The Health Belief Model and Smoking Cessation: Making it Bigger and Stronger Doesn’t Make It Better - Catherine Snow

The Public Health Department of the city of New York recently began airing a commercial that has been receiving a lot publicity. It was featured on NBC’s Today Show on both April 2 and April 3, 2009, and has generated considerable controversy (1). The commercial features a boy, perhaps four years of age, who becomes separated from his mother at a crowded train station and begins to cry, quite convincingly. The tagline of the commercial is, “This is how your child feels after losing you for a minute. Just imagine if they lost you for life.” (2) The implication being that smoking can cause death, thereby leaving your children parentless. Unfortunately the controversy has nothing to do with smoking, or all of the children that are left without parents as a result of the habit, but whether the child actually shed some real tears during the commercial. The ad is doing a wonderful job of making people think about child actors and their protections (or lack thereof), but the ability of the commercial to fulfill its intended goal, getting current smokes to quit, is inherently flawed.
The commercial was taken from an Australian anti-smoking campaign called Quit (3). The campaign has been around for about 15 years and has made commercials increasingly graphic in an attempt to get people to quit smoking. What may have been effective fifteen, or even five years ago, will not continue to be effective. This campaign, which is now being adopted by New York state, is striking in that is identical to the majority of ad campaigns we have seen in the U.S. since anti-smoking initiatives began: If we just show people how bad smoking is for them, they will quit. If this were effective, then there would be far fewer smokers. It does not matter how graphic, or heart-wrenching we make the imagery, the ads do not address source of the problem. There are three main reasons this campaign will not be successful; 1) it continues to intervene at the individual level; 2) it continues to assume rational behavior; and 3) it maintains that behavior is planned.
The Importance of Social Considerations
Increasingly studies find that human behavior is influenced, not at the individual level, but at the group level. In fact, Social Network Theory posits that the individual influence on behavior is less important than that of the group within which the individual has social ties. Intuitively this seems to make sense. Smokers typically congregate with other smokers, and are often encouraged to find a quit partner. Smokers themselves define smoking as a social activity, and some people refer to themselves a “social smokers”. Studies show that factors such as race, education level, and socioeconomic status contribute to how likely someone is to be a smoker. All of this leads to the assumption that smoking behavior is affected significantly by forces beyond that of the individual.
The impact of social networks as it relates to smoking behavior was examined in a paper by Nicholas Christakis and James Fowler entitled “The Collective Dynamics of Smoking in a Large Social Network”. They looked at a network of over 12,000 people and found that “whole connected clusters within the social network stopped smoking roughly in concert.” Social connections influencing smoking behavior were present among all types of relationships, including spousal, sibling, friend, and colleague. Additionally, there is even some evidence on the larger scale that smoking behavior is subject to Diffusion of Innovation criteria. Those with higher education levels appeared to have more influence on the those with lesser education regarding smoking behavior, causing the behavior to diffuse through other social groups as a result of the adoption by the more educated (4).
All of these findings suggest that smoking behavior is far more complex than an individual seeing an advertisement that alerts them to the more dire consequences of smoking. Yet the most the Quit advertisement does is extend the decision to quit to encompass the effect it has on your children, while leaving the behavior as individually motivated and achieved. Children are certainly important determinants in many of the decisions that we make, but to assume that dramatizing a fairly well-known correlation will lead to behavior change underestimates the importance of how we use complex social networks to define ourselves and our behaviors.
The “Rationality” of Risk-Benefit Analysis
The Quit campaign contains many other commercials, many with graphic depictions of smoking related health problems, including mouth cancer, lung cancer, clogged arteries, and others, all of which can be viewed on their website (3). The implication is that if only we show people how severe the consequences can be, then they will quit. It assumes the decision is arrived at solely based on a rational risk-benefit analysis. This approach may be useful in circumstances where there is a lack of awareness, but given this is the same approach that has been used for decades, there is already awareness of the risks. In fact, Quit boasts on their website that they have been running ads like these since 1985 (3). Instead of being a marker of a successful campaign, one is more inclined to think a different approach should be taken if after 20 years there is still a substantial need for intervention.
In 2009 there are very few people in Australia or the United States, if any, who are not aware of at least some of the health risks of smoking, and most smokers even acknowledge these risks are legitimate. One of the newest commercials in the Quit campaign is entitled “Everybody Knows.” It shows a montage of previous campaign ads to the soundtrack of a deep voice singing “everybody knows”, implying that everybody already knows the health risks of smoking, particularly those already espoused by the campaign (5). Interesting that they would pour resources into a rerun of previous ads they feel everyone already knows about. Will images in montage form make viewers see the risks differently enough to decide to quit?
Smoking is a complex behavior, and cannot be easily packaged into a risk-benefit analysis. A distinction needs to be made between short term and long term risk benefit analyses. If looking at the short term, the analysis does not always work in favor of behavior change sought by the intervention we are discussing. The short term benefits of quitting are minimal when weighed against the difficulties. Not only are there the physical symptoms of withdrawal, but there are social adjustments which can be equally as difficult to deal with. To be the only person in a social circle who doesn’t go out for a cigarette break can be equally as difficult as being the only person who does. These are all factors that weigh against the benefit, and since they are all short term, they can be powerful counterweights.
Smoking in itself can be a benefit to a smoker, which is easy for non-smokers to trivialize. It is calming, familiar, reliable, and a powerful coping mechanism. It is also a self-defining characteristic for many smokers. The act of smoking provides instant gratification, and often that can be enough of a benefit to outweigh a risk. The “rationality” of weighing risks and benefits can be very subjective.
It is very difficult to translate long term health benefits, which may never be tangible, into compelling enough benefits. You will never know if you would have had lung cancer, you can only assume it is a benefit to quitting. For many of the remaining smokers this campaign is trying to reach, the risk-benefit analysis has not been as clear cut at the advertisements now running in New York would like to portray them. There needs to be a more direct and immediate incentive to compel the behavior alteration.
Even smokers for whom the heath risks have become so tangible that there is no risk-benefit analysis that cannot favor behavior change, the habit persists. In 2007 the Centers for Disease Control reported that more than 40% of those who suffered from emphysema and chronic bronchitis are current smokers (6). Even participants in public health campaigns continue to smoke despite the risks. In 2008, the Daily News reported that Skip LeGault, who was the main actor in some of New York’s anti-smoking commercials, continues to smoke, despite ads that show him warning others the habit has brought him “multiple heart attacks, surgeries, strokes, and an amputated right leg” (7).
It turns out many smokers actually want to quit. According to the Centers for Disease Control, 70% of current smokers report they want to quit, and in 2006, an estimated 44.2% had attempted to quit (8). If these large percentages already want to quit, why are resources being spent trying to convince people that they should? The issue would appear to be something other than convincing people that smoking cessation is in their best interest. The Quit campaign functions under the assumption that if people develop an intention to quit, then behavior will follow. There is very little that supports this assumption of human behavior. As illustrated above, human behavior is not rational. In basic matters there are a great many things that people intend to do that they never do. It is absurd to assume that a behavior will inherently follow an intention.
Planning Isn’t Everything
Many smoking cessation campaigns, including the Quit campaign, recommend that those who want to quit plan their efforts. Suggestions such as making lists, picking a quit date, weaning for a certain number of days, keeping journals, etc, are all common themes in quitting assistance programs. Yet the success rate for cessation is extremely low. The planning of behavior doesn’t seem to be advantageous.
An article from the British Journal of Medicine written by Robert West and Taj Sohal entitled “’Catastrophic’ Pathways to Smoking Cessation: Findings From National Survey” starkly illustrates this. They looked at the success rates of people who had quit smoking using both planned and unplanned attempts. They found that the unplanned attempts succeeded for longer. While only 42.3% of the planned attempts lasted at least 6 months, 65.4% of the unplanned attempts did. Even after controlling for age, sex, and socioeconomic group, the unplanned quit attempts remained more successful at 6 months. West and Sohal attribute this to Catastrophe Theory, which posits that “tensions develop in systems so that even small triggers can lead to sudden ‘catastrophic’ changes.” They go even further to say that when the trigger leads the smoker to plan for future action, that it “may signify a lower level of commitment.” (9)
These findings indicate that the Quit campaign (and many others like it) fails not only in their advertisements, but in their strategies to lead those who decide to quit to behavior change. There is even evidence to say that even if the campaigns are successful in getting people to plan to quit, they may not be as committed, and therefore not as likely to succeed.
Bigger and Stronger Isn’t Better
For New York to adopt the same campaign that they have used in Australia is folly. It is not a new or innovative approach to get people to stop smoking. It is the same approach that has been used since smoking cessation public health campaigns began. It is simply the Health-Belief Model, telling us that if only the perceived benefits outweigh the perceived barriers, people will decide to quit and actually follow through with it. The only novelty to these commercials is that they have an unprecedented degree of drama and graphic content. Even those of us with iron stomachs can’t help but wince at a close up of a gloved surgical hand squeezing fatty deposits out of an arterial segment (10). Despite their new found intensity the message is the same, and the message isn’t reaching any more people than it did the last time it was implemented in a public health campaign.
These advertisements are to the point where they are distracting from their purpose. Particularly in the case of the advertisement featuring the crying child described at the beginning of this paper. There have been all sorts of discussions about this commercial, but none of it has been to bring to the forefront the importance of getting smokers to quit. No one is discussing that ads have become this intense because smoking continues to be a significant issue despite years of efforts. There is only discussion of how terrible it is that this boy may have shed a few real tears. There are internet postings of people asking that it be pulled from the airwaves because it has “gone too far” (11). A commercial that is not being aired is not intervening with anything.
It is time to try another approach. The Health Belief model neglects the social aspects of behavior, and assumes that we act as rational beings who plan behaviors to achieve rationally weighed outcomes. Everyday the social sciences tell us that this not the case, yet public health departments continue with the old model thinking if only they make the message bigger and stronger it will somehow reach the demographic they keep missing. Unfortunately, none of this makes the Health Belief Model better. If anything it is causing the Health Belief Mode to make itself irrelevant as it draws the focus away from the public health issue it is trying to raise awareness of.

So What is Better? An Alternative Approach
Most public health interventions aimed at smoking cessation have been ineffective due to their reliance on the false premises of the Health Belief model. Just like the Quit campaign, most public health interventions assume that behavior is individually motivated, behavior is rational, and intention leads to behavior. The Health Belief Model can be useful, as in circumstances where the health effects of behavior are not well known. Surely when the ill effects of smoking were first conclusively identified such interventions did get large numbers of people to quit. At present, there are few if any people who are not aware of at least some of the myriad negative health effects of smoking, so it does not make sense to continue to use the same intervention.
It is unequivocal that smoking cessation is extraordinarily difficult. Using broad-based media campaigns, although reaching many, does not provide any real support or tools for individuals to successfully quit. Those who continue to smoke, likely are those who need a more direct, hands-on intervention in order for it to have any impact. Public health interventions should substantially narrow in scope and target much smaller populations, providing them with the support and resources necessary to have a significant effect.
Community Organization Theory and Social Network Theory are two social network theories that can achieve this. The most important aspect of this is appropriately choosing the community. If too large, the social connections will be too tenuous to influence behavior. A specific community(s) should be identified and evaluated at the local level and be based on some type of cost-benefit analysis.
As an example, the city of Boston could identify that within a specific neighborhood, low income residents have a very high incidence of child asthma related hospitalizations. Most of these children have parents who smoke, and a great deal of them live in public housing. The city could target a smoking cessation intervention focusing of public housing residents of a particular neighborhood. Not only will it be addressing the health problems of the smokers directly, but also those of everyone else living in those areas. Additionally, given these are low income residents likely on Medicaid, it will continue to provide returns to the city if successful.
Social Network Theory tells us that people exist in social networks, and people change as social networks. Looking at social networks involves looking at the characteristics of relationships within those networks, such as complexity, reciprocity, diversity, and subgroups. The intervention also needs to be designed so that the network is used as the facilitator of the intervention (12).
This is where Community Organization Theory is useful. It uses the community, in this case the public housing community, as the facilitator of the intervention. There are 3 types of community organization: Social Planning, Locality Development, and Social Action. Social Planning involves a group of outside experts with the help of community members, Locality Development involves experts and community members working together as equals, and Social Action is controlled by community members (13). Regardless of the type of community organization, all interventions should have community members participate in each phase, and supply training and knowledge where necessary to empower community members to actively participate in the intervention (13).
Developing a Social Network
For a smoking cessation intervention, Locality Development is the best approach. Quitting smoking is hard, and experts should be on hand to help increase success rates and provider resources. They can provide the participants with resources like how to run effective support groups and provide a supply of nicotine patches. However, the community needs to be equally vested. They need to have a personal stake in their own well-being and the health of their community for any intervention to be effective.
The best way to do this is to identify the community leaders within the public housing units, and enlist them as leaders in the public health initiative. This should be fairly easy since most public housing already have such figures planning social activities for residents. Getting these key figures can lead to diffusion of the behavior throughout the community (4).
Using the community addresses the problem of focusing on the individual that other interventions have had. Having this small network of connected community members with a concern not only for their own health, but those of the children in their community who have problems with asthma helps to provide an incentive that goes beyond the individual. Behaviors now have far more implications than individual ones.
Additionally, there now exists an immediate and accessible support network that is omnipresent. People who used to congregate outside the building at established times to smoke and socialize will now have to redefine that time and those rituals together. “Social smokers” no longer have a social catalyst to light up. The social component to smoking is very powerful, and changing that dynamic can be very powerful.
A Changed Risk Benefit Analysis
The Health Belief Model rests on the assumption that behavior decisions are based on a rational weighing of of perceived benefits and perceived barriers. With smoking cessation, the rationality of that weighing is anything but. Using an individual model, the short term benefits are non-existent. The short term brings withdrawal, social adjustments, identity re-evaluation, and stress. The rational decision to maintain long term survival through better health behaviors is unable to overtake the need for instant gratification.
Using a community intervention removes the need to make the risk benefit analysis about individual health benefits. Instead the risks and benefits shift to include all of the short term, less rational indicators discussed. Rational or not, there is a need to be an active participant of the social network that you are in. Whereas an individual trying to quit smoking has to deal with not having his/her morning break on the front stoop with the 6 other smokers he/she chats with, if an action is taken at the community level, continuing to go outside while everyone else is attempting to develop a new habit will become stigmatic. The short term social risk-benefit analysis has been reversed.
Although there will still be issues such as withdrawal and stress, having a framework within which to cope with them that allows you to maintain consistent social relationships, in itself becomes a benefit. You are strengthening your connection within the community and receive instant gratification whenever support is needed because you are immersed in a support network at all times.
Planning Still Isn’t Everything
Regardless of how well executed an intervention it cannot make people spontaneously decide to quit in order to increase their chances of success. However, having the intervention embedded within a small defined social network can increase the likelihood of a quit attempt. Again, people’s behaviors are heavily influenced by their social networks.
Having an entire housing project focused on a specific health goal, makes the said goal omnipresent in the environment. Having cues throughout your environment may prompt a spontaneous quit attempt. Also noting that we have tied childhood asthma as an additional incentive, perhaps the connection of suffering children within their own community can act as a trigger. The more potential cues present in the environment, the more likely that one will act as the trigger that West and Sophal claim can lead to a “catastrophic” change in behavior (9).
Even West and Sophal cede that their “findings do not necessarily imply that planning quit attempts is counterproductive, and use of behavioral support and nicotine replacement therapy are known to improve the chances of success even though they require planning ahead” (9). This tells us that even if quit attempts on behalf of the residents are planned, they are not necessarily doomed to failure. For those who do quit without prior planning, it follows that having proven resources readily available whenever that decision is made will only increase the likelihood of success.
Sometimes Smaller is Better
A new approach is needed in addressing the smoking habits of individuals who have thus far been unable to be reached by previous interventions. A broad-based approach no longer yields results, and resources would be far better allocated to a more intensive smaller scale approach. Using Community Organization Theory to implement the principles of Social Network Theory shifts the focus from the individual to the community, changes the risk benefit analysis away from simple health benefits to the more complex considerations of social identity, and provides the greatest opportunities for success for all community members willing to execute a behavior change.
References
1. “Today on NBC”. April 3, 2009. http://today.msnbc.msn.com/id/30027473
2. ”Separation”. Quit Victoria: 2008. http://www.quit.org.au/article.asp?ContentID=45812

3. Quit Victoria. 2005. www.quit.org.au

4. Christakis NA, Fowler JH. The Collective Dynamics of Smoking in a Large Social Network. New England Journal of Medicine 2008; 358:2249-2258.

5. “Everybody Knows”. Quit Victoria: 2009.

6. Centers for Disease Control and Prevention. Cigarette Smoking Among Adults-United States, 2006. Morbidity and Mortality Weekly Reports. Vol. 56. No.44. November 9, 2007. http://www.cdc.gov/tobacco/data_statistics/mmwrs/2007/mm5644_highlights.htm

7. Lite, Jordan. Man in Anti-Smoking Ad Still Lights Up. Daily News. January 11, 2008. http://www.nydailynews.com/lifestyle/health/2008/01/11/2008-01-11_man_in_antismoking_ad_still_lights_up.html

8. Centers for Disease Control and Prevention. Smoking and Tobacco Use. Atlanta, GA: 2008. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/cessation2.htm

9. West R, Sohal T. “Catastrophic” Pathways to Smoking Cessation: Findings From National Survey. British Medical Journal 2006; 332:458-460.

10. “Artery”. Quit Victoria: 1997. http://www.quit.org.au/article.asp?ContentID=33338

11. Emotional anti-smoking ad: Low blow or good campaign?. http://www.newsvine.com/_question/2009/04/02/2632900-emotional-anti-smoking-ad-low-blow-or-good-campaign

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

13. The Health Communication Unit at the Centre for Health Promotion. Tipsheet: Summary of Social Science Theories. University of Toronto. 1992. http://www.thcu.ca/infoandresources/publications/Summary_of_Social_Science_Theories_v1.2.july.29.03.pdf

Smoking Cessation Campaign “Every Cigarette is Doing You Damage”: A Health Belief Model Approach that Doesn’t Work- Ekaterina Solovieva

Introduction
Millions of dollars are spent each year in order to target smoking cessation campaigns at the smoking population, and yet only 2 to 3 percent of smokers quit each year in the United States (1). The question remains – are these dollars being spent wisely? “Every Cigarette is Doing You Damage” is a worldwide smoking cessation campaign that is currently being used in United States and Australia (2, 5). The campaign was previously run in a number of other countries such as Germany, Norway, and United Kingdom (16, 17). This campaign, which is based on the concepts of the Health Belief Model, fails to address some of the key issues associated with smoking behavior such as psychological, social, and environmental factors, and yet United States and Australia continue to use it (3, 4).
The Campaign
“Every Cigarette is Doing You Damage” campaign consists of print ads and commercials. The campaign aims to encourage smoking cessation among smokers by showing the various risks associated with smoking such as cancer, artery disease, blindness, stroke, etc. According to the Australian government, the initial creator of the “Every Cigarette is Doing You Damage” campaign, the campaign was developed to: “reduce the level of tobacco use … aimed directly at smokers, both youth and adults” (2).
For the purposes of this analysis, we are going to take a look at a specific commercial that is focused on informing smokers about the risk of getting lung cancer. The commercial begins with an image of a middle-aged man smoking a cigarette as he waits for the bus. As he inhales the cigarette smoke, we get a view of the smoke going into his mouth, and then into his lungs. As we go deeper, cancerous-growth formations can be seen on the interior walls of his lungs. Meanwhile there is a narration that goes as follows: “Every cigarette is doing you damage. New research shows how tobacco smoke attacks a vital gene which protects lung cells from cancer. One damaged cell is all it takes to start lung cancer growing. Every Cigarette is doing you damage… So the sooner you quit the better you’ll be." The commercial ends with a screen shot of the following message: “For Help Quitting Call: New York State Smokers’ Quitline…” (5).
This public health campaign is based on the concept of the Health Belief Model (HBM) which is the oldest and most widely used individual behavior theory in public health. In fact, this model is so popular for smoking cessation campaigns that the American Cancer Society (ACS) presents this theory as a way to analyze if an individual will quit smoking (6). On the ACS website you can find the following statement: “The Health Belief Model says that you will be more likely to stop smoking if you, 1) believe that you could get a smoking-related disease and this worries you, 2) believe that you can make an honest attempt at quitting smoking, 3)believe that the benefits of quitting outweigh the benefits of continuing to smoke, and 4)know of someone who has had health problems as a result of their smoking.” The statement is followed with the following words, “Do any of these apply to you?” (6).
Argument #1: People are well aware of the risks associated with smoking
As stated earlier, HBM is a very popular model for smoking cessation interventions, but as statistics of smoking cessation among adults show, this type of intervention hasn’t been very successful in the last decade (only 2 to 3 percent of smokers quit per year while 97 to 98 percent of smokers continue to engage in this risky behavior). Indeed, HBM is a very useful tool in the early stages of a public health campaign where it can be used to educate the public about a new disease, epidemic, etc. In fact, in the case of smoking cessation, HBM was very successful during the publication of the Surgeon General’s Report in 1964, which educated the population about the link between lung cancer and smoking for the first time, and as a result reduced smoking by as much as 30 percent (7). This report revolutionized the public’s perceived susceptibility, perceived severity, perceived benefits, and so forth about smoking and smoking cessation. However, with the help of the media, internet, and organized teen smoking prevention programs in schools today, people are significantly more aware of the side-effects associated with smoking than they were about fifty, sixty, twenty, and even ten years ago.
Such a campaign is unnecessary in the United States because people are already aware of the risks associated with smoking. “Every Cigarette is Doing You Damage” campaign is being targeted towards adults in relatively wealthy countries whilst recent research literature says that smokers in high-income countries are generally aware of their increased risks of disease when smoking tobacco (8). It makes you wonder: why is “Every Cigarette is Doing You Damage” campaign still predominantly focused on informing the public about the risks of smoking when they could be addressing social factors such as the current image that smoking is cool, and addressing psychosocial factors for smoking that are led on by stress and negative emotions (3). Instead of draining money into airing this campaign, public health practitioners behind this campaign should spend more money on researching the core values of smokers and trying to figure out what will sell to them because clearly education can’t achieve the goal of smoking cessation on its own.
Argument #2: People are not always rational (Long term health doesn’t sell)
With only 2 to 3 percent of smokers quitting per year, it shows that the HBM approach in “Every Cigarette is Doing You Damage” campaign, fails to successfully convey a public health message that encourages smoking cessation. This is largely due to the fact that HBM assumes people are rational individuals when in fact they are not - emotions, social norms, and expectations, are some of the forces that influence their behavior (9). The visual images of the cancerous growths inside the middle-aged man’s lungs, and the statement “just one cigarette is doing you damage… The sooner you quit, the better you’ll be”, attempts to target people’s perceived severity, perceived susceptibility, and perceived benefits. At the same time, by offering a number for a quit-line, the campaign attempts to address perceived barriers. However, just because a person has the perfect formula for smoking cessation according to HBM, it doesn’t necessarily mean that the person is going to take on the health-related action. This is primarily due to the fact that this campaign is based on an individual-level model that doesn’t take into account the fact that people’s behavior is influenced by their expectations of who they are and where they belong (9).
The “Every Cigarette is Doing You Damage” campaign coincides with public health practitioners’ historical reliance on selling long-term health. However, health is not the most effective product that a smoking cessation campaign can offer (10). According to Marketing Public Health: Strategies to Promote Social Change, “The most compelling product of the public health practitioner is the freedom, independence, autonomy, and control over life that come s with health… If public health practitioners fail to make this subtle, yet critical distinction in how they define and then market their product, they are unlikely to be successful” (10). Health is indeed important to people; however, the idea of long-term health is just too far away for people to care about. People have other values and priorities that are significantly more important to them than long-term health; likewise, addiction to nicotine overpowers smokers desire to quit. People’s decisions do not solely rely on individual level factors, but also on external factors such as their social context and environment (4, 10). For example, “women who are subject to discrimination or oppression (such as battered women, victims of sexual assault, immigrants, racial minorities, women with disabilities) may be more likely to be smokers” (3). For these groups of people, long term health is low on the list of priorities and is overpowered by nicotine addiction, grief, frustration, helplessness, the fear of gaining weight and becoming more marginalized in society, loneliness, etc (3, 18). “Every Cigarette is Doing You Damage” campaign is very informative, but it fails to address social and environmental issues that are important to smokers and people in general.
If people were always rational, then the most extreme cases where a person fulfils all of the components of HBM should quit smoking as a result of seeing the “Every Cigarette is Doing You Damage” campaign. However, smokers who are diagnosed with lung cancer are an example of the exception. By the time a person is diagnosed with a disease related to smoking, their perceived severity and perceived susceptibility is very high, and yet studies show that approximately half of the smokers who are diagnosed with early stages of lung cancer and have surgery, continue to smoke even though they could prolong the length of their life and speed up their recovery process (13, 14, 15). Patients are educated about the fact that smoking “diminishes treatment effectiveness, exacerbate side effects and interfere with wound healing,” and yet approximately half of these patients continue to smoke (13, 15). In fact studies have shown that in general “higher education was associated with a greater likelihood of smoking after surgery” (15). Perhaps educating smokers about the risks of smoking is not the key ingredient to smoking cessation because long-term health doesn’t sell to them (people have a difficult time thinking rationally) (9). Public health practitioners behind the “Every Cigarette is Doing You Damage” campaign need to stray away from the old fashioned Health Belief Model approach, and learn from their peers in the corporate market industry. Corporate organizations rely heavily on the latest research and techniques to market their product because they need to stay afloat in the industry and keep their market share. Corporate marketers that sell health products generally do not rely on the benefits of health and people’s rationality to buy their products (11). For example, “Health clubs are marketed to consumers not based on their ability to improve long-term health outcomes and prevent disease, but based on their ability to give people a feeling of control over how they look, how they feel, and how attractive they are to others” (11). Public health practitioners behind the “Every Cigarette is Doing You Damage” campaign need to learn from corporations who spend millions of dollars researching the core values that sell to people, use them to their advantage, and essentially avoid the cost of expensive research.
Argument #3: Negative messages do more harm than good
The concept of framing refers to the way a product or health behavior is packaged; framing is vital to creating a message that is successful at informing people about the health-related action they should take and how they would benefit from it (10). When it comes to framing a health related behavior, research has found the following: “In general, positive appeals are considered to be more effective. Based on interviews with 29 health communication practitioners, Baker and colleagues (1992) concluded that campaigns that emphasize positive behavior change and/or current rewards are more effective than those that emphasize negative consequences” (11). While commercials outside of the public health realm have been using this research to their advantage, public health practitioners behind the “Every Cigarette is Doing You Damage” campaign have failed to take advantage of this research (11). Not only is smoking cessation behavior in the “One Cigarette is Doing You Damage” commercial framed as a negative message, the frame implies that there is no point in quitting smoking because just “one” cigarette can do you damage and attack a vital gene that causes lung cancer. Instead of giving hope to smokers and giving them a desire to quit by pointing out that “the health benefits of smoking cessation are immediate and substantial…Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives,” this commercial leaves smokers helpless and encourages them to continue smoking because the “damage” has already been done (14, 19). Since success of tobacco companies is tremendous, perhaps public health practitioners should learn from their enemy about what “sells” to people because “there can be little question that cigarette ads attempt to create a positive image of the ‘smoker’” (19).
If the way a message is framed doesn’t make a difference on how people react to a public health campaign, people should always make the same decision when given the same information. A study by Tversky and Kahneman (1981) proved that this is not always true (12). They gave different students the same decision. For some students, the “decision was phrased in positive terms as a choice between a sure gain and an uncertain gamble”. The majority of these students chose the “sure gain” option. The rest of the students were given the same choices, but the choices were phrased in” negative terms as a choice between a sure-loss option and the risky gamble.” The majority of these students chose the risky gamble (12). Such an example provides further proof as to why public health practitioners behind the “Every Cigarette is Doing You Damage” campaign have to be very careful with the way they frame their message.
Conclusion
Public health practitioners behind “Every Cigarette is Doing You Damage” campaign need to re-evaluate the success of their campaign and recognize that an HBM approach might not be the best option for American smokers. These public health practitioners need to understand that a campaign that might have worked ten years ago, might not work anymore because of people’s changing environment, social norms, etc. Likewise, they need to take into consideration that a campaign that worked in Australia might not work in the United States because of the two country’s different social norms, culture, level of education about the risks of smoking, etc. Furthermore, these public health practitioners need to look at American corporations that sell health and learn from what works and doesn’t work for them- If corporate commercials/ads weren’t working, they wouldn’t still be in business today because they rely on making a profit. Likewise, they need think outside the box and focus on alternative theories to market smoking cessation such as marketing theory, branding theory, and framing theory, which are some of the leading theories the tobacco industry and other successful businesses uses today.






Response to the Smoking Cessation Campaign “Every Cigarette is Doing You Damage”: Alternative Campaign Based on Marketing, Branding, and Framing Theory - Ekaterina Solovieva

Introduction
In the previous critique, we showed reasons for why the smoking cessation campaign “Every Cigarette is Doing You Damage”, a Health Belief Model approach, is unsuccessful. Consequently, we suggested that public health practitioners should look at the selling techniques of successful corporations such as Nike, Abercrombie, L.A. Fitness, and alike, as guide to identifying what approach is currently hip, modern, and selling to Americans; given that these companies solely rely on profits, they have to be doing something right in order to be able to continue staying in business. It’s important to point out that although companies like Nike sell a product, they also sell an image associated with using that product such as success, the ability to do anything, attractiveness, likability, etc. Therefore, public health practitioner should not be concerned with selling “health” since long-term health doesn’t sell, and take advantage of the idea that a commercial that sells the image associated with being healthy, such as being attractive, could be a lot more successful. We recommend an alternative smoking cessation campaign that utilizes theories that are currently successful in some of the leading corporations in the United States; in particular, Marketing, Branding, and Framing theory.
Alternative Campaign: “Every Piece of Nicotine Gum is Getting You Closer to Joining the Group of Women Who Are Falling in Love”
Our alternative smoking cessation campaign utilizes Marketing, Branding, and Framing Theory. The campaign consists of commercials that address specific core values (shaped by social and environmental factors) that are important to our target audience: women between the ages of eighteen and thirty years old, who generally speaking tend to be unmarried. However, this commercial can be altered to address the male or older population as long as the commercial continues to follow the main principles of the theories we utilized.
At the heart of Marketing Theory is the task of identifying and understanding consumer needs and core values, and subsequently packaging and presenting the product/ health-related behavior in a way that addresses those consumer needs and core values (20). For smoking cessation campaigns, this approach requires more than just assuming that “long- term health” sells to consumers; it requires public health practitioners to understand other driving-factors for health such as the desire to look attractive, to be accepted in school, work, etc, or the desire to continue smoking because of addiction, the ability to relieve stress while smoking, and perhaps having an image that smoking is cool. The task of properly identifying and understanding consumer’s needs and core values makes research an integral part of marketing, and the major critique of this approach for selling health-related behavior because often times public health organization do not have funding for such research. However, as proposed earlier, the cost of research can be offset by utilizing the research of other successful corporations.
Since we do not have the financial means to conduct a study on the core values that sells to unmarried women, we relied on literature and used the Ralph Lauren Romance perfume commercial as a source to get us closer to understanding what sells to women in America. Romance perfume has been one of the most successful and lasting perfume lines for women, and this is why we felt comfortable relying on their marketing/branding technique. Branding theory is the concept of packaging that we briefly mentioned earlier; we use branding to influence people’s perceived costs and benefits of engaging in smoking cessation behavior (4). A branded message gives consumer a sense of value for engaging in smoking cessation behavior (21). “Brands, recognition of brands, and the relationship between brand and consumer are essential to marketing and largely explain the tremendous success of product advertising” (21). Consequently, we heavily rely on Marketing and Branding theory to sell our “product”.
According to the Ralph Lauren (RL) website, Romance is “the sensual fragrance for men and women that evokes the timeless essence of falling in love” (22). RL’s branded message gives consumers the idea that if you use Romance perfume, you will feel like you are/will fall in love. After analyzing the way RL presents their product to women (based on the commercial for women), we recognized that “romance” is a core value that sells to women. Likewise, we took a look at an Orbit Gum (for whiter teeth) commercial that is set in the context of a wedding reception where a bride is put on a pedestal and is praised by everyone; showing that marriage, falling in love, being praised and accepted is something that is important to women as well. Likewise, a Levi’s Jeans commercial that shows people walking for miles just to meet each other in “the name of love,” shows that finding the “right” and “perfect” man is another core value that sells. As a result of our research, we created a commercial implies that women who don’t smoke fall in love and end up with attractive, sexy, and romantic men.
The commercial begins with an image of a woman walking down a street chewing nicotine gum (making it clear that it is indeed nicotine gum). As she approaches a restaurant, she spits out her gum into a nearby garbage can, in slow motion that makes her look extremely attractive. She than walks in and greets an attractive and muscular man - he is waiting for her with flowers (a romantic quality). The following message appears: “This is Kelly’s first date with Jack”. Jack and Kelly proceed to have a lovely evening; at the end of the date, Jack leans in to kiss Kelly goodnight, his eyes light up, and he is in love because Kelly’s breath is so fresh. He thinks, “There is nothing like the bad taste of cigarette breath! Her breath is great. She is the ONE.” Then the commercial shows images of couples lovingly kissing while the girl’s are holding packs of nicotine gum. The narrator ends by saying the words, “Quit today and join the group of women falling in love” as the following message is written on the screen: “the health benefits of smoking cessation are immediate and substantial…Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives” (14, 19).
Addressing Argument 1: People are well aware of the risks associated with smoking
For the reasons presented in the original critique of “Every Cigarette is Doing You Damage”, an educational/informative smoking cessation campaign is unnecessary in the United States because people are already aware of the risks associated with smoking due to educational anti-smoking programs in schools, etc. American’s need a campaign that address’s the social and environmental issues that are important to smokers and society in general. “Although American’s certainly value health, they also hold other values that tend to be more important, more salient, and more influential on individual behavior” (20). Instead of preaching the health benefits of smoking cessation or the health risks associated with smoking, our alternative smoking cessation campaign utilizes Marketing and Branding theory to package smoking cessation in a way that addresses social and environmental factors that often times outweigh the desire to be healthy. The essence of our brand is that if you quit smoking/chew nicotine gum, you are going to become a part of a group of women that are falling in love; we do this not only because we recognize that people want to feel like they are a part of something (a group) that they can relate to, but also because of the concept of irrational/unplanned behavior that can hit groups of individuals almost like epidemic and cause them to all change their behavior at the same time (9,18). By addressing women’s desire to find “the perfect” and romantic man, we are targeting a core value that might be much stronger than health; indeed we are still addressing health, but in a context that the smoker can relate to. We feel that this is much a much more effective way to utilize financial resources than teaching about the health benefits of smoking cessation that American’s are already well aware of through other programs.
Addressing Argument 2: People are not always rational (Long term health doesn’t sell)

The Health Belief Model approach fails to successfully convey a public health message that encourages smoking cessation- this is mainly due to the reliance of the false idea that people are rational, that long-term health is on the top of their to do list, and that if a public health campaigns correctly addresses an individual’s formula for his/her perceived benefits and perceived barriers associated with a health-related behavior, than that individual will actually perform the behavior. “We[consumers] are really far less rational than standard economic theory assumes” (9). If people valued long term health, than people who are diagnosed with a disease related to smoking, should, if they were rational, quit smoking immediately because their perceived severity and perceived susceptibility is very high. However, studies have shown that approximately half of the smoker’s who are diagnosed with early stages of lung cancer and have surgery, continue to smoke even though they could prolong the length of their life and speed up their recovery process (13, 14, 15).
“The most compelling product of the public health practitioner is the freedom, independence, autonomy, and control over life that comes with health” (10). Instead of preaching the health benefits associated with smoking cessation and the negatives associated with continuing to smoke, in our commercial we are presenting the social and environmental benefits associated with smoking cessation (such as participating in the social norm of finding a husband and having a family). Similarly, we are presenting a way for smokers to “improve” their chance of falling in love and essentially giving them the ability to have control over this matter.
Addressing Argument 3: Negative messages do more harm than good
In the previous critique we proved that when it comes to framing a health related behavior, positive appeals are considered to be more effective; it is detrimental to the success of a smoking cessation campaign to frame smoking cessation in a way that is positive and encouraging (11). “Campaigns that emphasize positive behavior change and/or current rewards are more effective than those that emphasize negative consequences” (11). Not only is smoking cessation behavior in “One Cigarette is Doing You Damage” commercial framed as a negative message, the frame implies that there is no point in quitting smoking because just “one” cigarette can do you damage and attack a vital gene that causes lung cancer.
The ultimate competitor of smoking cessation campaigns are tobacco companies themselves, and since they too use this framing theory concept by creating a positive image of smoking, it is only natural that we utilize it as well for selling smoking cessation behavior (19). Accordingly, our campaign presents the positive aspects of quitting smoking, and does not try to reprimand people by showing the consequences associated with smoking or making them feel bad that they are slowly killing their body and the people around them. As opposed to offering a reward (long-term health) that is too far away for younger people to think about, our commercial offers a reward that can be realized today and can help the consumer feel like they fit into society: as a result of smoking cessation, they will be more attractive to the opposite sex.
Because we criticized “Every Cigarette is Doing You Damage” campaign for evoking a sense of helplessness among smokers, our campaign specifically includes these words in the commercial: “the health benefits of smoking cessation are immediate and substantial…Smoking cessation represents the single most important step that smokers can take to enhance the length and quality of their lives” (14, 19). We anticipate that this line will give people hope and the feeling that “the damage can be reversed” as opposed to “the damage has already been done.” Indeed the behavior we are selling is smoking cessation; however, smoking cessation behavior is linked to the use of nicotine gum to help consumers overcome the nicotine withdrawal associated with quitting smoking (11). Nicotine gum offers smoker the chance to slow down the effects of nicotine withdrawal that are feared by female smokers; not only does the fear include the chance of weight gain, but also the “impaired ability to concentrate, disruptive cognitive performance, mood changes, and impaired brain function” (3).
Conclusion
We present a smoking cessation campaign that we feel will successfully sell to female smokers between the ages of eighteen and thirty years old. As opposed to preaching the benefits of long-term health and relying on people’s rationality to quit smoking, we brand smoking cessation as benefit that female smokers can relate to, and provide a tool (nicotine gum) to help them in overcoming their addiction.
REFERENCES
1) Gordon, S. Promise of Cash Prompts Smokers to Quit: Financial incentives tripled rates of cessation, study found. HealthDay, 2009. http://www.nlm.nih.gov/medlineplus/news/fullstory_80237.html
2) Australian Government: Department of Health and Aging. The National Tobacco Campaign. http://www.quitnow.info.au/internet/quitnow/publishing.nsf/Content/home
3) World Health Organization. Women and Tobacco. Geneva: World Health Organization, 1992
4) Edberg, M. Health Issues and Behavior. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sadbury, MA: Jones and Bartlett Publishers, 2007.
5) New York State. Every Cigarette is Doing You Damage. http://doingyoudamage.com/tumors.htm
6) American Cancer Society. Prevention and Early Detection: Guide to Quitting Smoking. http://www.cancer.org/docroot/PED/content/PED_10_13X_Guide_for_Quitting_Smoking.asp
7) Reducing Tobacco Use. Chapter 2: A Historical Review of Efforts to Reduce Smoking in the United States. http://www.cdc.gov.ezproxy.bu.edu/tobacco/data_statistics/sgr/sgr_2000/00_pdfs/Chapter2.pdf
8) Curbing the Epidemic : Governments and the Economics of Tobacco Control. Do Smokers Know Their Risks and Bear Their Costs? Washington, D.C.: World Bank, 1999. http://www1.worldbank.org/tobacco/book/html/chapter3.htm
9) Ariely, D. Predictably Irrational. The Hidden Forces That Shape Our Decisions. New York: HarperCollins Publishers, 2008
10) Siegel, M. Marketing Public Health. Strategies to promote Social Change. Gaithesberg, MD: Aspen Publication. 1998. Pg. 45-49, 122
11) Siegel, M. Marketing Public Health. Strategies to promote Social Change. Sadbury, MA: Jones and Bartlett Publishers. 2004. Pg. 334
12) California State University. Framing and Framing Theory. http://www.csun.edu/~rk33883/Framing%20Theory%20Lecture%20Ubertopic.htm
13) New-Medical. One-half of cancer patients continue to smoke after diagnosis. 2005 http://www.news-medical.net/?id=14720
14) A Report of the Surgeon General. The Health Benefits of Smoking Cessation. Rockville, MD: Center for Disease Control, 1990.
15) Fitness & Exercise for Senior Citizens. Exercise Provides Significant Reduction in Lung Cancer Risk for Women Smokers, 2006 http://seniorjournal.com/NEWS/Fitness/6-12-11-ExerciseProvides.htm
16) Public Health HSC Agency. Every Cigarette is Doing You Damage. 2009 http://www.healthpromotionagency.org.uk/Work/Tobacco/campaigns1.htm
17) Tobacco Control in Norway. Milestones in Norwegian Tobacco Control, 2006. http://www.helsedirektoratet.no/portal/page?_pageid=134,67665&_dad=portal&_schema=PORTAL&_piref134_76551_134_67665_67665.artSectionId=816&navigation1_parentItemId=996&_piref134_76551_134_67665_67665.articleId=50816
18) Christakis NA, Fowler JH. New England Journal of Medicine. The Collective Dynamics of Smoking in a Large Social Network, 2008; 358: 2249-2258.
19) Institute of Medicine. Growing Up Tobacco Free. Washington, D.C.: National Academy Press, 1994. 4:117- 118.
20) Kotler, P. Marketing Management: Analysis, planning and control (3rd Ed.) Englewood Cliffs, NJ: Prentice-Hall. 1976
21) Evans, D. and Hastings, G. Public Health Branding: Applying Marketing for Social Change. Oxford, UK: Oxford University Press. 2008.
22) RLTV: The world of Ralph Lauren in Motion Picture. Romance. http://www.entertainment.polo.com/rltv/

Soul City is Not the Sole Solution: How Educational Television Fails to Address HIV/AIDS in South Africa- Kathleen Wood

An estimated 5.5 million South Africans are living with HIV, and approximately 500,000 more people are infected each year (1). The prevalence of HIV in South Africa is higher than anywhere else in the world and the rate at which this disease continues to spread points to failures of existing public health interventions to address this epidemic. A prominent public health campaign which is unproductive in its mission to curtail the spread of HIV/AIDS in South Africa is Soul City. This television series is funded by the Department for International Development and attempts to encourage HIV awareness and prevention. Soul City is a drama that depicts characters in situations that deal with HIV/AIDS and follows them through scenarios as they chose healthy behaviors.
With a solid base of viewers, Soul City is a success as a television series; however it fails as a public health intervention. Soul City began in 1994 and has been extremely popular. An evaluation conducted by Soul City found that over 80% of people were familiar with the programming, 53.5% of adults and 61.5% of children had watched the television show (2). However, despite the high level visibility and popularity, Soul City has not been successful in slowing the spread of HIV/AIDS. HIV rates have increased, not decreased, during the time the show has been on the air (1). I believe Soul City’s lack of impact can be traced to three major flaws in the intervention model. First, Soul City does not reach rural communities effectively. This population makes up a large proportion of the country and is most in need of intervention. Rural communities, however, are the least likely to have access to this intervention. Second, the theoretical framework upon which Soul City is based assumes that conveying information is enough to change behavior. This assumption does not account for the many factors which play into the decision to change behavior or address the barriers which so often prevent action. Finally, Soul City has no engagement with the population. For those few individuals who do receive the messages, and make the leap to take action, there is not support to make meaningful changes.
Ineffective in Accessing Rural Communities
The regions most profoundly affected by the HIV/AIDS epidemic are rural South African communities. These areas have a prevalence of HIV which is even higher than the already staggering statistics of HIV prevalence in the county as a whole (3). This is why it is so unfortunate that Soul City as an HIV intervention neglects these areas. Rural South Africans have less access to television. 40% of South Africans do not have television in the home and the majority of these are rural South Africans (4, 5). In a 2007 article on AIDS in South Africa from the Social Psychology Department at the London School of Economics, Campbell et. al. stated that “[rural] residents have little or no access to radio, television or any sources of information about HIV/AIDS or how to avoid it” (6).
Soul City’s inability to educate rural South Africa is not limited to just those who do not have television. Even if the programming does make it to the segment of this population with access to television, the individuals are unlikely to connect with the material. First, the program generally uses English or Zulu in dialogue. While using Zulu is a positive step, we must remember that there are 11 official languages and many more dialects in South Africa (7). While individuals in urban centers often speak English, this becomes less common in rural areas. Therefore, messages and information delivered in English to those who do not know or frequently use the language may be lost or not fully understood (8, 9). Furthermore, even if English is spoken by an individual, the message will be weakened if English is not their preferred language (7). This leads to another point, the material most often focuses on characters in urban settings. Those in rural settings have a much different lifestyle than the characters depicted in the series. The program’s power to relate to rural viewers is lessened if they cannot connect with storylines. Rural settings are often isolated, underdeveloped and lacking infrastructure (6). When Soul City depicts scenes of urban centers and crowded townships individuals who are rarely, if ever, exposed to such settings will find it hard to relate to situations. With estimates that approximately half of the South African population live in rural areas it is unacceptable that they are neglected by this intervention model (6).
Flawed Theoretical Model
I have outlined how a major segment of the population does not receive Soul City programming or cannot relate to it. Now I will explain how even for those who do hear and understand the messages, this awareness does not translate into improvement of personal health behavior. Soul City as a public health intervention follows the Theory of Reasoned Action. The Theory of Reasoned Action relies on the premise that people are rational and that our attitudes about a particular issue combined with our view of the behavior others in our social context will determine behavior (10). The theory faults in a presumption that a person’s attitudes and intention are directly linked to behavior. The theory does not explain why people with full understanding of health risks and appropriate behaviors do not practice those behaviors. This issue is continuously seen in HIV/AIDS risk behaviors (9, 11). Additionally, this theory makes the assumption that people carefully assess their feelings about a behavior before taking action. This process does not take into account the fact that people sometimes act in an irrational manner, without thinking first, or that they may act while in an altered state. In the case of limiting risky sexual behavior associated with HIV infection, factors such as alcohol use and heightened sexual arousal could likely reduce the amount of rational consideration an individual makes about their behavior. Situations such as these limit the individual’s ability to think coherently and could lead an individual to behave in a way that is not in line with their rational attitudes and knowledge about the behavior (12). I highlight this as another factor contributing to HIV/AIDS risk behaviors that it wholly unaddressed by mass media interventions such as Soul City.
Lack of Engagement and Support
The criticisms explored above point to the need for a more customized approach to HIV/AIDS intervention. This leads me to my final argument against Soul City as an effective intervention. Soul City lacks engagement with communities to support adoption of better health behaviors relating to HIV/AIDS. A number of studies have suggested although mass media campaigns such as Soul City can be effective in raising awareness of interventions, they may fail to change actual behavior unless followed with individualized contact and discussion (13, 14, 15). Furthermore, mass media as a form of health intervention risks conveying information which may be misinterpreted. This argument is particularly true in the case of South Africa where the multitude of languages, dialects, and culture make complex messages ripe for misinterpretation (14). Individuals watching the show to can incorrectly infer conclusions from the limited information Soul City can convey over the course of a single episode. Moreover, dues to the fact that these messages are conveyed via television, there is no opportunity for clarification. Even Soul City itself recognizes this as an issue. Data from a Soul City evaluation states that “knowledge of how the HIV virus is transmitted remained limited and many misconceptions continued.”(2) Without individuals in the community to hear and clarify information, there is a risk that other misconceptions are being spread through the conversations sparked by Soul City programming.
An intervention which is more targeted will be needed in order to make real change possible. An intensely stigmatized environment surrounds all aspects of HIV/AIDS in South Africa. In order for individuals to overcome the immense barriers to behavior change, they will need more support than what can be offered from a television program alone. Episodes in the series deal with confronting partners and spouses about using protection, getting tested, and obtaining treatment. The culture that exists presently will make taking these steps extremely difficult and they may even be dangerous. This is particularly true for women who risk abuse for bringing up issues around sexual behavior with their partner and who are often alienated if HIV status is discovered (16). Soul City has no way of guiding, supporting, or protecting individuals who chose to take action. Furthermore, even those who do want to make a change will not have information on resources available to them at the local level. It is clear that individual components such as information, self-efficacy, and expectations about outcomes affect behavior choices, but in order for a person to change their actions, social supports must be in place as well (11). Soul City does not provide this support.
Conclusion
The three major flaws outlined in this critique compound one another and progressively limit Soul City’s impact on the HIV/AIDS epidemic in South Africa. When examining this intervention, we immediately become aware that a large segment of the South African population are eliminated as potential beneficiaries of this intervention—those without television. Now, from the reduced population we have left, another portion will be unable to interpret complex messages about HIV/AIDS due to language barriers. A larger portion still will feel unconnected with the characters and environment portrayed. Surely there will be some individuals who do not fall into those categories and who will see and understand the show. However, major deficiencies in the model remain. The removed nature of mass communication as an intervention does not spur people to take action. This is particularly true in environments, such as South Africa where stigma is deeply engrained into the culture. Thus, even the limited number of individuals who do receive the Soul City messages and decide they want to take action, will not find themselves in an environment where there is social support to do so.
Soul City puts itself forward as a health promotion and behavioral change project, however, this campaign does not address the issues that would allow this change to be possible. The inability of Soul City to reach the population most in need, the ineffectiveness of the model upon which it is based and its lack of practical support, combine to form a failed attempt at health promotion. As witnessed by the continued spread of the disease, this intervention is unsuccessful. Soul City has proven to be little more than an entertaining soap opera, popular because it deals with edgy story lines, but unable to effect real change on the health of South Africa.

Counter-Proposal: Street Counselors-Kathleen Wood
As an alternative to flawed intervention methods delivered through Soul City, I propose Street Counselors. Street Counselors is a peer education and mentorship program which works with adolescent youth towards its mission of breaking through stigma associated with HIV, effectively connecting individuals to resources, and promoting youth ownership of a new era in which HIV is defeated. Program developers select natural leaders from existing youth networks within target communities to serve as counselors. These are informal leaders who are outside of the educational, health, and political institutions; such as coaches of sports teams, musicians and community workers. These young adults have the attention and trust of the youth in their communities and understand the complexity of the HIV crisis in the specific setting. Positive health behaviors are then promoted through culturally relevant programming developed through a collaborative process between counselors, public health professionals and youth participants. In order to provide connection to practical resources, the program will develop strategic partnerships with medical facilities which provide community members with testing and treatment. Street Counselors provides youth, with long-term, psychosocial support that promotes prevention and provides access to testing, treatment, and counseling.
Street Counselors will directly addresses the weaknesses outlined in the critique of Soul City. First, I will demonstrate how Street Counselors is specifically designed to access rural South African communities. Second, will describe the theoretical framework upon which it was based and explain how it is a stronger model than that of Soul City to confront the HIV in this environment. Finally, I will show how this program will engage directly with the community and provide practical support to facilitate health-enhancing behavior change. I believe Street Counselors to be a more comprehensive and effective way to address HIV/AIDS in the South African populations most affected by this epidemic.
Effectively Accesses Rural Communities
Street Counselors will be much more effective in accessing rural communities than Soul City because it does not rely on mass media as a means of delivering its message. The issues that arise due to Soul City’s mass media format are that those who don’t have television can’t access programming and cultural differences prevented others from fully relating to and understanding messages. These issues are addressed in the Street Counselors intervention model.
This program was conceived specifically to reach rural populations who currently receive a disproportionately small amount of HIV/AIDS interventions. Street Counselors interacts directly with rural communities; so lack of personal resources, such as a television will not limit access to the program. Indeed, the communities which have the fewest resources and the least exposure to urban influences will likely be the areas first targeted by Street Counselors. Not only can Street Counselors effectively access rural communities, but due to the fact that is developed with community involvement it can be adapted and scaled to fit many different environments. I believe this to be a major strength of the program.
Within Soul City, there were issues around the programming’s focus on urban environments for episode backdrops and the use of only 2 of the country’s many languages. These factors did not allow rural South Africans or those who did not speak the selected languages to connect with programming and opened room for misinterpretation of messages by non-native speakers. These issues are definitively addressed by Street Counselors because the program employs individuals from the rural community to serve as counselors delivering messages in the resident’s native language. Additionally, if there are misconceptions, then unlike Soul City, counselors are present to speak with and can clarify messages and reinforce vital details.
Drawing on community members to serve as Street Counselors is crucial. Natural youth leaders have formed connections with the people the messages need to reach and know the issues that must be addressed. Catherine Campbell, a social psychologist at the London School of Economics wrote about the key strategies for facilitating the development of HIV interventions in rural South Africa. Identified within Campbell’s key strategies were the following: developing local leadership, emphasizing community strengths, and addressing the specific impact of the disease in different communities (6). It is clear that local individuals, who know the intricacies of life in a rural community, will be unparalleled in their ability to address distinctive needs and overcome barriers to behavioral change. Furthermore, study has found that short-term programs which swoop in and out of poor communities from more developed countries or regions can undermine local capacity to create long-term and effective responses to health problems (17). Street Counselors will draw on local capacity to strengthen the program and eventually turn over workings to the community completely. I think that Campbell summed up this idea well when she stated “building ‘AIDS-competent communities’ does not necessarily involve importing solutions, conceptualized and managed by outside experts, but rather facilitating the most promising local responses” (6). In employing community members on the project and working collaboratively on programming it is hoped that community adoption of Street Counselors will be promoted, in turn creating a long-term community-based intervention which does not rely on external direction.
Appropriate Theoretical Model
Soul City was based on the Theory of Reasoned Action. It is clear that there are aspects of this model which translate poorly into an intervention for HIV/AIDS. The theory wrongly assumes that knowledge leads to action, which is a particularly relevant criticism when attempting to address HIV/AIDS risk behaviors (9, 11). Choi, Yep, and Kumekawa discussed how interventions based on models such as the Theory of Reasoned Action do not fully take into account the social context that people find themselves in and how each situation affects health behavior choices (11). This led me to conclude a more comprehensive approach is required.
The Social Network Theory is a better choice as an intervention model to address HIV/AIDS in South Africa. Engaging key individuals in established social networks will spur change within entire groups of South African youth. Social Network Theory focuses on the power that relationships have in determining an individual’s health behavior. It suggests that major changes in behavior are likely to occur in groups of people simultaneously rather than by individual choices alone (18). When applied to the area of health behavior, the Social Network Theory shows us that networks are a major force in determining whether or not an individual will adopt behaviors that support health. Health habits are often seen to reflect the health patterns of social groups (18, 19). Specifically with regard to sexual behavior, research has proven that peer influence is an important determining factor and critical dialogue about such topics as intimacy and sexuality are most likely to occur in an atmosphere of trust and solidarity (20). I believe that Street Counselors facilitates such an atmosphere through use of peer counselors.
Writing on the Social Network Theory focuses the need to closely examine and map relationships between individuals within a network. Developers of this program will select counselors who are central players within exiting social groups. This will allow counselors to use natural avenues of communication to disseminate information. Employing community members to draw on their existing influence is a powerful strategy in the Social Network Theory. The rapport that counselors already have with participants will create a naturally supportive environment within the program. The concept of community involvement is also supported by Campbell’s research. She emphasizes that community ownership and solidarity among program participants is needed to see genuine change (6). Accessing and influencing social networks spur change within groups which will then lead to change in larger surrounding networks.
Engagement and Support
The removed nature of mass media as a public health intervention left no mechanism for engagement or support through Soul City. While I do not want to argue that mass media campaigns are wholly unproductive, it is clear that when addressing sensitive subjects such as sexual behavior, more personal engagement is needed (14). Street Counselors provides a safe venue for discussion on these sensitive issues. Street Counselors will be formally trained to have the information and tools to provide to youth they work with. They will deliver health messages informally through peer education and display of positive health behaviors, but most importantly, street counselors will use their established roles as leaders to create social spaces within existing youth groups for open discussion of HIV/AIDS. I believe that the protective social network Street Counselors will create is especially important in light of the fact that HIV/AIDS is so intensely stigmatized in some communities of South Africa. The supportive environment will allow groups to question widely held misconceptions. Street Counselors will guide, support, and protect individuals who chose to take action.
Street Counselors will also have partnerships with facilities that can provide testing, treatment, and counseling. Not only will participants have a place to discuss and understand HIV/AIDS, but in express contrast to Soul City, this program has the capability to connect people with the resources needed to take action. This type of connection of multiple stakeholders has proven to be a successful technique in creating environments that support HIV-prevention and treatment efforts (6). Counselors are present to support and assist those who need to access medical facilities. They will encourage testing and adherence to treatment. In an environment that is not currently tolerant of those known to be HIV positive individuals, counselors will be present to provide psychosocial support during acute times of stress. This health behavior intervention will more effectively spur change and facilitate HIV prevention, testing, and treatment in local youth groups.
Conclusion
The power of Street Counselors is that it recognizing the problem of HIV in South Africa goes beyond simply imparting information to the public. Addressing the complexity of this epidemic requires a more comprehensive and holistic approach. A successful intervention must reach isolated populations, spur change by creating supportive groups of informed people, and connect those who wish to change with the resources required to do so. Street Counselors is a peer education program that recruits the most influential leaders, creates spaces for critical thinking, builds solidarity and community ownership of the cause, and adapts to addresses the specific impact of the disease in each community. The goal is for South African youth to become the first generation of change agents to effectively swing the tide in the fight against HIV/AIDS.
REFERENCES:

1. UNAIDS. (2007). AIDS epidemic update: Sub-Saharan Africa. UNAIDS World Health Organization. http://data.unaids.org/pub/Report/2008/jc1526_epibriefs_ssafrica_en.pdf

2. Soul City. (2005). Evaluation of Soul City season 6. Institute for Health and Development Communication. Houghton, South Africa. http://www.soulcity.org.za/programmes/the-soul-city-series/soul-city-series-6

3. Shisana, O., et al. (2005). Nelson Mandela/HSRC study of HIV/AIDS: South African national HIV prevalence, HIV incidence, behaviour and communications survey. Cape Town: HSRC Press.

4. Bhorat, H., Van der Westhuizen, C., & Goga, S. (2008). Welfare shifts in the post-apartheid South Africa: A comprehensive measurement of changes. DPRU Working Paper No. 07-128. http://ssrn.com/abstract=1028254

5. Statistics South Africa. (2007). General Household Survey. http://www.statssa.gov.za/PublicationsHTML/P0318July2007/html/P0318July2007.html

6. Campbell, C., Nair, Y., Maimane, S., & Sibiya Z. (2007). Supporting people with AIDS and their carers in rural South Africa: Possibilities and challenges. Health and Place. 14 (3): 507-518.

7. Govender, R.D. (2005). The barriers and challenges to Health Promotion in Africa. South African Family Practice, 47 (10): 39-42.

8. Pillay, K. (1999). Access to Health Care: Language as a Barrier. Socioeconomic Rights. 2005: 1, 2.

9. Alali, A., & Jinadu B. (2002). Health communication in Africa: Contexts, constraints and lessons. New York: University Press of America, Inc.

10. Salazar, M.K. (1991). Comparison of four behavioral theories. AAOHN Journal, 39:128-135.

11. Choi, K., Yep, G.A., & Kumekawa, E. (1998). HIV prevention among Asian and Pacific Islander men who have sex with men: A critical review of theoretical models and directions for future research. AIDS Education and Prevention. 10(Supplement A):19-30.

12. Airely, D. (2008). Predictably irrational: The hidden forces that shape our decisions. New York, NY: HarperCollins Publishers.

13. Dagron, A. G. (2001). Making waves: Soul City. Communication Initiative. Johannesburg, South Africa. http://www.comminit.com/en/node/1652

14. Black, M.E., Yamada, J. and Mann, V. (2002). A systematic literature review of the effectiveness of community-based strategies to increase cervical cancer screening. Canadian Journal of Public Health, 93, 386–393.

15. Prochaska, J., Norcross, J., & DiClemente, C.C. (1994). Changing for good. William Morrow, New York.

16. Dunkle, K., et al. (2004). Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. The Lancet, 363 (9419): 1415-21.

17. Pfeiffer, J. (2003). International NGOs and primary health care in Mocambique: The need for a new model of collaboration. Social Science and Medicine, 56: 725-738.

18. Edberg, M. (2007). Essentials of health behavior: Social and behavioral theory in public health. Sudbury, MA: Jones and Bartlett Publishers.

19. Christakis, N.A., Fowler, J.H. (2008). The collective dynamics of smoking in a large social network. New England Journal of Medicine, 358:2249-2258.

20. Campbell, C., & MacPhail, C. (2002). Peer education, gender and the development of critical consciousness: Participatory HIV prevention by South African youth. Social Science and Medicine. 55 (2), 331-345.

Recognizing Differences in Racial Minorities: Using Social Sciences to Combat Childhood Obesity- Caitlin Quinn

Introduction
The obesity epidemic plagues America as a whole, as there is not one race, community, or state not affected by the issue. When looked at more closely however, it becomes evident that one of the fastest growing groups are black and Hispanic children. Furthermore, not only do many weight loss trials fail to include this population, those that do have poor results. In the previous paper I addressed that public health obesity interventions are failing minority children because they fail to recognize the difference between racially diverse groups. The following paper will illustrate that by recognizing differences in the home environment, school environment, and sociocultural perception of weight will allow for the creation of obesity interventions that will be successful for minority children.
Home Environment
With more minority families living below poverty and in segregated neighborhoods compared to whites, it should be no surprise that they face different challenges when it comes to being healthy (1). With lacking supermarket access and areas to play safely outside, public health interventions such as the Fruits and Veggies More Matters campaign and Physical Activity Guidelines for Americans do not apply to people living in these communities (2). In the next two sections I will propose that the limited supermarket access can be overcome using the Community Mobilization approach, while the lack of physical activity can be addressed using Maslow’s Hierarchy of Need.
Supermarket Access
Minorities living in poor communities are well aware that they are unable to afford and or gain access to fresh fruits and vegetables. Just because this population has a higher obesity rate does not mean that they actively choose not to eat fruits and vegetables. Using a Community Mobilization approach to address this issue therefore, would not only help families learn ways to make these children healthier but will also empower them to become advocates for their communities. For this intervention I propose that campaigns already advocating healthy eating such as the More Matters campaign develop “lesson plans” which can be used in communities that lack the ability to feed their children a variety of fruits and vegetables. These materials would cover topics such as how to stretch shopping budgets, alternatives to buying fresh fruits and vegetables, and ways to preserve groceries. The lessons can be disseminated to community leaders who could in turn create groups where families can come each week and learn as well as discuss how to overcome the challenges of healthy eating. Each week the sessions will end with a cooking demonstration using inexpensive ingredients that will then be tasted amongst the group. Not only will the meal be a way to demonstrate that you can eat healthy on a budget, but it will also act as an incentive to come to the class. It is important that these classes be taught by members of the community rather than a doctor or social worker from the outside because the people attending these sessions have to feel that the facilitator can relate to the frustrations and challenges of not being able to feed healthy meals to their children.
Using a group setting to pass on this information has several benefits. For one it will bring together parents who share the common goal of making their children healthy, which can help to form social networks. These networks may be useful in coming up with ways to carpool to grocery stores so that people without transportation can feel comfortable asking for help. Also, the social mobilization approach is popular for empowering the people who take part to make a change (3). In this case the change may be lobbying for a supermarket to be put into the community. If community members can convince supermarket companies that the store is needed, and will be supported, developers may be more willing to build in the area. I feel that this approach is the best solution to the lack of supermarkets because it teaches skills needed to keep children healthy even in less than ideal circumstances.
Physical Activity in Unsafe Neighborhoods
Forty-six percent of Americans consider their neighborhoods unsafe, with minorities twice as likely to report living in unsafe areas (4). Often minority children living in these neighborhoods are unable to play outside after school or afford the equipment needed to play on a team sport. Unfortunately these issues are often ignored in interventions aimed at getting kids to become more active. In the MyPyramid for children safety issues are ignored as if all children live in safe environments.
Maslow’s Hierarchy of Need is often used as a way to track an adult’s journey to self actualization. What is often forgotten is that children also have inherent needs that they strive to fulfill especially the need for safety (5). Using the hierarchy, commercials can be developed that address the different needs of children. For example commercials can show children dancing in their bedrooms or having jumping jacks competitions with a sibling or friend could encourage kids to be physically active without worrying about their safety outside.
Using this approach will be effective for one key reason; it has been shown that minority children watch more television than their white counterparts, and therefore would most likely be reached through this approach (6). The commercials could even depict a child shutting off the television to dance to the radio or having the jumping jacks contest during the show’s commercial breaks. Using Maslow’s Hierarchy, children will be able to achieve their need for safety while still having fun and getting healthy.
School Environment
Just as much of the minority population live in segregated communities, minority children often attend under funded schools, lacking the ability to provide the healthiest food choices (7). In the previous paper the issue of vending machines generating a large income for these schools while providing high calorie and fat items, as well as the inability of these schools to provide extra fruit and vegetables through the Department of Defense Program was addressed. To solve these issues I suggest Diffusion of Innovation be used to introduce healthy alternatives to the vending machines, while the Organizational Change approach be used to change school lunches .
Vending Machines
Stonyfield Farms has created a Do it Yourself Vending Machine Makeover Guide which recognizes how important revenue from the vending machines are, and gives a list of over 300 healthy alternatives which can be put in the machines (8). This outlet coupled with the Diffusion of Innovation approach can make for a smooth and successful vending machine makeover. Using this approach, a select group of children can be chosen to taste test the new foods and then used to serve as the early adopters who introduce the rest of the students to the new items (9). Coupling this approach with contests such as which class can collect the most empty milk or water bottles can make it seem more like a game than a method to get children healthier. Diffusion of Innovation will work well within school settings because children are always looking to try “cool” new things, so as long as there is a group who is on board to being with the rest should be soon to follow. The other benefit to this approach is that under funded schools who need vending machines the most will not have to worry about losing such a great source of revenue.
School Lunch Program
Although it is hard to develop an intervention targeting the USDA and the Department of Defense there are some approaches that may help get more fruits and vegetables into under funded schools. Using an Organizational Change approach, schools that are unable to purchase extra produce from the DOD can band together to lobby for support. Further, they could work together and buy directly from farmers at a lower price since they would be buying in such large quantities. The Organizational Change approach would help with this situation because multiple schools with the same goals would have a chance to come together and lobby for a change (10).
Sociocultural Perception of Weight
Medically obesity is viewed as “bad” or unhealthy because of the health issues associated with it. Using this medical approach then, it is no wonder why public health interventions aimed at obesity are evaluated in terms of weight lost. When you look into different cultures however, it becomes clear that not all view overweight as a bad thing. In order then to successfully design interventions that incorporate minority children it is important that you understand what they and their parents view as unhealthy. In order to design such an intervention Cultural Anthropology can be used to plan an approach targeting obesity.
Cultural Anthropology can be used to identify the eating patterns of minority children and their parents. It can also be used to look into what parents see as unhealthy in terms of their children, and how they define appropriate weight (3). This is useful because as was seen in the last paper, some mothers view their children as overweight only when a condition such as asthma or trouble walking develops.
Using this approach, an example of an intervention is one that targets problems associated with obesity such as Type 2 Diabetes. There are no cultures or races to my knowledge that view this disease as positive so it seems likely that it is something they would want to prevent in their children. The intervention could provide information on the dangers of diabetes and how it can be prevented. Since prevention comes from eating healthfully and exercising, the hope is that children at risk will lose weight in the process. By making obesity prevention a secondary measure more families of minorities may be willing to participate since weight is not the primary focus.
Conclusion
Public Health has failed minority children in the past because they overlooked the differences between races. The home and school environments as well as sociocultural perceptions of weight need to be looked at when designing interventions targeting obesity. Using social, cultural, and environmental theories when developing new approaches will help close the gap of racial disparities not only when it comes to obesity rates but for health in general.

References
1. Williams DR, Collins C. Racial Residential Segregation: A Fundamental cause of Racal Disparities in Health. Public Health Reports 2001; 116: 404-416
2. Brown MR. Supermarket blackout- lack of quality grocery stores in black communities (pp 9-8). In: Black Enterprise. New York, NY: Earl G. Graves Publishing Co, 1999.
3. Edberg M. Social, cultural, and environmental theories (Part II) (pp. 65-76). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
4. Bush CL, Pittman S, McKay S, et al. Park-based obesity intervention program for inner-city minority children. Journal of Pediatrics 2007; 151: 513-517.
5. Investing in Children. Maslow’s Hierarchy of Needs. 2006. http://www.investinginchildren.on.ca/Communications/articles/maslow.html.
6. Kumanyika S. Special issues regarding obesity in minority populations. Annals of Internal Medicine 1993; 119: 650-654
7. Orfield G, Eaton SE. Dismantling desegregation: the quiet reversal of Brown v. Board of Education. New York: New Press, 1996.
8. Stonyfield Farms. Menu for Change. 2003. http://www.stonyfield.com/MenuForChange/success/MFCSuccessStories.cfm.
9. Edberg M. Social, cultural, and environmental theories (Part I) (pp. 52-64). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.


Failure to Recognize Differences in Racial Minorities: Public Health Failures in Addressing Childhood Obesity- Caitlin Quinn

Introduction
In a country of surplus is it any surprise that obesity is the most talked about epidemic facing Americans? The rise in obesity rates especially among children has made it so that the coming generation will be the first in history not to outlive their parents. Among children aged 6-11 obesity has risen from 6.5 to 17% in the past 30 years. For adolescents aged 12-19 the prevalence has more than tripled from 5 to 17.6% (1). Dividing this overall statistic amongst different races it becomes clear that children from minority groups have higher rates of obesity. NHANES 2002 shows that Mexican American boys have the highest rates of obesity at 26.5% between the ages of 6 and 11, and 24.7% of those aged between 12 and 19. Among the female population, African American girls have the highest rates of obesity at 22.8 and 23.6% respectively. These percentages can be put into prospective when compared to rates of obesity amongst white children with about 14% of boys and 12% of girls classifying as obese (2).
Although obesity is prevalent in all three racial groups, it is clear that minority children are more commonly afflicted by the disease. My question then is why are the public health interventions that have been developed to fight obesity in children applicable only to white, middle class adolescents? In the following paper I will show how the minority populations are largely being ignored by the move to put an end to childhood obesity. The failure comes in the lack of attention given to three major factors affecting the lives of many minority children: home environments, school environments, and sociocultural differences on weight perception.
Home environment
The US Census Bureau reports that as of 2007 24% of African Americans and 20% of Hispanics were below the poverty line, compared to 8% of whites (3). Living below poverty means that these people are unable to live in ideal neighborhoods or attend the best schools, which can have major implications when trying to implement a health intervention. Residential segregation has been identified as central to the racial inequalities in America. Although policies that once limited the worst neighborhoods for minorities are now outlawed, national statistics show that 66% of blacks remain in these segregated neighborhoods today (4). Living in largely segregated areas have many implications that have been ignored by public health interventions, including lack of supermarkets, and recreational facilities.
The Fruits and Veggies More Matters campaign emphasizes the importance of eating at least five servings of fruits and vegetables each day (5). What is not addressed however is the fact that for people living in poor communities supermarkets that carry quality produce at competitive prices are hard to come by. Often, several modes of transportation are needed to find a grocery store, or residents are limited to what is available at the nearest Seven-Eleven (6). The More Matters campaign fails minority children because it is using the Theory of Reasoned Action as its base, which states that someone’s intention to do a behavior comes from their attitude towards the behavior. If the person sees the outcome of the behavior as positive, and feels it would be well accepted by others, the behavioral intention will be high (7). Although this is a nice thought, many children of minority and their parents want to be healthy and eat well, but are unable to do so because of where they live. It is astonishing to me that the More Matters website does not even address issues associated with where to buy less expensive produce, or how families on a budget can still eat fruits and vegetables. You would think that a national campaign to stop the obesity epidemic would target more than white middle class families. This is a prime example of how intention does not always lead to behavior, and the failure that comes when public health professionals ignore the different populations within America.
Forty-six percent of Americans in the US consider their neighborhoods unsafe, with minorities twice as likely to report living in an unsafe area than whites (8). Consequently, it is not as easy for children living in such unsafe neighborhoods to walk to the nearest playground, or ride bikes down the street, thus getting the exercise they need. As part of a focus group addressing overweight in urban African American youth, one mother stated “You got crime that’s going on where we’re leery of letting them go out down the street” (9). Reports have also shown that there are less parks, fields, and pools in inner city neighborhoods (4).
The Physical Activity Guidelines for Americans says a child should get at least 60 minutes of physical activity a day. Within this 60 minutes there should be at least three days each week the child is participating in muscle strengthening as well as bone strengthening activities. The guidelines give a list of ways parents can get their kids more active such as letting them walk or bike to school, buying them equipment that encourages physical activity, and enrolling them in team sports (10). What is completely void in these recommendations is what a child can do if there is no money to sign up for a sport or the neighborhood is not safe enough to play outside. In the previously mentioned focus group a mother said “My daughter, she would like to enroll in karate classes and a ballet class… but I just couldn’t afford it. I couldn’t afford it”(9). This mother knows that these classes would help her child but because she cannot afford them she is at a loss as to how to help her child lose weight.
The new USDA food pyramid for kids adopted the motto “Eat right. Exercise. Have fun”, and displays children riding bikes, playing soccer, walking the dog, and even playing basketball in wheelchairs (11). While it is wonderful children with disabilities are being recognized, this poster fails to show any type of indoor activity children can do to stay active. If minority children, especially those living in unsafe neighborhoods see this poster how are they supposed to relate to it? These two public health programs make it seem as if it is impossible to get any type of exercise inside a home. In order for all children to be able to relate to these messages, activities such as dancing to a radio or to the TV, or having a push-up contest with friends should be shown.
The USDA’s pyramid and the CDC’s guideline for physical activity mirror the common theme seen in public health where social factors along with formative research are ignored (12). By trying to target all children in America with one intervention, black and Hispanic children are marginalized.
School environment
In the previous section, today’s existence of racial segregation was highlighted. Unfortunately, racial segregation in neighborhoods has also affected public schools. Generally, schools with a high proportion of African American and Hispanic children are often under funded, and in poor communities, which has major implications for the health of their students (13).
In order to generate revenue, schools throughout the US have put in vending machines which typically sell calorie dense, but nutrient poor snacks and drinks. These vending machines can often raise up to $10,000 per year to be used as the school sees fit (14). The revenue that comes from these vending machines is often used to fund field trips, needed supplies, and foodservice operations. With the recognition of the obesity epidemic in children, there have been numerous attempts to get rid of vending machines in schools throughout the US, with at least 30 states considering legislations banning the machines (15). The problem with state wide bans is that they are not taking into consideration how much some under funded schools rely on the revenue. Further complicating matters, current research published in the Journal of the American Dietetic Association shows that children of minority are more likely to purchase soft drinks from school vending machines (16). Applying these findings, it becomes evident that schools with high proportions of black and Hispanic students, not only rely on vending machines more, but also generate more revenue from them when compared to mostly Caucasian populated schools. It is essential that state legislators look into the facts before putting state wide bans on vending machines in schools because it could have detrimental effects in some districts. Although it would seem that since minorities are more apt to buy soda at school, banning these products would be a step in the right direction, it is essential that funding be available to replace the revenue.
The National School Lunch Program is not known for its healthy options. Although it is regulated by the USDA, it is nearly impossible to enforce the sale of foods that entirely meet the USDA guidelines. A common complaint is that the traditional school lunches are severely lacking in fruits and vegetables. In response to this, the USDA partnered with the Department of Defense (DOD) to develop a program that supplies fresh fruits and vegetables directly to school districts (17). Since its implementation in the mid 90’s, DOD-Fresh has provided up to 900 different products to schools across the country. The major downfall of this program is that it only serves schools that can pay for it. In order to receive the program benefits, schools need to purchase the products using lunch cash reimbursements, and children’s payments. Basically, due to a lack of federal funding, underprivileged school districts are unable to participate in the program. Here is an example of how minorities are being left out again as they are overlooked when trying to better the nutrition environment of school systems.
With 95% of children attending school in the US, it plays a key role in the development of healthy eating habits. School based prevention programs have the potential to markedly reduce the prevalence of childhood obesity through the promotion of healthful eating, but it seems that government and state based prevention programs mostly benefit the less afflicted schools. The children who need these programs most are the ones who are being marginalized simply because they do not attend the right schools.
Sociocultural perception of weight
Mass media and even physicians’ reliance on BMIs to assess overweight and obesity make it so that any outsider would think American’s highly value thin figures. Even research on childhood obesity looks mostly on reducing pounds rather then focusing on the real reasons someone is overweight in the first place. Since the thin ideology is so engrained in our society I do not think many people stop to realize that not all Americas view being overweight with such negative connotations.
Shifting away from the solely medical based theories on why being overweight is “bad”, socially based research has revealed that race is a major factor in how one perceives their body. In a study that took place in ethnically diverse high schools across the United States, ninth and tenth graders were shown pictures of models in popular magazines, “White girls, despite their criticism, are stilled harmed by the images because they believe that others find the images important… Minority girls do not identify with ‘white’ media images nor believe that significant others are affected by them” (18). Other studies have found that African American and Hispanic adolescents report greater comfort with their bodies than white adolescents, and are less likely to stigmatize weight problems and to equate attractiveness with thinness (19).
In communities where most members are obese, it is likely that there are actually positive attitudes about being overweight. Puerto Rican mothers for example, often want heavier children because they interpret thinness as a sign that the child is sick or improperly cared for (20). Similarly, African American parents of overweight children were more likely to recognize their children as overweight only when a health problem such as trouble breathing was involved. Otherwise they classified their children as having a “larger frame”, and thus not applying to any charts (9). These views make it clear as to why campaigns based on traditional behavior theories like the Health Belief Model, or the Theory of Reasoned Action are unsuccessful. These theories are based off the assumptions that being obese is not the social norm, people have a negative attitude toward obesity, and people understand the severe consequences with being overweight (21). These assumptions however are just that – assumptions. If any formative research had been done it would have been clear that there is no cookie cut answer for any problem.
Public health interventions addressed toward children are so focused on winning the battle on obesity, they have failed to recognize that by making weight the primary issue, they are losing the interest of the population who needs the most help. These national campaigns need to recognize that not all Americans view obesity the same. In order to really be effective in the delivery of any intervention they should focus more on curing the health problems related to obesity, rather than obesity itself.
Conclusion
Ignoring differences in home, school, and sociocultural environments has led to the development of public health interventions that simply do not apply to children of racially diverse backgrounds. In order to treat and prevent childhood obesity in minorities all issues that apply the population will have to be considered, as well as the role they play in thwarting the success of the program (22). It simply is not enough to tell a child to ride a bike to get exercise, nor is it to recommend five servings of fruits and vegetables a day. Despite substantial intervention efforts racial and ethnic disparities in adolescent obesity continue to grow (23). This paper has shown that rates will continue to increase unless public health professionals take the time to recognize the differences embedded in this population.
References
1. Center for Disease Control and Prevention. Make a Difference at you School. Atlanta, GA: Center of Chronic Disease Prevention and Health Promotion, 2008
2. National Center for Health Statistics. Trends in the Health of Americans. Hyattsville, MD: NHANES, 2004.
3. US Census Bureau. People and Families in Poverty by Selected Characteristics: 2006-2007. Suitland MD: US Census Bureau. http://www.census.gov/hhes/www/poverty/poverty07/table3.pdf
4. Williams DR, Collins C. Racial Residential Segregation: A Fundamental cause of Racal Disparities in Health. Public Health Reports 2001; 116: 404-416.
5. Center for Disease Control. Fruits and Veggies Matter. Atlanta, GA: Center of Chronic Disease Prevention and Health Promotion, 2008.
http://www.fruitsandveggiesmatter.gov/index.html
6. Brown MR. Supermarket blackout- lack of quality grocery stores in black communities (pp 9-8). In: Black Enterprise. New York, NY: Earl G. Graves Publishing Co, 1999.
7. Edberg M. Individual health behavior theories (pp. 35-49). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
8. Bush CL, Pittman S, McKay S, et al. Park-based obesity intervention program for inner-city minority children. Journal of Pediatrics 2007; 151: 513-517.
9. Burnet DL, Plaut AJ, Ossowski K, et al. Community and family perspectives on addressing overweight in urban African American youth. Journal of General Internal Medicine 2007; 23: 175-179.
10. Center for Disease Control and Prevention. Making Physical Activity a part of a Child’s Life. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/physicalactivity/everyone/getactive/children.html
11. US Department of Agriculture. My Pyramid for Kids. Washington DC: USDA, 2005.
12. Edberg M. On health behavior- An introduction (pp. 1-9). In: Edberg M, Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
13. Orfield G, Eaton SE. Dismantling desegregation: the quiet reversal of Brown v. Board of Education. New York: New Press, 1996.
14. United States General Accounting Office. School Lunch Program: Efforts Needed to Improve Nutrition and Encourage Healthy Eating. Washington, DC: GAO, 2003.
15. CNN. School Vending Machines losing favor. New York, NY: CNN. http://www.cnn.com/2003/EDUCATION/07/14/food.vending.reut/