Sergeant Choice- Failures and Solutions-- Hector Mendez

Introduction

The overweight and obesity epidemic has been propelled into the spotlight of current health issues affecting America’s population, and particularly, America’s youth. Currently there are approximately 142 million people nationwide that are overweight or obese. A total of 17% of teenagers are carrying extra weight (1). It’s increasingly important that teenagers of all ages learn to live healthy lifestyles, in order for them to avoid deleterious health outcomes due to their weight. One particular phenomenon that affects our country’s young adults is the “Freshman Fifteen”: the belief that freshmen gain fifteen pounds in their first semester of college. Each September, college from all over the country travel by car, plane and train to reside at their school of choice. Even though some studies show that freshmen don’t actually gain the full fifteen pounds, it’s important that we look at this phenomenon in order to determine how we can prevent a lifetime of bad eating habits and promote healthy lifestyles (2). One particular health approach that seeks to promote healthy eating habits is the Sargent Choice. The goal of this approach is to “improve the eating choices and ultimately the health of the entire BU community”. The program’s recipes and healthy menu options are developed by registered dieticians, as well as graduate and undergraduate nutrition students. Although BU Dining Services and Sargent College have made healthy options available to students, Sargent Choice has failed to infiltrate the mindsets of BU students on the Charles River campus, particularly because of three main flaws: 1) as an innovation it has not been disseminated effectively, 2) it is based on traditional health models which assume that human beings behave rationally and, 3) it doesn’t teach individuals anything regarding healthy and nutritious foods, which would affect self-efficacy.

Ineffective Dissemination

The Sargent Choice program (SC) was started in 2004; they sought to offer healthier options in the dining halls, in an effort to promote a healthy campus. The program has evolved in the past 5 years, and currently has its own interactive website with videos, recipes, and tips on how to eat and live healthily. However, as an innovation, SC has not been adopted by most BU students. Most students don’t even know much about what the program is, or how they can use it to improve their health.

According to one of the Social Process theories, the Diffusion of Innovations (DOI), an important part of the adoption and implementation of an innovation into a community is the process of dissemination. This theory was developed by Everett M. Rogers, who claimed that an innovation must be effectively communicated through different “channels over time among member of a social system”. DOI theory defines dissemination as the “active knowledge transfer from the resource system to the user system” (4). There is a chronological set of events that leads to the innovation reaching all the target population; dissemination is one of the key elements.

Adoption of the SC has been minimal, particularly because the uptake of behavior requires knowledge regarding the innovation. In this case, most BU students are unaware of what exactly SC is and, more importantly, how to use it effectively. There has not been any significant effort by the part of Sargent College or by Dining Services to really create a positive attitude toward SC; most students are apathetic or have minimal understanding of the program, and believe that it’s not actually a healthier option. Essentially, students lack procedural, and principles knowledge. These are two of the three “knowledges” that influence and individual’s decision to adopt or take up a behavior or innovation (4).

There are other factors that also contribute to the rate and extent of diffusion that an innovation, like SC, can have. There is some level of compatibility with the target audience, however, it does not seem to have any “observability”, meaning that the results are not easily measured or observed. In addition, the innovation cannot truly be adopted without strict commitment. This is arguably one of the most important factors regarding adoption of SC. Most students don’t have the time to seek out SC in the dining halls; this is, in part, due to the lack of knowledge. If students actually knew what the benefits were, or how to measure their observable results, they would have more incentive to participate in SC.

Irrational Behavior

Sargent Choice is also partially based on some traditional health behavior theories that assume humans behave rationally and that intent is a direct determinant of behavior. One of the theories, the Health Belief Model (HBM), suggests that if an individual believes that if truly believes that adopting the behavior, Sargent Choice, will avoid a negative health outcome, the individual will uptake it. Students must also believe that they are susceptible to an unhealthy outcome and that the outcome can be severe and affect some aspect of their life; adopting SC must have some healthy outcome that will either diminish or completely prevent an undesirable health outcome. Assuming that there are no barriers preventing a student from incorporating SC into their daily routines, the student will adopt the behavior (5). This model makes the assumption that an individual’s intent leads to behavior without any other impeding factors.

HBM doesn’t take into account the students’ attitudes toward the behavior. In order for them to adopt the behavior they must believe that it will have some sort of positive outcome. If the social norm around campus is to eat healthily, this will also affect the intent to behavior pathway. The Theory of Reasoned Action (TRA) posits that attitudes and social norms affect a person’s intent and then lead to behavior. However, even though it is socially acceptable to eat options from the Sargent Choice menu, most students will disregard the signs when dining. Students choose what is most convenient and what seems most palatable; in general, the SC logo is disregarded. This traces back to the inefficient dissemination of information regarding SC.

It is evident on the SC website that the program is based on rational behavior. Sargent Choice assumes makes the claim: “Eating well will never be this easy again”(3). If students had knowledge about the nutritious ingredients used in SC, they would undoubtedly choose the SC menu option over anything else in the dining hall. This is the assumption made by the SC team. However, when other menu options that are not as healthy, are placed in front of students, they are less likely to choose the healthy choice. SC overlooks various factors that could affect a person’s decision making process, as it is by no means a linear one. Other determinants could include emotional status and cultural differences food palates and eating habits (4).

SC also assumes that students eat the correct proportions and in moderation. However, many students continue to eat even past satiety; even if a dish is healthy, if it is not eaten in moderation, it can also have deleterious effects on health if we’re eating more calories than are expended. Even if a student eats a healthy SC food item, there are other items there that are at the students’ disposal. SC promotes their food options as a kind of mindless way of choosing what is healthy; however, they need to incorporate nutrition education in order for students to be more health-conscious. More importantly, students should be made aware of the harmful health effects that eating an unhealthy diet. Students should understand the health problems that accompany being overweight or obese, which include, diabetes and cardiovascular problems(1). Since humans do not act rationally, SC has not had a major impact on the health of the Charles River campus. Even if students don’t perceive themselves to be susceptible to these health outcomes, knowing the severity can have an impact on their choice of foods according to the “principles knowledge” that is part of DOI. If students understand that the innovation can help reduce negative health outcomes, it can influence their decision to adopt Sargent Choice.

Lack of Self-Efficacy

Sargent Choice does not promote self-efficacy. The self-efficacy construct is “a person’s belief in his or her ability to take the action” (4). This major flaw is propagate because SC does not actually make a significant effort to teach students about eating healthy and making good choices when it comes to choosing the foods they eat. The website claims: “Sargent Choice foods aren’t available anywhere but here at BU” (3). If the dining halls were the only place students ate at, then SC would have better results. However, students have the entire city and towns surrounding campus, where they can choose from countless different eateries. Thus, what good is SC doing if it doesn’t educate the students and lay down a foundation on which to work. The new website is very much interactive; it includes numerous tips on how to eat healthy, who needs to eat healthy, and where you can get SC food options. Nevertheless, the website is not very well advertised throughout the campus, and most students do not visit it. If the resources available on the website were made available in the dining halls, students would access them more. In this way, students would be educated and empowered with the knowledge to eat well. Students need to feel that they can perform the health behavior, and they must feel that it is really going to make a difference in their lives.

If SC focused on educating students about nutrition and overall health, students would be able to make healthy decisions in and out of the dining hall. This would promote a sense of self-efficacy and even reciprocal determinism as postulated by Albert Bandura in his Social Cognitive Theory (SCT). Reciprocal determinism is the process by which a person acts according to individual and environmental factors, receive a response after adopting the behavior, and according to the response they will go back and adjust the behavior before performing it again. Reciprocal determinism ties into the idea of self-efficacy, since it promotes the idea that we can adjust our behavior and try it again. In regards to the Sargent Choice, this means that we can adopt the behavior, and depending on the results and response we receive from the environment, we can adjust and continue the behavior (4). These two ideas are important in implementing and maintaining a health behavior because students feel empowered and able to perform the behavior. When students truly understand how to use SC, and can apply the principles behind SC to their meals outside of the dining hall, then SC will truly have an impact on the overall health of the BU community.

Conclusion

Sargent Choice attempts to address an important problem facing America today: maintaining a healthy lifestyle despite the countless fast food and unhealthy food options. However, this public health approach aimed at BU students is based on some of the traditional health behavior theories that fail to incorporate some important ideas. One of the major flaws of the program is that it has not been properly publicized around campus. They have failed to really disseminate information regarding SC throughout campus. Many students are unaware of the benefits that eating healthy can have, or more importantly, unaware of the effects bad food choices can have on one’s health. Without sufficient knowledge about Sargent Choice, students fail to implement this innovation on campus, and therefore it is by no means maintained by very many students. Since it is based on traditional health behavior theories, it makes the assumption that students are going to think rationally and that they make a linear decision making process. The program must take into account that even though the healthy choice may be obvious, intent does not directly lead to behavior. Finally, the program does not educate students about making nutritional choices. Students must be educated on how to eat healthily, and maintaining a balance between diet and exercise. Once students know how to make healthy food choices in and out of the dining halls, they can truly incorporate SC principles into their daily lives. When this goal is reached, students can develop a sense of self-efficacy, meaning that they will feel apt to make good choices regarding foods, and continue to make the correct choices.

Reference List

1. Crombie A, Ilich J, Dutton G, Panton L, Abood D. “The freshman weight gain phenomenon revisited”. Nutrition Reviews [serial online]. February 2009;67(2):83-94. Available from: Alt HealthWatch, Ipswich, MA. Accessed April 8, 2009.
2. Mihalopoulos, Nicole L., Peggy Auinger, and Jonathan D. Klein. "The freshman 15: is it real?(Clinical and Program Note)." Journal of American College Health 56.5 (March-April 2008): 531(3).
3. Why Sargent Choice. The Sargent Choice Website. Available at: www.sargentchoice.com. Accessed April 6, 2009.
4. Edberg, M.. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Ontario: Jones and Bartlett Publishers; 2007.
5. Rosenstock, I.M. (1974). The health belief model and preventive health behavior. Health Education Monograph, 354-386.

The New Sargent Choice: Stay Smart, Eat Healthy — Hector Mendez

College students lead fast-paced, high-energy, and sometimes, unhealthy lifestyles. Oftentimes, they don’t have time to think about making healthy food choices. The current Sargent Choice Program at Boston University has several flaws that have rendered it ineffective among the student body. SCP doesn’t address the irrational behavior of human beings, the necessity for an approach that promotes self-efficacy and maintenance, and it has failed to effectively influence the community at large. An alternative and effective intervention is necessary to address the serious issue of obesity affecting all age groups of American society. One of the greatest increases in obesity has been seen in the 18-29 year-old age bracket. In 2001, the overall prevalence of obesity among 18-29 year-olds was 14%, and even higher among those with some college education, at 21% (1). Equally surprising is the data from the National College Health Risk Behavior Survey, which projects that 35% of college students are overweight or obese (2). When we look closer, we see that students aren’t engaging in healthy eating habits, and according to one study, approximately 70% of students are eating less than the recommended 5 servings of fruits and vegetables per day (1). Sargent Choice has established a pretty good foundation for an intervention aimed at improving the eating choices and ultimately the health of the entire BU community” (3). In order to make it a success and perhaps a model for other campuses, we must make sure that knowledge and information about the program is properly disseminated to every corner of campus. More importantly, it’s important that it mirror health models that incorporate the social and environmental context in which individuals live; the health behavior theories that focus on the context in which individuals make decisions account for “external factors” that can affect health behavior (4). One of the most important adjustments to the SC program, is going to be the incorporation of important facts that will provide individuals the knowledge to eat healthy not only in the dining halls, but elsewhere on campus. This knowledge will enable students to uptake healthy eating in general, and allow them to maintain the behavior.

We Must Reach Every Corner of Campus

In order for a public health intervention to be successful it’s important that individuals be aware of it. In designing an alternative approach to the current SCP, it’s important to borrow some principles from the Diffusion of Innovations (DOI), and Social Marketing theories. The proper definition of dissemination is the “active knowledge transfer from the resource system to the user system” (4). The identification of adequate communication channels is important to this transfer process. Without dissemination it is impossible to continue to the next step in the DOI process—adoption of the health behavior (4). According to a study by Valente and Fosados, there are few studies that have incorporated interpersonal communication as a part of dissemination. These researchers were focusing on STD/HIV prevention, and they concluded that interventions that included interpersonal communication were successful and “observed successes in health promotion”. They claim that a “social network analysis” may be an effective tool in designing appropriate and successful public health programs (5). As part of the new SCP, there will be a group of student health ambassadors that are knowledgeable yet approachable. They will visit the freshman dorms on the Charles River Campus to spread the word about the New Sargent Choice program (NSC), and let students know what NSC is all about and what they should look out for in the dining halls. Through this interpersonal communication, the student body will become aware of the intervention, and they can go on to the adoption phase of DOI.

Using another social process theory—Social Marketing (SM), the NSC will be treated as a “product” that we are marketing. Our goal in marketing NSC, is to have the student body adopt the new health behavior by their own volition. The four main principles of the SM approach include: product, price, place, and promotion. First, we need to market NSC as a product that includes many benefits. In this case, price would not be an issue, since students eating at the dining halls have meal plans that are paid for ahead of time. The place where NSC will be “distributed” is easy—the dining halls. In terms of promoting the product, interpersonal communication will be crucial. This can be student-to-student with the use of the student health ambassadors, but, the communication can also come from a professor or an academic advisor who meets with a student on a regular basis. Aside from that, other channels of communication can be used. In particular we can use the internet, e-mail, BU’s television channel, and the radio station (4). Ideas from the SM and DOI theories, really intertwine to help make dissemination of a health promotion program more effective.

A Rational Approach to Irrational Behavior

The old SC program seemed to mirror principles from traditional health belief models, like the Health Belief Model (HBM). HBM and other traditional health behavior models assume that intent is a direct determinant of behavior. However, HBM fails to incorporate “attitudes and beliefs” that are related to and account for “variance in behaviors” (6). Some important principles that are going to form the basis of the NSC, are going to include self efficacy, reciprocal determinism, and different internal and external factors from the Social Cognitive Theory (SCT). Individual characteristics include the principle of self-efficacy, which is the individual’s confidence in their capability to perform the behavior, as well as the individual’s expectations, self-control, and ability to cope emotionally. The environmental factors include an individual’s physical and social surroundings, reinforcements, and modeling of behavior from other individuals. Finally, reciprocal determinism is a process by which a person acts according to individual and environmental factors, receives a response from the environment and then goes on to adjust the behavior and perform it again (4). It’s important that NSC be easy to use; this will provide students with a greater efficacy expectation. This will have a strong effect on the ultimate performance of this target population. If NSC is marketed as an easy task, students will have a greater sense of self-efficacy, meaning that they feel competent enough to perform this task. Another important factor relating to self-efficacy, is generality. Students must feel that NSC can be generalized to other situations, such as eating at home, or at local restaurants. If there is generality, students feel that they can perform the task in an unsupervised setting (7). Essentially, they must believe that they have the necessary skills to achieve the goal—healthy eating choices. Therefore, we must provide them sufficient knowledge about nutrition for them to make intelligent choices beyond the walls of the dining halls; in this way, they will be empowered to maintain a healthy lifestyle.

Empowerment

The major flaw of the previous program was the lack of self-efficacy. However, with the NSC, we’re going to empower the students with the knowledge to make healthy eating choices to improve their general health and well-being. While the old SC claimed that SC foods were “exclusively at BU”, the NSC is going to provide students with more detailed information (3). Students should know the calorie value of all of the foods in the dining halls. How can students make healthy eating choices, if they don’t know how much they’re taking in? At BU’s dining halls in particular, they are an all-you-can-eat dining feast. Students are also free to stay at the dining halls for as long as they like. So as part of the NSC, students will have the ability to keep track of their calorie intake. Aside from that, NSC will continue to promote healthier eating choices, with an NSC menu full of whole wheats and other nutritious ingredients. The new interactive website is going to be a key tool not only to spread the word about NSC, but also to spread valuable knowledge that will provide students with the skills necessary to make healthy eating habits. The University should promote the website wherever and whenever possible-- at University-wide events, as well as smaller functions within the different schools and colleges. Another important part of NSC is going to be workshops that teach students how to maintain a healthy diet, and not just counting calories in the dining halls. Workshops should include many of the things discussed on the SC website, like what they call “macronutrients” – Carbohydrates, protein, and fat. However, with workshops, students will receive that interpersonal communication that is important in establishing a successful intervention (5). With these different measures in place, students will truly have a sense of self-efficacy that is a crucial component of Bandura’s SCT. Students will be able to understand NSC, what it can do for them, and how they can use it; as students incorporate it into their daily lives, it will change and reshape the health of the BU community.

Conclusion

The New Sargent Choice program really provides students with invaluable information and knowledge that is key to establishing healthy eating habits. Through different workshops on nutrition and healthy eating, through effective dissemination and awareness of the program, and through empowerment by self efficacy, NSC will really make a difference in the lives of students. When they feel competent and capable, they will be more likely to adopt the behavior. With the tools that NSC provides, like the website and the calorie displays, students will also be able to adjust their behavior once they have adopted the innovation or product. This is the main difference between the two approaches to healthy eating on BU’s campus—the empowerment of individuals to feel that they have the knowledge to make their own decisions outside of the dining halls, while having quick and easy choices that enable and promote healthy food options. As the program reaches out to every school and college at the university, and to every residence hall, students will learn about making good choices when it comes to foods, NSC principles will be incorporated into their lives, and they will be able to maintain this behavior.

REFERENCES

1. Huang, Terry T.-K, Kari Jo Harris, Rebecca E. Lee, Niaman Nazir, Wendi Born, and Harsohena Kaur. "Assessing overweight, obesity, diet, and physical activity in college students." Journal of American College Health 52.2 (Sept-Oct 2003): 83(4). Academic OneFile. Gale. Boston Univ, Mugar Memorial Library. 29 Apr. 2009
2. Lowry R, Galuska DA, Fulton JE, Wechsler H, Kann L, Collins JL. Physical activity, food choice, and weight management goals and practices among US college students. Am J Prev Med. 2000;18:18-27.
3. Why Sargent Choice. The Sargent Choice Website. Available at: www.sargentchoice.com. Accessed April 6, 2009.
4. Edberg, M.. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Ontario: Jones and Bartlett Publishers; 2007.
5. Valente, Thomas W., and Raquel Fosados. "Diffusion of innovations and network segmentation: the part played by people in promoting health." Sexually Transmitted Diseases 33.7 (July 2006): S23(9). Academic OneFile. Gale. Boston Univ, Mugar Memorial Library. 30 Apr. 2009
6. Janz, N., and Becker, M.. “The health belief model: A decade later”. Health Education Quaterly. 1984: 11(1), 1-47.
7. Salazar, MK. “Comparison of Four Behavioral Theories: A Literature Review”. AAOHN Journal 1991; 39 (3): 128-135.

We Can! Campaign Targeting Obesity Translates to We Can Fail –Ta-wei Lin

Introduction

According to the World Health Organization, chronic diseases, such as heart disease and stroke, represent 60% of all deaths worldwide (1). Consequently, the public health field is continuing to shift its focus from traditional infectious diseases to chronic diseases. Of these, obesity is among the most dire. The WHO estimates that approximately 1.6 billion adults worldwide are overweight, with 400 million reaching levels of obesity (2). The Center for Disease Control (CDC) reports that among adult males in the United States, the prevalence of obesity reached 33.2% in 2005-2006. Among adult females, that number reached 35.3%. Children have also been affected by these recent trends, with an obesity rate of 16.3% among children from age 2 – 19 (3).

Increased body mass index (BMI) is a major risk factor for a number of health conditions, such as coronary heart disease, Type 2 diabetes, cancer, and stroke(4). Overweight and obesity also poses as a major economic burden. Medical expenses attributed to overweight and obesity may have reached as high as $78.5 billion in 1998, half of which was paid for by Medicaid and Medicare (5). The severe negative consequences of obesity necessitate a major public health response.

The National Heart Lung and Blood Institute have implemented a national program to address the issue of obesity in children called We Can! We Can! stands for Ways to Enhance Children's Activity & Nutrition. The program is a national education program designed to allow parents help children from age 8-13 stay at a healthy weight(6). The basic premise of the program is to provide science-based information to parents and caregivers to promote healthy eating habits, increased physical activity, and decreased time in front of televisions for children.

The We Can! program is a good demonstration of the health belief model. It runs under the assumption that what is lacking in the fight against obesity is education and awareness, while ignoring other underlying and complex factors. The program makes the generalization that all parents and communities have equal access to resources and information and chooses not to address the social and economic discrepancies that exist throughout the country. As a result, the program will have very limited success.

Solely Providing Information is Often Insufficient for Producing Behavior Changes

The Health Belief Model has traditionally been the theory behind which many public health interventions are derived from. The model states that behavior related to health is motivated by four factors: perceived susceptibility, perceived severity, perceived benefits of action, and perceived barriers to action (7). These factors lead to an intention, which then leads to behavior.

Critics of this behavior model have pointed out that focusing solely on the individual level has very limited utility (8). The model ignores any social or environmental factors that people may be influenced by. It also assumes that behavior is the result of calculated, rational thought. The model also runs under the assumption that everyone has equal access to information and resources (7).

The We Can! program is subject to the same criticisms. The main principle behind the intervention is providing parents with information about obesity and how to prevent it through diet changes, physical activity, and parenting guides. Perceived susceptibility is increased by providing prevalence statistics on overweight and obese individuals. Perceived severity is increased by listing the risk factors involved with elevated BMI. Perceived benefits of behavior change are increased by the promotion of health. And perceived barriers to behavior change is decreased through diet tips, physical activity ideas, and an “Eat Well and Move More” track sheet that allows one to see their progress. The program also promotes the maintenance of behavior change through ideas for non-food rewards for positive behavior, such as a day at the park to fly kites with the family, new workout clothes, or a ball (9).

If the health belief model were to work in all situations, the We Can! program would inevitably be a success if implemented properly. However, this is not the case. As with most chronic illnesses, the issue is not simply lack of information. A study of the prevalence of smoking among patients after lung cancer surgery showed that 37% of patients smoked 12 months after the operation, and 43% smoked at some point after (10). It can be argued that perceived susceptibility and perceived severity is highest in these patients, yet the health belief model failed to predict their behavior with almost half choosing to smoke once again.

Individuals function in a social environment subject to many factors that lie outside of their immediate control. Studies have shown that adult body weight and obesity are inversely related to socioeconomic advantage (11). In other words, there is a higher prevalence of obesity among individuals with low socioeconomic status (SES). This trend hints towards the complexity that surrounds the obesity epidemic. Simply providing parents and children with information on obesity that may already be widely known will likely result in no effect.

Interventions Targeting Obesity Must Consider Environmental Factors

One way the We Can! program attempts to influence diet is through the labeling of Go, Slow, and Whoa foods (12). Go foods are products that can be eaten anytime, such as fruits, vegetables, and nonfat milk. Slow foods are foods that can be eaten sometimes, such as French toast, peanut butter, and whole eggs. Whoa foods are foods that should only be eaten once in a while such as cookies, fried meals, and soda. The program also attempts to increase physical activity through promoting family activities such as biking, swimming, or running (13).

While improving diet and physical fitness is essential for reducing obesity, the program makes no attempt to recognize environmental factors that affect one's ability to take such actions. Studies have shown that the prevalence of obesity is higher in areas with fast food chains and small grocery stores and lower in areas with supermarkets (14). This reflects the effect that the environment has on diet choices and obesity. Therefore, simply telling individuals that they should eat more Go foods, such as fruits and vegetables, and less Whoa foods, such as fast food burgers, will have no effect on those individuals have no access to supermarkets, but easy access cheap, fast food.

Physical activity is also largely dependent on the built environment. Our urban sprawl model for development has created car-dependent communities all across the country. While encouraging people to bike to school and work is a great way to increase physical activity, it is simply not possible for those with long commutes and for those living in areas where biking is not possible. The other suggestions given by the We Can! program are also largely dependent on the environment. Swimming and running both require areas in which to do so.

It is clear that sedentary lifestyles and poor diet are major causes for obesity and public health interventions need to address these issues. However, simply providing guides for behavior and failing to consider environmental factors is not sufficient. Dietary tips will only be effective if individuals have access to cheap, healthy food. Therefore, promotion of farmer's markets or supermarket development in conjunction with community outreach for improved diet will be far more effective. In a similar fashion, exercise promotion will only be effective in conjunction with changes in the built environment, such as bike paths, sidewalks, parks, hiking trails, etc.

The Intervention Assumes Behavior Change in Children Relies Solely on the Parents or Caregivers

The We Can! program is specifically targeted towards reforming the behavior of children age 8-13. However, the program makes no attempt to address the target age directly. Instead, it places all the responsibility and decision making in the hands of the parents and caregivers. While parents have a very large influence on the values and behaviors of children, they are by no means the only influential factors in children's lives.

Albert Bandura's concept of self-efficacy is the belief that one has the ability to perform a certain action or attain a certain goal (7). This concept is included in many behavioral learning theories. By not addressing these children directly and placing all of the control in the hands of the parents, the program is not instilling a sense of confidence that is essential for behavior change and maintenance.

According to the psychological reactance theory, reactance will occur when rules threaten or eliminate certain freedoms. Forcing the decision upon individuals them rather than allowing them to make the decision for themselves may produce an unwanted, opposite effect of rebellion. In this situation, forcing children to watch less television and eat more vegetables may cause a desire to perform the opposite action. This effect is heightened when a dissimilar group is delivering the message. Reactance was seen in the Above the Influence Campaign. The campaign was perceived by youth as a removal of freedom and actually had a counterproductive effect on drug use according to a study performed by the Government Accountability Office (16).

Social and Economic Disparities Exist and Cannot Be Ignored

The major flaw in the We Can! program is that it completely ignores socioeconomic, racial, and gender disparities that exist in the United States and throughout the world. Failing to address these social issues is not limited to this program alone, but is pervasive throughout the field of public health. General programs that assume equal resources and equal access to information fail to understand the world in which we exist and consequently will fail to resonate with a large percentage of the population.

In 2000, According to the American Obesity Association, 28.7% of non-Hispanic whites were obese, compared to 34.4% of Hispanics, and 39.9% of African Americans (17). Across all racial lines, women experienced higher prevalence of obesity than men, with African American experiencing the highest prevalence of obesity at 50.8%. There is also evidence that suggests poor health during childhood is associated with lower education, lower social status, and health problems, suggesting a mechanism by which economic status is transferred (11).

The We Can! program can only benefit those that have access to the resources necessary for a healthy lifestyle. Low-cost, energy dense foods may be the only option for certain people. The program not only fails to provide an alternative for these individuals, but fails to recognize that they even exist. By assuming a level playing field, socioeconomic disparities not only remain but are perpetuated. Minority populations, being the most affected by the obesity epidemic, should be targeted, not ignored if significant progress is to be made to reverse the obesity trend. Culturally sensitive information should be made available to all populations in various languages for a comprehensive program to work.

Conclusions

The We Can! program provides the keys for a healthier lifestyle. Poor diets and lack of physical activity are major causes of the obesity epidemic and need to be addressed by the public health field. However, the limited understanding of how individuals function in our complex world will inevitably lead to the program's failure.

The solution to the obesity epidemic cannot simply be reduced to “Go Foods” and exercise. Providing individuals with information is not sufficient for producing behavior change. This is because health is not always highest on an individual's priority list. The We Can! program relies too heavily on the health belief model. The health belief model is strictly an individual level theory that fails to understand how we make decisions. We do not consciously calculate benefits and barriers prior to making choices. The power in making those choices also does not solely lie on the individual, but is rather a culmination of social and environmental forces.

The We Can! program also fails to consider environmental factors involved with obesity. Telling people to eat healthier is not useful if they do not have easy access to affordable, healthy groceries. Telling people to bike or run is not useful if they live in areas without sidewalks, bike paths, or parks. Changes to the built environment are essential for combating the sedentary lifestyle that many have grown accustomed to.

The program, like so many other public health interventions, must stop ignoring the socioeconomic, racial, and gender disparities that exist in the world today. The assumption that people have equal access to resources and information represents a major flaw in many public health programs and marginalizes the most sensitive populations that we should be focusing on. Public health practitioners cannot simply be distributors of health information, but rather leaders of social change. The social disparities in health need to be addressed, rather than perpetuated through programs such as We Can!

Community Leaders Fighting Obesity: A Public Health Intervention Utilizing the Social Sciences – Ta-wei Lin

The Community Leaders Fighting Obesity (CLFO) program is a hypothetical intervention with the goal of reversing obesity trends through community involvement and empowerment. The intervention involves the cultivation of local community leaders and providing them with the tools to develop their own interventions that address their specific needs. Unlike the We Can! Program, which is a very broad, generalized program for the entire country, this intervention is highly tailored towards specific communities.

The first step in the CLFO program is to identify communities with a high risk for obesity. Because obesity rates are much higher among African American and Hispanics compared to non-Hispanic whites, the program will mainly target minority rich, lower SES communities (17). Once communities are chosen, we will then recruit a board of local community members of different ages and backgrounds. These individuals may include involved high school students, teachers, coaches, local business owners, and active seniors.

Once the board of community leaders is formed, the next step is to identify the strengths and the needs of the community to design a proper intervention to target obesity. The intervention will attempt to highlight the strengths of the community while addressing the needs. The board will assess the community on individual, environmental, and policy levels.

On the individual level, the board will look at things such as overall level of physical activity, general eating habits, predominant modes of transportation, and interest in organized events like sports leagues, spinning classes, yoga lessons, etc. The board will also assess the overall comprehension level of obesity and its risk factors. If comprehension is high, then there would be no need for the programs to focus on the distribution of information.

On the environmental level, the board will assess the built environment of the community as well as the identify possile impediments to outdoor, physical activity and healthy eating habits. This may include an assessment of local parks, presence of swimming areas, bike lanes or bike friendly roads, walkable sidewalks, amount of green space, availability and affordability of fresh, healthy foods, and presence of fast food restaurants. These programs will attempt to highlight the positive aspects of the built environment in various ways, such as keeping these resources clean and accessible and organizing events centered around these areas. The board can also try and ensure the availability of fresh fruits and vegetables by organizing a farmer's market with local farms. A crucial aspect of the environmental level assessment is that it requires an honest and comprehensive look at the communities strengths and needs. Programs cannot encourage physical activity without ensuring that individuals have a convenient way to engage in them.

On the policy level, the board will try and address the weaknesses of the community through policy change. For the program to be successful, it is crucial that elected officials be involved in the process. The board, acting as an organized and well-versed lobby of community members, can work with these elected officials to address the needs of the community. For example, the board can improve the state of the local parks by lobbying for increased funding for the department of parks and recreation. The board can also lobby for other built environment changes such as bike paths, hiking trails, and zoning changes to stop the growth of unhealthy food vendors. This level is crucial because policies can have a drastic positive and negative effect on behaviors and social change.

CLFO Does Much More Than Just Provide Information

One of the main weaknesses of the We Can! program is its reliance on the health belief model. The health belief model relies on the generation and distribution of generalizable knowledge to predict, explain, and control behavior (18). While this model is not without merit, it has very limited utility when dealing with more complex health issues. Current attempts to target the obesity epidemic have largely been limited to distribution of information. However, much like cigarette smoking, the issue isn't lack of knowledge.

The CLFO program is a very general, highly flexible program geared towards community involvement and community empowerment. All communities across the country have a unique collection of individuals, resources, strengths, needs, and challenges. It is not plausible to organize a general public health intervention for all communities in response to a complex chronic disease and expect widespread success. The key feature of the program is that it makes little to no assumptions about a community prior to forming the intervention. Instead, the program elicits help from community itself to design its own intervention based on their strength and needs.

While the program will most likely involve the distribution of information on the risk factors of obesity and obesity trends, that is a very small part of what the program will provide. Unlike the We Can! program, this program is not solely an individual level intervention. The program addresses the obesity problem on an individual, environmental, social, and political levels. Focusing solely on the individual level may ignore the fundamental cause of this disease (19). This is why a comprehensive, mulit-level response is necessary.

Environmental Factors is a Major Part of the CLFO Response to Obesity

While the choice to eat healthier and get more exercise is an individual level decision, it is strongly influenced by the environment in which a person lives. The built environment and its effect on health is quickly becoming a major focus of the public health field (20). Walkable city designs, presence of green space, and zoning all have major impacts on activity levels and overall health. Before encouraging people to be more active and adopt healthy eating habits, we must ensure that they have the opportunity to do so.

The We Can! program, while encouraging physical activity such as biking, running, and swimming, makes no attempt to address disparities in the built environment across different communities. The program assumes that everyone has access to areas where physical activity is possible. Unfortunately, this is not the case. A successful public health response must not only encourage physical activity, but ensure that the environment is conducive for health.

The CLFO program is largely focused on environmental changes to encourage a healthier lifestyle. This may involve something as simple as cleaning up a local park to major zoning changes to encourage the development of more health conscious establishments. Because the intervention is designed by the community members themselves, they'll be sure to implement changes that they will take advantage of. Adding a bicycle path in a community that is generally disinterested in biking would not have as great of an effect. The CLFO program attempts to ensure that individuals in these communities have the ability to make proper health conscious decisions, rather than simply giving them lifestyle change tips.

The Message of The Program is Delivered By Peers

A major flaw of the We Can! program is that the message for children to live healthier was delivered by adults. According to Reactance Theory, individuals will feel a sense of rebellion if they perceive their freedoms are being threatened. This effect is heightened when dissimilar groups are delivering the message. While parents do have a large influence on children's decisions, forcing decisions upon them is not always the best way to encourage healthy lifestyle choices.

The strength of the CLFO program is that the entire program is designed and implemented by members of the community. The board of community leaders consists of individuals of all ages and backgrounds, ensuring that various perspectives are taken into consideration and various needs are addressed. Members of a community will be much more receptive to suggestions given by respected community members.

Messages delivered by peers may also help instill a sense of self-efficacy throughout the community. Since the intervention was designed and implemented by the community itself, the members of that community will feel a greater sense of pride in the changes that arise from program. Community members will also be able to see their neighbors utilizing the park or the bicycle path and buying groceries from the new farmer's market, which may encourage them to do it as well.

The CLFO Program Addresses Racial Disparities by Targeting Low SES Neighborhoods

Communities that have a high minority population with low socioeconomic status are at high risk for obesity, as well as many other chronic diseases (17). For this reason, it is essential that the public health field target these populations, rather than ignoring them by implementing a general response for the entire country. By not addressing populations with low socioeconomic status directly, we risk perpetuating the health disparities that exist across socioeconomic and racial lines.

The CLFO program initially identifies communities with high obesity rates. While these are not limited to minority dense populations, obesity trends tend to be the most drastic in low SES communities. Through community empowerment and the cultivation of community leaders, we set the stage for interventions that are not just limited to obesity. The program, if successful, becomes a venue for social progress.

Community building has the effect of encouraging a more heterogeneous population. Low SES neighborhoods tend to remain in the same socioeconomic state due to a concentration of low-income, minority populations. Members of those communities that have relatively higher economic success tend to leave for other areas due to poor school systems, crime, poor living conditions, and other factors. Through additions to a neighborhood such as parks, trees, and playgrounds, properties in that community become more valuable and members in that community may be more encouraged to stay. While this process may take a significant amount of time, visible progress is still being made.

Conclusion

The Community Leaders Fighting Obesity program improves upon the We Can! program in various ways. The CLFO program is not an individual level intervention based on the health belief model. It is a multi-level, comprehensive response aimed towards fighting the fundamental causes of obesity. The CLFO program also is entirely designed and implemented by members of the community. This ensures that community needs are understood and that the interventions are carefully catered towards those needs. This also ensures that the message will be received by other members of the community.

The CLFO also specifically targets high risk, low SES populations. The We Can! program offers a highly generalized response, which assumes equal access to resources and information. This is not beneficial when there is a major disparity in health and SES status. The CLFO program does not ignore SES disparities. On the contrary, the program specifically targets low SES communities. By empowering these communities and providing them with the resources to fight chronic diseases such as obesity, we take a step in the right direction in terms of eliminating health disparities along socioeconomic lines. The public health field needs to be a venue for social change, rather than an impediment.

References

1.World Health Organization. Chronic Diseases. September 2006.
http://www.who.int/topics/chronic_diseases/en/
2.World Health Organization. Obesity and Overweight. September 2006. http://www.who.int/mediacentre/factsheets/fs311/en/index.html
3.Centers for Disease Control and Prevention. Overweight and Obesity. 24 March 2009. http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm
4.Centers for Disease Control and Prevention. Overweight and Obesity Health Consequences. 3 February 2009. http://www.cdc.gov/nccdphp/dnpa/obesity/consequences.htm
5.Finkelstein, EA, Fiebelkorn, IC, Wang, G., National medical spending attributable to overweight and obesity: How much, and who’s paying? Health Affairs. 2003; W3;219–226.
6.National Heart Lung and Blood Institute. Welcome to We Can! http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/index.htm
7.Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health.
8.Choi, Yep, Kumekawa. Hiv Prevention Among Asian and Pacific Islander American Men Who Have Sex With Men: A Critical Review of Theoretical Models and Directions for Future Research.
9.National Heart Lung and Blood Institute. Live It. Healthy Weight For Life. Http:// www.nhlbi.nih.gov/health/public/heart/obesity/wecan/live-it/healthy.htm
10.Live Science. After Lung Cancer Surgery, Nearly Half of Patients Resume Smoking. 11 December 2006. http://www.livescience.com/health/061211_smokers_resume.html
11.Baum II, Ruhm. Age , Socioeconomic Status and Obesity Growth. July 2007. http:// www.livescience.com/health/061211_smokers_resume.html
12.National Heart Lung and Blood Institute. Go, Slow, and WHOA Foods. Http:// www.nhlbi.nih.gov/health/public/heart/obesity/wecan/live-it/go-slow-whoa.htm
13.National Heart Lung and Blood Institute. Energy Out Activities. http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/live-it/energy- out.htm
14.Morland, Evenson. Obesity Prevalence and the Local Food Environment. 2008. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VH5-4TMBPYM&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=6e721491d45e8e8c137654af6485209c
15.National Heart Lung and Blood Institute.. Helpful Ways to Reduce Screen Time. http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/live-it/screen- time.htm
16.United States Government Accountability Office. ONDCP Media Campaign. August 2006. http://www.gao.gov/new.items/d06818.pdf
17.American Obesity Association. AOA Fact Sheets. 2002. http://obesity1.tempdomainname.com/subs/fastfacts/Obesity_Minority_Pop.shtml

18. Thomas, Linda. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing. July – August 1995.

19. Link, Bruce. Phelan, Jo. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior 1995. 80-94

20. National Institute of Environmental Health Studies. Obesity & the Built Environment. http://www.niehs.nih.gov/news/events/pastmtg/2004/built/

A Critique of the Current Anti-Smoking Efforts in Egypt – Gilan Abdelmegeed

Introduction:

In August 2007 the Egyptian government established the Smoking Control Department (SCD). The objective of the SCD is to create successful public health anti-smoking campaigns. After numerous unsuccessful anti-smoking laws, the SCD was established. Since 1977, a ban on all tobacco radio and television advertisements has been put into affect. A 1981 legislation required tobacco companies to print health warning labels on cigarette packs. It also banned smoking in enclosed public areas and on public transportation, including the subways and buses. The 1981 legislation was amended in 1994 to include a fine for smoking violations. In spite of the tobacco legislation implemented by the Egyptian government thus far, there has not been a decrease in smoking prevalence amongst Egyptians (3, 7).

Smoking in the Arab Republic of Egypt has evolved within the past 30 years to become a socially integrated behavior. Egypt has the highest rate of tobacco consumption in the Arab world, with a current prevalence of 40%, increasing at a rate of 8% per year. This percentage rises among certain professions with 45% of teachers and 43% of physicians smoking. There are 25 new smokers in Egypt per hour. According to the WHO, 1/3 of Egyptian smokers start before the age of 10, with the majority of adult smokers’ beginning before the age of 18. Smoking is responsible for over 150,000 deaths in Egypt annually. The direct annual cost of treating diseases caused by tobacco use is estimated at US$ 545.5 million. Smoking has become a way of life in Egypt, where children and adults alike are socially accepted to practice it (3, 6).

On August 1, 2008 the SCD launched an anti-smoking campaign. The strategy of the campaign is to reduce smoking prevalence through educating the public on the health affects of smoking on the smoker and on women and children through second hand smoke. The campaign requires tobacco companies to print graphic labels on cigarette packs depicting the health effects of smoking. The use of women and children targets the importance of family and children in the Egyptian community. It does not indicate that only males smoke, but instead, that the affect of second hand smoking on women affect children and family life consequently. This campaign fails in reducing smoking rates in Egypt because education does not result in action, it does not address smoker’s self-efficacy to quit smoking, and it does not acknowledge the social factors which are in fact the root of the smoking crisis in Egypt (3, 7).

Argument 1: Education does not Result in Action

The SCD fails to reduce smoking prevalence because education does not lead to action. The information written on the cigarette packs convey the negative health affects on the smoker and on smoker’s family life. These health effects include the health risks on spouses, children and developing fetuses. The graphic labels on the cigarette packs also illustrate the negative affect smoking has on personal and sexual relationships. Research has been conducted which supports the claim that education does not have a direct causal relationship with behavior change. The SCD campaign, which lacks an official title, is a classic example of the Health Belief Model (HBM). The HBM is a Behavior Change model which states individuals judge a behavior change by comparing the perceived severity and perceived susceptibility of the outcome of their current behavior. Individuals then compare the perceived benefits and the perceived barriers of the new behavior and from there, create an intention to act, which entails either changing the behavior or not. The intention is the only factor affecting the decision to act (2, 4).

The HBM, as well as the SCD campaign, are both too simplistic in their approach. The assumption that education will naturally lead to a change in behavior is naïve and flawed. There have been other Behavior Change models which demonstrate the flaws in the argument that solely education can cause action. The Theory of Reasoned Action (TRA) is a behavior model that builds on the HBM and states that the attitudes towards, and the perceived social norms of, the behavior change play a vital role in adopting an action. TRA also introduces the concepts of belief, attitudes and irrational behavior. The Theory of Planned Behavior (TPB) builds on the HBM even more to add a vital concept of behavior change: Self-efficacy. Self-efficacy is an individual’s belief in whether he/she can carry out the behavior change. The TRA and TPB demonstrate that intention is only a small part of executing an action (1, 2).

The current data on the demographics of smokers in Egypt illustrate that education is not sufficient for this campaign. First, with the prevalence of smoking being higher among the most medically educated proportion of society, education clearly does not have a negative affect on smoking. Second, in a study by the WHO in 2001, 82.1% of smokers said they had the intention to stop smoking. 60.9% of these people wanted to quit due to known health reasons (3). The majority of the population is already aware of the health affects, have the intention of quitting but are unable. Again, education alone is clearly insufficient. Third, the campaign is based exclusively on written health information, and at a 30% national illiteracy rate, the campaign is unable to reach a large proportion of the society (3).

Argument # 2: The Campaign Doest not Address Self-Efficacy.

The SCD campaign fails to provide the self-efficacy smokers need in order to quit smoking. Self-efficacy is an essential factor in promoting health behavior change. Three Behavior Change models support this: The Theory of Planned Behavior, The Social Learning Theory and The Social Cognitive Theory. All three theories state that self-efficacy is a vital part of behavior change. The Theory of Reasoned Action goes further to say that without self-efficacy one does not even have the intention to act (1, 2). The campaign ignores three important factors for smoker’s self-efficacy: the addictive nature of nicotine, the pleasures derived from smoking, and the habitual nature of smoking in Egypt.

The campaign falls short on addressing the addictiveness of nicotine. It does not provide alternatives to smoking, like the patch, nicotine gum or a social support network. The existence of such alternative measures is overall scarce in Egypt and are not well advertised nor understood. The campaign needs to acknowledge the need for biological and psychological nicotine rehabilitation. 45.4% of Egyptian smokers perceive smoking as an addiction. This campaign provides no means to show smokers that they have the ability to stop smoking. In fact, it shows that smoking is a circle of unhealthy, uncontrollable behavior (3).

The SCD campaign does not provide the self-efficacy needed for smokers to give up their personal gains from smoking. Smokers in Egypt identified the personal gains from smoking to be self-confidence, being fashionable and social acceptance. 26.3% of Egyptians say smoking increases their self-confidence and 24.6% say they find it fashionable (3). The campaign does not illustrate how one can quit smoking yet still maintain the perceived benefits.

The SCD does not acknowledge the habitual nature of smoking. Smoking is a daily or even hourly habit, easily accessible and affordable in Egypt. 46.6% of Egyptians perceive smoking to be a habit, resulting in 71.2% of smokers smoking at least once a day (3). The message is not given by smokers, instead by a government whom the average public has a hostile attitude towards. 88% of Egyptians believe that advertisement countering smoking is not enough (3). The campaign provides no successful examples of individuals who have been able to quit. Especially in Egypt where the default health role models, doctors and teachers, heavily smoke, the need for good examples to imitate is essential. Behavior Change Theories support the need for positive role models and outcomes. The Marketing Theory and Branding Theory both establish that you need to have a set of associations with what you are selling (1). In theory the SCD campaign is selling “stop smoking”; however it is not advertising it well. The SCD needs to represent the positive outcomes of the behavior change. It needs to represent the ability to make that change and to provide the self-efficacy.

Argument # 3: To change a social behavior you need to address the social norms

The campaign fails to address the fundamental social influence on smoking. It regards smoking as an individual problem, not as a group-level one. The campaign does not account for the pervasive nature of smoking, the cultural aspects which embed it into daily routine, or an alternate to, reduce the incidence of smoking.

Tobacco advertising on television and radio stations has been illegal since 1977 (7). However, tobacco companies simply do not need to promote cigarettes because social norms and networks have become the promoters. The popularity of smoking has been embedded into the culture and become socially acceptable. There is no stigma against it, and no encouragement for people to stop smoking. The SCD’s campaign is directing its efforts towards individuals to stop smoke. Instead, SCD needs to target the social networks. The Social Networking Theory (SNT) states that people exist in social networks not as individuals and people change as networks and not as individuals (1, 2). As smoking has become such a vast practice in Egypt, targeting each of the 35 million smokers as individuals, rather than as social networks, to quit is a resource-wasteful method.

The SCD ignores the traditional and cultural aspects of smoking in Egypt. Smoking in Egypt is socially acceptable where many smokers start early in their youth. Smoking is placed as a priority in social households and it builds on traditional Egyptian customs such as the Egyptian tobacco water-pipe, also known as the “shisha”. A number of Behavior Change theories state that social agendas need to be incorporated into campaigns. These theories include the SNT, The Agenda Setting Theory and The Framing Theory. All three focus on changing behavior at a social level that includes factors that influence the social, rather than the personal attitudes towards smoking. Smoking in Egypt is a cultural phenomenon; therefore, it needs to be addressed as a social problem. Most smokers start while they are still minors, with a 1/3 of smokers starting before the age of 10 (3). Youth are commonly sent to buy cigarettes, are given cigarettes by adults and often work in stores, markets and cafes which either sell cigarettes or serve “Shisha”. Their childhood involves cigarettes and smoking on a daily basis. By the time they reach adulthood, smoking has become a part of the norm.

The priority of smoking in the household is further evidence that smoking in Egypt is an acquired social practice. On average, 6% of the total Egyptian household expenditure is spent on tobacco (3, 7). This rate reflects a slight increase in total tobacco expenditure despite inflation in prices. Tobacco is considered an inelastic commodity in Egypt. Hence, even with the increase in tobacco taxation, the sales of cigarettes did not significantly decrease. Heads of family were simply increasing the percentage of income spent on cigarettes, where they have spent more on cigarettes than on activities and sports for their children combined. Smoking takes precedence over the activities and development of children which reflects the primacy of smoking in Egyptian households and hence Egyptian culture (3).

Smoking builds on traditional Egyptian customs and hence should be approached using social behavioral change theories. Cigarette smoking is similar to the “Shisha” or tobacco water pipe, which is consumed on a daily basis in social settings such as traditional Egyptian cafés, bars and restaurants. Smoking shisha has been a tradition for centuries. 92% of Egyptians who smoke cigarettes also smoke Shisha (3). This strong correlation suggests their influence on each other. Cigarette smoking mirrors the cultural practices, has become a tradition like the Shisha, and has been practiced everywhere. Interventions and campaigns will not be influential enough to stop this habit if they do not approach smoking as a tradition (3).

The SCD campaign ignores the social pressures to start smoking by not promoting smoking prevention methods. With such a large portion of smokers starting at a young age, smoking is socially embedded. The Branding Theory and The Framing Theory support a reframing of how people think of the behavior, reinforcing the core values of society. By ignoring the social factors of smoking in Egypt, the SCD is overseeing possible important points of intervention that are more influential. The objective of the SCD should be to reduce the prevalence of smoking and to reduce its incidence of smoking in Egypt as well (1, 5).

Conclusion:

The SCD campaign builds on the assumption that human behavior is rational, intentional and controllable. However, smoking counters these three fundamental behavior assumptions. Tobacco education is an important step towards reducing tobacco usage, but it is not enough. The SCD did not create a campaign built to target the Egyptian smoker specifically. The SCD is trying to promote quitting; yet it ignores the need to create preventative campaigns, the addictive nature of smoking and the social pressures pertaining to smoking in Egypt. It is far easier to prevent one from smoking, than to try to have them overcome an addictive behavior. Maintaining the SCD campaign will lead to minute results. To build a campaign based on educating individuals on the harms of a culturally integrated practice in Egypt is ignoring the fundamental problems and reasoning behind the harmful behavior.

References

¹Ball-Rokeach, Sandra. Defleur, Melvin. Theories of Mass Communication. White Plains, NY. Longman Inc. 1989

²Edberg, Mark. Essentials of Health Behavior: Social and Behavorial Theory in Public Health. Jones and Bartlett. 2007

³Nasser, Heba. The Economics of Tobacco in Egypt, A New Analysis of Demand. The International Bank for Reconstruction and Development/The World Bank. 2003.

⁴Rosenstock IM. Historical origins of the Health Belief Model. Health Educ Monogr. 1974;2:328-335.

⁵Salazar, Mary Kathryn. Comparison of Four Behavioral Theories. AAOHN Jounral. 1991;39 128-135

⁶Saker, Hala. Anti-Smoking Scores. Al-Ahram Weekly. 2002.

⁷World Health Organization. The tobacco industry’s tactics and plans to undermine control efforts in Egypt and North Africa. Second Edition. Regional Office for the Eastern Mediterranean. 2008.

Role Models as a Means to Alter Smoking Behavior Patterns - Gilan AbdelMegeed

Introduction

Tahader is a novel anti-smoking campaign aimed at addressing the ubiquity of smoking in Egypt. Tahader roughly translates from Arabic to mean development. In fact, Tahader means more than the development of infrastructure, health, and housing; it extends to the social and economical growth required for progress to occur. It is the concept that building personal traits, such as education, is needed for development. Tahader is a national goal. This campaign title links the concept of national and personal development to a smoke-free environment. It reframes the effects of smoking from an individual-level health problem to an issue of national development. The campaign utilizes Egyptian role models as a key means of improvement and change. The campaign creates role models, based on exalted personalities in Egypt. These role models are the major players in changing the social attitude towards smoking. The campaign is launched using the radio, television and billboards and well as other non-media methods. The role models are displayed through the media to increase the self-efficacy of smokers to quit, to reduce the accessibility of cigarettes and to bring about social change.

Section 1: Smoker’s Self-efficacy to Quit.

Tahader addresses self-efficacy of smokers by establishing support groups and by promoting the use of smoker alternatives such as nicotine gum and nicotine patches. The structure of the support groups are group meetings similar to the concept of Alcoholics Anonymous. These groups are complete with trained rehab doctors, rehab and medical facilities, and anonymity of members. Individuals can recruit themselves, or friends and family can call to recommend someone to join. Friends smoke together, but rarely quite together or support quitting. The support groups will provide an additional source of encouragement and support.

The alternatives to smoking, such as the nicotine patch and gum, will be advertised to the public through the media advertisements using the role models. This will allow for both a promotion of alternatives and a visual confirmation of their success and feasibility. Successfully promoting these alternatives is important as the public is not generally aware of them. Promoting alternatives will increase their self-efficacy as a majority of Egyptians perceive smoking to be an insurmountable biological addiction. The media advertisements will display the role models actively and effectively using these alternatives. Providing both social support groups and medical assistance will provide Egyptians smokers with the self-efficacy needed to stop smoking.

Section 2: Decreasing the Accessibility of Cigarettes

The second part of the campaign is to decrease the accessibility of cigarettes to children, youth, and adults alike. Enacting and enforcing laws prohibiting minors’ possession of tobacco have been ineffective (4, 5). Tahader is proposed to the Egyptian government for implementation. This campaign therefore proposes enacting laws to increase the taxes on tobacco products. Tahader decreases the accessibility of cigarettes by increasing the taxes on tobacco products. From the tobacco tax increases in 1995 and 2000, data show a decrease in cigarette consumption (4). The data also show a correlation between price and consumption. By increasing the price, the consumption of tobacco products decreased. Following this pattern, enacting an additional tobacco tax will result in a decrease in accessibility of cigarettes and a decrease in tobacco consumption.

Tahader tackles why youth start smoking, and provides the much needed role models that set the example for a smoking-free life. Youth start smoking due to boredom, expectancies, and social pressure (3). There are documentaries and films produced in Egypt which portray the common life of the Egyptian adolescent. These documentaries reflect on Egyptian adolescent’s relationship with smoking, it being a habitual behavior to fill the void of daily activities (1, 3, 5).

This campaign furthermore decreases accessibility by encouraging a more responsible adult-child relationship. Many Egyptian smokers begin at a young age (4, 5). Children obtain a large proportion of their cigarettes from adults, parents, and superiors at work and school (3, 4). The media advertisements include the role models displaying a more responsible approach to the adult-child relationship with respect to cigarettes. This includes refusing children tobacco, removing tobacco from easily accessible areas, and encouraging a smoke-free child environment. It redefines responsible adult behavior, encouraging adults to deal with tobacco in a manner that protects the youth from it. Increasing the tobacco taxes and promoting a responsible adult-child relationship concerning tobacco products will lead to an overall decrease in Egyptian smoker’s accessibility of tobacco.

Section 3: Stimulating a Social Change

Egyptian adolescents have a lack of local role models and this hinders changing smoking behavior patterns (1). Tahader creates role models who are reflective of the Egyptian culture and are representatives of Egyptians. The purpose of the role models is to help every youth in Egypt believe that they can become a role model as well. The role models are from four age groups: children, teenage adolescents, young adults and adults. These four categories are designated in order for the campaign to address each Egyptian with a representative of their age group. It will be more effective to have an adolescent address an adolescent as opposed to having an adult address an adolescent (2,3). Among each age group four different characters are demonstrated: the Rebel, the Family man, the Patriot, and the Successful Entrepreneur. These four characters were chosen because they represent four highly exalted personalities in Egypt (1, 3, 5). These four characters were also chosen because they play a role in Egyptian’s perception of Tahader. Development in Egypt goes hand in hand with education, success, patriotism, and family/friend commitment (1, 3).

In the media advertisements, the role models will each depict one of the four characters. In the advertisement, the role models will also demonstrate an active refusal to smoke by discarding of a cigarette or a cigarette pack. The role models will depict the characters by cliché actions. For example, the Successful Entrepreneur will be depicted by attaining a promotion at work or achieving high grades in school. The role models will be transparent and will have achievements within reach to the average Egyptian. These attainable goals send the positive message that Egyptians can become their role models. The visual affirmation of role models and of role model behavior will induce a social change in the attitude of smoking, not because of health risks, but because of a responsibility towards acting like the role models.

Conclusion

Tahader reframes smoking because it does not exclusively address the health affects. The campaign addresses how smoking affects an individual and national goal in Egypt. Tahader personalizes the problems arising from smoking. An increasing number of Egyptian youth and adults are suffering from a lack of role models (1). The role models provide a compass for behavior change, and are messengers and representations of commended personalities in Egypt. They add to the self-efficacy of smoking behavior change, and promote a responsible adult-child relationship regarding tobacco products. This campaign triggers a change in the attitude towards smoking. Tahader provides a different perspective on the types of damage smoking causes. Targeting matters of the heart induce the most response. The success of Tahader lies in encouraging Egyptians to become their own role model, and in doing so, alters their smoking behavior patterns.

¹Raweh Rageh, Egypt’s Youth Lack Local Role Models. Al Jazeera Network. 2009

²Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones and Bartlett. 2007

³Moustafa, Mohammed. Awqat Faragh, The Movie. Kalla, Hussein. 2006

⁴Nasser, Heba. The Economics of Tobacco in Egypt, A New Analysis of Demand. The International Bank for Reconstruction and Development/The World Bank. 2003.

⁵Saker, Hala. Anti-Smoking Scores. Al-Ahram Weekly. 2002.

⁶World Health Organization. The tobacco industry’s tactics and plans to undermine control efforts in Egypt and North Africa. Second Edition. Regional Office for the Eastern Mediterranean. 2008.