden related issues in the community. Gardeners in upstate New York successfully advocated for better sidewalks and playgrounds, fought to keep a supermarket in the community, established crime watches and neighborhood associations, etc. (31)
The "Small Steps" posters and radio did not build self-efficacy in communities burdened by problems since the intervention did not offer real solutions. On the other hand, the community garden is a tangible solution to many problems and gives community members the opportunity to provide for their own families. The community garden builds individual pride and "nurtures community capacity." Stronger community capacity makes health interventions more effective. (32). Health promotion campaigns need to work on fostering self-efficacy on the broader level by supporting projects that build the capacity of the community as a whole.
Community Gardens – A Safe Place for Physical Activity
Gardening is considered a form of moderate exercise. Several gardeners in various studies reported increased physical activity and improved health as a benefit of gardening. (27, 30,33) A garden that offers a play area for the children would provide safe place for families to exercise while improving the appearance of the built environment. Gardeners reported that gardening kept them physically and mentally active and got them out their houses. This was especially true for elderly gardeners who tend to be more isolated in their homes. A gardener in Southeast Toronto called gardening, "a form of exercise, relaxation. . . getting away from the TV." (30) and this sentiment was echoed by gardeners in other areas as well. Community gardens often incorporate raised beds so that elderly and handicapped individuals can still participate, and for the elderly, this may be their one social outlet. Several gardeners also cited the relaxation and improvements to mental health as benefits to gardening. (27, 30, 31) A gardener was quoted as saying that the garden "helps you hold onto life." (30)
Some community gardens, especially in urban areas, the fenced-in space allows residents to feel safe outdoors. It was a place where their children could play outside safely. (30) This eliminates some of the hesitancy to exercise outdoors if parents feel there is a safe place for their children to spend their time. The perception that the communities were safer and cleaner also helps to facilitate physical activity in the larger community outside the garden fences as well.
Promoting Healthier Eating
The primary benefit cited by numerous studies about community gardens was better access to fresh fruits and vegetables. All studies reported that the gardeners consumed more fruits and vegetables, since joining the community garden. (27, 30, 31,33) This is particularly important in areas where there are no supermarkets or other foods stores that are providing good quality produce. The gardeners could also grow a wide variety of foods, and could grow those that were culturally appropriate. Latin American gardeners said that buying fruits and vegetables from their native countries in stores was not always possible, and when stores did carry these products they were very expensive and not fresh. Many gardeners also grow herbs which can be very expensive and difficult to find in local stores. (27, 31) Gardeners were proud of the fresh food that they were growing and the benefit it had on their families. (30) The garden was building self-esteem since it was allowing people to provide for their families, as well as a sense of ownership, even if it were just of a small plot of land.
The community garden also provides organic fruits and vegetables at a much lower cost than are sold in supermarkets. A gardener from NYC reported that he saved at least $200 per season by growing his own tomatoes. (27) Gardeners part of the Rutgers gardening program in New Jersey reported that they didn’t have to buy vegetables in the supermarket. They gardened to save money and planted the things that were found to be too costly for purchase at supermarkets. (33)
Many gardeners also reported giving produce to neighbors and friends and donating produce to local shelters, food pantries, churches, elderly residents and other social service organizations. (27,30,31) This signifies the larger community is benefiting from the community garden.
Other gardens are involved in economic activity setting up community supported agriculture shares and selling food at farm stands or farmers markets. The Food Project (34) based in Boston has both urban and suburban farms, and it sells fresh produce at farmers markets and through community supported agriculture shares. It sells produce in several areas such as Roxbury and at Boston Medical Center that don’t typically have access to fresh organic produce. This type of project should be replicated on a greater scale throughout the city and in other cities as well, so that small scale agriculture could become a source of economic development.
Conclusion
The money spent on developing slick ads for the "Small Steps" campaign would have been better spent helping to establish community gardens and providing much needed funds to gardens that are trying to become more stable fixtures in the community. These community gardens could be staffed with nutrition and gardening experts who could engage children and adults in growing their own food and choosing healthier food options. Community gardens could be used to address health promotion and diabetes prevention at a group level, and directly provide nutritious fruits and vegetables, as well as a venue for daily physical activity, as well as having numerous other benefits.
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