Challenging Dogma


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

Sunday, April 22, 2007

The Partnership for a Drug-Free America Fails to Consider Self-Efficacy Among Teens and Cultural Differences– Elizabeth DesRoche

With deadly drugs easily accessible and inexpensive, drug-abuse among teenage kids is on the rise. Shannah DeSisto, a nineteen year old girl, is just one example of hundreds. Shannah was not your stereotypical teenage drug-addict. As her mother says, “’I figured myself as middle, upper class… It’s always been, you know, the people on the streets, or indigents.’” Five-months pregnant with her son Aiden, Shannah died of a drug overdose on June 11, 2005. An addiction that began with OxyContin (OC), ended tragically with heroin. “It was extremely easy to get… It was everywhere and it worked. It covered up all your pain and misery,” (1). In the South-Shore area of Massachusetts, seventy-four deaths from opiate overdoses occurred in the span of year and a half. Forty-three of these cases lived in a suburban area. The average age of addicts who died: twenty-three (2). These are terrifying statistics.

Successfully designing a public health campaign that addresses all potential components is a difficult task – perhaps near impossible. However, social sciences should be at the heart of any campaign. For in order to reach a target audience, we must look at the psychological processes that influence decision making.

The Partnership for a Drug-Free America (PDFA) is a nonprofit association of “communication, health, medical and educational professionals working to reduce illicit drug use and help people live healthy, drug-free lives,” (3). This campaign addresses the secondary aspect of health – treatment. It provides advice for “treating” peer-pressure and drug abuse. The secondary level of health is designed for physicians to treat individual cases. This is not the role of a public health campaign. Campaigns should be designed at the primary level – the group level of prevention. It is the level that accounts for personal experiences, cultural background, and education.

This critique is based on the absence of social sciences in The Partnership for a Drug-Free America Campaign. It aims to look at the increasing drug-abuse problem in the United States. Social sciences study human behavior – human behavior such as drug-abuse. The PDFA failed to effectively use such social and behavioral sciences to reach its goal – a goal of reducing drug-abuse in the United States. It has failed to address the crucial issues involved in any public health campaign such as addressing the target audience most susceptible and reaching out to a diversity of cultures.

What is a public health campaign without Self-Efficacy? Ineffective
What is self-efficacy? It is an impression that one is capable of acting a certain way or attaining designated goals. It is the belief that one has the power to produce a desired effect. Quite frankly, it is having the self-confidence to achieve a desired goal. Albert Bandura’s Social Cognitive Theory asserts that self-efficacy leads to behavioral change. He emphasizes that individuals will be more likely to “take on a task if they believe they can succeed.” Too little self-efficacy results in poor planning and higher stress. Too much self-efficacy can inspire greater risk taking and the belief that failure is out of one’s control. Too much self-efficacy does not cause harm – but too little certainly can (4).

Bandura developed four key points that will affect personal self-efficacy. Number one, and most important, is experience. A successful personal experience will raise self-efficacy where an unsuccessful personal experience will lower it. Modeling, or vicarious experience, is his next point. Observing someone else succeed will strengthen self-efficacy. Observing someone fail will lower it. Social persuasions are Bandura’s third point – referring to encouragements and discouragements. Discouragements dominate encouragements in the human mind – thereby lowering self-efficacy. Lastly, physiological factors alter self-efficacy. It is how we view physiological reactions to stressful situations – physiological reactions such as shakes, nausea, fatigue, etc. A positive outlook can increase self-efficacy where a negative outlook will decrease it. If one believes such physiological reactions occur because of inability, self-efficacy is significantly lowered. But by turning these reactions into a more positive outlook, self-efficacy can be raised (4).

The Partnership for a Drug-Free America does not strengthen self-efficacy. Self-efficacy is imperative to this campaign; all campaigns for that matter. It allows one to be above the pressures of drug-use. It is believing that one has the capabilities to manage potential pressures associated with drug-use. “[People] do things that give them self-satisfaction and a sense of pride and self-worth, and refrain from behaving in ways that give rise to self-dissatisfaction, self-devaluation, and self-censure,” (5). In essence, this is self-efficacy. The campaign ads model both positive and negative experiences with drug-abuse. Ads where individuals are portrayed living drug-free lives; and ads where individuals are portrayed succumbing to drug-abuse. This provides very mixed messages of vicarious experiences. Positive social persuasions are non-existent in their campaign ads. Physiological factors are not even discussed.

The PDFA is responsible for numerous alarming advertisements. For example, they depict an egg smashed into a frying pan as a representation of your brain on drugs (3). While such advertisements certainly bring this topic to the table of discussion, it does not move to the next step of prevention. This issue has been sitting on the table for some time now – we get the point. There are many other advertisements from this campaign that elicit fear and shock. Their print ads are horrific, showing open wounds on skin caused by drug use. Scare tactics are very popular in many public health campaigns – yet are often ineffective. They are meant to elicit fear, “the negatively valenced emotion that may be felt by a person exposed to a threat appeal. It can be dealt with… maladaptively by a psychological response meant to dispose of the fear – for example, denying the truth or personal relevance of the message,” (6). How, by scaring an individual, are you empowering him – inspiring self-efficacy? Such ads lower self-efficacy according to Bandura’s points of modeling and social persuasion. To raise self-efficacy, the vicarious experience should be positive. These ads are saying that so many have fallen to drug-abuse, don’t let it be you. This is not exactly a hopeful message. The ads do not offer encouragement to resist drugs. Instead, they leave you with this alarming sense of horror. Fear does not inspire self-efficacy. It does not provide the self-efficacy to resist drugs because they harm your body, mind and personal relationships.

The teen portion of the PDFA website is dedicated to teens who already experience drug-abuse. The television commercials are aimed at petrifying teenagers of the long-term risks. The print ads show horrific images of drug-abusers. These avenues do not reach out to the experiences and attitudes teenagers face in their complicated lives. Without properly educating and motivating teens to avoid drugs, they will not make the single-most important behavioral change this campaign wishes to address – resistance.

What population needs the most support? Easy answer – Teenagers
In the United States today, what age group is most vulnerable to drug-use? “There is evidence of a substantial increase in teen use of both cigars and marijuana over the last decade,” (7). A study done by the Partnership for a Drug-Free America found that “nearly one in five teens has tried prescription medication,” and “one in ten teens report abusing cough medicine to get high.” Teen drug abuse is also increasing among inhalants -“Teen trial of inhalants has increased over the past three years to an alarming twenty percent,” (8). Why, then, does the Partnership for a Drug-Free America campaign seem to target parents just as much as it does teenagers, if not more? The mediums through which the campaign advertises the most (television, radio, print ads) simply scare teenagers or empower parents – parents that are not at risk for drug-abuse.

The website homepage for the PDFA contains more links directed towards parents than it does any other population. While it is certainly important to educate parents and encourage them to talk about drug-use with their children, we cannot neglect to address the most important group - teenagers. Statistics show that parents are already addressing this issue with their children and it is proving to be idle. “Nine out of ten parents say they have talked to their teen about the dangers of drugs, yet fewer than one third of teens say they [actually] learn a lot about the risks of drugs from their parents,” (8). For a campaign to put so much emphasis into addressing parents is ineffective. Perhaps addressing teenagers to a greater degree would prove beneficial. Perhaps using role models teenagers admire would be more effective.

The National Youth Anti-Drug Campaign (Media Campaign) seems to be taking steps in the right direction – inspiring self-efficacy in teenagers. The website advertises for adult and youth mentors – encouraging modeling and social persuasion. This website asks for new, creative messages to be developed – a way of truly gaining the experiences and thoughts of the affected population. This is social science at its best. In fact, the website provides several health behavior models that address each area of the campaign. Each model has taken into account much more than the basic models. It accounts for the availability of ads on mass media, attitudes toward drug use among all those most involved in teen lives, etc. (9).

The PDFA website is a great tool for parents, but it is not something one would find teen eager to ‘surf-to.’ This campaign needs to find a better medium through which to educate and inform adolescents. The Media Campaign has found various avenues to reach teens and is “the most visible symbol of the federal government’s commitment to youth drug prevention,” (9). For example, the Media Campaign delivers anti-drug information to teenagers through more than 1,300 media outlets. It has established entertainment outreach where it provides accurate information to television writers and producers. The campaign has created a multicultural outreach program. These essential components are missing from the PDFA Campaign. These avenues make use of social sciences in a very positive manner that could make the PDFA Campaign much more valuable.

The PDFA campaign has not employed a visible health behavior model where the attitudes, experiences and social norms have been investigated. While the models for the Media Campaign are elaborate – they seem to look at all possible barriers a teenager faces. The PDFA has not effectively reached the teenage population in the United States. It has done a great job educating parents and putting this problem on the agenda – but it’s time to take the next step. The Media Campaign focuses on teen drug-use. It’s time the PDFA did the same.

Cultural Differences – Much more than a language barrier.
America is comprised of hundreds of nationalities, each with different cultural values and experiences. However, we often fail to address these cultural differences in our public health campaigns. The Partnership for a Drug-Free America is no exception. In a campaign aimed at reducing methamphetamine use among Hispanics, the Partnership for a Drug-Free America joined forces with the White House Office of National Drug Control Policy. They created public service advertisements in both English and Spanish for television, radio and print. This campaign is “the largest scale Spanish-language anti-meth effort to date,” (10). The campaign did not account for cultural differences but merely translated the message into Spanish. A common misconception is that by translating a message into a different language, we have successfully broken a cultural barrier. Language is not the only difference among different ethnic groups.

Attitudes, lifestyles, experiences, education and various other factors make each culture unique. In fact, the National Institute on Drug Abuse (NIDA) has done a study investigating the role ethnic identification and cultural ties have in preventing drug use. “NIDA-supported research demonstrated different patterns of drug abuse among different subgroups… These findings suggest that incorporating ethnic and cultural components into drug abuse prevention programs can make these programs more effective,” (11). Another study supported by the NIDA found that there were definite differences in drug use patterns among differing ethnic groups. Chinese and Vietnamese were more likely to use cocaine as their primary drug. Filipinos were four times more likely to use heroin. The studies also found that “adolescents who strongly identify with their communities and culture are less vulnerable to risk factors for drug use,” (11). Therefore, if we take a step back and address cultural experiences, we may be much more effective in our efforts. The Partnership for a Drug-Free America has not yet tried this path.

None of the advertisements for the Partnership for a Drug-Free America address cultural boundaries. The website, television and print ads simply offer translation. Cultural differences are present in almost every aspect of life – not strictly drug use. “A patient’s culture has an effect on his or her view of illness, decision to seek care, and adherence to treatment plans and follow-up visits,” (12). This is quite obvious. Unfortunately, The Partnership for a Drug-Free American is not alone in using the ‘translation fallacy’ to address cultural differences – but part of the majority. If Public Health campaigns are to make a difference, cultural boundaries is a very large area to address.

Conclusion
Shannah DeSisto is just one tragic case of hundreds – even thousands. Teenage drug-abuse is on the rise. There are several You Tube videos making a mockery of the PDFA’s efforts to prevent drug use. A man named Nick Ferrell is responsible for just a few of those scornful videos. He is also accountable for the United League of Drug and Narcotic Enthusiasts – a group designed to ridicule the Partnership for a Drug-Free America. These videos are created to show drug-use in a positive light. They are showing the comedic effects of drug use while criticizing the PDFA (13).

This country is in desperate need of an effective public health campaign to turn this epidemic around. The Partnership for a Drug-Free America needs to revamp its campaign strategies. This organization needs to do some serious field work if we truly wish to save our adolescents. This issue has been on the agenda for some time now. The PDFA needs to implement prevention campaigns to adolescents.

Self-efficacy is the key to any behavioral change. Supplying courage and self-esteem are crucial. As much of an impact parents would like to believe they have, there is a limit in the mind if any teen. This campaign needs to move beyond scare-tactics as their source of education. Sponsor sporting events, drama-clubs, visit school systems – all are potential avenues. We need to stop thinking that by merely translating we are affecting differing cultures. It is insulting. While the intentions of this campaign are inspiring, the strategies need a lot of work. The Partnership for a Drug-Free America is not effective. By implementing social and behavioral sciences, we can set this campaign in the right direction.

Examples of PDFA Campaign Ads (Hyperlink)
http://www.mediacampaign.org/newsroom/press06/060506.html
http://www.nickferrell.com/partnership_main.html
http://www.youtube.com/watch?v=twz1Z6Ap7aU&mode=related&search=
http://www.drugfree.org/Portal/20_Years_of_Partnering_With_Families

REFERENCES
1. Damish, Steve. 2007. Drugs rip dreams, then life, from pregnant teen. The Enterprise. Retrieved April 4, 2007 from, http://southofboston.net/entreports/heroin/day1.html
2. Grim Figures. The Enterprise. Retrieved April 4, 2007 from, http://southofboston.net/entreports/heroin/day1-charts.html.
3. The Partnership for a Drug-Free America. Retrieved April 2, 2007 from, http://www.drugfree.org/Portal/.
4. Wikipedia. Self-Efficacy. Retrieved April 16, 2007 from, http://en.wikipedia.org/wiki/Self-efficacy.
5.Bandura, Albert. 2001. Social Cognitive Theory: An Agentic Perspective. Department of Psychology, Stanford University. Retrieved April 2, 2007 from, http://arjournals.annualreviews.org/doi/pdf/10.1146/annurev.psych.52.1.1?cookieSet=1
6. Chapman, S., Donovan, R., and Hill, D. 1998. The return of scare tactics. Retrieved April 2, 2007 from, http://tobaccocontrol.bmj.com/cgi/content/full/7/1/5.
7. Stoltz, A. RN, MS, and Sanders, B. PhD. 2000. Cigar and Marijuana Use: Their relationship in teens. The Journal of School Nursing. Retrieved April 2, 2007 from, http://nasn.allenpress.com/nasnonline/?request=get-abstract&issn=1059-8405&volume=016&issue=04&page=0028.
8. Generation Rx: National study confirms abuse of prescription and over-the-counter drugs. The Partnership for a Drug-Free America. Retrieved April 2, 2007 from, http://www.drugfree.org/Portal/DrugIssue/Research/Teens_2005/Generation_Rx_Study_Confirms_Abuse_of_Prescription.
9. Campaign Overview. National Youth Anti-Drug Media Campaign. Retrieved April 16, 2007 from, http://www.mediacampaign.org/newsroom/factsheets/overview.html.
10. Deaktor, Hallie. June 5, 2006. Partnership for a Drug-Free America and White House Office of National Drug Control Policy launch new ad campaign aimed at preventing meth use among Hispanics. Office of National Drug Control Policy. Retrieved April 16, 2007 from, http://www.mediacampaign.org/newsroom/press06/060506.html.
11. Zickler, Patrick. September 1999. Ethnic identification and cultural ties may help prevent drug use. National Institute on Drug Abuse. Retrieved April 16, 2007 from, http://www.nida.nih.gov/NIDA_notes/NNVol14N3/Ethnic.html.
12. Batista, M. MSW, Blaschke, G. MD, MPH, Hametz, P. MD, Meyer, D. MD, Reznik, V. MD, MPH, Salguero, R. MD, MPH, and Sidelinger, D. MD, MSEd. April 4, 2005. Communities as Teachers: Learning to deliver culturally effective care in pediatrics. Official Journal of the American Academy of Pediatrics. Retrieved April 2, 2007 from, http://pediatrics.aappublications.org/cgi/content/full/115/4/S1/1160.
13. Partnership for a Drug-Free America…right. You Tube. Retrieved April 16, 2007 from, http://www.youtube.com/watch?v=twz1Z6Ap7aU&mode=related&search=.

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