Challenging Dogma

...Using social sciences to improve the practice of public health

Wednesday, May 2, 2007

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.


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.


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Tuesday, May 1, 2007

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)”

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. 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 “,” returns the 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 “” 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 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.


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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.
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.

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Monday, April 30, 2007

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.


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.


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.


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.


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Mental Health Services, National Institute of Mental Health, 1999

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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.

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Research Needs and Future Direction. Journal of Autism and Developmental

Disorders, 2000; 30(5); 373.

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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

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

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

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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 20th 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.


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.

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