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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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














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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Funding that has Fueled an Ineffective Intervention-Isadora Nogueira

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

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

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

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

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

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

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

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

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

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

Counter Intervention

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

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

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

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

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





References

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

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

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

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

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

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

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

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

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



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


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

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

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

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

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

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

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

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

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

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