Agenda-Setting in Childhood Obesity Battle Falls Short: A Critique of BMI Report Cards in Schools – Elizabeth Roller

Childhood overweight and obesity is a growing public health problem. Recent analysis of the National Health and Nutrition Examination Survey (NHANES) estimated 17.1% of US children (aged 2-19 years) were overweight in 2003-2004 (1). This figure represents a significant trend of increasing prevalence in overweight children from previous surveys since NHANES began in 1971 (1-2). The increase in prevalence from NHANES 1971-74 to NHANES 2003-04 is dramatic across all age groups: 5.0% to 13.9% for children aged 2-5 years, 4.0% to 18.8% for children aged 6-11 years and 6.1% to 17.4% for children aged 12-19 years (1-2). Childhood overweight and obesity is a major public health problem with overweight children and adolescents facing both direct health problems and increased risk of health problems later in life (3). Overweight children and adolescents have increased risk factors for cardiovascular disease such as high blood pressure and elevated cholesterol, triglyceride and fasting insulin levels (4). Childhood overweight is also associated with Type 2 diabetes, sleep apnea (3, 5), liver degeneration (3) and asthma (6). Being overweight as a child or adolescent also greatly increases the risk of becoming obese in adulthood (7-8).

Given the severity of childhood overweight and obesity consequences, public health interventions are necessary to address this growing problem. One recent intervention informs parents of potential weight problems by sending Body Mass Index (BMI) report cards home from school. Arkansas was the first state to require school BMI report cards in 2003. California, Illinois, New York, Pennsylvania, Tennessee and West Virginia now also require school BMI report cards (9). The effect of this intervention is similar to agenda-setting in mass media where the extent to which the media covers a certain topic influences how important the public views the topic, with more media coverage inspiring greater public importance (10). Recipients of BMI report cards are likely to regard BMI and childhood obesity as an important topic, but may differ in their opinion and response to it. In this manner, BMI report cards may be a successful agenda-setting tactic in the childhood obesity battle, but without considering tools that promote self-efficacy, the potential for negative labeling, the relevance of BMI to healthy behaviors or the key role self-esteem plays in children’s hierarchy of needs, this intervention falls short and could do more harm than good.

BMI Report Cards Lack Tools to Promote Self-Efficacy

Though just one factor in the complex system that influences behavior, self-efficacy provides a useful framework in which to evaluate some of the shortcomings of the BMI report card. Albert Bandura’s social cognitive theory and concept of self-efficacy posits that a person’s decision to engage in a particular behavior and his or her persistence in obtaining a goal is influenced by the person’s perception that he or she can successfully complete the behavior and achieve the desired outcome – that is, his or her level of self-efficacy (11-12). People with high levels of self-efficacy are more likely to try new behaviors and persist in their completion (12). Self-efficacy is further influenced by the person’s mastery experience (success in performance), vicarious experience (modeling from others), social persuasions (encouragement or discouragement from others) and physiological factors (response to stress) (11-12).

The BMI report card simply provides parents with a number categorizing their child as underweight, normal weight, at risk for overweight or overweight. This information by itself does not provide parents with any tools to address the problem and promote self-efficacy. Some BMI report cards include suggestions of daily lifestyle changes such as watching less than 2 hours watching television, getting 1 hour physical activity and eating 5 servings of fruits and vegetables (13). Communicating this knowledge is important, but with an emotionally charged issue such as weight this may not be an effective method to connect with parents. Many parents receiving BMI report cards for the first time were angry and responded by throwing them away (14-15). A more personal approach, such as a counseling session, would be a more effective way to get the message across. Recipients of BMI report cards lacking such examples of healthful behaviors are without any tools or suggestions to address the problem.

Additionally, providing examples of healthful behaviors is not enough to promote self-efficacy. Parents and children need to feel as though they can be successful engaging in these behaviors. This intervention will not succeed unless the environment at school supports the desired behaviors. Providing healthful foods and encouraging physical activity at school would promote self-efficacy by providing the opportunity for modeling from other students and encouragement from teachers and students. Environments where unhealthy food and low physical activity is the norm do not promote self-efficacy. Unfortunately, this is the typical situation in many schools. Despite adhering to the state-mandated BMI report cards, one rural school district in New York does not provide all children year-round physical education and serves pizza and funnel cake for breakfast (15). Without properly providing parents and children tools to promote self-efficacy, those receiving a BMI report card may feel helpless and unable to do anything to improve the situation.

BMI Report Cards Risk Negative Labeling

BMI report cards seek to identify at risk or overweight children to intervene and improve their health. Unfortunately, by using the “report card” format and focusing on the individual, this intervention increases the risk of labeling a child as ‘fat.’ The negative impact of labeling in this situation is two-pronged: it renders the intervention ineffective in the overweight population and it encourages unintended negative health consequences in the healthy weight population. According to labeling theory, an individual’s behavior is influenced by how they are judged by society and the ‘label’ they are given. Labeling can encourage negative behavior as individuals conform to their label in a self-fulfilling prophecy (16). In this manner, BMI report cards could perpetuate obesity as children who feel they are labeled as fat may begin to see that as their social role and resign to being ‘fat’ in a self-fulfilling prophecy. Some children may overeat and shy away from physical activity because they feel that is what is expected of them as ‘fat’ children.

Labeling can also act in the opposite direction by making non-overweight children feel as though they are being judged by their weight and fear being labeled as fat. In response to this fear, healthy-weight children may engage in unhealthy dieting to avoid a ‘fat’ label which they recognize as socially undesirable. Children adopt society’s social bias against fat people at young ages. Children as young as 5 rate thin figures more favorably than heavy ones and are more likely to choose thin figures as their friends (17). Overweight children are less likely to receive friendship nominations from their peers (18) and are often teased about their appearance (19-20). Given teasing and negative attitudes towards fat children, it is possible that some normal weight children and adolescents may respond to BMI report cards with unhealthy weight control practices to avoid this undesired label.

It is not difficult to see a potential link between BMI report cards and unhealthy weight control practices. Unhealthy weight-related behaviors such as dieting, fasting, binging and purging are alarmingly prevalent in US adolescents (21-22). In a recent study among adolescents, 57% girls and 33% boys reported unhealthy weight control behaviors while 12% girls and 5% boys reported extreme weight control behaviors (21). Moreover, current research suggests that it is adolescents’ perception of their weight, not their actual weight that puts them risk for body image and weight-related disordered behaviors. Adolescents teased about their weight were more likely to have unhealthy weight control behaviors (binging, frequent dieting) five years later, after controlling for their actual BMI (19). Additionally, adolescents teased about their weight have a greater risk of low body satisfaction, low self-esteem, high depressive symptoms and suicide ideation or attempt after controlling for their actual BMI (23). BMI report cards have the potential to make some children feel as though they are being graded on their appearance and consequently alter their perception of their body. It is this altered perception that puts them at risk for the behaviors described above. Additionally, BMI report cards are likely to make weight a popular topic among schoolchildren. This could increase weight-based teasing, which puts both overweight and normal weight children at greater risk for negative health behaviors and outcomes (19, 23).

BMI Report Cards do not Emphasize Healthy Behaviors

By focusing on a number, BMI report cards do not address the unhealthy behaviors that lead to obesity such as an unhealthful diet and lack of exercise. Though lack of physical activity and poor diet are considered important contributors to obesity (24-25) these behaviors extend beyond children and adolescents with BMIs considered overweight. In the 2005 Youth Behavior Risk Survey (YBRS) only 20.1% of high school students reported eating 5 or more servings of fruits and vegetables daily in the week preceding the survey and only 33% reported attending daily physical education classes (26). Both low consumption of fruits and vegetables and physical inactivity are linked to increased risk of cardiovascular disease and some cancers (27-29). Many children may have normal BMIs, but have unhealthy diet and exercise behaviors that could lead to health problems later in life. With a report card format, parents and children who receive a ‘normal’ score may interpret that as validation of their current lifestyle and consequently not be encouraged to consider healthful lifestyle changes. By focusing on BMI, this intervention neglects a large population of at risk children.

BMI Report Cards Fail to Recognize Importance of Self-Esteem

BMI report cards fail to recognize the key role self-esteem plays in school children’s hierarchy of needs. Abraham Maslow’s Hierarchy of Needs puts forth different stages of human needs and how they affect motivation and behavior. As described by Maslow, deficiency needs including physiological, safety, social, and esteem must be satisfied before a person is able to tackle higher-level growth needs of self-actualization (30). According to this theory, children and adolescents will not be able to adequately address healthful diet and exercise behaviors if their basic need for self-esteem is unmet. Being overweight is associated with low self-esteem (31-32) particularly among adolescents teased about their weight (23). Without addressing the problem of low self-esteem in this population, interventions to combat childhood obesity will not be successful. Rather than considering ways to improve self-esteem, BMI report cards are more likely to decrease self-esteem by making children feel as though they are being judged on their weight. BMI report cards could also promote weight-based teasing in school, further decreasing self-esteem in the target population. Lacking self-esteem, overweight children and adolescents are ill equipped to tackle healthful behavioral changes.

Conclusion

BMI report cards may be a successful agenda-setting tactic in the fight against childhood obesity, but this intervention is unlikely to be effective and could have unintended negative consequences. This intervention lacks tools to promote self-efficacy, leaving parents and children feeling helpless and unable to adopt a healthful lifestyle. The ‘report card’ format presents the risk of negatively labeling children as ‘fat,’ perpetuating unhealthful behavior as children begin to see this as their social role and resign to this label in a self-fulfilling prophecy. BMI report cards could also promote unhealthful weight control behavior in healthy children who fear the ‘fat’ label. Additionally, by focusing on BMI rather than promoting healthful diet and exercise behavior, this intervention neglects a large population of children who have normal BMIs but unhealthful diet and exercise behaviors. Finally, this intervention neglects the important role self-esteem plays in school children’s abilities to modify behavior.

A more appropriate intervention would focus on positively promoting healthy eating and exercise habits for all children. Focusing on behavior rather than BMI targets the health of all children while removing the report card judgment with risk of negative labeling and decreased self-esteem. Promoting healthful behaviors will also improve self-efficacy by demonstrating what children and parents can do to have healthy bodies. The intervention would also be more successful if it focused on the school system, rather than individual parents and children. Healthy behaviors need to be supported in a school environment when children are surrounded by their peers. Making physical activity and healthful food choices the norm in a typical school day is an important step towards overcoming childhood obesity.

REFERENCES

1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006; 295:1549-1555.
2. Ogden CL, Flegal KM Carroll MD, Johnson CL. Prevalence and trends of overweight among US children and adolescents, 1999-2000. JAMA 2002; 288:1728-32.
3. Department of Health and Human Services: Centers for Disease Control and Prevention. Overweight and Obesity: Childhood Overweight. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/index.htm
4. Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics 1999;103:1175-1182.
5. Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, Robinson TN, Scott BJ, Jeor SS, Williams CL. Overweight in Children and Adolescents: Pathophysiology, Consequences, Prevention and Treatment. Circulation 2005;111:1999-2012.
6. Rodriguez MA, Winkleby MA, Ahn D, Sundquist J, Kraemer HC. Identification of population subgroups of children and adolescents with high asthma prevalence: findings from the Third National Health and Nutrition Examination Survey. Arch Pediatr Adolesc Med 2002;156:269-275.
7. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;37:869-873.
8. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med 1993;22:167-177.
9. Wadas-Willingham V. Six States Get ‘A’ For Work Against Kids’ Obesity. CNN.com. Jan 31, 2007 (CNN). (Accessed March 25, 2007 at http://www.cnn.com/2007/HEALTH/diet.fitness/01/30/obesity.report/index.html?eref=rss_health.)
10. McCombs M, Shaw DL. The agenda-setting function of the mass media. Public Opinion Quarterly 1972;36:176-185.
11. Salazar MK. Comparison of four behavioral models. AAOHN 1991;39:128-135.
12. Wikipedia. Self-efficacy. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Self_efficacy.
13. Ikeda JP, Crawford PB, Woodward-Lopes G. BMI screening in schools: helpful or harmful. Health Education Research 2006;21:761-769.
14. Schools monitor children’s weight. KSN.com. January 31, 2007 (KSN). (Accessed February 11, 2007 at http://www.ksn.com/news/health/5428041.html.)
15. Kantor J. To report-card woes, add body-mass blues. The International Herald Tribune. January 9, 2007 (The New York Times Media Group).
16. Wikipedia. Labeling Theory. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Labeling_theory.
17. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body size stigmatization in preschool children: the role of control attributions. Journal of Pediatric Psychology 2004;29:613-20.
18. Strauss RS, Pollack HA. Social Marginalization of Overweight Children. Arch Pediatr Adolesc Med 2003;157:746-652.
19. Haines J, Neumark-Sztainer D, Eisenberg ME, Hannan PJ. Weight Teasing and Disordered Eating Behaviors in Adolescents: Longitudinal Findings From Project EAT (Eating Among Teans). Pediatrics 2006;117:209-215.
20. Neumark-Sztainer D, Falkner N, Story M, Perry C, Hannan PJ, Mulert S. Weight-teasing among adolescents: correlations with weight status and disordered eating behaviors. International Journal of Obesity 2002;26:123-131.
21. Neumark-Sztainer D, Story, M, Hannan PJ, Perry CL, Irving LM. Weight-Related Concerns and Behaviors Among Overweight and Nonoverweight Adolescents. Arch Pediatr Adolesc Med 2002;156:171-178.
22. Hoffman-Forman V. High prevalence of abnormal eating and weight control practices among US high-school students. Eating Behaviors 2004;5:325-336.
23. Eisenberg ME, Neumark-Sztainer D, Story M. Associations of Weight-Based Teasing and Emotional Well-being Among Adolescents. Arch Pediatr Adolesc Med. 2003;157:733-738.
24. Dehghan M, Akhta-Danesh N, Merchant AT. Childhood obesity, prevalence and prevention. Nutrition Journal 2005;4:24.
25. Stubbs CO, Lee AJ. The obesity epidemic: both energy intake and physical activity contribute. Med J Aust2004;181:498-91.
26. Centers for Disease Control and Prevention. Youth Risk Behaviors Surveillance – United States, 2005. Surveillance Summaries, June 9, 2006. MMWR 2006;55(No SS-5).
27. Franco OH, de Laet C, Peeters A, Jonker J, Mackenbach J, Nusselder W. Effects of Physical Activity on Life Expectancy With Cardiovascular Disease. Arch Intern Med 2005;165:2355-2360.
28. National Cancer Institute. Physical Activity and Cancer: Fact Sheet. Bethesda, MD: National Cancer Institute, US National Institutes of Health. (Accessed March 31, 2007 at http://www.cancer.gov/cancertopics/factsheet/physical-activity-qa.)
29. National Cancer Institute. Cancer Trend Progress Report: Fruits and Vegetable Consumption 2005 Update. Bethesda, MD: National Cancer Institute, US National Institutes of Health. (Accessed March 31, 2007 at http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2005&chid=21&coid=207&mid=.)
30. Wikipedia. Maslow’s Hierarchy of Needs. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Maslow%27s_hierarchy_of_needs.
31. Hesketh K, Wake M, Waters E. Body mass index and parent-reported self-esteem in elementary school children: evidence for a causal relationship. International Journal of Obesity. 2004;28:1233-1237.
32. Strauss RS. Childhood Obesity and Self-Esteem. Pediatrics 2000;105:e15.

MetroWest Kids Campaign Misses the Mark: Anti-Obesity Campaign Based on Health Belief Model Fails to Inspire Healthy Behavior – Heidi Elsinger

The MetroWest Community Health Care Foundation (MCHCF) recently launched a new public health campaign aimed at getting parents involved in the fight against rising rates of childhood overweight and obesity. The campaign, The MetroWest (Mass.) Kids Campaign, was born out of collaboration between public health officials and local parents. While the goal of the campaign may very well be on target (1), the campaign itself was poorly designed and thus has little chance to bring about the desired change, a reduction in the number of overweight and obese children in the MetroWest area.

There are three main problems with the campaign’s design. First, the billboards themselves were poorly designed and actually hide the message the campaign is trying to spread. Therefore, the controversial billboards draw attention to the way certain people look, but do little to spread health information. Secondly, since the campaign was designed using the Health Belief Model (2), even when the billboards can be read, the messages on them do not contain the information people need to effectively address the issue. Finally, since the campaign uses billboards to point people to a web site, it does not provide the modeling or social support that people rely on when trying to make changes in their lives.

If the MCHCF is truly dedicated to trying to lowering rates of childhood overweight and obesity, it can look to an unusual source, public health’s long-time scapegoats, fast food restaurants and video game makers, for ideas on how to get people eating better and moving more. While an unlikely ally, these two industries, led by Subway and Nintendo, can teach public health officials how to effectively use social learning and advertising theories to make healthy behaviors appealing.

MetroWest Kids Billboard Design Flaws

Due to design flaws, the campaign’s billboards focus people’s attention on looks rather than health. The billboards are too text heavy, and poor color choices further obscure the message the MCHCF is trying to spread.

The first set of billboards featured an image of an overweight child’s legs and feet on a scale. The background is black and in big, bold red letters the words “FAT CHANCE” grab the attention of people who pass by. In smaller, white lettering the following text appears, “Obese children are a good bet for type 2 diabetes. Heart disease. Stroke. Cancer. Sleep apnea. Depression.” The text then becomes even smaller, and in red font reads, “Obesity is robbing our kids of their future. Anything you can do about it? First step, go to (slightly bigger text) www.metrowestkids.org”

The most visible billboard in the campaign was placed at the intersection of Routes 9 and 30 in Framingham, facing Route 9 eastbound traffic. The billboard was not placed at a traffic light or major intersection, but directly before an underpass on a stretch of road on which cars travel at approximately 50 miles per hour. Since traffic is not usually stopped in this area (even during rush hour), most of the people who see this billboard only see the image and the words “Fat Chance.” Traveling by the billboard, the white text becomes a blur of white and the smaller red text virtually disappears into the background of the billboard. Even if the text was written in a more visible size and color, there is no time for a passenger in a car moving by the billboard to read all of it.

Thus, for a majority of the people who come into contact with this billboard, it simply sends the message that being fat is bad. With none of the health information processed, the billboard becomes a message condoning looks-based biases in people. It is unlikely this will help with any of the conditions listed in the text of the billboard. Further, it could actually worsen depression in people who view themselves as having a “Fat Chance.”

The planned launch of another billboard was called off amid concerns that it was offensive and “showed too much skin.” This billboard would have shown an obese teen’s back with the text, “If that’s your child, what are you waiting for.” According the Kate Billingmeier, Inside Out Communication’s account executive for the campaign, the new billboard may change to be more of a text ad (3). If that is the case, it would likely carry with it the same design flaws seen in the first roll-out of billboards.

Failure of the Health Belief Model to Inspire Healthy Behaviors

Even for those who read one of the billboards in its entirety, the message on the billboards does not provide the information needed to address the problem of childhood overweight and obesity. As the billboards were designed around the Health Belief Model, the message was designed to make raise the perceived severity level of childhood overweight and obesity rather than to make healthy behaviors appealing.

The Health Belief Model states that people make decisions regarding health behaviors based on a rational weighing of their perceived susceptibility to a disease and its perceived severity versus the perceived barriers or costs of taking action against the disease and likelihood that the action will effectively reduce the likelihood and/or severity of the disease in question. The model also allows for the use of cues to action to spur action through increasing the perceived threat of an adverse health outcome (2). It is a negatively based model that does not account for things such as the desirability of an alternative action or creating self-efficacy beliefs in the people who view these ads.

Creating self-efficacy, the belief that a person can actually perform the desired behavior, is a key component in changing behaviors according to social cognitive theory. This theory states that self-efficacy is a vital part of people’s motivation because without the belief that they can perform actions that will lead to the desired result, there is little incentive for them to take actions toward the goal (4).

Ignoring the concept of self-efficacy, this billboard campaign is one of the Health Belief Model’s cues to action. It is designed to spur a reduction in childhood overweight and obesity by creating fear of its adverse effects. However, these fear campaigns do not work. A recent meta-analysis of fear campaigns concluded that these campaigns actually backfire when people believe that they have the characteristics that put them at risk. The study also showed that strong fear campaigns only work when accompanied by equally strong message of self-efficacy (5).

Since this ad campaign ignores, and could actually decrease self-efficacy in overweight and obese people, it is unlikely to work. As stated above, the billboards’ most visible message is “Fat Chance.” Since this phrase is commonly accepted in American culture to mean that something will not happen, those viewing these billboards could internalize the message that there is a “fat chance” that they could change their situation and health outcomes.

MetroWestKids.org Unable to Fill Gaps Left by the Billboards

Another vital flaw in the campaign’s design is its reliance on a web site to affect behavioral changes in a population. This strategy depends on a person’s ability and desire to find the campaign’s web site and read the information, while taking human interaction out of the equation.

This design flaw is compounded by a failure to work out a deal with major internet search engines to display the website associated with the campaign. If someone sees the billboard ad, but doesn’t remember the complete web site, a Goggle search of “MetroWest Kids,” and even “Metrowestkids.org,” returns the MetroWestKids.com web site as its top choice. This web site refers parents to summer camp and day care options and has a section on arts and craft activities. It is not linked to the campaign’s web site. Furthermore, specifically searching “MetroWestkids.org” only returns the correct web site within the text of a newspaper article from the MetroWest Daily News. The actual web site of the campaign does not appear as a stand alone option to click in any of the lists returned using “Metrowest” and “kids” as the search criteria. Therefore, the information on the campaign’s web site is as hidden as the information on its billboards.

Again, even if a person successfully navigates to the web page and is able to read its full contents, there is little there that is useful in making health behavior changes. According to the design of the campaign, the consumer has now been informed about the dangers of childhood overweight and obesity by viewing the billboards and is on the “first step” of addressing the problem, visiting the web site listed on the billboards.

The site is broken down into three main areas: one for children, one for parents and one for schools. Each area has a monthly challenge targeted at the designated group as well as some other information. However, the little information that is on the site is too general to be useful and does not address any of the reasons why people are not already performing healthy behaviors or show people that their friends and neighbors are.

For example, the monthly challenge for parents in March was, “March is National Nutrition Month  and we want you to help your family see the rainbow on their plate. Try serving fruits, vegetables, and grains that show a spectrum of colors. Looking for ideas? Find them on our Healthy Eating page.” Unfortunately, following the link to the healthy eating page provides visitors with only two recipes, titled, “Frozen Fruit Pops,” and “5 a Day Salad.” While these recipes may be good and nutritious, they are simply not enough to overhaul the eating patterns ingrained in American society.

Challenges for children and school were equally unhelpful. Children were told in February to do 25 jumping jacks a day, and in March to plan a menu for a day. Schools were challenged to display information on food both months. In February, the challenge was to create a healthy eating bulletin board in one hallway, and in March they were challenged to display books with healthy recipes in classrooms (6).

Using Social Learning and Advertising Theories to Promote Healthy Behaviors

Understanding that people’s decisions are not always totally rational, but are influenced by familial and societal norms and values would help public health officials design anti-obesity campaigns that will have a positive impact on their communities. Likewise, lessons learned from advertising can be incorporated to help make healthy behaviors appealing to children of all ages.

Social learning theory states that people develop and maintain their behaviors through observing and modeling the behaviors, attitudes and emotional responses of people around them. According to this theory, people are most likely to perform behaviors that result in desired outcomes and that are modeled by people that are perceived as being similar to the observer and are admired (7). Advertising theory enters public health through social marketing. Social marketing promotes health behaviors by offering benefits the audience wants, reducing the barriers they are concerned about and persuading participation. As such, social marketing gets people to fulfill their own self interests (as defined by the marketers) by promoting the benefits they receive (8).

Several studies and reports have shown that social learning theory and social marketing can be effectively used to promote healthy behaviors. Peer modeling in the home, school and community is cited in several studies as key component to developing healthy behaviors in children (9-14). Government agencies have also begun to recognize and promote the importance of social marketing (13, 14).

Public health officials can learn how to use these theories from two companies that stand out in the ways in which they have promoted healthy behaviors, Subway and Nintendo. Both companies have used basic modeling and marketing techniques to promote their products. These techniques can be used to move people toward healthier lifestyles. Subway’s “Eat Fresh” campaign and tag line promotes healthier fast food. Meanwhile, Nintendo’s new Wii gaming system includes new technology that essentially allows consumers to play sports against an opponent or the system in the comfort of their own homes.

Subway’s “Eat Fresh” campaign stands out in two ways. First, it uses an actual person, Jared, who lost weight eating the company’s products and is portrayed as now being both healthier and happier. Secondly, the “Eat Fresh” tag line is appealing; it certainly sounds better to consumers than a call to eat a “mini whole wheat bagel,” one of the snack options offered up by the MetroWestKids.org web site (6).

People who come into contact with Subway’s campaign can be expected to take two main messages away. The first is one of self-efficacy, “if Jared can do it, so can I.” Unlike the MetroWest Kids Campaign, which sends the “Fat Chance” message, this ad campaign sends the message that everyone can eat healthy food. Whether the people viewing these ads need to lose a lot, a little or no weight, they see someone they can identify with making healthier food choices that led to visible results, and didn’t take any longer or cost more money than other options.

Secondly, healthy food is desirable. While “Eat Fresh” is a quick and simple tagline, it is also one that’s hard to argue with. A person could argue that eating a hamburger and fries tastes better and is more satisfying than eating a salad with dressing on the side. However, you’d be hard pressed to find a person who would argue that s/he wanted to eat old, wilted food that had been sitting under a heat lamp for a half hour or longer because that was better than a fresh sandwich made right in front of you when you ordered it.

Certain aspects of Nintendo’s recent successful launch of its new Wii gaming system can also be used in public heath to further promote health behaviors. The new Wii gaming system has people playing sports on their terms. The campaign got people were they already were, in front of their television sets, doing something they were already doing, playing video games. The difference is that now they are using a system that is a newer, better, more advanced version of what they used to use. These factors worked together to make the system, and its ability to simulate playing baseball, bowling and other activities, desirable.

These factors point to ways public health officials can make healthy behaviors desirable. Joining the lessons learned from Subway’s “Eat Fresh” campaign and Nintendo’s launch of its new Wii gaming system can help public health officials shape future anti-obesity campaigns that will have the desired effect of making the people in their communities healthier.

Officials can identify key people in the community to model healthy behaviors for the community at large. Every community has its Jareds, people who are admired and can positively impact the activities and health behaviors of their communities. By making sure the community sees its social leaders engaging in healthy eating and physical activities, officials can make these health behaviors desirable, and increase self-efficacy about healthy behaviors in their community.

Public health officials can also get people where they are, using television as an ally in the fight against childhood overweight and obesity. Instead of focusing on public service announcements, campaigns could focus more on product placement. Inserting healthy behaviors into television shows and movies could have a large impact on the way children make their decisions. For instance, officials can work with producers to replace product placements involving soda and candy with milk, water and fruits. Physical activity can also be easily worked into many television shows and movies by beginning or ending a scene with the characters walking, inline skating, or biking to meet each other or get between places.

Furthermore, officials can use the fact that children are using Wii systems to simulate activities like bowling and playing baseball to get the children to actually participate in these activities. By identifying some of the things that make the simulated activities fun, officials can use those attributes to market the actual activities.

For instance, bowling allows participants to compete against themselves and to chart their progress as their averages go up and their handicaps go down. It also has the added bonus of not requiring a high level of fitness to begin participating and being an activity that can engage people of all ages. Families can take part together, thereby incorporating physical activity into the family’s norms.

A billboard designed using these insights would look vastly different than the one the MCHCF created. It may contain a picture of a group of friends (preferably people actually from the community) bowling, maybe showing someone celebrating with teammates after rolling a strike. Healthy snacks could be on the table by the lane in use. A simple tag line that could be applied to this and other marketing pieces, such as “Live Healthy. Live Strong. Live FUN!” could be added with information from a local bowling alley.

By taking advantage of social learning and marketing theories, public health officials can design interventions that make healthy behaviors desirable by conveying the benefits of the behaviors in ways that will motivate the people in their communities to want to adopt the behaviors. These actions will also work to help people believe that they can perform the behavior and make healthy living an ingrained part of the community culture.

References

1. von Hippel, P. T. Changes in Children’s Body Mass Index During the School Year and During Summer Vacation. American Journal of Public Health 2007. 4: 696-702.
2. Salazar,M.K. Comparison of Four Behavioral Theories: A Literature Review. American Association of Occupational Health Nurses Journal 1991; 39(3): 128-135.
3. Manuse, Andrew J. Obesity billboard idea yanked. The MetroWest Daily News. Jan. 31, 2007
4. Pajares, F. Overview of Social Cognitive Theory and of Self-Efficacy. Atlanta, GA. Emory University. http://www.des.emory.edu/mfp/eff.htmlhttp://www.des.emory.edu/mfp/eff.html
5. Witte, K. and Allen, M. A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns. Health Education and Behavior 2000; 27(5): 591-615.
6. MetroWest Community Health Care Foundation. Framingham, MA: MetroWest Community Health Care Foundation. http://www.metrowestkids.org.
7. Kearsley, G. Social Learning Theory (A. Bandura). Jacksonville, FL. Theory into Practice Database. http://tip.psychology.org/index.html.
8. Maibach, E.W., Rothschild, M.L., and Novelli, W. Social Marketing (pp. 437-461). In Glanz, K., Rimer, B.K. and Lewis, F.M. Health Behavior & Health Education: Theory Research & Practice 3rd Edition. San Francisco, CA: Jessey-Bass, 2002.
9. Buttriss, J. et al. Successful ways to modify food choices: lessons from the literature. London, Eng: British Nutrition Foundation Newsletter Bulletin 2004; 29: 333-343.
10. Lindsay, A.C., Sussner, K.M., Kim, J. and Gortmaker, S. The Role of Parents in Preventing Childhood Obesity. The Future of Children 2006; 16(1) 169-186.
11. Epstein, L. Family-Based Behavioural Interventions for Obese Children. International Journal of Obesity and Related Metabolic Disorders 1996; 20(1) S14-21.
12. Hood, M.Y. et al. Parental Eating Attitudes and the Development of Obesity in Children: The Framingham Children’s Study. International Journal of Obesity and Related Metabolic Disorders 2000; 24(10: 1319-1325.
13. Secretary of Health and Human Services and Secretary of Education. Promoting Better Health for Young People Through Physical Activity and Sports. Washington. D.C. Centers for Disease Control and Prevention. http://www.cdc.gov/healthyyouth/physicalactivity/promoting_health/index.html.
14. U.S. Department of Health and Human Services. Prevent and Decrease Overweight and Obesity, 2001: Surgeon General’s Call to Action. Rockville, MD. U.S. Department of Health and Human Services, 2001.

The Public Health Campaign Surrounding Childhood Autism: A Critique-Laney Eisenberg

In recent years Autism Spectrum Disorder has become a widely publicized issue, as a result of the drastic increase in its prevalence throughout the country. Childhood autism, in particular, has been the focus of a vigorous public health campaign, with efforts from government and non-profit groups to educate the public regarding symptoms, treatments, and possible causes. Currently the Center for Disease Control estimates that 1 out of 150 children are diagnosed with autism each year, making it the country’s fastest -growing disability (1). Conversely, Down Syndrome has an occurrence of 1 in 800, and juvenile diabetes occurs in 1 in 400-500 children (2). In previous decades the prevalence of autism was estimated as 4-5 per 10,000 children; in the past 10-12 years alone, autism rates have increased by 172% (3). Thus, it is clear that this disorder is a pressing public health concern, as parents of affected children must be made aware of available treatments and services. Information regarding how, and from whom, to seek help, as well as resources for emotional support, are critically important for parents whose children have received a diagnosis.

While the aforementioned groups have enacted media campaigns that have successfully familiarized the public with Autism Spectrum Disorder, the focus of their recommendations has often been flawed. This paper examines the guidelines put forth by institutions such as the Center for Disease Control, National Institutes of Health, and Autism Speaks (an advocacy group for families affected by Autistic Spectrum Disorder), outlining their position on the most effective course of action for families affected by childhood autism. All autism awareness groups are in agreement that intensive early intervention is the optimal response when a child or toddler receives a diagnosis. Currently, a standard treatment plan includes several hours per day of home-based behavioral therapy. The public health community must refocus their priorities in order to better serve the needs of families struggling with this disorder. Treatment plans that address the needs of the child and the family are essential, as is improved access to services for low socioeconomic status consumers. Additionally, the media campaign around childhood autism must be carefully re-examined in order to avoid inadvertent perpetuation of the stigma associated with cognitive disability.

Treatment Methods

The public health campaign around Autistic Spectrum Disorder includes treatment plans that are designed to lessen the symptoms of autism. Treatment is considered effective when the affected child comes to resemble a “typical child” as closely as possible, in terms of linguistic ability, motor skills, and social behavior. Most public health initiatives acknowledge that there are a number of possible treatment approaches for autistic children; however, the most widely advertised option is applied behavioral analysis, an intervention based on behavioral therapy. This type of therapy, prominently advertised by the National Institutes of Health and Autism Speaks, is designed to lessen autistic behaviors through positive and negative reinforcement. In 1999, Mental Health: A Report of the Surgeon General stated, "Thirty years of research demonstrated the efficacy of applied behavioral methods in reducing inappropriate behavior and in increasing communication, learning, and appropriate social behavior” (4). Combined with speech and occupational therapy, applied behavioral analysis is the cornerstone of early interventions targeted toward autistic children. However, the endorsement of this type of intervention by the public health community fails to fully address the needs of children and families.

Behavioral therapy as a treatment plan shows a lack of insight into the values of the parents and families affected by childhood autism. It is clear that this disorder affects the family of the diagnosed child as strongly as the child himself. Research has indicated that mothers of children with intellectual disabilities have higher levels of depression than mothers of typically developing children; additionally, mothers of children with autism have higher levels of depression than mothers of children with other disabilities (5). The child’s lack of ability to interact socially with his or her parents, as well as form bonds with siblings or caretakers, clearly affects the overall dynamic of the family. One must take into consideration the emotional toll of autism on families, in order to determine their true needs in terms of treatment options.

Applied behavioral analysis, as designed by Ivar Lovaas, is described by the National Institute of Mental Health as “an intensive, one-on-one child-teacher interaction for 40 hours a week [that] laid a foundation for other educators and researchers in the search for effective early interventions to help those with ASD attain their potential. The goal of behavioral management is to reinforce desirable behaviors and reduce undesirable ones” (6). While studies have shown that many children make significant gains due to immersion in applied behavioral analysis programs, the skills acquired are not necessarily those which are most important to their parents and family members. Those critical of the behavioral model emphasize the issue of generalization-the ability to generalize the skills learned in a discrete trial setting to spontaneous, unstructured situations. One study cited “cue dependency, lack of spontaneity and self-initiated behavior, rote responding, and failure to generalize behavioral gains across settings and responses” (7). In other words, behavioral interventions over-emphasize rote learning, while failing to address the issues which are likely most important to parents, including spontaneous communications, and social and emotional bonding.

This leads to the question of how to best address the needs of parents and families by means of alternative treatments. In recent years, interventions have been designed that focus more extensively on integrating children with autism into the family and classroom units, as well as teaching skills that can be generalized into all settings. Examples of such programs include the Walden Program at Emory University, which focuses on integration of typical and autistic peers in classroom settings (8), and Learning Experiences, an Alternative Program (LEAP) at the University of Colorado at Denver, an intervention that trains non-autistic children to work with autistic peers in an integrated classroom environment (9). The research literature indicates that “naturalistic” interventions, when compared to discrete trial-based applied behavioral analysis, result in increased positive affect in both children and parents, as well as a reduction in problem behaviors (10).

These types of interventions far better serve the emotional needs of families and the educational needs of their children, as compared with behavioral programs aimed at symptom reduction. Given the rapid increase of autism diagnoses over the past decade, programs that successfully integrate autistic children with typically developing classmates are extremely important. Over-reliance on restrictive environments fails to provide children with an optimal educational experience, and further distances them from peers. Furthermore, the skills learned through naturalistic programs address the needs of family members far better than those gained through discrete trials. The public health community’s focus on strict behaviorally-based interventions, as well as their frequent failure to include programs such as the aforementioned in their awareness campaigns, does a disservice to autistic children, as well as their parents and family members.

Accessibility

As stated, the current recommendations from governmental and advocacy groups include intensive early intervention as a key component of treatment plans. Lovaas’ suggestion of forty hours per week of extensive one-to-one behavioral therapy is equivalent to a full time work week. While the National Institutes of Health, National Institute of Mental Health, Center for Disease Control and other groups do not specifically advise this intensive a schedule, they continue to espouse the belief that children benefit proportionally from exposure to services. The National Institute of Mental Health states:

“An effective treatment program will build on the child's interests, offer a predictable schedule, teach tasks as a series of simple steps, actively engage the child's attention in highly structured activities, and provide regular reinforcement of behavior. Parental involvement has emerged as a major factor in treatment success. Parents work with teachers and therapists to identify the behaviors to be changed and the skills to be taught. Recognizing that parents are the child's earliest teachers, more programs are beginning to train parents to continue the therapy at home” (11).

This statement’s focus on parental involvement is another aspect of the public health campaign surrounding childhood autism that must be considered. Clearly it is necessary for parents of children with autism to be involved in devising treatment plans; they must be prepared to devote much time and energy to their children. However, the suggestion from the National Institute of Mental Health that parents continue therapy at home is problematic. One can assume that public health professionals put forth this recommendation based on the assumption that the intention to act will lead to action. It is likely that the great majority of parents have the best intentions toward their children, yet the feasibility of this recommendation is questionable. In families of lower socioeconomic status and social capital, a number of variables may contribute to their inability to access necessary or desired services.

According to Penchansky and Thomas, access is defined as a “consumer’s ability or willingness to use the [system]…a fit between patients and the [system]” (12). In the case of parents of children with Autistic Spectrum Disorder, barriers to services might include a lack of financial means, lack of information regarding available resources, poor coping skills, and varying cultural norms with regard to perceptions of disability.

For the majority of early intervention programs, there is little guarantee that staff members will be able to provide one family with up to forty hours of services per week. Thus, it becomes necessary for parents to hire outside help if they are to reach this suggested goal. Clearly, this is financially impractical for most families; additionally, families with two working parents cannot commit to having one family member stay home with the child so s/he can receive services. One must also keep in mind that access to basic primary care may be needed for an affected child to receive a diagnosis, thereby qualifying for early intervention services. Low income families without insurance are at a disadvantage in terms of ensuring that their children will receive even this basic service (13).

Lack of information about available services is another potential barrier facing families. Availability of services is described as a basic tenant of access to care; while early intervention is available in every state, families located in rural, isolated areas are likely less able to secure the large number of treatment options and sources of emotional support available in heavily populated cities (14).

Additionally, one must consider the personal and cultural dimensions to access of care. As noted above, Autistic Spectrum Disorder is a devastating diagnosis for families, often leading to maternal depression (15). The encouragement by the National Institutes of Health, Center for Disease Control, and autism advocacy groups for intensive, at-home therapy is not necessarily conducive to the needs of the parents. Shreibman states: “Factors such as parental stress, parental depression, marital adjustment, and perceived community support are examples of potentially significant variables. For example, a parent who is very depressed or highly stressed may be less able to provide intensive treatment to the child”. Parents experiencing high levels of stress are thus likely to be less able to access care, as well as less likely to continue treatment methods on their own time (16).

Shreibman likewise considers the cultural implications of parental access to care. She notes that there is a large range in terms of parental expectations towards their children. Parents from cultures that embrace independence in children may be more amenable to exploring different treatment options; conversely, cultures with lower value placed on independence in early childhood may be less willing to seek out a variety of treatment options (17).

Clearly, a number of factors influence the type and number of services that families with autistic children receive. However, as in traditional healthcare, one can see that families with low economic resources and a lack of social capital are far more limited in their access to resources and treatment options. Given the emphasis public health literature places on early and intensive services as necessary components of optimal care for childhood autism, it is essential that the public health community consider and address the barriers to access many affected families face.

Stigmatization

The public health campaign to publicize the growing prevalence of autism has been centered around media campaigns focused primarily on statistics. Websites from groups including governmental agencies and the Autism Society of America (18) use prominent visuals to emphasize the severe increase in autistic children in the past decade; similarly, television commercials from Autism Speaks are generally centered around the growing prevalence rate. While public health professionals appear to be using these dramatic figures as a means of Agenda Setting Theory-capturing the public’s attention through shock value-they are ultimately failing in their campaign to better serve these children. Given the estimate of the Center for Disease Control that approximately 560,000 people aged 0-21 in the United States have a diagnosis of autism (19), it seems necessary to educate the public on other autism-related issues, rather than only growing numbers. The fact that autism is not curable indicates that most people will have contact with an autistic person at some point in their lives. The public health community, for the benefit of autistic and non-autistic people, should focus their efforts on educating the public about the condition, rather than focusing solely on its prevalence.

It is important to consider the role the media plays with regard to the public’s perception of different social groups. DeFleur and Ball-Rokeach state: “The mass media are a major source of patterned social expectations about the social organization of specific groups in modern society…they describe or portray the norms, roles, rankings, and sanctions of virtually every kind of group known in contemporary social life” (20). Thus, it is crucial that one not underestimate the impact the media has on the general public’s perception of the disabled. One can see that, rather than focusing on positive images of autism, the media campaign relies on the perception that this condition is frightening, untreatable, and ultimately undesirable. This approach can only increase the sense of isolation felt by affected parents, as well as influence their ability to care for a child with special needs. Parents should not be made to feel powerless when confronted with a diagnosis of autism in their child. Rather, the media should refocus their campaign to portray a different face of autism to the general public. Their current approach serves only to marginalize autistic individuals and their families, and widen the divide between the disabled and the mainstream population.

Conclusion

While the public health community has embraced the effort to publicize autism, as well as alerted parents and families to the symptoms and risks posed to their children, their campaign has mistakenly focused on narrow treatment options, neglected potential barriers to care, and failed to address solutions for improving the marginalized status of the disabled. By doing so, they run the risk of parents who rely on this information using their available resources inefficiently, forgoing services, or choosing options that are ultimately not right for their children. Finally, the public health community’s approach toward autism has been stigmatizing to a degree; little effort has been made to educate the public about the needs of autistic people, or to promote tolerance and acceptance. Given the number of people in the country living with autism, less attention should be focused on rates of the disorder, and more on how to best accommodate these people. It is within the scope and the mission of public health professionals to incorporate this aim into their agenda.

REFERENCES

1. Http://www.cdc.gov/ncbddd/autism/faq_prevalence.htm. Retrieved April 1,

2007.

2. Http://www.cdc.gov/ncbdd/autism/faq_prevalence.htm. Retrieved April 1,

2007.

3. Http://www.cdc.gov/ncbdd/autism/faq_prevalence.htm. Retrieved April 1,

2007.

4. Department of Health and Human Services. Mental Health: A Report of the

Surgeon General. Rockville, MD: Department of Health and Human Services,

Substance Abuse and Mental Health Services Administration, Center for

Mental Health Services, National Institute of Mental Health, 1999

5. Olsson, M.B. & Hwang, C.P. Depression in mothers and fathers of children with intellectual disability. Journal of Intellectual Disability Research 2001;

45(6): 535–543.

6. Lovaas OI. Behavioral treatment and normal educational and intellectual

functioning in young autistic children. Journal of Consulting and Clinical

Psychology, 1987; 55: 3-9.

7. Shreibman, L. Intensive Behavioral Psychoeducational Treatments for Autism:

Research Needs and Future Direction. Journal of Autism and Developmental

Disorders, 2000; 30(5); 373.

8. McGee, G. G., Daly, T., & Jacobs, H. A. The Walden preschool (pp. 127-162). In

Harris, S.L. & Handleman, J.S. (Eds.). Preschool education programs for

children with autism. New York: Pro-Ed, 1994.

9. Strain, P. S., Kohler, F. W., & Goldstein, H. Learning experiences . . . an

alternative program: Peer-mediated interventions for young children with

autism (pp. 573-587). In Hibbs, E.D. & Jensen, P.S. (Eds.). Psychosocial

treatment for child and adolescent disorders: Empirically based strategies

for clinical practice. Washington, DC: American Psychological Association,

1996.

10. Shreibman, L. Intensive Behavioral Psychoeducational Treatments for

Autism: Research Needs and Future Direction. Journal of Autism and

Developmental Disorders, 2000; 30(5); 373.

11. Http://www.nimh.nih.gov/publicat/autism.cfm#treatment. Retrieved April

2, 2007.

12. Penchansky, R., & Thomas, J.W. The Concept of Access Definition and

Relationship to Consumer Satisfaction. Medical Care 1981; XIX(2): 127-140.

13. Norris, T.L. & Aiken, M. Personal Access to Health Care: A Concept Analysis.

Public Health Nursing 2006: 23:59-66.

14. Norris, T.L. & Aiken, M. Personal Access to Health Care: A Concept Analysis.

Public Health Nursing 2006: 23:59-66.

15. Olsson, M.B. & Hwang, C.P. Depression in mothers and fathers of children

with intellectual disability. Journal of Intellectual Disability Research 2001;

45(6): 535–543.

16. Shreibman, L. Intensive Behavioral Psychoeducational Treatments for

Autism: Research Needs and Future Direction. Journal of Autism and

Developmental Disorders, 2000; 30(5); 373.

17. Shreibman, L. Intensive Behavioral Psychoeducational Treatments for

Autism: Research Needs and Future Direction. Journal of Autism and

Developmental Disorders, 2000; 30(5); 373

18. Http://www.autism-society.org/site/PageServer. Retrieved April 3, 2007.

19. Http://www.cdc.gov/ncbddd/autism/faq_prevalence.htm. Retrieved April 4,

2007.

20.DeFleur, M.L. & Ball-Rokeach, S.J. Socialization and Theories of Indirect

Influence (pp. 202-227). In: DeFleur, M.L. & Ball-Rokeach. Theories of Mass

Communication. White Plains,, NY: Longman, Inc., 1989.

The Flaws of Applying the Health Belief Model to the “War on Drugs”: a Critique of America's Use of the Prison System in the “War”- Heather Brand

The increase in the availability of illicit drugs in the last half of the 20^th century has become a tremendous problem for the United States. In 2005, a reported 22.5 million Americans were diagnosed with substance abuse and dependence (Substance abuse and Mental Health Services Administration in 1). America’s “War on Drugs” has largely been carried out by the deployment of the criminal justice system to punish those who take part in drug-related activities. However, placing the emphasis on drug use as an immoral, illegal act one voluntarily chooses to engage in has actually exacerbated America’s drug problem and, furthermore, has prevented effective treatment strategies from being implemented on a grand scale. America's use of the prison system as a means to combat drug use is a failure because it is based on the health belief model, which does not address the environmental and social determinants of illegal drug use and is not based on the scientific evidence that drug use is an addiction that requires comprehensive treatment to overcome.

Our individual behavior, including the activity of engaging in drug- related behavior, is shaped by our environment and the social interactions we participate in, a fact that the health-belief model fails to account for. Many social and public health problems associated with illicit drugs are concentrated in disadvantaged urban communities, marked by poverty, high unemployment rates, low levels of education attainment, and social disorganization, and the risk of using increases dramatically with the number of risk factors present in a community (2). Poverty is inextricably related to drug use (2,3,4,5) which has become yet another facet of the ever-expanding divide separating the plush, comfortable existence of the upper-class from the harsh realities endured by the lower economic class. Drug use in impoverished communities is appealing because it provides a means of enjoyment and escape from the unmerciful social realities they find themselves engrossed in. The prison system, of which drug- related offences account for roughly 35% of the 1.4 million Americans incarcerated, actually contributes to the poverty that plagues disadvantaged, drug- stricken communities. The innercity residents who enter the correctional system, mostly African Americans and Latinos, are removed from their communities and transferred to facilities in predominantly white, exurban communities. The inmates are then counted in the national census as residents of those communities, which results in decreased subsidies for urban areas while increasing federal aid and grants for the prison communities.

The low levels of educational achievement that characterize many disadvantaged communities make finding and maintaining a well-paying job near impossible, leading many individuals to become involved in the sale and distributions of drugs, given the large amount of profit to be gained in short periods of time. The prison system confounds this problem by releasing uneducated, unskilled ex-inmates back into urban areas, where they are confronted once again by the business of drug sales and other criminal activities, and where access to a viable, satisfying, conventional way of life is hard to come by (4).

It is interesting to note that as local and state governments decreased spending on programs intended to raise the public health, education and employment of the poor, funds for the construction and maintenance of prison systems increased; in the 1990s, spending on employment and training programs were cut 50%, while money for correctional facilities increased by 521% (4). Communities are at an increased risk to become socially disorganized when there is a lack of social service institutions, leading to the unabated emergence of drug use, crime and delinquency, and violence in the community (2). Neighborhood and community social organization is crucial in mediating the impact of broader environmental influences, such as social inequality resulting from low socio-economic status.

Yet socio-economic status and neighborhood environment are not the only variables that exert an effect on one’s life. J.S. Coleman’s Social Capital Theory focuses on how the quality (time and effort), structure (attachments formed), and content of social relationships- including those formed in the family, work, school, neighborhood, and community environments- affect the transmission of resources (capital) across generations that shape opportunities and life trajectories (6). The effects of social capital are cumulative, that is, individuals carry lessons learned with them throughout their life and apply them to all varieties of relationships and social interactions.

Social Capital Theory recognizes the family as perhaps the most fundamental vessel through which social capital flows, so is used here to exemplify the three important ways “capital” is transmitted. Firstly, parents transmit social capital to their offspring by investing time and effort in their children’s lives, the ultimate goal being to raise socially competent youth who are psychologically adjusted and behaviorally appropriate. Forging strong family attachments is the most effective means by which to achieve these goals and is the second necessity for high social capital to accumulate. Studies have shown that even in the presence of other risk factors, an intact family life may act as a barrier against drug abuse (3). Conversely, studies have found an increase in the incidence of dysfunctional family environments among drug users, and have also concluded that exposure to child abuse and neglect increases the likelihood of substance abuse (3). Therefore, it is important that the content of the messages reinforces prosocial behavior patterns, as it is evident that certain forms of capital may actually facilitate criminal involvement (6).

The reliance on the criminal justice system to address drug abuse removes individuals from their families and communities, the very sources of social capital and social support critical to helping them overcome their addiction. According to the social capital theory, the most promising solution would be to utilize the resources and social support of the community they are connected to. By isolating them in the prison environment, their social support ceases to exist and along with it any chances of they had of successfully dealing with their addiction.

By applying the social capital theory, it is easy to see how the social environment created within the American prison system has exacerbated America’s drug problem. Several studies have shown that drug use is widely accepted as a normal part of the correctional system, so by placing users in a socially isolated subculture where drug use is the norm, their substance abuse is not only maintained, but often increased (7). With 1 of every 138 Americans incarcerated, it is no wonder that the social capital accumulated while in prison has been brought to the streets, particularly affecting disadvantaged communities and African Americans, who account for 50% of the prison population. In these communities marked by low social capital where traditional family caretakers and role models have disappeared, moral authority has been transferred to “street smart” individuals, whose power and oppression instilled in them from the their experience in the prison system is brought to the streets and used as a source of influence over others to maintain the cycle of violence and drug use, an activity that has become glamorized in these communities; “doing time” is considered a rite of passage (4). By ignoring the pressing environmental and social determinants of drug use, America has failed to help its drug abusing citizens and has only worsened their plight through the use of the prison system.

The application of the health belief model has lead policy makers to the decision that the criminal justice system is the best means by which to deter individuals from engaging in drug activity. This decision is based on the assumption that drug users are rational individuals who will calculate the cost versus the benefits of criminal activity, i.e. their drug use, and decide not to engage in the activity due to the threat of a criminal conviction and punishment. However, this is hardly the case. Studies show that dug users are impulsive and sensation-seeking, and the crimes they commit are often violent and unpremeditated; this is because certain drugs, especially one like PCP and amphetamines, have pharmacological properties that directly influence areas of the brain responsible for aggressive, impulsive behavior (3). Furthermore, there is considerable evidence that particular genetic, biochemical, physiological, and psychological features may influence drug taking behaviors and the possibility of addiction. Many crimes perpetrated by drug users are attributed to the drug cravings, frenzy, and withdrawal resulting from addiction, further debunking the “rational decision” theory expressed in the health belief model (3). The stigma surrounding drug users and addiction is largely unwarranted, as it is imperative to remember that many individuals in society are at risk for becoming addicted to alcohol and other drugs. However, in the presence of a deleterious environment the risk for drug abuse among individuals with existing psychopathology is substantially compounded (3).

As humans, we are conditioned to steer away from situations perceived as painful and towards situations perceived as pleasurable. Environmental cues assist us in recognizing these situations. Once an individual has been exposed to a drug of abuse, the drug serves as a powerful reward to the brain that spirals beyond the control of the user. Not only do drug users become addicted to the euphoric chemical effect of the drug, but also to the behaviors and paraphernalia associated with the drug. For example, cocaine users report extreme drug craving when they see a dollar bill, talcum powder, or a drug- taking peer (3). The ubiquity of social cues, even in the absence of the drug itself, makes addiction extremely difficult to overcome. In fact, without treatment 9 out of 10 drug using offenders will re-offend and return to drug use after leaving prison, with most being rearrested within 3 years (7).

The use of the prison system has stigmatized individuals who are addicted to drugs, labeling them as criminals and creating a barrier to recovery. According to stigma theory, because they are stigmatized, they lose self-esteem and self-respect, things which we know are powerful risk factors for drug use (8). So the prison system intensifies, rather than ameliorates the factors that are leading to drug abuse in the first place. Furthermore, labeling theory holds that a person, once labeled, tends to fulfill the expectations of that label (9). By labeling drug users as criminals, they may pick up the identity of a criminal. Spending time in jail may make them more likely to identify themselves as a criminal, rather than deter them from future drug use. We must abandon the pernicious moral stance that drug use results from an unwillingness to control voluntary behavior and revoke the use of the criminal justice system in “the war on drugs”.

The application of the health belief model to solve America’s drug problem could not be a more obvious mistake. By placing the solution to drug abuse in the hands of the criminal justice system instead of in the hands of comprehensive treatment programs, individuals, families, neighborhoods, and communities at large have suffered immensely. Its use has lead the social and environmental factors contributing to drug use to go unnoticed. The psychological and addictive qualities central to one’s drug using behavior have been diminished to a level of minuscule importance. If the health belief model maintains its role in America’s “war on drugs”, these crucial factors will remain invisible and the problems associated with drug use will continue to paralyze our communities and strip individuals of numerous opportunities for a healthy, fulfilling life.

References

1. French, M.T., Homer, J.F., Nielsen, A.L. Does America spend enough on addiction treatment? Results from public opinion surveys. Journal of Substance Abuse Treatment. Vol. 31 (3). 2006. 245-254.
2. Aguirre-Molina, M., Gorman, D.M. Community-Based approaches for the prevention of alcohol, tobacco, and other drug use. Annual Review of Public Health. 1996. 337-358.
3. Fishbein, D.H. Medicalizing the drug war. Behavioral Sciences and the Law. (9). 1991. 323-344.
4. Golembeski, C., Fullilove, R. Criminal (in)justice in the city and its associated health consequences. American Journal of Public Health. Vol. 95 (10). 2005. 1701-1706.
5. Rehm, J. The importance of environmental modifiers of the relationship between substance use and harm. Addiction. (99). 2004. 663-666.
6. Wright, J.P., Cullen, F.T., Miller, J.T. Family social capital and delinquent involvement. Journal of Criminal Justice. Vol. 29 (1). 2001. 1-9.
7. O’Callaghan, F., Sonderegger, N., Klag, S. Drug and crime cycle: evaluating traditional methods versus diversion strategies for drug-related offences. Australian Psychologist. Vol. 39 (3). 2004. 188-200.
8. Goffman, E. Stigma: Notes on Management of Spoiled Identity. New Jersey: Prentince Hall, 1963. 3.
9. Akers, R.L. Labeling Theories. Criminological Theories. 1997. chap. 6.

Treating the Victims of Sexual Assault at the University Level: Why Are We Failing to Reach Them? – Alexis Maule

The reported incidence of sexual assault perpetrated against women increases from ages 14-24 and peaks during the ages normally spent in college, 18-24. In fact, when the National Longitudinal Study of Adolescent Health conducted a study, “69.8% of college women had experienced at least 1 instance of sexual violence from age 14 through the fourth year of college” (1). There have been fairly recent policy changes at the university level to address the widespread issue of sexual assault. Throughout the 1990s, Congress amended the Student-Right-to-Know and Campus Security Act to expand the basic rights of all sexual assault victims and put an increased emphasis on reporting these crimes on campus (2). However, I believe that the sexual assault and domestic violence victim treatment programs offered in the university setting fail to reach the majority of the population they are targeting because these programs are founded a few basic behavioral theories that unsuccessfully explain the behavior and perceptions of the victim.

College women are already at increased risk for assaults because college is “a time characterized by greater independence and opportunities to engage in risk behavior” (3). Officials in the field of public health should strive to reach out to these women and to also address the health and well-being of the victims of assaults. We must improve the victim treatment programs to care for the immediate physical and mental problems caused by sexual victimization and to help these victims avoid future poor health outcomes. Being the victim of a sexual crime has recently been linked to an increased risk of poor health outcomes including: obesity, substance abuse, risky behavior, and suicide (4).

Shortcomings of the Theory of Reasoned Action

I think the first reason sexual assault victim treatment programs at local universities, specifically at BU, do not work is because their main focus is on treating the victim after the crime occurs. I believe that this approach uses the Theory of Reasoned Action (5). It assumes that victims of crimes will act reasonably and contact the proper authorities after the crime occurs. However, I think that this theory fails to address one important fact about sexual/domestic violent crimes; multitudes of victims do not report the assault or the abuse, so these programs are unable to reach these people. These programs fail because many victims go silent after the crime occurs. According to data from the National Crime Victimization Survey in 2002, only slightly more than 50% of victims of sexual assault reported the crime to the police (2). To address this issue, I think these programs need to understand their target clientele and the reasons why these victims live in silence.

Violence as a Social Norm

Sexual victimization has been defined as “an event in which one person attempts to obtain a sexual behavior from another individual against her or his wishes, using some sort of physical and/or psychological coercion” (2). In many, but not all instances this definition is understood and socially accepted. When reaching out to victims of sexual crimes, these programs assume that there is a strict social norm in place, which tells the victims of these assaults what constitutes as violence and what does not. However, the perceived amount of violence a person experiences or is witness to can be different across age groups and across backgrounds (1).

What may seem like an act of violence worthy of report to one person may seem like normal behavior to another person. In the case of the latter person, their social norm has shifted, so that more and more extreme acts of violence become tolerable or acceptable and they may neglect reporting any act of sexual violence imposed on them. Sexual assault victim treatment programs need to recognize these shifts in social norms, which largely depend on the experiences a person has as a child or adolescent, and they need to figure out ways to reach out to these target groups because many times it is these people who are at the highest risk of being victims of sexual assault/violence. People who grow up with a greater “lifetime community violence exposure” are more likely accept violence as a social norm, and furthermore, it makes a person more likely to accept violence in a relationship (whether it is an intimate partner or a friend) (3). Unfortunately, carrying past experiences with violence into future situations is especially true for women. Women who witnessed or experienced violence as children or as adolescents are less likely to seek help when in a sexually abusive situation as adults (6).

Remaining Silent

The main motivation for writing this paper came from an article reporting the sexual assault statistics for the Allston/Brighton area. It stated that 36 sexual assaults were reported in these neighborhoods in 2006. Of those 36 assaults, 35 of the victims knew their attacker. In another study conducted specifically at the university level, 95% of the sexual assault offenders were identified by the victims as boyfriends, friends, or casual acquaintances (1). This presents a huge obstacle when encouraging victims to report the crime and utilize treatment resources. Because the victims are personally linked to the majority of their attackers this may intimidate victims to report the crime or they may feel like they somehow caused their attack. Women, in particular, are more likely to assume the blame for the attack when they are being victimized. They also avoid reporting the incident to “minimize personal hurt and relational problems” (6).

Once again, I believe that the Theory of Reasoned Action is at fault. Many people, once they become victims, do not act in a reasonable way. Their self esteem and self worth have been severely damaged, especially when the assault comes from someone close to them. These victims fail to realize that the sexual victimization “cannot be justly attributed to the victim or the relationship” (6).

It is important to consider Maslow’s hierarchy of needs when talking about the relationship between self-esteem and the probability that a victim will report an assault. According to Maslow, the need for human beings to have their safety needs met comes directly after having their physiological needs met (7). Safety needs can be those related to having shelter or the protection of our body. When a person is sexually assaulted they may no longer feel that their need for safety is being met because their body has been violated. If a victim feels that their need for safety is not being met, they cannot move on to the other stages of need, particularly, the need for esteem, which includes self-esteem, self-confidence, and self-respect. As a result of the sexual victimization, a person will often feel unsafe in their environment and therefore less confident about their value as human being (7). A lack of self-confidence may prevent the victim from reporting the crime and a lack of self-esteem may cause a victim to deem themselves unworthy of treatment. Until the victims safety needs are being met, most likely through proper treatment, they will remain in a state of low self-esteem and low self-confidence.

Another reason for a lack of reporting may stem from other circumstances surrounding the crime. One study found that more than half of victims reported alcohol being involved in the situation before the crime occurred (8). This may also lead the victim to feel that their actions and behaviors somehow make them responsible for the assault. They may be embarrassed about the events surrounding the crime, so to keep from revealing their alcohol use they remain silent about the sexual victimization.

Furthermore, in a study conducted at Brown University, many of the women who admitted being a victim of sexual assault to the study investigators, listed “lack of confidentiality, fear, embarrassment and guilt” as several reasons for not reporting the crime to an official (2). The feelings expressed by the students not only prevented them from reporting the crime, but from seeking treatment as well. The study investigators compared the percentage of students who claimed to know about on-campus resources for victim treatment to the percentage who actually utilized the resources. They found that 90% of victims and 88% of non-victims knew about available on-campus resources for victims of sexual assault; however, only 22% of the victims utilized these resources after their crime occurred (2). Furthermore, the study investigators asked those students who reported no incidence of sexual victimization if they would use the on-campus resources if they became a victim of a sexual crime. Ninety-seven percent reported that they would (2).

It is evident that this percentage is vastly different than the percentage of students who actually sought treatment. This is direct evidence of the Theory of Reasoned Action failing because once these women became victims; they no longer acted reasonably and sought treatment.

Focusing on the Wrong Behavior Changes

Additionally, these programs fail is they focus on the behavior of victims and sometimes would-be victims and possible behavioral changes they can make to protect themselves. I think that these programs give good information and education, but I believe that the scope of the program is very limited. In a college setting, the majority of victims are female and the majority of attackers are male. I think that prevention programs should start focusing on educating and changing the behavior of males as well as females, otherwise they are reinforcing “themes of power inequality” and also the notion that a female’s behavior is somehow linked to the crime (6). The unequal footing women often have in relationships may be one of the primary underlying causes of female sexual victimization (9). Furthermore, these programs need to consider a person’s past experiences with violence and with relationships. The people we choose to surround ourselves with can depend heavily on our childhood experiences. Upon coming to college, students are surrounded by hundreds of new people and they seek out people similar to those who they have had relationships with in the past. People who have past experiences with violence are more likely to accept violence as a normal part of a relationship (6). Maybe rather than focusing on behavioral changes victims can make, we can shift the focus to building better, more communicative and more equal relationships with each other.

Sexual assault rates for women in late adolescence and college-age groups are two to three time higher than rates for women in other age groups. This epidemic of violence is widespread and affects women of all races and socioeconomic status. In fact, the National College Women Sexual Victimization study conduced in 1997 found that between one fifth and one quarter of college women will experience “a completed rape or attempted rate over the course of their college career” (2). Fortunately, it is not the case that victims do not know that treatment services exist; however, there are several factors that prevent women from reporting the victimization and seeking treatment. It is imperative that we bridge this gap and find new ways to effectively reach and treat these victims with compassion and understanding.

References

1. Smith, P., White, J., Holland, L. A Longitudinal Perspective on Dating Violence Among Adolescent and College-Age Women. American Journal of Public Health. 2003; 93:1104-1109.
2. Nasta, A., Shah, B., Brahmanandam, S., Richman, K., Wittels, K., Allsworth, J., Boardman, L. Sexual Victimization: Incidence, Knowledge and Resource Use among a Population of College Women. Journal of Pediatric Adolescent Gynecology. 2003; 18:91-96.
3. Brady, S. Lifetime Community Violence Exposure and Health Risk Behavior among Young Adults in College. Journal of Adolescent Health. 2006; 39:610-613.
4. Stein, MB., Barrett-Conner, E. Sexual Assault and Physical Health: Findings from a Population-based Study of Older Adults. Psychosomatic Medicine. 2000; 62(6):838-843.
5. Fishbein, M. A Theory of Reasoned Action: Some Applications and Implications. Nebraska Symposium on Motivation. 1980; 27:65-116.
6. Wekerle, C., Wolfe, D. Dating Violence in Mid-Adolescence: Theory, Significance, and Emerging Prevention Initiatives. Clinical Psychology Review. 1999; 19:435-455.
7. Vianna, LC., Bomfim, GF., and Chicone, G. Self-esteem of raped women. Rev Latino-am Enfermagem. 2006;14:695-701.
8. Abbey, A. Alcohol-related sexual assault: a common problem among college students. Journal of Studies on Alcohol. 2002; 14:118.
9. Matud, M. Dating Violence and Domestic Violence, Editorial. Journal of Adolescent Health. 2007; 40:295-297.

Rape Crisis Intervention: A Critique of Individual Prevention, And an Argument for a Community Based Approach-Thomas A. Amoroso

Abstract: The current approach to prevention of sexual assault stresses watchfulness on the part of women (who are potentially at risk), and to a lesser extent stresses knowledge of “what constitutes sexual assault” for both men and women. Programs of this type have been shown to have limited effect on the rate of sexual assault. We argue that a more community based approach, based on the use of community norms of behaviour to help guide both men and women around the issues of sexual and power behaviour. We use elements of self-efficacy theory to critique the current approach, and suggest new and innovative approaches.

Rape and rape prevention strategies

Open on a dark parking lot, a single woman walking alone, her shoes clicking on the pavement. Sound over footsteps, in a more bass tone indicating men’s shoes, apparently behind her. Close up on the woman’s face - she looks behind her, an apprehensive look on her face.
--A possibly familiar opening scene from a public service announcement promoting rape prevention.

Current rape prevention programs (more accurately, rape avoidance programs), especially on college campuses, place their major emphasis on increasing individual awareness of the risk factors for rape; these include such items as having company when walking, especially at night, using care at home with regard to letting people into your home, and avoiding alcohol in certain social situations (1, 2). These approaches stress individual responsibility for preventing a potential rapist from targeting a specific person; the assumption is that if you are forewarned of the dangers of walking alone at night, you will be protected from rape. These interventions all are based on the “Health Belief Model”, which posits that by providing information to individuals about specific health risks, a rational person will act to to avoid or minimize those risks, thus minimizing or avoiding the health problem in question. It can be shown that, despite active research in rape prevention models, most rape prevention models are quite similar (3).

Unfortunately, the Health Belief Model (HBM) is inadequate to the task of preventing rape for several reasons. First and foremost, the HBM is, at its core, a model of rational action; if you know about a health problem or risk, you will, as a rational actor, act to avoid the risk. This model fails to take into account several core aspects of human experience, especially the emotional aspects. It also fails to take into account the concept of competing risks, or the hierarchy of risk, which people face daily. People will take risks based considerations other than the risk; while a woman may acknowledge rationally that she is at risk to be raped if she walks home alone at night, this might be outweighed by a need to get home to a child left alone at home due to a lack of child care, or some other compelling reason.

Moreover, the HBM fails to explain why rape takes place at all. In some ways, we can see the model used as another example of holding the victim responsible for being raped; had she been following the guidelines for avoidance, she wouldn’t have been raped. A more useful model would place the responsibility for rape correctly: in the hands of the rapist. In order to do this, we need to investigate why rape occurs, and look at how we can identify potential rapists or rape situations and defuse them.

Rape is a complex behaviour. At its core, the act of rape is sexual contact in the absence of consent. However, unanswered in the bare definition are many questions. Who can consent to sex, in terms of mental capacity to consent, which may be compromised by youth or drugs? What constitutes consent, and what communicates refusal? What leads a perpetrator to have a different answer to these questions than a victim? There are societal influences which can promote or prevent rape, or which see a set of facts as rape or not rape, depending on circumstances. Rape is a traumatic event for the victim, but likely less so for the rapist.

To the extent that there are shared answers and beliefs between rapist and rape victim, Belief System Theory (BST) indicates that rape is less likely to occur (4). In short, BST states that “The ultimate function of human values is to provide us with a set of standards to guide us in our efforts to satisfy our needs and...maintain and enhance self-esteem” (5). Community education efforts directed at educating people as to the traumatic effects of rape on the victim, those close to her, and on the general tone of society (prevalence of rape creates a culture of fear, especially around issues of sex and intimacy), and encouragement of more open dialogue around issues of sex and consent, could change the standard of behaviour with respect to sex, especially in the crucial, formative adolescent and young adult years, when many people are initiating their first sexual experiences.

Rapists tend to see their victims as objects, rather than people, and there are signal differences between rapists and their victims on assessments such as “How traumatic is it to be raped?”, and “A woman will say no even if she means yes”; in this model, education of potential rapists (either all men in general, or men who are known to have committed rape) regarding the effects of rape on an individual could be effective in reducing rape. Several studies have approached this using an intervention aimed at college males, and found that it was possible to induce lasting attitudinal change (6, 7); whether this leads to long-term behaviour change has not been studied, and there is no data on whether this intervention can reduce rape rates in the studied population (college males).

Other systemic causes of rape, such as socioeconomic status and substance abuse, as well as cultural factors in both victims and perpetrators, can also be addressed in rape prevention campaigns. The United States is ideally a ‘melting pot”, where people from different countries and cultures come and are forged into an alloy called “American”. More accurately, this mixing produces a mosaic or quilt; there are clear edges where birth culture and adopted culture meet. Nowhere is this more likely than in core concepts involving very private acts, and whether one regards rape as a crime of power and control or an expression of deviant sexuality. The sexual nature of the crime puts it squarely in the realm of privacy and secrecy.

In a study of recent immigrants to Israel from the Ukraine (8), it was found that Ukrainian men felt they had to be “tough and violent”, specifically in order to be “the boyfriend of a pretty girl”. Sex is seen as a biological need, unrelated to love or emotions; thus, if a man ‘needs’ sex, he is, in the Ukrainian cultural view, at least somewhat justified in using some level of force to satisfy that need. (An analogous ‘need’ would be for food or water; if you need food, there is thought to be some ethical justification in stealing it from someone who has food). Thus both men and women might see a man as helpless to avoid committing the act of rape, as they see him as acting from a ‘biological need’ rather than a voluntary desire.

Furthermore, it is (again!) the woman’s responsibility to avoid putting herself in situations where she might be the target of this ‘need’. (In some ways, cross-cultural studies are revealing of Western attitudes we thought we’d left behind; in the Ukraine, a woman who is raped is thought to be ‘spoiled’, and because of this, is not encouraged to report the rape, either by her relatives or by her own internal incentives - who wants to reveal they are spoiled? While those of us in the West would like to believe these attitudes long dead, I suspect that there remains enough of this attitude to inhibit reporting of rape).

The same study revealed that attitudes among sex offenders from the Ukraine reveal a more external locus of control compared to Western offenders, especially at younger ages. Ukrainian teenagers, trained in the Soviet system of subservience to the State in all aspects of life, frequently also blame the State when they commit criminal acts. Bandura (9) reports that “The capacity to exercise some measure of control over one's thought processes, motivation, affect, and action operates through mechanisms of personal agency”, but this seems to be less the case with the Ukrainian teenagers studied, who appear to look to (or at least are willing to blame) an outside locus of control over their actions for any actions which are later perceived as wrong. It may be possible to demonstrate that an increase in self-efficacy, in the form of a changed masculine ideal different from the one perceived by the Ukrainian teenagers, would decrease rates of rape in that population; to the extent that these attitudes bleed over into more mainstream culture, this may affect rates of rape across the spectrum. Just as some cultures do not start from the assumption that rape is a power crime, or that it’s necessarily ‘the man’s fault’, an argument can be made that even Western culture has not completely made that leap as yet.

Finally, the issue of community involvement in rape prevention is only now beginning to be addressed. In a recent Boston Globe article, bartenders and bar owners in a Boston neighborhood were invited to assist in preventing rape by calling taxis for intoxicated women (at increased risk of being raped) rather than “simply shooing them out the door”, and making it clear to bar owners that calls to police to assist with intoxicated female patrons were welcome (it had been thought by bar owners that making this type of call would invite negative attention from the licensing board) (10). Increased community involvement of this type may be more effective than any other intervention in the prevention of rape in a community. Unfortunately, most ‘community prevention’ programs are, in the end, rape crisis treatment and mitigation programs; one study (11) does show that a community intervention program can change attitudes and behaviour in a way that might prevent rapes from occurring, as well as mitigating their effects afterwards. Specifically, the researchers used “a community of responsibility model to teach women and men how to intervene safely and effectively in cases of sexual violence before, during, and after incidents with strangers, acquaintances, or friends”. [Emphasis added]

In summary, rape is a complex of individual actions set against a cultural and societal matrix which both condemns it and allows it to occur. Education efforts have been ineffectual in reducing the incidence of rape, although this is a matter of some controversy; rates of rape have been steadily decreasing over the past five years, in the setting of an across the board decrease in violent crime. Rates of rape have decreased somewhat more than other crimes. The cause of this decrease is controversial; rape prevention advocates are not yet prepared to assign credit to rape prevention programs, while crime prevention advocates are eager to claim credit for their programs for the decrease. Regardless, it is clear that many, if not most, rape prevention programs do not take into account the complex cultural and interpersonal factors in order to truly prevent rape across the spectrum of behaviour. The approach most law enforcement agencies have taken is akin to military target hardening and avoidance, rather than approaching the root causes of rape - cultural attitudes which allow men to rape with little or no emotional or legal consequence, and cultural attitudes which condone rape as being beyond the control of men who ‘need’ sexual gratification. While these attitudes may be more prevalent in non-Western cultures, it seems clear that Western culture is not free of these tropes, and more can be done to change the thinking, and the actions, of our culture with respect to rape prevention.

References

1. Hendersonville Police Department. Rape Prevention Tips, Hendersonville, AZ. http://www.hendersonville-pd.org/PreventionTips/RapePreventionTips.html; this site is representative of literally dozens available via a Google search using keywords “rape prevention”, and is also representative of programs run at many area colleges
2. Arming Women Against Rape and Endangerment, Bedford, MA http://www.aware.org
3. Townsend S, Campbell R, Homogeneity in community-based rape prevention programs. J Comm Psych 2007 May; 35(3): 367-382
4. Quackenbush RL Comparison and Contrast Between Belief System Theory and Cognitive Theory. J. Psychology 1989 Jul;123(4): 315-328
5. Ibid. p.315
6. O’Donohue W, Yeater E, Fanetti M , Rape Prevention With College Males J Interpers. Viol 2003 May; 18(5): 513-531
7. Johansson-Love J, Geer JH, Investigation of Attitude Change in a Rape Prevention Program. J Interpers Viol. 2003 Jan; 18(1): 84-99
8. Sherer M, Etgar T Attitudes Toward Sex and Sex Offences Among Israeli and Former Union of Soviet Socialist Republic Youth J Interpers. Viol. 2005 Jun; 20(6): 680-700
9. Bandura et al, Sociocognitive Self-Regulatory Mechanisms Governing Transgressive Behavior. J. Pers. Soc. Psychol. 2001; 80(1): 125-135
10. Bar owners asked to help stop rapes, Radin CA, Boston Globe February 10, 2007
11. Banyard VL et al. Rape Prevention Through Bystander Education: Bringing a Broader Community Perspective to Sexual Violence Prevention http://www.ncjrs.gov/App/Publications/abstract.aspx?ID=208701

The “Above the Influence” Television Media Campaign: Employment of Social Learning Theory Gone Awry — Megan Chen

The United States Government Accountability Office (GAO) has determined the National Youth Anti-Drug Media Campaign, an endeavor that has spent over $1.2 billion between 1998 and 2004, ineffective at reducing adolescent marijuana use (1). The GAO report found that, according to a study by Westat Inc. and the University of Pennsylvania, the campaign was unsuccessful in both preventing initiation of marijuana use as well as diminishing current marijuana smoking habits among youth in the U.S. Although the GAO recommends discontinuation of the campaign due to its unproductive outcomes, the Bush administration continues to include the campaign in the national budget, in fact, with a $20 million increase from the previous year (2). Supplying more money for a program that is dependent on ineffectual methods seems fruitless, and, indeed, current campaign attempts seem equally ineffective. The latest theme of the federal anti-drug campaign, “Above the Influence”, will most likely also be unsuccessful in decreasing drug use among adolescents because most of its TV ads attempt to inappropriately apply Social Learning Theory.

Social Learning Theory is based on the tenet that people do not learn behaviors in a vacuum, isolated from external interactions (3). The theory stresses that a large contribution to adopting behaviors stems from observing and then emulating the actions of others within an individual’s community. Being aware of both the activities of others and the consequences that result facilitates the awareness and development of previously nonexistent behaviors to the observant individual. Three principles encapsulate the theory’s essence: a) Observational learning is best acquired by translating the behavior to symbols before performing the behavior in an exaggerated manner; b) The modeled behavior is more easily learned if its consequences are valued by the observing individual; c) If the behavior is highly valued or admired and it serves a purpose for the individual, she is more apt to follow the modeled action.

The adolescent population seems ideal for employing Social Learning Theory techniques to reduce illicit drug use. One study deemed peer drug use as universally labeled the factor most likely to influence current drug use (4). It has also been shown that peer influence is especially instrumental in initiation and continuation of smoking marijuana (5). Therefore, since research indicates that peer behavior is a strong indicator of individual behavior during adolescence, young adults most likely have an increased susceptibility to adopting modeled behavior; utilizing Social Learning Theory methods could potentially result in successful outcomes. Despite this possibility, however, the “Above the Influence” television ads fail to connect with their young audience due to four key factors.

1. Failure to create behavior adolescents will want to model

One television commercial employed in the campaign is a cartoon called “Not Again” (6), one of five ads drawn as childish cartoons. Examining and analyzing this ad will help explain how the campaign was faulty in utilizing Social Learning Theory. The piece begins with two poorly drawn stick figures sitting next to each other on a nondescript bench while lackadaisical piano music (which mimics the chopsticks-like, elementary recital piece) plays in the background. One figure, assumed the “boy”, since it doesn’t have long hair and isn’t wearing a skirt, starts smoking a joint, while the other one (the “girl”) watches. Her face turns forward (presumably, to the television viewing audience), exhibiting an incredibly unremarkable expression, and the words “not again” are written in red next to her. All of a sudden, an unidentified flying object appears in the distance, lands, and a little alien descends toward the couple (at least, one assumes it’s an alien only because it came from the U.F.O., not because of its appearance, which is basically the same stick-figure body with a more triangular head and larger, wider eyes). The pot-smoker offers the alien a drag, and, only after closer inspection, the alien turns away with a raised hand, and the words, “no thanks” appear next to it in red. Upon this refusal of the marijuana offering, the girl stands up quickly. Obviously swooning with love for this species unknown to her , a red heart blinks repeatedly over her head. The cartoon concludes with the girl and the alien floating through the sky inside the aircraft, cute, moth-like insects flitting alongside, and the boy watching stoically from below.

“Not Again”, in an attempt to employ Social Learning Theory, presents the idea that if you don’t smoke marijuana you get the girl. Or, in the case of the girl’s perspective, ditching the pot-smoker will afford you love and happiness. While the commercial makes an honest attempt to fulfill the first principle of Social Learning Theory by creating a symbolic representation of behavior, the use of the alien forces the ad’s portrayal to cross from exaggerated to entirely unrealistic. Furthermore, “Not Again” is a cartoon, drawn in silly stick-figure-like images that remind one of preschool, not of junior or high schoolers. Students will likely not want to emulate these characters because the commercial itself undermines their maturity as adolescents by trying to cater to them with cartoons. Adolescence is a unique period during development where individuals gain more independence and maturity as they prepare to enter the adult world (7). Attempting to elicit this group’s attention through immature cartoons disrespects this essential aspect of being a young adult.

Secondly, the thrust of the ad is that the girl ditches the pot-smoker for, not another law-abiding, upstanding, fellow student, but an alien that suddenly comes out of the sky. The preposterousness of this ending is also insulting to adolescents’ intelligence, which represents another reason for an unwillingness to model the behavior.

2. Adolescents may model undesired behavior

The second main component of Social Learning Theory is that people will be inclined to adopt a modeled behavior if it results in a desired outcome. What is the desired outcome in this ad? Falling in love with a random alien? The sheer inclusion of the alien makes the behavior the campaign promotes seem fruitless, considering that the chances of this happening in reality are slim. Most teens will not value a romantic relationship with another species.

Furthermore, how can the campaign writers be sure that adolescents won’t model the kid smoking marijuana since his outcome is continuing to enjoy his joint and getting rid of a flippant, uncaring, potentially undesirable girl who wants to date an alien? Studies have shown that the onset of puberty in adolescence confers an increase in “sensation-seeking, risk-taking and reckless behavior” (8). It could be entirely normal for a young adult to admire the marijuana smoker as a risk-taking rebel, free to do as he pleases, and immune to the shackles of authority.

Additionally, many studies have proposed that one motivation behind adolescent risk-taking behavior involves improving status among peers (9). The teen desiring more attention or popularity among her social circle may model the cool marijuana-smoker in the hope of gaining esteem and approval. Indeed, it has been shown that more popular teens are heavily influenced by their peers, even to the point of increasing their “deviant behavior” in order to continue being liked (10). Teens may also want to model the pot-smoker in the attempt to disassociate themselves from the alien refusing marijuana. Again, use of the alien creates undesirable consequences, as it could introduce or reinforce the notion that only those who are foreign, different, weird, and thus probably “uncool” do not engage in illicit drug use. Therefore, the campaign fails to establish correctly which behavior adolescents are more likely to model, and thus may be promoting actions opposite to its intent.

In fact, the notion that adolescents may adopt the nonintended behavior is not merely conjecture. The Westat study also indicated that “those who were more exposed to the Campaign tended to move more markedly in a ‘pro-drug’ direction as they aged than those who were exposed less” (1). Additional evidence of Westat’s finding involves another commercial concocted by the “Above the Influence” campaign, entitled, “Slom” (11). The ad depicts young adults (real actors this time) engaging in slomming, which stands for “sticking leeches on myself”, to create a euphoric effect. The ad concludes with, “What could you be convinced to do?” Before the airing of this commercial, slomming was entirely fictional, and, to the campaign writers, so extremely ridiculous to ever be considered a potential means to get high. Again, this assumption is where the writers ultimately falter, since they disregard the scientific research that has repeatedly indicated adolescents are more prone to risk-taking and sensation-seeking behavior (8). Furthermore, evidence has asserted that adolescents choose risky activities even while being aware and understanding the potential hazards associated with the behavior (12). Accordingly, teens may understand that subjecting oneself to leeches may be harmful, bizarre, and even ludicrous, but some will still try slomming, nevertheless. Thus, the inevitable happened and/or is happening. According to urbandictionary.com, young adults have actually tried slomming since the ads aired, and the act is even gaining “minor popularity” among some groups (13).

3. Slogan and intent are contradictory

The campaign is called “Above the Influence”, emphasizing the fact that teens should be empowered to act on their own volitions instead of catering to popularity or peer influence. All five of the commercials drawn as cartoons depict two figures: one engaging in drug use and the other figure either admonishing, ignoring, or abandoning the pot-smoker. The intent of these ads is to exhibit correct behavior (from the character refusing drugs) that adolescent viewers can model. However, every ad ends with the key message, “Above the Influence”. The fact that the campaign uses Social Learning Theory in its television ads sends a confusing message because modeling behavior is exactly contrary to the campaign’s slogan. Furthermore, “Above the Influence” could just as easily be interpreted to disregard all potential influences in an adolescents’ life, which includes good advice from other peers, parents, teachers, role models, even the ads themselves.

4. A better use of Social Learning Theory, disregarded

One commercial was unique in that it employed Social Learning Theory more successfully. “Grant”, an ad depicting a dedicated, young surfer, was previously aired on television and available on the National Youth Anti-Drug Media Campaign website in the Television Ad Gallery (as of March 1, 2007). To date, its status has been demoted to a print ad, with freeze frames of the commercial lined up on a poster and Grant’s thoughts (“You have to have a quick mind so you can surf harder. I get motivated just by thinking of surfing. I would never think of smoking pot.”) alongside them (14). The stills on the poster that were live action on the commercial include Grant surfing, contemplating on the beach, and bike riding, surf board in tow. In many of the scenes, he is accompanied by his friends, and, especially in the television ad, a sense of camaraderie is notable. There is no pot-smoker or negative image for teens to emulate; Grant’s positive presence is the only figure available to model. Furthermore, adolescents will most likely favorably view the outcome of Grant’s behavior as enjoying his life, having a steady group of friends and being motivated by an activity he likes.

The National Anti-Drug Media Campaign writers fail to realize the significance of purely positive peer influence, which encompasses actions and behaviors that transcend “just saying no” or refusing an unhealthy behavior when offered. One study revealed the protective effect against substance use among adolescents whose friends were involved in “prosocial behaviors (e.g., assisting troubled teens; involvement in school activities)” (15). Grant also represents a peer role model with prosocial behaviors, exhibiting a positive, motivated and focused attitude that can help influence adolescents to find their own passions and interests without resorting to drug use. Some campaign writer understood this important effect of positive peer modeling just by creating the “Grant” commercial, but it seems the leaders and/or majority of the campaign creative staff are not following her stead. Taking “Grant” off the air, only allowing limited viewing of it geographically, visually, experientially and in time, and continuing to air misleading commercials in its place reveals a lack of knowledge about the great potential of positive peer influence as well as an ineptitude about adolescent behaviors.

In conclusion

Social Learning Theory techniques hold great potential to result in the successful adoption of healthy behaviors (and thus, less drug use) in adolescents. However, as revealed in the “Above the Influence” media campaign, faulty implementation of the theory coupled with an ignorance of this group’s characteristics as a whole can lead to unintended and unfavorable consequences. This defective and potentially harmful campaign is still being funded and still currently reaching adolescent audiences. While the federal government seems immune to any evidence against the campaign, the public health community is surely not. We need to connect to our youth with better messages and methods before more resources are wasted, and most importantly, more adolescents are potentially enticed to try unhealthy behaviors.

REFERENCES

1. United States Government Accountability Office. Contractor’s National Evaluation Did Not Find That the Youth Anti-Drug Media Campaign Was Effective in Reducing Youth Drug Use. Washington, DC:GAO 06-818, 2006.
2. Leinwand D. Anti-drug advertising campaign a failure, GAO report says. USA Today. 2006 Aug [cited 2006 Aug 28]. Available from: http://www.usatoday.com/news/washington/2006-08-28-anti-drug-ads_x.htm.
3. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
4. Swadi H. Individual risk factors for adolescent substance use. Drug and Alcohol Dependence. 1999; 55:209-24.
5. Kandel D, Kessler R, Margulies R. Antecedents of adolescent initiation into stages of drug use: a developmental analysis (pp. 73-99). In: Kandel D, ed. Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues. Washington, DC: Hemisphere, 1978.
6. “Not Again”. Television Ad Gallery. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.mediacampaign.org/mg/television.html.
7. Irwin CE, Scott SJ, Burg BA, Cart CU. America’s Adolescents: Where Have We Been, Where Are We Going? Journal of Adolescent Health. 2002; 31:91-121.
8. Martin CA, Kelly TH, Rayens MK, Brogli BR, Brenzel A, Smith WJ, Omar HA. Sensation seeking, puberty and nicotine, alcohol and marijuana use in adolescence. Journal of the American Academy of Child Adolescent Psychiatry. 2002; 41:1495-502.
9. Moffitt T. Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychology Review. 1993; 100:674-701.
10. Allen JP, Porter MR, McFarland FC, Marsh P, McElhaney KB. The Two Faces of Adolescents’ Success With Peers: Adolescent Popularity, Social Adaptation, and Deviant Behavior. Child Development. 2005; 76:747-60.
11. “Slom”. Television Ad Gallery. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.mediacampaign.org/mg/television.html.
12. Benthin A, Slovic P, Moran P, Severson H, Mertz CK, Gerrard M. Adolescent health-threatening and health-enhancing behaviors: A study of word association and imagery. Journal of Adolescent Health. 1995; 17:143-52.
13. Urban Dictionary. “Slom” definition. Urban Dictionary. http://www.urbandictionary.com/define.php?term=Slom.
14. “Grant”. Print Ad Gallery. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.mediacampaign.org/mg/print/ad_grant.html.
15. Prinstein M, Boergers J, Spirito A. Adolescents’ and Their Friends’ Health-Risk Behavior: Factors That Alter or Add to Peer Influence. Journal of Pediatric Psychology. 2001; 26:287-98.

Framing Eating Disorders Matters: Why Health Belief Model Based Programs On College Campuses Are Failing To Have An Impact – Morgan Kutzman

In the United States, 9.3 million adults reported having had suffered from an eating disorder some time in their life, 4.5% of the population (1). Eating disorders are prevalent on the cover of celebrity gossip magazines most every month. Usually a woman is portrayed starving herself obsessed with the desire to be thin, right next to a headline about dieting secrets. It is no wonder people are confused about eating disorders.

The public tends to perceive Anorexia Nervosa as loss of appetite or fear of food, which is a gross over simplification of a complex psychological disease. In reality, very few people with Anorexia Nervosa actually have a loss of appetite (2). Patients with eating disorders suffer from obsessive thoughts and behaviors resulting from depression or anxiety that lead to starvation behaviors (3). Although the media portrays eating disorders with extremely skinny women the medical diagnostic criteria for Bulimia and Binge-Eating disorder do not include the requirement for low body weight; patients of these diseases can appear to have normal body weight (4). Moreover, one fourth of people suffering from the disorders are male (1). The public might believe weight controlling behaviors in eating disorder patients result from an obsession with appearance, in reality these behaviors are how the depression or anxiety the patient is suffering from is managed. Eating disorders result from a complex pathway of risk factors including genetic, neurochemical, psychodevelopmental and sociocultural (4). Similar to any other disease, these risk factors combine into the pathology of eating disorders. Whitaker uses an example of heart disease, which develops from physical factors: production of cholesterol, behavioral factors: smoking and dietary, and psychological factors: type A vs. type B personality. These all contribute to the development of the disease. Although behavioral factors contribute to heart disease it is never portrayed as an individual’s responsibility (5). In comparison eating disorders have many risk factors, but they are portrayed mostly as being an individual’s responsibility.

The college social environment is complex; many students may feel overwhelmed by the responsibility of being on their own, handling difficult course work, pressure to fit in and find a social group. This can lead to feelings of loss of control, which for some can be fulfilled by controlling weight and restricting diet (6). The shift in student’s social context can be triggering to those already at risk for the development of an eating disorder. Behaviors such as restricting diet, use of diet pills, and excessive exercise are common among college students, 61% have reported these behaviors (6). There is a line between the psychological illness of an eating disorder with behavioral and clinical profiles, and eating disordered behaviors (5). When college students are surrounded by these behaviors, it can be difficult to distinguish a psychological illness (6). The prevalence of these disordered eating behaviors, and the social context of college life contributes to the high prevalence of eating disorders on college campuses.

Eating disorders, which affect 5-7% of college students, have underlying factors, including the need for control, anxiety, and depression, that are not usually recognized (6). Intervention programs for eating disorders on college campuses are mainly centered on the Health Belief Model and aim to impact individuals’ behaviors by influencing their attitudes and intentions about eating disorders. Most of the programs frame eating disorders as a concern with food, body image, and a desire to appeal to the opposite sex. Research has shown this approach is ineffective; moreover, the prevalence of eating disorders among college students is increasing (7, 8). Some researchers argue that intervention programs that implement a social model and present how one feels with a healthy body image may improve success (7). Eating disorders are about more than food; they have complex underlying factors. Reframing the diseases can help redesign college campus intervention programs.

Society frames eating disorders as an obsession with food, a woman’s fear of being fat, obsessions with appearance, and desire to appeal to the opposite sex. The public then perceives the diseases as an individual’s responsibility or something they have control over. This frame does not address the underlying issues of depression, the need for control, and anxiety. People’s understanding of the diseases and the way interventions are designed are based on the frame. A frame is a “label the mind uses to find what it knows” (9), which is a powerful tool in public health because the language used by public health practitioners to frame a problem can generate support or lack thereof. In addition, the frame dictates what people perceive to be the truth, thus facts about a certain disease will be ignored unless they fit in the frame (10). Eating disorders are framed as personal responsibility, which requires public health practitioners to develop interventions that focus solely on individual’s behavior change (9).

The public’s perception of eating disorders is reflected in the designing of prevention and interventions programs. The first goal in planning an intervention for college students should be to understand the social environment of the student, then the disease (6). Traditional interventions on college campuses serve to educate about the diseases and where to go for help, but may only change an individuals’ intentions and attitudes about eating disorders (7). Education alone does not provide them with the motivation to change their behaviors; it does not address the underlying depression, anxiety or loss of control the students are suffering from. The programs may even make some more aware of their body image, further perpetuating eating disorder behaviors (11). Intervention programs succeed at increasing knowledge about eating disorders, but a study by Carter shows knowledge does not correlate with behavior change. Furthermore, at the six month follow up participants has significantly increased their eating disorder related behaviors (11).

Martz studied interventions for college students designed to provide education about eating disorders and referral resources. The educational sessions were preceded by information on perceived body size, and techniques for increasing ones own body image. Results of the study showed minimal effects. Additionally, the intervention was redesigned implementing emotional persuasive content, but was repeated with no improvement. The researchers felt that the interventions should have focused on showing how it feels to have a healthy body image, and clarified the distinction of improving body image vs. improving physical appearance (7).

A different study, by Becker focused on interventions targeting individuals’ awareness of the risks associated with eating disorders. Results showed after the intervention, 81% of participants reported being aware of the disease and were confident about accessing recourses for treatment, yet only one half of the subjects recommended for treatment followed through. The authors found it concerning participants who felt educated and had access to care, decided not to pursue treatment. The presumed barriers: lack of information and treatment resources, did not factor into individuals seeking care (8). The model used for the interventions made the programs insufficient; it educated the participants on the dangers of eating disorders but could not influence their health behaviors.

The Health Belief Model links the three example studies. The model caused the interventions to be focused on individuals’ health behaviors and their perceptions of eating disorders. The programs, through education about the costs and benefits of eating disorders, should have provided individuals with motivation to change their behavior (12). The Health Belief Model leaves no room to account for the influences of the individuals’ objective environment (13). The environment college students live in is associated with the diseases, but it is not addressed in interventions based on the Health Belief Model (6). Interventions that focus on “blaming the individual,” and do not include community level factors have a small effect (13). Framing eating disorders at the individual level causes innervations on college campuses to focus on changing individuals’ behavior with out regard to the social context of the diseases.

On college campuses, most of the behaviors associated eating disorders are socially accepted and not recognized as being the development of diseases (6). When unhealthy behaviors are thought to be the norm in a social group, such as college campuses, the urge to conform affects behaviors. Social Norm Theory aims to promote accurate norms of health and safety (14). In contrast to the Health Belief Model, this allows for the interventions to address the social context of the diseases. The Health Belief Model focuses on the individual, without regard to the individuals’ social experience (15). College students are at increased risk for feelings of anxiety and loss of control, especially freshmen because of their new social environment (6). Eating disorders often develop out of these underlying risk factors; individuals find control by controlling food intake and their weight (16). In the social context of college, behaviors associated with eating disorders are not recognized as diseases, supported by the misperception that “everyone” partakes in food and weight control (6).

Social Norm Theory accounts for individuals’ perception of social norms in their group. Health behaviors perceived to be the norm influence individuals’ actions (14). High-risk groups can be targeted with comprehensive programs using positive messages and normative feedback, and important aspect of the theory (17). Eating disorder behaviors thought to be common and socially accepted among college students adds to the problem of misperception.

Eating disorders are framed by the public as diseases only about food and an individuals struggle to control their weight. The public’s perception of the diseases influences how interventions are designed. When public health practitioners consider eating disorders an individual issue, interventions target individuals’ behavior. Significantly higher prevalence of the diseases exists on college campuses partially because social factors of college life can contribute to the development of the diseases. Health Belief Model based interventions fail to address the social context in which eating disorders occur rendering them ineffective on college campuses. Social Norm Theory takes into account the influences of the social group with regards to individuals’ health behaviors. In order for the public health community to successfully design interventions for eating disorders on college campus, perceptions of the disease must first change. Reframing eating disorders in the correct way, having interventions focus on increasing awareness about the underlying issues, and including the contribution from social factors; may help to decrease the prevalence of eating disorders on college campuses.

References

1. Gellene, Denise. “Eating disorders a guy thing too, study finds.” Los Angeles Times February 1, 2007.

2. Halmi, Katherine. “Psychopathology of Anorexia Nervosa.” International Journal of Eating Disorders 37 S20-S21, 2005.

3. Sodersten, Per, Cecilia Bergh, and Michel Zandian. “Understanding eating disorders.” Hormones and Behavior; 50:572-578 (2006).

4. Becker, Anne, Steven Grinspoon, Anne Klibanski, and David Herzog. “Eating Disorders.” New England Journal of Medicine; 340:1092-1098 (1999).

5. Whitaker, Leighton. “The Bulimic College Student: Evaluation, Treatment and Prevention.” Haworth Press Inc., NY 1989.

6. Knowlton, Kerry. “The Beast Within: An Exploration into Eating Disorders among College Women.” Journal of Student Affairs; 10:2000-2001. Accessed February 13, 2007 .

7. Martz, Denise M. “Eating disorders preventions programming may be failing: Evaluation of 2 one-shot programs.” Journal of College Student Development; Jan/Feb 1999. Accessed February 2007 .

8. Becker, Anne, Debra Franko, Karin Nussbaum, and David Herzog. “Secondary Prevention for Eating Disorders: The Impact of Education, Screening, and Referral in a College-Based Screening Program.” International Journal of Eating Disorders 36: 157-162, 2004.

9. Dorfman, Lori, Lawarnce Wallack and Katie Woodruff. “More than a message: Framing Public Health Advocacy to Change Corporate Practices.” Accessed March 2007. .

10. Chua, Kao-Ping. “Introduction to Framing.” Accessed March 2007 .

11. Carter, JC. “Primary prevention of eating disorders: Might it do more harm then good?” International Journal of Eating Disorders; 22:167-172, 1997.

12. Salazar, Mary Kathryn. “Comparison of Four Behavioral Theories.” AAOHN Journal; 39: 128-135, 1991.

13. Marks, David. “Health Psychology in Context.” Journal of Health Psychology; 1:7-21, 1996.

14. Haines, Michael. “Best Practices Social Norms.” Accessed March 2007 .

15. Thomas, Linda. “A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education.” Journal of Professional Nursing; 11:246-252.

16. Walter H. Kaye, M.D., Cynthia M. Bulik, Ph.D., Laura Thornton, Ph.D., Nicole Barbarich, B.S., Kim Masters, B.S. and the Price Foundation Collaborative Group. “Co morbidity of Anxiety Disorders With Anorexia and Bulimia Nervosa.” American Journal of Psychiatry; 161:2215-2221, 2004.

17. Berkowitz, Alan. “Higher Education Center: The Social Norms Approach: Theory, Research and Annotated Bibliography.” Accessed March 2007 .

A Critique of the CFDA Health Guidelines: Addressing the Issue of Overly Thin Runway Models or Simply Paying Lip Service? - Marie Elaine Pahilan

On August 2, 2006, Luisel Ramos, a 22 year-old model from Uruguay fainted on her way to the dressing room after taking her turn on the catwalk. She died of heart failure due to anorexia nervosa. At the time of her death, the 5 foot 9 inches model weighed 98 lbs with a body mass index (BMI) of 14.5.

On October 25, 2006, Ana Carolina Reston, a 21 year-old model from Brazil was hospitalized for kidney malfunction due to anorexia nervosa and bulimia. On November 15, 2006, she died due to kidney failure. At the time of her death, the 5 foot 8 inches model weighed 88 lbs with a BMI of 13.4.

The death of Luisel Ramos, weeks before the Fall Fashion Shows, brought attention to the increasingly slim models gracing the catwalks. On September 13, 2006, Spain’s top fashion show made international headlines deciding to enact a government ban on underweight models during Madrid Fashion Week. The ban kept models with a BMI of less than 18 off the runways. The World Health Organization standard states that anyone with a BMI of less than 18.5 is underweight. (1) For a model who is 5 foot 9, the weight requirement would be 126 lbs. Over 30% of models who participated in the Madrid Fashion Show in 2005 were deemed ineligible due to the ban. In Milan, models now need to present a doctor’s certificate of good health before they will be allowed to walk in shows. Designers participating in the Milan shows agreed not to hire models younger than 16 and underage models must be chaperoned.

During New York’s Fall Fashion week in September, Tim Gunn, chairman of the fashion design department at Parsons the New School for Design commented, ‘Some of the girls caused you to gasp. When the knee joint is wider than the thigh, it can be scary.” These events and commentaries similar to Mr. Gunn’s, spurred the Council of Fashion Designers of America (CFDA) to take action.

The CFDA is a not-for-profit trade association for America’s fashion and accessory designers. It was founded in 1962 to “advance the culture of fashion design as a branch of American art and culture.” (2) Following the deaths of the two runway models and the decision in Spain to ban models who do not meet the minimum BMI, the CFDA formed the Council of Fashion Designers of America Health Initiative. The goal of this group was to address the issue of models who are unhealthily thin. The Health Initiative members included Diane von Furstenberg, designer and president of the CFDA, Susan Ice, M.D., the medical director of the Renfrew Center (a treatment center dedicated exclusively on the treatment of eating disorders), nutritionists, modeling agents and physical trainers.

On January 12, 2007 the CFDA Health Initiative presented their recommendations for the fashion industry prior to New York’s Spring Fashion Week. These recommendations included: 1) educating the industry to identify early warning signs in an individual at risk of developing an eating disorder, 2) requiring these individuals, once identified, to seek professional help, 3) developing workshops for the fashion industry on the nature of eating disorders, 4) supplying health meals, snacks, and water backstage and at photo shoots and providing nutrition and fitness education, and 5) promoting a healthy backstage environment by raising the awareness of the impact of smoking and addressing underage drinking by prohibiting alcohol. The recommendations also included keeping models under the age of 16 off the runways and not allowing models under the age of 18 to work at fittings and photo shoots past midnight. (3)

The guidelines officially introduced by the CFDA Health Initiative rely heavily on the idea of educating models and their families as a means of promoting healthy lifestyle choices. The idea of education as a means of intervention stems from the Health-Belief Model. The health-belief model is a social-behavioral model that posits that the intention to change behavior stems from a weighing of the perceived susceptibility and perceived risks of developing a disease against the perceived barriers against accomplishing the behavior change. (4) By basing their intervention on the health-belief model the CFDA Health Initiative assumes that the barriers to healthier lifestyles and eating habits outweigh the risk and perceived susceptibility of runway models. This is not necessarily the case.

To the designers, runway models are walking hangers for their designs. It is the designers who call modeling agencies and inform them of the type of models they want for their shows. Many models believe that being slim is the only way they are going to get any runway work. In 2004, Ana Carolina Reston, on her first overseas casting call in China, was told by the casting directors she was ‘too fat.’(5) At the CFDA Health Panel on February 5, 2007, model Natalia Vodianova, the face of Calvin Klein, spoke of how after giving birth to her first child, she weighed 117 lbs. Designers complained that she no longer fit the clothes and her weight dropped to 106 lbs. Following the weight loss, Ms. Vodianova became one of the fashion industry’s most sought after runway models. This creates a perception within the modeling community that not being extremely slim will prevent a model from booking shows. Health guidelines based on the health-belief model do not take into account that the potential loss of livelihood is an enormous barrier to models.

The health-belief model is one that focuses on the individual and does not take into account the outside forces that affect an individual’s behavior. Many runway models come from poor backgrounds. By modeling they become the breadwinners for their entire family. Ana Carolina Reston’s father was diagnosed with Parkinson’s and Alzheimer’s when she was a young teen. After winning a beauty contest at 14, she signed with Ford Modeling Agency and provided for the rest of her family. (5) Natalia Vodianova presented a similar story of growing up poor in Russia at the CFDA Health Panel. (6) Responsibilities to families are another barrier that may prevent models from adopting a healthier lifestyle.

The CFDA Health Initiative guidelines also do not take into account that many of these models are extremely young. At 16, models can take to the runway. These guidelines do not take into account that adolescents respond to health matters in a way that is not always rational. The health-belief model assumes that an individual will always make rational decisions. Adolescents do not always respond rationally when presented with the potential outcomes of their actions. Adolescents respond better to short-term negative effects as opposed to long-term negative effects. (7) Telling a 16 year-old that if she is too skinny she may suffer kidney failure and heart problems is not sufficient. These are abstract dangers. It would be more effective to emphasize that being extremely thin will cause her hair to fall out.

The approach for change outlined by the CFDA relies wholly on education. This type of approach for changing human behavior is an empirical-rational strategy. (8) The two main assumptions in this type of strategy are that humans are rational beings and that once the rational course is revealed to them; people will adopt the behavior change. I have already discussed how assuming rational responses in the modeling population, especially from teen models, is not a proper assumption; further showing how the guidelines put forth by the CFDA do not effectively address the problem of overly thin models.

Another strategy is a normative-re-educative approach (8), which uses the power of persuasion to change behavior. To see this behavior change, it is necessary to change the social norms of the population, a change in attitudes and values in addition to education. Simple persuasion would not be enough for models, because even if they can be persuaded, even if they believe that changing their eating habits is the best choice, the standard body type in the modeling community is not decided by the models themselves. For such an attitude and value change to occur in the fashion industry, the CFDA would have to focus their intervention on the designers and persuade them to use size 4 and size 6 dress forms in creating sample clothing as opposed to the current norms of size 0 and size 2 samples. Thus far, designers have been resistant in changing sample sizes.

In this scenario, the most effective strategy for change is a power-coercive approach (8). This approach demands the compliance of the target population, by enacting laws or enforcing bans to bring about changes in behavior. This is the path the Spanish government has taken. Ban models whose BMI is below the WHO standard from the runway. In an atmosphere where education is not enough to change behavior and persuasion is useless if other parties will not help the modeling community in achieving a healthier lifestyle, the option you are left with is coercion. If models are banned from the runway when they are anorexic and overly thin, designers will have to change their standards; otherwise they will no longer be able to show their designs.

The CFDA should be commended for addressing the issue of overly thin models. While I do not feel that the guidelines are enough to protect models and promote healthier lifestyles, it is the first step the American Fashion Industry has taken. A ban on models with a BMI lower than the WHO standards would be another step in the correct direction. If, as I argue, the problem with the guidelines is that they incorrectly assume that the barriers to healthier lifestyle decisions do not outweigh the risks of being overly thin because the potential loss of livelihood is too great a barrier, then setting a minimum BMI would completely remove that barrier. Unless they are a healthy weight, their livelihood would be gone. If fashion designers continue to produce clothing for overly thin models and a ban is in place, they will soon find themselves without models to show their clothes and will also find their livelihood gone.

It is important that the Fashion Industry continue to move away from the overly thin model as the ideal. Fashion and the models the industry employ set the standard of beauty that the public strive for. The image portrayed on the runway will affect the decisions of the teenage girl reading Vogue and Cosmopolitan, watching Project Runway and America’s Next Top Model (9, 10).

On February 13, 2007, Eliana Ramos, an 18 year-old model from Uruguay, was found dead in her grandparents’ home. Preliminary examinations indicate the cause of death was heart attack due to malnutrition. She was the younger sister of Luisel Ramos.

REFERENCES

1. World Health Organization. Physical Status: The Use and Interpretation of Anthropometry. Geneva, Switzerland: WHO Technical Report Series, 1995.

2. Council of Fashion Designers of America. http://www.cfda.com.

3. Council of Fashion Designers of America. Council of Fashion Designers of America Health Initiative. New York, NY: Council of Fashion Designers of America, 2007.

4. Rosenstock IM. Historical Origins of the Health Belief Model. Health Education Monographs 1974; 2:328-335.

5. Phillips T. Everyone knew she was ill. The Observer. January 14, 2007.

6. Karimzadeh, M. At CFDA Health Panel, A Model’s Story. Women’s Wear Daily. February 6, 2007.

7. Kunter L. Holiday drinking opens adolescents’ eyes to alcohol. The New York Times 1991; p.C9.

8. Chin R, Benne KD. General strategies for effective change in human systems (pp. 22-45). In Bennis W et al. eds. The Planning of Change (3rd edition). New York: Holt, Rinehart and Winston, 1976.

9. Botta RA. Television Images and Adolescent Girls’ Body Image Disturbance. Journal of Communication, 1999.

10. Field AE, et al. Exposure to the Mass Media and Weight Concerns Among Girls. Pediatrics 1999; 103:36-40.

Why Local Board of Health Regulations are Ineffective in Addressing the Public Health Impacts of Animal Hoarding-Kathleen MacVarish

The Massachusetts Constitution (1) provides governmental powers to cities and towns which allow for the adoption of local ordinances and by-laws. This is commonly referred to as home rule. Further, the Massachusetts General Laws Chapter 111: Section 31 provides authority for Boards of Health to make reasonable health regulations (2). In Massachusetts there are 351 cities and towns which are governed by either a Board of Health or Health Commission; either governing body has the ability to adopt local health regulations. This authority has resulted in the adoption of many local regulations that impact public health covering areas such as abrasive blasting, body art, dredging, dumpsters, hazardous materials, land application of sludge and tobacco (3).

Background
In the summer of 2005 the Randolph Board of Health received a housing complaint involving a single family home and an excessive number of cats living in the home. Boards of Health in Massachusetts are charged with enforcing the State Sanitary Code 105 CMR 410.000: Minimum Standards of Fitness for Human Habitation (4). The Randolph Board of Health Agent obtained permission to enter the home for inspection along with the Massachusetts Society for Prevention of Cruelty to Animals (MSPCA). A cat hoarding situation was identified and the Board of Health, in close cooperation with the MSPCA, took immediate action. Approximately 25 cats were removed from the home by the MSPCA and the Board of Health initiated enforcement efforts to achieve compliance with the minimum standards set forth in the State Sanitary Code.

To resolve this case considerable time and effort were expended by the Board of Health members and the Board of Health staff. The workload stressed the resources of this small town department (3 staff members and 3 volunteer Board of Health members). In an effort to preserve the Board’s limited resources and to prevent future cat hoarding issues in the town, the Board adopted a regulation that stipulated that no person within the Town shall keep more than three cats/kittens and if they do, they shall be punished with a fine (5).

Failure to Consider the Complexities of Hoarding Behavior
Hoarding is a complex behavior associated with many different mental disorders and has been defined as “the accumulation of possessions that are useless and that interfere with the ability to function” (6, 7). While severe hoarding has serious health consequences, the information available about this behavior is diverse, not well integrated and lacking in details about the frequency and severity of the problem. Also lacking is an understanding of the nature of compulsive hoarding (is it a symptom of another disorder or one in its own right?), a formally recognized diagnosis and successful treatment options (8, 9).

Efforts have been made to characterize this multi-faceted problem and a systematic definition with three characteristics has been proposed by Frost and Hartl (10 p. 906):
1. The acquisition of, and failure to discard a large number of possessions that appear to be useless or of limited value;
2. Living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed;
3. Significant distress or impairment in functioning caused by the hoarding.

The reasons that local Boards of Health get involved in hoarding cases include concerns for the health and safety of the individual hoarders, their families, their neighbors, and the general public. These concerns include fire hazards, egress issues, safety (trip and fall) hazards, health concerns, and lack of access for emergency personnel. These are difficult cases to manage as individuals who come to the attention of the Board of Health for hoarding face possible home eviction, homelessness, enforcement orders, court actions, and expensive cleanup efforts. They also face pressure from family, friends and neighbors and may suffer from anxiety, shame, helplessness and frustration (11).

The hoarding of animals is even less well understood than general hoarding behavior and there is a lack of scientific attention, psychiatric research, formal recognition and systematic reporting for it (12, 13, 14). As with general hoarding behavior, what distinguishes the syndrome is not how many items are accumulated or collected (in this case animals) but the fact that the individual is overwhelmed by the ability to provide acceptable care. Dr. Patronek defined an animal hoarder as “someone who has accumulated a large number of animals, which has overwhelmed that person’s ability to provide even minimal standards of nutrition, sanitation and veterinary care; failed to acknowledge the deteriorating condition of the animal (including disease, starvation and even death) and the household environment (severe overcrowding, very unsanitary conditions) and failed to recognize the negative effect of the collection on his or her own health and well-being, and on that of other household members” (15, p. 1).

Animal hoarders may have dozens to scores of animals in their home; both living and dead. When officials get involved, many animals face euthanasia due to poor health (from inadequate living conditions and inadequate medical care) and poor socialization. Self-neglect and neglect of dependent family members is of real concern and sanitary conditions in the home can also deteriorate to the point that officials may have to consider condemnation. Frequently observed sanitation problems include: an accumulation of feces and urine; filth of the dwelling, furniture and other items; and inoperative appliances and basic utilities. Additional health hazards are created for the residents and neighbors that include exposure to zoonotic diseases, respiratory irritants (ammonia), potential insect and rodent infestations and community nuisance odor conditions (13, 15).

The Regulation that the Randolph Board of Health adopted failed to recognize that hoarding behavior, especially when animals are involved, is a complex issue that is not well understood and is difficult to diagnose and treat. A regulation that simply states that you can not have more than three cats will have little impact on an individual who exhibits hoarding behavior.

Failure to Consider the Transtheoretical and Cognitive Behavior Therapy Models
Compulsive hoarding is traditionally thought of as a condition where the hoarder is resistant to treatment. In fact, many hoarders don’t recognize they even have a problem. Animal hoarders not only lack insight into their living conditions but are often in denial about the risks and harm to the animals that they claim to love; they often strongly believe that they are providing proper care (13). However, research studies show that dead or sick animals were discovered in 80% of reported cases and nearly 60% of the hoarders involved would not acknowledge a problem (14). This denial and the lack of successful treatment models lead to a high recidivism rate; estimated to be between 60% – 100% (14, 16).

Despite these facts, after one animal hoarding incident in Randolph, the Board of Health quickly decided to adopt a local regulation at their September 12, 2005 meeting, to be effective on Monday, October 3, 2005. This simple, four paragraph (187 word) regulation states little more than “No person, firm or corporation shall keep within the Town, in any building, or on any premises…. or house any more than three cats/kittens for a period of time not to exceed six weeks… whoever violates any provisions of the foregoing regulation or order made thereunder shall be punished by a fine of $25.00 dollars for each day such violation continues”.

The Board of Health crafted and adopted this regulation without public input and without discussion with interested stakeholders such as the Board of Selectmen, Animal Control Officers, local Veterinarians and mental health experts, and the Town’s Animal Welfare Committee. The Regulation provided no treatment options or community resources and certainly did not account for any of the complex social and behavioral issues that surround hoarding behavior.

The Randolph Board of Health should have considered the transtheoretical and the cognitive behavior therapy models to develop an approach to deal with the public health impacts of hoarding behavior. The Transtheoretical Model (TTM) has three components: states of change, processes of change; and levels of change. There are five stages of change (precontemplation; contemplation; preparation; action; maintenance) that are facilitated by different processes. These different processes must be matched to the particular stage an individual is in for effective treatment (17). As explained above, hoarders exist in the pre-contemplation stage; they are not even considering changing their behavior because they are unaware they have a problem. When these matters come to the attention of public health officials or concerned family members, hoarders can be moved to the contemplation stage. While they may now have some understanding that they do indeed have a problem, many are ambivalent or even unwilling participants, in treatment (18).

If hoarders are successfully moved through the contemplation stage and into the preparation stage, cognitive behavior therapy (CBT) has been shown to have some success (18, 19). The CBT model suggests that the symptoms of hoarding (excessive acquisition, difficulty discarding and clutter) are the result of three factors: information processing deficits; maladaptive beliefs about, and emotional attachment to, possessions; and emotional distress and avoidance (20). CBT helps patients to organize, to make decisions, to distinguish between items of real and perceived value and to begin the cleanup. The patient must be made aware that treatment is a long and difficult process (18).

If hoarders move into the action stage, the CBT model can be utilized to develop a treatment protocol. One treatment protocol proposed by Tolin et al. involves a multi-method assessment and motivational interviewing to evaluate the patient and plan the treatment. These sessions take place in the therapist’s office and in the patient’s home. The treatment plan involves interventions that target the three manifestations of hoarding: disorganization, compulsive acquisition and difficulty discarding (20). Successful treatment of hoarding is rare but if one is successful, the maintenance stage is critical to avoid recidivism. Further research is needed to explore effective hoarding treatments (19).

The Randolph Board of Health should have considered the complexities and the unknowns when it comes to successful treatment of hoarding behavior when they developed their plan of action to address hoarding in their community. They should not have relied only on a punitive regulation which does not take into account the necessity of treatment for this problem.

Failure to Consider Addiction Models
Similarities have been noted between hoarders and others with impulse control problems such as substance abusers and compulsive gamblers (15). An addictions psychiatric model has been suggested for animal hoarding due to the similarities to substance abuse: preoccupation; denial of the problem; excuses for the behavior; social isolation; and self-neglect (14). Due to these similarities, the Randolph Board of have should have given consideration to the unsuccessful attempts to control substance abuse with punitive measures during their regulation development process.

Decades of research on substance abuse and the criminal justice system illustrate that punitive measures such as imprisonment and fines are not effective at preventing or controlling the addictive behavior. In fact, the percentage of drug offenders in the federal prison system has increased from 25% in 1980 to 59% in 1998 despite stricter drug laws, “three strikes and you’re out”, and mandatory minimum sentencing. Untreated substance abusers are more likely to relapse and resort to criminal behavior. What does seem to work is treatment of the substance abusers and it has been estimated that for every dollar invested in treatment, approximately $7 in future costs are saved (21, 22, 23).

Successful treatment requires an appreciation for the cognitive and behavioral processes that influence personal choice; punishing individuals rather than understanding these processes won’t lead to successful rehabilitation (24). A treatment approach with multiple options that integrate public health and public safety is an effective strategy for reducing crime and substance abuse (25).

In response to efforts by communities to prosecute animal hoarders Dr. Patronek states “Besides being inefficient and expensive, this moves what may be a mental or public health issue into the criminal justice arena, which can impede timely recognition of important health issues and delivery of needed services….Prosecution offers at best an incomplete solution…” (12, p. 86).
Regulators whose goal is to address the public health impacts of hoarding should incorporate this body of knowledge into their approach. While an initiative may include the adoption of regulations, it should not be the only solution. There must also be recognition of the social and behavioral factors that influence individuals and impact effective treatment options. A suggestion for a successful community initiative to address hoarding behavior includes creating a community task force which will work to: identify community resources (i.e. mental health agencies, legal aid services); identify individual resources (i.e. health insurance); initiate connections to these resources; provide information and referrals; and develop programs to treat hoarders (11).

Conclusion
While the actions of the Randolph Board of Health were well-intended and properly executed they failed to address the actual root cause of the behavior that created the public health problem and were therefore futile. Other communities have attempted to prevent or remedy hoarding by passing local ordinances similar to Randolph’s but there is no data to support their effectiveness. What the literature and news reports indicate is that these regulations are “widely unpopular, difficult to enforce, and likely to be opposed by a broad coalition of pet fanciers, breeders, rescue groups, and animal protection organizations” (15, p. 3). For a number of reasons the Randolph Board of Health did rescind their regulation in January of 2006. Residents quoted in the local newspaper summed up the issue: “The proposed three cat limit in Randolph is an awful idea. While wanting to prevent animal hoarding is admirable, the people who hoard will not care about the limit” (26) and “… the regulation didn’t address the problems” of hoarding and the health issues they cause (27).

References
1. Massachusetts Government. Massachusetts Constitution. http://www.mass.gov/legis/const.htm.
2. Massachusetts Government. Massachusetts General Laws. http://www.mass.gov/legis/laws/mgl/111-31.htm.
3. Massachusetts Association of Health Boards. http://www.mahb.org/Library/library.htm.
4. Massachusetts Government. State Sanitary Code. http://www.mass.gov/Eeohhs2/docs/dph/regs/105cmr410.pdf.
5. Randolph Board of Health. Cat Regulation adopted on Monday, September 12, 2005. Randolph, MA, 2005.
6. Maier, T. On Phenomenology and Classification of Hoarding: A Review. Acta Psychiatrica Scandinavica 2004; 110(5): 323.
7. Frost R, Steketee G, Williams L. Hoarding: A Community Health Problem. Health & Social Care in the Community 2000; 8(4): 229.
8. Frost R, Hartl L. A Cognitive-Behavioral Model of Compulsive Hoarding. Behavioral Research and Therapy 1996; 34(4):341-50.
9. Obsessive Compulsive Foundation Compulsive Hoarding Website. Roadblock to Successfully Treating Compulsive Hoarding. New Haven, CT: http://www.ocfoundation.org/hoarding/treatment.phpttp.
10. Sketekee G, Frost R. Compulsive Hoarding: Current Status of the Research. Clinical Psychology Review 2003; 23: 905-927.
11. Hoarding Task Force. Hoarding: Too Much Clutter—A Resource Guide. Hampshire, Hampden & Franklin Counties, MA.
12. Patronek G. Hoarding of Animals: An Under-Recognized Public Health Problem in a Difficult to Study Population. Public Health Reports 1999; 114: 81-88.
13. Hoarding of Animals Research Consortium. Health Implications of Animal Hoarding. Health and Social Work 2002; 27(2) 125-136.
14. Frost R. People Who Hoard Animals. Psychiatric Times 2000; 17(4).
15. Patronek G. The Problems of Animal Hoarding. Municipal Lawyers 2001; 19: 6-9.
16. Patronek G. Animal Hoarding: A Public Health Problem Veterinarians can take a Lead on Solving. Journal of the American Veterinary Medical Association 2002. http://www.avma.org/onlnews/javma/oct02/02105a.asp.
17. Wikipedia. Transtheoretical Model. http://www.wikipedia.org/wiki/Transtheoretical_Model.
18. Obsessive Compulsive Foundation Compulsive Hoarding Website. Motivation and Compulsive Hoarding Treatment. New Haven, CT: http://www.ocfoundation.org/hoarding/treatment.phpttp.
19. Frost R, Skeketee G, Kamala A, Greene M. Cognitive and Behavioral Treatment of Compulsive Hoarding. Brief Treatment and Crisis Intervention 2003; 3 (3): 323-337.
20. Tolin D, Frost R, Steketee G. An Open Trial of Cognitive-Behavioral Therapy for Compulsive Hoarding. Behavior Research and Therapy 2007; 1(1).
21. Executive Office of the President Office of National Drug Control Policy. Drug Treatment in the Criminal Justice System. Drug Policy Information Clearinghouse Fact Sheet, 2001.
22. National Institute of Health National institute on Drug Abuse. Treatment for Drug Abusers in the Criminal Justice System. NIDA Info Facts, 2006.
23. National Library of Medicine TIP 44. Substance Abuse Treatment for Adults in the Criminal Justice System. http://www.ncbi.nlm.nih.gov/books.
24. Committee on the Addictions of the Group for Advancement of Psychiatry. Responsibility and Choice in Addiction. Psychiatric Services 2002; 53(6) 707- 713.
25. American Correctional Association On the Line. The National Criminal Justice Treatment Practices Survey. 2004 27(3).
26. Patriot Ledger Article. Reader’s View: Cat Limits Awful. November 18, 2005. http://www.ledger.southofboston.com/articles/2005/11/18/opinion/opin04.txt.
27. Patriot Ledger Article. Cat Limit on Hold, Could be Ending Ninth Life. November 29, 2005. http://www.ledger.southofboston.com/articles/2005/11/29/news/news07.txt.

New Look, Same Problem: A Critique Of The Food Guide Pyramid’s Continued Reliance On The Health Belief Model For Obesity Prevention – Alison Little

Obesity is perhaps the most widely discussed public health problem in the United States today. Americans receive information about the benefits of good nutrition and the health risks of obesity from several sources. Physicians and other healthcare providers counsel individual patients about these topics. At the population level, people receive information from the media and the government’s obesity prevention initiatives, including the Food Guide Pyramid (1). The Food Guide Pyramid is an educational tool designed by the United States Department of Agriculture (USDA) to promote healthy food choices. The Pyramid was recently redesigned as part of an attempt to address America’s growing obesity problem (2). However, most of the revisions focused on the Pyramid’s nutritional recommendations. The new Food Guide Pyramid still fails to take into account social and behavioral factors that influence eating behaviors, and for this reason it is destined to fail as an obesity prevention tool.

Definition, Prevalence and Consequences of Obesity and Overweight

CDC defines obesity and overweight using body mass index (BMI), which is a measure of weight for height. Adults with BMIs over 25 are considered overweight, and those with BMIs greater than 30 are considered obese (3). A child is classified as overweight if her BMI exceeds the 95^th percentile for her age. A child whose BMI is between the 85^th and 95^th percentile for age is considered at risk of becoming overweight. CDC does not define obesity in children under 18 (4).

In 2004, nearly one third of US adults were obese, and another third were overweight. In addition, approximately half of all children in the US were overweight or at risk. The prevalence of obesity and overweight has been increasing in the United States among all demographic groups for more than two decades. However, the problem is not distributed uniformly throughout the population. Black Non-Hispanics and Mexican Americans are more likely to be overweight or obese than White Non-Hispanics (5). The prevalence also increases as income and educational levels decrease (6).

The consequences of obesity are numerous and far-reaching. These consequences affect obese individuals as well as society at large. Obese individuals are at increased risk of developing serious medical conditions such as type II diabetes and heart disease. These individuals may also struggle socially, as they are often perceived as less intelligent and hardworking than their peers. Obesity’s economic costs for society are substantial. Such costs include publicly-financed medical care for the obese as well as decreased workforce productivity due to obesity-associated morbidities. The costs of decreased productivity alone total more than $20 billion per year in the US (7).

The Role of the Food Guide Pyramid in Obesity Prevention

The US government’s obesity prevention methods center on the Health Belief Model. The Health Belief Model states that when confronted with a health decision, individuals rationally evaluate their own likelihood of being affected by a disease as well as the benefits of and barriers to behavior change. They then develop the intention to change and accordingly change their behaviors (8). The role of the Food Guide Pyramid is to eliminate barriers and facilitate behavior change by providing the public with accurate information about healthy diets.

Originally developed in the early 1990s, the Food Guide Pyramid was revised in 2005 to provide more accurate nutrition information to the public (2). The content of the Pyramid was improved in several ways. For example, the new Pyramid differentiates between refined and whole grains and low and high fat dairy products. It also provides somewhat individualized recommendations and emphasizes the role of exercise in a healthy lifestyle (1).

While its content has improved substantially, the Pyramid itself remains committed to the Health Belief Model as a means of changing eating behavior. It assumes that all individuals have the desire and capacity to develop healthy eating habits. Once provided with the necessary nutrition knowledge, they will successfully adopt healthier diets, leading to weight loss or maintenance. Unfortunately, research suggests that this view is far too simplistic to support long-term dietary improvements and reverse the current obesity trends. The remainder of this critique will examine the ways in which the assumptions underlying the Food Guide Pyramid are flawed.

The Influence of Social, Emotional and Cultural Factors on Eating Behavior

Q: “And how often do you eat beans?”

A: “Oh, everyday. Haitian people eat beans everyday, honey.”

The success of the Food Guide Pyramid as a behavior modification tool rests on the assumption that eating behavior is entirely rational. Research suggests that this is not necessarily the case (9). Food choices can be determined by social, emotional and cultural factors as well as by subconsciously developed habits. For example, individuals may prefer and choose certain foods to which they were exposed as children. They may also prepare foods that their family members will eat and enjoy, even if these are not the healthiest options. These behaviors can become so ingrained in people’s everyday lives that they cease to become conscious choices. People may also use unhealthy foods as rewards for good behavior. After maintaining a healthy diet for a period of time, individuals may feel that they deserve a favorite unhealthy snack. Exceptions may also be made at restaurants or during holidays (9).

Cultural factors can also mediate food choices. The statement that “Haitian people eat beans every day” is an excellent example of an individual’s identification of a specific eating behavior with her culture. While the cultural norm of bean consumption is a healthy one, this is not always the case. For some Asian individuals, white rice is an integral part of a meal. Brown rice, which is more nutritious, may not be perceived as an acceptable substitute (10). Simply informing these individuals that brown rice is a better choice is not enough to change their eating behavior, because the food is a part of their cultural identity.

The above discussion showcases the fact that although people often have the capacity to make rational food choices, they may not always do so. However, even individuals with the best intentions may be unable to execute a rational eating decision due to environmental circumstances. A Detroit study demonstrates that large grocery facilities are less likely to locate in neighborhoods populated with minority and low-income residents. This is important because larger chain stores are more likely than small convenience stores to stock a wide variety of healthy foods, such as fruits and vegetables, at affordable prices (11). A similar study in Eastern Los Angeles found that urban residents had greater access to fast food restaurants than grocery stores. Compounding the problem was the fact that less than one in five grocery stores had a large selection of fresh produce. Nearly half of the grocery stores sold no fruit at all (12). These findings suggest that, especially in low-income, urban areas, residents may not have easy access to the healthy foods they know they should eat. They may knowingly make less healthy choices simply because they are more accessible.

The Importance of Self-Efficacy and Stages of Change in Eating Behavior

Q: “Strive for Five…what does that mean, five per week?”

A: “It’s actually five per day.”

Q: “I need to eat five per DAY?”

Another assumption implicit in the Food Guide Pyramid is that all individuals are ready and able to comply with its recommendations. It ignores important behavioral models such as Social Cognitive Theory and the Transtheoretical Model. Social Cognitive Theory emphasizes that an individual’s perception of her ability to successfully adopt a behavior, or self-efficacy, is an important determinant of behavior change (13). The Transtheoretical Model posits that individuals pass through distinct stages as they strive to reach a behavioral goal, and that individuals in each stage will respond differently to intervention (14).

Factors such as self-efficacy and readiness to change are important because the recommendations put forth by the Food Guide Pyramid are complex and extensive. For a moderately active female in her early twenties, the recommendations include eating 3 cups of vegetables and 7 ounces of grains per day (1). These recommendations are problematic on two levels. First, they use complicated and varied units of measurement. It can be difficult to conceptualize “ounces” of grains and “cups” of vegetables. The daily recommendation of “six teaspoons” of oils is complicated by the fact that lipids are often incorporated into processed foods, which makes it difficult to measure them in terms of teaspoons. These measurement issues may be overwhelming to an individual who is not familiar with nutrition. According to Social Cognitive Theory, if people feel that these recommendations are too complicated for everyday use, they may not be compelled to make any effort to change their behavior (13).

A second problem with the recommendations is the sheer amount of each food that is required. These requirements might seem very high, depending on the individual’s initial level of consumption. For a person who currently eats fresh produce infrequently, the prospect of consuming five fruits and vegetables per day may be daunting. Recommendations that delineate the types of vegetables to be eaten each week present yet another challenge. Some people may feel that trying to comply with these recommendations will only result in failure, and may not attempt any change in consumption at all (13).

An individual’s response to the recommendations of the Food Guide Pyramid may also depend on her readiness to change, as predicted by the Transtheoretical Model (14). A limitation of the Pyramid is that it is only useful to a very specific group of individuals: those who recognize their problems, plan to change their behaviors, and need the nutritional knowledge to support this decision. The Pyramid is not helpful to individuals who have not accepted nutrition as an important issue in their lives. These people must feel that behavior change is necessary and feasible before specific nutritional recommendations become relevant. Similarly, the Pyramid does not benefit individuals who have already tried and failed to adopt healthy eating behaviors. These individuals are likely to be aware of the foods they should eat but are not confident in their ability to adopt these changes. The Food Guide Pyramid fails both of these groups of individuals by neglecting provide them with the advice they need to change their behaviors.

Competing Values in the Determination of Eating Behavior

“I usually buy whatever’s cheapest, unless it’s all the same price. Then I don’t know what to do.”

The Food Guide Pyramid assumes that all eating behavior is motivated by a desire to achieve optimum health. However, research suggests that the motivations underlying food choice vary and are embedded in a life course behavioral model (9). Life experiences and sociocultural factors lead individuals to develop values and preferences about food and eating. An individual’s current life situation, which includes financial resources, cooking ability, nutritional knowledge and family structure, is also important. An individual brings experiences from her past and current life situation to each food decision. At each decision, a variety of factors may be in opposition, including health benefits of a particular food as well as cost, convenience and individual preference. Individuals reconcile these conflicts based on their past and current experience, and health may not always be a top priority (9). Some individuals place a higher value on cost: they buy the cheapest foods either out of necessity or because they were taught as children to value cost highly. Other individuals value convenience or taste over health.

Cost considerations become highly relevant when considering the socioeconomic disparities in obesity. According to Maslow’s Hierarchy of Needs, individuals must satisfy certain basic needs, such as adequate food and water, before they can consider more complex problems such as health (15). For low-income individuals, procuring enough food for themselves and their families can be challenging (6). They are likely to be more concerned with satiating hunger now than preventing disease in the future. Therefore, cost is likely to supersede health as the determining factor of food choice. Unfortunately, this often leads to poor food choices, as foods of low nutritional value are usually less expensive than healthier options like fresh fruits and vegetables (6). In this way, it may simply not be possible economically for these individuals to meet the recommendations of the Food Guide Pyramid.

Conclusion

The Food Guide Pyramid was redesigned by intelligent professionals who undoubtedly care deeply about the health of Americans. The revisions have improved the quality of nutrition information available to the public by increasing the compliance of the Pyramid’s recommendations with the Dietary Guidelines. However, an improved understanding of nutrition by itself is insufficient to change eating behavior. People often eat for reasons other than to satiate hunger and improve their health, and some may value other factors such as cost and convenience more than health. Others may not feel ready or able to adopt changes in their eating behavior. Still others are limited by the availability of healthy foods in their neighborhoods. Until these considerations are acknowledged, it is unlikely that the Food Guide Pyramid will greatly affect America’s obesity problem.

The social and behavioral science theories discussed above are helpful in identifying useful changes to the Food Guide Pyramid. The Food Guide Pyramid could be improved by helping individuals who value cost or convenience identify healthy options that are feasible for their lifestyles. It could also address readiness to change by providing tailored advice for individuals who are in the beginning stages of dietary change, those who are ready to adopt changes and those who are trying to maintain healthy behavior. To its credit, the new Pyramid does offer specific suggestions and encourage incremental dietary changes (1), which may improve people’s self-efficacy. It should also acknowledge that permanent changes in eating behavior require continuous effort and relapses are not uncommon. Accepting relapses as a natural part of the process of weight reduction and maintenance could help people feel less intimidated by the hard work involved in weight loss. They may feel more comfortable making efforts to change and ultimately be more successful in achieving a healthy weight.

References

1. United States Department of Agriculture.MyPyramid: Steps to a Healthier You.Washington, D.C.: USDA.http://www.mypyramid.gov
2. Wikipedia.Food Guide Pyramid.Wikimedia Foundation.http://en.wikipedia.org/wiki/Food_guide_pyramid
3. Centers for Disease Control and Prevention.Overweight and Obesity: Defining Overweight and Obesity. Atlanta: CDC.http://www.cdc.gov/nccdphp/dnpa/obesity/defining.htm
4. Centers for Disease Control and Prevention.About BMI for Children and Teens.Atlanta: CDC.http://www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/about_childrens_BMI.htm
5. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States,1999-2004. JAMA. 2006 Apr 5; 295(13):1549-55.
6. Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. American Journal of Clinical Nutrition 2004; 79:6-16.
7. Daniels SR. The Consequences of Childhood Overweight and Obesity. The Future of Children 2006; 16(1): 47-67.
8. Wikipedia. Health Belief Model. Wikimedia Foundation. http://en.wikipedia.org/wiki/Health_Belief_Model
9. Furst T, Connors M, Bisogni CA, Sobal J, Falk LW. Food choice: a conceptual model of the process. Appetite 1996; 26:247-66.
10. Wong, S. Personal communication. 08 April 2007.
11. Zenk SN, Schulz AJ, Israel BA, James SA, Bao S, Wilson ML. Neighborhood racial composition, neighborhood poverty, and the spatial accessibility of supermarkets in metropolitan Detroit. American Journal of Public Health 2005; 95:660-7.
12. Kipke MD, Iverson E, Moore D, Booker C, Ruelas V, Peters AL, Kaufman F. Food and park environments: neighborhood-level risks for childhood obesity in East Los Angeles. Journal of Adolescent Health 2007; 40:325-33.
13. Wikipedia. Social Cognitive Theory. Wikimedia Foundation. http://en.wikipedia.org/wiki/Social_cognitive_theory
14. Wikipedia. Transtheoretical Model. Wikimedia Foundation. http://en.wikipedia.org/wiki/Transtheoretical_Model
15. Wikipedia. Maslow’s Hierarchy of Needs. Wikimedia Foundation. http://en.wikipedia.org/wiki/Maslow%27s_hierarchy_of_needs

Public School Sex Education: The Failure of the Health Belief Model to Effectively Promote Abstinence Among Adolescents – Kelli Jarrett

Background

Since 1996, there has been a dramatic shift in the curriculum of sex education programs funded by the federal government. Section 510 of the 1996 Social Security Act, part of welfare reform, laid out 8 rules that now govern state programs on sex education that received federal funding (1). Beginning with this act, for states to receive federal funding for sex education programs, they must teach Abstinence Only Education (AOE), and the rules created by Section 510 specifically prohibit disseminating information on contraceptive services, sexual orientation and gender identity, and other aspects of human sexuality (1). This trend towards AOE continued with the creation of Community-Based Abstinence Education projects in 2000, which were funded through an earmark in the Maternal Child Health block grant entitled Special Projects of Regional and National Significance (SPRANS). SPRANS bypasses the earlier 1996 Section 510 rules for the state approval process, and makes grants directly available to community-based organizations, including faith-based organizations (2).

This dramatic shift away from comprehensive sex education for youth, towards Abstinence Only Education necessitates a critical look at the goals and underlying assumptions of these programs. No evidence currently exists on the effectiveness of these programs on delaying initiation of sexual activity in youths, or reducing teen pregnancy and Sexually Transmitted Disease rates. There is some evidence to show, however, that some of these programs decrease rates of contraceptive use among youth when they do initiate sexual activity (3). The failures of Abstinence Only Education can be explained in large part by its failure to employ valid Social and Behavioral Science models of health behaviors.

The Failure of the Health Belief Model in Abstinence Only Education

Abstinence Only Education is grounded in the Health Belief Model. The eight rules laid out in Section 510 of the Social Security Act of 1996 for Abstinence Only Education focus on emphasizing the dangers of premarital sex. The two most relevant of these eight rules are that schools receiving federal funding for sex education are required to teach: 1) Sexual activity outside of marriage is likely to have harmful psychological and physical effects, and 2) Bearing a child out of wedlock is likely to have harmful consequences for the child, its parents, and society (1). These two requirements for Abstinence Only Education focus on increasing youth’s perceived severity of the potential adverse consequences of sex before marriage. The Health Belief Model describes a rational decision making process where one’s perceived susceptibility to a health outcome and the perceived severity of that outcome is weighed against the perceived barriers to performing a certain health behavior, which ultimately leads to intention and then the health behavior (4). By focusing on the negative effects of sex before marriage and trying to scare adolescents by telling them what may happen if they engage in sexual activity before marriage, AOE is trying to build up the “perceived severity” block of the Health Belief Model, with the hope that this will lead youth to the intention of remaining abstinent, which will consequently result in them performing the desired “behavior,” which is remaining abstinent until marriage.

What the Health Belief Model fails to account for, however, is the outside influences that affect an adolescent’s decision to initiate sexual activity. The Health Belief Model is based solely on the idea that an individual rationally weighs the costs and benefits to come to a decision about the health behavior (4). One health behavior model that does account for some outside influence in the decision making process is the Theory of Reasoned Action, which includes the role of attitudes and perceived norms in forming intention and health behavior (5). By including one’s perceived norms, this health behavior model begins to take into account some of the social factors that affect the decision whether or not to have sex. In American society, it is clear that sex outside of marriage is the norm. Popular media promotes this stance, both in highly sexualized advertising and in popular television shows and movies that quite often depict individuals having sex outside of marital relationships. Even within their own home, many adolescents are exposed to intimate relationships that are not within marital ties. With the divorce rate in this country currently hovering around 50% (6), more than half of families at some point experience relationships outside of marital ties, and children in these families see their parents engaged in intimate relationships with new partners to whom they are not married.

With these outside influences informing their perceived norms, adolescents are much less likely (according to the Theory of Reasoned Action) to intend to remain abstinent. The Health Belief Model fails to take into account social norms and other influences outside of the individual rationally balancing the pros and cons, which is one reason that Abstinence Only Education, by relying on the health belief model, is failing to achieve its goals of delaying initiation of sexual activity and reducing rates of adolescent pregnancy.

Social Learning Theory and Abstinence Only Education

Another social science theory that can account for some of the failure of Abstinence Only Education is Social Learning Theory, which states that people have a tendency to model behavior they see in others (7). It is well known that adolescents are especially susceptible to outside influences, especially the behaviors they see others engaging in. Role modeling is especially important in this age group. Thus, when the role models that are most important to adolescents are highly sexualized individuals, adolescents tend to model this behavior rather than what they are taught through AOE.

One well known adolescent role model is Paris Hilton. She is a household name in the United States, especially in the world of adolescents. From media coverage, to her televisions show, to her infamous “sex tape,” she has become a prominent icon, and one that this generation of adolescents perceives as “cool.” She has become a role model for many teenage girls across the country, who model her clothing, hairstyle, as well as her highly sexualized behavior. The fact that Paris has engaged in premarital sex has been highly publicized, from the media reporting on her constantly changing boyfriends, to the aforementioned sex tape. Social Learning Theory states, then, that because she is a widely recognized role model, the health behaviors she engages in are likely to be modeled by adolescents. Abstinence Only Education, by focusing on individual decision making, does not take this modeling phenomenon into account. A focus on promoting better role models who are not highly sexualized would, according to Social Learning Theory, have a much greater impact on informing the decision of adolescents regarding their own sexual behavior than simply informing them of the risks of premarital sex.

Psychology, Adolescence, and Abstinence

Another model of health behavior from the social sciences that Abstinence Only Education fails to account for is Erikson’s Stages of Psychosocial Development (8). Adolescence is identified by Erikson as one of the psychosocial stages of development, which occurs between the ages of 11 and 18. During this period in ones life, the psychosocial crisis identified by Erikson is Identity versus Role Confusion (8). Adolescents are, for the first time, concerned with how they appear to others. Their central task during this time period is to identify peer groups and cliques, which comprise their significant relationships (8). This concern with how they are perceived by others has a strong influence on how susceptible adolescents are to peer pressure, which will have an effect on their decision making process concerning sexual activity and abstinence.

One important aspect of the theory that Erikson describes about adolescents’ concern with peers and how they appear to others is the importance of relationships with boyfriends and girlfriends, which are first developed in adolescent years. This is a specific element of the peer groups that Erikson describes, and thus adolescents tend to be very concerned about how they are perceived by their boyfriends and girlfriends. This has a clear impact on their decisions of whether or not to engage in sex. Concern for how their boyfriend or girlfriend will think of them, as well as what their peer groups think about sex and about people who have sex, plays an important role in determining whether or not adolescents will engage in this activity. Abstinence Only Education fails to address this factor at all. To effectively address it, one would have to find ways to change the perception of sex in adolescents as a group, instead of focusing on the decisions that an individual is making. Erikson’s stages of psychosocial development demonstrates the importance of the Theory of Reasoned Action and Social Learning Theory in predicting adolescent health behavior. Because in this stage of their lives adolescents are very concerned about their peer groups and how they appear to others, their perceived norms and the behaviors they see others engaging in have a much stronger influence on them than it might have on a different age group. If sex is acceptable to their peer groups, and tends to be the social “norm” that they see modeled for them, this is what they are likely to engage in. Abstinence Only Education focuses instead on the individual, as modeled by the Health Belief Model. It presumes that if you convince an individual of the risks of a certain behavior, they will weigh this out rationally and make a decision. As described by both Erikson’s Stages of Psychosocial Development and the other health behavior models described here, there are many factors outside of the individual that affect health behavior decision making, especially during the period of adolescence.

Conclusion

The failure of Abstinence Only Education stems from its focus on the individual’s decision making process, as modeled by the Health Belief Model. There are many factors outside of the individual that influence decision making regarding health behaviors, especially for adolescents. To achieve its goal of delaying the initiation of sexual activity and reducing the amount of adolescent pregnancy and STD infection, AOE programs must start to consider the social aspects of decision making, especially the unique aspects of adolescence and the effect that has on one’s decision making process. Using more appropriate social science models, such as Social Learning Theory or Erikson’s Stages of Psychosocial Development, would account for these interpersonal factors and lead to developing more effective programs to address the issue of teen sexual activity and its consequences.

References

1. Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Pub. L. no. 104-193, 110 Stat 2105 (1996).

2. Maternal and Child Health Bureau. Womens Health USA 2003. Rockville, MD: Maternal and Child Health Bureau, 2003. http://mchb.hrsa.gov/pages/page_03.htm

3. Santelli J, Ott MA, Lyon M, Rogers J, Summers D, Schleifer R. Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 2006; 38: 72-81.

4. Rosenstock IM. Historical Origins of the Health Belief Model. Health Education Monographs 1974; 2: 328-335

5. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39: 128-135.

6. Centers for Disease Control and Prevention. Marriage and Divorce. Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/nchs/faststats/divorce.htm

7. Bandura A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall, 1986.

8. Erikson EH. Childhood and Society. New York, NY: Norton, 1950.

Let's Talk About Sex, Baby; Why Abstinence-Only Education is Failing America's Youth – Stephanie Trilling

Generations of children have gazed trustingly into their parents eyes, timidly asking the same question, "Mommy, where do babies come from?" And just as many generations of parents have been caught off guard only to sheepishly cough up a variety of ridiculous explanations. Frantic parents have come up with stories ranging from a giant flying bird that drops pink and blue wrapped babies down chimneys to the most anatomically correct medical definitions they could possibly muster. And why shouldn't parents feel uneasy when answering their innocent progeny's questions? Sexual intercourse does not only answer where babies come from, it is also answers scarier questions like, "Where do genital herpes come from?" Higher risk of teen pregnancy, abortion, and sexually transmitted infections (STIs) are only a few examples of what teenagers are up against once they start having sex. Sexual intercourse can also put people at risk for complex emotional, spiritual, and mental health consequences. Adults agree that something needs to be done, but a staunch dispute has been brewing in this country for quite some time about what the appropriate method should be.

The Debate. Typically, parents today fall into two camps, “tell ‘em how to be safe,” and “don’t give ‘em any ideas!” One hundred years ago, before the "sexual revolution," American society repressed any discussion of sexual health. Sex was something a woman found out about on her wedding night and was never to be discussed before or after for fear of offending her virginal ears with such vulgarity. Men, just as today, had a little more of an unspoken flexibility, but such things would never be revealed in a company of mixed gender. Whether it was the invention of oral contraceptives or the financial independence women gained after WWII (1), the US slowly began ridding itself of the "sex taboo". Now, as we proceed further into the new Millennium, there has been a noticeable shift in ideology, backed up by government funding, pertaining to the best way to keep kids safe from the risks associated with sexual activity. There was a time not so long ago when it was not only tolerable to teach about condoms and contraceptives, but encouraged! Now abstinence-only education reigns supreme and is the only acceptable form of sex education allowed in our nation's public schools. This paper aims at critiquing the model that this current change in educational policy and funding is based on by exploring theories from adolescent psychology as well as arguing for comprehensive sex education to be taught once again in our public schools.

The Policy. Since the turn of the century, over a billion dollars have been spent on abstinence-only programs. In 2006 the federal budget allotted $215 million dollars to abstinence-only education, jumping 15% from the year before and more than doubling the amount spent in 2001. In 1996, Title V of the Social Security Act redefined definitions of abstinence-only programming. Title V is made up of an 8-point plan for programs, teaching themes to adolescents such as sex is only acceptable within marriage and that children born out of wedlock are harmful to society (2). Title V annually receives $87.5 million from the government in funding. For every four dollars the federal government spends the states match it with three dollars. Almost every state accepts money from Title V, which means they must comply with the 8-point definition of abstinence-only education laid out in the legislature. Another federal program, Community Based Abstinence Education, spends $115 million a year on programs that adhere to Title V's 8-points. According to the SEICUS webpage under Title V, "…the discussion of abortion and contraceptive instruction are explicitly prohibited. However, the guidelines encourage teaching failure rates for contraceptives and emphasizing the inherent differences between men and women…" (3). The rest of the money spent yearly is allocated through other legislature like the Adolescent Family Life Plan, which receives $13 million dollars and whose effectiveness has never been substantiated (3).

The Reality. Teenagers have sex and teenagers get pregnant. According to a study on teenage sexuality and contraception one out of every three girls in America have had sex by the age of 16 and by 18 it's two out of every three (4). Approximately 750,000 women between the ages of 15-19 still become pregnant each year. While teen pregnancy is down by almost 30% since 1990, the United States continues to lag behind the rest of the western world. According to the Alan Guttmacher Institute, a sexually active teen that does not use contraception has a 90 percent chance of pregnancy within one year (5).

"Despite years of evaluation in this area, there is no evidence to date that abstinence-only education delays teen sexual activity. Moreover, recent research shows that abstinence-only strategies may deter contraceptive use among sexually active teens, increasing their risk of unintended pregnancy and STIs." (6).

Conservative politics are determining health education policy in this country by controlling federal money. Unfortunately the politics of this matter don’t seem to be concerned with effectiveness. SEICUS, the Sexuality Information and Education Council of the United States, supports “abstinence-based” education which places messages about abstinence in a context and allows for more comprehensive education to be covered as well. SEICUS “does not believe that fear-based, abstinence-only programs will achieve their goals.” SEICUS points to studies such as one done a failed abstinence-only program in California to back up its position. According to SEICUS, five million dollars were spent on an abstinence-only program in CA only to find an increase in the number of young people who engaged in sexual intercourse after completing the program (7).

The Reasons. Abstinence-only education is a public health program that aims at reducing sexual health related risks by giving all public school students one message; sex is only appropriate within a marriage. The underlying assumption is that individuals make rational decisions about their sexual health. The thought process the proponents of abstinence-only education aim students to have is, “If I have sex outside of marriage I could end up pregnant or with an STI.” These scenarios, or the “perceived severity” of risks, must weigh greater on the decision-maker than the “perceived benefit” of sexual intercourse prior to or outside of marriage. Abstinence-only education creates a very high perceived susceptibility to these risks in the hopes of changing students' intentions so that they will wait until marriage for sex. This is a perfect example of the Health Belief Model (HBM). The HBM is one of the most popular models used in the field of public health today. The main critique of the model is that intention (ie: wanting to wait until marriage) doesn't always indicate behavior (8). Other things may impact a teenager’s decision on sexual intercourse, such as self-efficacy, or believing they are capable of behaving in this manner. The Social Cognitive Theory, envisioned by psychologist Albert Bandura, is another traditional behavior model used in planning public health interventions (9). While still rooted in rational thought and individual intention, it provides a more realistic approach for a public health intervention, particularly one aimed at teenagers. If teenagers were educated on methods that seem more “doable” they would have more of a chance of modifying risky behavior. Comprehensive sex education allows more options for adolescents who may not consider abstaining until marriage a realistic goal.

The Sex and the City Era: Many adolescents don’t see abstinence as a reasonable possibility as they are products of today’s society. Turn on the TV and chances are you'll get a glimpse of our sex-crazed society within moments. Popular television series like Sex and the City, Dawson's Creek, even Will and Grace, jumble the messages that teenagers are getting at school or from their parents about acceptable sexual behavior. Teenage boys and girls are getting mixed messages about what is acceptable sexual behavior. Girls read articles from magazines like Cosmo about how to best please your man, and boys read Maxim, which is known for its scantily clad models, showcasing women as sexual objects. Choi, who critiqued the Health Belief Model as it applied to Asian and Pacific Islander American men who have sex with men, claimed that the HBM "ignores the wider social context within which an individual may be a member," (10). All of the power of decision-making is left up to the individual in this model, which can be difficult for adolescents who are particularly susceptible to pressures from their peers and the rest of the outside world to "fit in" and do what everyone else is doing. According to the Social Learning Theory, yet another public health model fashioned by Bandura, purports that humans model what they see others in their social network doing. In his famous “Bobo Doll Experiment”, Bandura found that young children were much more likely to create violent acts against a life-size doll if they first observed adults doing the same thing (11). According to this theory, teenagers are apt to model the behavior they see in characters like Carrie Bradshaw, from HBO’s Sex in the City, who has several extra-marital affairs throughout the length of the series.

The Health Belief Model and Cultural Relativity. Another drawback to using the Health Belief Model for a sexual education program is that it assumes the target population is of the same culture; one which prioritizes health and pregnancy prevention. The United States is an incredibly diverse country and its public school students come from varying backgrounds and cultures. Abstinence only education does not account for this complex interweaving of cultural differences. By only offering one option it fails to address differing cultural norms, religious beliefs, even language barriers. It is particularly harmful for adolescents who have been brought up in cultures where talking about sex is still very taboo. These teens are even more at risk because they lose all opportunity to talk about and understand sexual health at home and at school. They have nowhere to turn for open discussion about sexual health and choices. Linda Thomas in her critique of the HBM from a feminist perspective writes,

"This paradigm has been oppressive in nature, depriving persons of value and contextual meanings which are embedded in cultural practices, skills, and languages. From the HBM perspective, persons are viewed as a collective group, confined and reduced to 'objective' data without regard for their sociopolitical and historical experiences” (12). Statistically speaking, teenage pregnancy rates around the country are higher in lower SES and minority communities. For example, black women between the ages of 15-19 have a pregnancy rate of 143 out of 1000 followed by Latina's who are at 131 per 1000 as compared to white women aged 15-19, whose pregnancy rate is at 48 per 1000 (13). Abstinence-only education, based on the HBM, is failing the minority demographic because it refuses to take into account different cultural norms. Thomas goes on to say that the HBM does not address issues such as, "social desirability and social/political barriers." Minorities have historically been at a loss for political representation in the government and still are today. This could be one reason why they have not been able to counter abstinence-only education programs, which is clearly not serving their needs as a population.

Adolescent Psychology as a Framework. A major problem with the Health Belief Model is the fact that it assumes all of human behavior is rational. Unfortunately, we do not always act rationally, especially when it comes to matters of the heart. According to Salazar in her, Comparison of Four Behavioral Theories, the HBM, "does not address the issue of coping skills. It focuses on rational, intentional behavior and does not take into account the spontaneous activity that characterizes much of human behavior"(14). This is problematic for the abstinence-only campaign seeing as sexual activity is often a spontaneous decision made in the moment. Furthermore, sexual activity can a lot of times go hand in hand with alcohol or substance use, which deters one even further from the prospect of rational decision making.

Adolescents, it has been shown, prioritize their friends and social network above most other things in their life. The Health Belief Model expects people to determine intention through rational decision making; however teenagers cannot be considered rational because of their value system. Teenagers are also prone to believing they are invincible, so the perceived threat of STIs and pregnancy may not be strong enough for them to choose the hoped for behavior, in this case, not having sex outside of marriage.

The HBM almost completely fails to take into account human psychology at all as a way to determine behavior. Abraham Maslow, one of the founding fathers of social psychology, is famous for his Hierarchy of Needs (15). Often depicted as a pyramid, the needs are stacked on top of each other from the most basic physiological to the most advanced top of the pyramid, self-actualization. The most basic needs are usually met before the higher levels can be reached, but there is room flexibility. Interestingly enough, Maslow placed sex in the most basic, deficiency needs along with the need for shelter and the need for food. This would be the physical benefits of sexual intercourse, release of endorphins and exercise. Next is the need for safety, such as security of employment or the need to feel stable in your health. The fact that sexual intimacy is on the level of a lower-order need and must be met before one can move up the pyramid to where concerns about healthcare lie proves that teenagers may not be able to rationally choose the less risky health behavior over meeting their sexual biological needs. Maslow also places the emotional connection of sexual intimacy in the third tier of the pyramid, along with social acceptance and love. If one cannot meet the needs of this level, which provides emotional well-being, the person may no longer care about meeting the needs of higher-order tiers.

"In the absence of these elements, many people become susceptible to loneliness, social anxiety, and depression. This need for belonging can often overcome the physiological and security needs, depending on the strength of the peer pressure. e.g. An anorexic ignores the need to eat and the security of health for a feeling of belonging." (15).

Rebels Without a Cause. Adolescents, who cannot be considered rational beings, are also known for their rebellion. Erikson, a prominent psychologist, in his Theory of Socioemotional Development, claims that during the adolescent years (approximately between the ages of 13-20) teenagers enter the "Fidelity" stage (16). This stage is characterized by the struggle between finding their unique identity and fitting that into the greater, societal picture. Almost every teenager will experience some delinquency and experiment with some sort of rebellion as a way to find out who they are and where they belong in the world (16). What this means for a program like abstinence-only education is that with only one option available to teens from authority figures such as teachers or parents, they are more likely to experiment with other options. In fact, the very set up of an authority figure giving a teenager no choices is exactly a situation teenagers are drawn to rebel against. They are reaching an age where they are almost considered adults by society, and they are testing the waters and starting to exert their independence. Abstinence-only education doesn't allow them to make their own, educated decisions about their sexual health; instead it forces one down their throat. If the teen doesn't want to conform, and due to their inherent rebelliousness they many times will not, abstinence-only education leaves them without resources or tools to act in safe manner. If they are never educated about contraception or condoms, and instead only told to wait until marriage, they will be unprepared to reduce their risk if they do choose to have sex outside of marriage.

As a high school teacher, I was privy to many adolescent conversations on sex. I was walking through the hall one day when I overheard a conversation between two 14 year old girls talking about contraception in an abstinence-only public school. "I took one of Chelsea's birth control pills today so that I won't get pregnant." Had this girl been given the proper tools and resources that she would have received in a comprehensive sex education class she would have known that birth control pills need to be taken at the same time, daily, for at least a month to prevent pregnancy and even then, they will not prevent STIs or HIV.

Comprehensive Sex Education as a Solution. Although abstinence-only programs are failing our country's youth, we needn't abandon the idea of presenting abstinence as a viable option for teens. Studies have shown that teaching kids to wait until marriage can be an effective measure to delay the age of a first sexual encounter. It simply isn't a comprehensive plan that could benefit all teenagers, including those that decide to have sex, are already having sex, or are already pregnant. Abstinence-only education also leaves out sexuality education, leaving GLBTQ students, who do not have the right to legally wed in this country (except MA!), absolutely no alternative but to abstain from sex for their entire lives, which is not always a practical expectation. Advocates of comprehensive sex education encourage openness and frank discussion. Some organizations go so far as calling themselves "sex-positive" meaning that no judgment is put upon any sexual behaviors and that risk reduction is the aim or education. This type of environment would be ideal for teenagers who are eager to rebel, as a non-judgmental, open and educational atmosphere won't leave any room for them to rebel. According to Erickson, adolescents are at a stage in their development where they are coming to terms with their own individual beliefs and values. If sex education embraced and educated on everything from abstinence to sexuality teens would have a chance to assert their own values, rather than be coerced into a lifestyle they may not agree with which would lead them only to rebel against it. As Salt-N-Peppa put it over 10 years ago, it's about time we, "…Talk about sex, baby/ Let's talk about you and me/ Let's talk about all the good things and the bad things that may be/ Let's talk about sex."

REFERENCES

1.Petigny A. Illegitimacy, Postwar Psychology, and the Reperiodization of the Sexual Revolution. Journal of Social History, 2004.

2. Social Security Act, Title V Section 510 http://www.ssa.gov/OP_Home/ssact/title05/0510.htm

3. SEICUS. A Portrait of Sexuality Education and Abstinence-Only-Until Marriage Programs in the States. http://www.siecus.org/policy/states/

4.K.A. Driscoll, A.K. Lindberg. A Statistical Portrait of Adolescent Sex, Contraception, and Childbearing, 1998.

5. Alan Guttmacher Institute. Sex and America's Teenagers. New York and Washington, DC: 1994

6. Alan Guttmacher Institute. Facts on Sex Education in the United States. http://www.guttmacher.org/pubs/fb_sexEd2006.html

7. Haffner DW. What's wrong with abstinence-only sexuality education programs? SIECUS Rep. 1997 Apr-May;25(4):9-13.

8. Rosenstock I. Historical Origins of the Health Belief Model (pp. 328-335). In: Health Education Monographs VOL. 2, NO. 4

9. Bandura, A. Organizational Application of Social Cognitive Theory. Australian Journal of Management, 1998; 13(2), 275-302. http://en.wikipedia.org/wiki/Social_cognitive_theory

10. Choi M. Centers for Disease Control and Prevention. HIV Prevention Among Asian and Pacific Islander Men Who Have Sex With Men: A Critical Review of Theoretical Models and Directions for Future Research.

11. Bandura, A. Self-efficacy: The exercise of control. New York, 1997; W.H. Freeman. http://tip.psychology.org/bandura.html

12. L Thomas. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing. 1995; 11:246-252.

13. see 6

14. Salazar MK.Comparison of Four Behavioral Theories. AAOHN Journal. 1991; 39:128-135.

15. http://en.wikipedia.org/wiki/Abraham_Maslow

16. Huitt W. Socioemotional development. Educational Psychology Interactive. Valdosta, GA. 1997; Valdosta State University http://chiron.valdosta.edu/whuitt/col/affsys/erikson.html

Steps to a HealthierUS: Is the DHS Program Aimed at Lifestyle Change for the Obese Leading the U.S. Down the Right Path? - Amy Bitterman

The Office of the Surgeon General believes that America has a weight problem. In 2001 it published “The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity (1).” The statistics are disheartening. Since 1980, the prevalence of overweight children has doubled, and the prevalence of overweight adolescents has tripled (2). In response to this, and other related health risks for people of all ages, the Secretary of Health Tommy Thompson launched the “Steps to a HealthierUS” (“Steps”) initiative. The program has two major components, the national education initiative, which provides tools and information about leading a healthier lifestyle (3), and the Steps to HealthierUS Cooperative Agreement Program that funds communities implementing chronic disease prevention and control programs focused on obesity, diabetes, and asthma, as well as their underlying risk factors of physical inactivity, poor nutrition, and tobacco use (4).

While Steps multi-level approach is a move in the right direction, Steps stumbles with its top down methods and failure to address some of the larger systemic problems that keep its target communities at-risk. America doesn’t have a weight problem, America has much more fundamental problems, and the program doesn’t address them. The program purports to implement socioecological strategies, but further examination reveals that Steps frames the risk factors for obesity and chronic illness as behaviors chosen by individuals, reflecting that the blame still rests where it traditionally has, on the shoulders of those at risk (5). Steps failure to implement its theoretical adherence to a socioecological approach is apparent through the limitations of its methods for promoting health. The Steps to a HealthierUS strategy for reducing the burden of chronic illness through promotion of healthy eating and physical activity is limited by its adherence to the health belief model which deemphasizes external factors, its focus on individual behavior and responsibility for conditions that often carry a stigma, and its failure to recognize the importance of Maslow’s Hierarchy of Needs in relation to behavior change.

The Socioecological Approach or Business as Usual?

The Steps to a HealthierUS promotion of healthy eating and physical activity guidelines spend a fair amount of time discussing the ways in which the program seeks to integrate all the components of the socioecological model, individual, interpersonal, organizational, environmental, and policy (6). The initiative acknowledges that interventions have the best chance of succeeding when they are directed at all members of a social network (family members, friends, colleagues, acquaintances) at once (7). However, while espousing the importance external social factors, the guidelines recommend that all interventions focus on behavior change strategies that focus on individual choice. The program looks at only highly prevalent risk factors that are modifiable by individual behavior change (8). This means that while the program pays lip service to the need for change in physical and social environments to allow for enduring change in lifestyle, it stops short of promoting any changes to the external environment, choosing instead to attempt to impact individuals health behavior choices. Its broad requirements for community partner programs call for social integration of changes, providing recommendations in seven major areas, including 1) leadership, planning/management, and coordination; 2) policy change; 3) mass communications; 4) community programs and community development; 5) programs for children and adolescents; 6) health care delivery; and 7) surveillance, epidemiology, and research (9). These areas do not target the physical environment or socioeconomic entrenchment, external behavior determining factors, but do represent an important step away from a completely internal decision making process. Nevertheless, the programs own national strategy belies even this slightly more enlightened approach.

Exclusion of External Factors Indicates a Limiting Adherence to the Health Belief Model

The Steps national campaign is mainly a web-based education tool. An interested person clicks on the link, and gets brightly colored pictures ordering them to “Be Physically Active Each Day,” and “Eat a Nutritious Diet (10). The set up implies that the reason people are not healthier is because they don’t know how, or understand how their actions impact their health. The multi-million dollar, supposedly socioecological approach to encouraging physical fitness includes instructions about the minimal amount of exercise required to attain the benefits of physical activity, a list of the benefits, and the potential harms of a sentient lifestyle. This particular set of information suggests that the national program was designed according to the health belief model.

The traditional health belief model is a psychological model that attempts to predict behavior change. The model is structured around four key concepts: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. The model is useful to the extent that it takes into account the influence of individual values and expectations, but because it assumes rational decision-making taking place entirely at the individual level, it limits the potential of a public health intervention to meaningful effect behavior change. Consider one of the Steps program’s target populations, underprivileged urban youth. The HealthierUS website recommends “walking your dog,” or “digging in your garden (11).” For children and adolescents living in an apartment, the likelihood that they have a dog or garden is very slim. Moreover, even if they did have a dog or garden the neighborhood may be too dangerous to go out, particularly alone if they have parents that work long hours. The goal of the information on the website is to help individuals choose a healthier lifestyle, but then promotes activities that may, due to entirely external factors, be impossible for its target population to “choose.”

It is also ironic that this information is available primarily on the internet, where the target populations, particularly the urban youth and the underserved elderly, are unlikely ever to see it. By failing to look at external factors, the program may fail to even interact with the communities it hopes to impact.

Methods that Discount Self-Efficacy and Reinforce Stigma

The Steps Program improperly frames the cause of chronic illness by emphasizing individual decision-making and therefore personal responsibility for medical conditions. This focus on the individual choices associated with physical activity and nutrition compromises the potential efficacy of the Steps program because it implies that the population suffering from the chronic conditions Steps is combating are to blame for their own poor health. People begin to associate their diagnoses of obesity or diabetes with other unfavorable characteristics, reducing their self-esteem. An example of this is the reduced self-esteem that comes with childhood obesity. Children associate being “fat” with being lazy and unattractive, images perpetuated and supported by the media, their peers, and health programs that tell them they’d become beautiful and fit if they’d just exercise a little and take some initiative. Their sense of responsibility for creating these characteristics in themselves can lead to self-loathing, and even depression (12). Moreover, promoting this view of individual responsibility can create a societal impression of individual responsibility, reducing empathy and creating stigma. People will not want to be diagnosed for conditions they associate with these negative stereotypes, leading to untreated chronic conditions. An example of this is the social stigma associated with Diabetes. In some communities where individual responsibility for this chronic condition is emphasized, people see sufferers as “self-inflicting the disease as a result of over-indulgence.” There is also anger at individuals with diabetes for their poor choices using up society’s health care resources. Sufferer’s then don’t want to let people know they have the disease for fear of drawing this stigma. This can cause them to fail to check their blood sugar with sufficient frequency or self-administer necessary insulin injections, activities which could out them as over-indulgent and selfish diabetics (13). If someone is not yet diagnosed, they may be resistant to a diagnosis of diabetes that will label them in this way, or put off seeing the doctor if they suspect a diagnosis of diabetes will result. What this example illustrates is that if there is a stigma associated with a condition, sufferer’s reduced self-esteem can impact their self-efficacy, their sense that they have the ability to and should positively impact their health. If stigma prevents people from getting diagnosed early, it compromises their actual ability to positively impact their health. Steps strategies of individual action and responsibility promote stigma by subtly reinforcing this concept of self-infliction of disease, and should be rethought, considering external factor, to promote the self-efficacy of their target populations.

Unrealistic Assessment of the Needs of the Target Populations

The Steps Program focuses on behavioral alterations that relate to higher order needs in populations that are struggling to meet their most fundamental needs. A useful tool for describing the needs of individuals is Maslow’s Hierarchy of Needs (14). Maslow’s Hierarchy is broken down into five basic needs, (1) physiological needs (2) safety needs, (3) love needs, (4) esteem needs, (5) self actualization needs (15). The needs are organized in the order in which they will consume a person’s conscious actions as goals. For example, one will not bother with a love need (affection, belonging), until his or her physiological needs are substantially met (16). Steps has selected as its populations of interest urban residents, small town residents, and tribes. Within those categories it has selected to target border populations, Hispanics/Latinos, American Indians, African Americans, Asians, immigrants, low-income populations, people with disabilities, youth, senior citizens, and people who are uninsured or underinsured (17). While the racial categories are poorly descriptive, the other categories of target populations describe groups that are often struggling to meet their most basic needs.

The Steps program, by failing to recognize external factors that lead to unhealthy lifestyles, fails to recognize that until someone can be assured that they will eat, they will not worry whether or not they are eating right. This premise could perhaps be extended into choices that parents make for their children. The Steps program recommends that parents monitor and budget their children’s television watching time to promote their increased physical activity (18). While parents are concerned about the health of their children (a safety need), they will not sacrifice their livelihood (a physiological need) in order to make sure they are reducing their children’s television watching time. Low-income wage earners without much job autonomy cannot ensure that they are around to watch their children after school. They will not be able to effectively budget and monitor their children’s TV watching behavior and will not sacrifice to do so. Another example is the recommendation that women breast feed for six months after giving birth (19). If all of their basic needs were being met, many women would breast feed. A person is unlikely to breast feed when they need to get back to work to ensure that they themselves are fed.

Conclusion

The Steps to a HealthierUS initiative suffers from several limitations. The program attempts to integrate a socioecological approach into its strategies, but often falls back onto the health belief model, focusing strictly on individual decision-making, and ignoring external factors. The emphasis on individual decision-making may have a negative impact on its target populations, making them feel they are responsible for conditions beyond their control. They may begin to associate their conditions with negative stereotypes and feel or be stigmatized by their diagnosis. This stigmatization has the potential to decrease the target populations self-efficacy or actual ability to engage in behaviors that can positively impact their health. Finally, the Steps initiative does not take into account the needs of their target populations. These shortcomings may significantly impact the efficacy of the program, and lead public health workers down the wrong path, away from a healthier U.S.

References

1. Office of the Surgeon General. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, Md: Office of the Surgeon General, 2001; http://www.surgeongeneral.gov/topics/obesity.

2. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999–2000. JAMA. 2002; 288:1728–1732

3. U.S. Department of Health and Human Services. HealthierUS Education Tools. Washington, DC: DHHS http://www.healthierus.gov/index.html.

4. Center for Disease Control and Prevention. Steps to a HealthierUS Homepage, Atlanta, GA: CDC. http://www.cdc.gov/steps/.

5. U.S. Department of Health and Human Services. Essential Strategies: The Socioecological Approach. Washington, DC: DHHS. http://www.healthierus.gov/steps/summit/prevportfolio/strategies/reducing/heart/public.htm#essential.

6. McLeroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly 1988; 15:351-377.

7. Center for Disease Control and Prevention. Promoting Healthy Eating and Physical Activity for a Healthier Nation, 7-5. Atlanta, GA: CDC. www.cdc.gov/HealthyYouth/publications/pdf/PP-Ch7.pdf

8. Id.

9. Id.

10. supra n. 3

11. U.S. Department of Health and Human Services. HealthierUS Physical Activites Website. Washington, DC: DHHS. http://www.healthierus.gov/exercise.html#start

12. American Obesity Association. Childhood Obesity. Washington, DC: AOA. http://www.obesity.org/subs/childhood/healthrisks.shtml.

13. Ann Tak-Ying Shiu, Jo Jo Yee-Mei Kwan, Rebecca Yee-Man Wong. Social Stigma as a Barrier to Diabetes Self-Management: Implications for Multi-Level Interventions. Journal of Clinical Nursing 2003; 12:149-150.

14. U.S. Department of Health and Human Services. Steps to a HealthierUS Cooperative Agreement Program. Washington, DC: DHHS. http://www.healthierus.gov/STEPS/documents.html

15. Maslow A. A Theory of Human Motivation, Psychological Review, 50(4):370-396. http://emotionalliteracyeducation.com/abraham-maslow-theory-human-motivation.shtml

16. Id. at 395

17. Id. at 381

18. supra n. 6 at 7-7; Robinson TN. Reducing Children’s Television Viewing to Prevent Obesity: A Randomized Controlled Trial. JAMA 1999; 282(16):1561-1567.

19. supra n. 7 at 7-2

New Food Labels and Calorie Count are Ineffective: The FDA Needs to Change Its Strategies on Obesity Prevention - Alex Hsi

Introduction
The increasing prevalence of obesity has been regarded as a major pandemic in developed and developing countries (1). United States has the highest rates of obesity in the developed countries. From 1980 to 2002, obesity has doubled in adults and overweight prevalence has tripled in children and adolescents. From 2003-2004, "children and adolescents aged 2 to 19 years, 17.1% were overweight...and 32.2% of adults aged 20 years or older were obese”(2). The fast increasing population of obesity and overweight become a major social issue in the United State. In order to reduce the prevalence of obesity, policies and campaigns are created by local and federal agencies. The FDA (The Food and Drug Administation) released, on March 12, 2004, the final report of its Obesity Working Group. In this report, the FDA proposed that the way to control weight was through keeping calorie balance. The calorie in must be equal to calorie out. The FDA enhanced food labeling to display calorie information more prominently and used meaningful serving sizes. Also, FDA asked food providers, which included food industries and restaurants, to provide the nutritional information to consumers (3). FDA believed people would use the nutritional information provided by food labels to choose better food and keep the calorie balance.

However, food labels never worked as well as FDA believed. Before the FDA’s report released in 2004, the Nutrition Labeling and Education Act (NELA), which took effect in 1994, has been enacted for more than a decade (4). Under NLEA, food labeling was mandatory for most processed foods. It required manufacturers of packaged foods to display the Nutrition Facts panel to list the key nutrients and serving sizes (5). In the other word, the FDA’s campaign on “Calorie Count” was actually based entirely on an old policy. The main problem of the labeling policy was that it did not reduce the increasing percentage of obesity. Although many people declared that food labels helped them in choosing healthy food and several researches found statistical correlations between label uses and dietary intake (6), the increases of obesity in the past decade was accelerating. Data from the National Health Interview Survey (NHIS) suggested that adult obesity has increased continuously since the NLEA enforcement which went up from 18% in 1995 to 23% in 2003 (7). The FDA, in their report, admitted that “Despite reports of a positive correlation between label use and certain positive dietary characteristics, the trend toward obesity has accelerated over the past decades”. Therefore, it became very questionable if the FDA new campaign will stifle the trend of obesity. The campaigns of “Calorie Count” and “Enhanced Food Labels” are just derivatives from their old and ineffective predecessor. The FDA is still using the same logic as it has done decades ago.

What are the reasons that food labels could not work well as the FDA expects. We need to reevaluate calorie count and food labels in socioeconomic perspectives, not just scientific perspective which the FDA uses, to find out why it is not and will not be effective against obesity.

Ineffective Application on Health Belief Model
The first problem of food labels and calorie count is that the FDA believes that consumers’ behavior is determined by an objective logical thought process (8). In health belief model, person’s beliefs on susceptibility to the disease and the availability and the effectiveness of action determine what action they will take (9). Therefore, the FDA assumes that people acknowledge obesity to be a major threat to health and want to prevent it. Researchers of the FDA did lots of scientific analyses and found the calorie balance in human body. Consumers should be educated to keep calorie in and calorie out at equilibrium. Food labels can provide the nutritional information for people to count calories more easily. Once people take actions on keeping calorie balance, the obesity is prevented. In the other word, the FDA is trying to lower barrier of behavior change and increasing the availability and effectiveness of new behavior.

The health belief model has been criticized by many scholars and researchers. It has limited ability to account for variance in behaviors that relate to attitude and belief (10). Its fundamental assumption is that health is highly valued. It also assumes that people behave logically. However, both assumptions are not correct. For example, some individuals choose vegetable over meat because their religious beliefs make them do it. Although they have a healthy dietary, it has nothing to do with health or health belief model. Also, people with obesity may keep on eating high-calorie food because they simply want to enjoy food and not to be restricted. Health belief model fails when individual has low cognition on healthy problem or does not behave logically. Therefore, it is the first reason that food labeling is not effective on preventing obesity. If people do not want to eat healthy, they would discard any information that the labels provide. Even if the FDA makes the label cover the entire package, the customers will not read it. Since food labels can not grab their attention, customers definitely do not participate the calorie count.

Lack the Consideration of Social and Environmental Factors
Since the FDA’s campaign of food labeling and calorie count bases mainly on HBM, it also lacks the consideration on other social and environmental factors which have strong influences on dietary. Those factors can come from advertising, socioeconomic status and peer influence.

1) Advertising
Advertising is one of the strongest stimuli which can change public’s value and behaviors (11, 12). In U.S., 98% of households have televisions and adults spend an average of 2 hours per days watch TV. They are exposed to TV commercials at least 6 min per hours (12). Unfortunately, fast food restaurants has spent 98% of its advertising budgets on TV ads. Therefore, adults in U.S. are highly exposed to fast food commercials. In contrast to the food labels that customers have to read the information on it, TV ads actively send fast food information and stimulation to their receivers. Those commercials could influence the viewer’s choice toward higher-fat or higher-energy food on a level which surpasses the education from the FDA.

2) Socioeconomic Status
Education level and income has been determined to have strong associations with health status (14). Different income and demographic groups have different values and priorities on health behaviors. Food label has been reported to bring benefit to only one demographic group: non-Hispanic white female (7). The influence of labels on other demographic groups was not observed. Also, prize of food has been account for one major factor that influences food consumption (15). Therefore, socioeconomic status can not be ignored in preventing obesity. However, the FDA’s plans did not consider it. Both Food labeling and calorie count work on the individual level. The disregard of social inequalities in health would be an obstacle to the effectiveness of FDA’s campaign.

3) Peer Pressure
Individual has the inclination to adopt certain behavior patterns or attitudes in the social group which he felt obligation. This psycholgical motivation is usally appearant on children and teenagers. Also, teeangers have a inclination to oppose authority from parents and teachers. The FDA’s policy never considered influences from peers which can drive individuls to ignore labels and choose high-calorie food and drink that would be considered cool within the group.

Lack the Stimuli to Force People Change Their Dietary
There are three groups of strategies for effecting changes in human’s behavior: 1) empirical-rational strategies; 2) normative-re-educative strategies; 3) power-coercive strategies (16). Food labels and calorie count are in the first group. The empirical-rational strategies are assumed that men are rational and would follow a logical self-interest if they have the knowledge. So, the FDA provides customers lots of information of calories and other nutrition and beleives that customers would learn from the labels and choose low-calorie diet in order to improve their health. However, this kind of strategies is not enough. Since people are not always rational and motivate logically by self-interest, they may not choose food based on improving health. Strong stimuli are required to force people change their dietary.

The FDA needs to apply its strategies more on normative-re-educative approaches and power-coercive approaches. Normative-re-educative approaches focus on socio-cultural norms and their interactions with individual’s value. Robert Chin and Kenneth Benne stated “Men does not passively await given stimuli from his environment in order to respond. He takes stimuli as furthering or thwarting the goals of his ongoing action”. So, by enforcing normative-re-educative approaches, individuals can be driven by stimuli from socio-cultural norms and environment to change their behavior.

Also, power-coercive approaches could be used. Power-coercive approaches are defined as enforcement from greater power toward less power. FDA, a federal agency, could use strategies involving more on law or administrative policy, like the policies they made on alcohol and drugs, to change people’s behavior.

Conclusion
The new campaign of the FDA in 2004 is a revision of old food-labeling policy. The old food labels did not prevent nor slow the increase of obesity population in U.S. Since 2004, The FDA has started educating on how to choose nutritional food and count calorie in order to balance calorie-in and calorie-out. However, the FDA’s endeavor may not be effective in obesity prevention. It has made the new plans based on Health Belief Model and believes it can stimulate logical behavior change in the dietary of people in United States . However, HBM is criticized to be unrealistic in analyzing human behaviors and lack social and environmental factors. In order to improve health and prevent increasing obese population in U.S., a plan which includes socio-environmental factors and strong stimuli to direct behavior change is required. Food labeling and calorie count are ineffective. FDA has to change its conceptions on public health and made a better policy.

References
1. Cill T. Key issues in the prevention of obesity. Br Med Bull 1997; 53(2):359-88
2. Ogden C., Carroll M., Curtin L., McDowell M., Tabak C. & Flegal K. Prevalence of Overweight and Obesity in the United States, 1999 - 2004. JAMA 2006;295:1549-1555
3. The U.S. Food and Drug Administration. The FDA Proposes Action Plan to Confront Nation's Obesity Problem. Rockville, MD. http://www.fda.gov/default.htm
4. Kurtzweil P. New Food Label: Good Reading for Good Eating. FDA Consumer 27, 1993
5. The U.S. Food and Drug Administration. The Food Label. Rockville, MD. Http://www.fda.gov/opacom/backgrounders/foodlabel/newlabel.html.
6. Kreuter M, Brennan L, Scharff D & Lukwago S. Do Nutrition Label Readers Eat Healthier Diets? Behavioral Correlates of Adults’ Use of Food Labels. American Journal of Preventive Medicine 1997;13:277-283.
7. Variyam J and Cawley J. Nutrition Labels and Obesity. National Bureau of Economic Research, 2004.
8. Kathryn M. Comparison of Four Behavioral Theories, a Literature Review. AAOHN journal, March 1991; 39(3): 128-135
9. Rosenstock I.M. The health belief model and preventive health behavior. Health Education Monograph 1974; 354-386.
10. Janz N. & Becker M. The Health Belief Model: A Decade Later. Health Education Quarterly 1984;11(1). 1-47
11. French S., Story M. & Jeffery R. Environmental Influences on Eating and Physical Activity. Annu. Rev. Public Health 2001; 22:309-35
12. Hill JO & Peters JC. Environmental contributions to the obesity epidemic. Science 280:1371-74
13. Nielsen Media Res. 2000 Report on Television: The First 50 Years’ New York: AC Nielsen Co.
14. Lantz P.M., Lynch J.W., House J.S., Lepkowski J.M., Mero R.P, Musick M.A. & Williams D.R. Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviors. Social Science & Medicine 2001; 53:29-40
15. Dyson LK. American cuisine in the 20th century. Food Rev. 2000; 23:2-7
16. Bennis W., Benne K., Chin R. & Corey K. The Planning of Change. 3rd edition. Holt, Rinehart and Winston, Inc. 1976

Using Communication Theory to Critique the current framework promoting National Health Care Reform: Why America Can’t Achieve Action- Lisbeth Balligan

The Issue
Many health care professionals currently engaged in the medical profession would agree that the present system of delivering heath care is inadequate and fails to meet the nation’s needs. A 2005 report found that at least 45 million people, 15.6% of the population, in the United States are without basic medical services (1). Ironically, the United States spends more than any other industrialized country on health care yet it has some of the lowest life expectancy rates (2). In addition, health care accounts for the largest portion of gross domestic spending at 15.3% in 2003, and this portion has been rising yearly (3).
The majority of Americans agree that everyone in the country should have access to and coverage for necessary services (4). These services should include, dental care, eye care, primary care, and emergency care. Contrary to the public sentiment in favor of reform efforts, the nation has been unable to achieve national health care coverage for decades. The efforts to pass a comprehensive system have been unable to rise above the partisan divides within our state and federal government. A good example of this failure is the attempted reform during former President Bill Clinton’s first term in office. In 1993, first lady Hilary Clinton campaigned for national health care reform. The proposal ultimately failed to pass because agreement could not be reached between congressional Democrats and Republicans (5). Little has changed since this time. Currently, no constitutionally recognized right to health care has been articulated. Portions of the population are covered under piecemeal government programs such as Medicare, Medicaid, Children’s Health Insurance Program (CHIP), and the Veteran’s Administration. Coverage under these programs varies from state to state and is often inadequate at meeting individual’s health needs because many needed procedures are not covered.
Framing and Contextualization
The context in which the issue is presented in the popular press and journal articles affects the general populations’ perceptions of health care reform. The term “framing” comes from cognitive science, which defines a frame as a conceptual structure used to influence individual’s perceptions of their worldview (6). Issue framing, developing and implementing a way of understanding a particular issue, is one of the central and best-documented methods available to political players to structure political debates (7). The framing technique involves developing a strategic way of presenting an issue to meet a particular goal. The frame has a core position that it holds as its main belief. Often this belief is expressed by appealing to different values that individuals may hold, such as, freedom, justice, autonomy, health, and equity. Frames can often be recognized by certain catch phrases and implied solutions. Also, framing often provokes certain metaphors and images that help strengthen the frame and its ability to gain acceptance and integration by its target audience.
The frame most often used in the health care debate is the Universal Health Care frame. This frame is flawed for several reasons which will be explained in the following section. One important inadequacy of the current frame is that it aims to communicate on a level three analysis and not on a level one analysis (8). A level three analysis focuses on programs and policy reforms while a level one analysis focuses on values and principles. Individual’s values and principles must be considered when articulating an adequate frame to promote national health care reform. Health care reform is a collective issue that requires the coordination of all members of the U.S. population. By currently focusing on policy- level reforms the frame does not allow individuals to feel empowered to advocate for changes in their health care benefits. Values and principles are what stir individuals to action. By using social science theory and addressing the importance of efficacy in influencing behavior changes a new frame promoting reform can be developed. This new approach can empower individuals to influence their legislators and request that changes be made.
The Frames
There are three frames that dominate the popular literature are used to characterize health care reform proposals. They are universal health care, a right to health care, and socialized medicine (9). The goal of health care reform efforts is to achieve a comprehensive health care system that includes access to care and coverage of necessary services. None of the existing frames meet this goal. A new frame can be developed by critiquing these frames and highlighting their strengths and weaknesses.
The first and most popular frame, universal health care, focuses on the core value of health. This is a weak core value because it does not illicit strong personal emotions. Other core values such as justice and freedom are stronger because they appeal to virtues that individuals tend to care more about and find more value in. Key phrases for the universal health care frame include “full coverage,” “universal,” and “single payer.” The metaphor used in this frame is, ‘other countries have a national health care system so should the U.S.’ This metaphor is also weak because it does not resonate with Americans. Americans pride themselves on being unique, autonomous individuals, so knowing that our actions are different then other countries is often perceived as a compliment by Americans. The frame also does not promote any strong images which are essential if individuals are to internalize the frame. Overall, the universal health care frame is very weak and this is the main reason that health care reform initiatives have not received the momentum needed to achieve successful reform.
Another frame, a right to health care, is flawed based on its reliance of a ‘right’ to health care. Currently, there is no recognized right to health care in the Federal or any State Constitution. Without this right, the frame loses its force. Alternately, the core values on which the frame relies, fairness and justice, are strong. Also, the metaphor of the civil rights movement is engaging because it resonates with many individuals. The Civil Rights movement is an example of a successful nationwide system reform. The movement elicits visions of peaceful protest and a call for action. These sentiments and the parallel conceptualization they provide are helpful in making the issue of health care reform important to the general public. Regardless of how successful these images of reform are, without the constitutionally recognized right to health care the frame for health care as a right has no foundation and is thus ineffective.
The socialized medicine frame asserts that governments can and should meet their citizens needs for health care. In our current democratic nation, this sentiment holds sway but the frame neglects to propose a solution to the problem. Taxes would need to be increased to allow the government to implement and run a socialized national health care system. Some Americans are opposed to the idea of funding a health care system that is already very costly and has no mechanisms for cost control in place. In addition, ideas of socialized medicine bring to mind images of Big Brother regulations and are in direct conflict with the core values of freedom and autonomy which are highly valued by Americans. Thus, the idea of complete health care coverage by government implementation and control fails to address some fundamental inadequacies that currently exist.
The Remedy
Because all of the existing frames promoting national health care reform are flawed, a new approach must be articulated. By drawing from social science theory and social cognitive theory in particular a new frame that addresses the failures of the existing frames can be articulated.
Social Cognitive Theory
Self efficacy is the belief that one has the capacity and ability to execute the courses of action required to meet a particular purpose or goal (10). Self efficacy is particular to an individual. Whether or not they perceive an act to be self efficacious can be influenced by outside forces, but the ultimate belief is an individual construct. There are four sources that influence a person’s self efficacy; modeling, experience, persuasions, and physiological/emotional factors .
Self efficacy becomes important in the context of the health care reform debate because in order for people to engage in the promotion of systematic health care reform, they must be able to act as self efficacious individuals. They must see the reform as achievable and they must see the proposed health care system as accessible. Self efficacy plays a direct role in motivation. Low self efficacy can lead people to believe that tasks are harder then they really are and can cause a lack of motivation to attempt the task. Alternately, high self efficacy occurs when an individual believes the task is possible and provides the motivation to attempt the task. By reframing health care reform in a way that promotes individual self efficacy, people can be motivated to act for change.
Implications for a new national health care reform frame
The nation’s current health care system is in need of overhaul and reform. The frames used to articulate the debate have focused entirely on policies and programs and have done little to capture the importance of individual perceptions and behaviors. By neglecting to address the importance of an individual’s contribution to reform and failing to incorporate them into the vision of a national health reform program, the motivation for a fundamental change in the nation’s health system has been lost. In order for the reform to gain the momentum and acceptance it needs to pass and be successfully implemented, the proposed changes must be seen as effective and necessary in the eyes of the general population. Individuals must feel that the new system and the frame used to promote it are empowering. A successful frame will promote individual self efficacy and allow individuals to use their motivations as fuel for legislative action.
References
(1)Health and Human Services. Working Paper: Estimating the number of individuals in the United States without health insurance. Actuarial Research Corportaion, Annandale, VA. http://aspe.hhs.gov/health/reports/05/est-uninsured/report.pdf
(2)Bodenheimer T. Understanding Health Policy: A Clinical Approach, 4th Edition. New York, NY: McGraw Hill Medical Publishing Division, 2005.
(3)Health and Human Services. Effects of Health Care Spending on U.S. Economy. http://aspe.hhs.gov/health/costgrowthchart
(4)Kaiser Family Foundation. Public Opinion Spotlight. http://www.kff.org/spotlight/uninsured/index.cfm.
(5)Clinton B. My Life. New York, NY: Knopf, 2004.
(6)Chua K. Introduction to Framing. http://www.amsa.org/uhc/FramingIntro.pdf.
(7)Terkildsen N. Interest Groups , the media, and policy debate formation: an analysis of message structure, rhetoric, and cues. Political Communication 1998; 15:45-61.
(8) Chua K. Introduction to Framing. http://www.amsa.org/uhc/FramingIntro.pdf.
(9) Table
(10) Self Efficacy. Wikpedia. http://en.wikipedia.org/wiki/Self_efficacy

Why the National Breastfeeding Awareness Campaign will not Increase Breastfeeding Rates: A Critique Based on Social Cognitive Theory– Lauren R. Pino

Warning: Public health officials have determined that formula feeding is hazardous to your baby’s health.

There is no warning label like this affixed to cans of infant formula or tucked into the corner of magazine advertisements, at least not yet. Nevertheless, that is the explicit message of the National Breastfeeding Awareness Campaign (NBAC). In 2004, the Department of Health and Human Services Office on Women’s Health and the Ad Council launched a $40 million dollar national campaign encouraging first-time mothers to breastfeed exclusively for six months. With the tag line: “Babies were born to be breastfed,” this ongoing campaign aimed to empower women to commit to breastfeeding and to highlight research supporting the health benefits of breastfeeding. The NBAC employed communication techniques through a variety of channels, including public service announcements for television, radio, newspapers, magazines, mass transit, billboards and the Internet in an effort to increase breastfeeding rates. For example, the television announcements featured pregnant women engaging in dangerous sporting events, such as roller derby, with the voiceover: “You’d never take risks while you’re pregnant. Why start when the baby’s born? Babies who are exclusively breastfed for 6 months are less likely to develop ear infections, diarrhea, respiratory illnesses, and may be less likely to develop childhood obesity.”
According to the National Immunization Survey (2005), 21 states in the United States achieved the national Healthy People 2010 objective of 75% of mothers initiating breastfeeding; whereas 5 and 11 states achieved the objective of having 50% of mothers breastfeeding their children at 6 months of age and 25% of mothers breastfeeding their children at 12 months of age, respectively. Only 5 states — California, Hawaii, Oregon, Vermont and Washington — achieved all three of these Healthy People 2010 objectives (1). However, the American Academy of Pediatrics (AAP) recommends that an infant be breastfed without supplemental foods or liquids for the first 6 months of age (known as exclusive breastfeeding). Only one state — Oregon — achieved an exclusive breastfeeding rate of 25% or greater through 6 months of age. Apparently, the vast majorities of women in this country do not attempt to breastfeed or cease breastfeeding much earlier than the Academy of Pediatrics recommends. Why is this so? NBAC supporters believe that women bottle-feed because the general public assumes that infant formula is comparable to breast milk. However, according to the Centers for Disease Control HealthStyles Survey (2005), only 26.4% of respondents agreed that infant formula is as good as breast milk and 49.1% agreed that babies should be breastfed for at least six months (2). Contrary to the NBAC’s beliefs, the general public is aware of the benefits of breast milk over formula and many pregnant women intend on breastfeeding once their child is born. This illustrates that the act of breastfeeding depends not only on women’s knowledge, desire or intention to breastfeed, but also on additional internal and external factors. Numerous studies attest to this fact. O’Campo and colleagues examined the psychosocial, demographic, and medical factors associated with longer breastfeeding duration among 198 urban breastfeeding women (3). Of 11 psychosocial and demographic factors examined, the following 4 were the most significant influences on breastfeeding duration: normative beliefs, maternal confidence, social learning, and behavioral beliefs about breastfeeding. Clearly, multiple factors disrupt the intention—behavior pathway. However, the NBAC, like countless other breastfeeding promotion campaigns of its kind, neglects to consider this reality. The NBAC public service announcements previously described disregard self-efficacy and observational learning as significant factors affecting a woman’s decision to breastfeed. Finally, the NBAC shows no appreciation of the numerous social barriers to exclusive breastfeeding. Such barriers include: work environments with inadequate breast pumping areas and lack of support at home.
Self-Efficacy
The NBAC will continue to fail because it does not consider the effect of self-efficacy on behavior. Bandura (4), who coined the term, defined an efficacy expectation as “the conviction that one can successfully execute the behavior required to produce outcomes.” Further, Bandura asserts that “outcome and efficacy expectations are differentiated, because individuals can believe that a particular course of action will produce certain outcomes, but if they entertain serious doubts about whether they can perform the necessary activities such information does not influence their behavior” (5). In his definition, Bandura clearly draws distinctions between perceptions of self and perceptions regarding the recommended behavior. Social science research supports Bandura's claim that when self-efficacy is low, people rarely attempt behavior change (5).
Further, self-efficacy judgments help determine not only whether we undertake particular activities, but also, the amount of effort we put into them, and the length of time we persist in striving for goals in particular situations (6). Therefore, a new mother with low self-efficacy will not attempt to breastfeed even if she believes that breastfeeding is best for her child. As such, if the new mother does attempt to breastfeed, it is highly unlikely that she will continue to do so exclusively for six months. For that reason, breastfeeding messages should not merely tell new mothers the risks of not breastfeeding, but rather, bolster their beliefs that they can successfully breastfeed. Techniques for bolstering self-efficacy include showing women that they are capable or demonstrating that breastfeeding exclusively for six months can be accomplished.
Additionally, Bandura asserts that somatic and emotional states such as anxiety, stress, arousal, and mood states provide information about efficacy beliefs (7). People can gauge their degree of confidence by the emotional state they experience as they contemplate an action. Strong emotional reactions to a task provide cues about the anticipated success or failure of the outcome. When they experience negative thoughts and fears about their capabilities, those affective reactions can themselves lower self-efficacy perceptions and trigger additional stress and agitation that help ensure the inadequate performance they fear (7). Thus, the NBAC will continue to fail because the campaign attempted to manufacture and exploit fear among new mothers. When new mothers associate uncomfortable images (log-rolling, bull-riding, etc.) and dismal clinical terms (ear infections, diarrhea, respiratory illnesses, etc.) with breastfeeding, they will be less likely to breastfeed.
Observational Learning
Moreover, Bandura affirms that people retrieve efficacy information by watching others, especially during times of uncertainty (8). Bandura contends that observation of behavior often outweighs verbal instruction as an influence on self-perceptions of competence and the internalization of morals and standards. However, people do not passively absorb all the standards of behavior to which they are exposed. Instead, the standards that are internalized are dependent on the degree to which the model is like oneself, the value of an activity, and one's perception of their degree of personal control over the behavior (8). Therefore, the public service announcements featured in NBAC that display physically fit, pregnant white women engaged in ridiculous stunts are not effective interventions if the primary goal of the campaign is to increase breastfeeding rates among women of color. Moreover, how could any woman, regardless of race, relate to images of women log-rolling? To increase breastfeeding rates in this country, public service announcements should include scenes of women incorporating breastfeeding into their daily routine. For example, images of a woman doing something one-handed while nursing her baby with the other, or of a woman nursing in her office before a meeting would have been influential models for women to emulate.
Social Challenges
The National Immunization Survey revealed that in 2005 a mere 8.8% of unmarried and 10.3% of socioeconomically disadvantaged women (pov-inc ratio< href="http://www.4woman.gov/">http://www.4woman.gov) offers women an ample amount of breastfeeding support regardless of their social situation. I agree that the website offers practical advice concerning the physical challenges of breastfeeding (engorgement, sore nipples, etc.), however, the website halfheartedly addresses the social challenges for women, especially single mothers and the socioeconomically disadvantaged who do not have the comfort of living in a supportive, nurturing environment. For instance, under the heading Coping with Breastfeeding Challenges, the website encourages women to, “take as much time off work as possible, since it will help you get breastfeeding well established and also reduce the number of months you may need to pump your milk while you are at work” (9). How would a single mother, earning hourly wages, struggling to pay the bills benefit from that advice? Is she even guaranteed a quiet, comfortable office at work where she can pump in peace? Although the answers to these questions are quite obvious, proponents of the NBAC appear oblivious to these issues. Furthermore, although 35% of mothers in our society are single, the website encourages women to look to their baby’s father for social support (1). Under the heading, Feeding at Home, the website claims, “Fathers can play a major role in the breastfeeding experience by being sensitive to the mother’s needs and encouraging breastfeeding when the mother is feeling tired or discouraged”(9). Clearly the NBAC’s ignorance and overall disregard for the social challenges specific to these groups of women will lead to the campaign’s ultimate failure.
Final Thoughts
As public health professionals, it is critical that we address self-efficacy, observational learning, and social challenges as moderators in the pathway between intention and behavior. The NBAC, like so many other maternal and child health campaigns, is failing as an effective public health intervention because it did not integrate behavioral science theory into its campaign design.
REFERENCES
1. Centers for Disease Control and Prevention. National Immunization Survey. 2005.
2. Centers for Disease Control and Prevention. HealthStyles Survey. 2005.
3. O'Campo P, Faden RR, Gielen AC, Wang MC. (1992) Prenatal factors associated with breastfeeding duration: recommendations for prenatal interventions. Birth. Dec;19(4):195-201.
4. Bandura. A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215.
5. Bandura, A. (1978). The self system in reciprocal determinism. American Psychologist, 33, 344-358.
6. Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman Press.
7. Bandura, A. (2001). Social cognitive theory: An agentive perspective. Annual Review of Psychology, 52, 1-26.
8. Bandura A and Jourden FJ. (1991) Self-regulatory mechanisms governing social comparison effects on complex decision-making. Journal of Personality and Social Psychology, 60: 941-951.
9. Office on Women’s Health. The National Breastfeeding Awareness Campaign. The U.S. Department of Health and Human Services. Washington, DC. http://www.4woman.gov.

Marginalization of Women in Poverty by AIDS/HIV Initiatives: A Result of Reliance on the Health Belief Model & Inadequate Assessment- Kate Russell

Public health HIV/AIDS prevention programs for women have only recently come about and many of these programs are failing to curb the rising rate of women infected with HIV, especially women living in poverty (1). Many early prevention programs geared towards women highlighted promiscuity and injection drug use as main causes for infection and placed blame on women for this disease portraying them as vectors rather than victims of the disease (2). This blame placing further lowers women’s self worth, increasing their risk of participating in high-risk behaviors. Most prevention programs geared towards women have relied on the health-belief model; believing that once women are informed of ways to prevent HIV infection (abstinence and condom use) they will be able to put these ideas into practice to decrease their own risk of infection. These programs fail to take into account social and behavioral risk factors, such as poverty, depression, gender inequalities and the vast array of other problems plaguing these women, as well as the inability of some women to negotiate safer sex practices with their partners. This paper aims to address these issues and how public health initiatives have failed these women.
Women in poverty as a ‘risk group’
In the U.S. the proportion of women infected with HIV has more than tripled since 1985 (1). Seventy one percent of new HIV infections in 2005 were women (3). However these statistics do not tell the whole story. HIV/AIDS disproportionately affects women living in poverty. Nancy Stoller, Professor of Community studies at the University of California states, “HIV among women is a disease of the poor, the uneducated, and the ghetto-ized (4).” Among areas with high rates of HIV-infected women, the women most affected are poor, belong to communities that are racially or ethnically oppressed, or are drug users (2). Women with any of these characteristics are less likely to receive care and services, and for women with all three characteristics it is nearly impossible to get any access to care or services.
For many of these women, HIV prevention may not be their highest concern. AIDS is just another of a long list of serious health problems experienced by this population (5). These women have other, more pressing concerns, such as finding money for food, rent, etc. They may be dependent on their partner for these things and therefore are not in a position to press for safer sex practices and condom use. For example, a study of African American women in Los Angeles showed that women who depended on their partners for money for rent were less likely to use condoms than women who were not dependent (6).
Current AIDS/HIV Prevention Programs
Many HIV/AIDS prevention programs that target women living in poverty are failing to curb the rising rates of infection among this group. Many of these programs utilize the health belief model, which ignores social and behavioral risk factors that are the underlying causes that put these women at risk for infection. The following HIV/AIDS prevention initiatives and programs are examples of Public Health’s continued use of this flawed behavior theory.
A recent HIV/AIDS prevention initiative put forth by the CDC is entitled Advancing HIV Prevention: New Strategies for a Changing Epidemic. Despite the progressive sounding name, the strategy is based on the continued use of the Health Belief Model and lacks needs assessment for women living in poverty as well as minorities and other at risk groups. This program includes four aims. The first of which is to include HIV testing in regular medical care. The program allows for the fact that many high risk populations are not getting regular medical care by aiming to include testing outside of the medical environment in bars, bathhouses, homeless shelters and prisons. The initiative focuses also on preventing new infections by working with HIV positive individuals and their partners and increasing partner notification programs. The last strategy is to further decrease HIV transmission from mother to child (7).
The program’s main focus is on individuals with a known HIV positive diagnosis. The belief is that by targeting these individuals to modify their behavior to reduce infection rates. A main focus of this initiative is Partner Counseling and Referral Services (PCRS). While counseling services for partners of HIV positive persons is certainly important, it focuses on stable relationships in which the serostatus of both partners are willing to receive counseling and know their serostatus. However, for high risk groups, many relationships are unstable and HIV serostatus is unknown. This program aims to increase knowledge of HIV serostatus by offering HIV testing as a routine part of medical care and by offering testing services outside of the medical environment. However, a study by the CDC showed that the most common reason for getting tested was not because the test was offered or recommended by a health-care facility or provider (10% for men, and 17% for women) but because of illness (42%) which can occur long after infection (8). A large drawback of this program is its sole focus on individuals with a known positive serostatus, some of whom will need ongoing prevention services to ensure a lasting change in behavior. Others may be unwilling to participate in a program that requires them to contact previous partners and may fear others finding out their serostatus. Also, though the program may be able to increase the number of individuals who know their serostatus, there is no guarantee that individuals found to be positive for HIV will be able to procure the drugs they need to treat their infection.
Other programs, such as New York City’s recent distribution of millions of condoms in the Subway, solely focus on distribution of condoms, without consideration that many of these women at risk are unable to negotiate the use of condoms, even when they are available. Bedimo et al. found that women in their study who did not consistently use condoms stated reasons for non-use as a lack of trust in the reliability of condoms to protect them, a lack of desire for pregnancy prevention, and the male partner’s refusal to use condoms (9). Increased availability of condoms will not address any of the reasons for these women’s inconsistency in condom use. Programs to address these issues should consider increased education for these women, including how to negotiate safe sex practices with their male partners.
Failure of the Health Belief Model
Many other programs focus on educating women about routes of transmission and condom use and utilize the Health Belief Model. The belief is that if women are simply told that they are at risk for this disease and they can prevent it through condom use, they will. However, most women in U.S. at risk for HIV are already aware that they are at risk and that condom use can prevent transmission but these women are unable to insist on safe sex practices due to power imbalances in their relationships (10). Schneider states “Knowledge of HIV transmission and its prevention does little good if women do not have the necessary social status and economic independence to negotiate sexual relations with their partners or to chose not to sell sex (2).”
Nyamathi et al. studied AIDS-related knowledge, perceptions and behaviors of impoverished Latina women. The study found that women at risk correctly identified themselves as ‘at risk’ and correctly identified methods of transmission and prevention methods, i.e. condom use and abstinence. They even tended to overestimate the risk of contracting HIV/AIDS. Surprisingly, the investigators conclude the paper by recommending culturally sensitive education programs to increase knowledge of susceptibility and modes of transmission as a solution for the higher prevalence of AIDS among minority women (11). Though they acknowledge that greater knowledge did not lead to safer behavior, they instead suggest perceived vulnerability as a better method to change behavior. This is turning once again to the health belief model. Rather than focus on social reasons, they focus on perceived vulnerability to HIV as a way to scare women into safer behaviors.
Another study by Gedlen et al. tested the use of the health belief model to promote safe sexual behaviors in women. They found that women were motivated to try to use condoms by their beliefs about susceptibility, severity, and barriers. However these women failed to continue to practice protective barriers in the long term, declaring them ‘burdensome’ (12). Though it may have worked to scare women into practice safer behaviors in the short term, only by addressing the social and behaviors causes of the women’s behaviors can you have a lasting impact.
The Need for Needs Assessment
Current prevention programs are addressing only surface issues of what places these women at risk. Learning the perspective of these women and their own perception of their HIV risk through needs assessment will enable public health professionals to tailor unique programs to address social and behavioral factors that place these women at heighten risk for HIV/AIDS. Programs that will truly help these women will incorporate three necessary concepts: community involvement, empowerment, and self-efficacy. Communities should be involved in the planning and executing of prevention programs. A program entitled SISTA: Sisters Informing Sisters About Topics on AIDS is based on the social cognitive theory is finding success in implementing social-skills based training programs to reduce risk behavior among African American women, who are particularly at risk for infection (15). Though African Americans account for only 13% of the population, they accounted for 66% of AIDS cases in 2005 (3). Programs that are not only culturally sensitive, but also involve the community will have the greatest effect on this population. Involving the community will not only allow for peer educators and support groups, but will include involvement of male partners. This is vital in order to decrease infection rates in women. The Advancing HIV Prevention initiative does include partners, but this only affects stable relationships. Involvement of all males to educate them about their role in HIV prevention for women is necessary.
Educational programs for women need to emphasize empowerment, self-efficacy, and communication skills. These will provide women with the skills necessary to negotiate safer sex practices with their partners. Many studies looking at HIV/AIDS in women have found that a lack of self-efficacy and power imbalances result in a lack of condom use but many prevention programs still focus solely on instructing women to use condoms to prevent infection, without providing them with skills necessary to negotiate the use of condoms with their partners. A study by Hetherington et al. demonstrated that one of the reasons African American women in their study continued to practice high risk behavior despite their knowledge of AIDS was their perceived powerlessness in negotiating condom use (11). Women who perceive their partners as dominant in their relationships have less confidence in their ability to negotiate condom use and a greater fear of negative consequences with their partners for demanding safer sex practices (13). A needs assessment for these women will allow for programs tailored to these populations that will be able to address underlying issues placing them at risk to provide for long-lasting, successful HIV prevention.
Conclusion
The lack of appropriate HIV/AIDS prevention programs for women living in poverty is due to the use of the Health Belief Model and a lack of needs assessment for these women. Programs continue to focus solely on education about risk factors and condom use despite growing evidence for a need for programs that address underlying social reasons affecting these at-risk women such as poverty, depression, and power-imbalances in relationships.
There is an urgent need for programs that address these issues in order to curb the rising rates of HIV infection among women living in poverty. Initiatives should take a multi-focal approach and involve communities as well as educate and empower women to be able to protect themselves from infection.
References:
1. amfAR, Women and HIV/AIDS, www.amfar.org
2. Schneider, B and N. Stoller. Women Resisting AIDS: Feminist Strategies of Empowerment. Philidelphia, PA: Temple University Press, 1994.
3. Center for Disease Control and Prevention. AIDS/HIV. www.cdc.gov
4. Stoller N. Lessons for the Damned: Queers, Whores, and Junkies Respond to AIDS. New York, NY: Routledge, 1998.
5. Ward, M. A different disease: HIV/AIDS and health care for women in poverty.
6. Farmer, P. Women, Poverty and AIDS: Sex, Drugs, and Sexual Violence. Monroe, ME: Common Courage Press, 1996.
7. Center for Disease Control and Prevention. Advancing HIV Prevention: New Strategies for a Changing Epidemic. Atlanta, Georgia: AVERT. http://www.cdc.gov/hiv/topics/prev_prog/AHP
8. CDC. Advancing HIV Prevention: New Strategies for a Changing Epidemic. Morbidity and Mortality Weekly Report. 2003; 52(15):329-332
9. Bedimo, A., Bennett, M., Kissinger, P., and R. Clark. Understanding barriers to condom usage among HIV-infected African American women. Journal of the Association of Nurses in AIDS Care. 1998; 9(3): 48-58.
10. Farmer, P. Infections and Inequalities: The Modern Plagues. University of California Press, 2001.
11. Nyamathi, A., Bennett, C., Leake, B., Lewis, C., and J. Flaskerud. AIDS-related Knowledge, Perceptions, and Behaviors among Impoverished Minority Women. Journal of American Public Health 1993; 83: 65-71.
12. Gielen, A., Faden, R., O’Campo, P., Kass, N., and J. Andrson. Women’s protective sexual barriers: a test of the Health Belief Model. AIDS Education and Prevention 1994; 6(1): 1-11.
13. Pittsburg AIDS Task Force. AIDS/HIV Prevention Programs. http://www.patf.org/preventionPrograms.asp
14. Hetherington, S., Harris, R., Bausell, R., Kavanagh, K., and D. Scott. AIDS prevention in high-risk African-American women: behavioral, psychological, and gender issues. Journal of Sex and Marital Therapy.
15. Soet, J., Dudley, W., and C. Dilorio. The Effects of Ethnicity and Perceived Power on Women’s Sexual Behavior. Psychology of Women Quarterly 1999; 23(4): 707-723.

Choose Your Cover: The Failure of a Skin Cancer Prevention Campaign to Consider Teenage Perceptions And Developmental Issues- Emily Learner

In 1920, French designer Coco Chanel inadvertently introduced a new fashion trend to the world, which has since become a major public health problem. While on vacation, Ms. Chanel accidentally obtained a suntan. Tanned skin was not popular at the time, but Ms. Chanel embraced the look. Tan skin nicely complemented her new fashion designs, which were styled to reveal more skin (1 ,2). Almost overnight, tan skin became a mark of beauty, and a popular fashion trend. Fashion magazine, Vogue, quoted Coco Chanel as saying, a “girl must be tanned. A golden tan is the index of chic” (2). Tan skin became a sign of beauty, health, and youth, and it has grown to become a widespread cultural obsession.
Public health officials are now trying to curb this obsession because of the serious the health problems associated with tanning. Studies have shown a positive correlation between UV exposure and skin cancer, and tanning is strong predictor of skin cancer development (3, 4). This is of particular concern, as the incidence of skin cancer has more than tripled in the past 30 years, and the rates continue to rise while the mean age of diagnosis of melanomas continues to fall (3, 4). To combat the nation’s “tanorexia”, the Center for Disease Control has introduced a campaign to educate people about the dangers of tanning and to encourage people to practice skin prevention techniques. This campaign, called Choose Your Cover, was created with the goal of decreasing dangerous UV exposure among young people. Despite Choose Your Cover’s education initiatives, however, the campaign has not had a significant impact on teenagers (3, 4). The Choose Your Cover Campaign has been unsuccessful in changing the tanning behaviors of teenagers because it fails to address tanning from a teenage perspective, and does not consider the psychological and cognitive development of teenagers.
Teenage Perceptions and Social Norms
The underlying assumption of Choose Your Cover is that education about the risks of tanning will influence teenagers’ intentions to protect their skin and ultimately cause them to avoid tans. Research shows that this is not the case. A study organized by the American Association of Dermatology shows that among young adults,“79% are aware that getting a tan from the sun can be dangerous for their skin and 81% know that the sunburns they got as a child increase their risk of developing skin cancer as an adult” (3 ,4,). Still, only around 30% of teenagers (12-18 years old) use sun protection and 80% admit to getting at least one sunburn a year, which significantly increases skin cancer risk (3 ,4). Furthermore, surveys show that between 30% and 40% of teens visit indoor tanning salons eight to fifteen times a month (3, 4). Clearly, ignorance of the dangers of UV radiation and how to protect one’s skin is not a contributing factor to tanning behavior.
Social pressure is a contributing factor however. The influence of societal norms on teenagers is especially strong, as teens base decisions on peer norms and image norms (5- 7). Teenagers are especially “likely to engage in harmful types of behavior, such as tanning, if they perceive the behavior to be typical among peers (5). Research has shown that tanning is both typical and prevalent among teens (6), and teenagers’ tendencies to tan have been correlated with having friends who tan. This peer pressure to tan is complemented by image pressure. Tans are looked upon with positive attitudes, as bronze-skinned fashion icons and celebrities depict tan skin to be sexy, beautiful and fashionable (2,5). Furthermore, the failure to use preventative techniques has been directly related to self-perceived “image vis-a-vis peers” (6). This suggests that even if adolescents have the self-efficacy for sun protection, “they may be unwilling to forgo a suntan, given strong perceived advantages of tanning” (7). These perceived advantages certainly outweigh the risks. A college student explained, “I like the way that my skin looks. I feel healthier, although I know it's not healthier… It's worth it for me to have the color and feel good about myself” (8). Theoretical and anecdotal evidence shows that teens are highly influenced by social pressure, and that social norms lead teens to believe that the benefits of tanning, namely looking and feeling more attractive, and fitting in with one’s peers, outweigh the risks of tanning.
The Choose Your Cover campaign underestimates the importance of these social norms on teenagers. Although the campaign does suggest that social norms be taken into account, it fails identify which specific social norms are most valued by teenagers and which are most influential on their behavior. As a result, image norms and peer norms are neglected and not incorporated into the campaign’s design. This neglect is evident through the campaign’s encouragement to cover skin. The campaign instructs teenagers to cover up by wearing long sleeved shirts, long pants and wide brimmed hats, all made of UV protective fabrics, and wearing wrap around sunglasses (9). For a demographic concerned primarily with physical appearance and fitting in, asking teenagers to cover up is practical, yet completely unrealistic. To teenagers, these suggestions mean compromising their physical appearance, self-concept and social status not only by having pale skin but also by wearing unpopular clothing and clothing styles (6-8). A more successful approach should take into account teenage perceptions; preventative techniques that are more compatible with teenage social norms would be more likely to appeal to the teenage demographic.
Perhaps the largest oversight of Choose Your Cover with respect to social norms is its failure to address intentional tanning. The campaign does not differentiate between passive tanning and active tanning, and it treats these passive and active behaviors as one. The suggestions to apply sunscreen and wear protective clothing are relevant only to teens who spend a lot of time in the sun playing sports, attending camp or working outdoors. These teenagers tan, but the tan is secondary to other activities. Many teenagers consciously and intentionally tan via sunbathing and artificial tanning. Surveys suggest that some 2.3 million teens use tanning salons, and that teenagers visit tanning salons more frequently than all other age groups (3, 10). These visits put the teenage demographic at considerably higher risk for skin cancer, as the UV rays of tanning beds and booths are ten to fifteen times higher than natural UV rays (3). Teenagers who intentionally tan are highly influenced by social norms, as they feel compelled to look tan. Suggestions to cover up and wear sunscreen do not address the behavior of actively tanning, and are therefore inappropriate and irrelevant. A more careful consideration of teenage social norms by Choose Your Cover would generate skin protection approaches that address intentional tanning, such promoting the use sunless tanners to achieve a tanned appearance. Unfortunately, the campaign’s failure to recognize the social norms that motivate teenagers results in its failure to change skin protection behaviors of teenagers.
Teenage Developmental Issues
Psychological and cognitive development also play important roles in determining teenage behavior, but Choose Your Cover does take these developmental issues into consideration. The campaign lacks sensitivity towards teenage attitudes and learning processes. Specifically, Choose Your Cover neglects teenage attitudes and behavior in response to authority. Part of the transition from childhood to adolescence involves the establishment of independence, and this is often characterized by rebellion and defiance (11). The campaign’s authoritative, instructive tone has the intention of preventing teenagers from engaging in the risky behavior of tanning, but it actually has the opposite effect. This boomerang effect can be explained by reactance theory, which predicts that people are threatened by perceived restrictions to their freedom (11, 12). These threats make behaviors resisting the restrictions more attractive. Teenagers have a need to declare independence, and are “predisposed to respond with reactance to any forms of persuasion advocating change in their health-risk behavior” (12). The combination of being “influenced by an awareness of the many social and commercial forces that promote” (11, 12) tanning and an authoritative voice telling them to avoid tanning causes teens to consciously avoid protection and to actively tan.
The Choose Your Cover threatens teenage autonomy not only by merely telling people to avoid tans, but also by advocating for the implementation of policies that would cause social, behavioral and environmental changes. One of these policies would require schools and youth organizations to urge parents and caregivers to routinely provide to their youth advice and information concerning skin cancer prevention. Strangely, the campaign does recognize that teens may interpret this advice as a type of parental control and that “direct influence of parents might decrease and be subordinated by peer influence,” (9) but it fails to suggest an alternative policy. Instead, the campaign treats the reactance as dismissible by saying “nonetheless, family support plays a key role in extending the desirable effects of school skin cancer prevention efforts” (9).
A second campaign policy change is geared towards promoting protective clothing in school, with the hopes that using protective clothing will translate to non-school activities as well. Specifically, the campaign recommends that schools “develop policies that encourage or require students to wear protective clothing, hats, and sunglasses to prevent excessive sun exposure. These measures could be employed during physical education classes, recess, field trips, outdoor sports or band events, and camping or field trips” (9). Again, teenagers will not readily take to this change in policy as it threatens not only their perceived attractiveness, but also their autonomy. Telling kids to wear specific clothes, hats and sunglasses will likely inspire them to avoid wearing these things. Choose Your Cover barely considers reactance theory and teenage attitude in its policies, which sets up the campaign for failure.
Finally, Choose Your Cover is ineffective because the campaign’s guidelines for educational programs are appropriate cognitively and behaviorally only for elementary school children, and not for teenagers. However, the campaign suggests that its materials be used in all levels of schooling. Choose Your Cover acknowledges curriculums should vary with the age of students and that educational “activities should be tailored to the cognitive and behavioral level of the students.” (9) The campaign does a credible job of addressing cognition and learning processes by suggesting that younger student might learn through repetitious rhyming or games, while older students might learn better from more intellectually challenging activities, such as understanding the scientific basis of solar radiation and global climates. These suggestions are cognitively age-appropriate, but the campaign makes no mention of how to shape curriculums to be behaviorally age appropriate. It does not consider that teenagers have unique psychological developmental characteristics that affect how they make decisions.
The Choose Your Cover campaign does not make a distinction between behaviors of younger children and teenagers, and therefore does not address how optimistic bias, perceived susceptibility and perceived invulnerability influence teenage decision-making. Teenagers exercise a high degree of optimistic bias, which causes them to believe that they are less susceptible to unpleasant circumstances than the general population (13). Optimistic bias also causes teens to have an unrealistic perceived delay of onset, which refers to believing in an unrealistically long length of time between the behavior and the occurrence of a negative event associated with the behavior (14). This lack of perceived personal susceptibility and unrealistic perceived delay of onset, and a high degree egocentrism accounts for the “it won’t happen to me” attitude of teenagers, and contributes to their decision-making (13-15). As seen in smoking and lung cancer campaigns, steroid use and muscle deterioration campaigns, and drug use and brain damage campaigns, teenagers are superficially aware of adverse health consequences, but they decide to engage in these risky behaviors because they perceive themselves less susceptible and at times invincible to these health risks (15). Teenage perceived risk of tanning is no different. Teens continue to tan because of their distorted perception of vulnerability; they cannot imagine any other state of being than the “bloom and resilience of youth.”
While education about the health risks caused by tanning is certainly necessary, failing to consider teenage behavior, psychology and decision-making trivializes the message and minimizes the impact of the educational campaign (14). Adjusting educational programs for cognitive ability is not enough. Consideration of how teens make decisions links what teenagers know with how they use that knowledge, and the failure to incorporate optimistic bias into education programs renders Choose Your Cover educational guidelines ineffective.
The Future
With skin cancer rates on the rise, promoting skin protection techniques and discouraging indoor tanning have become increasingly important. The Choose Your Cover campaign is the necessary first step in causing widespread behavior modification, but it must examine tanning from the perspective of children as well as teenagers, and differentiate social and behavioral factors between the two groups in order to be effective. Teenagers engage in risky behaviors not because they are unaware of the dangers of their behaviors, but because they are highly influenced by social norms, are unrealistically optimistic about their futures, and react strongly to authority. Choose Your Cover’s educational approach, therefore, is only half of the battle. Continued emphasis on the dangers of tanning is important, but to effectively reach teenagers and cause behavior change, Choose Your Cover must figure out how to portray tanning as unpopular and unattractive in a manner that does not threaten autonomy but does imply personal risk.
REFERENCES
1. Health 24. A History of Tanning. 2006. Available at http://www.health24.com/about/Contact_us/13-704.asp. Accessed April 4, 2007.
2. Randle H. Suntanning: Differences in Perceptions Across History. Mayo Clinic Proceedings. 1997; 72:461-466.
3. American Academy of Dermatology. Skin Disorders and Diseases. 2006. Available at http://www.aad.org/public/Parentskids/KidsConnection/skindisdis.htm. Accessed April 4, 2007.
4. Skin Cancer Foundation. 2007 Skin Cancer Facts. 2007. Available at http://www.skincancer.org/skincancer-facts.php. Accessed April 4, 2007.
5. Jackson K, Aiken L. Social Model of Sun Protection and Sunbathing in Women: The Impact of Health Beliefs, Attitudes, Norms and Self-Efficacy for Sun Protection. Health Psychology. 2000; 19: 469-478.
6. Wichstom L. Predictors of Norwegian Adolescents' Sunbathing and Use of Sunscreen. Health Psychology. 1994; 13: 412-420
7. Jackson K, Aiken L. Evaluation of a Multicomponent Appearance-Based Sun-Protective Intervention for Young Women: Uncovering the Mechanisms of Program Efficacy. Health Psychology. 2006; 25: 34-46
8. MSNBC. Teens know tanning’s risks, do it anyway. 2005. Available at http://www.msnbc.msn.com/id/7706126/. Accessed April 4, 2007.
9. Center for Disease Control and Prevention. Choose Your Cover. 2006. Available at http://www.cdc.gov/cancer/skin/chooseyourcover/. Accessed April 4, 2007.
10. Center for Disease Control and Prevention. Health Youth! Health Topics Skin Cancer. 2006. Available at http://www.cdc.gov/HealthyYouth/skincancer/facts.htm. Accessed April 4, 2007.
11. Dillard J, Shen L. On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs. 2005; 72: 144-168.
12. Czyzewska M, Ginsburg H. Explicit and implicit effects of anti-marijuana and anti-tobacco TV advertisements. Addicted Behaviors. 2007; 32: 114-127.
13. Sjoberg L, Holm L, Ullen H, Brandberg Y. Tanning and Risk Perception in Adolescents. Health, Risk and Society. 2004; 6: 81-94.
14. Chapin J. It Won’t Happen to Me: The Role of Optimistic Bias in African American Teens’ Risky Sexual Practices. The Howard Journal of Communication. 2001; 12: 49-59.
15. Clarke V, Williams T, Arthey S. Skin Type and Optimistic Bias in Relation to the Sun Protection and Suntanning Behaviors of Young Adults. Journal of Behavioral Medicine. 1997; 20: 207-222.

A Critique of the Global Fund for AIDS, TB, and Malaria for Treatment Focus in Malawi: an examination of Social and Economic factors- Lindsay Cloutier

When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more. It is the same cause that wears out
Our bodies and our clothes.
The pain in our shoulder comes
You say, from the damp; and this is also the reason
For the stain on the wall of our flat.
So tell us:
Where does the damp come from?
Bertolt Brecht, “A Worker’s Speech to a Doctor” (1)

Malawi, a small developing country in Southern Africa, is among the poorest nations in the world with more than half of its population (55%) under the poverty line. It is no surprise that it is also among the least healthy with a life expectancy of just 41.7 years among the general population, largely due to its high prevalence of HIV/AIDS (2). Malaria and tuberculosis are also major issues in Malawi with approximately 13,00o and 7,000 deaths, respectively, in 2003 alone (3). The Global Fund for AIDS, Tuberculosis and Malaria distributes funds to developing nations to fight these three major killers around the world. The Fund has a clear mission of targeting these three diseases and has made medical treatment a major proportion of grant money donated to Malawi. There seems to be a trend in international public health to underestimate or ignore the impact of underlying social and economic factors that propagate disease. The Global Fund should broaden their efforts beyond medical interventions and should consider initiatives that affect social and economic obstacles to health; this will have a greater and overarching effect on AIDS, TB, Malaria, and many other important diseases that contribute to the high morbidity and mortality in Malawi and elsewhere.
The Issue
The Global Fund is supporting a treatment-based solution for disease in the hopes that it will also alleviate the issue of poverty in Malawi. The Fund has already pledged more than 200 million dollars in grants to Malawi with the purpose of relieving the devastation caused by the three diseases. Approximately half of the funding in grants goes directly to drugs, commodities, and products (2). Here is a perfect example of how ideological frameworks form public health intervention. If you believe that disease is the major problem, then treatment to cure disease will take care of the problem. What is not taken into account by this approach is the cyclical nature of poverty on health, and health back on poverty. It has been established by numerous studies that poverty has a major impact on health even after adjustment for other factors (4). In developing countries such as Malawi, treatment is not, and cannot be the only solution for alleviating disease. Certainly, the million people in Malawi affected by AIDS, and their lack of productivity has disturbed the workforce and devastated the economy. It also must be looked at from the opposite view, what has the socioeconomic situation of Malawi done to foster AIDS? It is paramount that before making treatment the solution of choice, that the Global Fund analyze what the macroeconomic instability of Malawi has done to foster disease and incorporate these factors into their grant proposals.
Food Security, Malnutrition, and Disease
In the past few years, Southern Africa has suffered terrible droughtwhich has created a food shortage crisis in Malawi. The country is mainly an agrarian society and has been hit both economically and nutritionally from the shortage. The Red Cross reports that Malawi has some of the highest rates of childhood malnutrition in sub-Saharan Africa with about 50% of children under the age of five suffering from chronic protein energy deficiency (5). The Red Cross, unlike the Global Fund has seen the value of distributing food rations for the purpose of alleviating the impact of AIDS (5). The Red Cross is using programs whose models are based on Maslow’s Hierarchy of Needs, which states that basic physiologic needs such as shelter, food, and drinking water must be met before Malawi can be a productive and healthy society. The on-going Fund project entitled “National Response to HIV/AIDS in Malawi,” a 73 million dollar grant, does not even mention these fundamental factors of health in any of its objectives. It has been known for years that people who are malnourished are at higher risk of developing disease. A recent study discusses how pre-existing malnutrition may exacerbate the effects of HIV due to its effects on the immune system. Malnutrition can act on the cells similarly to AIDS by decreasing CD4 T cells and provoking abnormal B-cell responses at the cellular level of the immune system (6). Studies have also shown that outcomes for HIV infected patients with insufficient micronutrient intake were poorer and the risk of death was higher than adequately nourished patients (6). If the Fund acknowledged the synergistic effects of malnutrition and poverty on HIV, they would have a more substantial impact on the health and productivity level of those suffering from HIV in Malawi. If people could be more productive than this would also alleviate some of the economic stress the country faces. Paul Farmer, a major figure in international health, has seen first hand the effects of treatment-only versus poverty conscious strategies against tuberculosis in Haiti. He and colleagues developed a small study to test the differences between patients receiving basic care versus those that also received financial aid, nutritional supplements, and money for travel among other things. Patients themselves argued that, “to give medicines without food was tantamount to…washing one’s hands and then wiping them dry in the dirt.” After a year, the group with the basic treatment plan had a cure rate that was barely half that of the more comprehensive plan (1). This example shows the importance of putting treatment in the context of the socio-economic framework of a country and how interventions that acknowledge these constraints will have greater success than those that focus solely on treatment. The Fund needs to look beyond the diseases themselves and look at the relevant socio-economic factors that influence these diseases. By alleviating economic stressors and adding a nutritional component combined with a treatment plan, the Fund will have greater success in its fight against HIV/AIDS, Tuberculosis and Malaria.
Health Workers and the Economy
The Fund has clearly defined goals for fighting AIDS, TB and Malaria in Malawi, but seems not to see the potential impact of initiatives that deal directly with socio-economic and political issues, such as low salaries for health care workers. By having such a narrow framework, the Fund has set itself up for a difficult task in the battle against these diseases. A major problem in Malawi in recent years has been the migration of health workers, especially nurses, to countries such as the UK where it is more economical to be a health professional. This medical “brain drain” not only depletes countries of much needed medical staff, but adds economic pressure due to the losing of investments made toward medical education to other countries. The health professionals that do stay have more workload, which can contribute to lower quality of care in an already strained medical setting. Malawi is inevitably losing millions of dollars due to its lack of adequate salary to health professionals (7). Round 1 of the Fund grant for “The National Response to HIV/AIDS,” which is currently in progress, grossly underestimated the value of human resources in the context of Malawi. Without the staff to administer drugs and use the products to which much of the money the Global Fund is distributing, there will still be shortages of care. Fortunately, the Fund has noticed this major issue and has since added a proposal for Round 5 of grants, which has yet to begin, for the scale up of human resources (8). The Global Fund should have acknowledged this major macroeconomic barrier to treatment before it implemented any health systems scale up. In a study published in 2006, Drager et al. describes the Global Fund’s position on how spending proposals for human resources must show that they will strengthen the health systems, and that there will be sustainability after the proposal period has ended. It has already been established in different studies that there is a direct causal link between health outcomes and the proportion of the health workforce (9). More than 90% of proposals support training for health workers but lack plans to do any follow-up or evaluation (9). Regardless of training, without first focusing attention on the issue of migration of health workers due to poor salaries, spending on training will be fruitless. In this circumstance it would be more beneficial for both the Global Fund and the government of Malawi, to work together on such large macroeconomic issues before funding treatment. By doing so, the Global Fund would have made more of a contribution to the health systems of the country than when ignoring this major economic crisis.
Conclusion:
The contribution the Global Fund has made toward HIV/AIDS, Tuberculosis and Malaria would be more valuable to Malawi if it broadened its focus beyond treatment of the diseases and acknowledged the socioeconomic barriers to implementing programs. Socioeconomic intervention would help the baseline health of the people affected by these diseases and would be a major prevention strategy. By changing their objectives to include some of the basic physiologic needs of the people, the Fund will be able to make an even greater impact on the health of Malawi’s people beyond just AIDS, TB and Malaria. Another important consideration involves the economic stability of the country and its effect on the proportion of health workers. If the Fund had looked at the context to which they were implementing treatment and health systems scale-up they would have seen the need for a major health resources expansion. In this way they would have had more initial success, saved more lives, and done more to fix the struggling Malawian economy. Certainly treatment is an invaluable resource that must be utilized in order to lessen the burden of disease but it is imperative that the Fund and other international organizations look at how social and economic factors affect disease and the programs they implement.
REFERENCES
1. Farmer P. Pathologies of Power: health, human rights, and the new war on the poor. Los Angeles, California: University of California Press, 2005.
2. CIA World Fact Book. Malawi. Washington, DC: CIA. https://www.cia.gov/cia/publications/factbook/geos/mi.html.
3. The Global Fund to fight AIDS, Tuberculosis, and Malaria. Country Statistics and Disease Indicators. http://www.theglobalfund.org/programs/countrystats.aspx?CountryId=MLW&lang=en.
4. Haan M., Kaplan G., & Camacho T. Poverty and Health: prospective evidence from the Alameda county study. American Journal of Epidemiology 1987; 125, 6: 989-998.
5. The American National Red Cross. Food Crisis in Africa.Washington, DC: The American National Red Cross: http://www.redcross.org/news/in/ Africa/030127africacrisis.html
6. Piwoz E., & Bentley M., Women’s voices, women’s choices: the challenge of nutrition and HIV/AIDS. The American Society for Nutritional Sciences 2005; 135: 933-937.
7. Muula A., Panulo B., & Maseko F. The financial losses from the migration of nurses from Malawi. BMC Nursing 2006; 5; 9.
8. The Global Fund to fight AIDS, Tuberculosis, and Malaria. Grant: HIV/AIDS Round 5. The Global Fund to Fight AIDS, Tuberculosis, and Malaria.http://www.theglobalfund.org/programs/grantdetails.aspx?compid=1141&grantid=462&lang=en&CountryId=MLW
9. Drager S., Gedik G. & Dal Poz M. Health workforce issues and the Global Fund to Fight AIDS, Tuberculosis and Malaria: an analytical review. Human Resources for Health 2006; 4:23.

Ontario’s Colorectal Cancer-Screening Campaign: How Reliance on the Health Belief Model Leads to Overlooking Many Barriers- Megan Statkewicz

In January of 2007 the government of Ontario, Canada launched a province-wide colorectal cancer-screening program. This program, set to begin in spring of 2007, is aimed at increasing screening rates so that colorectal cancer diagnoses can be made earlier in the attempt to reduce the mortality of this disease. During the slow five-year build-up period, Ontario’s colorectal cancer-screening program will provide public education on colorectal cancer as well as the importance of screening. Specifically, citizens of Ontario over the age of 50 will be targeted with both mailed reminders and physician counseling because that is the age group most at risk for developing colorectal cancer. In addition to this education, the screening program will be making fecal occult blood test (FOBT) screening kits available for these individuals at their physician’s offices. FOBT kits are able to detect trace amounts of blood in the stool, a symptom of colorectal cancer or polyps. This trace blood is detected after an individual applies a small amount of his or her own stool to a cardboard slide. The hope is that patients will take these tests home, perform the test, and then return it to a lab for testing. The lab will then notify individuals and physicians of their results and encourage follow-up in the case of a positive test and reinforce the importance of yearly testing for those who test negative (1).
POTENTIAL COMPLICATIONS
Although the goals of this public health campaign are focused and well intentioned, there are several problems and barriers that Cancer Care Ontario, the agency organizing the program, will likely encounter in the process of implementing the plan. This campaign is focusing predominately on education of the target population in the hopes that it will be sufficient to ensure the success of their program. However, Ontario’s colorectal cancer-screening program fails to identify how they will approach many barriers on the society and individual levels.
HEAVY RELIANCE ON THE HEALTH BELIEF MODEL
Information about the colorectal screening program can be found at the Cancer Care Ontario website. This website provides individuals with information about the benefits of screening for colorectal screening and also lets them know how they will be able to access the FOBT at their doctor’s office. This presentation of information entrusts much of the success of this program to the effectiveness of the Health Belief Model (2). The premise of the Health Belief Model is that if any individual has information about the benefits and costs of a behavior, they will weigh that information so that it results in an intention to engage in a certain behavior. However, wholly subscribing to the Health Belief Model and assuming that informing individuals about the risks and benefits of a behavior is enough to motivate individuals to actually engage in the behavior can be problematic.
We have learned for other public health interventions such as the Five A Day campaign that merely providing individuals with the risks and benefits of engaging in a behavior does not always result in them opting to engage in that desired behavior (3). For the Ontario Colorectal campaign, there is an expectation that individuals will take the initiative to do a FOBT at home based predominately on knowledge of the benefits of doing so and the risks of not doing so. Unfortunately, previous studies have shown that this alone has not been sufficient. A 2006 study looking solely at the ability of the Health Belief Model to influence patient’s participation in FOBTs. They found that when reliance on the Health Belief Model did not help in meeting the goal of increasing patient participation in FOBTs(4). Reasons that they cited for this included many social and individual-level barriers that interefered with a person’s behaviors and intentions. Following from this research, it therefore seems doubtful reliance on the Health Belief Model will be enough to push the citizens of Ontario towards developing an intention to follow through with both the test and any necessary follow-up.
SOCIETAL BARRIERS
Although this program appears to be relying predominately on the Health Belief Model, it is useful to use other models as a lens with which to further critique Ontario’s colorectal cancer screening program. The Theory of Reasoned Action identifies social norms and attitudes towards certain behaviors as variables that greatly influence an individual’s likelihood of engaging in a behavior (5). This theory addresses one of the shortcomings of the Health Belief Model, that societal forces have the ability to change minds. Unfortunately, this colorectal cancer-screening program has to confront attitudes and social norms concerning two behaviors in order to succeed. The social norms and attitudes surrounding colorectal issues present somewhat of a challenge. In a study published in 2007, patients cited both fear and embarrassment as barriers to colorectal cancer screening (6). In addition, it is a procedure and type of cancer that many individuals are very uncomfortable discussing, and are very fearful of developing (7).
Although the Ontario’s colorectal cancer-screening campaign is designed to detect colorectal cancer early, many individuals have a tendency to be in denial when it comes to diseases such as colorectal cancer. In addition to this attitude of fear, attitudes surrounding the handling of one’s own feces have to be overcome. Even if it is in order to perform a medical test, getting individuals to smear their feces on a testing strip and to then return it to a medical center will likely present many barriers because of an aversion to the behavior under other circumstances.
ADDITIONAL PERSONAL AND ENVIRONMENTAL BARRIERS
Framing problematic aspects of Ontario’s colorectal cancer screening program with social science models allows you to critique on a broader social level. However, there are many individual level factors that also determine the success of a program. Since success of the program is largely pending on an individual’s willingness to take the test, drop it off and to see their physician for any follow up visits that may be needed it is important to consider barriers that may be encountered in this process. The major barriers related to the colorectal cancer-screening program can be looked at in two categories on the individual-level; environmental and personal barriers.
Barriers that individuals have to overcome on the personal level range from ability to pay for visits to family and work obligations that may impair one’s ability to participate. Lacking insurance or having an insurance plan that does not cover colorectal screening testing is very much related to an individual’s personal ability to take part in the screening program. In addition, time obligations to both family and work help to determine the likelihood that an individual will have the ability to take part (8). Environmental factors include things such as proximity to a doctor’s office, access to transportation as well as ability to schedule an appointment. All of these environmental factors present barriers to individuals that may determine their ability to participate in this program, regardless of other desires to do so. Unfortunately, those individuals with the most personal and environmental barriers tend to be of lower socioeconomic status. Therefore, it is no surprise that this group that tends to be more susceptible to colorectal cancer (9).
AREAS FOR IMPROVEMENT AND FUTURE IMPLICATIONS
Ontario’s colorectal cancer-screening program is not hopeless though. By focusing on the reduction of barriers and recognizing the impact that some social norms and attitudes have, this program has the potential to be rather effective when it comes to increasing colorectal cancer-screening rates. By allowing individuals to perform the FOBT at their physician’s office during their visit rather than having them take it home many of the personal barriers will be avoided because the test will be in conjunction with another outing, accomplishing both the physical and FOBT in a single errand. Doing the test in the physician’s office also allows the patient to discuss any conflicting attitudes they may have towards performing the test.
In the end Ontario’s colorectal-cancer screening program is an example of how heavy reliance on the Health Belief Model can result in overlooking many other barriers to effective implementation. The Health Belief Model shows us that this particular public health campaign may encounter difficulties because of the sensitivity to cancer as well as the aversion to performance of the fecal occult blood test. In addition to these broad social barriers, individuals each have specific environmental and personal barriers that may impact their ability or desire to participate. Ultimately, the program will likely be more successful if it recognizes these complications and gears their education campaign towards breaking down some of the negative attitudes and norms as well as reducing some of the individual level variables such as transportation and time conflicts simultaneously. It will be interesting to watch the progress of Ontario’s colorectal cancer-screening campaign over the next five years as an example of the Health Belief Model in action. Hopefully this will not turn into another Five A Day campaign and the government of Ontario as well Cancer Care Ontario will be able to adapt to any of the challenges that they may encounter throughout their five-year implementation period.
REFERENCES
1.Cancer Care Ontario, Colorectal Cancer-Screening Program. 2007.
http://www.ccac-accc.ca/
2. Rosenstock, H. Health Belief Model. 2002. http://excusercise.org/health_belief.htm
3. Kelly, CM. Diet and Cardiovascular disease in the UK: are the messages getting across? Cambridge Journals. 2003(62):583-589.
4. Coughlin, Stephen. CDC-funded intervention research aimed at promoting colorectal cancer screening in communities. Cancer. 2006:107:1196-1204.
5. Hale, J. L., Householder, B.J., & Greene, K.L. (2003). The theory of reasoned action. The persuasion handbook: Developments in theory and practice (pp. 259 - 286)
6. Kelly, KM. Physician and staff perceptions of barriers to colorectal cancer screening in Appalachian Kentucky. Cancer Control. 2007: Apr 14(2):167-75.
7. Tessaro I. Knowledge, barriers and predictors of colorectal cancer screening in an Appalachian church population. Prevention of Chronic Disease. 2006:Oct 3(4):A123.
8. Worthley DL et al. Screening for colorectal cancer by faecal occult blood test: why people choose to refuse. Internal Medicine Journal. 2006. Sep 26(9):607- 610.
9. Ward, Elizabeth. Cancer Disparities by Race/Ethnicity and Socioeconomic Status. CA Cancer Journal, 2004:54:78-93.

Don’t Ignore the C in ABC: Using Examples from Effective International Programs to Reframe Safe Sex a Public Health Issue in the US- Maiyu Fernandez

What is the ABC approach:
This is the president’s emergency plan for HIV/AIDS relief. It employs population specific interventions that emphasize abstinence for youth and other unmarried persons, including delay of sexual debut; mutual faithfulness and partner reduction for sexually active adults; and correct and consistent use of condoms by those whose behavior places them at risk for transmitting or becoming infected with HIV(1).
The Issue with ABC:
This program will only provide funding to country’s that will agree to meet the specific teachings for HIV Prevention. Many countries will do anything to have this funding and in turn will submit to following the ABC’s principles. The funding shapes the focus of the HIV prevention methods. Although the program is termed “ABC”, C is not emphasized nearly as much as A or B. Abstinence and/or be faithful programs that are implemented on a stand alone basis will be funded by the emergency plan (1). However, programs that include the “C” component must include information about abstinence and faithfulness to be funded. Conservatives assert that the availability of condoms had a disinhibiting effect on peoples sexual behavior (1).Marketing campaigns that simply target youth and encourage condom use as a primary prevention will not be funded by the plan (1). The ABC model does however recognize that “certain” young people will engage in sexual activity. According to the Youth Risk Behavioral Surveillance Survey, an estimated 47 percent, or nearly half of adolescents reported having had sexual intercourse (2). For at-risk populations including: youth with risky sexual behavior, sex workers, substance abusers, men who have sex with men an integrated AB and C approach is allowed to be taught.
HIV is a complex, multicultural problem with no simple answer:
HIV affects every continent in the world and can affect any individual. Between 1.2 and 1.3 million people in the US are living with HIV, many are not aware they are infected. In the continent of Africa countries such as Botswana, Lesotho, Zimbabwe and Swaziland have an HIV prevalence of greater than 20 percent (3). In east African countries (Uganda, Kenya) the prevalence of HIV exceeds 6 percent (3). For Latin America, Brazil has the highest HIV prevalence estimated at 0.67 percent. It has more than one third of the total number of HIV cases in South America. HIV is also seen in Asia. The HIV prevalence in Thailand, one of the capitals for commercial sex, is estimated at 1.4 %( 3). It must be known that HIV is not only prevalent in third world countries or in countries where sex is a commodity. HIV can even affect countries that have spent much money and time in safe sex education. Both Sweden and Denmark have a low but still meaningful prevalence rate of .2 percent (3). As seen with the statistics no one country has the solution to the HIV epidemic. With this said, each country can truly stand to learn from each other.
Denmark and Sweden’s Lesson:
Their positive view of sex and early safe sex education is a lesson that could stand to be learned by other nations. Acceptance of sexuality is a healthy and normal part of Danish life (4). Sex in Denmark does not have a stigma as it does in the United States. The stated legislative goal of sex education in Denmark for pupils is “to acquire knowledge of sexual matters as to learn to take responsibility for their own lives and to demonstrate consideration for others” (4). With the ABC program the main responsibility for people is to remain abstinent. In the United States there are moral judgments regarding sex. Thus, even if an individual has protected sex it is still stigmatized. Yet, Swedish educators believe that if young people see sexual matters as secretive or shameful they will soon believe their sexuality is wrong (5). In the ABC program sex is seen as wrong and no sex is seen as right. At the core of Swedish sex education is the sense that sex is seen as a source of joy and happiness shared with another individual and as an integral part of human life (5). Denmark’s openness to sex and sexuality has made it easier to talk about AIDS. Their national campaign conveys the message that sex is good, healthy, and beautiful but requires responsible behavior through safe sex practices (4). In Sweden each age group has a targeted sexual education topic. At 6 years old one learns about social and personal relationships, at 10 years of age one learns about the physiologic and hormonal changes that occur in a body, at 13 years old one learns about STDs, sex hormones, contraception and when one turns 16 the subjects are all repeated in much greater detail. In both Sweden and Denmark contraception and contraception counseling is readily available. All persons born or resident in Denmark are entitled to free contraceptive counseling (4). In Sweden all birth control services are free and parental consent is not required (5). Condoms are made readily available at vending machines, grocery stores and barbershops. In the United States individuals must have certain insurance and go to a specific location to receive contraception and or contraception counseling. Both Swedish and Danish educators focus on being realistic with students. There lies one of the main issues with the ABC program: the program is not realistic. Young people will engage in risky behavior and will at one point in their life have sex. That is why the program should focus on safe sexual behavior. Both Swedish and Denmark educators believe that only with realism will they be able to win over young people’s confidence (5).
A lesson to be learned from Thailand:
A country’s response to the epidemic is influenced to a great extent by the information that is made readily available. As knowledge of the risk behavior grew in Thailand the government’s willingness to alter their strategies and policies were grand. (7). Thailand has had a scientific assessment system with respect to HIV. Since the 1990’s, the Thai government has been extremely committed to the prevention of AIDS/HIV. However, it is not only their commitment that has been crucial; it is the combined commitment of all sectors in society that has made a difference. Modifications of health and social services to cope with the evolving epidemiological trends of the disease are vital to the success of HIV prevention (7). In Thailand, the public health problem quickly became a dual social and economic issue.
In the past 14 years, the spread of HIV has slowed dramatically. In Thailand, the rate of new infections had plummeted from 143,000 in 1991 to 21,000 in 2003 (3). In 1990, after a behavioral study showed the passive risk behavior of Thaïs, policy makers allowed HIV/AIDS warning messages to be publicized though all kinds of media. In 1991 the government sponsored the “100 % condom program” after realizing how large the commercial sex trade in Thailand had expanded to. This program called for cooperation from sex workers and sex establishment owners to promote condom use (7).
Recent data indicate that a large percentage of the new HIV infections are occurring in people (mostly married women) considered to be at low risk for HIV infection (8). It is hypothesized that married men have unprotected sex with commercial sex workers (CSWs) and their wives. They act as bridges between the high-risk CSWs and the general population. (7). The government has taken these numbers very seriously and is now encouraging married couples to be tested for HIV and use condoms regularly. They are also asking CSWs to act more responsibility and always use condoms The Thailand government introduces new prevention activities for HIV as fast as new information becomes available and new scientific studies are published.
Lesson from Brazil:
A combined effort of government ads, messages of empowerment and free antiretroviral medications are combating HIV. This country is home to 620,000 people living with HIV. The country’s emphasis on prevention and treatment has helped to keep its HIV epidemic stable for the past several years (8). Among Brazilians of all ages condom use has increased by almost 50% since 1998 (8).Brazil is best known for its pioneering decision in 1996 to offer free combination antiretroviral therapy to all citizens with AIDS (9). The program has improved the health and extended the survival of tens of thousands of Brazilians, and has saved the country an estimated $2.2 billion in hospital costs between 1996 and 2004 (9). In addition to the free ARV therapy, Brazil has explicitly worded government HIV-prevention message. In 2003, Brazil’s Ministry of Health launched a campaign aimed at promoting the use of condoms by adolescent women (10). One of the messages was to empower the girls and encourage them not to be ashamed to buy condoms and to demand their partners to use them. Just as Denmark and Sweden don’t stigmatize the act of sex, Brazil emphasizes that the act of buying a condom is a normal and healthy activity of daily life. Brazil is now forming a network for technology sharing with Argentina, China, Cuba, Nigeria, Russia, Ukraine, and Thailand to improve each country's capacity to manufacture medicines, condoms, and laboratory reagents needed to fight AIDS.
Can Uganda teach the nations?
In the early 1990’s Uganda achieved an extraordinary feat: it stopped the spread of HIV/AIDS in its tracks and saw the nation’s HIV/AIDS rate plummet. Many attribute its success to the ABC approach. However, it is not possible to make a direct causal link between the changes that took place in Uganda and the policies or programs that may have caused them to happen (11). As a Harvard medical anthropologist noted “ABC is far from all that Uganda has done”, “Uganda reduced the stigma of Aids, brought sex behavior out for discussion, let HIV infected people attend public education, and improved the status of women…” There were many factors involved in Uganda’s success. Abstinence was not the sole solution to the problem. Contrary to assertions from social conservatives there is no evidence that abstinence only educational programs were even a significant factor for Uganda between ‘88 and ‘95 (11).
HIV prevalence in Uganda which has been looked at worldwide as a success story is now beginning to increase (11). The increase in HIV prevalence in Uganda is being fueled by complacency, as well as decreased intensity of prevention programs, funding, and political commitment (11). For many countries gender inequity is a powerful factor in the spread of HIV. Gender norms create inequality between the sexes in power and well being, typically to the disadvantage of women (12). The importance of including gender related interventions is a lesson to be learned from Uganda, where policies to advance women’s status were part of the ABC strategy (12). A main focus besides abstinence in the ABC approach should be deciphering gender norms. To be effective in the long term, programs must work to transform the gender norms that make women subordinate to men and encourage men to take risks in the name of masculinity (12).
Conclusion/Future:
There is no one solution to the HIV epidemic. The ABC program is not the only approach and certainly not a solution by itself. However, the examples of successful HIV control programs presented above had one thing in common; a strong government commitment. The spread of HIV has been minimal in Denmark and Sweden where early sex education, access to condoms and a belief that sex is part of health adolescence has helped shaped effective prevention polices for all sexually transmitted diseases. The government of Thailand has decreased the spread of HIV dramatically by showing commitment to fight HIV/AIDS and building its HIV prevention programs based on scientific–evidence. Like Thailand, Brazil too has been successful due to strong government commitment and universal access to condoms as well as care and treatment for people living with AIDS. Finally, Uganda’s success had as much to do with government commitment and gender equality as it did with being faithful.
The ABC campaign assumes abstinence will allow young women to focus on going to school, controlling their relations, and becoming empowered and yet it fails to acknowledge the social circumstances driving sex in the first place (12). Emphasis on abstinence does not help prevent the spread of HIV; it simply may delay first contact. For example, studies show that many young women in Swaziland abstain from sex until their late teens but once they have sex they encounter high risks of becoming HIV positive (8). The effectiveness of abstinence as a long term strategy was also refuted by a study done by the American Psychological Society that reported that the virginity pledge was broken by more than 60 percent of the pledgers, and 55 percent admitted to engaging in risky forms of non vaginal sex (13).
To be effective in the long term, programs must also work to transform gender norms that make women subordinate to men and encourage men to take risks in the name of their masculinity (12).
The lack of emphasis on condom use in the ABC campaign, for all types of individuals, hurts prevention efforts. Condom stigma still exists, and this taboo must be removed. By promoting condoms as part of a standard package of prevention, condoms can begin to be destigmatized and normalized (12). The male latex condom is the single most effective available technology to reduce the sexual transmission of HIV and other STDS (13).
Whatever the difficulties of condom promotion, this approach must be used to best advantage. There are not so many weapons against Aids that we can forgo any, nor is any so effective that it makes the other superfluous (14).
References
1. Department of State. ABC Guidance #1. Washington D.C.: The President’s Emergency Plan for AIDS Relief, 2005.
2. Centers for Disease Control website. www.cdc.gov
3. A UK and AIDS Charity. www.avert.org
4. David H. United States and Denmark: Different Approaches to Health care and Family Planning. Studies in Family Planning 1990; 21: 1-19.
5. Boethius C. Sex Education in Swedish Schools: The facts and The fiction. Family Planning Perspectives, 1985; 17: 276-279.
6. Brown P. The Swedish approach to Sex Education and Adolescent Pregnancy: Some Impressions. Family Planning Perspectives, 15; 1983:90-95.
7. Phoolcharoen W. HIV/AIDS Prevention in Thailand: Success and Challenges. Science; 280; 1998:1873-1874.
8. UN AIDS and WHO. AIDS Epidemic Update. Geneva, Switzerland: UN AIDS, 2006.
9. Okie S. Fighting HIV- Lessons from Brazil. The New England Journal of Medicine, 2006; 354:1977-1981.
10. Porto MP. Fighting Aids among adolescent women: effects of a public communication campaign in Brazil. Journal of Health Communication, 1996; 5:100-103.
11. Munnabi G. HIV/AIDS: Uganda Slides Back. Ultimate Media Consult.Nov 27, 2006.
12. Murphy E. Was the “ABC” Approach responsible for Uganda’s Decline in HIV? Plos Medicine 3; 2006:1443-1447.
13. Sinding S. Does CNN work better than ABC in attacking the AIDS epidemic? International Family Planning Perspectives 2007; 31:38-40.
14. Hearst N and Chen S. Condom Promotion for AIDS Prevention in the Developing World: Is it working? Studies in Family Planning 2004; 35:39-47.

Failures Of The ABC Campaign In Africa: The Need To Reframe The Issue Of HIV/AIDS By Addressing Underlying Social Conditions – Lindsay Litwin

The AIDS epidemic has devastated the African population and consequently more developed nations are funding AIDS prevention programs in Africa. The most commonly implemented intervention is the ABC campaign, which promotes abstinence from sex, being faithful to one’s partner, and condom use. This theory is based on a limited perspective of Africans and their culture, and thus ignores many important factors that shape sexual behavior in these societies. The ABC campaign places too much emphasis on the individual, perpetuates cultural stigmas regarding AIDS and does not consider the social construct of gender in African nations. Overall, the ABC prevention strategy focuses on changing individual behavior in order to effectively slow the spread of HIV/AIDS; however it fails to address underlying social norms, which are the true root of the AIDS epidemic in Africa.
The Health Belief Model: A Faulty Foundation for the ABC Campaign
Most public health interventions are formatted based on the Health-Belief Model, a tool, which constrains the thinking of public health professionals. The Health-Belief Model maps out factors that influence an individual’s health behavior choices. In contemplating one’s behavior, according to the Health-Belief Model, an individual will consider the severity of a disease and their personal perceived likelihood of developing the health outcome (1). The individual then measures these perceived risks against the barriers that one foresees in changing one’s behavior (1). From this contemplative stage the individual develops an intention to act regarding a health behavior and then successfully carries out the action. The Health-Belief Model is inherently flawed because it only considers rational decision-making at an individual level and does not consider community factors and social norms, which dictate the decisions and behaviors of individuals. Since the ABC campaign is based on the reasoning of the Health-Belief Model, it is also inherently flawed and insufficient for preventing AIDS in Africa. In a continent with a rich history and long-standing cultural practices, these community factors influence an individual at all steps of behavior planning.
One limitation of the Health-Belief Model is the fact that this model assumes that an individual will change his/her behavior if he/she believes they are susceptible to the negative health outcome (1). Embedded in the ABC campaign is the assumption that Africans will feel a danger of contracting AIDS and that the fear of death will promote preventative behavior changes. Africans understand the fatal consequences of contracting AIDS, as the majority of them have seen the damaging effects that the disease has had on their family and friends. However, even high perceived susceptibility and risk of death among Africans do not motivate the majority of the population to embrace ABC behavior changes. This is because death and illness are not viewed the same way in African cultures as in western cultures. Due to religious and cultural beliefs, Africans discount the fatality associated with AIDS (2). Many people believe that disease is caused by the supernatural and is a punishment for an individual’s past inequities (2). Thus, contracting AIDS is predetermined and inescapable, so an individual does not have any control over disease outcome. Therefore, many Africans believe that adopting ABC behavioral changes will not decrease their risk of contracting AIDS.
Furthermore, AIDS is so rampant that many Africans either believe that they already have the disease or will contract it despite changing their sexual behaviors. In either case, an individual does not believe that the ABC campaign will help them. Before a behavior change can occur, the masses must want to change and there must be the motivation to do so. The ABC campaign is based on the idea that internal reasoning of an individual will result in rational behavioral choices, however this is not always true (1). The ABC campaign fails to address this lack of motivation in the African population. One program that could motivate the African community to adopt less risky sexual behaviors is the implementation of widespread AIDS screening practices. Research shows that if an individual is aware that he/she is HIV negative, he/she is more likely to adhere to the standards of the ABC campaign and adopt safer sexual practices (3). This widespread screening framework must be in place prior to the implementation of ABC campaign in order for the campaign to succeed.
A Fundamental Problem: The ABC Campaign Ignores Cultural Norms
According to western theory, the ABC campaign promotes logical and acceptable sexual practices; however these assumptions are not adjusted to consider African culture and gender roles. In any program, “if assumptions have not been questioned and alternative sources of knowledge sought, then the knowledge can be faulted” (2). The ABC campaign is not comprehensive enough to effectively change the face of the AIDS epidemic in Africa. The ABC strategy is based on promoting three succinct behaviors: abstinence from sex, being faithful to one’s sexual partner, and using condoms consistently (4). The focus of this intervention is to promote behavioral change; however it does not consider why the African population does not adhere to the ABC standards. Unfortunately, the ABC campaign fails to address the fundamental reason why sexual behavior change is not possible in the 25-35 year old age group, which accounts for the largest burden of the disease. At this stage in life, African people are focused on bearing children, especially giving birth to at least one son (4). Therefore, at this time it is not feasible to apply either the A (abstinence) or the C (condoms) of the ABC campaign. The only part of the campaign that applies is B, be faithful, which is the least feasible portion of the overall campaign. This fundamental barrier cannot be changed, but the scope of the ABC campaign can be changed to include social norms.
Another central shortcoming of the ABC campaign is that it focuses on the individual and does not place that individual within a society. As people live collectively in a community, it is inaccurate to believe that any one person is an island unto himself. Epidemiologists rarely consider social factors in assessing heath outcomes; however for successful public health interventions to be implemented, public health professionals must consider such factors. Applying ideas from the social sciences as well as studying an individual in the context of his/her environment will positively enhance prevention projects like the ABC campaign (5). Social norms are often risk factors for health outcomes and barriers to behavioral change. Many scholars agree that “the worst policy would be one that minimizes the problem [of AIDS] by treating it as a private matter, that is, as an individual’s concern and responsibility rather than a crisis that must be addressed by the society as a whole,” which the ABC campaign fails to do (3). The ABC campaign will not be accepted by Africans unless the campaign is reframed to address cultural stigmas and social norms in sexual behavior.
By definition, culture is engrained in individuals of a community and societal norms perpetuate both positive and negative behaviors. From a young age, all children in Africa are socialized to adopt cultural identities as they mature (4). Many of these beliefs are in conflict with the behaviors promoted in the ABC campaign. Condoms are taboo in many African cultures and religions. They are shunned as products that commercial sex workers and the unfaithful use and are not acceptable for married or ‘exclusive’ couples to use consistently (4). The ABC campaign uses mass media and other advertising outlets to encourage condom use, but these efforts fall short in addressing social barriers. The ABC campaign must be reevaluated in a cultural framework and incorporate religious and political leaders in order to shift social norms and promote the ABC behaviors as an accepted part of an African’s daily life. Furthermore, the ABC campaign does not address the cultural belief that men cannot abstain from sex. Approximately 39% of African males and 29% of African females believe that men cannot control their desires to have sex (4). The message to abstain from sex is reaching the African population, however the tools to overturn these cultural barriers are missing from the ABC campaign. In addition to these social reasons that the ABC campaign fails, there are numerous other cultural barriers that oppose the ABC behavioral change program in African communities.
African Gender Construct: A Barrier to the ABC Campaign
The concept of gender is central in African cultures. Learned gender roles in African societies, as well as some governmental policies perpetuate the masculinity and femininity paradoxes, which shape life in Africa. In its implementation, the ABC campaign fails to address the issue of gender in African communities. In many Sub-Saharan African communities, the core values of manhood are a man’s ability to support his family, sexual competence, and an aggressive nature (4). All of which assure that a male is dominant in his relationships. In contrast, women are expected to be passive, physically weak, sexually reserved, and exhibit marianismo. Marianismo is the idea that women are morally superior to men, and thus must have an aversion to sex and acceptance of male dominance including physical abuse (4). Additionally, unprotected sex is a rite of passage for men who must be sexually experienced before marriage (4). The cultural practices that all men perform increase the spread of AIDS. Furthermore, the subordinate and helpless role of the women further perpetuates male dominancy and risky sexual behaviors. Unfortunately the gender-blind approach of the ABC campaign does not address these gender inequalities. It ignores the fact that women are disempowered and often unable to decide whether or not they will have sex. This makes it impossible for females to adhere to the ABC campaign if males do not.
The ABC campaign places the responsibility to change sexual behavior in the hands of the individual; however gender roles impede the progress of behavior change. In theory, the gender-neutral ABC campaign allows for males and females to make personal choices, however females do not have the control to use any of the ABC prevention behaviors (4). None of the ABC campaign policies relate to the actual life experiences of women in Africa (2). For example, both males and females must follow the ‘be faithful’ portion of the ABC campaign in order for it to be effective. In Rwanda 80% of HIV positive women were monogamous and 25% of these women only had one sexual partner in their entire life (6). These results are consistent throughout Africa and indicate that even if females follow the parameters of the ABC campaign, males continue to follow the social norm of having multiple sexual partners (4). Women can uphold the restrained sexual values, but this female-only approach cannot decrease the AIDS epidemic. In fact the percentage of women infected by AIDS is increasing. Overall, marriage is becoming a risk factor for contracting AIDS, because men are unfaithful and also refuse to use condoms in their own households with their wives (6). The condom use component of the ABC campaign is also in the control of men. Women can negotiate with their partners to use condoms, however the power and decision to perform the action ultimately lies with the males (2). Considering the gender roles in Africa society, it is clear that “the HIV epidemic is driven by men” (4). However, the prominent use of the ABC campaign is gender-neutral and fails to target men. Redefining masculinity and gender roles in African is the most essential prevention strategy for controlling the AIDS epidemic.
Conclusion: A Look Forward
AIDS prevention in Africa is essential to the development of this continent. In order to lower the rates of AIDS transmission in Africa, prevention strategies cannot be constrained to the ABC campaign. Collectively, policymakers must expand prevention programs beyond influencing individual, rational behavior and consider the context in which the individuals live. Involving prominent social figures in the prevention efforts can be a first step in gaining public support and breaking social barriers. The life of individuals in Africa must be studied closely and conceptualized so that policymakers comprehend their experiences and incorporate this information into campaigns in order to address stigmas. Most importantly, gender roles in African society must be considered when forming AIDS prevention programs. These efforts must target males, address destructive social norms, and reframe responsible sexual behavior as a sign of a powerful man. In addition, it is important to provide women with tool like female condoms to increase their power and role in preventing the spread of AIDS. Preventing the spread of AIDS Africa is attainable only if social influences and norms are addressed in the policies.
References:
(1) Salazar MK. Comparison of Four Behavioral Theories. AAOHN Journal 1991; 39:128-135
(2) Reid E. Gender, Knowledge and Responsibility. HIV and Development Programme date; 10.
(3) Daly JL. AIDS in Swaziland: The Battle from Within. African Studies Review 2001; 44: 21-35.
(4) Jordaan S. A Gendered Critique of the ABC Prevention Policy of the South African Government Concerning HIV/AIDS: A Case Study of Northern KwaZulu-Natal. http://etd.uj.ac.za/theses/available/etd-02242006-085106/restricted/SunetJordaan.pdf
(5) Herrell RK. HIV/AIDS Research and the Social Sciences. Current Anthropology 1991; 32: 199-203.
(6) Sinding SW. Does ‘CNN’ (Condoms, Needles and Negotiation) Work Better than ‘ABC’ (Abstinence, Being Faithful and Condom Use) In Attacking the AIDS Epidemic?. International Family Planning Perspectives 2005; 31: 38-40.

A Compelling Argument Against Abstinence Only Sex Education Programs –Matthew Katz

‘Abstinence Only’ is the major sex education program being taught across the country today. In recent years, comprehensive sex education programs have become relatively scarce. Starting in 1999, the federal government granted $80 million to abstinence only sex education programs. In 2005 Congress allocated $167 million dollars to abstinence only programs. The stipulations being that education programs were required to discuss abstinence only. Eligible programs also must be geared towards encouraging youth not to engage in sexual intercourse until marriage. However, scientific data gathered since its inception has proven this program to be a failure. This failure, I argue, is a result of three essential shortcomings of the campaign; firstly, this message doesn’t resonate in our sexually exploitative culture; second, the individuals orchestrating this shift in curriculum have themselves lost the moral high-ground; and finally, children are too resourceful to be kept ignorant of certain facts that would likely preclude any adherence to abstinence.
Firstly, let us examine normative values of the American public as illustrated through various statistics. Studies have found that the average age of women who first had sex is 17, whereas the average age that women marry in America is 25 [1]. In 2005, 63.1% of seniors in high school engaged in sexual intercourse at least once [2]. Overall, about 95% of Americans become sexually active before marriage. Beyond these statistics, America’s tacit preoccupation with premarital, consequence-free sex can be seen through any media outlet. Several mainstream rappers have contracts to write music for, and often star in full length adult videos [3]. Even outside these arrangements, the line between mainstream entertainment and all-out pornography has become increasingly blurred in recent years. Posters of artists such as Fergie and Christina Aguilera, whose music videos could be mistaken for adult video trailers, can be found lining most teens’ lockers these days.
The pervasive exploitation of youth and sexuality of the entertainment industry has itself become a cause célèbre. Recent parodies, including a Saturday Night Live video entitled “My Dick in a Box” and Mad T.V.’s Christina Aguilera spoof “Virginal (to see if it will pay)”, serve to illustrate this point. Entertainment is a private industry and executives know better than to push something that doesn’t sell. For better or worse, premarital sex is clearly woven into the fabric of our society. Simply telling adolescents not to engage is an apparent national pastime seems unrealistic and impractical, even for our current administration.
In examining the failing of this new curriculum we must also address the context in which it’s implemented; within the classroom. School is where children learn facts, formulas, history and critical thinking skills. This curriculum aims to instill something very different in children and adolescents; values. Ironically, the very same political group pushing this educational agenda into our public schools is known for its belief that values are instilled through family and learned at home. Many maintain that “little if any credible research exists to substantiate the claims that abstinence-only programming leads to positive behavior change among youth” [4]. If nobody believes such values are are or can be learned in schools, why then is there such controversy over the curriculum?
It seems likely that the Abstinence Only campaign is more about what isn’t being taught than what is- it’s simply a means of controlling and censoring information. Preventing children from learning the facts about safe-sex practices may have been deemed an integral part of a successful Abstinence campaign. To this effect, Congress has stipulated that if public schools mentioned safe sex practices, it could only be done so in the context of their failure1. The Federal Government, in fact, has clearly made a tremendous investment into this concept of controlling information. In a December 2004, Representative Henry Waxman and the United States House of Representatives Committee on Government Reform released a report analyzing the abstinence-only education program owing to the fact that the federal government doesn’t review the curriculum from these programs. Waxman and his staff found that over 80% of abstinence-only curriculum from the largest funded programs was false, misleading or distorted. Often these programs cite research that the science community and health officials have discredited. Adolescents were being taught that “no controlled scientific study supports the value of condoms in helping to protect against sexually transmitted diseases including HIV” and that a pregnancy occurs 1 out of 7 times when a condom is used. One curriculum instructs students:
“Think on a microscopic level. Sperm cells, STI organisms, and HIV
cannot be seen with the naked eye — you need a microscope. Any
imperfections in the contraceptive not visible to the eye, could allow
sperm, STI, or HIV to pass through. . . . The size difference between a
sperm cell and the HIV virus can be roughly related to the difference
between the size of a football field and a football.” [5]
Another shortcoming of the program is its backers themselves. Abstinence Only, not unlike Intelligent Design, has no official link to any religion, but is forwarded almost exclusively by Christians. With this in mind we should now put ourselves in the shoes of a sexually frustrated teenager and ask ourselves the obvious question, “do these people practice what they preach?” The answer, of course, can be found on the cover of virtually news source printed since 1990, save the National Catholic Reporter and FOX News. A Google search of the terms “clergy” and “sexual abuse” retrieves 1.1 million web pages. The American Catholic boasts that a mere 4,392 priests have been accused of sexual misconduct during the second half of the twentieth century, averaging under 90 incidents per year by a mere 4 percent of practicing priests [6]. While these figures may be impressive by NAMBLA’s standards, they further pale in the face of more recent statistics. From 2004 to 2006 there were 2,589 reports of sexual abuse by priests. This means one of two things; either clergy abuse has increased by nine hundred-eighty percent since The American Catholic released their 2002 report, or pedophilia has been both persistent and grossly underreported for at least the last half-century. The underlying point is this; teenagers with raging hormones are unlikely to hear the message of strict abstinence from the likes of Rev. Ted Haggard.
Finally, the Abstinence Only initiative overlooks the resourcefulness of teenagers. As previously stated, abstinence curriculums are upwards of 80% misleading or distorted. Certainly, adolescents and young adults cannot be kept from this fact throughout their teens and up until marriage. In all likelihood, most children will feel deceived by this fact and lose faith in their sexual education altogether. There’s evidence that teens coming from Abstinence Only programs initiate sexual activity at the same age as those coming from comprehensive sex education programs. However, the teens from the abstinence programs are more likely to engage in risky sexual activity for lack of knowledge about safe sex [7]. The danger is that teens may only learn part of the story from their resources. A young male may learn on the internet that, if he engages in unprotected sex with an HIV-positive individual, he only has a 1 in 1,000 chance of acquiring the disease. He may also learn about a 1993 study of heterosexual couples in which one partner has HIV found that of couples who always used condoms 2 out of 171 couples contracted the disease. In contrast of the couples who did not use condoms, 8 in 10 of the women contracted HIV [8]. Both reports are true, but the latter promotes a healthy sexual attitude while the former promotes risky behavior. In 2005, eighty-seven percent of teens had access to the internet and more than fifty percent used it daily [9]. Children are becoming increasingly resourceful and computer literate. All these facts underscore the danger in feeding them half-truths regarding sexual health. They’re likely to find the truths on their own. Comprehensive sex education helps lead them towards the positive truths so that they can create a healthy and safe attitude towards sex. Abstinence Only ignores the issue entirely.
We cannot simply say that Abstinence Only is a failure of policy, it’s a failure to an entire generation. How many young people with dreams of higher education and professional careers will find themselves dropping out of school early to take care of unwanted children? How many will have their lives cut short by debilitating or fatal STDs? We owe these children to provide a sound education that will provide them with the tools and structure they require to succeed in this world, to achieve their dreams. To this end, we must design a sexual education and reproductive health program that is realistic and appropriate for today’s world and offers due appreciation and respect for their intelligence.
REFERENCES
1 Rector, Robert. The Effectiveness of Abstinence Education Programs in Reducing Sexual Activity Among Youth. The Heritage Foundation. April 2002.
2 US Center for Disease Control, Teen Sexual Activity in the US, updated June 2006, retrieved April 2007
http://www.teenpregnancy.org/resources/data/pdf/TeenSexActivityOnePagerJune06.pdf
3Xpress Online, Sabrina Ford, Hip Hop and Women’s Sexuality, last updated October 2004, The Golden Gate [X]Press Online, retrieved April 2007 http://xpress.sfsu.edu/archives/editorials/001990.html
4 Collins C, Alagiri P, Summers T, Morin S. Abstinence Only vs. Comprehensive Sex Education: What are the arguments? What is the evidence?. AIDS Research Institute. Policy Monograph Series. March 2002.
5 Waxman H. The Content of Federally Funded Abstinence-Only Education Programs. Congressional staff analysis. December 2004. Online: http://www.democrats.reform.house.gov
6 AmericanCatholic.org, Atostino Bono, The Catholic Church and Sexual Abuse by Priests, updated 2002, accessed April 2007
http://www.americancatholic.org/News/ClergySexAbuse/
7 Bleakley Amy, Hennessy Michael, Fishbein Martin. Public Opinion on Sex Education in US Schools. Arch PEdiatr Adolesc Med. 2006;1151-1156.3.
8 Planned Parenthood. The Condom. Online: http://www.plannedparenthood.org/birth-control-pregnancy/birth-control/condom.htm (retrieved April 2007).
9 Pew Internet and American Life Project, Amanda Lenhart, Mary Madden, Paul Hitlin, Teens and Technology, updated July 2005, retrieved April 2007
http://www.pewinternet.org/pdfs/PIP_Teens_Tech_July2005web.pdf

40,000 & Steady: An Economic And Cultural Critique Of HIV/AIDS Prevention In The United States – Jesse Moran Welsh

Unlike many diseases that capture headlines around the world, HIV/AIDS is entirely preventable. When the epidemic made headlines in the early 1980s, the United States responded within the social and political limits of the times – and great strides were made. Over the years we have seen scientific developments and changes to the very social fabric of our nation as a result of the disease. Still, young Americans have never known a world without the AIDS virus. We have been unable to implement adequate prevention programs and now face a resurgence of the epidemic in the black community. Despite increasing global attention to the HIV/AIDS epidemic, the enormous progress once seen in the United States has been replaced by consistent, and disproportionate, infection rates as a result of inadequate funding and meaningful public health initiatives. Our society and technologies may have progress in the past twenty-five years, but our response to the HIV/AIDS has not.
Consistent infection rates over the past 15 years are a direct result of under funding. In his 2001 article, Donald Francis, M.D. recounts the early years of the epidemic and the United States’ response. He describes how the Centers for Disease Control picked up the first signs of the epidemic relatively quickly and began appropriate investigatory and educational activities [1]. The results from the Holtgrave and Kates study also show that the CDC’s HIV prevention budget increased most sharply in the early years of the epidemic [2]. Yet what both articles go on to conclude is a failing on the part of the United States and its public health agencies to sustain adequate prevention and funding. Holtgrave and Kates found that from the mid-1980’s onward…budget anticipates incidence rather than vice versa [2]. Ultimately, as the CDC’s budget began to level off in the early 1990’s so too did the rate of infection. And while there are certainly other factors that can be attributed to these statistics – the development of new medications and the scale of the epidemic in third world countries to name a few – they do not excuse our complacency. When applying meaningful resources, the United States had the ability to reduce the number of new infections by 75% in five years - from 161,000 in 1985 to 40,000 in 1990 [2]. Yet because of a variety of intersecting political and social realities of the time, Francis points out, the CDC was unable to take the next essential step—the delivery of prevention programs equal to the risk posed by HIV [1]. The key phrase being: prevention programs. Immediate action by the United States and the CDC in the early years of the epidemic saw immediate results. From then on, the steady budget has been unable to sufficiently meet the needs of the population. As with so many other diseases that plague our nation, the fact that we value disease treatment far higher than disease prevention set up a vicious cycle: if society doesn’t value prevention, why should politicians spend political capital to support it?[1] The United States has fallen into this pattern of treating what for many has become a chronic illness. Unless we resume our early efforts to attack the spread of infection, we cannot escape the consequences.
Following, and in many ways resulting from, a lack of adequate funding for prevention of HIV/AIDS, specific communities have been hard hit by the epidemic in recent years. For the black community, this disproportionate and increasing rate of infection is largely due to a lack of meaningful public health initiatives that address the specific needs of this cultural group. In 1995 the black community had the greatest number of new infections (18,510), almost 7,000 more than any other group. They also have the highest number of cumulative AIDS cases (399,637) by over 10,000 [3]. This reflects the increasing overrepresentation in recent years of both new HIV cases and prevalence of AIDS cases. In their article on eliminating health disparities in HIV/AIDS, Fitzpatrick et al. stress that because of these increasing imbalances, developing strategies to enhance prevention in the black community is crucial. They suggest the importance of minority investigators as a step toward closing the gap, specifically in their ability to conduct meaningful research and prevention programs and cite Harlan Dalton, professor of law at Yale Law School, who declared that “public health officials cannot enter inner cities with expertise in one hand and goodwill in the other and expect to slay the disease dragon. They must first discern who this public is and how it sees itself in relation to them [4].” Fitzpatrick and colleagues have identified the deep need for understanding that must come before any progress can be made. As with funding, many policies and prevention programs were designed in the early years of the epidemic when politics and fear were large motivators. Going into southern, black communities without newly investigating why they are facing a resurgence of the disease in the first place will only be a waste of efforts. For example, public health officials must understand the knowledge gaps in these highly affected communities about how HIV is spread [5]. Research has already shown that African Americans delay starting anti-HIV treatments by an average of eight months and are less likely to remain on the medication [5]. Another study on collective consciousness pinned much of the failure to act on the shoulders of churches within the black community citing unwillingness on behalf of clergy to separate health and morality [6]. These facts alone exemplify the need to understand and address the specific customs and knowledge of the black community as a first step toward designing meaningful public health initiatives.
Though it failed to reach its original deadline for halving HIV incidence, the United States and the CDC has the ability to obtain its goal. The means is twofold: In order to once again see a decrease in infection rates, the United States must increase funding and attention to programs that will build the “social capital” of our most highly affected communities. Identifying social capital as the cohesion in a society, Holtgrave suggests that improving the foundations of these affected communities will directly increase our ability to reduce the number of new HIV infections [7]. Sociologist would agree. Robert Sampson uses the term “collective efficacy” to describe a communities willingness to act on behalf of the common good [6]. And though both terms suggest a community that recognizes problems and has the ability make unified efforts at improvement, we have yet to fully employ either. Realizing that infection rates dominate specific communities, efforts should be made to stabilize and invigorate those communities to act. This cannot be done without increasing funding and applying that money toward meaningful programs. With the development of effective medical treatments, we have already made enormous strides improving the quality of life for those infected. Many in the healthcare field have also rallied behind the CDC’s 2006 recommendation of HIV testing as part of routine medical care. With one quarter – 250,000 – of all persons with HIV/AIDS are not aware they are infected, this seems to be a great way to increase personal knowledge and awareness of one’s own status. Still, medical treatment and widespread testing are both one step away from the prevention programs that are desperately needed in high-risk areas. Funding must be provided to not only maintain current programs, but to adequately support community-based prevention programs. Our ability to combat the epidemic is a social action that requires the corresponding efforts of many people [6]. Without fostering these programs and building social capital, we will fail to curb the consistent and disproportionate infection rates in the United States.
As of now, we continue to apply band-aids to the epidemic. We have funded research, treatments, and programs in such a way that public health officials have been unable to adapt to the changing face of HIV/AIDS in the Untied States. But this is not to say real prevention is impossible. There must be a reinvestment at every level. Funding has already been shown to have a direct relationship to the number of infections, and we are beginning to recognize the deep impact of community-based interventions. For real progress to once again be made, financial reinvestment in the social capital of HIV/AIDS impacted communities must take precedence.
References:
Francis DP. Have We Learned Anything After 20 Years of AIDS? Call for a National Health Board. Public Health Reports 2001; 116:390-395.
Holtgrave DR, Kates J. HIV Incidence and CDC’s HIV Prevention Budget. American Journal of Preventative Medicine 2007; 32(1):63-67.
Centers for Disease Control. Basic Statistics and Surveillance for HIV/AIDS. Atlanta, GA: CDC. http://www.cdc.gov/hiv/topics/surveillance/print/basic.htm
Fitzpatrick LK, Sutton M, Greenberg AE. Toward Eliminating Health Disparities in HIV/AIDS: The Importance of the Minority Investigator in Addressing Scientific Gaps in Black and Latino Communities. Journal of the National Medical Association 2006; 98(12):1906-1911.
Garnet C. HIV and AIDS Still Gaining Strength Among Minorities, Women. The NIH Word on Health. Bethesda, MD. November 2002.
Wallace RM, Fullilove MT et al. Collective consciousness and its pathologies: Understanding the failure of AIDS control and treatment in the United States. Theoretical Biology and Medical Modeling 2007; 4(10).
Johns Hopkins School of Public Health. Q & A with David Holtgrave. Baltimore, MD: Johns Hopkins School of Public Health News Center. http://www.jhsph.edu/worldaidsday/holtgrave.html

Homophobia In The Black Community: The Underlying Resistance To Successfully Promoting Safe-Sex Campaigns Among Black Gay Men – Jerry Minor-Gordon

What does homosexuality mean?
The experience of homosexuality is certainly not new among humans as it has been around since the ancient times; however, its definition, identification, and connotation has changed over time. The term ‘homosexual’ as society refers to it today, was first documented by Karl-Maria Kertbeny in 1869 and became popular with Richard Freiherr von Krafft-Ebing's 1886 book Psychopathia Sexualis (1). Since then, there has been great debate among scientists and social theorists on what causes a person to become homosexual (the nature versus nurture argument). The debate is whether if it is a matter of choice that a person becomes gay (or if they are born that way), or if it is simply a phase that people eventually outgrow. Individuals form their own opinions about homosexuality, regardless of the scientific data that exists and unfortunately many, though not all, are in disagreement of that lifestyle.
Some people feel uncomfortable embracing issues that lay outside social norms, while others are convicted by their religious views that homosexuality is wrong and immoral. The tension that has build-up due to divide in opinions has resulted in widespread discrimination, targeted violent acts against gays, and out-casting them from society. In response to these vicious actions, several movements have arisen, both isolated and mainstream, of gay community members and supporters challenging the heterosexual social norms, fighting for basic human rights, and for gays to be recognized as positive contributing members of society. Great progress has been made for gay rights and several laws have passed that provide legal rights and protections (2,3); yet homosexuality still provokes heated discussion and volatile arguments.
The Changing Face of AIDS
The beginning of the AIDS epidemic in the 1980’s negatively changed how people viewed homosexuality. People referred to gays as ‘those people’ who were dirty, spread disease and were a threat to everyone else’s health. The truth is that everyone’s health was, and still is, at risk. Not because gays physically live among straight people posing a health risk, but because people have been careless with their own sexual encounters, not using protection and not taking the responsibility to get tested for HIV. This new epidemic has prompted public health practitioners and health agencies to create and implement campaigns to inform and educate the public on how to engage in safer-sex practices to reduce the transmission of the virus that leads to AIDS, as well as other sexually transmitted diseases. These campaigns have achieved some level of success, yet 15 years later the same basic safe-sex messages are still promoted.
What was once thought by blacks as ‘the white man’s disease’ has now infected over 40 million people globally (4), both gay and straight, and across all color lines. Although blacks comprise only 13% of the US population in 2005, the incidence of HIV/AIDS cases among blacks was estimated around 18,510 (49%) and reporting the primary route of transmission as men who have sex with men (5). These statistics clearly show that black gay men are in greatest need of an intervention. Why aren’t the campaign messages making a difference for blacks?
The Role of the Black Church
During slavery, blacks were forced to abandon their native religions and follow Christianity. Since then, even after slavery was abolished, the black church has played a pivotal role and has remained the unwavering and prevailing force in the black community. It is a central cultural institution that offers its community spiritual guidance and social order. The church serves as a safe haven for people to congregate, seek refuge, share ideas, discuss community and political decisions, and hosts non-religious events. When people have no where else to turn, they go to the church. The doctrines and views of the church prevail throughout the community and are accepted as the social norm. The black church view on homosexuality is one with which everyone may not agree, however it is what is widely recognized and most commonly adhered.
Although Christianity teaches acceptance of others without judgment, the church has often been hypocritical by discriminating and marginalizing people who do not fit into their selective mold of what a perfect Christian should be (6). The church condemns homosexuality and identifies people who live a gay lifestyle as sinners that will not go to heaven after death, rather will burn in hell (7). This has created such an uncomfortable and unwelcoming environment to openly discuss sexuality and has lead to an array of social and intrapersonal development challenges (identity crises, low self-esteem, lack of self-awareness and identification, and feeling isolated from the community). Due to the view of the church and its strong influence in the community, black gay men are facing a unique situation that has been the underlying hindrance for safe-sex campaigns to be successful.
Erikson’s Stages of Development
Being comfortable with one’s identity is extremely important to lead a healthy life, as it is the foundation of who we are, our values and how we relate to our surrounding environments. Finding or creating an identity is not an instant occurrence, rather it transpires gradually over periods of a person’s life. Erik Erikson, a German developmental psychologist and psychoanalyst, developed a theory in the 1950’s that describes the eight stages of psychosocial development that every person experiences throughout their lives (8). Each stage is categorized by a particular age range, and must be ‘mastered’ to avoid the negative consequences that result from an unsettled resolution of unhealthy psychosocial development (9). The two stages, according to Erikson, in which people search for identities corresponds to the age ranges usually targeted for safe-sex campaigns: adolescence and early adulthood.
During adolescence, men are searching for their identity, sense of self, and trust. They are concerned with how others view them and seek acceptance amongst their peers through membership in groups and sexual relationships. It is during this stage that people generally suffer from identity crisis that will stifle further development. “If the adolescent can not make deliberate decisions and choices especially about vocation and sexual orientation, …role of confusion becomes a threat.” (10)
During early adulthood, men are searching for intimacy, the fostering of stable relationships, and life-long partners. The consequences for not mastering this stage are feelings of isolation and the inability to commit to a relationship. It is extremely difficult for gay men living in a hostile, homophobic community to foster meaningful relationships (9).
Going through an identity crisis and not finding intimacy results in unresolved feelings of self-awareness and insecurities about how to fit into society. Safe-sex intervention messages therefore may not be a priority. Some men end up living a life of secrecy, will not admit to being gay, and will not participate in intervention efforts for fear of being seen and labeled as gay. Other men are in self-denial about their own sexuality because the community has conditioned them that homosexuality is wrong and they have internalized and suppressed their true feelings to the point they do not identify themselves as homosexual. For this group, health interventions targeted towards gay men are not of concern since they don’t think of themselves as belonging to that group.
Erikson’s views do not come without criticism. His theories of human development are seen though a heterosexual lens; however, the concepts are also applicable to homosexuals, as they also experience the same emotions as straight people.
Maslow’s Hierarchy of Needs
Maslow’s Hierarchy of Needs, depicted as pyramid, describes the five stages of psychological and physiological needs people experience in their lives; each stage needing to be completed before the higher stages become a priority. Once the goals in the lower level are fulfilled, then a person can advance to the next stage of the pyramid (11). Maslow believes the highest stage, self-actualization, every person should strive to achieve. It is at this stage that a person is considered whole with clear morality, accepting of facts, lacking prejudice and able to solve problems (11). It is at this stage where interventions are effective in influencing behavior change, since a person’s basic needs have been met. Each stage presents a unique challenge for gay black men to reach their level of self-actualization; and as each stage is not satisfied the more likely it is for a man to stifle in his development leading to issues of low self-esteem (10).
The lower four stages of the pyramid are known as deficiency needs and are associated with physiological needs. These include basic needs such as having food, water, air to breathe, and the need for sexual activity (10). A black gay man who is subjected to homophobic attitudes may be hesitant to seek a relationship with a man and therefore settle to interact with a woman; suppressing his true sexual feelings. This can lead to issues of lowered self-esteem, especially if the man feels he will never be able to live openly and has to conceal his sexual desires.
The second stage of the pyramid is safety needs: security of employment, family, property, and resources, as well as security of health (11). One can assume the meaning of assume health in this context, is considered sickness that has a quick onset and is easily identifiable even with limited medical knowledge; such as a cold or the flu. This stage presents a great threat for blacks who live in less affluent neighborhoods who are concerned about basic safety issues, and for gay black men living in this community presents two issues. One, the safety and security issues that all black people in the community face and secondly, additional safety and security issues faced by open or suspected gay men who are discriminated against and ostracized by members of their own community.
The third stage of the pyramid is belonging and emotional needs: sexual intimacy, having support and being accepted by society (11). Gay black men greatly suffer from lack of support by their communities since most members follow the doctrines of the church. The consequence of not having these needs met are loneliness and depression (11). The priorities at this stage are finding a place of belonging, comfort, and feeling accepted, thus messages promoting safe-sex campaigns may not be of great concern.
The fourth stage of the pyramid is self-esteem. Self-esteem means to respect oneself, respecting others and being respected by others (11). People who have high self-esteem have higher levels of self-worth and values of themselves, as compared to people who suffer from depression or feel isolated. Unfortunately, the black community’s homophobic attitudes do not respect the lifestyles of gay men. Furthermore, they do not accept gay men, purposely making them inferior, and less worthy to be a part of the community. Eventually a person will start taking the attitudes of others and internalizing those feelings which can lead to low self-esteem. A person with deficient levels self-esteem, according to Maslow, will not advance to the level of self-actualization, and therefore will not perceive health promotion messages as a priority.
Tailoring campaign messages for the real sub-group
As new health issues emerge in society, the role of public health continues to expand in order to address these issues and create ways to prevent or minimize adverse health effects. How to effectively address these issues, communicate risk, and promote health behavior changes, is an extremely important and arduous task to accomplish. Some public health programs and interventions only benefit a particular segment of the target population and unintentionally exclude the subgroups within the larger group. Other campaigns and interventions are well-organized and have properly identified a target audience, but still do not translate into improved behaviors.
In this particular situation, the groups are black gay men and the messages are tailored accordingly. However, within that group is a sub-group that is not being reached by the safe-sex campaigns. This sub-group are gay men who do not identify themselves as gay men. The Rap-it-up campaign, for example has a commercial featuring a gay black man urging the viewer to use a condom when engaging in sexual activity. The focus of the message is to influence behavior, and completely avoids the identification of gay men (12). Gay men who are in self-denial about their own sexuality are unlikely to relate to messages and interventions that target gay men. The homophobic attitudes that the black church promotes, permeates throughout the community causing black gay men to internalize and suppress their own sexuality and consequently suffer from identity crisis, be in self-denial and lack awareness. The campaigns fail to consider gay men who do not think of themselves as gay.
Community Involvement - Recommendations for improved interventions
The homophobia that persists in black communities has been the main resisting force against the success of safe-sex campaigns and interventions for black gay men. Intervention efforts mainly consist of messages aimed towards the individual – for the individual to take action and become more sexually responsible by getting tested for HIV and wearing a condom during intercourse. This approach in the black community, for even the most targeted campaigns, is not effective in promoting behavioral changes. Instead of addressing the individuals, interventions need to first address the community and their homophobic attitudes - the real source to why campaigns have not been successful.
The best way to reach people is not through advertisement or catchy slogans, but rather to sit down and talk with them. To begin, we need to include a representative from each group (gay men, straight men and women, homophobic and non-homophobic people) in the initial conversations to figure out the best way to approach that particular community. Having a range of viewpoints will provide a broad perspective and deeper understanding of the community’s values in order to develop culturally sensitive messages. It is always more constructive to plan and talk with the people who will be affected by a program, rather than talking at and planning for them. I would suggest hosting a series of discussion sessions, inviting only small groups at a time, facilitated by a trained individual from the community, to openly discuss issues and attitudes about sexuality, love, and acceptance. The overall goal is to examine their own (not the church’s) feelings and to provoke challenging conversations while advocating for people to have open minds about homosexuality. Further explaining and encouraging the group to consider that gay men are people, who like everyone else, want to be able to feel safe in their own environment, provide for their families, and experience love without the fear of being discriminated and humiliated. Perhaps appealing to the community members’ guilt of how they feel when discriminated simply because of their race or gender is effective to bring about empathy and compassion for gay men. Also, the discussions should include conversations to promote safe-sex practices for everyone, providing sex education materials, male and female contraceptives. Hopefully the message will also reach heterosexual, as well as, gay people who are in self-denial about their sexuality.
Understanding that changing how an entire community views homosexuality takes time, these discussion workshops can serve as an interim solution, making a difference in one person at a time. Once the attitude of the community changes and new social norms are established it will allow gay men to be more comfortable and confident to openly live their lives without fear of discrimination. When gay men feel like their lives are worth protecting, they will positively change their sexual behavior, and safe-sex practice campaigns will be truly successful.
REFERENCES
1. Feray, J. and Herzer, M. Homosexual Studies and Politics in the 19th Century: Karl Maria Kertbeny. Journal of Homosexuality 1990; 19 (1).
2. United States. 104th Congress. Defense of Marriage Act. House of Representatives Committee Report. 1996.
3. U.S. Office of Personnel Management. Washington, DC 2007.
http://www.opm.gov/er/address2/guide01.asp
4. World Health Organization & UNAIDS. AIDS epidemic update: December 2005. Switzerland. http://www.unaids.org/epi/2005/doc/EPIupdate2005_pdf_en/Epi05_13_en.pdf
5. Centers for Disease Control and Prevention. Fact Sheet: HIV/AIDS among African Americans. Atlanta, GA. January 2007. http://www.cdc.gov/hiv/topics/aa/resources/factsheets/aa.htm
6. Miller R. Legacy denied: African American gay men, AIDS, and the black church. Social Work. 2007 ;52(1):51-61.
7. The Holy Bible New International Version. Leviticus 18:22 and 20:13. Grand Rapids, MI: Zondervan Publishing House. 1984.
8. Wikipedia. Erik Erikson’s Biography. March 2007. http://en.wikipedia.org/wiki/Erik_Erikson
9. Wikipedia. Erikson’s stages of psychological development. April 2007.
http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development
10. Krementz, J. ErikErikson: The Father of Psychosocial Development. State University of New York College at Cortland. http://web.cortland.edu/andersmd/ERIK/stageint.HTML
11. Wikipedia. Maslow’s Hierarchy of Needs. April 2007. http://en.wikipedia.org/wiki/Maslow's_hierarchy_of_needs
12. Black Entertainment Television. Rap-it-up Campaign. Washington, DC: BET.com 2007.
http://www.bet.com/Health/aboutrapitup.htm??Referrer={075A8562-234A-400A-BB5B-B2EFC7363045}

Where the Health Belief and Theory Of Reason Action Models Fail: Why Universal Access Will Not Fix The Disparities In Health – Preet Ghuman

Since World War II, as Europe began to rebuild and the United States began to heal its wounded, healthcare across the industrialized world began to take shape. Most European nations began to fully develop single payer nationalized systems; fortifying their belief that healthcare was an innate right of its citizenry. The United States saw its own transformation after WWII ended, as a system of “insurance” arose across the country, beginning with indemnity insurance and leading to what is now managed care. This stark divide in the paths between the European nations and the United States is the subject of harsh criticism by proponents of universal healthcare in this country.
Reports on the 2005 census have shown that as many as 46.6 million Americans lack health insurance coverage, 11.2 percent of which are children (1). This number is predicted to rise to approximately 56 million by 2013 (2). Socioeconomic gaps have formed in healthcare access, utilization, and delivery since WWII. This disparity is even more prevalently in minority groups across the country, due to lower level of education and low-income levels (3). Much of the socioeconomic disparities in health are blamed on this lack of access to many essential health services. Many researchers go a step further and make the claim that providing full access to healthcare will eliminate the socioeconomic and racial disparities in health, implying and arguing that access will lead to utilization across the country (4)(5). This, as many new students in the Boston University School of Public Health are learning, is the crutch of the public health problem: intention does not always lead to behavior and more importantly access does not always lead to utilization.
Increased research on the overall effects of universal care is beginning to show that access is only the metaphorical “tip of the iceberg”; with many arguing that there are a number of underlying social/behavioral factors that will limit overall utilization of the system among minorities and inner-city populations. Other socioeconomic factors such as race and income level need to be addressed before any universal system can be successful.
Decades Old Dogma – Universal Coverage Will Fix All Socioeconomic Health Woes
Imagine a United States where healthcare was not only free but open to access by anyone, anywhere in the country. Imagine minorities and whites, people of all levels of income receiving the same coverage and same quality of care across the country. Strong proponents of universal healthcare say we can achieve this by simply giving access to healthcare to all residents and delivering it to them at a level affordable to all. It is a decades old public health dogma that began forming after managed care could not control spiraling health costs across the nation during the 1980s. Large amounts of research dollars have poured into the subject, ultimately culminating in the Clinton Universal Healthcare Plan of 1997, which sought to create universal coverage based on regional risk pools across the United States (6).
Some of the earliest and most cited studies have simply examined the role of access in improving individual health, especially among minorities and the poor. The model of many of these studies, based upon theory and implication, was that “...medical treatments create healthy populations” (7). This model was used widely for healthcare reform in this country and abroad in 1980s and 1990s. A 1981 study examined economic status with access and utilization, and showed that “the poor continue to experience illness at a much greater rate than do the nonpoor” due lack of utilization caused by little or no access to a physician (8). The study concluded that if access could be extended to those who were uninsured, especially minorities, then overall health among these populations would generally increase. Those who go uninsured and without access to essential medical care face: higher medical bills, unsatisfactory care, and access problems (9). Many argue that universal access will alleviate many problems among the poor, and overcome copayment barriers. As Freeman Et. Al. states, “...access is determined largely by insurance status”(10).
Many similar studies also examined the types of barriers that would exist for poorer and minority populations (vulnerable groups) even if they had access to medical services. A key study performed by Bierman et. al. identified barriers within healthcare systems that must be removed for universal access to be successful, such as navigating through the health care bureaucracy as a patient. This study, while taking steps towards identifying the causes and solutions for underlying causes of health disparities, only examined barriers regarding the actual system itself (while ignoring the many other social and economic issues which can cause health disparities). It concluded that if these barriers could be removed, universal access to care could easily bridge age, gender, social, and economic gaps. Lack of insurance coverage (and access) was commonly found to be the single biggest cause of racial disparities between whites and Hispanics, and whites and African American (11)(12)(13).
It is also long believed in public health that the lack of access to care leads to lower health outcomes in minorities than the rest of general public. Proponents argue, citing these studies, by removing the perceived barrier of limited access more minorities will access and use their primary care physician. This in turn will limit very simple medical conditions from worsening and becoming a larger burden on the medical system later on (14)(15)(16). Many of these earlier studies formed foundations for the universal access movement.
The 1990s and 2000s brought what proponents of universal coverage had originally ignored: examination of health outcomes. Many studies began studying the effects of insurance and universal coverage on health outcomes in poor populations. The same model above was used: health coverage and access will lead to better outcomes among the insured and those with access. A study performed