Challenging Dogma - Fall 2008

Is America Sicker or Overmedicated? The Public's Abandoment by the Health Sector—Zhandra Ferreira-Cesar

2008-12-18T13:58:00.001-08:00

The Issue-

It is true that many drugs help people live longer and better lives. However, others may hurt patients in ways they do not know about. Everyday people place their full trust and lives in the hands of doctors, public health practitioners and pharmaceutical companies who advertise their mission to be an increase in the quality of life and the eradication of diseases. However, what happens when those same professionals whom the public trusts to educate and create the safest medications are also the same individuals who regularly treat the creation of drugs as a billion dollar industry that can be manipulated to enhance profits regardless of what this means for the population? Pharmaceutical and supplement manufacturers have to increase sales and profits, as all businesses must, and they do so in part by developing drugs to treat disease and also by convincing people they need medications to prevent disease or lessen the perceived risk of future illness. Is America sicker or just overmedicated? While the number of people with disease is not growing, the number of adult Americans taking medication is increasing. According to J. Douglas Bremner, MD 50% of Americans take prescriptions drugs and 81% take at least one pill everyday [3]. This problem can be attributed to the increase in the number of advertisements used by the pharmaceutical companies who have moved from the area of sick people, to individuals who look well but may have some genetic marker that makes them more susceptible to disease [9]. Thus the era of disease prevention starts in the medical world. At the end of the day, however, rather than increasing awareness about the key diseases affecting the public, public health practitioners have lost control of the efforts and joined in a billion dollar industry dedicated to treating people who are not sick.

Healthcare or business-

Throughout history people have regarded medical professionals as compassionate, selfless, devoted individuals who dedicate their lives to saving others. This image however has been tarnished with the latest movement to get new pills off the shelves and into the mouth of the American public. This frenzy began when government deregulation and an earnest attempt to help HIV/AIDS patients get easier access to crucial life extending drugs collided. A need for faster approval of drugs to serve patients coupled with an understaffed FDA dealt the leading hand to the pharmaceutical companies [3]. In order to speed drug patenting, the FDA had to develop a system that would provide it with the necessary funds to operate. In a response to this need, Congress passed a law mandating that pharmaceutical companies pay a fee every time a drug patent is requested in an attempt to offset the bureaucratic cost of the FDA [8]. However, this fee implementation did not obtain the necessary funds, and thus the funding for surveillance and research of approved drugs was drastically diminished. This initial budget cut initiated the snowballing effect of a hungry industry to make money and forget the focus of its initial humanitarian purpose—the well being of individuals [3].

Another interesting event came as a result of the change in law: the limits and boundaries between pharmaceutical companies, the FDA, and doctors became increasingly vague. In some cases, individuals that worked for the FDA acquired jobs with drug companies; therefore making their relationships with the FDA a major priority for the success of their careers [3]. These same FDA officials who approve a drug are also in charge of monitoring it after it enters the market, which means that these people have no incentives to admit an error and say that the drugs that they previously categorized as safe are now unsafe, even if it means that those patients making use of these drugs may be at risk [2]. Finally, it is noteworthy to mention that the FDA gets most of its input from a panel of doctors who are experts in their fields [8]. However, it is not accurate to say that these doctors are unbiased when analyzing the data presented to them since most of these doctors receive payment as consultants, or are given research grants and support for travel to conferences from drug companies [1]. All these incentives deter physicians from fully acknowledging all side effects of the drugs being presented for approval, thus increasing the chances that they will be patented and reach the public to cause harm and leave behind catastrophic death rates, like the arthritis medication Vioxx did by increasing the incidence of heart disease [3]. The cooperation between the FDA, drug companies, and doctors therefore, actually presents itself as a conflict of interest that completely disregards the initial job of the healthcare system, which is to care for, treat and educate individuals about pertinent health issues [4].

Take for example, USA Today reported on October 16th, 2004 in the article “Cholesterol Guidelines Become a Morality Play” that nine of the doctors that sat on the committee for the production of cholesterol guidelines were also making money from the companies that developed drugs to lower cholesterol, which were urging Americans to take these drugs via the media [3]. This exemplifies the heavy influence that drug companies have upon physicians, which leads to the conclusion that not even family physicians have the power to control the treatment for their patients. Ultimately, the drug companies have the power to dictate which drugs are being consumed and which diseases will emerge by means of carefully framing and delivering their desired message through the media. This is mainly because only so much information reaches physicians, and the information that does reach doctors is carefully selected and presented as the ultimate truth in the medical world [12]. Dr. Curt D. Furberg, a former head of clinical trials at the National Heart, Lung and Blood Institute describes the way in which information reaches physicians as published on the Los Angeles Times on December 22nd, 2004, “The National Institutes of Health: Public Servant or Private Marketer?” saying, “The company reps tell the doctors,’ you should follow these guidelines’ implying that you’re not a good doctor if you don’t follow these guidelines” [9].

One point that should be made on behalf of the doctors, however, is that these physicians do not have the time to be reading every journal and study that is released. Thus, it is only natural that they place their trust in the drug companies who claim to have the same interests as they do [6]. This is clearly not true as pharmaceutical companies often ignore obvious signs that a drug is failing in order to make extra earning regardless of how many individuals are being affected.

The media and pharmaceutical companies-

People have inherent trust in medical professionals due to the social acceptance and glorification that has been established over time. Surveys conducted of the general population show that Americans trust pharmaceutical companies to advertise the adequate and proper information regarding the side effects of drugs and their advantages [2]. However, is the purpose of drug advertisement really to increase awareness and educate the mass public about the positive and negative effects of new drugs or is their main purpose to make profits?

The first clue that the pharmaceutical market has turned its back on the sick population is displayed in the creation and expansion of a new market that is composed of healthy individuals as the target for preventive medicine, which has become a multibillion-dollar business. In order to promote this market shift, pharmaceutical companies have initiated educational programs, which they claim are meant to identify those individuals who are at risk of developing the targeted conditions. Some examples of these are hypertension, heart disease, and osteoporosis [11]. These programs are usually put on by making large donations to the organizations that research and support the various diseases, and in return these organizations “spread the word” about these newly invented drugs that promise to prevent undiagnosed and underdeveloped diseases [2]. This increases awareness and the number of screenings and with that also the number of individuals who can potentially take the medication. This is fine for individuals who have not been diagnosed with high blood pressure or for those at the early stages of cancer; however, these campaigns are not created to be completely altruistic and educational. Most of these campaigns are directly linked to the pharmaceutical companies’ media campaigns, whose only intentions are to convince the average American that they need a pill to prevent any possible disease [8].

Another factor that has increased the use of prescription drugs in America took place in 1997 when the FDA lifted the ban on direct consumer advertising. In addition, the law that requires every possible side effect to be listed was also removed [3]. The effect of this change is displayed strongly on the various television advertisements that target the emotional state of viewers rather than identifying the problem and effect of the drugs being advertised. This change in legislation allowed drug companies to attack Americans with a mass amount of media and news telling Americans to go and “ask [their] doctor for a specific drug [8]. In fact, America is the only country where you can turn on the TV, open the newspaper or a magazine and be told to go ask your doctor for a specific drug and brand [6]. However, what is more alarming is that doctors will prescribe medications to their patients if they ask for them even if they do not entirely need it. Dr. Marcia Angell author of “The Truth about Drug Companies” says that studies show that 54% of the time physicians will prescribe a brand of medication if the patient asks for it [3].

The prime example of this medical fraud that has let America down and destroyed the public’s trust involves ADHD medications. The creation of ADHD as a disease is one example of a series of conditions that has given the pharmaceutical companies an open door into the market of healthy people to promote long-term drug consumption [2]. The media has emphasized ADHD as a serious behavioral disorder that must be controlled with medication. However, it has failed to inform the public that in fact there is very little known about ADHD aside from the very broad hyperactive behavior, which many argue is just a characteristic of childhood [10]. Therefore, rather than informing the public of the serious side effects of ADHD medications, which some doctors have compared to the effects of cocaine, the drug companies, physicians, and public health practitioners have increased the use of ADHD medication by 369% in the past three years [9]. In the case of ADHD medication, rather than increasing awareness of the disease and promoting various modes of treatment, health professionals have increased drug use among American youth [12]. Rather than improving their quality of life, the use of ADHD medications has added a new dimension to their lives, which includes increased social isolation and cognitive toxicity [1]. Cognitive toxicity refers to the power of drugs to superficially create focus and increase simple analysis, while inhibiting more complex cognitive behavior and function [10]. Side effects such as these and the rapid increase of youth drug use are clear evidence that the alternative model of advertising and marketing, in the case of drug treatment awareness has failed, and rather than aiding American society it has opened the doors to a lucrative industry that is more interested in making money than helping the public [4].

The drug deregulations and the obvious favoring that occurs on behalf of the drug companies by removing the educational component of advertising campaigns leaves people wondering if in fact the well being of society is the priority of the FDA. It is obvious however that what lies at the top of the priority list for the FDA includes the protection of profit for pharmaceutical companies.

Modern medicine and American society:

Culture has a lot to do with the effectiveness of the various advertising attempts made by the business sector. In essence, the media cannot succeed if they do not know the beliefs and customs of the target population. However, what is even more complicated is that these beliefs and sentiments are often established by the media themselves and just accepted and adopted by society [8]. This leads one to the conclusion: that in order to increase awareness and establish a desired pattern of behavior, the media is the right means by which to do this [3]. It is clear that health practitioners have already discovered this, and as a result of this also discovered the tremendous opportunity to make money at the expense of people’s trust and health.

Health practitioners constantly express their regard and concern for the health of Americans; however, if these are genuine then the question persists—why is America still sick? There is no doubt that America has a prescription drug problem. The United States spends twice as much money on drugs and intakes twice as many drugs than other countries and yet still continues to have worse health than other industrialized countries [5].

It is no accident that throughout time America has become obsessed with health and the infinite number of pills available to cure so-called diseases. The purpose here is not to discredit all medications, or to say that drugs do not ever successfully treat diseases. However, the fact of the matter is that the health field has lost perspective of their mission and become greedy. John Abramson, M.D. author of Overdosed America: The broken Promise of American Medicine explains that America is pouring money into expensive drugs and outrageous medical devices, and in the process has left behind the best type of preventive treatment, which includes diet modification and exercise [3]. In order to refocus and alter the current beliefs of society, there needs to be a massive media movement that will push America away from the medication frenzy that has driven this society to the overconsumption and long-term addiction to the various drugs created by the industry that claims to have the public’s interest in mind.

Implications for the public health field-

Public health practitioners have as their focus and goal to improve the physical, mental and social health of Americans. As a result of this, they have joined with the various groups on the medical field to increase awareness and health screenings across America. However, this cooperation with medical sectors such as pharmaceutical companies has proclaimed this mission of awareness and goals of better health and opportunities as a failure.

Detox for an Overmedicated America-

Health professionals have throughout time been given the responsibility of taking care of the welfare of the public. This trust has been given without any hesitation and with the full confidence that these well-intentioned and trained individuals possess the ability, moral and ethical obligation to improve the overall health of the public. However, it is clear that they have failed to reach their publicized goal of educating and increasing awareness of the most common diseases attacking the American public and the prescription drugs available for use. Instead they have created a multibillion-dollar industry that survives and flourishes rapidly at the expense of the American people’s trust and health. It is clear that the health professionals’ attempt at increasing awareness and educating the public regarding the various health threats attacking them have been a complete failure that has resulted in an overmedicated America that finds relief and comfort in the hands of pharmaceutical companies. Therefore, the means by which the field initiated intervention to increase awareness and education need to be reevaluated and reinvented so that the goal of helping the public can be refocused and accomplished. The reinvention of the initial efforts to increase awareness on medical screening and the threats common diseases pose upon people must include the cooperation of government agencies, the education department, health professionals and the media.

The initial step that needs to be taken in order to achieve the initial goal of increasing awareness and education regarding disease prevention involves the government of the United States of America. This government was founded with the idea that it is “a government by the people for the people.” This statement, however, does not seem to be supported any longer as government organizations such as the FDA, seem to love the profit being generated by direct-to-consumer advertising so much that they have made it even easier for the drug companies to advertise their products by not requiring that all side effects be listed during commercials and by being able to run direct ads through the television and printed news scripts [5]. Therefore, it is time that the FDA rearranges its priorities and puts the welfare of people at the top rather than pharmaceutical profits. It is crucial that limits are set for these companies and that rather than advertising a brand by invoking overall positive emotions, their true effects and ability to help individuals is advertised [12]. The introduction of a new set of advertising guidelines put forth by the FDA for pharmaceutical companies will then reverse the standing effect of simply selling drugs for profit to a more focused idea that involves helping the public understand the proper use of prescription drugs and their side effects and other potential risks.

The next step to the successful intervention on the use of prescription drugs and their potential side effects involves the full cooperation of health professionals at all levels. The problem of overmedicating in America is due to the notion that a pill can solve every symptom of discomfort. This erroneous belief needs to be fixed at its root and this can only be accomplished by encouraging all health professionals to start taking the time with their patients to explain alternative preventive methods, such as an increase in exercise and a change in diet, in order to prevent a large majority of these diseases such as hypertension and diabetes that are affecting the American public at alarming rates [4]. In addition, physicians need to be reminded that their number one priority is the well being of people and that as public servants they must first and foremost fulfill this duty. If these physicians do no fulfill their duty they are in fact violating their medical oath and ought to be reminded of their priority. However, it would be illogical to place the responsibility of changing existing social trends entirely on physicians. Therefore, public health practitioners must also reassess the techniques being used to alter existing destructive behaviors and societal beliefs. In order to accomplish a successful intervention, it is crucial that they work in cooperation with physicians and social workers in order to introduce this new way of thinking into mainstream America and to assure that it is accepted and implemented at all societal levels. Once health professionals at all levels have reached a consensus on the best and most efficient way to educate and implement alternatives methods of preventive medicine, they can then take a step forward in an attempt to reverse the negative effects that a media-drug-driven America have had on its members.

Once the missions of the FDA, health professionals and pharmaceutical companies have been reevaluated and focused, an effective intervention should work to target and teach educators the importance of a balanced diet and exercise. In addition, teachers should be asked to join the team and provided with the necessary and proper diagnostic and observational tools that can help them to accurately distinguish a child that is in fact suffering from a behavioral disorder from one that is just simply acting according to their age. Such important and convenient tools can drastically reduce the number of misdiagnosed ADHD cases, a disorder that has claimed millions of children as slaves of Ritalin [1]. This addition to the education department has the ability to reset the American standards of medical treatment and therefore raise a generation that is not drug dependent and that amidst this fast progressing society is able to find health by means of the traditional treatment of a healthy lifestyle, awareness, education and alternative methods of preventive medicine. Even though a new method of treatment and means of implementation can be designed and deemed appropriate and ethical, in the 21st century whatever intervention designed will not be successful if the most powerful form of introduction and acceptance of new ideas in this society is not brought aboard to cooperate and make this issue the utmost important matter affecting the nation currently

The problem of overmedicating in America already exists and abolishing this already accepted way of thinking is one of the hardest goals to accomplish. Regardless of how well teachers and doctors are trained to teach and advertise the importance of understanding the use of prescription drugs and alternative methods of preventive medicine, the bottom line is that America is a society of consumers that relies on the media to be told what is ok to do, what it is that one needs, and the various things one should purchase. It is because of this that the number one factor that could help save America from overdosing is ironically the same instrument that brought it to the alarming high consumption of drugs at which it stands today. In order to reverse the beliefs of this industrialized society in addition to the full cooperation of government, medical professionals and educators, the ultimate intervention to limit the use of unnecessary drugs in America and the development of preventable diseases can only be successful if the media places this issue at the top of its agenda. They, in addition, must award the time, framing and present it with a degree of urgency that deserves to be spoken about daily until the American public realizes that a change in lifestyle and their current medical treatment options need to be changed. Furthermore, the prioritization of this issue by the media should also teach Americans to seek other options other than the easy way out and attempt to treat their various symptoms at the root rather than superficially with the use of pharmaceutical medications.

After educating the different levels of professionals regarding the changes that must be made in order to bring the alarming use of drugs in America to a halt, an advertising plan needs to be created in order to change the awareness, knowledge, and attitude of consumers towards a specific change being discussed. These changes take place all throughout the buying, a decision-making pattern that results in a change of behavior and standard beliefs. The first step in this intervention would involve the introduction of awareness. Past interventions have shown that the simple introduction of the importance of exercise and a balanced diet is not successful due to their lack of understanding of the average American lifestyle, which is fast paced and constantly being bombarded by economic hardships. Therefore, it is imperative that this campaign works to show first the alarming effects of overmedicating and the detrimental effects it can have on any one person. Once the negative aspects and acknowledgement of the problem is introduced the intervention moves into the next stage of consideration. In order for consideration to occur a solution to this alarming problem must be introduced with careful consideration of the various social and environmental factors that are affecting Americans today. It is at this point that the intervention seeks to make a connection with the consumer. Highlighting the costs of the various unnecessary medications being consumed and the money that pharmaceutical companies are wasting on advertising rather than investing on research are truly affecting the American society and the world can help make this connection. This approach on the economic effect is sure to receive attention especially due to the economic hardships that America is confronting today. It is at this point that alternative “cheaper” methods of preventive medicine can be introduced and the name of health professionals advertised as large pools of information at the disposal of the public.

The third stage of this intervention involves reaffirmation. At this stage of the advertising campaign the public reassesses the product or idea being introduced and attempts to find a place for it in their lives thus determining how convenient and appropriate it is for them. It is at this point that the importance of paying a visit to their physician is important and that a change in lifestyle that is characterized by an increase in exercise and a balanced diet can be stressed. However, the stress placed on these changes should be made in a different manner than in the past. They should be marketed with alternatives methods such as the addition of easy enjoyable exercises that can be done at home or outside or even ones that can be integrated during the workday. In an effort to obtain and retain a large audience these changes that need to be made must be attached with the idea that consumers will be saving money when opting for this option rather than spending thousands of dollars on unnecessary medications. This approach will certainly catch the attention of consumers during this time of recession.

The last couple of stages of this intervention all happen quite quickly as action tends to take place once the behavior is introduced enough times into the life of the individuals targeted. This is then reinforced by the constant repetition of the issue and its recommended solutions by the media who use the trusted physicians and other health care professionals in order to submit the desired behavior as a social standard and therefore into mainstream culture [12].

In conclusion the intervention used in order to assess the overmedicating problem in America needs to start with the cooperation from all levels of the health sector in this country. Once this cooperation has been reached, an advertising campaign displaying the negative effects of overmedicating and the various affordable solutions available to avoid future spending due to unnecessary problems can be used to grab the attention of an America that is overwhelmingly concerned with the ongoing recession.

References:

1-Are Children being given too many Drugs? Norwich Evening News 24, August 2006.

2-Bergin, Sue 2005. Stoning Young America: Over Prescribing Harmful Stimulants as a Treatment for Children with ADHD. Brigham Young University.

3-Bremner, Douglas J. 2006. Why do Americans take so many Prescription Drugs? Prescription drugs Review.

4-Healy, Melissa 2007. The Push to label many drugs isn’t well studied in children Revise standards, critics say. Los Angeles Times, Health.

5- Jensen, Peter S. MD; Kettle, Lori BS; R, Margeret T. MS; Sloan, Michael T. BA; Dulcan, Mina K. MD; Hoven, Cristina Dr PH; Bird, Hector. MD; Bauermeister, Jose J. PhD; Payne, Jennifer D, 1999. Are Stimulants Overprescribed? Treatment of ADHD in Four U.S. Communities. Child and Adolescent Psychiatry.

6-National Center for Health Statistics and Centers for Disease Control and Prevention. Health, United States, 2007. Department of Health and Human Services.

7-Null, Gary, PhD; Dean, Carolyn MD, ND; and Feldman, Martin, MD. 2006. Overmedication Seniors. LE Magazine.

8-Overmedicating of America. CBS News, Health. 2000.

9-Rados, Carol. 2004. Truth in Advertising: Rx Drug Ads Come of Age. FDA Consumer Magazine.

10-Rowland, Rhonda 2001. Ritalin Debate: Are we Over-medicating? CNN Health, CNN Medical Unit.

11-Salaman, Maureen Kennedy 2006. The Medicating of America. National Health Federation News.

12- Sighn, Llina, 2004. Doing their jobs: mothering with Ritalin in a culture of mother-blame. Faculty of Social and Political Sciences, Center for Family Research, University of Cambridge, Cambridge, UK.

13-Standish, Maude, 2008. Too many drugs? American Academy of Pediatrics News. Vol. 29 No. 9, p. 28.

14-Too many Drugs “Not Child Tested.” BBC News, Health. 2006.

MetroWest's Fat Chance at Fighting Childhood Obesity- Maithili Davada

2008-12-18T11:22:00.000-08:00

Introduction

Due to economic inequalities many people around the world suffer from starvation and malnutrition; meanwhile many others suffer from obesity and the health and social problems associated with it.(1) Obesity is an issue that concerns not only adults but children, too.(1) Childhood overweight and obesity are issues of growing concern in the United States. According to a survey conducted by the National Health and Nutrition Examination Survey (NHANES), in 2003-04, 17 percent of children and adolescents ages 2-19 years were overweight. (2,3)

The MetroWest Kids campaign, launched by the MetroWest Community Health Care Foundation, aims at decreasing the prevalence of childhood obesity. The campaign includes local billboards, print advertising, a website (metrowestkids.org) that tries to provide useful tips for parents, kids and schools.

However, firstly, the campaign not only fails to inspire self-efficacy and provide positive reinforcement, but also ends up traumatizing the kids and assigning stigma to obesity. Secondly, the suggestions made on the website fall into the most common fallacy of using only individual level factors, and they do not play on group dynamics and they lack practicality, also, some of the suggestions are unsafe. Finally, the intervention also does nothing to address important environmental factors like availability and affordability.

“Fat Chance!” Fat chance of losing weight?

Bandura’s Social Cognitive Theory states any change in human behavior is influenced by: environmental, social and individual factors. Self-efficacy is one of the individual level factors explained in the theory. Self-efficacy is an individual’s confidence, faith, belief in their ability to successfully complete any behavior. Reinforcement is one of the environmental factors. Reinforcements may be in the form of positive or negative response to their behavior.(7,9)

Their billboard says “fat chance” and shows the chubby feet of an overweight child standing on a scale. Unfortunately, it conveys a message of doom and gloom and hopelessness as opposed to inspiring hope and determination to fight the battle against childhood obesity. According to Catharine Curran-Kelly, an assistant professor of marketing at the University of Massachusetts at Dartmouth, the billboards instill fear in people who do not have the problem, and parents whose kids are obese tend to argue against it.(4) The parents’ response may be one of righteous indignation.

Not only are these billboards nonproductive, they may also be counter-productive. “They traumatize the very children they're trying to help," said Peggy Howell, a spokeswoman for the California-based National Association to Advance Fat Acceptance, a group that works for social acceptance of overweight people. According to her, the image on the billboard results in further bullying of obese kids by their peers, and provides reinforcement of this kind of negative behavior.(5) Competition, teasing and bullying are major barriers for students to be physically active during physical education class, on sports teams, and before and after school activities. (6) Thus the billboard not only causes internal and emotional trauma to the kids, but it also results in them being bullied, which results in harming self-efficacy. This is especially the case when it comes to obese children, resulting in them not participating in the above activities and leading a sedentary life resulting in further weight gain. Being bullied and teased results in negative reinforcement and hence lack of participation of obese kids in these activities. That reinforcement plays a major role in bringing about behavior modification is well-explained by Bandura’s Social Cognitive Theory (SCT). (7,9) Thus, the billboard not only results in negative reinforcement of healthy behavior in obese children, it also adds to the problem by causing positive reinforcement to bullying and as a result traumatization of these kids by their peers, which also negatively affects their sence of ‘self’, self-worth and self-efficacy.

That stigma negatively affects the self-esteem of individuals which also affects their self-efficacy is supported by several theories, which include social comparison theory (8,10), and social identity theory.(8,11) Even though the billboards are aimed at parents of obese children, the children themselves see them, too. The billboards assign stigma towards obesity resulting in harm to self-esteem of these children. This in turn has a negative effect on self-efficacy which, according to the social cognitive theory, is an important factor in enabling positive behavior change. (7,9) Dr. Gordon Cochrane, a registered psychologist, supports this idea. He presents the idea that an enhanced sense of self worth and self-efficacy give a person enough faith in themselves to follow healthy behavior and achieve an ideal weight and as a result overcome obesity. (12) Thus, by stigmatizing obesity, not only does the intervention fail to encourage and promote self-efficacy; in fact, it negatively affects the self-esteem and self worth of these children and as a result negatively affects their self-efficacy.

Are some of the options really safe or feasible?

Social norms and the social network, that an individual belongs to, play a major role in affecting behavior change. This idea is supported by the Social Expectations Theory and the Social Network Theory, respectively.(7,13,14) The intervention does not address these factors and focuses only on individual activities.

The MetroWest Kids website lists a few suggestions to help increase activity levels of kids. Some of the activities that the website suggests are not practical or safe and none of them take into account the effect of social norms, group dynamics and herd mentality. Although the website itself has a lot of useful information, sitting in front of the computer and reading information does not get kids to indulge in any physical activity. Also, the activities listed on the website are all solitary, so even if kids do follow them, they might eventually get bored of those activities and fall back into their old sedentary lifestyle. Furthermore, these activities do nothing to change the social norms, which according to the social expectation theory are an important factor affecting behavior change.(7,13) According to the social network theory, behavior change occurs and is maintained in groups(7,14), and none of the activities mentioned on the website are group activities.

One of the activities mentioned is going for a walk, but kids are in school all day and by the time they get back home and eat, it is already dark outside and if they live in an unsafe neighborhood, they cannot possibly go out. Some of the other activities suggested include rearranging the furniture, crawling under the table, setting up an obstacle course in the house, etc. These activities are not only disruptive to the parents but may also result in the kids hurting themselves. Another suggestion was to get off the bus a few stops before the destination which could prove to be dangerous in a high crime neighborhood; it also may lead to vehicular accidents if the kids are not cautious enough while crossing the road.

The intervention fails to bring about a change in the social norms, or target groups and social networks and does not take into account group dynamics and herd mentality. Behavior of most kids and adolescents today is influenced by the very factors that the intervention fails to address, according to the social expectations theory(7,13) and the social network theory(7,14) respectively.

What is MetroWest Kids doing to help with the real issues of environment, availability and affordability?

Additionally, the intervention does nothing about the environment and practical roadblocks such as lack of availability and affordability of healthy food and/or safe as well as affordable places to do physical activities like riding bikes or walking. The locations for parks and recreational areas provided on the website are few and far away from most places like Boston, Dorchester, Roxbury, Quincy etc. For most people these might be the only places where they can go for physical activities due to constraints such as living in an unsafe neighborhood or inability to afford the high membership fees for gyms, especially in these difficult economic times.

Also, processed and fast foods are cheaper and more easily available than healthy foods. Wherever we go, we are surrounded by vending machines and franchises like Dunkin Donuts, McDonald’s, Wendy’s, etc., which provide cheaper and tastier alternatives to the expensive salads. Also, most salads available at these places contain cheese or some kind of creamy dressing. According to the SCT another major factor affecting individual behavior is the environment surrounding them.(7,9) Additionally, the low-socioeconomic areas have fewer and costlier grocery stores compared to the high socio-economic areas and suburbs where most of the relatively cheaper chain stores are located. The intervention fails to take any measures that address these problems.(15)

According to a study, conducted in 2000, the quality of the food served, easy access to non nutritious snacks, limited time for lunch period are the major factors affecting the food choices made by high school kids. Many of the students and staff members complained that the cafeteria food was too greasy. Moreover, they felt that presence of snack carts and vending machines influenced students’ food choices. It was noted by many of the staff members that students are less likely to select nutritious foods for lunch in the presence of these other attractive non nutritious options in their environment.(6) One of the students made a very interesting statement which emphasizes the role that the environment surrounding an individual plays in their decisions. She said, "How Can We Stay Healthy when you’re Throwing All of this in Front of Us?" with reference to the food choices available at their high school.(6) Although high school cafeterias have begun to offer some healthier foods, many continue to sell sodas and fries. If you were an average American teenager, given a choice between fries or salad and soda or milk, what would you choose? Besides, the intervention does nothing to provide positive reinforcement to consume healthy foods, which according to SCT is an important aspect in enabling positive health behavior change. (7,9)

Introduction

Childhood obesity is a serious issue and requires a multilevel intervention that targets the environment of the kids on the whole, including their home, school and social environment. It should provide them with the confidence, self-efficacy and positive reinforcement required to enable them to make the necessary lifestyle modification in order to combat obesity.(7,9) According to The Social Expectation Theory(SET), behavior change occurs in groups and an individual’s behavior is largely dependent on the social norms that dictate the social environment.(7,13) It is important to understand that intention may not lead to behavior changes unless individuals also have a positive environment and access to healthy and affordable food and a safe place to exercise.

Intervention

Most of the requirements needed to fight the battle against childhood obesity can be met by schools. Schools can provide a safe environment for the kids to stay active in by arranging non-competitive after-school activities like aerobics, yoga, dance, and martial arts. They should make it mandatory for every student to be enrolled in at least one of these activities, regardless of whether or not they are obese so as to avoid stigma to obesity. To make sure that the obese kids do not get teased or bullied, they should start with the basics and go at a pace everyone can keep up with.

Schools could organize discussion sessions for parents and kids together, as well as just for kids, where they can promote self efficacy and provide positive reinforcement for these kids. Another purpose of these meetings would be to encourage parents to bond among themselves and exchange ideas on how to support their kids and provide their kids with appealing healthy food at home. In addition, the school can organize a monthly talk given by a formerly obese, now well balanced and successful peer or role model followed by an interactive discussion session. The school should encourage the students to host a social event that serves only healthy food and has fun activities, at the end of each semester. Instead of vending machines with junk food and sodas, they could have, carrot sticks, cherry tomatoes, apples, grapes, bananas and juices at an affordable price. School cafeterias and social events should have healthy food, too.

The intervention that I propose is based mainly on Bandura’s SCT and also derives support from the Social Expectation Theory and some published articles.

Self-efficacy and positive reinforcement

The above intervention promotes self-efficacy and provides positive reinforcement, which are key factors affecting behavior change in an individual according to Bandura’s Social Cognitive Theory.(7,9)

The after-school activities promote self-efficacy by showing the students that they are capable of doing these activities despite obesity. Also, being able to successfully learn these activities enhances their sense of ‘self’. On the other hand, competitiveness negatively affects physical activity.(16) Thus it is essential to keep the activities non-competitive to avoid bullying and make the activities non-stressful and fun. The monthly talks are aimed at promoting self-efficacy and providing positive reinforcement using modeling (behavior of others) and vicarious learning (consequences of others’ behavior), as suggested by SCT.(7,9)

The end of the semester social also raises self-efficacy by giving students the confidence that comes from successfully organizing the event, and it makes them aware of their behavioral capabilities, which is one of the individual-level factors influencing behavior change according to the SCT.(7,9)That self-efficacy is an important factor affecting behavior change is supported by Dr Gordon Cochrane, a registered psychologist. (12)

The weekly parent meetings educate parents on how to support their kids emotionally and help them build confidence, self efficacy and provide positive reinforcement, which are key factors influencing behavior change according to SCT.(7,9)

Safe environment and non-competitive group activities

Unlike the Metrowestkids campaign, which focused on individual-level activities and did not provide practical options for activities, this intervention provides a safe environment for the kids to come together and participate in non-competitive, fun activities and to host group discussions. The Metowestkids campaign suggested that the kids walk to school, which could be dangerous for them. For example, Bauer, Yang and Austin reported that various staff members of a school observed and were worried about incidents in which students were approached by strangers while walking to school. As a result, the administrators discouraged parents from letting their kids walk to school. They said the high density of car traffic further compromised the safety of these kids.(6,16) Since the activities suggested by the current intervention happen at school, after school, students are spared the risk and expenses of travelling and trying to find a safe place to carry out these activities.

According to the Social Expectation Theory, individual behavior is driven by each person’s desire to conform to social norms. (7,13) Norms may be established and/or changed over time. This process can occur in three ways: “top-down influences, including official edicts and role models; bottom-up influences in which local customs and practices coalesce into norms; and lateral influences in which established norms from one type of interaction are transferred to related types of interactions.”(17) All the kids are required to participate in these activities, and physical activities are promoted by the role-models during the monthly discussion sessions (top-down influence), and it is an established norm that rules are followed (lateral influence). Additionally, some kids might be interested in these activities and will encourage their friends also to get involved in all these activities (bottoms-up influence). Hence, it is only a matter of time before being active becomes a social norm.

Adressing availability and affordability

The most important roadblock in fighting the battle against obesity is the lack of availability and affordability of healthy food and a safe place for physical activities. Also, the presence of unhealthy temptations all around us prevents us from making healthy choices easily and quickly. (6,16) This is especially the case for kids who are less aware of the serious consequences of these choices.

Replacing the unhealthy options in school vending machines with healthier affordable options takes away the temptation and increases the availability of healthy food. A study published by the Society of Public Health Education quoted some students as saying that “if the cafeteria offered fruits and vegetables in greater quantity and quality, they would choose to eat them instead of the less nutritious entrees or snack foods”(6). Providing healthy choices at school ensures that students have at least one healthy meal a day, regardless of what is available at their individual homes. Additionally, the weekly meetings for parents are aimed at encouraging healthy food choices at home and educating parents on what is healthy. Having kids present at these meetings could give them a chance to express their opinion in these matters too, and help them communicate their suggestions and choices.

The after school activities also provide a safe non-expensive place and environment for the kids to stay active and bond and explore options that would otherwise not be available or affordable, like yoga and aerobics. This is especially important in these difficult economic times.

Conclusion

The suggested intervention is based partly on the SCT and SET, and provides a feasible way to combat childhood obesity. The habits we develop during the formative childhood years last us a long time. If we make sure that this generation of kids develops healthy habits at an early stage and incorporates these habits of eating healthy and staying active into the social norms, we are on our way to winning the battle against obesity.

Conclusion:

The MetroWest Kids Campaign, like most other Public health campaign fails to rise above the individual level factors influencing behavior. Even while addressing only individual level factors they fail to address important individual level factors like self-efficacy and positive reinforcement. They do not take into account that an individual is affected by, the social norms and the environment surrounding them. It does nothing to increase the availability of healthy food. It also fails to address the issue of affordability, of both healthy food and a safe place to exercise, especially in these difficult economic times.

References:

1. Nestle Marion. The Ironic Politics of Obesity. Science; 2/7/2003, Vol. 299 Issue 5608, p781.

2. CDC’s National Centre for Health Statistics. Prevalence of Overweight among Children and Adolescents: United States, 2003-2004.

http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm

3. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 295:1549-1555. 2006.

4. Manuse Andrew J. Obesity billboard idea yanked. The MetroWest Daily News. Posted Jan 31, 2007 at 12:38 AM. Last update Jan 31, 2007 at 04:47 PM

http://www.metrowestdailynews.com/homepage/8998967371255250943

5. Reuell Peter. MetroWest 'fat' ads attract the ire of national obesity tolerance outfit. The MetroWest Daily News. Posted Feb 13, 2007 at 11:23 PM. Last update Feb 14, 2007 at 11:48 AM.

6. Bauer Katherine W., Yang Wendy Y. and Austin Bryn S. "How Can We Stay Healthy when you’re Throwing All of this in Front of Us?" Findings from Focus Groups and Interviews in Middle Schools on Environmental Influences on Nutrition and Physical Activity. Health Education and Behavior. 2004; 31; 34.

7. Edberg M. Essentials of health behavior:Social and behavioral theories in public health. Sudbury, Ma : Jones and Bartlett Publishers.

8. Crocker Jennifer and Major Brenda, Social Stigma and Self-Esteem: The Self-Protective Properties of Stigma. Psychological Review, Vol 96(4), Oct 1989. pp. 608-630

9. Bandura A. Social Foundation of Thoughts and Action. Englewood Cliffs, NJ: Prentice Hall; 1986.

10. Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7,71-82.

11. Tajfel, H., & Turner, J. C. (1986). The social identity theory of intergroup behavior. In W, Austin & S. Worchel (Eds,), The social psychology of intergroup relations (pp. 7-24). Monterey, CA: Brooks/Cole.

12. Cochrane Gordon. Role for a sense of self-worth in weight-loss treatments: Helping patients develop self-efficacy. College of Family Physicians of Canada. Can Fam Physician. 2008 April; 54(4): 543–547.

13. Hornick, Robert. Alternative Models of Behavior Change. Annenburg School for Communication, Working Paper 131, 1990, p 5/6

14. Barnes JA. Class and communities in a Norwegian island parish. Human Relations. 1954;7:39-58.

15. Chung C., Myers, S. Do the poor pay more for food? An analysis of grocery store availability and food price disparities. The Journal Of Consumer Affairs.(1999)Pg 276.

16. Olga López de Dicastillo. Promotion of physical activity and healthy food quality food, easy access to non-nutritious food, and choices was hampered by competitiveness, lack of time constraints. Evid. Based Nurs. 2004;7;123

http://journals.bmj.com/cgi/reprintform

17. Edited by Durlauf Steven N., Blume Lawrence E. New Palgrave Dictionary of Economics, Second Edition.

Shifting the Paradigm to No Where: How the American College Health Association Failed Primary Prevention – Erin Williston

2008-12-18T11:20:00.000-08:00

United States college students are increasingly threatened with violence on campus. One of the most pervasive forms of violence happens in a place students rarely anticipate. National studies have consistently found approximately 32% of college students experience domestic/ relationship violence (1). The overwhelming prevalence of violence against women on college campuses is well documented nationally. Women ages 16-24 are at the highest risk for rape and other forms of intimate partner violence (2). While the statistics are omnipresent, higher education has neglected to set their sights higher than simply responding to incidents of violence, a form of public health called tertiary prevention.

In April 2007, the American College Health Association stepped out with their, “Position Statement on Preventing Sexual Violence on College and University Campuses”. What followed was a document with a mission to “provide facts, ideas, strategies, conversation starters and resources to everyone on campus who cares about prevention of sexual violence” – the ACHA toolkit, Shifting the Paradigm: Primary Prevention of Sexual Violence. Primary prevention is a public health approach using environmental and system-level strategies, policies, and actions that prevent sexual violence from initially occurring. The problem with Shifting the Paradigm surrounds not its idea to use primary prevention to address the issue – but in the theories and interventions it encourages its audience to use. The interventions presented are deficient, archaic, and fail to speak the language of higher education as an organization.

Promoting a Deficient Tool – Opening Pandora’s Box

Shifting the Paradigm authors encourage screening for sexual violence in college health and wellness services. This tool could help identify survivors of sexual assault, provide client centered services in the health care setting and encourage reporting. While screening is widely debated and mildly supported in medical-based literature, it is not primary prevention (11).

What is most interesting in this proposed intervention is the missing critical piece. There is no mention on training medical care providers to ask the questions proposed in this intervention! There isn’t even an analysis of student health centers and their ability to train and implement an effective screening tool. The classic study Opening Pandora’s Box helps explain why it is vital to deliver training to providers who will implement these screening tools.

An analysis of interviews with physicians found exploring domestic violence in the clinical setting analogous to "opening Pandora's box." Their issues included lack of comfort, fear of offending, powerlessness, loss of control, and time constraints. This study revealed several barriers that physicians perceived as preventing them from comfortably intervening with domestic violence victims. These issues need to be addressed in training programs (3).

Student health centers are not equipped to respond to the answers these questions will bring. Questions such as:

“Has someone ever touched you in a sexual manner against your will or without your consent?”
“Have you ever recognized you had ‘unwanted’ sex while drunk or using drugs?”
“Do you feel that you have control over your sexual relationships and your partner will respect your wishes if you say no to specific sexual activities?”

These questions don’t fit in to the 15 minute appointment providers have with students in a clinical setting; especially if the training or programs to support these questions doesn’t exist (3). Shifting the Paradigm misses the mark by calling this primary prevention and proposing it without mention of proper training for providers.

Revisiting Individual Models

Shifting the Paradigm makes several attempts to provide tangible primary prevention exercises for college health educators to use with their students. One of the first interventions is “[to] facilitate conversations about sex that focus on individual choices along the continuum of sexual activity… [to] identify and popularize healthy sexuality that respects gender, sexual orientation, and gender identity.” Another intervention encourages educators to distribute “10 ways young men can prevent sexual violence” to fraternities and other male dominated organizations on campus.

These are both classic examples of the Health Belief Model – an individualized public health model that assumes no social interaction, and demands rational behavior (4-5). This model and proposed intervention fails to understand one important issue in human behavior: people are not rational; they do not make decisions in silos and are easily influenced by unconscious factors.

Dan Ariely helps make this clear in his book Predictably Irrational: The Hidden Forces That Shape Our Decisions. Dr. Ariely conducted a study with Berkeley undergraduate students who underwent a variety of sessions in different orders answering questions about sexual and moral decisions. In one session students predicted their sexual and moral decisions while in a cold, dispassionate state. In another, they did the same but while in a hot, aroused state.

“In every case, our bright young participants answered the questions very differently when they were aroused from when they were in a ‘cold’ state….when participants were aroused they predicted that their desire to engage in a variety of somewhat odd sexual activities would be nearly twice as high as they had predicted when they were ‘cold’.” (6)

The results go on to demonstrate how in a cold, rational state, the men involved in this study respected women. They thought they understood themselves, their preferences and what actions they were capable of. These men, like many young college students, underestimated their reactions to arousal and the outside environment. It does not make these participants social deviants; it proves that human behavior is irrational.

This study is critical to understanding that college students do not make decisions in a vacuum; they are highly influenced in their vulnerable state of transition from high school to higher education. While Shifting the Paradigm encourages discussion about respecting gender and being aware of pop-cultures messages, the reality is college students are having good, bad and ugly sex without the influence of these conversations in the bedroom.

Could We Get a Little Buy In?

Contributing authors to Shifting the Paradigm express their hopes for primary prevention in the preface: “[primary prevention] must reach the same level of efficacy and adoptions as programs that respond to its consequences.”

Shifting the Paradigm authors makes 2 assumptions with this statement: 1. it assumes the reader is on a campus that is effectively responding to consequences of violence and 2. The reader understands the levels of public health prevention and the concept of moving upstream. These are erroneous assumptions considering many campuses are failing to make the basic responses to victimization work on campus. According to a 2005 National Institute of Justice report, of the nations institutions of higher education less than half listed a contact phone number for students who have been sexually assaulted that was accessible after “normal” business hours – when most assaults happen (7).

This demonstrates the lack of understanding Shifting the Paradigm authors have in regard to higher education organizations. If the authors had followed organizational development theory, they would have understood that one of the keys to mobilizing an organization is to know your community priorities. For example, by pairing a health issue with other priority issues you can maximize the potential for community action (8).

Shifting the Paradigm fails to speak the language of higher education and answer the questions critical to administrators in the organization. Administrators hold the keys to what college health professionals need – support from the institution: both financially and politically. Why should higher education administration care about sexual violence? How does it impact the organization and the students we serve? How much money will it save us if we invest in these programs? College health educators need to make the connection between health and academic success in order to speak the language of our stakeholders (9). Without this connection, administrators will fail to see the value in sexual violence prevention.

Moving Past Shifting the Paradigm

The authors and consultants for the ACHA toolkit neglected to produce a sound document for their intended audience. They sent out a grab bag of deficient, archaic and inconsistent tools for overburdened campus professionals to toss out at the end of the day. It is unfortunate that this opportunity to speak to higher education about primary prevention was wasted with the promotion of such tools as “discussion starters” and “screening interventions”. The lack of outcry from ACHA members isn’t surprising; many of them lost value in the document before reading it. In an effort to move forward and adopt a primary prevention approach to sexual violence, new theories must be brought to the table.

Smedley and Syme explain in their article Promoting Health: Intervention Strategies from Social and Behavioral Research, “It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural and physical environment conspire against such change.” Smedley and Syme, along with many others in this field support the need for a social and behavioral approach to violence prevention (6,12-18). Shifting the Paradigm could benefit from considering two specific social science theories: Organizational Development (OD) and Fostering Healthy Norms (Norming) (8, 16-18, 20-21,). The finale of this post will provide empirical data and examples in support of using OD and Norming to address primary prevention of sexual violence on a college campus. It is vital to know these methods lend themselves concurrently however; creating an environment open to change from the top down should be the first step.

Stimulating Change

Community mobilization around a specific issue can be challenging. It requires much from the agent of change in order to move an organization toward a new behavior (16). ACHA members fit into the role of ‘agent of change’ and learning to speak the same language is a gateway to common ground. ACHA members would benefit by cultivating relationships with professional leaders on campus; one great approach is to appeal to the individual’s self-interest, showing how their participation in your cause can aid in achieving their own goals and objectives (23). Utilizing OD theory to foster shared goals and motivation among members of the institution will aid in the change process (16-18). Organizational Development theory encourages community and organizational change while taking into account the culture, organizational climate and capacity (16). Systematizing an institutional change utilizing the culture, climate and capacity is critical to avoid simply replicating what other schools do without evidence of an effective intervention.

To mobilize an institution to address sexual violence through primary prevention, three key issues should be addressed (17).

Define the community: Develop an understanding of the chain of command within the institution. Set up individual interviews with key players and learn who the movers and shakers behind decisions made on campus might be.
Assess and work with the community’s capacity for mobilization: Are their experienced professionals on campus who are researching or addressing sexual violence currently? What is the history of task forces or committees to address sexual violence appointed by upper administration? Look for current action within the institution and work with those players to assess the ability to move upstream in addressing sexual violence.
Understand the community agenda and select the right issue: ACHA members should look at the mission of the institution and assess how sexual violence might impact that mission. This could be done by reviewing national and local data regarding sexual violence. Sources may include the ACHA National College Health Assessment, Jeanne Clery Act Reports, local police and prosecutor’s office data and qualitative data from local organizations that work in the area of sexual violence. The impact sexual violence has on matriculation, retention, and graduation could be a critical piece of information for upper administration. Successfully selling primary prevention of sexual violence can be achieved if you pair the institution’s goals and objectives with your topic area goals and objectives.

Fostering Healthy Norms

There are 5 damaging norms that impact attitudes and beliefs about sexual violence (12). These norms are:

1. Women: limited roles for and objectification and oppression of women

2. Power: value placed on claiming and maintaining power (manifested in power over)

3. Violence: tolerance of aggression and attribution of blame to victims

4. Masculinity: traditional constructs of manhood, including domination, control and risk-taking

5. Privacy: notions of individual and family privacy that foster secrecy and silence.

ACHA members can address these norms by strategically promoting normalizing messages about positive female roles, egalitarian relationships, men standing up to aggression, downplaying negative risk-taking, and engaging citizens. The social norms approach provides tools for increasing perceived support to take action to address health and violence behaviors (20). The key is to create and sustain healthy norms within the institution and surrounding community (12).

We know that one of the critical places students’ receive and trust messages is from health care providers (26). A mandatory training with continuing education credit for all health care professionals on campus (in the student health center and otherwise) could help foster norms at an individual level. This curriculum would consist of trust building, using positive sexuality language and sharing healthy relationship guidance in a clinical setting (12-13). Providers would be expected to use the tools learned in this curriculum with patients to build trust and promote the health center as a safe, positive place to receive information and services. In order to implement this type of care, health care providers will need more time with patients. A critical role for ACHA members will be advocating for longer visits with providers and promoting efficiency in scheduling visits (3, 12).

The second component to this ‘Fostering Healthy Norms’ approach is to develop a marketing campaign that is interactive and promotes positive environmental change. Studies suggest that the social norms approach to sexual assault prevention is a promising practice that is worthy of further attention and research to determine its effectiveness (20). For example, at James Madison University a campaign designed to change men’s intimate behavior towards women was implemented. Data demonstrated significant increase in the percentage of men who indicated “stop the first time a date says no to sexual activity” and a significant decrease in the percentage of men who said “when I want to touch someone sexually, I try and see how they react.” (20). Other campaigns have demonstrated similar findings, making social norms marketing campaigns a promising practice in prevention of sexual violence.

No Substitute for Planning

The American College Health Association’s toolkit, Shifting the Paradigm: Primary Prevention of Sexual Violence would be a greater resource if the role of health and its impact in higher education was all ready established. However, without this critical collaboration, no campus is ready to implement tools that have not been grounded in research. The interventions fail to speak the language of higher education as an organization or foster change in the current climate.

In an effort to design a replicable toolkit, ACHA would have done well to offer planning and evaluation tools for primary prevention of sexual violence on college campuses. Saltz and DeJong’s comment in ‘In Reducing Alcohol Problems on Campus: A Guide to Planning and Evaluation’, “Simply replicating what other schools are doing is not a substitute for sound planning.” Utilizing Organizational Development theory to stimulate change from the top down, followed by a comprehensive implementation of Fostering Healthy Norms allows flexibility to accommodate the institution’s individuality and take research to practice.

References

Feminist Majority Foundation. Violence Against Women on College Campuses. 2005

Gross A.M., Winslett A., Roberts M., and Gohm C.L. An Examination of Sexual Violence Against College Women. Violence Against Women 2006; 12(3): 288.
Sugg NK, Inui T. Primary care physicians' response to domestic violence. Opening Pandora's Box. JAMA 1992; 267(23):3157-60.
Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr 1974; 2: Entire issue.

Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q 1984; 11(1): 1-47

Ariely, D. The Influence of Arousal (pp. 89-108). In: Ariely, D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. Harper Collins 2008

Kariane H.M., Fisher B. S., Cullen F. T. Sexual Assault on Campus: What Colleges and Universities Are Doing About It, U.S. Department of Justice Office of Justice Programs, December 2005, National Institute of Justice www.ojp.usdoj.gov/nij

Cummings, Worley. Organization Development and Change, 6^th ed. Boston, MA: South-Western; 1997

McNeil M., Grizzel J. Linking Student Health with Academic Success: American College Health Association Annual Meeting 2006.

American College Health Association. Shifting the Paradigm: Primary Prevention of Sexual Violence. www.acha.org/SexualViolence August 2008

PREVENT Program at University of North Carolina Injury Prevention Research Center. Prevent Provider Toolkit Module 1. January 2007

Davis R., Fujie-Parks L., Cohen L. Sexual Violence and the Spectrum of Prevention: Towards a Community Solution. National Sexual Violence Resource Center 2006.

Cohen L, Swift S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Inj Prev. 1999; 5:203-207.

Smedley BD, Syme SL, A social environmental approach to health and health interventions. In: Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C. National Academy Press 2000:4.

Banyard, V.L.; Plante, E.; and Moynihan, M. M. Bystander Education: Bringing a Broader Community Perspective to Sexual Violence Prevention. Journal of Community Psychology 2004 32: 61-79.

Steckler A., Goodman RM, Kogler MC. Mobilizing organizations for health enhancement: theories of organizational change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Research and Practice, 3^rd ed. San Francisco, CA: Jossey-Bass; 2002.

Freire P. Pedagogy of the Oppressed. New York: Seabury Press; 1970.
Wendell L French; Cecil Bell (1973). Organization development: behavioral science interventions for organization improvement. Englewood Cliffs, N.J.: Prentice-Hall. chapter 8.
Berkowitz, A. Fostering Healthy Norms to Prevent Violence and Abuse: The Social Norms Approach. Preventing Sexual Violence and Exploitation: A Sourcebook. Wood and Barnes Publishers, 2007.

Berkowitz, A.; Jaffe, P.; Peacock, D.; Rosenbluth, B.; and Sousa, C. Young Men as Allies in Preventing Violence and Abuse: Building Effective Partnerships with Schools. San Francisco: The Family Violence Prevention Fund, undated. http://new.vawnet.org/Assoc_Files_VAWnet/YoungMenAllies.pdf

Morrison, S.; Hardison, J.; Anita Mathew, A.; and O’Neil, J. An Evidence-Based Review of Sexual Assault Preventive Intervention Programs. Research Triangle Park, N.C.: RTI International, 2004. http://www.ncjrs.gov/pdffiles1/nij/grants/207262.pdf

Langford L., DeJong W., Strategic Planning for Prevention Professionals on Campus, U.S. Department of Education, Office of Safe and Drug-Free Schools, Higher Education Center for Alcohol and Other Drug Abuse and Violence Prevention, Washington, D.C., 2008.

Bachar, K.J., and Koss, M.P. From Prevalence to Prevention: Closing the Gap Between What We Know About Rape and What We Do. In: Renzetti, C. M.; Bergen R. K.; and Edelson, J. L. eds Sourcebook on Violence Against Women, Thousand Oaks, Calif.: Sage Publications 2000.

Bartholomew, L.K.; Parcel, G.S.; Kok, G; and Gottlieb, N.H. Planning Health Promotion Programs: An Intervention Mapping Approach. 2^nd ed. San Francisco: Jossey-Bass, 2006.

American College Health Association. Publications and Reports. Baltimore, MD: American College Health Association. http://www.acha-ncha.org/pubs_rpts.html

Population Council. Yaari Dosti: A Training Manual. New Delhi, India. Population Council. , 2006.

Tactful Approach to Childhood Overweight and Obesity Prevention: Implementation of School-Based Programs- Samantha Roy

2008-12-18T10:04:00.000-08:00

Suggested Approach to Childhood Overweight and Obesity
A number of childhood obesity prevention programs, promoting healthy weight and lifestyle in children, have been enacted. However, recent statistical analysis on childhood overweight and obesity reveals an increasing trend, indicating the lack of a successful intervention and leaving public health practitioners ardent for a solution (11). One example of an ineffective initiative is the “Fat chance” billboard, endorsed by the MetroWest Community Health Care Foundation in Framingham, Massachusetts.
Firstly, the ad negatively labels and stigmatizes overweight and obese children. Society’s mockery and negative view of obesity exacerbate obese-related behaviors; children eternalize the stigma and adopt the label, augmenting the severe condition of childhood overweight and obesity. Secondly, it fails to consider group-level factors, which contextualize the fundamental factors of obesity. An emphasis on individual-level factors assumes that all individuals behave the same, which is highly inaccurate. Finally, it disregards the influence of social networks. The behavior of overweight and obese children may be greatly influenced by the behavior of their social networks, which may predominantly be obese. The billboard is daunting and humiliating; it hinders its target audience of overweight and obese children from modifying behavior to acquire a healthier lifestyle.
A more practical intervention involves the implementation of school-based programs that, when combined, successfully approach childhood overweight and obesity. Currently, more than 95% of children and adolescents are enrolled in school, demonstrating the potential success of a school-based intervention. According to the Continuing Survey of Food Intakes by Individuals (CSFII) 1994-1996, 1998, 31% of boys aged 6-11 years and 34% of girls aged 6-11 years meet the fat-intake guideline of the U.S. Dietary Guidelines (14). Such findings indicate that the majority of children aged 6-11 years have a fat-intake greater than 35% of total calories from fat (28). Establishing healthy behaviors, such as physical activity and eating habits, at a young age increases the likelihood of proper child growth and development, as well as the possibility that healthy behavior and habits continue in adulthood (12). Implementation of nutrition standards and education, physical activity requirements, and Body Mass Index (BMI) screenings in schools would expose children to nutritious foods and healthy behaviors, and it would inform parents of their child’s likelihood of obesity, a more tactful approach to preventing childhood overweight and obesity
Implementation of Nutrition Standards and Education in Schools
Nutrition standards and education in primary and secondary schools would give to every child the opportunity to develop an understanding of proper eating habits and conscious, healthy behavior. Although the overall upbringing of a child is the parents’ responsibility, schools can utilize the time in class and during lunch period to introduce children to healthy behaviors and foods, which may or may not be present or available at home.
School cafeteria foods should be regulated under the Dietary Guidelines of Americans, jointly published by the United States Department of Agriculture (USDA) and Department of Health and Human Services (HHS) (42). The Dietary Guidelines “provide science-based advice to promote health and to reduce risk for major chronic diseases through diet and physical activity,” (42). During early school hours, cafeterias should provide breakfast options that fulfill “one-fourth of the Recommended Dietary Allowance (RDA) for protein, calcium, iron, Vitamin A, Vitamin C, and calories;” actual food items for all meals are chosen by individual schools, but should include multi-grain/whole-grain breads and cereals, fresh fruit and eggs, non-fat or low-fat milk, and additive free juices (39). Lunch menus must also incorporate USDA guidelines and serve foods that provide one-third of the RDA, such as bread and grains, fresh fruits and vegetables, lean meats and poultry, non-fat or low-fat milk, and additive free juices (35). After school snacks, following USDA guidelines, may also be provided to children in after school programs or extracurricular activities. Most importantly, schools should adhere to appropriate serving sizes and keep prices affordable for all children.
In addition to standardized cafeteria foods, on-campus vending machines must also be regulated to sell healthier options. According to a report by the Government Accountability Office, 83% of elementary schools and 97% of middle schools sell foods out of vending machines, which is why vending machine regulations are in dire need (18). Instead of selling ice cream, candy bars, cookies, fruit cups with syrup, chips, and pop, school vending machines should sell frozen fruit juice bars (with no sugar or high fructose corn syrup), granola bars, peanut butter crackers, low-sodium soups, low-fat yogurts, rice cakes, and 100% fruit juices (40). Changing vending options in schools prevents children from purchasing the unhealthy foods that may contribute to overweight and obesity. Outside of school, children may encounter vending machines that do not follow healthy vending guidelines, established by the USDA; thus, it is ultimately the child’s decision to carryout conscious, healthy behaviors and to consume nutritious foods, which is why an emphasis on healthy foods and nutrition education is imperative.
Nutrition education informs children of the relationship between diet, physical activity, and health, which is necessary to realize at an early age (30). A course on nutrition is as important as the core subjects of reading, math, and science; what a child eats affects his/her health, growth, and ability to learn (33). Children should be taught age-appropriate nutrition concepts, varying from identifying healthy foods, understanding the food pyramid, discussing healthy behaviors, and reading nutritional labels, to identifying USDA guidelines and applying knowledge for a healthier lifestyle (43). Interactive lessons, puzzles, and games can make learning nutrition exciting for children. Classrooms should have fun, colorful posters, diagrams, and images conducive to learning the foods to eat and avoid, the types of physical activities that can be performed, and the benefits of a healthy lifestyle. Teachers should be trained in nutrition to ensure that accurate nutrition information is communicated to children and positive, healthy behaviors are encouraged.
Early involvement in nutrition education and exposure to nutritious foods can instill attitudes and behaviors in children that may continue in adulthood. Requiring nutrition standards and education in schools enables every child the opportunity to eat healthy, fresh foods and acquire healthy behaviors. Most importantly, this approach considers the group-level factor of institutional menus, an improvement from the “Fat chance” billboard, which focuses on individual-level factors. Nutrition standards in schools are a contextual variable; the foods served in schools may be a fundamental cause of childhood overweight and obesity. Wholesome foods and nutrition education should not be a privilege; every child should have the same advantage in accessing fresh foods and learning the role of diet and health in school.
Implementation of Physical Activity Requirements in Schools
Children should be required to participate in physical education and activity to establish an awareness and understanding of the association between healthy diet and exercise. The Office of the Surgeon General (OSG) recommends children to engage in 60 minutes of moderate activity most days of the week; currently, less than 25% of children get at least 30 minutes of any type of physical activity each day (39). Physical education standards, established by the National Association for Sport and Physical Education (NASPE), require that a physically educated individual: demonstrates motor skills, understands movement concepts, principles, and skills, participates in regular physical activity, exhibits responsible, respectful behavior, and “values physical activity for health, enjoyment, challenge, self-expression, and/or social interaction,” (29). Designating time in schools for physical education and activity can increase the rate of physical activity children obtain on a daily basis.
Recently, schools have reduced or eliminated physical education in response to budget concerns and pressures to improve academic test scores (1). Results from the 2006 School Health Policies and Programs Study indicate the need for elementary school improvements: 3.8% of schools offered daily physical education, which entails 150 minutes a week for 36 weeks (as recommended by NAESP), 74% of schools provided regularly scheduled recess, and about 50% of schools offered intramural or physical activity clubs (24). Physical activity requirements, including gym class, recess, and intramural sports, not only positively affect musculoskeletal and cardiovascular health and cholesterol and triglyceride levels, but also reduce anxiety and stress levels, increase self-esteem, and even lay the foundation for regular activity in adulthood (22). Interestingly, children that participate in physical activity show improvements in the classroom (1). A national study conducted in 2006 examined the relationship between physical activity and academic performance: those children who reported participation in physical activity were 20% more likely than their peers to earn an “A” in math or English (1). If children reveal better academic performance in schools with physical education and activity requirements, school systems must consider incorporating physical activity requirements into the school day.
It is crucial to create an environment that prevents negative labeling and the degradation of children. Teachers and school monitors must advocate against peer bullying to ensure that no mocking or humiliation of overweight and obese children occurs. Children should not feel threatened or insecure when participating in physical education or activity. Results, based on Canadian records from the 2001/2002 World Health Organization (WHO) Health Behavior in School-Aged Children Survey, reveal a strong and significant association between relational and overt victimization and overweight and obese children. In addition, some overweight and obese children were more likely to perpetrate bullying than their normal-weight peers (6). Children should not be exposed to negative criticisms at such a young age; bullying behaviors may “hinder the short- and long-term social and psychological development of overweight and obese youth,” (6).
The implementation of physical education and activity in schools is an improvement to the “Fat chance” billboard: children enrolled in schools are given the opportunity to fulfill the recommended physical activity requirements for an improved, healthy life. Regardless of the child’s socio-economic status (SES), school gymnasiums, playgrounds, and athletic fields can offer a safer location to participate in physical activity, which may not be the case for a child in a lower SES (4). Overall, schools must create a positive and supportive learning environment and incorporate academics and physical activity, an approach to reduce the rate of childhood overweight and obesity.

Implementation of BMI Screenings in Schools
Annual school-based BMI screenings would inform parents of their child’s risk for weight-related health problems and notify schools of the health status of its students. BMI is a relatively easy number to calculate from an individual’s height and weight; it is a reliable indicator of body fat and for risk of weight-related health conditions (12). Currently, 10 states have BMI report requirements in effect; some may be state required aggregate reports while others may be individual reports sent to parents (31). A study, which examined recent BMI trends for U.S. children and adolescents from 2003-2006, found that 11.3% of children and adolescents were at or above the 97th percentile, 16.3% were at or above the 95th percentile, and 31.9% were at or above the 85th percentile (9). A child is considered overweight with a BMI between the 85th to less than 95th percentile and obese with a BMI equal to or greater than the 95th percentile (12). With the current rate of childhood overweight and obesity, school-based BMI screening reports address the need for conscious, healthy behavior in children.
BMI reports are not intended to offend children or parents; the goals of BMI reports are to increase awareness of the severity of overweight and obese-related health problems and suggest appropriate, healthy solutions to live a healthier life. It is vital that school-based BMI reports provide parents “a clear and respectful explanation of the BMI results and appropriate follow-up actions” so that parents understand the purpose of BMI reports (22). Parents may not perceive their child as overweight or obese, so providing a clinically standardized children’s BMI scale assures parents of the accuracy of the report. Reports should be mailed to parents to prevent children from feeling stigmatized; most BMI reports are handed to children in class, which creates fear and embarrassment, a current complaint with BMI reports. BMI screenings are similar to additional screenings conducted in schools, such as hearing, vision, and speech tests, so it should not be correlated with an overweight or obese label or stigma (19).
School-based BMI screenings allow schools to gather a general consensus of the health of its student body and apply findings to improve nutrition and physical activity requirements. Every child receives a BMI screening, regardless of weight, so schools do not explicitly differentiate between students. School-based BMI screenings is a better approach to the “Fat chance” billboard: instead of solely informing a child and his/her parents that he/she is overweight or obese, BMI reports provide advice on how to improve health.
Conclusion
A more logical approach to preventing childhood overweight and obesity is the implementation of school-based programs. A successful intervention cannot rely on one single implementation; a multi-based approach is crucial. Nutrition education and standards in schools gives children enrolled in school the opportunity to learn healthy behaviors and to eat nutritious foods. Children from families in a lower SES may not be able to afford fresh foods, so making nutritious foods available in schools increases the likelihood of those children consuming healthy foods. Physical education and activity give children the opportunity to be active, self-expressive, and social, which enhance health and academic performance. Children may not live in a safe neighborhood with recreational parks nearby; providing children a safe location to play can encourage physical activity. Importantly, schools must advocate against peer-bullying so that negative labeling or stigmatization does not occur; peer-bullying victimizes overweight and obese children more than their normal-weight peers. Finally, school-based BMI screenings would inform parents of their child’s current weight-related health; it also would provide straightforward information and advice on BMI results and improving health.
Although parents are responsible for a child’s upbringing and likelihood of acquiring a healthy lifestyle, school systems can play a major role in preventing childhood overweight and obesity. Schools that adhere to this intervention would provide an environment where children can learn healthy attitudes and behaviors from their teachers and peers. It is important to emphasize health and nutrition at a young age so that healthy behaviors become habit in adulthood.

REFERENCES
1. Active Living Research. (2007). Active education: Physical education, physical activity and academic performance. [Electronic version.] Retrieved December 3, 2008, from http://www.activelivingresearch.org/alr/alr/files/Active_Ed.pdf
2. Adams, J. L., Escarce, J. J., Freedman, V. A., Kapur, K., Rogowski, J. A., & Wickstrom, S. L. (2004). Socioeconomic status and medical care expenditures in medicare and managed care. Retrieved November 16, 2008, from http://www.rand.org/pubs/working_papers/2005/RAND_WR216.pdf
3. Berenson, G. S., Dietz, W. H., Freedman, D. S., Mei, Z., & Srinivasan, S. R. (2007). Cardiovascular risk factors and excess adiposity among overweight children and adolescents: The bogalusa heart study. Journal of Pediatrics. 150(1).
4. Borsboom, G. J. J. M., Bosma, H., Dike van de Mheen, H., & Mackenbach, J. P. (2001). Neighborhood socioeconomic status and all-cause mortality. American Journal of Epidemiology, 153 (4). [Electronic version]. Retrieved November 18, 2008, from http://aje.oxfordjournals.org/cgi/content/full/153/4/363?maxtoshow=&HITS= 0&hits=&RESULTFORMAT=&fulltext=Neighborhood+socioeconomic+status+ nd+allcause+mortality&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT#S EC2
5. Bower, B. (2007). Weighting for friends: Obesity spreads in social networks. Science News, 172 (4).
6. Boyce, W. F., Craig, W. M., Janssen, I., & Pickett, W. (2004). Associations between overweight and obesity with bullying behaviors in school-aged children. Pediatrics, 113(5). [Electronic version.] Retrieved December 6, 2008, from http://pediatrics.aappublications.org/cgi/reprint/113/5/1187
7. Braet, C. & Decaluwe, V. (2003). Prevalence of binge-eating disorder in obese children and adolescents seeking weight-loss treatment. International Journal of Obesity, 27.
8. Cacioppo, J. T. (n.d.). Foundations in Social Neuroscience. Retrieved November 17, 2008, from http://books.google.com/books?hl=en&lr=&id=nQk5Pv9kfYC&oi=fnd&pg=PA1 095& q=socioeconomic+status&ots=rv8Y2PCcap&sig=tx7K-5wO8u- I33Su6ApXxPgW9Q8
9. Carroll, M. D., Flegal, K. M., & Ogden, C. L. (2008). High body mass index for age among US children and adolescents, 2003-2006. [Electronic version.] Retrieved December 2 2008, from http://jama.ama- assn.org/cgi/content/full/299/20/2401
10. Casper, R. C. (2000). Eating disturbances and eating disorders in childhood. Psychopharmacology. [Electronic version.] Retrieved November 15, 2008, from http://www.acnp.org/g4/GN401000162/CH.html
11. Centers for Disease Control and Prevention. (n.d.). Childhood obesity. Retrieved November 16, 2008, from http://www.cdc.gov/HealthyYouth/obesity/index.htm
12. Centers for Disease Control and Prevention. (n.d.). Healthy weight: About BMI for children and teens. Retrieved November 15, 2008, from
http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/childrens_BMI/about_childrens_BMI.htm
13. Centers for Disease Control and Prevention. (n.d.) Healthy youth: Physical activity. Retrieved December 2, 2008, from http://www.cdc.gov/HealthyYouth/physicalActivity/
14. Center for Disease Control and Prevention. (n.d.). Nutrition: School health guidelines. Retrieved December 6, 2008, from http://www.cdc.gov/healthyYouth/nutrition/guidelines/summary.htm
15. Centers for Disease Control and Prevention. (n.d.). Overweight and obesity. Retrieved November 15, 2008, from http://www.cdc.gov/nccdphp/dnpa/obesity/
16. Centers for Disease Control and Prevention. (n.d.). Overweight and obesity: Consequences. Retrieved November 15, 2008, from
http://cdc.gov/nccdphp/dnpa/obesity/childhood/consequences.htm
17. Centers for Disease Control and Prevention. (n.d.). Overweight and obesity: Contributing factors. Retrieved November 15, 2008, from http://www.cdc.gov/nccdphp/dnpa/obesity/contributing_factors.htm
18. Center for Science in the Public Interest. (2006). Bipartisan support on capitol hill for healthier school foods: Child nutrition promotion and school lunch protection act introduced. Retrieved December 5, 2008, from http://www.cspinet.org/new/200604052.html
19. Chmelynski, C. (2005). States weigh idea of BMI reports as they tackle obesity epidemic. National School Boards Association. Retrieved December 2, 2008, from http://www.nsba.org/MainMenu/SchoolHealth/SelectedNSBAPublications/Hea lthyEating/obesityepidemic.aspx
20. Christakis, N. A. & Fowler, J. H. (2007). The spread of obesity in a large social network over 32 years. The New England Journal of Medicine, 357. [Electronic version]. Retrieved November 16, 2008, from http://content.nejm.org/cgi/reprint/357/4/370.pdf
21. Diez Roux, A. V. (2004). The study of group-level factors in epidemiology: Rethinking variables, study designs, and analytical approaches. Epidemiologic Reviews, 26. [Electronic version]. Retrieved November 17, 2008, from http://epirev.oxfordjournals.org/cgi/content/full/26/1/104
22. Grummer-Strawn, L., Lee, S. M., McKenna, M., Nihiser, A. J., Odom, E., Reinold, C., Thompson, D., & Wechsler, H. (2007). Body mass index measurement in schools. Journal of School Health, 77. [Electronic version.] Retrieved December 5, 2008, from http://www.cdc.gov/HealthyYouth/obesity/BMI/pdf/BMI_execsumm.pdf
23. Kadushin, C. (2004). Basic network concepts: Introduction to social network theory. Retrieved November 16, 2008, from http://64.233.169.132/search?q=cache:48ThleuKviMJ:home.earthlink.net/~cka dushin/Txts/Basic%2520Network%2520Concepts.pdf+social+network+theory& hl=en&ct=clnkcd=4&gl=us&client=firefox-a
24. Kahan, D. (2008). Fitting physical activity into the elementary school day: There are many ways to add movement and exercise to classroom instruction. Leadership Compass, 6(1). [Electronic version]. Retrieved December 2, 2008, from http://www.naesp.org/resources/2/Leadership_Compass/2008/LC2008v6n1a4 .pdf
25. Leppert, J., Nilsson, K. W., & Sjoberg, R. L. (2005). Obesity, shame, and depression in school aged children: A population-based study. Official Journal of the American Academy of Pediatrics, 116.
26. Link, B. G. & Phelan, J. C. (2007). On stigma and its public health implications. Columbia Institute and New York State Psychiatric Institute. Retrieved November 16, 2008, from http://www.stigmaconference.nih.gov/FinalLinkPaper.html
27. MetroWest Community Health Care Foundation. (2007). MetroWest kids: Fat chance. Retrieved November 14, 2008, from http://www.metrowestkids.org/mediaroom/mediaresults.php?search_fd1=Billb oard
28. National Agricultural Library. (n.d.). Choose a diet low in fat, saturated fat, and cholesterol. Retrieved December 5, 2008, from http://www.nal.usda.gov/fnic/dga/dga95/lowfat.html
29. National Association for Sport and Physical Education. (n.d.) Moving into the future: National standards for physical education, 2nd edition. Retrieved December 3, 2008, from http://www.aahperd.org/naspe/template.cfm?template=publications- nationalstandards.html
30. National Center for Education Statistics. (n.d.). Nutrition education in public elementary and secondary schools: Nutrition education in the school curriculum. Retrieved December 3, 2008, from http://nces.ed.gov/surveys/frss/publications/96852/index.asp?sectionid=3
31. National Conference of State Legislatures (2007). Childhood obesity: 2006 update and overview of policy options. Retrieved December 5, 2008, from http://www.ncsl.org/programs/health/ChildhoodObesity-2006.htm#body
32. National Heart Lung and Blood Institute. (n.d.). How are overweight and obesity diagnosed? Retrieved November 15, 2008, from, http://www.nhlbi.nih.gov/health/dci/Diseases/obe/obe_diagnosis.html
33. Nutrition Explorations. (n.d.). Why teach nutrition? Retrieved December 2, 2008, from http://www.nutritionexplorations.org/educators/whyteach.asp)
34. Ofei, F. (2005). Obesity: A preventable disease. Ghana Medical Journal, 39 (3). [Electronic version.] Retrieved November 17, 2008, from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1790820
35. Pennsylvania Department of Education. (2008). Food and nutrition programs: National school lunch program. Retrieved December 6, 2008, from http://www.able.state.pa.us/food_nutrition/cwp/view.asp?a=5&Q=45622
36. Physical activity levels among children aged 9-13 years in united states, 2002. (2003). Morbidity and Mortality Weekly Report, 52 (33). Retrieved November 17, 2008, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5233a1.htm
37. School Health Policies and Programs Study. (2006). Physical education. [Electronic version.] Retrieved December 3, 2008, from http://www.cdc.gov/HealthyYouth/shpps/2006/factsheets/pdf/FS_PhysicalEdu cation_SH PPS2006.pdf
38. The Obesity Society. (n.d.). What is obesity? Retrieved November 15, 2008, from http://www.obesity.org/information/what_is_obesity.asp
39. United States Department of Agriculture Food and Nutrition Service. (n.d.). School breakfast program: Fact sheet. Retrieved December 5, 2008, from http://www.fns.usda.gov/cnd/breakfast/AboutBFast/bfastfacts.htm
40. United States Department of Education. (n.d.) Healthy vending machine. [Electronic version.] Retrieved December 6, 2008, from http://doe.sd.gov/oess/cans/training/docs/healthyvendingmachine.pdf
41. United States Department of Health and Human Services. (2006). Dietary guidelines. Retrieved December 5, 2008, from http://www.health.gov/DietaryGuidelines/
42. United States Department of Health and Human Services and U.S. Department of Agriculture. (2005). Dietary guidelines for americans, 2005. [Electronic version.] Retrieved December 6, 2008, from http://www.health.gov/DIETARYGUIDELINES/dga2005/document/pdf/DGA2 005.pdf
43. Utah State Office of Education. (n.d.) Responsible healthy lifestyles nutrition education. Retrieved December 6, 2008, from http://www.uen.org/utahlink/lp_res/nutri001.html
44. Wikipedia. (n.d.). Labeling theory. Retrieved November 16, 2008, from http://en.wikipedia.org/wiki/Labeling_theory

Analysis of Boston Public Health Commission’s Boston BestBites Restaurant Program to Fight Obesity – Lindsay Flaherty

2008-12-18T10:03:00.000-08:00

Introduction to Obesity and BestBites
As public health practitioners are very aware of, obesity is a major problem in the United States. In Massachusetts, the obesity rate for 2007 was 21.3 percent, which is lower than most states in the country (1). The obesity problem persists in the city of Boston as well, and five years ago, the Boston Public Health Commission created the Boston Steps program to address it, along with diabetes and asthma in eight Boston neighborhoods with the highest prevalence of these conditions. In this focused area including Chinatown, Dorchester, Hyde Park, Jamaica Plain, Mattapan, Roxbury, South Boston, and the South End, 33 percent of residents are overweight, while 20 percent are obese (2). One of the programs created as part of Boston Steps is called the Boston BestBites program.
Boston BestBites is designed to help Bostonians make healthier food options when dining out in the city. With all of the tempting restaurant choices in Boston, it is not surprising that that 40 percent of residents’ food dollars are spent while eating away from home (3). Restaurants that are interested in participating in BestBites submit potentially healthy recipes to nutritionists from Brigham and Women’s Hospital for analysis. The hospital nutrition department has developed guidelines constituting a healthy meal, outlining total calories, saturated fat, trans fat and sodium. Maximum allowances in these categories are outlined for an appetizer, entrée and a dessert. The guidelines fit in with the Dietary Guidelines for Americans 2005, which recommends a 2,000 calorie per day diet for the average American adult (4). Restaurants then work with the nutritionist to meet the guidelines, if they do not pass originally. Once the recipe meets the criteria, participating restaurants are given window decals, coasters, and table tents branded with the BestBites logo and are included in campaign advertising. Healthy menu items are designated in some way so diners know what they are choosing (5).
Boston BestBites launched in August of 2006 with 12 participating restaurants. It sent out 600 packets of information to garner restaurant participation (6). As of April of 2007, there were 21 participating restaurants, spanning some of the targeted neighborhoods, but not all. Information about the program after April of 2007 is difficult to find. It appears as though the program is no longer running, or doing so with minimal support. This could be due to a number of reasons, from lack of funding, to lack of restaurant support, or even poor outcomes.
This approach to fight obesity in restaurants taken by Boston BestBites is not unique. There have been other similar approaches developed. I developed a program that precluded BestBites called The Boston Heart Party Restaurant Program in which we garnered local Boston restaurants to develop heart-smart dishes to complement our free CVD screenings. Some national chain restaurants have created healthier options on their menus for those individuals who are dieting. One example of this was when Applebee’s teamed up with Weight Watchers in 2003 to create a menu that fit the Weight Watchers criteria and was offered alongside other menu choices (7). It is easy to understand the logic of such programs. By providing healthy options on a menu, it allows people to participate in the dining experience of eating out while staying true to their diet. It could even encourage non-dieters to choose healthy, good-tasting options. In reality, the people who have obesity issues may not have the willpower to make the healthy choices when they eat out, or else they may eat and drink other things along with the healthy option that wipe out the positive effects after all.
Critiques of the Intervention
While the Boston BestBites campaign and those like it are innovative and logical, this paper will examine how this program and others like it are flawed for three main reasons. The first is that the campaign as it stands is focused on the individual and does not account for several other options that affect dining choices. Second, it does not take into account social and cultural influences on changes in behavior that can be explained through sociology and anthropology’s influences on the field of public health. Finally, while the campaign had visually appealing collateral materials, it was not supported by a strong communications program, which could have helped to solidify consumer awareness adoption.
Argument #1: Insufficiency in an Individual-Based Model
The Boston BestBites campaign is based on the Health Belief Model (HBM). In the HBM, health behavior is motivated by the following thought processes: perceived susceptibility to an outcome, perceived severity of the outcome, perceived benefits of an action, perceived barriers of taking that action, cues to action and self-efficacy (8-10). When patrons take their seats in a restaurant with a menu to decide what to order, they are presented with an array of choices. They essentially go through the thought processes presented by the HBM as they decide what to eat. Specifically, some of the questions they may consider are:
· Should I choose the lasagna or the baked chicken BestBite option?
· Would the enjoyment of the lasagna be worth breaking my diet for the day?
· If I get the lasagna, will I have time to put in an extra long session at the gym tomorrow?
· Will the BestBite option make me feel good enough to pass up my favorite meal?
Unfortunately, the limitations to the HBM apply to the Boston BestBites campaign as well. One of the main limitations of the HBM is that it is an individual-based model and assumes that people make decisions in a vacuum. However, it is important to consider that other people may be part of the decision-making process and experience of dining in a restaurant. In reality, most people seldom dine out alone. When dining out in a group, people most likely discuss options of what to get with others at their table. Besides engaging others in their decision-making process while eating out, people often share food with others they dine with. Even if they order the healthy dish, they may still be going over their allotted caloric intake for a “healthy” meal because of sharing, sampling, or ordering appetizers and drinks.
Another limitation of the HBM model is that it is based on the assumption that people make rational decisions. The idea of ownership as it relates to rational behavior is discussed by Dan Ariely in his book Predictably Irrational. He uses an example of highly coveted Duke basketball tickets to show that if a person owns something, he puts a higher value on it than a person who does not own it but would like to (11). This concept can be applied to the experience of dining out for new dieters. For people who have been accustomed to unhealthy eating habits, their entire lives, then it will be more difficult for them to give up what they are used to and choose the healthy option. Consider the hypothetical example of a man named Joe. Joe is overweight and grew up in an Italian household that traditionally ate homemade lasagna every Sunday. This lasagna was not a new-fangled version of the dish containing low-fat, soy-based cheese, an abundance of vegetables and whole wheat noodles. Joe is accustomed to gooey, cheesy lasagna with ground beef and sausage loaded into it. Lasagna is comforting and nostalgic to Joe, as well as delicious. When he dines out at an Italian restaurant for the first time and sees the lasagna on the menu next to the BestBites baked chicken, he will think about how enjoyable and comforting lasagna is to him. The decision to choose the chicken would be more difficult for him than someone who has never eaten lasagna before, in the same way that the Duke basketball tickets are more valuable to someone who possesses them. The man in the example will be strongly focused on what he is losing when choosing the chicken over the lasagna, as opposed to the health benefits of the chicken and may act irrationally.
Argument #2: Lack of Consideration for Social and Cultural Influences
Boston neighborhoods are extremely diverse and different from one another. A comparison of the demographic make-up of two of the neighborhoods focused on in the Boston Steps program shows this. According to 2000 Census data, Roxbury has 63 percent black people, 24 percent Hispanic people, and five percent white people. Twenty-two percent of people speak Spanish at home (12). In contrast, South Boston 85 percent white people, 7 percent Hispanic people, and two percent black people. Only six percent of people speak Spanish at home (13). In the Boston BestBites program, a simple solution was applied to a range of ethnic restaurants in neighborhoods with culturally and ethnically diverse backgrounds. But addressing the needs in Boston’s diverse neighborhoods cannot be met by a one size fits all solution.
By considering and applying sociological and anthropological theories and research methods in the development of the BestBites program, a more effective program could have been created. Sociology incorporates a focus on social groups, hierarchies, structures and the nature of social interaction into public health programs. Anthropology emphasizes the role of culture in human behavior and public health problems and takes into account a holistic approach to behavioral decisions (14).
As described above, dining out is highly social and culturally unique. Companions, surrounding, and a person’s background can have a strong influence on the decision-making process at a restaurant and needs to be considered in the BestBites program. Additionally, a person’s cultural background and beliefs might play an important role in how he or she views dining out and what types of dining choices are typical. This must be considered in order to understand how to best influence behavior in a restaurant setting.
It is unclear what, if any, research was done to develop this intervention. Research methods common to sociology and anthropology could have been helpful in developing a successful program. Sociology typically utilizes both qualitative and quantitative research methods, while anthropology focuses mostly on using highly qualitative methods alone. Some of the research tactics that would have been helpful in the development of the program, include surveys, observation, one-on-one interviews, focus groups and experimentation. Data collection could then be used to generate theories about behavior and inform an intervention that could be more effective (15).
Argument #3: Failure to Support Program with Extensive Marketing Program
Finally, the Boston BestBites campaign did not thrive, because it was not supported by strong communications tactics resulting in visibility for the campaign. Even though the campaign had strong collateral materials, they could not serve to hold up the campaign’s success alone. As has been described in this analysis, the BestBites public health intervention is built in a setting that is greatly influenced by social factors. In order to have a greater impact on people’s decision-making, the campaign needs to be accompanied by a higher volume of social marketing, advertising and public relations. When searching for resources about BestBites, there are a couple of pages on the Boston Public Health Commission (BPHC) website, a press release for the launch, a couple of news articles from the launch, and a couple of website commentaries on the program. Other than that, it is impossible to find information about the program before walking in the doors to one of the few participating restaurants.
There are various studies and papers that outline how advertising and marketing can affect people’s actions. One such model is William J. McGuire’s Information Processing Model (IPM) (16). The IPM culminates in a communication/persuasion matrix including the thirteen steps in information processing. They are: exposure, attention, liking, comprehension, cognitive elaboration, skill acquisition, agreement, memory storage, retrieval, decision making, acting on a decision, cognitive consolidation, and proselytizing (16). The IPM model has received criticism that it reduces the decision-making process to a succession of steps which is too orderly. However, it outlines the importance of reaching audiences with messages in various ways and at various times in order to get the consumer through this long list of thirteen steps. The BestBites program is accompanied by clean and practical collateral materials (i.e. table tents and coasters); but if a person has not heard of the program before walking in the door to the restaurant, he or she will most likely not make it past steps one and two (exposure and attention) on the matrix hierarchy. This would most likely not be enough to choose to make a behavior change and order a healthy dining option.
Other communications theories also underscore the effectiveness of using message dissemination as a means to influence consumer thought and opinion. Diffusion of Innovation Theory says that the media can be used to influence and encourage people to help further a message (17). The Agenda-Setting Theory similarly contends that the media can be used to help and direct people on what topics to think about (18). Through better utilization of message distribution by the media and other means, the BestBites program may have been a higher priority in the minds of Bostonians. By hitting audiences with the BestBite messages in various ways – even low budget ones – the campaign could have gained more energy and momentum. This may have helped to influence more people to make the healthy menu item choices and encourage more restaurants to sign on to participate.
Conclusion
In summary, the Boston BestBites program that was developed as part of the Boston Steps program by the BPHC seems like an innovative and catchy idea on the surface. However, by considering the campaign through the lens of a knowledgeable public health practitioner, it is clear that it contains flaws that might limit its effectiveness. Restaurant patrons do not make their decision of what type of food to order while dining out on their own. They are influenced by their companions, surroundings, and cultural background. Such influences need to be taken into consideration in the development of an effective intervention. In addition, a program with flashy collateral materials cannot stand on its own without a full scale communications program to help disseminate messages repeatedly to restaurant patrons so they are more likely to make healthy choices while dining out.
A New Intervention
On the surface, the Boston BestBites program is a fun and innovative way to fight obesity in the Boston neighborhoods with the biggest disparities. In order to create a new and better intervention to help Bostonians make healthier choices while dining out, it will not be necessary to completely overhaul the program. Instead, I propose to renovate it using what we know about more effective – and often unconventional – methods of addressing public health problems. The revamped BestBites program will need to incorporate social and environmental factors into the decision-making process; be constructed based on sound qualitative research so that it will uniquely meet the needs of patrons who live in certain neighborhoods and frequent certain restaurants; and be supported by a strong communications program to not only build awareness, but also supplement the decision-making process.
The revised program will be called Boston BestBites Nites. The campaign will run for a year, and will offer two unique BestBites Nites per month, each at a different restaurant located in one of the neighborhoods targeted in the Boston Steps program. There will be a total of total of 24 “nites.” The restaurant participating at each BestBites Nite will be required to have two appetizers, two entrees and two desserts pass through the nutritional analysis developed by Brigham and Women’s Hospital. In addition to this requirement, restaurants will be given autonomy to add additional elements to their Nite in order to help to customize it to their own patrons. Public health professionals will be available to help develop these ideas based on both traditional and nontraditional models for behavior change. Examples of activities unique to a specific restaurant include offering the meals at a discounted price as a way to entice lower income patrons; a physical activity component such as dancing that is typical in a particular culture and could help garner attendance; or the development of “mocktails” to help teach people how to adopt other healthy lifestyle changes.
All of the Nites will incorporate an educational component as well. The BestBites collateral materials will be expanded to include educational materials. A nutritionist from Brigham and Women’s Hospital Department of Nutrition will be present to answer any questions that patrons have about healthy eating and meal creation. Restaurants will also be free to suggest and develop other educational components based on their customer base. Following a certain restaurant’s BestBites Nite, it will be required to leave at least one of the healthy options on its menu for the future, and continue to distribute educational materials and other campaign literature throughout the duration of the program.
Counter-Argument #1: Moving Beyond an Individual-Based Model
Dining out at a restaurant is not an individual experience, and so an intervention that is based on an individual-based model simply will not have the intended impact. There are several ways that BestBites Nites is more incorporative of social factors. First, the BestBites Nites program is based on the ecological model. This model considers that individual factors are only a small contributor to a person’s behavior. Other factors that affect behavior include social/cultural/group, socioeconomic and structural, political and environmental factors. All of these factors would work together to influence behavior, not work individually (19).
In the BestBites Nites program, the decision-making process shifts from one that is individually focused, to one that is group focused. Family and friends will decide together that they want to attend the BestBites Nite at a certain restaurant, and so one person will not be isolated in trying to choose a healthy menu option amid other temptations and social pressure. Social, cultural, socioeconomic and group factors are already built into the experience. The individual need only decide which of the healthy options he or she wants to eat when after arriving at the event. An evening shaped around healthy restaurant dining and fun removes the pressure from an individual to make a healthy choice while under the influence of environmental surroundings or social pressures. Dancing or entertainment will make the evening more appealing as a group activity. The educational component will arm diners with ideas on how to maintain healthy eating habits in everyday life or while dining out in the future. Since at least one of the healthy menu items will stay on the menu after the BestBites Nite at that location, diners will be more likely to choose it on an individual basis in future visits to that restaurant now that they have experienced it in a group they are comfortable with.
The BestBites Nites also take into account that people do not always make rational decisions. As discussed above, diners know what they are giving up when they choose a healthy meal. For example, patrons at Poppa B’s in Dorchester are accustomed to traditional soul food dishes such as BBQ ribs, fried chicken and sweet potato fries (20). The BestBites Nite at Poppa B’s should not exclude these soul food favorites, but update them into healthier options. Patrons who may be tempted to make an irrational decision will remember how good these items are and not necessarily be satisfied with a menu that does not include them. An example of a renovated, healthy, soul food menu could include BBQ chicken, oven fried chicken and oven baked sweet potato fries. The patrons will not feel like they are giving anything up.
Counter-Argument #2: Strong Consideration for Social and Cultural Influences
As mentioned above, Boston is an extremely diverse city, and it is hardly possible to create a one size fits all obesity intervention that would have an impact on the city’s diverse population. Since BestBites Nites will take place at one location at a time, it will allow the program to be more tailored to accommodate the unique diners who typically frequent those restaurants, based on common characteristics of local residents. In this way, a BestBites Nites held at Poppa B’s in Dorchester will be very different from a BestBites Nites at Centre Street Café in Jamaica Plain.
The public health practitioners who are tasked with development and implementation of the BestBites Nites program will be instrumental in helping restaurants to develop a unique evening at their restaurant that will specifically help to encourage healthy dining among their patrons. By utilizing data collection methods more typical in the fields of sociology and anthropology, a more precise and focused understanding of each restaurant’s customer base can be gathered. Therefore, for each of the 24 restaurants that participate in BestBites Nites, two customer focus groups, at least 200 surveys, and at least five one-on-one interviews will be conducted with restaurants and patrons. Some of the questions that can be posed through these qualitative research methods include:
· Why do you dine at this restaurant?
· What is your favorite menu item at this restaurant, and why do you choose it?
· Who do you typically dine at this restaurant with?
· Do you maintain a healthy diet at home?
· What do you think of when you hear “health food”?
· What does eating a meal with family and friends mean to you?
· How is the food at this restaurant different or similar from the food you eat at home?
· Are there any activities – such as dancing, games, or demonstrations – that you would find entertaining while dining at this restaurant?
The research will be compiled into a report including recommendations for unique tactics to meet those patrons’ needs. The public health professionals will then meet one-on-one with the restaurant owners to design the evening.
Counter-Argument #3: Development of a Strong Communications Program
As mentioned above, Boston BestBites is a creative idea accompanied by a strong base of sharp collateral materials. The campaign’s development of restaurant-friendly items such as coasters and a recognizable logo is an important first step in building recognition of the campaign. However, the program received practically no media attention, has an outdated website, and seems to have fizzled out soon after its inception. In order to drive attendance to BestBite Nites and provide education to people that will hopefully have a longer term impact on people’s dining choices, the campaign will need to be supported by a strong communications program. The existing materials should be used as a basis for this, and additional materials should be developed to build upon and expand them.
The communications program will need to include public relations, advertising and community relations components. It should be creative and wide-reaching. By repeatedly getting the BestBites message in front of residents of target neighborhoods, it should follow that the campaign will have greater adoption based on William J. McGuire’s Information Processing Model (IPM) (21) and the Agenda Setting Model. More specifically, some or all of the following tactics could be included in the communications campaign:
· Advertising in community media publications, such as the Roslindale Transcript, Brighton Tab, South End News, and Jamaica Plain Gazette.
· Hanging flyers at neighborhood libraries, coffee shops, book stores, grocery stores, etc.
· Working with a local healthy food store (such as Trader Joe’s) to have them distribute flyers for BestBites when bagging groceries or giving receipts to customers.
· Generating feature stories in regional, local and community media about participating restaurants.
· Place a news story in Brigham and Women’s weekly newsletter, as well as other Partners institutions – possibly even offering a promotion for all Partners employees.
· Scheduling a “chat” with one of the nutritionists from Brigham and Women’s on Boston.com, where users can write in questions about the program.
· Signing on a campaign “spokesperson” to help educate and influence consumers to eat healthy while eating out with the BestBites program.
In addition to these communications tactics, a strong and up-to-date website should be developed as a core information source of campaign information in addition to collateral materials. A catchy web address can appear on collateral materials, in advertising, or in news articles. When a user visits the website, it will have a detailed schedule and description of upcoming BestBites Nites and participating restaurants. Healthy dining tips and a blog by a Brigham and Women’s nutritionist could also be strong additions to the website. The online communications strategy could even incorporate the use of social media, where appropriate. For example, a Facebook group could be created for BestBites Nites to build buzz. For communities that do not have a high usage of the Internet, extra collateral materials and community relations tactics will be utilized to reach audiences in the most appropriate way.
In conclusion, Boston BestBites is an innovative program with a strong and established base. By tailoring and renovating the program to be more in tune with all of the factors that affect the decision-making process for diners at participating restaurants specifically, the intervention can have a greater impact. An improved intervention that is built around an individual-based decision-making model should also be strongly supported by a highly visible communications campaign that will help to foster a greater participation rate and, with hope, ultimately help improve the health of residents in the Boston neighborhoods facing the most disparaging obesity statistics today.
REFERENCES
1. U.S. Obesity Trends 1985 – 2007 – 2007 Obesity Rates. Centers of Disease Control and Prevention. Accessed on 11/15/08. http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/.
2. About Boston Steps – Boston Steps Project Area. Boston Public Health Commission Website. Accessed on 11/15/08. http://www.bphc.org/programs/initiative.asp?i=314&p=190&b=2&d=17.
3. Boston BestBites. Boston Public Health Commission Website. Accessed on 11/15/08. http://www.bphc.org/programs/initiative.asp?i=260&p=190&b=2&d=.
4. Dietary Guidelines for Americans, 2005. U.S. Department of Health and Human Services. Accessed on 11/15/08. http://www.health.gov/DietaryGuidelines/dga2005/document/default.htm.
5. Boston BestBites. Boston Public Health Commission Website. Accessed on 11/15/08. http://www.bphc.org/programs/initiative.asp?i=260&p=190&b=2&d=.
6. “Mayor Menino, Public Health Officials Kick-off Boston BestBites.” News & Press Releases. August 18, 2006. Accessed on 11/15/08. http://www.cityofboston.gov/news/default.aspx?id=3261.
7. “Applebee’s and Weight Watchers Announce Plans to Co-Develop New Menu.” Business Wire. July 25, 2003. Accessed on 11/15/08. http://www.allbusiness.com/medicine-health/diet-nutrition-fitness-dieting/5742140-1.html.
8. Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974; 2: Entire issue.
9. Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984; 11(1):1-47.
10. Rosenstock IM. Historical origins of the health belief model. Health Educ Monogr. 1974; 2:328-335.
11. Ariely, Dan. Predictably Irrational. Chapter 7, pages 127-138. Harper Collins Publishing. New York, NY. 2008.
12. Roxbury Data Profile. Department of Neighborhood Development, Policy Development and Research Division. US Bureau of the Census. May 1, 2006. www.cityofboston.gov/dnd/pdfs/Profiles/Roxbury_PD_Profile.pdf - 2006-05-01.
13. South Boston Data Profile. Department of Neighborhood Development, Policy Development and Research Division. US Bureau of the Census. May 1, 2006. www.cityofboston.gov/dnd/pdfs/Profiles/South_Boston_PD_Profile.pdf - 2006-05-01.
14. Edberg, Mark. Essentials of Health Behavior. Chapter 3, pages 31-32. Jones and Bartlett Publishers. Sudbury, MA. 2007.
15. Strunim, Lee. Disciplines of Social Sciences. Presentation Given to SB721 on November 6, 2008. Slides 12, 34.
16. McGuire, W. J. (1999). Constructing social psychology: Creative and critical processes. Cambridge: Cambridge University Press.
17. Lazarsfeld, P., Berelson, B., Gaudet, H. (1944) "The People's Choice." New York: Duell, Sloan and Pearce.
18. McCombs, M., & Shaw, D.L. (1972). The agenda-setting function of the mass media. Public Opinion Quarterly, 36, 176-185.
19. Green LW, Kreuter MW, eds. Health Promotion Planning: An Educational and Environmental Approach, 3rd ed. Mountain View, CA: Mayfield Publishing: 1998.
20. Poppa B’s Website. Menu. Accessed on December 9, 2008. http://www.poppab.com/menu.html#ldsides.
21. McGuire, W. J. (1999). Constructing social psychology: Creative and critical processes. Cambridge: Cambridge University Press.

Abstinence Only’s Alienation of Developmental Psychology, Social Psychology, and Public Health Basics - Joanna Matwiejczuk

2008-12-18T10:01:00.000-08:00

Over the last several decades, sexual education has been incorporated into high school classrooms across the country. While policies over comprehensive sexual education versus abstinence only education vary state by state and classroom by classroom, it is also evident that the political climate over this distinction has been in the eye of controversy. The federal government fiscally supports an abstinence only curriculum for adolescents and due to various factors, many schools have accepted the money from the government to teach abstinence only and thus have adopted an abstinence curriculum while forsaking comprehensive sexual education. However, not only is an abstinence only curriculum a close minded approach to sexual health education, but it is also unrealistic for the target audience, as well as irresponsible from a public health perspective. From the 2007 Centers for Disease Control Youth Risk Behavior Surveillance System, it has been found that 48.7% of adolescents have self-reported to being sexually active (1). An abstinence only curriculum therefore is virtually lost on almost half of its target population, statistically speaking. You can’t tell me what to do! What developmental psychology has to say. It comes as no surprise to parents, teachers, the general public and even adolescents themselves that the teenage years have been classified from a behavioral science perspective as a time to rebel, to break rules, to push limits and to act in exactly the opposite way that society would like them to act. This is not to say that all teenagers disobey their parents or the law, but it is inherently natural for them to engage in risky behaviors, especially behaviors that they are told not to engage in. Rebellion is a tool used by adolescents to begin establishing a sense of self and to gain independence. According to Erik Erikson's work in developmental psychology, "adolescence is a period of time in which a young person can take time to explore identity so as to work out conflicts and establish a secure sense of self" (2). Abstinence only teachings rely only on highlighting all the negative aspects of sex, such as the risks of unwanted pregnancy, the risks of contracting sexually transmitted infections, as well as the emotional harm that could result when one begins having sexual contact before they are mentally ready. However, from a developmental perspective, "youth may view abstinence as a developmentally appropriate stage, which precedes the equally appropriate stage of becoming sexually active when they are 'ready'" (3). Abstinence only education does not teach safe sex nor does it point out resources where adolescents can turn to if they do indeed choose to have sex. This absolutist curriculum is unrealistic given what we know about the psychological development of young people. They are essentially being told "do not have sex" which could only further fuel the need to rebel and thus engage in sexual activity. Our country's "just say no" attitude towards adolescent risky behaviors including alcohol consumption, substance use, tobacco use, and sex has not changed the fact that youth across the United States experiment with substances AND with sex on a daily basis.
Adolescence is also a time when young people seek greater freedom and when they hone their abilities to make positive choices. However, oftentimes, young people make many negative choices before they realize what the "right" choice is, but from a developmental perspective, they must be allowed (within reasonable means) to make various choices and recognize the repercussions of their actions. This is what learning and growth is about and this is what teenagers need in order to grow into healthy, balanced adults. "Teenagers’ identification of themselves a people committed to abstinence could keep them from considering situation in which they might someday choose to engage in sexual behavior and from learning how they might then protect themselves against unwanted pregnancy and STDs" (4).
As educators of adolescents, schools as well as the federal government, should create an atmosphere of learning where young people can be presented with many options and receive explanations of the various consequences (positive and negative) of sex before making an educated decision about how they choose to proceed in their own sexual lives. This is similar to various parenting styles in psychology developed by Diana Baumrind, in which there is strong evidence to show that authoritative parenting where children are allowed more freedom and decision making leads to better youth development outcomes, as opposed to authoritarian parenting which demands strong adherence to set rules and stunts psychological development (5). "Strong abstinence intentions may be linked with a view of sexual behavior that minimizes the role of personal choice and agency in making sexual decisions" (6). Restrictive statements and scare tactics about sex education will not foster positive youth development nor will it equip young people with the personal negotiation skills they will need for the more difficult choices in their futures. "Young people...need to be prepared to negotiate and renegotiate...[and] be treated in ways that encourage meaningful decision-making including in relation to sexuality, from a much earlier age" (7).What about your friends? Will they be around? Perspectives from social psychology. A very important aspect that is neglected in abstinence only education is the influence and power of the social environment of adolescents. In general, society is very influenced by community, peers, the media, etc. (8). This influence is heightened for our society's very impressionable teenager. Abstinence only education fails to factor in the everyday environmental exposures into the classroom curriculum. It does not account for what is already out there in the world and merely preaches a single answer (no) to a very complex issue like sex. Many (47.8%) of youth are already engaging in sexual activity and while 52.2% may not be, they are in contact with their peers daily and oftentimes intimately. Abstinence only teachings do not address the power of peers and social groups as a teenager seeks social approval and engages in conformity. Personal and group attitudes towards sex can often be much stronger than messages to simply not have sex. Young people will not only encounter sex as an issue among their peer groups, but will also be confronted with it on a much more personal level in their intimate relationships. A curriculum that incorporates the possibility of such situations and provides tools to navigate such situations would be much more appropriate given the national statistics concerning sex and adolescents and the social climate that youth live in. "They live in a largely peer-defined world easily accessible through communication technologies" (7). Another extremely powerful influence on young people is the media. Sex is not only on television, but in movies, on the radio and in music, in magazines, billboards, advertisements, news, commercials, etc. countless times each day. "The mass media are an increasingly accessible way for people to learn about and see sexual behavior. The media may be especially important for young people as they are developing their own sexual beliefs and patterns of behavior, and as parents and schools remain reluctant to discuss sexual topics" (9, 10). Adolescents are heavily exposed to the media and while they view others (adults and their celebrity peers) engaging and negotiating sexual situations in their "on screen lives," it is unrealistic to expect them not to be considering it in their own lives. Abstinence only education fails to acknowledge all of the publicity sex is gaining in our society's media and instead chooses to voice the same message of simply saying no to sex before marriage. Instead of addressing and perhaps utilizing examples of sex in the media as an avenue for a lesson plan about safe sex, abstinence only delivers the same messages today as it did decades ago. Just as Trojan condom commercials can highlight the positive consequences from engaging in safe sex, sexual health education should be able to do the same. I didn’t do it because I thought you were…Well I didn’t because you were supposed to…A stance on public health and education responsibility As educators and public health professionals, we need to consider the repercussions of an abstinence only curriculum. While it may seem "best" to encourage young people to wait until marriage or a long term relationship to have sex, in reality many youth are not taking this course of action. However, even those who do choose to wait will eventually need information, resources, and support to inform their decisions and judgment about sex. Unfortunately, an abstinence only curriculum does not equip these youth for their "next step." Abstinence only education alienates the sexually active as well as the homosexual youth population. Since these groups have either started having sex, or may not see sex in a heterosexual framework (i.e. at risk for pregnancy or for intercourse), these young people are not included and given no resources to protect their own sexual health (11).
As a center of learning, schools should take responsibility for teaching their students about sex, about the risks and benefits, about safe and protected sex, and guide young people to resources that can be utilized to help make decisions, to facilitate safe sex, or resources to turn to in a time of need following sex. "Ironically, the very methods aimed at protecting children often contribute to their abuse...[by] underminding their potential of being aware, knowledgeable, and competnet individuals" (12). Indeed we are doing a disservice to young people by not sharing the facts with them and allowing them to develop and make healthy decisions based on their individual needs. It is disturbing to think that sex education has been forced to exist only outside the classroom for so many young people. As educators, there is an opportunity to shed light, accurately inform, and spread a message but, instead abstinence only educators are just saying no. "This approach captures only negative consequences of sexual activity, ignoring potentially positive aspects, such as developing a sense of intimacy, achieving social skills and goals, and experiencing sexual pleasure" (3). For the public health world, where disease prevention and health promotion are key goals, sex in and of itself is not the public health problem. Unsafe and unprotected sex is what causes of the spread of STDs and unwanted pregnancies. Of course abstinence would solve the issues, but since that is not realistic in the long term, the focus needs to remain on the promotion of safe sex to all those at risk, including and especially, adolescents. "Sex education is intended to serve a very practical public health purpose...[but] the growing prominence of the abstinence only approach will likely have serious unintended consequences by denying young people access to the information they need to protect themselves" (11). Ignoring the issue, as abstinence only education does in a way, will not eradicate the problems associated with unsafe sexual activity.
It is also dangerous to assume that those adolescents engaged in sex and those thinking about initiating sex are armed with the facts they need in order to do it safely. Their information may not come from parents or other educational sources, but rather the internet, media, and peers which can be much less reliable and send unclear, mixed, inaccurate messages. What abstinence only education has taught us
In conclusion, abstinence only education fails to deliver what adolescents need at this developmental stage in their lives and ill equips them for skills needed to engage in positive decision making. Adolescents will eventually, if they aren't already, become a part of the sexually active population and when they reach that point, they must have some information about safe sex, as well as options and resources to turn to. "Society must recognize that a majority of adolescents will become involved in sexual relationships during their teenage years" (13). Abstinence only education has failed to account for the dynamic influence of social environment, especially media and peer groups. Instead, it has focused on a static, close minded approach to address a complex and ever changing issue that faces our teens. Above all else, abstinence only education has failed the public health community by bypassing the real issue at the heart of sex which is the prevention of disease. By not taking the curriculum to the next level, the ignorance of safe sex can lead to very negative and unfortunate outcomes for our young people. Abstinence only supporters are failing our young people by not providing them with the information they need to protect their health and well being. So it's our responsibility, but what can we do?
Given all this information, we should start to consider what a more ideal approach to achieving safe sex amongst adolescents should actually look like. We have learned that abstaining from the abstinence only educational approach may prove to be beneficial if executed properly. A comprehensive sex education program needs to be developed in order to address the multifaceted issues that adolescent sexuality raises. And, not only developed but implemented and mandated by government as the most responsible approach to sexual health education. Although "comprehensive sex education" curricula are in place in schools across the country, we must examine what that really means. I do believe that a comprehensive approach is necessary, but there are crucial, key elements missing from many of the current comprehensive programs. We must specifically address what is known about adolescent psychological development and factor that into every feature of the program. We must also carefully consider adolescent psychology from a social perspective and be aware of the social climate of our society. Lastly, in order to address the issues outlined prior, we must always keep in mind that it is the duty of educators and public health professionals to design programs that effectively incorporate information and strategies specific to adolescents when considering the features of a comprehensive sex education curriculum.
Comprehensive sex education, unlike abstinence only education, acknowledges that adolescents may already be engaging in sexual activity, or may be considering beginning engagement in sexual activity. It incorporates abstinence into the curriculum, but does not solely focus on abstinence as the only option for preventing unwanted pregnancy or the transmission of STIs. It also points out and encourages safe sex practices, such as using birth control and condoms as well as teaches communication skills to assist adolescents in negotiating sexual activity. This education should ideally be happening in the classroom, either at the middle school or high school level when a large percentage of adolescents are starting to initiate sexual activity or thinking about it. I strongly believe that a classroom setting is the most effective way to reach many young people because school is mandatory. They have to attend. School is also where youth learn everything from math to science, and sexual health should be another course that they need to complete. As an epicenter of learning in their communities, schools must take on this responsibility and intentionally address sexual health in order to fully serve the students, as well as their parents, the community members, and society as a whole. It is a public health responsibility to teach complete (comprehensive) sex education that addresses all topics and considers all members of a population. This responsibility can be achieved very effectively in a classroom setting. It is harmful to employ an abstinence only education as it falls short of information dissemination. Information that is essential to making safe, healthy decisions.But, won't they just do what they want anyway?
In order to address the complexity of adolescent psychological development it is important to acknowledge that adolescent rebellion exists and that there may not be an effective way to combat it, nor should we try to. Comprehensive sex education would be charged with needing to work around this issue and find a way to successfully incorporate strategies that can work in such an atmosphere. The message of "no sex" as abstinence only education sets forth is very absolutist and casts a rule out for adolescents to follow. Not only would this be ineffective knowing what we know about adolescent rebellion, but it also would not allow for adolescents to naturally develop cognitively. Adolescents will be faced with difficult situations throughout their lives, and "no" will not always be the answer. From a youth development standpoint, comprehensive sex education needs to allow for healthy decision-making, both encouraging the navigation of options available and also equipping adolescents with skills to be able to critically think through a decision in order to make a positive one. I propose incorporating into the comprehensive sexual education curriculum a unit on healthy relationships and decision-making strategies. This may involve interactive lesson plans that allow youth to practice skills and also must include posing situations to them about sexual scenarios that they may need to navigate. Healthy relationships will need to cover everything from friendships, "hooking up," and dating, to long-term relationships, homosexual relationships and unhealthy (abusive, etc.) relationships. Some of these topics may be sensitive and it may be difficult for teachers to talk about, but creating an open environment where frank discussion is not only allowed but encouraged may make all the difference.
Comprehensive sex education needs to exist on a continuum. In other words, information dissemination is only the first step, other supports and reinforcements need to be in place in order for the information to be fully processed and utilized. I propose supplying "sex goody bags" during sex education which include resources and samples of many commonly used contraceptives. Items can include male and female condoms, spermicide, a condom carrying case, and tangible "dummy" examples of prescription contraceptives such as the vaginal ring, the patch, etc. as well as information accompanying each piece in the bag. The bag can also include a resource list of health centers, or a business card with important information that can be kept with them at all times. This way, adolescents have a chance to experiment with the various options they have and may more effectively find one that suits them. This approach factors in adolescent development because it allows for experimentation in a controlled environment and also acknowledges that not all young people may be comfortable approaching an adult with questions about sex. This way, youth have the chance to explore various methods to prevent unwanted pregnancy and STIs, and truly get a feel for their options.They won't listen...there's too much competition...
It is critical to realize that there are many societal influences upon young people. Comprehensive sex education may have to compete for attention. Or, there may be a way to utilize and incorporate social influences (peer and media especially) into sex education. Not only are communication skills necessary for adolescents, but a reliable medium of communication is necessary. As previously discussed, young people may not be comfortable enough to raise questions about their own sexual health. I propose the creation of a text message network ("Sext me!") that can provide resources, answers to questions and support for teens thinking about sex, experiencing the emotional aftermath of sex, or needing to know where to go for help. This two-way, anonymous form of communication could be a relatively easy, non-judgmental, non-confrontational way to get questions answered and resources supplied. It goes beyond just supplying information and text messaging is a medium that adolescents communicate through a lot. Such a network and program can be established through community resources, not necessarily exclusively schools. To address staffing issues, resources can pooled through the community, or city, county, state, etc. in order to create an extended network. Also, incorporating youth into the development of the "sext network" as well as employing young people in the infrastructure can add to the legitimacy as well as the approachability that other young people will experience when they consider sending a text message to obtain sex information.
It may seem nearly impossible to counteract with media influence in the lives of young people. And although it would be extremely difficult to monitor or change what is shown in the media about sex, there is a way to counteract the messages that are conveyed about sex. I propose that classroom curricula devote time to digesting and discussing the week's, for example, media activity. Whether it be the latest episode of a popular teen sitcom, or the release of a controversial song, teachers should intentionally designate classroom time to view, discuss, demystify, and engage young people in talking about any questions that could arise. It is also important to address details that may be missing from the staged situation, or address what follow up to a scene may look like in reality. Incorporating humor and open-mindedness into the classroom discussion is essential in order for this approach to be effective. Although this does not eliminate inaccurate, unrealistic information from reaching a very impressionable audience like teenagers, it does provide a solution so as to not ignore that this indeed does exist as a very real and powerful influence in their lives. This approach also grants an opportunity for educators to remain at the forefront of current youth sex culture and remain informed. This information and experience can also help mold their classroom curriculum to be more relevant, current and timely for teenagers.In conclusion, abstinence only education barely scratches the surface of what is a complex, involved, and multifaceted issue like adolescent sexual health. Comprehensive sexual education is a primary step in the right directions. There are obviously many other interventions that can be incorporated at an after school level, or within the community, or in a young person's home. However, I believe that sex education needs to heavily involve educators who spend day after day with the same young people and who are expected to teach. And they must teach. All the options and uncover all the resources that are available. Comprehensive sex education as laid out in this discussion must incorporate creative and current strategies in order to be effective. As times change, curricula must as well. However, three facts that will not change is that adolescent sex education is the responsibility of the public health and education community. Also, interwoven into all aspects of a comprehensive sex education curriculum, must be principles seeped in what is known about adolescent psychological development and what positive, healthy youth development looks like. And finally, educators must never ignore the strong effects of peer groups and the media on our society's young people. Education need not combat these effects, but rather find meaningful ways to use social psychology principles to create a strong, all encompassing curriculum that will reach adolescents and ultimately shape their decision-making skills and capacities.

REFERENCES
1. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, Division of Adolescent and School Health, 2007.
2. Erikson, E. Identity: Youth and Crisis. London: W.W. Norton & Company, Inc., 1968.
3. Ott, MA, Pfeiffer, EJ, and Fortenberry, J. Perceptions of sexual abstinence among high-risk early and middle adolescents. Journal of Adolescent Health 2006; 39(2):192-198.
4. Masters, N, Beadnell, B, Morrison D, Hoppe, M, and Rogers Gilmore, M. The opposite of sex? Adolescents' thoughts about abstinence and sex, and their sexual behavior. Perspective on Sexual and Reproductive Health 2008; 40(2):87-93.
5. Baumrind, D. Parental disciplinary patterns and social competence in children. Youth and Society 1978; 9:238-276.
6. Fine, M. Sexuality, schooling, and adolescent females: the missing discourse of desire. Harvard Educational Review 1988; 58(1):29-53.
7. Lehr, V. Developing sexual agency: rethinking late nineteenth and early twentieth century theories for the twenty-first century. Sexuality & Culture 2008; 12:204-220.
8. Kirby, D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy, Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001. 9. Brown, JD. Mass media influences on sexuality. Journal of Sex Research 2002; 39: 42-45.
10. Brown, JD, Steele, JR, and Walsh-Childers, K (eds.). Sexual Teens, Sexual Media: Investigating Media's Influence on Adolescent Sexuality. Mahwah, NJ: Lawrence Erlbaum Associates, 2002. 11. Collins, C, Alagiri, P, and Summers, T. Abstinence Only vs. Comprehensive Sex Education: What are the arguments? What is the evidence? Policy Monograph Series, 2002.
12. Robinson, KH. Childhood and sexuality: adult constructions and silenced children (pp. 66-78). In: J.Mason, J.Mason, & T. Fattore (eds.). Children taken seriously: Theory, practice, and policy. London: Jessica Kingsley Publishers, 2005. 13. Sexuality Information and Education Council of the United States. Adolescent Sexuality Fact Sheets. New York, NY: Sexuality Information and Education Council of the United States. www.siecus.org.

First 5 Education Training Initiative: Preaching to the Choir – Jessica Kissen

2008-12-18T09:58:00.000-08:00

Oral hygiene is very important to children for various reasons. “Oral health affects people physically and psychologically and influences how they grow, enjoy life, look, speak, chew, taste food and socialize, as well as their feelings of social well-being.” (1) Children especially can be affected by bad oral hygiene. Dental caries, or tooth decay, can affect a child adversely. Children can experience severe “pain, discomfort, disfigurement, acute and chronic infections, and eating and sleep disruption.” (2) Dental problems in childhood could result in health problems in adulthood and/or could be signs of serious illness. (3) Unfortunately, across the world, maintaining good oral health is a big problem
Dental caries are an epidemic in the United States, although many in the United States don’t acknowledge it. According to research, many call the prevalence of dental caries a “silent epidemic.” This is due mostly because tooth ailments, although widespread, are not deadly and usually will just cause pain and discomfort that people can deal with until it is too late. (4) Unfortunately, it is more prevalent than people realize. Between the ages of 2 and 11, 42% of these children have dental caries. (5) What is worse is that Black and Hispanic people who live in poverty have the largest disparity of tooth decay. (6) But recently, because of an increased awareness to this epidemic, the United States has started to take notice and recognize oral health as something to focus on and has started to create different initiatives and interventions to help combat this growing epidemic.
In a study done in 2000, which was designed to assess a pediatrician’s knowledge of oral health and hygiene, the results show that pediatricians need more training in this area. (7) Stemming from this important study, a recent initiative was established called The First 5 Education Training Initiative; this intervention was piloted in California in February 2004. (8) The goals of this initiative is to educate and train dentists, medical professionals and early childhood educators about new scientific procedures and practices that can be used to promote oral health in children in their very early childhood (0 to 5 years). This intervention plans on eliminating the epidemic from the inside out. By educating the educators, this initiative is believed to provide more dental health care to children and better dental health care for children.
Unfortunately, this is not the case. This is obviously a very flawed intervention that doesn’t address the core problems with dental care and oral health. Although the study mentioned above recommends that pediatricians be educated in dental procedures and technology, this intervention does not address key elements to dental care. First 5 Initiatives do not address problems with the Medicaid Dental Care system. Although every single child who is enrolled in Medicaid has the right to dental services, only about 18 percent of these children have even come in for a check up. (9) Since the service is provided, why is there so small a number of children actually going to the dentist regularly? The other flaw deals with the target. Are we educating the right people with this program? Should we be educating the professionals or parents, teachers, and care-givers? The general public does not realize the severity of this epidemic, but professionals do. Why are we trying to educate people who already know that bad oral health is a major problem? The problem that might be hardest to combat is the social norms about dental care and oral health. Dental care is strongly viewed as an elective procedure for those who can afford it. Most people don’t believe the oral hygiene is very important. This program does not address how to make a change in the social norms about oral health. The program is ending its four year agenda in December 2008, and reports already show that it has been a failure. Failure to address the real problem with dental care and oral health made this initiative a waste of 7 million dollars.

First 5 Initiative Does Not Address How to Pay for Dental Procedures
Unfortunately, confirmed by the low percentage of Medicaid beneficiaries going to the dentist regularly, Medicaid’s plan does not seem to be attracting parents to send their children for regular check ups. “Medicaid programs face a myriad of difficulties, from low levels of participation by dentists to difficulties in teaching beneficiaries how to negotiate the dental care system.” (9) First 5 Initiatives tried to address the low participation through dentists. The program’s goal is to educate dental and medical professionals about the importance of dental care and oral health, and eventually these dentists and medical professionals will take Medicaid patients more often. Unfortunately, this could never be the case.
It has already been established that dental care for children is crucial to their overall health, but having a dental procedure takes time and money, and not many dentists or medical professionals are working for Medicaid. When a family has dental coverage, the dentist will be alert to the dental problems in the family and he will be reimbursed by that family’s dental insurance plan. Research shows that families who are in a higher socio-economic status (SES) go to the dentist regularly compared to mid to lower SES. (10) What does that tell us? People who are in the low SES range usually have Medicaid as their insurance. Medicaid families also have the State Children’s Health Insurance Plan, SCHIP, for their children, which is insurance coverage for mothers and their children. (11) SCHIP’s dental coverage is controlled on a state by state basis. There are still out-of-pocket fees, and other costs that apply to the program. As with many low-income families these fees may deter a mother from taking her child to the dentist. Not only are their fewer dentists that accept Medicaid and SCHIP, there are other constraints such as “inflexible work hours [and] distances to providers.” (10) These barriers do not help with dental care in children. And as the children age, these barriers don’t get any easier. Just because more professionals know about the problem, doesn’t mean that people are actually getting help. In conclusion, just by educating professionals about oral health does not help with payment and improvement in oral health.
First 5 Initiatives Does Not Target the Right People
The First 5 Initiative is a great plan addressing problems with knowledge about oral health in a professional community, but this professional community already knows about the dangers of dental caries and the need for regular visits to the dentist. The training that is instituted by this program is not even hands on. There are no patients on which they are performing procedures and check ups on. Many of the training sessions are even online through webcasting. How does this support a community of people who need to get dental care?
So who really needs the education? In an older study done in Romania that showed although many mothers knew about the dangers of poor oral hygiene, there was still a prevalence of tooth decay in many children. “On one hand, most of the mothers knew about the negative effect of sweets and candy; nevertheless, the consumption of various sugary foods was relatively frequent.”(12) This shows that although most mothers understand that some foods may cause a problem, they would rarely do anything about it. Translating this to First 5, shouldn’t we be training mothers to be more careful about what they feed their children? First 5 will do a great job educating professionals so that when a mother does bring a child in for a dental procedure or check up, the dentist will be able to talk to the mother. But, as we have discussed, many mothers don’t even take their children to the dentist. It is a waste of valuable training time.
When we look at this intervention in the perspective of a model, First 5 is trying to increase the amount of children going to the dentist from the inside out; meaning that the outcome we want to have is an increase in the number of children that get regular dental check ups. The exposure that we are using is educating professionals. Where is the link between professionals and children? Early educators are targeted by First 5. Unfortunately, this program targets children between the ages of 0 and 5 and this is before children have a chance to go to kindergarten. There is a missing link between the education of professionals and getting children to get dental care.
First 5 Ignores the Social Norms about Dental Care in the Community
Is dental care viewed as an essential and crucial part to a child’s health? Aside from the hassle and the money it takes to get a child to go to the dentist, do parents feel that it is so important that their children receive dental care? “Some parents mistakenly believe that younger children do not need to visit the dentist because the young children’s teeth are not permanent.”(10) Overall, the public doesn’t see dental care as very important to children who don’t have permanent teeth. Dental care seems to be put on a shelf until the children grow up. The barriers for dental insurance only get worse as children become older. Unfortunately, this can have some major consequences. What is the worst part about it is the fact that dental problems are easily preventable and treatable if the problem is diagnosed earlier. (13) This creates a rift between social norms and the consequence of not having dental care.
The questions to answer are how are any of the First 5 initiatives addressing the fact that people do not think dental care is important. This intervention fails to address the fact that the general public believes that dental care is a luxury. Mostly it is because parents do not realize that tooth decay is a real problem which is very preventable. In a report done by the Dental Health Foundation, the public opinion about “tooth decay [is that it] is a natural and minor occurrence that deserves little attention or dollars.”(14) Some parents can consider children caries as a minor inconvenience since they think that children’s teeth are temporary and the problem will go away when they have permanent teeth. (10)
Since dental care seems relatively unimportant to some people, people who can’t afford to take their children to the dentist for a regular check up will chose to avoid it. Having a co-pay or even gas on the trip may be more costly. In an important study published in the Journal of Community Dentistry and Oral Epidemiology, the author states that there is a need for educating mothers of a preschool age children about the importance of brushing teeth because mothers had no interest and no information about teaching their children how or why to brush their teeth daily. (15) Mothers had no interest to teach and monitor their children’s brushing habits because dental health isn’t as important to them as physical health. As stated above, evidence shows that it is just as important.
In conclusion, the First 5 was a complete disaster. It had the wrong target, the wrong approach, and the wrong idea. Educating people who were already educated was a waste of 7 million dollars. After looking at the data (16) we can even see that this was a failure. This pilot program did nothing but help us understand where First 5 went wrong. Although, from this intervention we will be able to create a better more effective initiative that targets the right people and puts money in the right places.

Learning from the First 5 Mistakes: First 5, Part 2 – Jessica Kissen

The First 5 Initiative piloted in California in 2004 didn’t work for many reasons. The initiative did not address key problems in dental health care delivery, coverage, and ignored the norms about dental health care. From the failure of First 5 we can learn from the mistakes and devise a new plan that has more potential to work because this new initiative focuses more on areas in health behavior that target the community and people to change attitudes and behaviors towards dental health. This plan is an extension of the First 5 Initiative and combats all the flaws that this initiative had.
The First 5 Free Dental Plan
The first problem to be addressed with First 5 deals with money. The First 5 initiative does not address how to pay for dental procedures. Not many people have dental insurance and dental procedures can be very expensive. As we have seen from previous research, much of the lower Socio-Economic Status population does not go to the dentist regularly. The government has tried to combat this by including some dental coverage in Medicaid and SCHIP. Unfortunately, this has not been working because even though there is a plan, the costs and premiums are still too high. In the First 5 Part 2 Initiative, these kinds of barriers will be eliminated with the First 5 Free Dental Plan. The First 5 Free Dental Plan (F5Plan) will be a government sponsored nationwide dental insurance plan. Families must apply for the plan and applicants will be chosen on the basis of their SES status and adherence to the First 5 Motherhood Training Program (to be discussed later). All applicants must have either Medicaid or SCHIP. They must also apply within the first year of the birth of their child. After enrolling in the program, the child will have bi-annual check-ups with dentists that are provided by the program. Dentists who are enrolled in the program will get subsidized for the check ups and can apply for an extra tax cut for providing more expensive procedures. This plan is based on a Political Economic model. (17) By addressing the monetary barriers that are faced by the mothers of the children, the mother will be more inclined to have dental coverage for their child. This will be done in conjunction with a plan that will educate the mother about the importance of oral health and the affordability of the F5Plan, called the First 5 Motherhood Training Program.
The First 5 Motherhood Training Program
Ideas about education are very important when it comes to dental health. Many people don’t understand the importance of oral health and the risks of poor oral hygiene, especially in children. In First 5, education is strongly emphasized in the professional community. Although the idea about education is the right way to go, medical professionals are already educated in the benefits of oral health. Parents don’t understand the importance of dental health for their children, especially at an early age. In Part 2, education will be geared towards the mothers of the children. Prenatal care is given to all expectant mothers enrolled in Medicaid and SCHIP. Part 2 will be included in this prenatal care and postnatal care.
In Part 2, there will be three training sessions during the last term of the mothers’ pregnancy. They will be free and will last between one to one and half hours. These training sessions will be designed specifically to educate mothers about the prevalence of poor oral hygiene, the severity of the problem, the consequences of poor dental care, and also about affordable dental care plans and the F5Plan. These sessions will be led by trained professionals, such as dentists and nurses. They will be able to answer questions that the mothers might have and also will provide brochures with even more information. If the mother attends all three sessions during the last term of her pregnancy, the mother will get a free dental exam and also be eligible for the Five Year Free Dental Program. Not only does this provide information to the mother about the oral health of their soon-to-be-born child, but it also gives the mother incentive to complete the program.
This program builds on the idea that most people don’t understand the health risks of having poor oral hygiene. As previous research has shown, much of the general population doesn’t understand the severity and importance of dental health. (18) The Health Behavior Model is one of the best ways to target these mothers with this program. (19) A mother sometimes doesn’t think that their child is susceptible to bad oral health. By showing that every child is at risk for dental caries and tooth decay, the mother will realize that their child is susceptible. The next step would be to help the mother understand that risks of poor oral hygiene. It can affect the child adversely and can damage their teeth and health for the rest of the child’s life. The mother can then learn about how easy it is to obtain dental insurance and get dental care for their child. This increases the self-efficacy of the mother because she now believes that she will be able to afford a dental plan. An increase in enrollment in dental insurance plans may spark more community involvement and a change in the social norms about dental coverage and care. The First 5 Community Incentive Program will help to further this change.
The First 5 Community Incentive Program
The next, and possibly the most important missing part of the First 5, is addressing the social norms about dental care. Although the First 5 Motherhood Training Program helps an individual understand the consequences and need for oral hygiene, the general population doesn’t understand the severity. This Community Incentive Program will be based in lower SES communities and is state-by-state sponsored. Here, the target is families in these communities and is less based on the oral hygiene of children, but more based of basic oral hygiene for everyone in that community. The idea behind this is to change the ideas about dental care to the parents of the children so that they will continue having dental insurance and coverage throughout the child’s life. Each state must sponsor a community education program that relates to teaching about dental health along with providing some form of dental services. Because this is a statewide program, every state may sponsor as much or as little as they would like, and can sponsor any program they see as best for the community. But the incentive part if the most important. At the end of each year there will be an assessment done by the government on the overall success of programs done in each state. The most successfully implemented plans and projects will be rewarded with a very large subsidy. Seventy percent of the subsidy must be used to expand the project to the next year and 30% can be used to the state’s discretion. Another perk of this program is that the most successful plans will be implemented nationwide in the third step of the First 5 Initiative’s overall plan.
This program builds on changing the community perspective on dental health care, coverage, and availability. Although plans may vary state to state, there are suggestions that can be rooted in the First 5 Community Incentive Program. There are so many ways a state may sponsor a program that can socially affect the community. Using the Social Networking Theory, a state can sponsor programs that target groups and then use those groups to outreach to other communities. (20) A state can sponsor dentists to come talk to a local community at a church and answer questions about dental care. Another way to help a community understand the importance of oral health is with the use of marketing and commercials. Community Access Television stations can be used to broadcast interviews with dentists. Dentists and nurses can be brought onto radios to answer questions in the community about dental insurance, coverage and care. Here, with the use of the communications theory, a state can fund the diffusion of information through public access. (21)
Overall, like most incentives, money is a huge issue. Without it, dentists don’t get paid, patients don’t get the treatment, children will have poor oral hygiene, and communities will still see oral health as something that isn’t important. By starting with this issue, the First 5 Initiative can build further onto other issues that deal with education and community involvement. This initiative has the potential to be very important and very beneficial to helping children get the dental care they need and helping parents understand the important of oral health.

REFERENCES
1. Locker D. Concepts of oral health, disease and the quality of life. In: Slade GD, editor. Measuring oral health and quality of life. Chapel Hill: University of North Carolina, Dental Ecology; 1997, pp. 11-23.
2. https://www.who.int/bulletin/volumes/83/9/editorial30905html/en/print.html
3. http://www.dentalhealthfoundation.org/images/lib_PDF/kaiser%20low%20income%20coverage_briefing.pdf
4. http://www.cdafoundation.org/library/docs/jour1007/young.pdf
5. http://www.dentalguideusa.org/dental_statistics/childhood_tooth_decay.htm
6. Watt, R., and A. Sheiham. "Inequalities in oral health: a review of the evidence and recommendations for action." BRITISH DENTAL JOURNAL 187 (1999): 6-12.
7. Lewis, Charlotte W., David C. Grossman, Peter K. Domoto, and Richard A. Deyo. "The Role of the Pediatrician in the Oral Health of Children: A National Survey." PEDIATRICS 106 (2000): 1-7.
8. http://www.dentalhealthfoundation.org/index.php?option=com_content&task=view&id=35&Itemid=52
9. Edelstein, Burton L. Crisis in Care: The Facts Behind Children’s Lack of Access to Medicaid Dental Care. United States of America. Department of Health and Human Services. National Center for Education in Maternal and Child Health. May 1998.
10. Vargas, Clemencia C., and Cynthia R. Ronzio. "Relationship Between Children’s Dental Needs and Dental Care Utilization: United States, 1988–1994." American Journal of Public Health 92, (2002): 1816-821.
11. http://www.cms.hhs.gov/home/schip.asp
12. Petersen, Poul Erik, Danila, Ioan and Samoila, Anca(1995)'Oral health behavior, knowledge, and attitudes of children, mothers, and schoolteachers in Romania in 1993',Acta Odontologica Scandinavica,53:6,363 — 368
13. Vargas, Clemencia M., Robert E. Isman, and James J. Crall. "Comparison of Children’s Medical and Dental Insurance Coverage by Sociodemographic Characteristics, United States, 1995." Journal of Public Health Dentistry 62 (2002): 38-44.
14. The Dental Health Foundation, CALIFORNIA WORKING FAMILIES POLICY SUMMIT, 18 Jan. 2007, 520 3rd Street, Suite 108 Oakland, CA 94607. POLICY RECOMMENDATIONS ON ORAL HEALTH. 1-4.
15. Blinkhorn, Anthony S. "Influence of social norms on toothbrushing behavior of preschool children." Community Dentistry and Oral Epidemiology 6 (1978): 222-26.
16. FIRST 5 CALIFORNIA, Oral Health Education and Training Project. Rep.No. BARBARA AVED ASSOCIATES. 1-137.
Singer M. AIDS and the health crisis of the U.S. urban poor: the perspective of critical medical anthropology. Soc Sci Med. 1994;39(7):931-948.
Vargas, Clemencia C., and Cynthia R. Ronzio. "Relationship Between Children’s Dental Needs and Dental Care Utilization: United States, 1988–1994." American Journal of Public Health 92, (2002): 1816-821.
Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984;11(1):1-47.
Pescosolido BA, Levt JA, eds. Social Networks and Health, 8th ed. Elsevier, Inc.; 2002.
Lasswell H. 1948. “The Structure and Function of Communication in Society.” In L. Bryson (Ed.), The Commnicatio of Ideas. New York: Harper & Row.

Dole Food Company’s Five a Day Campaign: A Critique and a Cure – Jason Itzkowitz

2008-12-18T09:54:00.000-08:00

A CRITIQUE OF DOLE FOOD COMPANY’S FIVE A DAY CAMPAIGN
This is a critique in response to Dole’s Five a Day Campaign which is aimed to encourage all Americans to eat a minimum of five servings of fruits and vegetables a day. This intervention began in 1991 and ended in 2003 (2). This campaign was ineffective because throughout these years, America has witnessed an increase of diseases such as heart disease and obesity. These were diseases in which Dole aimed to reduce, through its main message to encourage America to eat five to nine servings of fruits and vegetables a day (2). Dole Food Company is a founding member of this national Five a Day Campaign for better health program. Through nutritional education programs, they simply encourage children and their families to eat five to nine servings of vegetables and fruits a day. Educational materials and programs include five a day supermarket tours, Dole’s five a day website, five a day friends e-mail, and a Fun with Fruits and Vegetables Kids Cookbook (2).
Although this public health intervention is an effort to encourage healthy eating habits and decrease America’s serious obesity epidemic, it is ineffective and is flawed in many ways. First, the intervention is strictly individually based as it advocates that everyone must proactively on their own, take the initiative to eat a total of at least five servings of vegetables and fruits a day. This is far too simplistic and ignores many of the problems with enacting an intervention that is solely individually based. Second, it does not take into consideration the role of social factors that inevitably influences eating behaviors. Issues like socio-economic factors and social norms both impact diet. This study fails to acknowledge these endeavors and their impact on health. Finally, this campaign is ineffective because it is culturally incompetent and fails to consider the role of culture on diet. This campaign is consequently flawed because of these three claims. It will become quite apparent as to why in this paper.
Dole’s public health effort advocates for the individual to make the decision to eat five servings of vegetables and fruit a day. It is positive that this company raised awareness about healthy eating habits by promoting that people consume a sufficient amount of daily fruits and vegetables. However, their approach is flawed as their campaign will consequently result in a great deal of wasted time and money. To tell someone to eat their fruits and vegetables a day is far too simplistic. Diet and eating behaviors are complex conceptions. There are many factors at play that impact healthy eating habits. Everyone has their own unique lives and obstacles that may prevent them from eating a healthy diet. For example, an individual may hold such a stressful job that causes him/her to seek unhealthy candies in order to alleviate his/her anxiety. Although this person may take Dole’s health campaign seriously and evaluate the benefits of eating a minimum of five servings of vegetables and fruits a day, he/she may still not conform to the campaign’s goals because of this stressful job. In this campaign, it is up to the individual to take the initiative to enroll in Dole’s educational programs like the five a day supermarket tours. The reality is that many families and children will not get themselves to do so due to a lack of time and motivation.
Another reason why Dole’s intervention effort is flawed, due to its sole focus on the individual, is because individuals can be predictably irrational. This campaign assumes that individuals will observe their message to eat five servings of fruits and vegetables a day and will consequently make the rational decision to take on these eating behaviors due to its benefits. An individual may intend to comply with this message after perceiving that fruits and vegetables lead to weight loss and reduces the risks of certain diseases like cancer and CHD. However, because people can be irrational, this does not mean that this person will rationally make the decision to take on this novel behavior. For example, even though a person may intend to attend a five a day supermarket tour with the hope that it will encourage them to eat healthier, they may not rationally make the decision to do so. Due to the complexity of human nature, people can be irrational in this fashion. Because this campaign assumes that people are rational and will intend to follow through with their decision to consume this sufficient amount of fruits and vegetables, it is consequently flawed.
My argument declaring the ineffectiveness of this campaign due to its sole focus on the individual, leads me to my next claim which suggests Dole’s failure to consider important social factors that inevitably influence such healthy eating behaviors. Its focus on the individual overlooks the fact that behaviors like diet are made in the context of a complex ecological social environment. Socio-economic status is a higher level factor that has an impact on health behaviors and health outcomes. According to Haan et al in their study, “Poverty and Health” (1987), “Socioeconomic position is one of the most persistent and ubiquitous risk factors known. Members of lower socioeconomic groups experience higher incidence and mortality rates and poorer survival rates for most major chronic diseases” (4). It is therefore safe to say that the higher one’s socioeconomic status, the more these individuals will take on healthy behaviors like healthy diet, and the less they will experience an adverse health outcome like obesity or CHD. If “John,” the CEO of Dole, has access and money for foods like fruits and vegetables (which can sometimes be expensive), it can conveniently wind up in his house refrigerators. On the other hand, there is “Joe” who holds a minimum wage job and struggles to eat three healthy meals a day. This impoverished individual may take Dole’s campaign extremely seriously, and he may desire to eat nine servings of fruits and vegetables a day. However, due to his job that barely pays him enough money for monthly rent, he just cannot afford to eat nine servings of vegetables and fruits a day. Joe may also not be able to afford a computer which is essential for Dole’s campaign since many of its educational materials are through email and on the internet.
Another external factor is geographic location. In lower socioeconomic communities, supermarkets like Trader Joes that promote healthy eating habits and mainly sell healthy foods like fresh fruits and vegetables are simply not present. People like Joe would love to go there, but he lives in a working class neighborhood. The closest Trader Joes to him is about an hour away from him. Joe could take public transportation to this location but it would require him to change train lines and would take up too much time because he has to work every day. Also, he just cannot afford to take the train back and forth because that is money he usually relies on for his lunch. Joe, who is an advocate for the Five a Day Campaign, and desires to follow through with its message, is simply deterred from doing so. Unfortunately, Joe cannot adhere to the campaign because society’s structural forces of money, access, and geography simply restrict him from doing so. What Joe does have are three fast food joints (comprised of foods with high sodium and trans fats) within his distance so it is convenient and inexpensive for him to eat his meals. Why would he therefore put in all of that effort, time, and money to go to Trader Joes? Our friend John on the other hand, has a five minute car ride from Trader Joes which resides a few miles from his mansion on the ocean. John who believes in the Five a Day Campaign can consequently meet the intervention’s daily goals because of his location next to a supermarket that sells healthy foods and advocates for healthy eating habits. He also has the money to afford an endless amount of fruits and vegetables a day. He can also afford all of the campaign’s materials like the cookbook and a computer which allows him to participate in Dole’s website and email offers.
Although many individuals perceive the benefits of Dole’s campaign and would follow through with their intention to eat up to nine servings of vegetables and fruits a day, there is that barrier of socio-economic status which can restrict one from doing so. In my opinion, this is unfortunate because the majority of America’s population is in this position. I believe that this is a main reason as to why America has an obesity and heart disease epidemic.
Socioeconomic status is an important factor that this campaign blatantly overlooks. Instead of mundanely stating that everyone ought to eat a minimum of five servings of vegetables and fruits a day, there needs to be a campaign that promotes healthy eating behaviors that takes into consideration many complex social factors like socioeconomic status. Perhaps there ought to be a campaign which advocates for lowering the prices of fruits and vegetables and one that raises the importance of placing stores like Trader Joes in unprivileged communities. Such an intervention ought to be accomplished so that those of lower socioeconomic status have access and can afford such healthy foods which prevent adverse disease outcomes and lead to happier, healthier lives.
In addition, under this “social factors argument,” the Five a Day Campaign fails to take into consideration social norms. In certain communities or networks, the perceived norm may not be to ingest a sufficient amount of fruits and vegetables day in and day out. Especially in underprivileged communities, this expectation to eat in such a healthy manner may not be taken as seriously as it should be. This could be due to issues mentioned earlier like access, money and geography. Nevertheless, if eating up to nine servings of vegetables and fruits a day is perceived as abnormal in a clique or community, individuals will most likely not violate this hidden rule even if there is a campaign that advocates this message. A group of so called macho roommates, for example, may create the norm that it is “uncool” to eat fruits and vegetables and link its consumption with being effeminate. With the fear of looking womanly or “untough,” not one man may even buy any fruits or vegetables to put in their common refrigerator. Although each of these men may have seen the Five a Day Campaign ad on billboard on their way to the bar and may take it seriously, they simply will not consume a sufficient amount of fruits and vegetables with the fear that they will be ostracized from their group of roommates/friends. Moreover, the Five a Day Campaign fails to be effective due to the Social Expectations Theory (1).
Perhaps if the campaign implemented an element that addresses social norms it could somewhat be effective. Through an advertising campaign for example, their five a day ad could link eating vegetables and fruits with being manly and tough. Through its promise that eating up to nine servings of vegetables and fruits a day will make a man tough and rugged, it could work to normalize healthy eating behaviors in the male population. Nevertheless, this campaign fails to address issues like social norms and socioeconomic status. This last section aims to critique this campaign effort and reveal its last flaw which fails to address the components of culture and stigmatization in contemporary American society.
In the United States, where this campaign had reigned, there are many diverse belief systems and cultures. Some cultures may view the notion of health differently from another and may place a low value on eating up to nine servings of fruits and vegetables and some may not. Different cultures have unique norms about eating habits and what constitutes a healthy diet (3). This Five a Day Campaign is strictly from the point of view of what Americans believe comprises a good diet. American institutions such as the Surgeon General of the United States and the U.S Public Health Service all support and advocate for this campaign (2). Its platform is strictly what they think is the best diet for all Americans. This United States population includes citizens that can place different meanings on health and diet due to their unique culture.
Moreover, this campaign is run by American public health authorities and experts. Thus, its message to eat up to nine servings of vegetables and fruits a day is what Americans perceive as a good and healthy diet. Another person from a different culture may not feel the same way. In fact, some cultures view a large body type as being a positive endeavor as it echoes high self-esteem (3). Therefore, this culture may not place a high emphasis on eating fruits and vegetables because eating them will result in lean body types.
Also, another culture may not understand this message because it is strictly from an American’s perspective. Due to deeply embedded norms about food, diet, and eating, one from a foreign culture living in the United States may not comprehend this message and its intentions because their own culture places different values on what constitutes a healthy diet. For example, in Marsh et al’s study (2007), “Childhood Obesity Gender Actual-Ideal Body Image Discrepancies and Physical Self-Concept in Hong Kong Children: Cultural Differences of Moderation,” reveals that the Chinese culture values eating in moderation and accepts the notion of obesity more than western cultures like the United States (5).
In addition, one from a different culture may view this campaign as oppressive and as a means to coerce minorities into conforming to the American culture’s way of healthy eating. In this light, this campaign could have an opposite effect on such individual. He/she may purposely not conform to their message as a way of rebelling to the mainstream values of a culture who is attempting to tell them what to do. An individual may go out of their way and purposely not eat any vegetables or fruits at all in order to preserve their cultural pride and to prove that this American approach of a healthy diet is not superior to their own. In this light, the Five a Day Campaign is culturally incompetent as its goals and messages are strictly from an American perspective and fails to consider the many unique belief systems which reside in the country where this intervention takes place. It is culturally insensitive because this is a campaign that is addressed solely to the typical American. Eating a sufficient amount of fruits and vegetables a day has been constructed and maintained as an American norm regarding healthy diet. It may not be the same case for many unique cultures in America’s “melting pot.” Although American public health officials may have thought that this one approach may fit the entire American community, it simply does not. Being in America, one would think that such a campaign would be sensitive to other cultures. In order to promote a higher consumption of fruits and vegetables a day which leads to a healthy diet, more research on culture and the many belief systems that dwell in America must be accomplished.
The last issue which falls under my culture argument is the notion of stigmatization. This Five a Day Campaign overlooks this fact totally. There are those in America who are obese and overweight who may be stigmatized and feel inferior. Although there s a large number of obese Americans, obese individuals are not looked highly upon and can be discriminated against in the United States (7). Some gain the stigma that they are lazy due to a lack of exercise or that they lack self-control in their eating habits. This stigma in American culture where this Five a Day Campaign resides could prevent such an obese individual from adhering to its message (7). The reason is because stigmatization usually produces a sense of low self-esteem and hopelessness (7). Even though an obese individual may perceive the benefits of eating up to nine servings of fruits and vegetables a day, he/she may feel that doing so won’t matter. He/she may feel that nothing will solve their problem and that they may as well keep eating unhealthy because putting in the effort to conform to interventions, like the Five a Day Campaign, simply will not help.
The study, “Stigma, Obesity, and The Health of Nation’s Children,” by Puhl and Latner (2007), reveals that stigmatization in American obese children tend to result in negative health outcomes (7). To tackle the problem of obesity in their opinion is to solve the problems of weight stigmatization. The authors review stigma-reduction efforts that have been proven to improve attitudes toward obese children. They suggest that abolishing weight stigma in youths and enhancing their positive attitude consequently increases their chances of overcoming obesity and leads to better physical outcomes (7).
Similarly, the main issue here is not the simple consumption of fruits and vegetables, but rather augmenting these obese individuals self esteem and giving them hope that they can lose weight and become healthy by adhering to such a healthy diet. Dole’s Five a Day Campaign does not mention anything that could possibly increase self-efficacy and confidence within such individuals in order to get them to consume up to nine servings of vegetables and fruits a day. In fact, the campaign is pretty boring in my opinion and lacks any type of motivational factor to get the American population (never mind obese individuals) to conform to this healthy diet. If this Five a Day Campaign had any type of “jolt” or any interesting techniques to motivate individuals who may feel hopeless in their attempts to eat up to nine servings of vegetables and fruits a day, they would increase self-efficacy and confidence for those who desire to adhere to their intervention. This would consequently abolish the negative effects that stigmatization could have on their health campaign.
These three prior arguments reveal that Dole’s Five a Day Campaign is flawed and ineffective. The intervention’s sole focus on the individual, its lack of attention to social factors, and its ignorance to culture are three major reasons as to why this campaign has been unsuccessful in solving serious American health problems like heart disease and obesity. In 1991, when this campaign began, 10-14% of individuals in most states were considered obese, or in other words, they had a BMI of greater than or equal to 30 (6). In 2003, when this campaign ended, 20-24% of individuals in most states met the criterion of being obese. In fact, in 2003, there were four states in which over 25% of the people were obese (6). Moreover, while this intervention took effect, America actually grew fatter. In my opinion, those behind this campaign put no effort into researching how they could make their cause effective. Instead of investigating certain cultural and social factors, for example, all the campaign designers really did was simplistically and mundanely state, “eat a minimum of five servings of vegetables and fruits a day.”
In my opinion, Dole really did not care about making America healthier with their message. Instead, they sought to advertise their product “Dole.” Instead of a health campaign, it was more like an advertising campaign for their own selfish interests to sell their products like pineapples. By linking their company with a health campaign and revealing that they were connected to agencies like the American Board of Public Health, they believed that the American public would view their company as health conscious and as benevolent. Also, their campaign for individuals “to eat up to nine servings of fruits and vegetables a day” was designed so that people simply buy products that Dole sells which are unsurprisingly fruits and vegetables. Although they may be viewed in the public eye as one who advocates for better health and has products which will ameliorate America’s well-being, they’re intention is to solely sell a product.
This company could have put more time, effort, and money into researching important issues like social and cultural factors in order to make their campaign effective. However, they probably felt that they did not need to. They simply did what was good enough to help their own corporate cause and profits. This is so because their goal is not to improve the public’s health but rather to sell a product.
Moreover, I believe that corporations like Dole should not promote such health campaigns. Precious institutions like schools and universities ought to design campaigns as they have the research tools, they will put in the time and effort, and they also have the heart to truly improve America’s public health. Such institutions like Boston University, uncontaminated by American consumer culture, have designed effective interventions that focus not only on the individual, but also on social and cultural factors. These campaigns usually prove to be successful and therefore ought to be implemented in order to solve many of America’s important public health problems like obesity.
A CURE FOR DOLE FOOD COMPANY’S FIVE A DAY CAMPAIGN
As we have examined, Dole’s Five a Day Campaign was extremely flawed because it was based solely at the individual level and it neglects many important social and cultural factors. This paper focuses on addressing these problems in order to make this campaign effective. Here, I will fill in the holes of the Five a Day Campaign by considering the Social Networking Theory, Social Expectations Theory, socio-economic status, cultural competence and awareness, and stigmatization.
As assessed, Dole’s campaign’s sole focus on the individual results in an ineffective and unsuccessful intervention. To merely tell someone to eat a minimum of five servings of fruits and vegetables is too simplistic and mundane. Being strictly at the individual level, Dole’s campaign effort assumes that people will rationally decide to take on these eating behaviors because of its benefits. Although an individual may intend to eat up to nine servings of vegetables and fruits a day, this does not mean that a person will rationally make the decision to do so.
To address this issue, the Five a Day Campaign ought to implement the Social Networking Theory (3). The researchers of this intervention ought to identify people in certain networks like employees in a restaurant. For example, this campaign ought to be targeted to specific groups like workers at a Burger King. Responsibility should be placed on the manager who is someone these employees look up to and obey. These employees can make the effort to abide by the rules of Dole’s Five a Day Campaign in a communal effort. Perhaps the boss will command her workforce to come in with at least five servings of vegetables and fruits to eat throughout the day. Here, the individuals of this network are working towards the same goal which is to eat a sufficient amount of fruits and vegetables a day. Doing this only increases confidence within the group and augments their self-efficacy that they can adhere to this intervention. They will all gain a sense of accomplishment, they will feel healthier, and grow more connected as a group while being apart of a communal effort. Also, in this fashion, this campaign will work to be successful on a greater number of people at the same time.
In addition, Dole’s five a day campaign ignores many important social factors. First, this intervention takes place in a complex ecological social environment. It is therefore essential, that we consider social factors like socio-economic status and social norms. This campaign overlooks the fact that many Americans cannot afford such healthy foods and cannot travel to certain supermarkets comprised of healthy foods like Trader Joes. Individuals in impoverished neighborhoods are located far from such stores and simply do not have access to healthy foods. Traveling a far distance to a Trader Joe’s for many can be time consuming and expensive. Even if one wanted to abide by the Five a Day Campaign, they may not be able to due society’s many structural barriers.
Thus, within this campaign, there ought to be a strong element of advocacy in regards to socioeconomic status. The intervention should advocate lowering the prices of fruits and vegetables in general, and it ought to raise awareness about building stores like a Trader Joes in underprivileged communities. They ought to promote the fact that fruits and vegetables are extremely important due to their health benefits and thus ought to be affordable to everyone. In addition, perhaps Dole as a corporation could open up small stores in all communities where fruits and vegetables are cheap and conveniently accessible. This could not only work to make Americans healthier, but also it would certainly contribute to Dole’s advertising efforts and profits.
Also, in some communities the perceived norm may not be to consume a sufficient amount of fruits and vegetables. In underprivileged communities, for example, where fast food joints like Macdonald’s and Burger King reside, the expectation to eat up to nine servings of fruits and vegetables a day may not be taken as serious as it should be. If eating this amount of fruits and vegetables a day is viewed as abnormal in a community, these individuals will most likely not violate this concealed norm even if there is the Five a Day Campaign that supports this message.
Moreover, in order to make this intervention successful, Dole must consider the notion of social norms and implement the Social Expectation Theory (1). Through an advertisement, for example, Dole could link eating up to nine fruits and vegetables a day with success, love, and happiness. They could have many advertisements promising these endeavors that targets all social classes. For example, they could have an advertisement where a handsome man and a beautiful woman in a working class community are on their lunch break smiling and eating a meal comprised of rich, colorful vegetables. Of course, the couple is in love and appears extremely happy. Such an ad would promise that anyone who eats a minimum of five servings of fruits and vegetables a day will encounter love and happiness. Here, Dole could advertise their fruits and vegetables products in their commercials and also advocate their positive health message. Through these promises embedded within their advertisements, the campaign could work to normalize healthy eating behaviors in any given population. Once again, it would not only work to make America a healthier country, but it would also work to strengthen the profits of Dole Corporation.
The next issue that Dole’s campaign fails to address is culture. This intervention dwells in America where there are many diverse belief systems and cultures. Different cultures have distinct norms about what constitutes a healthy diet. As we have assessed, this campaign is strictly from the perspective of what Americans believe makes up a good diet. Thus, one from another culture in America may not understand Dole’s message, because of deeply ingrained norms regarding diet, food, and eating behaviors.
In order to fix this problem, Dole must employ researchers working on this campaign from different cultures, and hire those who are culturally competent and sensitive to others’ belief systems. Many cultures may view eating vegetables and fruits as important but may perceive the way Dole advocates the consumption of them as wrong and strange. Those designing this intervention must incorporate the main cultures that reside in the United States. In the campaign’s programs and materials, researchers must develop techniques that address these cultures. In order to accomplish this, extensive research should be done on the many cultures that comprise America’s “melting pot.” For example, the designers could implement recipes comprised of a sufficient amount of fruits and vegetables in accordance with specific cultures way of cooking and eating. For example, the Five a Day Campaign could be culturally sensitive to an Indian style of cooking and offer recipes that implements a variety of vegetables mixed with Indian spices like curry.
Also, because this intervention is strictly from an American point of view, some minorities may feel that this campaign is a means of coercing them into conforming to the American’s way of diet. One from a different culture may purposely not adhere to such an intervention because they do not want to be told what to do by the mainstream culture. They may also refuse to follow this effort in order to maintain their cultural pride and to prove that this American approach of eating healthy is not superior to their own. This is simply a matter of oppression. In order to address this potential problem, Dole should hire researchers working on this campaign from all different cultures and backgrounds. In addition, they should make light of the fact that they have employed a diverse group of experts, and emphasize the fact that it has been constructed by individuals from a variety of unique cultures. By revealing that this campaign is from the viewpoint of an array of different belief systems, their efforts to be culturally competent and sensitive would show. Moreover, the campaign should be designed in a way that is non-intimidating to cultures who may not be able to comprehend its messages, and who may feel that the campaign designers are attempting to acculturate them to America’s belief system. In this light, individuals from all backgrounds in America could abide by this campaign which advocates for the beneficial pursuit of a healthy diet.
The last issue that needs to be addressed is stigmatization. The Five a Day Campaign completely overlooks this fact. Especially in America, where the obesity epidemic is prevalent, those who are overweight or obese may feel inferior. Many are stigmatized as being lazy or as lacking self control in their eating habits. Such a stigma produces a sense of hopelessness and low self-esteem (7). This only works to hinder an obese person from adhering to this five a day campaign message which must be heard. As Puhl and Latner (2007), suggest, enhancing a positive attitude and increasing hope within children who are obese is the only way to eliminate stigmatization and thus augment self-efficacy to lose weight (7).
Similarly, this campaign must implement a sense of motivation or a “jolt” to those who may feel hopeless in their attempts to eat up to nine vegetables and fruits a day. For example, they should construct operant conditioning techniques. If an obese person eats up to nine servings of fruits and vegetables everyday for four months and then loses weight, Dole should give them free gift certificates to their food products. (Of course, the individual would have to come into a clinic and weigh themselves and then come in four months afterwards to monitor and evaluate their progress.)
In addition, the campaign ought to have language within it that encourages everyone, especially overweight and obese individuals in order to achieve its goals. It must stress the fact that it is never too late to change one’s diet and to eat healthy. This would only increase hope and confidence within obese individuals and eliminate stigma. Even if the person is not obese, such motivational efforts would work to increase the confidence for those who desire to comply with this intervention.
As Michael Siegel suggests in his work, “The Importance of Formative Research in Public Health Campaigns: An Example From the Area of HIV Prevention Among Gay Men (Appendix 3-A),” the campaign to encourage gay men to wear condoms was ineffective because gay men and their homosexual relationships (especially sexual relationships) are looked down upon in society and are viewed as abnormal (8). This stigma causes hopelessness for them to change their risky behaviors. He suggests that if gay men’s relationships were tolerated and appreciated, such stigmatization would be abolished.
Similarly, if Dole worked to eliminate such stigmas like laziness in obese individuals in American culture, their campaign would be successful and useful. If Dole increased the hope of such individuals in their campaign and encouraged them to have a positive attitude, such stigmatization would be eliminated and the acquirement of healthy eating behaviors would result. This could only work to make America a healthier society and curb its epidemic of obesity.
After criticizing Dole’s Five a Day Campaign was essential, the next task was to go back and mend its holes. Criticizing and commenting on such a campaign is essential but it is extremely necessary to go back and to cure its flaws. These prior solutions to the unsuccessful Five a Day Campaign will work to make this intervention successful and useful in any community. By addressing the problem of being solely at the individual with the Social Networking Theory and by considering social and cultural factors, this campaign would work to make America a healthier place to live.
REFERENCES:
1. DeFleur, M.L (1989). “Chapter 8: Socialization and Theories of Indirect Influence.” Theories of Mass Communication. New York: Longman Inc.
2. “Dole 5 A Day” (2004). Dole Food Company, Inc. .
3. Edberg, M (2007). Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers.
4. Haan, M et al (1987). Poverty and health. American Journal of Epidemiology, Vol. 125(6), pp.989-998.
5. Marsh, H. et al (2007). Childhood obesity, gender, actual-ideal body image discrepancies, and the physical self-concept in Hong Kong children: Cultural differences in the value of moderation. Developmental Psychology, Vol. 43(3), pp.647-662.
6. “Obesity in America.org.” .
7. Puhl, R.M and Latner, J.D (2007). Stigma, obesity, and the health of the nation’s children. Psychological Bulletin, Vol. 133(4), pp. 557-580.
8. Siegel M. The importance of formative research in public health campaigns: An example from the area of HIV prevention among gay men (appendix 3-A), pp. 66-69. In: Siegel M, Dover L. Marketing Public Health: Strategies to Promote Social Change.

Hand Hygiene Interventions Need Some Cleaning Up: A Critique of Current Hand Hygiene Program’s in Hospitals Nationwide - Emily Scheer

2008-12-18T09:51:00.000-08:00

Hospital acquired infections (also known as nosocomial infections) are a well documented cause of increased morbidity and mortality among hospitalized patients in the United States. Nearly 2 million patients are affected and almost 80,000 individuals die each year as a result of acquiring such infections making this a serious public health issue in the United States (4). Given the severity of this issue, successful public health interventions are necessary to halt the spread of disease.
Hand hygiene has been identified as an essential evidence based infection control measure to prevent the occurrence of hospital acquired infections, “Hand hygiene by hand washing or hand disinfection remains the single most important measure to prevent nosocomial infections” (9). Nonetheless, hand hygiene policies are not always followed by health care workers and poor compliance is repeatedly documented throughout entire hospitals and hospital systems nationwide. Some interventions have proven successful. However, success has been short lived. Hand hygiene programs in the United States have had difficulty achieving lasting improvement (4). If hand hygiene interventions fail to incorporate a multidimensional approach to behavior change, social norms and self efficacy, and continue to be unsuccessful in effectively educating health care workers, successful hand hygiene programs cannot be sustained.
Lack of an Interconnected Approach to Behavior Change

What many widespread hand hygiene interventions are missing is a multi faceted and creative design to change health behavior (4). Interventions aimed at improving compliance with hand hygiene must be based on the various levels of behavior interaction including the interdependence of individual factors, environmental constraints such as access to hand washing supplies at point of care, knowledge and values that are inherent to the many medical specialties, and institutional culture. Noncompliance with hand hygiene interventions may not only relate to the individual health care worker but to the group or specialty he/ she belongs to.
The complex dynamic of behavioral change involves a combination of education, motivation, and system change that acknowledges social norms and self efficacy. Hand hygiene interventions have traditionally followed the framework of the popular and frequently utilized model of health behavior, the Health Belief Model (3). This model focuses on behavior change at the individual level. It is limited in that it does not look at change in a group context nor does it account for social and environmental factors. Time after time, hand hygiene guidelines focus on the individual and fail to incorporate aspects of the complicated environment that the typical health care worker is in. Many risk factors for non-compliance with hand washing among health care workers are continuously faced including increased workload, stress, lack of time, psychology, the culture of the environment or unit of the hospital, individual values as well as values inherent to certain medical specialties, availability and access to hand washing materials, type and intensity of patient care required, nurse to patients ratios, and education as to what the correct hand-hygiene techniques are (9). Compliance with recommended instructions is commonly poor because hand hygiene models have failed to consider and account for these complex risk factors. Hand hygiene interventions have primarily focused on the individual which is not enough to result in sustainable change (7).
Failure to Establish a Culture of Safety that Incorporates Social Norms and Self Efficacy
Traditional hand hygiene interventions have failed to consider social norms in development of policies. In health care, as in many other environments, behavior will be influenced according to whether or not a person will meet approval or disapproval by his/her social groups, or in this case among the various medical specialties (nursing, physicians, respiratory, etc) (3). For example, if the intervention is driven by the nursing department, a physician may be less likely to comply because his/her group did not “buy in” to the program. The physician-in-chief did not support the program or feel that it was necessary and this attitude and belief trickled down to the rest of the physicians. Hand hygiene interventions must incorporate social norms and above all aim to make compliance the social norm among all medical specialties.
An additional limitation of current hand hygiene programs is the lack of incorporation of self efficacy. Staff must believe that they have the ability and power to make major improvements and that hand washing will lead to these big improvements. Health care workers must be empowered to remind other caregivers, regardless of rank, position, or specialty to practice hand hygiene and comply with all guidelines (4).

Failure to Educate and Communicate
A key element in implementing a successful hand hygiene program is educating and motivating the staff. Unfortunately, hand hygiene interventions based on the Health Belief Model assume that all health care workers have enough education and knowledge to make a rational decision surrounding hand washing. In reality, there is an overall lack of knowledge among health care workers regarding how hands are easily contaminated, how infection is spread, the efficacy of hand hygiene in reducing this spread, and lack of awareness of the recommended and most effective hand-washing techniques (8). The Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee published Guideline for Hand Hygiene in Health-Care Settings in 2002. Within these guidelines, it strongly recommended that alcohol-based hand rubs are the preferred method of hand hygiene because they are easy and quick to use and are extremely effective in killing bacteria and viruses that cause nosocomial infections. Introduction of alcohol-based hand rubs and education materials must be introduced as a part of hand hygiene programs and spread at a group level. Hospital employees need to be able to express knowledge and understanding that alcohol based hand rubs are extremely effective, are accessible, and are very quick and easy to use. Current hand hygiene programs have failed to ensure that staff entirely comprehend the rationale behind implementing hand hygiene programs. They are not designed in a way that results in high levels of staff “buy in” and high staff comprehension of the danger of not complying with the policies, not only to their patients but to themselves (2).
When asked, health care workers report the following reasons that they believe make it difficult to comply with hand hygiene programs: skin irritation caused by constant washing or use of the disinfectant rubs, “being too busy”, and “not thinking about it” (9). Health care workers must be educated that alcohol-based hand rubs have advantages to traditional hand washing because they require less time, are extremely fast acting and effective in preventing transmission of infection, and are less irritating to the skin. Studies have found that alcohol based hand rubs do contribute to the sustainability of high program compliance rates and are associated with decreased infection rates (7).
The Future of Hand Hygiene
Traditional hand hygiene programs may be successful short –term in some hospitals as an effective way to reduce hospital acquired infection rates but this intervention is not likely to be both effective and sustained for long periods of time. A more appropriate hand hygiene intervention would focus on health care worker’s behavior at the group level. Hand hygiene programs must be further developed to move beyond a model that focuses on individual behavior and include more psychosocial elements that will influence intention, attitude toward the behavior, perceived social norms, perceived risk of infection for self and patient, habits of hand hygiene practices, knowledge, and motivation at both the individual and group level. (7) Interventions must grow to incorporate a multidimensional approach to behavior change, social norms and self efficacy, and figure out how to effectively educate health care worker. Until then, morbidity and mortality due to hospital acquired infections will remain high in hospitals across the United States. Hand hygiene interventions must be changed so that quality of life can be improved for millions of patients in this nation’s health care system.
Hand Hygiene Programs in the United States: All Cleaned Up!
An unfortunate reality for the current health care system in the United States is that the prevalence of drug-resistant organisms in nosocomial infections is high and continues to be on the rise. The impact that this has on patient outcomes is incredibly severe. In light of all of this, it is well documented that prevention is possible. The key intervention suggested and supported by endless evidence is surprising in that it seems so simple. It is something that many of us were taught to do regularly since we were fairly young – wash our hands (7)! Although evidence based, proven important, and simple sounding, “hand hygiene by hand washing or hand disinfection remains the single most important measure to prevent nosocomial infections,” (9) hand hygiene interventions have been complicated and difficult to implement and sustain. Experts estimate that health care workers comply with recommended hand hygiene procedures less than 50 percent of the time — contributing to some terrible consequences (7).
Due to increased morbidity, mortality, and health costs that can result from health care workers failing to comply with hand hygiene protocols, this has become a major public health problem in the United States. Clearly, it is an issue that is worth working on and devoting substantial resources to. An alternative program must be implemented nationwide that moves away from policies based on the traditional health behavior models. A new program should incorporate an interconnected approach (specifically dealing with the health care environment and access issues), social norms, messages of empowerment and self efficacy, and improved education and communication of vital information.
Incorporating an Interconnected Approach to Behavior Change
An improved hand hygiene model should concentrate on taking an interconnected approach to improving compliance with hand hygiene programs. Unfortunately, many current hand hygiene programs currently take an “x causes y” approach to forming new policies and dealing with the issue. This type of approach does not deal with the “messiness of life.” Major risk factors for poor compliance with standard policies include lack of time or opportunity and poor access to hand washing facilities (7). These risk factors move beyond individual behavior and indicate that there are many external factors that can make behavior and life “messy” at times. This indicates that to implement a sustainable program these factors in the environment of the health care worker must be acknowledged.
In an ICU setting there is high workload and high demand of care. To improve access, opportunity, and deal with time constraints, the main hand hygiene agent promoted should be an alcohol based hand rub because it is quick to use, easy to access, and highly effective. Here, a focus study should be done with staff that examines various locations of the gel dispensers to ensure best possible access. The dispensers should be trialed at different locations at the bedside to determine where they are most easily accessed and most often remembered and used. Another proposal to improve access is to look at where health practitioners already keep items and information they want to have immediate access to. For example, many physicians keep tools the need to use in their white coat pockets such as patient notes, calculators, blackberries, etc. Leading alcohol based hand rub manufacturers have developed smaller and slightly flatter bottles. These could easily be stored in physician’s pockets without getting in the way. This would make hand hygiene available right at his/her hip in a location that is easy to remember and already part of their culture and behavior.
Establishing a Culture of Safety that Incorporates Social Norms and Self Efficacy
One major critique of current hand hygiene interventions is that they have traditionally followed the framework of the popular Health Belief Model (3). As mentioned previously, this model focuses on behavior change at the individual level instead of in a group context. It does not account for social and environmental factors. A hand hygiene program that changes focus to an alternative health behavior model that values and emphasizes social norms, such as Social Norms Theory, would prove to be a more successful and sustainable intervention. Social norms theory states that the behavior of an individual is greatly influenced by the way they perceive behavior of his/her social group (1). In the health care environment, if the worker views his/her medical specialty as being non-compliant with hand hygiene interventions, the urge that individual may feel to conform to that idea will negatively impact the compliance behavior of that entire group or specialty. However, if the various health care groups are educated effectively and hand hygiene is framed in ways that portray it as the norm and supported practice of the group, there may be more overall “buy in” to the program which would result in an overall higher compliance rate for the specialty group as well as the entire unit. Parallel to that, nosocomial infection rates and associated health costs would hopefully decrease.
Developing a culture of empowerment would help to foster compliance and change the social norm. There is an inherent hierarchy in the medical setting among the various specialties. Work should be done to eliminate this hierarchal structure and ensure that, for examples doctors and nurses feel that they are on the same level and have the same worth in influencing care of their patient. The feeling of empowerment developed by each group would trickle down to the individual and help him/her to be an advocate for a patient’s safety by kindly reminding his/her colleague to comply with hand hygiene policies. Hand hygiene is something that has to be practiced at every opportunity in order to get positive results. Therefore, self efficacy is an important component to any hand hygiene program. If health care workers believe that they have the ability and power to make major improvements by completing the simple task of washing hands per policy, compliance rates may rise. The action must be promoted as one small piece of a giant puzzle that makes up this major improvement.
Implementing Widespread Education and Communication
Many current hand hygiene programs have incorporated some type of education about hand hygiene through poster display or leaving pamphlets in staff mailboxes. However, merely making the poster is not an improvement and it is not adequate education and information. Instead, all efforts must be focused on placement and use of the poster. Posters should be informative, captivating, and placed in locations where they will not be missed (on the door to the unit, at the front desk, in the bathrooms, etc). Focus group should be formed by quality improvement staff and surveyed to assess whether or not people report noticing it, whether staff can answer questions about the material on the poster, and to ask people directly whether they believe it worked or not. The poster can be tested in various locations of visibility on the unit. Once the most ideal location is decided upon based on focus group feedback, information should be changed in and out on a regular basis to update, inform, and reeducate staff. To enhance communication, improvement leaders should make sure that data and audit results are disseminated to staff and posted where it can be seen. In many widespread surveys, health care workers report that they don’t see the numbers or results they just get the order to “do better” and this does not make them happy. Health care workers need to be made aware that hands need washing in certain situations. They should be educated on the specific definitions of hand hygiene “opportunities”, what supplies are available to them, and the location of such supplies. A hand hygiene program should identify and educate a few “champions” from each medical specialty who will go through training and evidence based education sessions. Each champion would be responsible for educating his/her appropriate group and advocating for change (5).
Education and communication also goes beyond the health care practitioners. A successful hand hygiene program should have a patient and visitor component, as well. A patient/visitor educational brochure and program should be developed that includes an orientation to the unit’s policies on hand hygiene and the negative outcomes that can occur as a result of failed compliance by health care workers. This will ensure that patients and families are aware and empower and encourage them to remind health care workers to wash their hands when caring for the patient (5).
Future
It is clear that a hand hygiene intervention that focuses on health care worker’s behavior at the group level will be successful and sustainable. Hand hygiene programs must move beyond a model that focuses on individual behavior and acknowledge that noncompliance with hand hygiene interventions may not only relate to the individual health care worker but to the environment and group or specialty he/ she belongs to. Therefore, a proposal to improve hand hygiene must incorporate the main attributes of social norms theory in order to make effective and sustainable change within hospital systems in the United States. It must also focus on access and environmental issues and utilize innovative education techniques. Overall, hand hygiene program designers and implementation managers must truly try to understand what really motivates people, specifically the medical staff in question, and work to gain better understanding of human behavior.
References:
1. Best Practices; Social Norms. http://wch.uhs.wisc.edu/13Eval/Tools/Resources/Social%20Norms.pdf
2. Boyce JM, Pittet D, et al. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity Mortality Weekly Report, 2002.

3. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

4. How-to Guide: Improving Hand Hygiene. Institute for Healthcare Improvement. 2006. http://www.ihi.org/NR/rdonlyres/E12206F9-6A81-4520-B92F-4BCB844133C2/3266/HandHygieneHowtoGuide1.pdf

5. Institute of Health Care Improvement. Improving Hand Hygiene Practice with Six Sigma. St. Paul, MN: HealthEast Care System. http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/ImprovingHandHygienePracticewithSixSigma.htm
6. Institute of Health Care Improvement. The Sound of Two Hands Washing: Improving Hand Hygiene. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/FSSoundofTwoHandsWashing.htm
7. Pittet, D. Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Diseases 2001.

8. Pittet D, Boyce JM. Hand hygiene and patient care: Pursuing the Semmelweis legacy. Lancet Infect Dis 2001.

9. Pittet D, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet 2000.
10. WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. World Health Organization, 2005. http://www.who.int/patientsafety/events/05/HH_en.pdf

Critique of the BMI Report Card – Jenna Tonet

2008-12-18T09:49:00.001-08:00

Obesity has been a continued concern in the United States, especially as it has risen dramatically in a relatively short period of time. One age group that is of great concern is children. Public health practitioners and health care professionals have worked to decrease obesity rates among adolescent using school-based interventions. One example of a public health intervention at the school level is the Body Mass Index (BMI) report card. Teachers issue students this card if the child is found to be at risk for becoming obese. This intervention is not effective for reasons that include labeling the child as overweight, framing the issue in a negative way, and preventing the child from believing they can change their behavior.
The intention of the BMI report card is to prevent obesity early enough in an individual’s life to make a difference. However, the approach is highly problematic because of its affect on an individual. Adolescence is a time in when children are very impressionable. Even though the intervention’s focus is to target the problem before it starts, the report card has more repercussions than good outcomes. The aim to prevent obesity becomes overshadowed by the harm caused to the child for a number of reasons. O’Dea (9) and Garner (4) both discuss the areas of concern regarding obesity prevention programs that are school-based, such as “stigmatization of pupils whose body weight are outside the “normal” range,” and “labeling of pupils as “overweight,” “obese,” “lazy” (1).
Stigmata Theory
The first and foremost reason is that the report card places a label on the child. This derives from the social science theory called the stigmata theory. When an individual is labeled a certain way, they develop a self-fulfilling prophecy (3). When the teacher gives the child this report card, they will often believe that they are and always will be overweight. Since the adolescent has this label, they will assume that this label is true. Therefore, they will not take understand how to interpret the original goal of the report card. The purpose of the card will not matter because the child and the parents will only focus on the label. According to the self-fulfilling prophecy, rather than trying to change the behavior, the child will assume the identity.
Since only the children who are found to be at risk for obesity receives this report card, they are singled out from the rest of the students. The stigma from this card affects how the individual views themselves and how they feel the other children look at them. If the report card has a negative connotation, the child will feel stigmatized. Also, they will feel isolated from the other children. When an individual is still developing their identity, they are vulnerable to impression, including what others think about them.
In a study of boys’ and girls’ perceptions of “fatness, thinness, social pressures and health” using focus groups, one of the conclusions was that the children believed that while being fat should not matter, they really did believe it does matter because those children were teased, bullied and had few friends (2). One such comment in the boys’ focus group was that “…people would be laughing at him, saying, “Ha ha, you’re fat, we’re strong” (2). With this label, the child’s stigmatization shows if other children tease them about the report card. The other children look at them differently because of the label given to the particular child with the report card.
Since not all children receive the report card, it is considered out of the social norm and not acceptable. The child can become victimized; and they suffer from being treated and viewed differently. In the focus group study, one of the boys accused the others of hypocrisy because they believed that the boys would single out the overweight child – “They say that now but in real life they’ll make fun of you if you’re different” (2). He had been an example of why that was true because he had been made fun of by boys in the group for that reason (2). Since adolescents do not know how to handle and understand differences, the child who is singled out is subject to their ridicule.
Social Cognitive Theory
Furthermore, the social cognitive theory illustrates more of the social factors addressed above. While this theory used to be known as the social learning theory, it moved from behaviorist roots to a theory that addresses individuals consciously operating within an environment (3). According to social cognitive theory, changing behavior is a function of individual characteristics, external factors, and an interactive process (3). However, the BMI report card directly contradicts this approach to changing a behavior. The self-fulfilling prophecy that results from the card’s issue prevents the first function of social cognitive theory.
This function, the individual’s characteristics, begins with the concept of self-efficacy, which is when a person has a sense about the new behavior, their confidence that they can do it and overcome obstacles (3). However, these components become questioned if the child does not believe that they can do it. The presentation of the report card can be viewed in a negative light. This does not allow the child to view a change in behavior as positive. Therefore, they will not want to change their behavior due to lack of confidence.
The child’s behavioral capability depends on their belief that they can make the behavioral change (3). Nonetheless, the report card is simply a piece of paper that warns the child and their parents that the child is at risk for becoming obese. In elementary school, an individual is still developing psychologically, so they will not completely understand the purpose of the card. Since they are singled out, the child only sees that and not the signal to make behavioral change. They also pick up cues from their classmates who bully them about their weight. In the focus group study, the boys felt pressure to tease others, and one comment in the focus group was “They’ll be miserable for the rest of their lives because they’ll get picked on” (2).
While it should be the parent’s role to deal with the card, they might see it as a problem and not accept it. For example, a teacher may notice a learning disability. In a number of cases, the parents do not want to believe that their child is “different.” The report card acts the same way because the parents may take it as a sign that their child is different from the other children. They do not want to see them as different or others to view them as different.
This leads to another component of the social cognitive theory, which is emotional coping (3). How the child and the parents handle the report card plays a significant part in the process. The child feels bad for getting the card and the parents do not like the label placed on their child. If no one can handle the situation in a beneficial way, then the intervention is ineffective. This result prevents the ability to handle change on a mental and emotional level (3).
The last two concepts within the first function of changing behavior, self-control and expectations, do not directly apply to this public health intervention. The report card deals more with the initiation of changing behavior and not the actual behavioral change. Self-control relates to the ability to carry out and change without returning to the original behavior. The fact that there the report card does not address these two factors contributes to the intervention’s ineffectiveness. The card just tells that there is a problem and does not provide information about what to do in the long term. In order to be effective, an intervention needs to follow through the progress of the behavioral change.
The next function of the social cognitive theory incorporates environmental factors. As stated before, the BMI report card does not address the environment. The external factors are the social and physical environment that surrounds individuals (3). Clearly, this intervention does not address the child’s peers – no one wants to be singled out of a group for something viewed as “bad.” It negatively influences the child’s social environment because they become susceptible to being teased by the other children in their class (2). Their self-esteem is lowered and they feel forced to make a change, which is not a healthy approach. For example, one girl in a focus group said: “When I was really chubby they all used to call me ‘fatty,’ so I had to stop tennis and so I went on a diet and nobody has called me ‘fatty’ since” (2).
The last function of the social cognitive theory is the “interactive process of reciprocal determinism, where a person acts based on individual factors and social/environmental cues, receives a response from that environment, adjusts behavior, acts again, and so on” (3). Again, due to its faults, the BMI report card does not even effectively achieve this function because the cues and individual factors do not produce positive results. If the child adjusts that behavior based on the social environment, it would not fit the intervention’s goals. Rather than change in order to lose weight, the child might hide from the children and focus on the embarrassment of the card. The problem shifts from obesity to avoidance. The intervention introduces another issue into the equation rather than dealing with the original issue.

Framing Theory
The last overarching reason for why the BMI report card is an ineffective public health intervention stems from the framing theory. The way an issue is framed significantly determines how people will react to it. The real battle is to change people’s behaviors by framing the issue accordingly. People do not respond to the facts but how the issue is framed (7). When facts do not fit a person’s frame, then the fact is not internalized (7). However, if the fact does fit the frame, then it is internalized (Lakoff).
The BMI report card is an example of how a public health issue is framed. The frame acts as a way to prevent the problem of obesity before it happens. However, this frame shows that the child has a problem and portrays it in a negative way. It is beyond the child’s comprehension and not within their frame of thinking. Also, the parents will not fit into the frame correctly either because they will see that their child has a weight “problem” that requires behavioral change, which is a result of how the issue is framed. Frames lead to either more or less effective ways of addressing an issue, and in this case, the frame is less effective.
The development of the interpretative framework is to understand why people come to be exposed to certain risk or protective factors (8). This is an example of contextualizing risk factors, which the BMI report card fails to do. This intervention develops the card based on limited screening. Like many public health interventions, the report card assumes an individualistic approach to behavioral change rather than accounting for the whole picture. It fails to incorporate factors that include socio-economic status, access to healthy foods and safe parks, and cultural values.
Another component of the framing theory is Lakoff’s Levels of Analysis, which utilizes frames to achieve social change (7). The BMI report card applies to the third level; the card falls into the program category in this level and addresses the issue of health care. However, even though it incorporates this level, it is not a successful frame. While obesity is a health care concern, this particular intervention has an overly broad approach. The generalization indicates that the frame needs to be more specific. The card should be framed at level one, which involves values and principles, such as personal health value (12). While this is at a more individual level, the card should also include social factors. That is where contextualizing social factors play a role. The card should not tell the child and the parents that the child is at risk for becoming obese. Rather, it should frame the issue as valuing health overall – physical, emotional, and mental. The card should be directed toward the individual child’s situation, which depends on their risk or protective factors such as cultural/ethnic background.
The facts do not change at this point because the wording only shifts when framed toward a specific situation. The parents will be less hostile toward the card if the facts are presented differently. If the facts are presented in a way that the parents can understand, then they internalize the frame – it is a fact of how humans think (12). Parents are often sensitive when it comes to their children because they do not like to be told that they are not properly raising their children. The report card does not explicitly say this, but that is how parents internalize feedback that they view negatively. That is why the intervention should be more positive.
Although children may be too young to make health based decisions by themselves, it should not just come from the teacher issuing a piece of paper. There should be more health based education tailored to the child’s level of comprehension. While some might argue that the school system can only do so much and that is more of a responsibility of the parents, schools should still do something because they cannot control the parents. However, the intervention should consider the issues of labeling, framing, and environmental influence as more significant than the report card demonstrates in order to be more effective.
Counter-Proposal Intervention to the BMI Report Card – Jenna Tonet
The problem of childhood obesity has been on the rise in the United States for some time now. While public health practitioners and health care professionals have worked to decrease obesity rates among adolescents using school-based interventions, the example of the BMI report card poses more harm than good. It is ineffective for reasons that include stigmatizing the child, framing the issue negatively, and lowering the child’s self-esteem. The school is a good place to have a community level intervention, but the intervention might not be successful. More effective interventions at the school level require community involvement, including parents, teachers, and health educators. Also, the approach should be a positive view of the child’s overall well-being and health. There should be no card, which acts as a label and singles the child out from their peers.
The intervention should be portrayed positively so that the teacher, child, and their parents view the situation in a more positive light. One type of intervention could take an existing component of the school system – parent-teacher conferences – and integrate feedback on the child’s overall well-being as observed in the classroom. The purpose of parent-teacher conferences is for the teacher to let the parents know how the child is doing in the classroom; this should be an overall and comprehensive evaluation. However, the teacher alone cannot evaluate all the health factors of the child. This is where health educators would come in to help assess the child’s health. The conference would address flaws of the BMI report card, including labeling, framing, and environmental influence, as will be shown in this paper.
To get rid of the BMI report card entirely would be better for the child, parents, and the teacher. Due to its limited individualistic development, the BMI report card fails to show that many factors contribute to an individual’s health and well-being. Also, without the BMI report card, the child does not receive a “label” with the actual card, they are not singled out from their peers, and the parents would not look at the situation as negatively. All of these factors imply that there is a need for a new paradigm. In other words, the issue requires a new frame.
Framing Theory—Positive Paradigm
Reframing the issue would provide a better way for everyone to comprehend the issue and internalize the facts. For example, O’Dea (10) mentions the need for a new paradigm: one example cited was the ‘health at any size’ movement, which has been successful in part due to the focus on health improvement instead of weight status. O’Dea (10) argues that this broad focus, which incorporates and highlights several components of health, can result in positive outcomes in child obesity prevention. These factors include the physical, psychological, social, and spiritual (10). This frame is better to suit everyone involved so that no one thinks negatively of the situation.
The parents could better comprehend the issue at hand because their ultimate concern is their child’s well-being. The point of the conference is to communicate with the teacher and to receive feedback from the teacher about their child. However, they will not internalize facts that are considered negative because the parents want what is best for their child since they believe that their child is perfect. If the teacher’s feedback tells them otherwise, or that they are not as ‘good’ as the other children in the classroom, then the parents will not think favorably of the situation. Rather than framing it as a “problem,” the teacher could address it as overall health well-being. The use of positive language makes a significant difference.
The way to develop a frame is to understand why people become exposed to certain risk or protective factors (8). This is an example of contextualizing risk factors. An intervention should incorporate factors that go beyond the individual level. Many current public health interventions assume an individualistic approach to behavioral change rather than accounting for the whole picture. Instead, the focus should be to encourage children to engage in a healthy lifestyle (11). While it is difficult to find or develop an intervention that draws upon several factors, the parent-teacher conference brings in the family and community levels.
Additionally, this approach addresses the best level from Lakoff’s Level of Analyses, which is level one (7). This level involves values and principles, such as personal health care (7). Even though this seems to be more individualistically based, the parent-teacher conference incorporates social factors by the involvement of the family and school community. Both the parents and the teacher are significant to a child’s well-being and overall development due to their roles and relationship with the child. The social network theory exemplifies this because the theory highlights the importance of relationships between and among individuals, and the nature of these relationships influence beliefs and behavior (3). If they can work together, they can help the child together through a network; they can help the child to act in ways that is good for their health (3).

Stigmata Theory—Labeling the Child
Reframing the issue also helps to deal with the issue of stigmatization. One example that the child already faces in regard to social stigmatization is: “Prejudiced attitudes from other children and resulting peer rejection is one of the most common sources of stigmatization of obese children” (11). This shows that the child already deals with negative peer influence. The parent-teacher conference replaces the BMI report card and takes away some stigma by taking away the physical label. While it is still an issue, the child is not subject to teasing from being singled out in another way.
The teacher is also influential in how the children interact. If begun as early as preschool, the teacher could teach and encourage the children how to accept each other. However, this would need to continue throughout the child’s development because their psychological development continues throughout elementary and middle school. Peer influence continues through adolescence because social networks develop and continually change through a person’s life. These relationships have a nature that can influence beliefs and behaviors (3). The relationships between the child and the teacher and between the child and their parents are opportunity to encourage health promotion. Their relationships are vital to help the child since they are a significant part of the child’s life.
As long as they maintain an active role in the child’s life, their influence is greater. One example of influence is that parental behavior could influence their child by encouraging better nutritional habits and self-regulation. “One study demonstrates that young children are more willing to taste novel foods if their mother models tasting the food first compared to a condition in which children are offered food with no adult model” (5, 11). This also demonstrates that environmental and individual factors contribute to the child’s overall health, which is part of the social cognitive theory.
Social Cognitive Theory—Environmental Influence
A significant part of the social cognitive theory brings the individual characteristics and environmental factors together, whether it comes from the parents, teachers, or peers (3). The parent-teacher conference addresses the environmental role by introducing the teacher and parental influence into the situation. With parental support, the child has a better chance of changing the behavior. A good support system builds upon the child’s self-esteem and self-efficacy. If they believe that they can make the change, the child has a greater opportunity to actually go through with the change.
Additionally, environmental factors also show how children can learn from others through the situation and by reinforcement (3). The school acts as one venue where teachers influence children through role modeling. “In several related quasi-experimental studies, silent teacher modelling was found to be ineffective in encouraging food acceptance among pre-schoolers, but ‘enthusiastic’ verbal teacher modelling was found to increase food acceptance” (6, 11). While more studies need to be conducted in order to best utilize teacher role modeling to best suite the children in the classroom, such studies are a great starting point for this intervention.
Lastly, the social cognitive theory puts together the individual and external factors through an “interactive process of reciprocal determinism, where a person acts based on individual factors and social/environmental cues, receives a response from that environment, adjusts behavior, acts again, and so on” (3). The child acts upon environmental influence and their attitudes and beliefs about the behavior. If they receive community and social support, i.e., from their parents and the teacher, they are likely to change their behavior as long as their environment allows them to do so.
While the BMI report card poses more harm than good, parent-teacher conferences could take advantage of the fact that the child should not be singled out in their classroom environment. This exchange occurs outside the child’s environment where they are vulnerable to judgment. The frame and context of the situation should be positive so that everyone involved internalizes the issue. The parents and the teacher take the time to talk about and address the child’s overall well-being, both academic wise and health wise. Also, they provide support for the child so that the child believes that they can make the behavioral change and be less subjected to harassment from the other children.
REFERENCES
1. Davidson, Fiona. Childhood obesity prevention and physical activity in schools. Health Education 2007; 107(4): 377-395.
2. Dixey, Rachael, Pinki Sahota, Serbjit Atwal, and Alex Turner. A qualitative study
of boys' and girls' perceptions of fatness. Health Education 2001; 101(5): 206-216.
3. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
4. Garner, D.M. (1985), “Iatrogenesis in anorexia nervosa and bulimia nervosa”,
International Journal of Eating Disorders, Vol. 4, pp. 348-63 in Davidson, Fiona. Childhood obesity prevention and physical activity in schools. Health Education 2007; 107(4): 377-395.
5. Harper KU, Sanders KM. The effect of adult’s eating on young children’s acceptance of unfamiliar foods. Journal of Experimental Child Psychology 1975; 20: 206–214, in Schwartz, M.B. and Puhl, R. (2003). “Childhood obesity: a societal problem to solve”, Obesity Reviews, Vol. 4, pp. 57-71.
6. Hendy HM, Raudenbush B. Effectiveness of teacher modeling to encourage food acceptance in preschool children. Appetite 2000; 34: 61–76.
7. Lakoff, G. “Simple Framing.” Available online at
http://www.rockridgeinstitute.org/projects/strategic/simple_framing, accessed
November 2008.
8. Link, BG and Phelan, J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; 35(extra issue): 80-94.
9. O’Dea, J.A. (2003), “Suggested activities to address body image issues, eating problems and Child obesity prevention in school environments”, Journal of the Home Economics Institute of Australia, Vol. 10 No. 3, pp. 2-12 in Davidson, Fiona. Childhood obesity prevention and physical activity in schools. Health Education 2007; 107(4): 377-395.
10. O’Dea, Jennifer A. Prevention of child obesity: ‘First, do no harm.’ Health Education Research 2005; 20(2): 259-265.
11. Schwartz, M.B. and Puhl, R. (2003). “Childhood obesity: a societal problem to solve”, Obesity Reviews, Vol. 4, pp. 57-71.
12. Wallack, Lawrence. “Framing: More Than a Message.” Available online at
http://www.longviewinstitute.org/research/wallack/levels, accessed November
2008.

The Plight Of America’s Veterans –Homelessness And The Remedy – Sara Patterson

2008-12-18T09:45:00.000-08:00

From the sunny sidewalks of Southern California to the shivering streets of New England, homelessness is an ever-present public health problem. Veterans comprise a significant percentage of the homeless population, and many seem to believe there is nowhere to turn for support. Men and women returning from war face hardships of reintegration. Suffering both mental and physical scars, they endure great difficulty while attempting to readjust to their former way of life.
Surely, the United States is one of the most affluent countries in the world. Why then, are hundreds of thousands of men and women who were honorably discharged from military service living in squalor? Veterans make up nine percent of the U.S. population, but 23% of the homeless population (1). Among homeless men, veterans make up 33% of the population (1). In addition, 67% of homeless veterans served in the military for at least three years, and 89% received an honorable discharge from the service (11).
“In the United States, however, homeless veterans are a large group of the needy whom few Americans are aware of. As silent sufferers of homelessness, they are even less likely to receive the help they deserve and need.” (11) Not only are there twice the number of homeless Vietnam veterans living on the streets than the 58,000 that died in the war (1) but the number of veterans from the Iraq and Afghanistan wars is on the rise as well. America’s public health system is failing veterans. “Traditionally, what happens to you after you leave has not been a concern of [the] service,” said Peter Dougherty, the Department of Veterans Affairs (VA) Director of Homeless Veterans programs (1). The estimates of homeless veterans range in numbers between 175,000 and 275,000 and include soldiers that served in World War II, the Korean War, the Vietnam War, the Persian Gulf War, and the wars in Iraq and Afghanistan.
There are various probable reasons why veterans become homeless. Post-traumatic stress syndrome, lack of affordable housing, service connected disability, separation from family for extended time periods (6), substance addiction (2), mental and emotional problems (3), “unemployment, poor education, frayed family relations” (1), limited applicability of military training in the civilian workplace (6), or a combination of these and other factors could be what leads up to a life on the streets. Whatever the cause of homelessness, the methods of prevention and intervention by public health are clearly falling short. “…the government is willing to praise its military before and during battle, but judging by the astonishing number of homeless veterans on the streets, has a diminishing commitment to them when they return home.” (11)

Flaws of Interventions

Public health, in general, employs models of intervention that deal with people on the individual level and require the assessment of the individual of their own situation. In the case of veterans, many do not know that they are at-risk for homelessness. Linda Boone, Executive Director of the National Coalition for Homeless Veterans (NCHV), states that “there’s a steady stream of wounded veterans coming home [from Iraq and Afghanistan] who don’t even know they’re casualties.” (5)
Of all the existing public health programs, realizing and understanding you are at-risk for a situation/behavior is a key factor for an individual to implement any of the models. The Health Belief Model, especially for the veteran population, would be inappropriate to use in that perceived susceptibility and perceived severity (4) (to homelessness) would not necessarily be taken into account by veterans, thus they would not realize intervention or a change in behavior is necessary. If a person does not see themselves as susceptible to homelessness, they are not going to take the necessary steps to prevent the outcome. The Health Belief Model falls short in this case. In addition, many of the factors that lead to veteran homelessness are ultimately out of their control.
A second critique of the Health Belief Model is that it assumes everyone has equal access to relevant services and information regarding their ability to make a decision to change a behavior. It is well documented that homeless veterans do not have the collective information they need to assist them when they return home from military service. Cheryl Beversdorf, President and CEO of the National Coalition for Homeless Veterans (NCHV), in an editorial to the Washington Post in 2008, stated that the United States needs public education for homeless veterans and at-risk veterans informing them of where to get services, not only at the VA but from community service providers throughout the country (10). She went on to say that the United States needs “a continuing public education campaign about the resources that are available to help America’s former guardians address their problems and rebuild their lives.” (10) To date, there are no existing public health programs that address these issues on a country-wide scale.
The Theory of Reasoned Action is also a poor model to base an intervention on for homeless veterans because it deals with people’s attitudes toward a specific behavior (4). In the case of veterans, there is not one specific behavior that causes the problem of homelessness. This theory is very precise and requires that a person individually assess a certain behavior that will cause either a positive or negative outcome. If a veteran does not consider themselves at risk for homelessness, then this intervention falls short.
Perhaps veterans become homeless as a result of an issue on a larger scale, for example, cultural anthropological factors such as norms. The Theory of Reasoned Action places emphasis on an individual’s perception of subjective norms associated with a behavior (4). However, there has not been much, if any, research into what influences a veteran’s social norms. Could it be family norms, military norms, civilian’s norms? Much like the different codes that military personnel use in the service to communicate with each other, there could be norms misunderstood by the general public that come into effect when trying to create successful public health interventions. In order to understand which programs and health intervention models will work for veterans, research into what the acceptable norms are for a veteran is crucial.

Lack of Resources for Veterans

Among soldiers, one of the biggest reasons for homelessness is a lack of available resources and services (9). “Compounding the difficulty of homeless veterans is the widely accepted belief that the [Department of Veteran Affairs (VA)] takes care of all veterans in need…the VA…will reach fewer than 20 percent of homeless veterans in this country.” (6) Lack of research and general knowledge about how homelessness affects veterans and a lack of adequate resources for public health programs to assist veterans, homeless or not, is a second way public health has failed these men and women living on the streets.
The VA alone is not responsible for the well-being of veterans. Public health needs to become more of a factor in helping veterans before and after they become homeless. Overall, there is a lack of knowledge by the general public that veterans are in need, therefore, there is not enough research of the homeless veteran population including causes, which leads to a deficiency of programs.
“In the past, data quantifying homelessness among veterans did not exist. It’s been precisely the lack of research that had us groping in the dark as far as what our response should be,” said Philip Mangano, head of U.S. Interagency Council on Homelessness (1). For this unique population, research needs to be collected on what causes veterans to become homeless and how they want to be helped, if at all, after becoming homeless. Research of the veteran population is the key to understanding, preventing and intervening in homelessness.
There were no VA funded programs to assist homeless veterans until 1987 (2). In 1990, service providers created the NCHV to raise public awareness of homeless veterans and to advocate for more federal aid (12). Even through the valiant efforts of the NCHV, there is currently not enough funding for programs to aid homeless veterans in the US. As recently as 2007, there was a lack of 9,600 transitional beds for vets which are supposed to serve as a starting point for independence from the streets (2). Homeless service providers are strained by veterans from the Vietnam War, and veterans from the wars in Iraq and Afghanistan requiring assistance have already begun to enter the system.
In New York City, homeless veterans outnumber the amount of other homeless people living in shelters (13). However, there are only two housing projects in the entire metropolitan area specifically for veterans and is located in the Bronx (13). There seems to be ample support for troops overseas fighting on the battlefields, but it is apparent what becomes of many soldiers when they return home. As a result of the current wars in Iraq and Afghanistan, the number of veterans in need is expected to rise.
A once homeless Vietnam veteran, Ken Smith, says “This [homelessness] is what happens when you don’t debrief your troops, when you [put them] red-hot from combat…on a plane. In Israel, when they pull a kid form the field, they give him as much support and counseling as he needs. Is that expensive to do? Probably, but did you ever see a homeless vet in Jerusalem? Whereas here…the shelters are packed solid. You tell me which is the more expensive approach.” (14) Public health needs more resources to help veterans who are returning from military service before they become at-risk for homelessness. It is much more effective to prevent homelessness for these men and women prior to their becoming homeless than it is to create affordable housing where none is available.
Another hurdle to providing assistance is exemplified by a recent report from the Department of Defense Mental Health Task Force which states that “nearly 50 percent of National Guard members and reservists report symptoms of mental disorders…and many return to homes in rural communities, from where they find it difficult to access military-provided clinical care and support groups.” (17) Services, as described by some homeless veterans, are “often difficult to obtain because the delivery system is unwieldy, inadequate, and inaccessible.” (16) It was further stated that the method of delivery is “a complex mass of programs and services with limited resources, staff that are excessively spread out, and inadequate funding to effectively address the severe problems facing homeless veterans.” (16)
The VA boasts of billions of dollars in funding for programs, which makes one wonder where all of the money is going and if the programs that are in place are the most effective use of the VA’s funds. Linda Boone, Executive Director of NHCV, states, “You see…cars with yellow ribbons saying ‘Support Our Troops.’ What you don’t see are signs saying ‘Support Our Veterans.’ But when those men and women take off their uniforms, that’s when they need support the most.” (5)

A Different Kind of Population

A third argument against the interventions that are currently being offered for homeless veterans is that they expect veterans to ask for assistance or come to a shelter of their own volition. Most veterans, at least traditionally, will not seek out help. There need to be programs that seek homeless veterans out and not the other way around. Most of the programs, even locally, require that a veteran come to them for support. Veterans are a proud bunch. Pete Dougherty, the VA’s director of homeless programs in Washington says that, “military service is a great place to learn in the harsh environment. They’re much better prepared [for homelessness] than non-veterans. They seem to have a higher tolerance and a certain degree of pride and toughness that they – more than the rest of us – can endure tough circumstances.” (7)
Veterans are a different kind of population to deal with because they “are very independent people,” (8) says Tammy Duckworth, Director of the Illinois Department of Veterans’ Affairs, “and we want to make them understand that this is not charity; this is the least of what they deserve for serving their country.” (8) Homeless veterans who see themselves as extremely independent and able to take care of themselves will not come to a shelter or ask anyone for aid. Studies indicate that an average of 12 years elapse before Vietnam veterans seek help for mental and emotional problems (3), providing strong evidence that veterans are less likely than the average person to ask for help. When they do, it is often on the brink of being too late for help to have a positive outcome.
There is a common distrust by veterans, especially the homeless, of the Department of Veterans Affairs. When asked to come to a shelter, a homeless veteran responded with, “I fought for the flag, but the flag never fought for me.” (1) His response typifies most soldiers’ sentiments of distrust for the VA and government in general, making it unlikely that veterans will seek any assistance provided by public health or government programs.
Veterans are more likely to favor a dangerous life on the streets rather than risk being in the hands of the VA. An attitude that implies a lack of responsibility for certain American veterans in need has been part of the problem of homelessness. According to Ralph Cooper, Executive Director of the Veterans Benefits Clearinghouse in 1995, the VA was run until recently by World War II vets, whose sentiment was, “We won our war and you lost yours, so we don’t owe you cowards and baby-killers anything.”(14)
Even though more than 30 years have passed since the war ended, still some Vietnam veterans exist who believe they returned to their country in dishonor and that they continue to be disrespected, a direct result of how the public health system and the government handled their homecoming. A Vietnam veteran living in a privately run Boston shelter wanted an interviewer to ask the VA a question on his behalf, “See, they gave amnesty to all the ones that ran away to Canada. In ’77, President Carter told ‘em all to come home and everything’d be forgiven, and it was. What I wanna know is, when will we be forgiven? We didn’t try to lose that war; we tried to serve our country. When can we come home?” (14)
Distrust and lack of awareness of assistance programs makes it difficult for homeless and at-risk veterans to take advantage of benefits. The Department of Veteran Affairs “relies on a system of self-help in which veterans must first be aware of the services that the VA provides and secondly want help in order to receive care.” (11) One of the most challenging factors is to convince proud, independent men and women that they might need help. It is very difficult to go about that task without damaging a person’s pride and sense of dignity. Upon being asked what he had been given at a local Boston shelter, a homeless veteran responded, “Hope…they’re willin’ to try to help me. That’s what the Vietnam vet needs – not a handout, a hand up.”(14)

The Future

As concern for the future of homeless veterans grows, a campaign by the National Coalition for Homeless Veterans has been implemented to increase awareness and to educate the public of the increasing crisis (6). Greater public knowledge should result in more effective intervention programs for veterans. The campaign has also “highlighted the need to recognize community-based organizations as a critical component of a coordinated, national strategy to increase the availability of services.” (6)
“Little is known about whether veterans served by VA’s homeless programs remain housed or employed, or whether they instead relapse into homelessness” therefore an evaluation of the effectiveness of VA programs should be initiated (15). It is time for public health to take responsibility for veterans and to not think of them as someone else’s problem. The VA has done what they can with their limited resources. Communities in which the homeless veterans live must now lend a helping hand to the men and women who once served the country with pride and honor in their rise from the streets.
In the words of a professor of social science at University of Massachusetts Boston and a Vietnam Veteran, Paul Camacho, “What are they going to do for these guys when they come home…other than wave a flag and buy them a beer?” (1)
Homelessness is a crisis facing an untold number of the most important citizens of the United States, veterans who may have already faced terrible circumstances defending their country and the people who live there. To better care for our returning heroes, several issues must be addressed. First, the types of interventions currently employed are not effective. Second, the types of resources available at present are only beginning to scratch the surface. Third, veterans are a unique faction with diverse circumstances that need to be considered.

The Right Kind of Intervention

In general, Public Health issues deal with choices made voluntarily. Since homelessness is not what individuals would typically choose as a lifestyle, the problem of veteran homelessness is an extraordinary Public Health dilemma for a unique group. The Social Expectations Theory asks the question, "How do groups change their behavior?" rather than "How does an individual change his/her behavior?" With research, this intervention would explore the social norms most important to veterans as a whole.
In the 60s and 70s, “epidemiology was developing holistic, community based models of disease that began to incorporate social and cultural factors. But this movement faded.” (18) Modern interventions for the homeless population should deal not only with the individual affected but also with social and cultural levels.
As with any population, veterans need an intervention that addresses the multiple levels that caused their homelessness. Some factors include social, cultural norms (both civilian and military), psychological and anthropological. Public Health needs to consider the contextual reasons that veterans become homeless and to look beyond the individual level. All levels (family, city, state, government and beyond) must be taken into account. The fundamental cause of veteran homelessness is likely to lie in one of those levels and, until all are addressed and studied, it is unlikely that veteran homelessness will be completely eliminated. Current programs are not effective in reaching out and extending help to returning veterans. Most do not know where to turn.
The Veterans Administration needs to understand that its responsibility to the men and women who served the United States on the battlefield does not end once the troops return home. The VA has a lifelong responsibility to the health and well-being of American soldiers. An effective intervention by the VA, with the help of public health organizations, must take into account the many factors which cause a veteran to become homeless and should occur before homelessness becomes the problem. Mandatory therapy for all soldiers returning from war has to be a number one priority. Veterans who engage in combat or witness things unknown to civilians need to talk about their feelings to someone who understands. Whether the therapy is individual or group, it does not matter, it should take place before a veteran is left on his or her own to deal with any possible trauma.
Another priority is to ensure that returning veterans can secure adequate employment. Currently, there are existing organizations available to assist with job search and placement for veterans. The VA works with public health organizations that are funded both privately and through the government. The organizations extend aid to veterans, but they often work independently from one another. If the various organizations learn to communicate with each other regarding the successes and failures of their programs, it may be beneficial to a local shelter that is battling a similar issue.
The most effective intervention is to increase public knowledge of the hardships that homeless veterans face, while the necessary types of interventions must be multilevel and encompass information obtained from other populations and social sciences. The intervention needs to “consider health and disease within the context of the total human environment.” (18)

Getting the Necessary Resources

The public is beginning to understand that veterans are a unique population and that many need support after they come home. Privately-funded programs are beginning to emerge across the United States. For example, at a Sears’ department store in Braintree, Massachusetts, volunteers solicit donations from Christmas shoppers to support the Heroes at Home program. Heroes at Home is just one of several outreach programs to aid military personnel that Sears supports and “is a program Sears Holdings has created in partnership with Rebuilding Together in response to an urgent need to assist military families facing hardship. By providing necessary repairs or adaptations to homes, Sears Holdings strives to improve the lives of military families across America. Heroes at Home is one of the many initiatives through which Sears Holdings acknowledges the sacrifice made by our troops every day in the line of duty, while supporting and honoring those heroes who remain at home." (21) According to Sears, “Homes are the foundation of our families, neighborhoods and nation. Home equity creates wealth for low- and middle-income families. It’s easy to see that helping home owners maintain their homes may be one of the most effective ways to strengthen the foundation of our country.” (21) Finding support from such a program must be a tremendous boost to the morale of returning soldiers, especially because scarcity of affordable housing is a major obstacle for veterans.
In 2007, the Department of Housing and Urban Development (HUD) and Veterans Affairs Supportive Housing (VASH), collectively called HUD-VASH received $75 million for 10,000 housing vouchers from Congress (20). HUD has asked for another $75 million dollars for 2009 and, if they get the requested money for the next few years, all chronically homeless veterans could potentially be living with a roof over their heads, saving taxpayers money in the long run (20).
Currently, Congress is considering multiple bills that would directly assist homeless veterans. One of the bills already passed, entitled Homes for Heroes Act, will help non-profit organizations provide housing for low-income veterans. While still a senator, President-elect Barack Obama introduced the Homes for Heroes Act on June 8, 2006. Obama has long been an advocate for homeless veterans, showing his support by offering bills to provide assistance. Ushering in a new generation of politics and politicians, Obama continues to show support to troops returning from Iraq and Afghanistan, by offering this bill. The bill finally passed on July 9, 2008 with a total of 413 ayes and 9 nays (27). Once enacted, the veteran homeless legislation will "establish a $225 million program to buy, build or rehabilitate housing for low-income veterans, expand rental assistance programs nearly tenfold, and create a position for a homeless veterans’ coordinator with the VA." (26)
Another bill allows for income tax forms to include an option for a taxpayer to donate $3 to aid homeless veterans (20). Increasing knowledge and empathy of the American public is crucial to creating successful pro-veteran programs. “We have to provide for the men and women coming home from the war. It would be a tragedy if we weren't prepared. We need to get ready to accept them back and give them the assistance they need to settle back into their lives," says James Jajuga, Haverhill Chamber of Commerce President (22).
One complaint of organizations that try to help homeless veterans get back on their feet is the lack of resources. Until 1987 there were no VA-funded programs specifically for the homeless veteran population and according to Peter Dougherty, the VA’s director of homeless programs, there are now more than 200. Unfortunately, with more than 200,000 veterans living on the streets the mere 200 programs that are funded by the VA are radically under representing the veteran population (2).

Helping a Different Kind of Population

Care for homeless veterans needs to be implemented by people who understand where they are coming from and with whom they can relate. Veterans helping veterans should be the public health motto, as well as Americans helping Americans. There is an entire continuum of care available, for veterans, which is essential to their recovery and rebuilding processes. The continuum has to start with "outreach and trust-building: a simple hand-shake and hello." (20) The purpose of outreach teams is to make contact with as many homeless veterans as possible, to get the word out that there are existing programs to help them and that all they need to do is drop by. In Las Vegas, there is a VA program encompassing a mobile outreach assistance clinic. The program "employs individuals who seek out homeless veterans, explain what can be done to help them, and entice them to go to a clinic." (25)
One type of outreach program is called a standdown. In the military, standdown means rest and recovery, a cessation of offensive military action. Stand downs are part of the VA's effort to provide services to homeless veterans. According to the VA's website, standdowns are "one to three day events providing services to homeless veterans such as food, shelter, clothing, health screenings, VA and Social Security benefits counseling, and referrals to a variety of other necessary services, such as housing, employment and substance abuse treatment. Stand Downs are collaborative events, coordinated between local VAs, other government agencies, and community agencies who serve the homeless." (23) Veterans seem to flock to these events as a result of the commonality that they feel with other veterans. Ed Whitley, a retired Air Force veteran, decided to become involved in a local standdown to "make amends for all the broken promises Vietnam veterans have had to endure from government and society...It's good to socialize with people who know what we went through, to have that camaraderie aspect." (24)
Because homeless veterans are a population that comes from a different background, they are less likely to trust someone from a government organization. That is the reason many groups are using veterans as volunteers. They are able to make a connection with the homeless veterans they are trying to reach. Helping Homeless Veterans and Families (HVAF) uses veterans in their organization to give them credibility. According to Philip Thomas, a homeless veterans coordinator for HVAF, "Our job is to try to meet them where they're at, find out what they want. A lot of them don't want to stop drinking...right away. They want to get off the street. It's hard for them to buy into a program when we say, 'You know, there are a few strings attached to our housing.' So it's our job to have faith and hope in them." (20)
Not enough veterans take advantage of the programs that are available to them, either through lack of knowledge or lack of understanding. Michael Ingham, Haverhill Director of Veteran Services, states that "...a lot of veterans think there's nothing wrong with them or that they are taking services away from other veterans so they don't go. The more people that take advantage of what's being offered, the better the programs will get." (22) Veterans, homeless or not, are also less likely to seek out help or assistance than someone from the general population.
After being in the military, veterans many times lack the necessary skills to re-acclimate themselves to society. The Valley Works Career Center in Haverhill, "helps unemployed veterans find jobs. Representatives advocate for veterans in the workplace, help them with resumes and use workshops to teach them how to present themselves in an interview." (22)
There are programs in use that cater to the homeless veteran population that are extremely effective. One such program is the New England Center for Homeless Veterans located locally in Boston, MA. In 1990, the nation's first and largest veteran-specific homeless shelter was opened by three Vietnam veterans. The New England Center offers a wide range of services through five different programs and support services that include Emergency Shelter, Transitional Housing, Single Room Occupancy Apartments, Training and Employment, and Health Care and Case Management. Each of these services assists veterans in solving the problems that led him/her to homelessness. Many of the staff and board are fellow veterans who understand and help their comrades back to recovery. Since opening their doors, they have provided aid to more than 12,000 veterans (19).
One therapist at the Center, Leslie Lightfoot, herself a Vietnam-era medic, says the program is so effective because it lets the homeless veterans talk about their anger and to get it out in the air. She says, “That… is why this works and the VA doesn’t—we care about these guys…because at some level they are us…either you’re a vet like they are and have been through some hell of your own, or as a rule, they won’t engage with you.” (14)
Although there has been much progress in reaching out to veterans to make their re-entry to the civilian world seamless, even more still needs to be done. Programs need to be more publicized and more available, and the government for whom the veterans gave their service should be the cornerstone of implementation. Veterans are too important a population to be left behind to fend for themselves. The entire country owes them a debt of gratitude for their sacrifice and must respond accordingly to solve the homelessness epidemic.

REFERENCES
1. Stewart, Jocelyn Y. The Nation: Column One. “From the Ranks to the Street.” Los Angeles Times; May 2004.
2. Ignelzi, Lenny. “Too Few Beds Available for Homeless Veterans.” Associated Press: Augusta Chronicle, San Diego; 2007.
3. PR Newswire. “National Coalition for Homeless Veterans Uniting Government and Public and Private Efforts to End Homelessness Among Veterans.” First Call, Washington; May 2005.
4. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers; 2007. p35-39, 73- 74.
5. Michelson, Andrea. “Survey Offers First Glimpse of ‘War on Terror.’ US Newswire. Washington; January 2005.
6. Pavich, Al. “Who Is Helping America’s Homeless Veterans?” Reserve Officers Association. Washington; November 2003.
7. Smith, Vicki. “Former Sailor Returned to West Virginia to Try to Rebuild His Life.” Associated Press: Charleston Daily Mail, South Carolina; 2005.
8. Chinwah, Larissa. “Veterans’ Chance at a Haircut.” Chicago Daily Herald: Chicago; 2007.
9. Bolding, Grady. “Americans Lack of Awareness of Homeless Veterans.” University Wire: Kansas State Collegian, Manhattan, Kansas; 2008.
10. Beversdorf, Cheryl. “How Can We Serve Homeless Veterans.” Washington Post, Washington; 2008.
11. Manushi. “Invisible Homeless Poor of America: The Plight of American War Veterans.” Contemporary Women’s Issues Database; 2003.
12. Science Letter Staff and Editors. “National Coalition for Homeless Veterans Holds Annual Conference in Washington, DC.” NewsRx.com: Science Letter; 2008.
13. Romney, Lynthia. “The Jericho Project Purchases Second Site for Homeless Veterans in the Bronx.” US Newswire: New York; May 2008.
14. Solotaroff, Paul. The House of Purple Hearts: Stories of Vietnam Vets Who Find Their Way Back. New York, NY: Harper Collins Publishers, Inc; 1995. p6-10, 17, 21, 42, 48, 60-61.
15. Government Accounting Office Report. Chairman: Honorable Arlen Specter. Homeless Veterans – VA Expands Partnerships, but Homeless Program Effectiveness Unclear. Federal Document Clearing House, 1999.
16. McMurray-Avila, Marsha. Homeless Veterans and Health Care: A Resource Guide For Providers. National Health Care for the Homeless Council. March 2001. p1-5.
17. Mental Health Weekly Digest Editors. “Veterans Mental Health Issues: Where Is Help Coming From?” NewsRx.com: Mental Health Weekly Digest; July 2007.
18. Shy, Carl M., “The Failure of Academic Epidemiology: Witness for the Prosecution.” American Journal of Epidemiology 1997; 145:479-84.
19. New England Center for Homeless Veterans Website. 13 Court Street, Boston, MA 02108. http://www.nechv.org/historyatnechv.html.
20. Callaghan, Philip M. "Nothing to Lose." The American Legion Magazine, Indianapolis, IN. December 2008. p34-40.
21. Heroes at Home Sears Holdings Program. http://www.searsholdings.com/communityrelations/hero/
22. Quinn, Joni. "Community Rallying Behind Veterans Returning Home." Haverhill Gazette: Haverhill, MA; May 2008.
23. U.S. Department of Veteran Affairs Stand Down. http://www1.va.gov/homeless/page.cfm?pg=6.
24. McGrath, Gareth. "Forgotten Generation Project Aims to Assist Homeless Veterans." Morning Star: Wilmington, NC; 2001.
25. Baker, Chuck N. "Helping Homeless Veterans: The Challenge of Coordinating Compassion." Las Vegas Review-Journal: Las Vegas, NV; 2003.
26. Slater, Grant. "Obama Files Bill to Help Homeless Veterans." Post-Dispatch Washington Bureau: Washington, DC; April 2007. http://obama.senate.gov/news/070411-obama_files_bil/
27. House Vote On Passage: H.R. 3329: Homes for Heroes Act of 2008. http://www.govtrack.us/congress/vote.xpd?vote=h2008-478.

PART I: Small Steps…In the Wrong Direction? - Megan Waterman

2008-12-18T09:41:00.000-08:00

How the Use of the Health Belief Model and Stigmatizing Advertisements Are Flawed Methods to Improve Nutrition and Exercise

When a user visits the U.S. Department of Human Services Smallstep Adult and Teen website, one of the first facts listed is that two out of every three Americans are defined as overweight or obese (1). Certainly, obesity is a growing problem in America, and Smallstep is one of HHS’s responses to that problem. Smallstep Adult and Teen aims to decrease overweight and obesity in the United States by providing information on health, healthy eating, and physical activity. Smallstep’s website features informative sections, such as “Get the Facts,” “Eat Better,” and “Get Active.” It includes a personalized Activity Tracker with which users can upload information about their physical activity goals, activities, and progress. Smallstep also includes Public Service Announcements on television, radio, newspapers, interactive online, and outdoors to advertise its campaign to reduce overweight and obesity.
Although it is well-intentioned, I argue here that the Smallstep Adult and Teen program is a flawed approach to improving nutrition and physical activity among Americans. This paper will outline three arguments based on social science theories and scientific literature about nutrition and exercise promotion that demonstrate the flawed nature of Smallstep. First, I will discuss how Smallstep’s focus on the individual level of behavior and its disregard for the social context limit its effectiveness as a health intervention. Second, the centrality of choice in Smallstep’s intervention scheme will be shown problematic, considering the largely irrational nature of human decision-making. Third, I will criticize Smallstep’s Public Service Announcements as stigmatizing to obese and overweight individuals and demonstrate how this may be counterproductive to the goal of promoting positive nutrition and exercise behavior.
Are Tools and Information Enough? Individuals Out of Context
The Smallstep program draws heavily from the Health Belief Model (HBM)—a model that places individuals in a rational balancing act, weighing the perceived barriers to health behavior against the perceived benefits, which include their perceived susceptibility to and the perceived severity of the outcome if they do not perform the health behavior (2-5). Smallstep’s very first page, “Get the Facts,” includes links to “The Issue” and “The Consequences.” This is a very clear use of HBM. It highlights to its readers their susceptibility to poor outcomes if they do not exercise and eat healthy: “2 out of 3 Americans are overweight or obese” and “300,000 deaths each year in the U.S are associated with obesity,” according to Smallstep’s Fact list (1). The severity of the outcomes is also addressed; Smallstep lists diabetes, heart disease, high blood pressure, and problems with mobility as potential health problems linked to obesity and overweight.
What are the consequences of this intervention’s reliance on HBM as its framework? Others have written about the problems with HBM. Foremost, the HBM approach to health behavior seeks to influence people as individuals removed from a social context. David Marks has criticized health psychology for this flaw, writing, “Health psychology is culturally ridden with individualism” (6, p.13). Marks discusses how health psychology has drawn from the biomedical models, focusing on the personal level of behavior change. This approach is ultimately flawed, as it assumes that individuals have control over their lives and are able to change if they only decide to do so.
Further, the individual focus of health psychology has been reflected in current epidemiology, which focuses on individual risk factors for disease. Pearce writes about the rise of risk factor epidemiology, describing how risk factors came to be conceptualized and analyzed in individual terms with greater emphasis on individual lifestyle (7). He argues that exposures to disease must be placed in their social and historical contexts, because “epidemiology is inevitably tangled with society” (7, p.682). When exposures are reduced to abstract individual risk factors, Pearce argues that we may miss the true causal factors of disease. More importantly, when epidemiological assessments fail to take into account social context, interventions based on those assessments are likely to fail to do so.
The Smallstep program is a prime example of an intervention based on individual risk factors of disease causation. Its focus on physical activity and healthy eating assumes the individual has control over his or her life, even if it is a small level of control. Smallstep maintains a list of “Tips” on different topics, including foods that one should eat and ways to incorporate exercise into one’s day, but these tips are entirely removed from any true social context. For example, consider Tip # 136: “Focus on fruits. Bag some fruit for your morning commute. Toss in an apple to munch with lunch and some raisins to satisfy you at snack time” (1). This tip assumes that individuals exist in a vacuum with unlimited supplies of fruit and without social barriers to healthy eating behaviors.
However, emerging social science and public health studies have demonstrated that social context matters in terms of healthy food consumption. Turrell and colleagues conducted a food purchasing study in Australia, showing that people of low socioeconomic status and educational attainment were less likely to purchase recommended food items and people in the low income group lived in areas with fewer supermarkets (8). Whelan and others explored the recently coined terms “Food Deserts” and the “disadvantaged consumer,” studying food retail access and perceived physical and economic access constraints on food purchasing (9). Other public health researchers have investigated the relationship between physical activity and the built environment, finding that access to exercise facilities, home exercise equipment, social support, neighborhood crime levels, heavy traffic, child care responsibility, and aesthetic qualities of neighborhoods impact physical activity levels (10-13). Clearly, social and ecological factors matter in determining health behaviors. Brownson and colleagues write of the importance of addressing public health problems at multiple levels (10); Estabrooks states that individual approaches must be expanded (11). Yet, the Smallstep program, a program funded by the United States Department of Health and Human Services, fails to take into account the social and ecological factors in its intervention strategy. What are the consequences of this failure? To illustrate this, an example used by Schwartz and Carpenter is useful (14). These authors discuss homelessness and the use of individual versus structural models of intervention. They argue that examining differences between those who are and are not homeless will not identify the cause of rising homelessness over time. Rather, they argue that lack of affordable housing is a “basic” cause, and that only by changing this basic cause can we reduce the overall amount of homelessness (14, p.1178). The Smallstep program can be conceived of in a similar fashion. Its focus on individual risk factors does not address the structural problems of access to physical activity and healthy food options. Without addressing these, Smallstep can only hope to influence who, among those with access, will lose weight by changing individual behaviors, while those without access are left with empty tips without the ability to realize improvement.
“A Healthy Lifestyle Made Up of Lots of [Irrational] Choices”
The above section discussed Smallstep’s likeness to HBM in its focus on individual behavior; this section will demonstrate another of its similarities to HBM and argue that this is another flaw in its design. The HBM presumes that individuals weigh benefits and barriers and make rational decisions (2-5). Smallstep certainly follows this aspect of the model, including a “Choices” section for both healthy eating and physical activity (1). “A healthy lifestyle is made up of lots of small choices,” Smallstep claims (1). However, evidence from behavioral economics has shown that individuals do not make rational decisions about many aspects of life. Dan Ariely writes about the ways that we make predictably irrational decisions; his writings are certainly applicable to decisions about exercise and nutrition (15). Ariely discusses several concepts that help to describe the ways that individuals act and choose irrationally, including: “arbitrary coherence,” “self-herding,” arousal, procrastination, ownership, and choice overload. In light of his concepts, it is possible to understand how irrationality enters decision making about exercise and nutrition, and to examine how Smallstep fails to address this irrationality.
First, the issue of arbitrary coherence refers to certain initial experiences with price and items ability to influence later decision-making (15, p. 26). In the context of nutrition, the low price of unhealthy food enters individuals’ minds as an “anchor,” making it unlikely that someone will purchase healthier (and likely more expensive) food items if they surpass that price anchor. Smallstep does not address the issue of cost of healthier options. Second, people also perform what Ariely calls “self-herding,” in which past personal experiences anchor individuals into habitual (but not rational!) behaviors (15, p. 37). A relevant example of this would be someone’s failure to exercise as a habitual behavior. Smallstep tries to convince individuals toward healthier lives in a rational process by providing information and knowledge about health risks and benefits, but this is likely to be ineffective against strong self-herding habits of non-exercise or unhealthy eating. Third, Ariely describes how arousal affects decision-making, in which people make decisions in “hot” states that they would not make in “cold” states (15, p. 104). Smallstep operates only at the “cold” level, encouraging people to consider its health tips and create an “activity planner,” but when people are tempted by momentary arousal—say, perhaps, by the smell of McDonald’s—they are likely to make irrational decisions. Fourth, procrastination is discussed as an irrational behavior (15, p.116). While Smallstep seeks to prevent individuals from procrastinating and failing to change exercise levels through the use of its online Activity Planner, this is not a coercive enough tool. It is unlikely that an individual will consider his or her obligation to an online calculator when they feel tired and unwilling to exercise. Fifth, Ariely discusses how individuals overvalue what we already have, and that this process applies to points of view (15, p. 137). If individuals irrationally hold tightly to their previous beliefs and values about inactivity or food choices, Smallstep’s rationally based intervention will have limited success in persuading individuals away from their “owned” points of view. Finally, choice overload is important to consider (15, p. 152). Ariely writes that people who are given more choices on a matter have been shown to have lower satisfaction with that outcome. Although Smallstep attempts to appeal to this idea of choice overload, writing on its “Get the Facts” page: “We are bombarded everyday with conflicting information about our health” (1). However, Smallstep contributes to this bombardment in its “Resources” section, including a list of links to various other health websites and information sources. Which link should a user choose to get the correct information? Surely people do not spend hours reading each website. Rather, they are confronted with a long list of possible resources, and they may avoid reading any of them because they could not easily choose one. Of course, choosing not to read valuable information about health is not a rational choice, but the overload of information available on Smallstep likely contributes to this potential irrational behavior.
Ariely’s concepts are very useful in thinking about irrational behavior and applying them to exercise and nutrition behaviors. Content-specific research about nutrition and irrationality conducted by Osberg and colleagues addresses the issue more directly (16). These researchers used an “Irrational Food Beliefs (IFB) Scale” and compared it to a “Rational Food Belief (RFB) Scale” to study effects on weight gain/loss. They found that high scores on the IFB scale were associated with recent weight gain and poor weight loss maintenance in a sample of college freshmen, and found that RFB score was unrelated to weight change. People who held irrational beliefs about food were likely to fail to lose weight, while rational beliefs did not make a difference. Considering this, health interventions appealing to irrational tendencies would probably more effective. Clearly, concepts about irrationality and health behavior are important and are emerging in the scientific literature. Smallstep’s inability to deal with irrational behavior is a serious limitation of the intervention.
Obese and Stigmatized: Media Images’ Perpetuation of Obesity
A third critique of Smallstep concerns its Public Service Announcements (PSAs) used in newspapers, television, radio, interactive internet, and outdoor ads (17). These PSAs emphasize that individuals can take “small steps” toward weight loss, but they do so with images of unclothed overweight and obese individuals. These images probably produce strong reactions with viewers, but what kind of reactions are they producing? What are the effects of these reactions, and do the PSAs encourage overweight and obese people to lose weight, as they purportedly intend?
These are important questions, considering sociological theory about stigma and labeling. In their article, Link and Phelan summarize Erving Goffman’s theory of stigma (18). They write that human characteristics become labeled, and certain labeled individuals are linked with undesirable characteristics. These labeled or stigmatized persons are thought of as separate from the “normal” group and experience discrimination due to their labeled statuses. Howard Becker, another sociologist from Goffman’s era, wrote of a similar concept, called deviance (19). He explained that deviant persons—people who do not behave according to social norms or rules—often continue their deviant behavior precisely because they have been labeled as such. Once labeled as deviant, individuals often continue to live up to the stigmatized label that they have been publicly given.
Smallstep’s PSAs have a great potential to invoke or encourage the stigmatization of obese people as vilified, disgusting, lazy individuals without self control. Obese people with dotted lines showing a slimmer version of the models are featured in the ads; along the dotted lines are written phrases about how one might lose weight with Smallstep. For example, one magazine ad, “Bikini,” contains phrases to describe an obese woman’s progression from obese to “obscene” with the following: “Started going for short walks during lunch hour,” “Stops ordering take-out and starts cooking healthy meals,” and “Just bought bikini that challenges some obscenity laws” (20). While this ad attempts humor with its final phrase, the image of an overweight/obese woman’s hip is not a pleasant one. Seeing images of overweight individuals may simply serve as a reminder of stigmatization and the label of overweight/obesity for afflicted individuals. Furthermore, the connection between the image of an obese person and the individual-based phrases that describe behavior change allow for continued stigmatization of obese persons who do not succeed in losing weight. Cohen and others write that common stereotypes about obese people include laziness, lack of self-control, low intelligence, and noncompliance to health recommendations (21). The authors state that these stereotypes are “played out in the daily popular media,” especially in advertisements that emphasize personal control (21, p. 155). Smallstep’s PSAs certainly fit this description. “Normal” individuals may see the Smallstep ad and think: “Obese people are just lazy individuals who don’t have enough self control to go for simple walks and cook healthy.” The images of obesity tied to personal control level changes—for example, walks during lunch breaks—allow stigma to continue and stereotypes to be affirmed.
What are the consequences of stigma? Cohen and colleagues address the issue of anxiety and mental health issues among the obese and attribute this to stigmatization (21). Link and Phelan discuss how stigma leads to stress, which may have negative effects on hypertension (18). Finally, we must consider Becker’s labeling theory, which predicts that labeled deviants continue deviant behavior precisely because they have been labeled (19). “Treating a person as though he were generally rather than specifically deviant produces a self-fulfilling prophecy,” Becker writes (19, p. 34). According to this theory, obese people who experience stigma will actually continue to act in manners that make them deviant. Thus, if Smallstep’s PSAs stigmatize obese and overweight individuals, the PSAs will actually have the opposite effect as intended, causing these people to be less inclined and hopeful to change their health behaviors.
Conclusion
This paper has focused on the U.S. Department of Health and Human Services’ Smallstep program, laying out three arguments to demonstrate its flawed nature as a public health intervention targeting overweight and obesity. Smallstep’s reliance on the Health Belief Model as its organizing framework is clear, with its emphasis on knowledge-building and rational choices. This paper has used existing social science and public health literature to attack Smallstep’s use of the Health Belief Model, arguing that (a) individuals cannot be removed from the social and ecological frameworks in which they exist, and (b) individuals often do not make rational decisions and that irrationality comes into play. Also, Smallstep’s advertising strategies have been discussed as potentially stigmatizing. Based on sociological theory and current research, I have shown that Smallstep’s use of unclothed images of obese people tied to personal control messages is likely to exacerbate the stigmatization of obesity, influencing stress, anxiety, depression, hypertension, and worse health behavior change results due to the “self-fulfilling prophecy” of labeling theory.
However, the arguments discussed here are relevant beyond a critique of the Smallstep program alone. Rather, they can be applied to a multitude of existing health interventions and used in the creation of new ones. As public health practitioners, we must always think critically about the flaws of existing interventions and seek to avoid interventions based solely on individual-based, rational models and those that use stigma to influence health behavior. I have drawn from several pieces of public health literature that call for the emerging use of social, ecological, historical, and geographical perspectives on health. Only with multidisciplinary and multi-level approaches such as these can we hope to effectively impact health behavior.

PART II: Cleaning Up Our Approach to Public Health Interventions: How a Proposed Alternative Intervention Focuses on the Social and Ecological Framework and Social Network Theory to Effect Nutrition and Exercise Behavior Change—Megan Waterman

In my previous paper, I used social science theories and scientific literature about nutrition and exercise promotion to criticize the U.S. Department of Health and Human Services’ SmallStep Adult and Teen Program, arguing that it takes a flawed approach in three important ways (1). These flaws include: (1) its individual level focus that disregards the social context; (2) the centrality of rational choice in the intervention model, and; (3) the use of stigmatizing Public Service Announcements (PSAs) to advertise for the program. Here, I will continue this discussion, proposing a three-pronged alternative intervention called “Clean Up Our Act” that will address the flaws found in the SmallStep program. First, I will demonstrate how this intervention addresses the social context of physical exercise and nutrition, providing increased access to healthy foods and exercise options via tailored community mobilization approaches. Second, this intervention will rely on the Social Network Theory in using group networks to address problems of irrational decision-making in regard to nutrition and physical activity. Third, I offer a new proposed approach to public service announcements that avoids stigmatization of obese and overweight individuals and shifts the focus of PSAs onto social and ecological causes of obesity. Combined, these three prongs of the proposed intervention not only address the flaws of SmallStep, but they offer a framework for future public health practice in the area of obesity prevention and reduction.

Changing the Built Environment through Community Mobilization
SmallStep is based heavily on the Health Belief Model (2-5). This health behavior change theory focuses on the individual level of behavior change and largely disregards the social context of behavior. It has been criticized in a general sense (6), as a central tenet of research and epidemiology (7), and specifically in relation to attempts to impact nutrition and physical exercise behaviors (8-13). There is a growing body of literature that calls for a social, environmental, and ecological approach to nutrition and exercise interventions (8-13); thus, the proposed intervention here will incorporate some of this literature.
What might a social, environmental, ecological approach look like? The existing literature addresses two components that are necessary for success (8, 10, 12-13). First, changes in the built environment must occur to enhance access to healthy food options and exercise. Second, these changes must be accomplished through tailored community mobilization efforts. Community mobilization is based in the concept of empowerment, where communities take charge of an issue, set the goals, and take action to achieve those goals (22-23). Any intervention that hopes to be effective at the level of local environmental changes must mobilize and engage communities to agree on the priorities of that intervention.
Considering these two components, my proposed intervention will occur at the community level, tailoring its programs to the community’s needs and using existing community organizations and groups to support the following environmental changes. Turrell and colleagues have argued that more supermarkets must be brought into low income areas and transportation to otherwise inaccessible supermarkets should be improved (8). Browson and others have called for local funding for the improvement of areas for outdoor physical activity—what Giles-Corti and Donovan have called “supportive neighborhood environments” (10; 12, p. 610). My proposed intervention, which I have named Clean Up Our Act, will assist communities in mobilizing these environmental changes through several programs. It would involve a transportation program with a “grocery shuttle” that brings individuals in “Food Deserts” (9) to large supermarkets, such as Whole Foods, at peak hours of the evening or weekends. It would also hold weekend “clean-up” days in which community members come together to revitalize vacant lots, littered areas, and overgrown trails to become safer, more attractive locations for physical exercise. Clean Up Our Act would fundraise to provide the necessary resources to aid in revitalization efforts. Clean Up Our Act could also use community mobilization to advocate to supermarket chains to bring quality food retailers into these areas.
It is important to note that the success of Clean Up Our Act relies on the engagement of individual members and organizations to partner together to create physical change and political advocacy. While a perhaps challenging endeavor, the ultimate effects of such a model are potentially great. Clean Up Our Act truly addresses the first flaw of the SmallStep program. SmallStep attempted to impact individuals’ health behaviors via a broad-based website in which individuals were viewed as living in a vacuum. Clean Up Our Act, on the other hand, has recognized the idea that social context—specifically the local social context—matters. It proposes to engage with specific communities and tailors approaches based on those community needs. Further, it addresses the environmental context of health behavior, addressing that access plays a key role in mediating nutrition and exercise behaviors.

Managing Irrational Behavior through Social Networks
In my second critique of the SmallStep program, I argued that SmallStep's reliance on the Health Belief Model resulted in its flawed assumption of rational behavior. Dan Ariely’s book, Predictably Irrational, provided useful theories to demonstrate that human behavior is irrational (15). One of Ariely’s concepts used in the critique of SmallStep was that of anchors and self-herding. Ariely argues that people act irrationally in choosing things because they remember the first encounter with a product or experience—the anchor—and then continue to choose that product or perform that behavior, herding themselves into this repeated (irrational) choice. My previous example of anchoring with food choice is how an unhealthy, cheaply priced food item can act as an anchor, discouraging individuals from purchasing higher priced, healthier foods. Similar self-herding occurs when individuals develop habits of physical inactivity. In his section on anchoring and herding, Ariely does offer insight as to how to break the cycle of anchoring and herding with the example of Starbucks. “If anchoring is based on our initial decisions, how did Starbucks manage to become an initial decision in the first place?” Ariely asks (15, p.38). The answer, Ariely explains, is separation. Starbucks made the entire experience of getting coffee at Starbucks feel different than the experience at existing coffee shops, creating a new anchor rather than failing to compete with the old one. Thus, if Clean Up Our Act hopes to create a new anchor for food choice or exercise behavior, it must make the entire experiences of eating, cooking, shopping, and exercising feel different than what is currently accepted.
To create a new anchor, Clean Up Our Act will utilize the Social Network Theory, which holds that relationships between people in networks are important determinants of health behavior (24-29). As an intervention program situated within communities, Clean Up Our Act will hold education sessions for groups of friends and neighbors to attend together. This education will be qualitatively different than the “Tips” provided on the SmallStep website, because it seeks to educate groups via discussion and interaction, rather than by dictation of information to individuals. After learning and discussing information about healthy food options and exercise, groups will be encouraged to schedule weekly shopping trips, cooking get-togethers, and exercise dates. These activities will serve as a new anchor for food shopping, cooking, and exercise experiences. For example, the experience of walking around a grocery store as a group and choosing food items that have been recently been an important topic of discussion between members of the group is a much different experience than one an individual might have had previously in the supermarket. Importantly, this component of the intervention does not rid the participants of their irrational behavior (that would be nearly impossible!); rather, it embraces the irrationality of anchor creation, using it to influence newly created behaviors of shopping, cooking, and exercising.
Second, the use of networks as facilitators for group-level change is relevant to the management of irrational behaviors of momentary arousal and procrastination. Clean Up Our Act groups would enter into agreements with one another about nutrition and exercise, agreeing that they will avoid unhealthy foods (like McDonalds, in the critique’s example) and will show up to exercise dates. Dan Ariely himself uses exercise as an example in suggesting a management strategy for procrastination: “if we don’t have the will to exercise regularly alone, we can make an appointment to exercise in the company of our friends,” he writes (15, p.117). Because the Clean Up Our Act groups will be composed of already socially connected friends and neighbors, the members of the groups will feel responsible and accountable to one another. Thus, the use of networks as coercive managers for nutrition and exercise behaviors is a good one that addresses the irrational flaws of momentary arousal and procrastination.
Finally, the irrational behaviors of “ownership” of ideas and choice overload can be addressed by Clean Up Our Act group work. Ariely is less optimistic about the elimination of the irrational, unyielding ownership of ideas. He writes, “There is no known cure for the ills of ownership….But being aware of it might help” (15, p.138). Considering this less than hopeful advice to combat ideological ownership, Clean Up Our Act might attempt to mitigate its effects by incorporating a discussion of group members’ strongly held points of view about nutrition and exercise into group meetings. By encouraging discussion about where different individuals in the groups are coming from, Clean Up Our Act can increase awareness and make people think twice about why they think what they think regarding food and exercise. Lastly, Clean Up Our Act should strive to clearly communicate information about nutrition and exercise to group members. One of SmallStep’s flaws was its overloading of resources and information on the website. Ariely has discussed how overabundance of choices can be overwhelming and counterproductive to decision-making. Clean Up Our Act will take this finding into account, providing clear, digestible health information to participants to aid in their decision-making processes.
Pointing Fingers at the True Determinants: Effective, Non-Stigmatizing PSAs

My third critique of the SmallStep program focused on its stigmatizing public service announcements (PSAs) that condemned obese and overweight individuals as personally responsible for their fates. I argued that Becker’s labeling theory suggested that individuals who were labeled deviant—such as obese/overweight individuals in the PSAs—would actually live up to that label and continue their deviant behavior (19). Thus, obese individuals who were stigmatized by SmallStep’s PSAs might actually respond negatively to the ads, continuing their poor health behaviors that made them obese/overweight in the first place.
Like SmallStep, Clean Up Our Act will utilize PSAs to educate people about exercise and nutrition as it relates to obesity and to get people involved in our community environmental projects and group network discussions. However, the approach taken in the PSAs will be markedly different from that taken in SmallStep. In Clean Up Our Act’s PSAs, the focus will be taken off of the individuals as responsible for obesity and overweight and moved onto the community as the locus of change. The themes of the images and the text will be very different in this intervention’s PSAs. While the imagery in SmallStep of obese individuals’ hips and bellies was visually provoking, I argue that images of dilapidated neighborhoods, vacant overgrown lots, and unappealing fruits and vegetables in small corner stores can be equally stimulating. These latter images will be those used in Clean Up Our Act’s PSAs. The text of SmallStep’s PSAs discussed individual level behaviors, which encouraged the reader to assume that obesity and overweight were solely under the control of the obese person himself. Clean Up Our Act PSA’s text will strongly challenge these ideas, including information about how the built environment and access to foods and exercise impacts obesity. I have created one example PSA, entitled “Who You Callin’ Lazy?” to demonstrate this concept (see attached). This PSA’s background image is that of an overgrown vacant lot in a local low income Boston neighborhood (taken by author). The text reads: “Sometimes, it’s not just about will power. When our options for exercise look like this one, no wonder we’re not getting fit. Cleaning up our neighborhoods is the first step to happier, healthier lives. Join the movement at CleanUpOurAct.org [not a real website].” Clearly, the message of this PSA is much different than that of the example SmallStep PSA discussed in the critique paper, “Bikini” (20). Instead of stigmatizing obese individuals for not taking personal control over their lives, my PSA appeals to its readers to think more broadly about obesity and health and to get involved in improving the physical environment that is impacting these outcomes.
Additionally, as community environmental improvements occur, “before & after” images of community sites could be used as PSAs. This would be an ironic, but empowering, imitation of the “before & after” weight loss images that have been condemned as stigmatizing to obese and overweight individuals (21). Further, participants in community improvement projects or network groups could be interviewed on the effects of Clean Up Our Act and used in television and radio PSAs.
Conclusion
This paper has built upon my previous critique of the U.S. Department of Health and Human Services SmallStep program, offering a potential alternative intervention program that addresses the flaws of SmallStep. This alternative intervention, called Clean Up Our Act, involves community mobilization towards environmental community improvements in access to supermarkets, transportation to supermarkets, and the creation of supportive neighborhood environments for exercise. This aspect of the intervention conceives that the local social and environmental context is ultimately important; this conception improves upon SmallStep’s assumption that health behavior exists and can be changed at the individual level in a vacuum. Clean Up Our Act also involves social networks to enter group education sessions and schedule outings to food shopping, cooking, eating, and exercising. Its use of social networks to address some issues with human irrational behavior is an improvement upon SmallStep’s model that seeks to intervene based on rational “choice.” Finally, Clean Up Our Act uses a markedly altered schema in developing public service announcements. It focuses on imagery of poor built environments and addresses the social and environmental causes of poor health outcomes. It avoids the stigmatization of obese and overweight individuals that SmallStep may have caused in its juxtaposition of stark, exposed images of obese hips and abdomens with claims of personal autonomy in weight loss. For these three reasons, Clean Up Our Act may provide a useful and forward-thinking model of health behavior change regarding nutrition, exercise, and obesity. It avoids the common flaws of traditionally modeled public health interventions such as the SmallStep program and challenges public health practitioners to think and work locally with communities while always keeping the social and ecological context of health in mind.
REFERENCES
. U.S. Department of Health & Human Services. Smallstep Adult and Teen. Washington, D.C.: U.S. Department of Health & Human Services. http://www.smallstep.gov.
2. Becker, MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974;2:Entire issue.
3. Janz, NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984;11(1):1-47.
4. Hochbaum GM. Public Participation in Medical Screening Programs: A Sociophysical Study. Public Health Service publication No. 572. Washington, DC: Government Printing Office; 1958.
5. Rosenstock IM. Historical origins of the health belief model. Health Educ Monogr. 1974;2:328-335.
6. Marks, D.F. Health psychology in context. Journal of Health Psychology 1996; 1:7-21.
7. Pearce, N. Traditional epidemiology, modern epidemiology, and public health. American Journal of Public Health 2006; 86:678-683.
8. Turrell, G., Hewitt, B., Patterson, C., Oldenberg, B., and Gould, T. Socioeconomic differences in food purchasing behaviour and suggested implications for diet-related health promotion. J Hum Nutr Dietet 2002; 15:355-364.
9. Whelan, A., Wrigley, N., Warm, D., and Cannings, E. Life in a ‘food desert.’ Urban Studies 2002; 39:2083-2100.
0. Browson, R.C., Baker, E.A., Housemann, R.A., Brennan, L.K., and Bacack, S.J. Environmental and policy determinants of physical activity in the United States. American Journal of Public Health 2001; 91: 1995-2003.
1 . Estabrooks, P.A., Lee, R.E., and Gyurcsik, N.C. Resources for physical activity participation: does availability and accessibility differ by neighborhood socioeconomic status? Ann Behav Med 2003; 25(2):100-104.
2. Giles-Corti, B. and Donovan, R.J. Socioeconomic status differences in recreational physical activity levels and real and perceived access to a supportive physical environment. Preventative Medicine 2002; 35:601-611.
3. Lee, C. and Moudon, A.V. Physical activity and environment research in the health field: implications for urban and transportation planning practice and research. Journal of Planning Literature 2004; 19:147-181.
4. Schwartz, S. and Carpenter, K.M. The right answer for the wrong question: consequences of type III error for public health research. American Journal of Public Health 1999; 89:1175-1180.
5. Ariely, D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York: HarperCollins Publishers, 2008.
6. Osberg, T.M., Poland, D., Aguayo, G., and MacDougall, S. The irrational food beliefs scale: development and validation. Eating Behaviors 2008; 9(1):25-40.
7. U.S. Department of Health & Human Services. Ad Council: Obesity Prevention. Washington, D.C.: U.S. Department of Health & Human Services. http://www.adcouncil.org/default.aspx?id=54.
8. Link, B.G. and Phelan, J.C. Stigma and its public health implications. Lancet 2006; 367:528-529.
9. Becker, H.S. Outsiders: Studies in the Sociology of Deviance. New York: The Free Press, 1963.
20. U.S. Department of Health & Human Services, and Ad Council. “Bikini.” Washington, D.C.: U.S. Department of Health & Human Services and Ad Council. http://www.adcouncil.org/files/obesity_bikini_mag.jpg.
2 . Cohen, L., Perales, D.P. and Steadman, C. The O word: why focus on obesity is harmful to community health. Californian Journal of Health Promotion 2005; 3(3):154-161.
22. Alinsky, S.D. Rules for Radicals. New York: Random House; 1972.
23. Friere, P. Pedagogy of the Oppressed. New York: Seabury Press; 1970.
24. Barnes, J.A. Class and communities in a Norwegian island parish. Human Relations. 1954;7:39-58.
25. Wasserman, S., Faust, K. Social Network Analysis. Cambridge: Cambridge University Press; 1994.
26. Scott, J. Social Network Analysis: A Handbook, 2nd ed. London: Sage; 2000.
27. Monge, P.R., Contractor, N.S. Theories of Communication Networks. New York: Oxford University Press; 2003.
28. Rogers, E.M., Kincaid, D.L. Communications Networks: Toward a New Paradigm for Research. New York: Free Press; 1981.
29. Pescosolido, B.A., Levy, J.A., eds. Social Networks and Health, 8th ed. Elsevier, Inc.; 2002.

A Hypertension Intervention for Black Males – Missing the Target and Ultimately Missing the Point - Nicolette Barbour

2008-12-18T09:36:00.000-08:00

A Look into the Health Belief Model That Shapes the Church/Health Fair Approach in the Black Community

African-Americans have long been disproportionately affected by health issues in America. From infant mortality to heart disease to homicide to the AIDS epidemic, high prevalence of disease among African-Americans has been astounding. Hypertension (high blood pressure) is one of many health concerns for African-Americans. According to Healthy People 2010 prevalence of hypertension among African-American adults was as high as 41% in 2000, up from 37% at baseline (1988-1994) (15). The prevalence of hypertension among black Americans was 1.5 times that of white Americans in 2000 and was the highest of all racial groups in the analysis (16, 5). There are also noteworthy gender differences among hypertensive African-Americans evident in the variation in hypertension prevalence, 41% for men and 44% for women (16). Hypertensive individuals are at an increased risk for heart disease and stroke which are two leading causes of death in the United States (1). Even more alarming is the unfortunate reality that of the top 10 causes of death, African-Americans have the highest mortality rate when compared to other racial groups for 8 of the top 10 causes of death ( 15, 11). Suffice to say, hypertension in the black community is a significant public health problem.
To address the serious health disparity of hypertension in the black community a number of interventions have been implemented. A popular intervention design is church health promotion programs and community health fairs. The church is especially regarded as a central institution in the black community, capable of mobilizing its members (7). These programs use social venues to provide information to attendants and increase awareness in the community (7, 6). Church programs and social/community events offer a forum for health professionals and community workers to offer free blood pressure screenings to members of the community in order to alert individuals of their risk of hypertension (6). This intervention uses the health belief model to increase individual’s perceived susceptibility and severity by providing attendants with vital information (18). Though these church and health fairs are widely utilized to address hypertension, the intervention proves to be substantially limited in targeting and impacting that of black males. The intervention may bring about awareness of the risks of hypertension for African-Americans but it is an ineffective outreach mechanism for black males, it completely neglects the realities of the unique social experience of black males, and it does not addresses the complexities of the patient-provider relationship that often serve as an obstacle to effective health care.
Ineffective Outreach to Black Males
African-American men have the highest mortality rates for cardiovascular disease, heart disease, and stroke when compared to black women, white men, and white women (15). Consequently effective interventions are needed for black men. Church and community health fairs are ineffective in targeting black males. By virtue of design these interventions are inadequate tools to provide effective outreach to black men. Though a large number of African-Americans attend church, a great deal more women then men make up these congregations (2,3). Assensoh and Assensoh found that in their study women were 23% more likely to attend church every week then men (3). A number of studies have confirmed the difference in church attendance of men and women. Therefore, programs implemented through the church as a main venue do not reach the larger number of African-American men that may be at risk or have hypertension.
Community fairs are also more frequented by women then men. One study noted as high as 78%, were women participants (averaged from two fairs) of the health fair (6). Another limitation of this intervention is that health fairs are commonly marketed as an opportunity for free screenings, clinic alternatives, and a way to “bring the professionals to you” (19). People often regard health fairs as a place to go when one has a health concern but limited resources to assess the concern. Black men often correlate sickness and being unhealthy with the presence of symptoms (13). Accordingly, if they feel healthy they will see no need to seek help. Since health fairs have been marketed as a means to seek help, African-American men may be less likely to attend. This is of extreme concern because high blood pressure is known as a “silent killer”, providing no real alarming symptoms when preventative measures would be most effective (13).
The Church and the community are support networks for their members. They serve as spiritual, physical, and political vehicles, ultimately promoting and supporting the well-being of its members (3). Yet black males report feeling a lower sense of tangible and instrumental social support then black women, and white men and women (12). Instead black males have cited mothers and sisters as their major support system (13). For this reason it is possible that black males connect less with larger social networks then their counterparts. Again, this point illustrates that church and community interventions are less appropriate and ineffective approaches when targeting black males.
Neglecting the Realities of the Unique Social Experience of Black Males
As follows with interventions utilizing the Health Belief Model, church and community health fair interventions fail to address the social and cultural context of African-American men and their perception of health. The reality of Blacks in America is one plagued with health disparities. Differential quality and access to care is exacerbated by the wide gap in socio-economic status and the lack of healthcare for all Americans (9). Nonetheless, studies show that “racial differences in blood pressure can persist despite adequate access to care” (1). Thus the root of health disparities must be addressed by exploring the social and cultural context in order to truly reduce the prevalence of hypertension among African-American men. The large divide in social experiences of whites and blacks is the aftermath of hundreds of years of segregation, slavery, and racial discrimination. America has never truly dealt with or healed from these issues. Because America never dealt with the consequences of the actions of slavery, segregation, and racial discrimination African-Americans unique past has manifested physically, mentally, and possibly genetically (11). This part of history is analogous to a child being raped and to deal with the issue the family moves to another city and acts like it never happened. Thus, with such a troubling history and trying current social environment, how do black males voice their concerns when the world around them does not relate to, or has little knowledge of their unique social experience. According to Abraham Maslow’s Hierarchy of Needs it is difficult to address health concerns when lower level needs such as physiological and safety needs cannot be met in such an environment (17).
Today, it is likely that discrimination is unconsciously committed based on stereotypes and social norms (5). African-Americans perceive grave differences in their social experience in America illustrated by a number of common themes such as extensive use of nontraditional support systems; general mistrust of European Americans; African Americans' being undervalued as human beings and members of American society; effective use of improvisation; uneven playing field as a result of persistent discrimination; preservation of a unique ethnic identity; socioeconomic status as a major influence and predictor of behaviors (14). Understanding and consideration of these influences must be taken into account in order to remove the adverse social differences in experience and effectively reduce high blood pressure among black men. Black men appreciate validation and acknowledgment of their unique social experience when seeking care and find it easier to achieve successful outcomes in such an environment (13). This intervention in no way addresses the unique social experience of black males and thus fails to effectively intervene on behalf of black men.
Another major social and cultural issue that is not addressed by the church and community health fair intervention is the tendency of black men to view seeking help as a sign of weakness (13). Black men find it hard to be vulnerable. They are taught at a young age not to cry and not to complain. Also an increase in single mothers raising black male children may add to this issue (5). In an effort to raise a tough boy mothers may not engage in emotional dialog and men may not know how to express themselves. This type of upbringing is apart of black males cultural context and may result in an inability to express concerns and share feelings. If they indeed need care, such obstacles may delay the act of seeking care.
Complexities of the Patient-Provider Relationship
“There are ethnic nuances in communication between doctor and patient. These ethnic nuances have a large effect on what is said to the patient and what is heard” (11). The church and community health fair model fails to tackle the issue of patient physician communication barriers. How the interaction between patient and physician plays out is a key indicator of whether or not the patient will return (13). Miscommunication can adversely affect the diagnosis and/or the treatment regime (10). Too little communication could also cause problems. For black men communication and expressions of care are highly valued. Too little information, not looking the patient in the eyes, and not taking the time to explain the treatment to the patient can lead to noncompliance and resentment of the profession or the professional (13).
Some external issues that physicians face may also affect patient-physician communication. Unfortunately many doctors have limited time with patients and cannot appear caring and approachable if they feel rushed to get the next patient (20). Due to a number of factors doctors are less able to make lasting connections with patients and advise patients on preventive measures that can be taken to reduce high blood pressure. Physicians have to schedule a large number of patients per day to maintain the pay bills. This may lead to heavy appointment days and less time per patient. There are also less primary care physicians in the United States compared to other developed nation (20). This may also aggravate the issue of time per patient due to a large number of patients per physician (20). Additionally the large number of uninsured patients in America may not be able to go to a physician, and could cause there not to be a physician patient relationship at all for some individuals. These issues lead to a decline in effective communication and poor patient care.
Cultural issues also complicate the patient physician relationship. Communication problems between white physicians and minority patients seem to be a risk factor of health disparities (10). Particularly with hypertension, black men have a hard time incorporating diet and exercise into their lives (13). Without the understanding of the doctor and further dialog as to the complexities of their (black men) lives and economic situations, adherence to and effectiveness of a treatment may prove increasingly difficult.
Conclusion
Though the church and community health fair intervention is effective in bringing about awareness of hypertension and the heightened risk of African-Americans to get the disease, it effectively misses Black males as a target. Black males are at higher risk to die from CVD, heart disease and stroke and need to be targeted with interventions that address their specific issues and concerns. Due to their low attendance rates in churches and at heath fairs, this intervention is by design ineffective. The intervention also follows the Health Belief Model and has no means of accounting for the unique social experience of Black males and the communication barriers between physicians and patients when seeking and receiving health care. The intervention’s inability to address these issues proves that it not only misses its target, it also misses the point.

Part II

Counter-Proposal to the Church/Community Health Fair
In light of the limitations of the health fair intervention derived from the health belief model, I propose a more integrated approach to address hypertension among black males. I propose an intervention that recruits black men to be the arbiters of the program. The program is modeled after the City Year program. Its focus would be to positively affect the health of those working for the program as well as the men the program targets. Within this program young black men would facilitate outreach events in their communities.
Like City Year, these men would commit a year to work on behalf of the program. They would be expected to learn about health issues that affect black men. Their own personal health would be assessed and they would be expected to lead a healthy lifestyle while in the program. Their responsibility would consist in going out into the community and talking to other black men about living a healthier life. They would also provide forums to address social and policy issues that affect black men’s health. The main objectives of the program would be effective outreach to black men, educating men about the social context and its effect on health, and active pursuit of eliminating health disparities. The program provides a voice for black men and a constructive use of resources and time.
A More Effective Outreach
The health fairs relied on men to come to them. For these men to hear the information, they had to go to church or a community health fair. This intervention would address the main flaw of the health fair intervention by truly reaching out to the men in the community. Who better to address black men’s health and issues than black men themselves. With this intervention the black men recruited by the program would go directly to places more frequented by other black men, such as their homes, the barbershop, college/school programs, or even on the streets, in addition to churches (26).
Black men have been known to be hard to reach in any one social institution (21,22). Accordingly, this program allows the intervention to diversify and use different methods to reach more people. Using the black men recruited by the program as a small focus group or cohort to get a better idea as to how to motivate and reach out to black males, more effective outreach methods tailored to that community could be created and implemented. The Program would have wide appeal because it would be implemented on a national as well as a local level. The same would foster strong relationships with influential organizations in the black community enlisting the support of black Greek letter fraternal organizations, the NAACP, local promotions companies, and black celebrities. By using this model, Black male youth have a constructive way to spend their time, they are given financially incentives, become engaged in their community, and help other black men in the community at the same time.
Addressing the Realities of the Unique Social Experience of Black Males
Addressing the realities of the consequences of discrimination, slavery, and racism in this country is a daunting task. Nonetheless, in order to begin to eliminate health disparities these issues must be addressed (5). The first step to closing the gap in health disparities is to understand the social and cultural context in which such disparities arise. Thus the history taught in school should not only address the events of the past but also the impact that those events have had and how that translates to our social environment today. The intervention proposed will be able to address this lack in education by having the men in the program talk to area schools. They could hold school summits and assemblies to talk about different pertinent social issues. This type of semi-informal forum will allow the stigma on speaking about race to dissipate.
In addition to these types of events the national level of the program will provide black men with a political voice that could place health disparities on the national agenda. The more exposure the program gets, the easier it is to get the issue on the national agenda (25). By using agenda setting to address these issues, the social norm of health disparities based on race may no longer be tolerated by society as a whole (25). By giving these men a voice in their community they will not internalize their feelings and have better tools and more knowledge to address their issues productively. Such an outlet could have profound effects on society.
Dealing with the Complexities of the Patient-Provider Relationship
Traditionally cultural competency or cultural sensitivity classes have been the answer to patient provider communication problems. However I believe that, in addition to this approach, this intervention can help to improve this relationship it two ways. First, the men involved in the program can provide forums to speak directly to the physician in the area. The men would be able to relay different concerns to the physician and the physicians would be able to learn in a real way how they can improve appropriateness of care for the men of that community. The second way is more indirect in nature. Race and ethnicity have stood out as major variables in the quality of care patients receive. Unfortunately as America grows more culturally diverse, the diversity among American’s physician’s has not grown to equal the patients they will serve (24). The program would give the young men involved exposure to the medical industry. This exposure may spark the interest of these men to go into the medical field. The intervention could then serve as a pipeline to careers in medicine. For future physicians learning how to deliver culturally competent care could be enhanced by learning medicine with students and from faculty who are themselves emblematic of society’s diversity (23). By increasing the diversity among physicians to mirror the diversity of the surrounding community (in addition to cultural competency classes) the medical workforce will be better equip to serve their patients and thus improve the overall quality of care.
Conclusion
Like any social science intervention there are limitations to this design. One intervention cannot abolish widespread social problems in our society. Also one intervention cannot end an era of political correctness that may impede some of the effects outlined above. I do not claim a cure for social problems. However, I do believe that reforms, policies, and interventions in this vein can positively impact health disparities. The intervention proposed unlike the Church/Community health fair intervention has a more comprehensive approach to addressing hypertension in black men. The proposed intervention accounts for social, cultural, and well as local issues. The intervention actively seeks out the target audience in the community and uses people from that audience to also deliver the message, thus actively engaging the community to participate in health awareness. The intervention also addresses cultural barriers in communication and barriers that cause disparities. This intervention is a superior option when compared to the health fair intervention because it goes beyond the individual level of awareness and addresses the barriers to implementation of better health behaviors.

References:

1. Bosworth H. et al.. Racial Differences in Blood Pressure Control: Potential Explanatory Factors. The American Journal of Medicine (2006) 119, 70.e9-70.e15
2. Reese L. and Brown R. Source The Effects of Religious Messages on Racial Identity and System Blame among African Americans. The Journal of Politics, Vol. 57, No. 1 (Feb., 1995), pp. 24-43
3. Alex-Assensoh Y. and Assensoh A.. Inner-City Contexts, Church Attendance, and African-American Political Participation. The Journal of Politics, Vol. 63, No. 3 (Aug., 2001), pp. 886-901
4. Felix AK, Levine D, Burstin HR. African American church participation
and health care practices. Journal of General Internal Medicine 2003;
18(11):908-913.
5. Williams D. et al. . Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health. Public Health Reports. (2001) vol. 119 pp 404-416
6. Jennings-Sanders A. Using health Fairs to Examine Health Promotion Behaviors of Older African-Americans. The ABNF Journal. 2003 pp13-16
7. Markens S. et al.. Role of Black Churches in Health Promotion Programs:Lessons From the Los Angeles Mammography Promotion in Churches Program. American Journal of Public Health. May 2002, Vol 92, No. 5
8. Bell C. et al.. Understanding the role of mediating risk factors and proxy
effects in the association between socio-economic status and
untreated hypertension. Social Science & Medicine 59 (2004) 275–283
9. Kington and Smith. Socioeconomic Status and Racial and Ethnic Differences in Functional Status Associated with Chronic Diseases. American Journal of Public Health. May 1997, Vol. 87, No. 5
10. Balsa A..Testing for Statistical Discrimination in Health Care. HSR 40:1 (2005)
11. Joel E. Dimsdale, MD.. Stalked by the Past: The Influence of Ethnicity on Health. Psychosomatic Medicine 62:161–170 (2000)
12. SAAB P. et al.. Influence of Ethnicity and Gender on Cardiovascular Responses to Active Coping and Inhibitory-Passive Coping Challenges Psychosomatic Medicine 59:434-446 (1997)
13. Rose L. et al.. The contexts of adherence for African Americans with high blood pressure. Journal of Advanced Nursing, 2000, 32(3), 587±594
14. Ard JD et al. Perceptions of African-American culture and implications for clinical trial design. Ethnicity & Disease. 15(2):292-9, 2005
15. Healthy People 2010
http://www.cdc.gov/nchs/ppt/hpdata2010/focusareas/fa12_bookcharts.ppt
16. Center for Disease Control and Prevention
http://www.cdc.gov/bloodpressure/facts.htm
17. Wikipedia. Maslow’s Hierarchy of Needs. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Maslow%27s_hierarchy_of_needs.
18. Rosenstock I.. Historical Origins of the Health Belief Model. Health Education Monographs. (1974) Vol. 2 no. 4
19. Rotary International Foundation http://www.rotary.org/en/MediaAndNews/News/Pages/080428_news_denver_russianhealthdelegates.aspx
20. Kowalczyk L. . Hospital doctors shut doors to new patients. The Boston Globe. November 12, 2006.
21. Becker DM.et al. Impact of a community-based multiple risk factor intervention on cardiovascular risk in black families with a history of premature coronary disease. Circulation. 111(10):1298-304, 2005 Mar 15.
22. Chalapati W. and Chumworathayi B. Can a home-visit invitation increase Pap smear screening in Samliem, Khon Kaen, Thailand?. Asian Pacific Journal of Cancer Prevention: Apjcp. 8(1):119-23, 2007 Jan-Mar.
23. Pilcher ES. et al. Development and assessment of a cultural competency curriculum. Journal of Dental Education. 72(9):1020-8, 2008 Sep.
24. Data is from Minorities in Medical Education: Facts and Figures 2005
25. Agenda-Setting Theory (http://en.wikipedia.org/wiki/Agenda-setting_theory)
26. Barbershops as Hypertension Detection, Referral, and Follow-Up hyper.ahajournals.org/cgi/content/full/49/5/1040

5 A Day Campaign: Are We Really Addicted To Bad Eating? - Jessica Spiegel

2008-12-18T09:25:00.000-08:00

Eating a diet full of fruits and vegetables will promote good health and will help to protect individuals from chronic diseases such as heart disease, diabetes and some cancers (22). In an effort to encourage individuals around the world to increase their fruit and vegetable intake, the National Caner Institute and the Produce for a Better Health Foundation formed a coalition and developed the ‘5 a Day’ campaign . It quickly became the largest partnership for nutrition and, in 2005, the Centers for Disease Control became the national healthy authority on the ‘5 a Day’ program (22). The ‘5 a Day’ campaign uses media as well as educational programming to promote eating five servings of both fruits and vegetables daily in order to improve health status. In March 2007, the ‘5 a Day’ campaign launched a new initiative called ‘More Matters’ to try to encourage even greater improvements in healthy eating. The previous dietary guidelines recommended eating 5 to 9 servings of fruits and vegetables every day. The new ‘More Matters’ guidelines recommend 2 to 6.5 cups of fruits and vegetables a day which is the equivalent of 4 to 13 servings. The ‘5 a Day’ campaign has been emphasized in schools through teachers and in school cafeterias. Teachers in primary schools encourage students to eat as many servings of fruits and vegetables as they possibly can and cafeterias try to accommodate these new guidelines by offering more of the ‘healthy’ options for the students to choose (7). There has also been a big push in lower income areas to try to encourage families to choose fruits and salads over the other fast food options (7)
The development of the ‘5 a Day’ program can be contributed to the Health Belief Model of health behavior change. The Health Belief Model is the most widely used theory of health behavior. The basis of the Health Belief Model has two parts, ‘Perceived Benefits’ and ‘Perceived Barriers’. Two components are involved in the “Perceived Benefits’ of a health behavior. One component is the individual’s ‘Perceived Susceptibility’ to the disease that would be inevitable if they do not change their behavior. It is formally defined as “the degree to which the person feels at risk for a health problem” (4). The other contributing component to an individual’s ‘Perceived Benefits’ is the ‘Perceived Severity of the Disease’. This can be described as the degree to which a person believes the disease they will develop will be detrimental to their life. The ‘Perceived Benefits’ of making a change to a health behavior weighed against the Barriers to making that change determines the individuals intent to act. In the Health Belief Model a person’s intent to act directly precedes a person’s behavior. According to the Heath Belief Model, individuals plan to act in a certain way and, as a result, they behave in the way they planned (4). The ‘5 a Day’ campaign used the outline of the Health Belief model as a way to encourage individuals to increase their healthy food consumption. The ‘5 a Day’ plan appeals to a person’s perceived susceptibility by using the media to convey the image that ‘if you do not eat the recommended amount of vegetables you are at an increased risk for heart disease and obesity’. The media also conveys the severity of heart disease, cerebriovascular disease and obesity by defining these issues as the leading causes of death in the United States (23). According to the Health Belief Model these educational aspects of the ‘5 a Day’ campaign should be enough to encourage all individuals to increase the number of servings of fruits and vegetables they eat. Unfortunately there are many weaknesses to the Health Belief Model and to the ‘5 a Day’ program that prevent the campaign from revolutionizing the eating habits of the population.
Self Efficacy: Can I really eat that many vegetables?
The ‘5 a Day’ campaign encourages all individuals to eat five servings of each fruits and vegetables a day. Current data suggests that the average adult eats fewer than three servings of fruits and vegetables a day. The data also illustrates that 42 percent of the population eats fewer than two servings of vegetables daily (3).Asking people to eat two or three more servings of healthy foods a day may seem unattainable to a vast majority of the population. Most people think that it’s completely impossible to reach the goal of five servings a day. A majority of the ‘5 a Day’ campaign is targeted towards youths, whom have very little control over the food they eat. If the food these kids are given does not coincide with the guidelines of the campaign, these kids may begin to believe that it is impossible for them to eat a healthy diet. If they believe this, when they can make their own food and diet decisions they will continue to make poor choices because they already assume that they aren’t capable of eating five servings of fruits and vegetables. The ‘5 a Day’ campaign is also targeted toward lower socio-economic groups who do not have ideal eating patterns. In these groups, fresh fruits and vegetables are not accessible due to their high prices and their availability. Although many families may understand that healthy eating is important, they may not have the tools necessary to achieve the goals set by the ‘5 a Day’ campaign. In terms of the ‘5 a Day’ campaign; individuals have a very low self efficacy. Self efficacy is a belief held by an individual that they are capable of performing in a certain manner or of achieving a set goal (16). The Social Learning Theory developed by Bandura, tells us that a persons decision to change behavior is dependant on the persons expectations of the outcomes of the behavior change and their self efficacy in the situation (2). The ‘5 a Day’ campaign fails to address this concept of self efficacy. If an individual feels that they are not capable of reaching a goal they will be discouraged from pursuing the behavior change at all (16). If the ‘5 a Day’ campaign had simply encouraged people to increase their fruits and vegetable consumptions they may have been more successful. By not specifying a specific serving goal that individuals need to reach, people will feel more capable of achieving the program goal. Research supports this idea, and confirms that if people have an increased sense of self efficacy they will increase the number of fruits and vegetables they consume daily (16). Therefore, in order for a campaign to successfully encourage individuals to eat more healthy foods, the program needs to support the population’s perception of self efficacy for the behavior change.
Culturally Fruits & Vegetables are not satisfying
A large focus of the ‘5 a Day’ campaign was in lower socio-economic, urban areas (11). These regions of focus have a very different cultural diversity then the rest of the country. For example, in Bronx, New York the demographics consist of 36% African Americans and 48% Hispanics. Over 50% of the population in the Bronx over the age of five does not speak English as their native language (12). In an area with a demographic diversity such as the Bronx, we can conclude that their poor diet habits are directly linked to their varying culture. Individuals that are from other nations have vastly different beliefs on what types of food are important. The typical diet of a native Caribbean consists of stewed, fried vegetables, and processed meats and fishes (26). African Americans also have very culturally based diets. Chitterlings is one of the foods that African Americans typically eat as well as fried chicken and items high in oil and butter (5).The ‘5 a Day’ campaign that was integrated into these communities through media, billboards and educational agendas, failed to address the fact that diet is very closely related to culture. People from many different nationalities do not weigh the importance of healthy eating decisions against the decision to eat their culturally designed diets. By failing to acknowledge the different cultural determinants of diet, the ‘5 a Day’ program failed to convert many to more healthy foods. If the campaign had provided culturally diverse areas, such as the Bronx, with recipes that are a healthier version of their culturally desired foods, there may have been more people that made the choice to eat more fruits and vegetables. This would also show individuals that it is possible to eat foods that they enjoy while also incorporating more fruits and vegetables into their diet.
It is also possible that adults, who were not educated in the United States, do not know the importance of eating a healthy diet rich in fresh vegetables. The native countries of most of the immigrants seen in the lower socio-economic areas are developing nations that do not have the resources available to promote healthy eating patterns. Instead these countries simply promote eating for calories. When these cultures come to America and see the ‘5 a Day’ campaign they may not be excited to change their eating habits because they do not understand its importance. The ‘5 a Day’ program failed to incorporate an educational facet for adults and for individuals who are not native English speakers. While the media did express the susceptibility of individuals who do not eat a healthy diet, those who need to hear these facts do not have access to news in a language they comprehend. Also, the educational aspects of the current ‘5 a Day’ campaign are focused on school aged children and not adults; neglecting to take into account that it’s the adults who ultimately make the household food decisions. A program such as the ‘5 a Day’ needs to address a lack of knowledge in these areas before suggesting that people increase their fruit and vegetable consumption. If the ‘5 a Day’ campaign incorporated an adult education campaign in multiple language there would be an increase in the number of people eating five fruits and vegetables a day.
Ronald McDonald vs. Apples & Oranges
In the lower socioeconomic areas that the ‘5 a Day’ campaign emphasized, financing five servings of fruits and vegetables a day for an entire family is a serious setback. In low socio-economic areas, such as the Bronx, the median household income was around $27,551 (15). People living in poorer areas have less dispensable income and can spend far less money on food then people living in wealthier areas. The monetary constraints on these families competes with the dietary guidelines sent out by the ‘5 a Day’ program. Many families have to choose between paying their rent and buying ‘healthy’ foods. In this situation almost everyone can agree that paying for rent is a higher priority then buying fruits and vegetables. Based on prices found at a Shaws supermarket, two heads of lettuce which would be enough to feed a family of four one meal cost around $6.00.This, of course, is not enough food for one meal and additional items need to be incorporated. Tomatoes cost an additional $3.50, Bell Peppers cost $3.39 a pound and Broccoli costs $4.00 a head. A meal that incorporates these four servings of vegetables for a family of four would cost upwards of $21.00 per family just for the salad. A meal at McDonalds which includes a hamburger, french fries and a beverage costs around $5.00 for each meal. For a family of four, a full meal can cost around $20.00.
Another reason why individuals in poorer communities find it difficult to get five servings of vegetables a day is because mothers cannot afford the time to go to the local store on a regular basis and buy fresh fruits and vegetables. Unfortunately, fresh foods have a short lifespan and spoil quickly. Because of this, keeping fruits and vegetable around requires a commitment to go to the food store once or twice a week. In these poorer neighborhoods mothers who work multiple jobs and are overwhelmed with responsibilities cannot set time aside to go to the store. Instead they keep frozen and canned foods on hand or rely on fast food to go.
A third barrier to healthy eating in poorer neighborhoods is the availability of fresh fruits and vegetables in the local bodegas. Because many people in these communities do not purchase the healthier foods options it is economically impractical for store owners to stock the items in their stores. As a result, even if someone wanted to purchase fruits and vegetables they are unable to do so. The ‘5 a Day’ campaign fails to recognize the economic barriers to consuming fruits and vegetables in lower socio-economic areas. Therefore, it is unrealistic to expect people to change their diets to incorporate a healthier option since it requires extra funds
What’s a better way to get your ‘5 a Day’?
The ‘5 a Day’ campaign fails to address some of the major forces that encourage health behavior change. By labeling the recommended daily serving of fruits and vegetables as five servings of each, the program is setting people up for failure. Currently the average adult consumes around 3 servings of fruits and/ or vegetables daily. Asking them to increase their intake so drastically seems impossible to most. Thus, the self efficacy relating to this campaign is very low and as a result very few individuals will make the healthy decision to follow the ‘5 a Day’ plan. The campaign also fails to incorporate the cultural basis of diets into their program. If the program advertised ways to change recipes for traditional foods to include more fresh vegetables, there would be more people eating healthy. The biggest failure of the ‘5 a Day’ campaign is the avoidance of the economic basis behind people’s diet choices. Because many people cannot afford these healthier food items, and they are not widely available in many poorer neighborhoods, few people make the necessary changes to their diets. If the ‘5 a Day’ campaign wants to improve their success rate they will first need to take the number 5 out of their program. If we do not make the goal of healthier eating seem unattainable, more individuals will modify their diets to include more of the fruits and vegetables. Also, if the ‘5 a Day’ campaign begins to addresses the cultural basis behind diets as well as the economic factors that act as barrier to healthier eating, there will be an increase in fruit and vegetable consumption. In order for a healthy eating program to be as successful as possible, it needs to address the barriers to diet change that are ignored by the “5 a Day” campaign. A possible solution to the failure of the “5 a Day” program is an intervention called “Grassroots Fruits & Vegetables”. This intervention is a three pronged approach to encourage healthier eating habits among the population.
“Grassroots Fruits & Vegetables”
More a Day the Fun Way
The first component to the Grassroots campaign involves taking over the current “5 a Day” program and changing its name to the “More a Day” program. By removing the five from the title, the campaign simply encourages individuals to eat more fruits and vegetables a day. The “More a Day” doesn’t set a very high goal for consumption, and as a result, it will not challenge self efficacy. Eating even just one more fruit or vegetable is not an overwhelming task and thus people will be more inclined to attempt to eat healthier (18). Studies have shown that self efficacy is a very strong predictor of the degree of behavior change that will result (2). This further supports the idea that if the “More a Day” campaign improves people’s self efficacy in healthy eating, we will see a greater number of individuals making the behavior change to increased vegetable consumption. Changing the campaign title to “More a Day” will also allow the Health Belief Model basis of the program to have a greater impact on the programs success. Without the factor of individual’s self efficacy, the program will lead individuals towards weighing the benefits of healthy eating against the barriers to doing so. They can then make an informed decision about their healthy eating behavior. By increasing self efficacy, the overall barriers to healthy eating are few for most individuals. The benefits of increased fruits and vegetable consumption include the severity of the disease that will result if the behavior is not changed, as well as the person’s susceptibility to the resulting illness. The focus of the “More a Day” program is to prevent obesity and obesity related illnesses such as heart disease, stroke, and some cancers. These illnesses are currently some of the leading causes of death in the United States (23). With the media presenting the severity of obesity-related illnesses daily, the susceptibility and severity of the resulting diseases are very clear. Under the “More a Day’ campaign the benefits of healthy eating appear to outweigh the barriers. According to the Health Belief Model, this will result in more individuals incorporating more fruits and vegetables into their current diets (4).
Learn to Love Your Fruits & Vegetables
The second facet of the “Grassroots Fruits & Vegetables” campaign is the educational component of the project. One of the problems with the “5 a Day” program was that it wasn’t culturally sensitive. Diet and food choice are very closely related to cultural and traditional beliefs (5). One of the proposed reasons why the “5 a Day” campaign has not been successful is because it does not show people how to incorporate fresh fruits and vegetables into their everyday diets without having to completely change their every day cultural ties. The ‘Grassroots Fruits & Vegetables’ program will go into very culturally diverse areas where many immigrants live and will offer free cooking classes that focus on how to take traditional dishes and use more vegetables and less fat. There will be a class offered for each different culture including Caribbean natives, African Americans who cook in a traditionally southern manner, and Hispanics Americans. Currently a program in Louisiana is attempting to encourage the same sort of behavior. “Stay Healthy Louisiana” is a program developed by the Louisiana Public Health Institution that encourages smoking cessation and health eating. On their website they have a section that lists the recipes for healthier versions of traditional southern foods such as cornbread, fried fish and chicken, and collard greens. They hope that by publicizing that it is possible to make healthier versions of the foods you enjoy, more people will change their diet (25). Under the “Grassroots Fruits & Vegetables” program there will also be a website that contains recipes for healthy versions of foods from all cultures and nationalities. However, under the grassroots program there will also be available a cookbook of all of these recipes that will be held in libraries and in food stores including local corner stores and bodegas. The cookbook will be free to eliminate any economic barrier to this part of the program. Making the health conscious recipes available will make it easier for more families to alter their diets to include more fruits and vegetables.
A Market for Healthy Eating
The third and most important component of the “Grassroots Fruits & Vegetables” campaign is the economics facet. One of the biggest barriers to healthy eating is the availability of fresh fruits and vegetables in local stores at a reasonable price (10). The economic part of the grassroots campaign hopes to combat this barrier through a three step process. The first part of this component will be to go to local corner stores and bodegas in lower socioeconomic areas and convince the store owners of the importance of carrying fresh produce for their patrons. As an incentive to the store owners we will offer them a subsidy to cover the initial costs of carrying these foods such as costs for displays and proper refrigeration units. We will also provide them with a subsidy so that they can keep the prices of the produce low. If fruits and vegetables are readily available in these areas for an equal or lesser price than unhealthy foods, it is more likely that people will make the change to fresh fruits and vegetables. This step of the economics project will also address the time commitment barrier to healthier eating. Having fresh produce readily available in local corner stores requires less of a time commitment to purchase vegetables on the way home each day. The second step of the economics component to the Grassroots campaign is Farmers Markets. By encouraging local farmers to sell their produce in these poorer neighborhoods you will be able to sell the vegetables for less than you would have to if they had been shipped form other parts of the country or world. Typically programs of this nature are run by the government and are, therefore, able to bypass typical food distribution policies to work directly with farmers (6). The aim of our farmers markets will be to get the local community involved in the health food market. This way they will be able to create a ‘local food system’ and local food economy that these people can continue to use after our intervention period is over (6). The third step of the economic component to the grassroots campaign is banning fast foods in poorer communities. This appears to be an unrealistic idea, however many public health organizations have been able to get restrictions on future fast food chains entering poorer areas (24). This restriction means that there will not be a saturated fast food market in these neighborhoods giving residents more freedom to choose from healthier options. The fewer fast food restaurants available the less chances people will consume fast food on a daily basis. Hopefully, they will consume increased healthier options that, at this point, are readily available to them (24). This step of the economics program is based off of the Social Learning Theory. People are influenced to make healthy decisions based on their environment, and their outcome expectancy (14). If they see fewer fast food restaurants, they will assume that there is a smaller demand for fast food in their neighborhood and they will be influenced to stay out of the fast food restaurants. All three steps coordinated together will help to combat the current economic barriers to healthy eating in lower socioeconomic communities.
Conclusion
The current “5 a Day” campaign for healthier eating has proven to be unsuccessful in really impacting the eating behaviors in the United States. It is really important that we have an appropriate public health intervention that works to encourage more fruits and vegetables and fewer fats. Obesity is a serious concern of today’s society because it increases a person’s risk of heart disease, diabetes, stroke and some cancer which are currently the leading causes of death. A campaign that would target obesity through changing eating habits would also be reducing the health risks of the population. The “Grassroots Fruits & Vegetables” campaign is an improvement to the current “5 a Day” program. It takes over the current program and changes its tagline to “More a Day” which will improve self efficacy in healthy eating decisions. As a result, more people will increase their fruits and vegetable consumption. The “Grassroots Fruits & Vegetables” program will also reach out the cultural diverse areas and encourage them to incorporate more fresh produce into the traditional meals through cooking lessons and free cookbooks. The most important improvement that the Grassroots campaign makes is in its economics component. By offering subsidies to local corner stores and bodegas, the program will make fresh fruits and vegetables accessible to poorer communities. Farmer’s markets in these neighborhoods will permit fresh produce to be sold at a remarkably low price as well. It will also create a community and local economy based on the market which will allow the healthy eating to continue long after our intervention. The “ Grassroots Fruits and Vegetables” campaign is merely just an addition to the current “ 5 a Day’ campaign for healthier eating, but the few changes to the program address some of the major barrier to health eating that the initial program failed to recognize. Through increased self efficacy, cultural sensitivity and economic considerations, the “ Grassroots Fruits and vegetables” programs hopes to have a deep impact on the food choices of the population as well as on the obesity epidemic that is currently the leading cause of death among our residents.

References:
Journal articles:
1. Bandura, A. (2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology, 52, 1-26.
2. Bandura, A, & Adams, N.E. (1977). Analysis of self-efficacy theory of behavioral change. Cognitive Therapy and Research. 1, 287-310.
3. Baranowski , T., & Stables, G. (2000). Process Evaluations of the 5-a-Day Projects. Health Educ Behav. 27, 157.
4. Becker, MH (1974).The health belief model and personal health behavior. Health Education Monogram. 2, 324-473
5. Byars, D. (1996).Traditional African American foods and African Americans . Agriculture and Human Values. 13, 74-78.
6. Duggan, T (2004, July 16). Bringing healthy produce to poor neighborhoods. San Fransico Chronicle, p. B1.
7. Heimendinger, J., Van Duyn, M. A., Chapelsky, D., Foerster, S., & Stables, G. (1996).The national 5 A Day for Better Health Program: a large-scale nutrition intervention. J Public Health Manag Pract, 2(2), 27-35.
8. Horacek, T. M., White, A., Betts, N. M., Hoerr, S., Georgiou, C., Nitzke, S., Ma, J., & Greene, G. (2002). Self-efficacy, perceived benefits, and weight satisfaction discriminate among stages of change for fruit and vegetable intakes for young men and women. J Am Diet Assoc, 102(10), 1466-1470.
9. Ma, J., Betts, N. M., Horacek, T., Georgiou, C., White, A., & Nitzke, S. (2002). The importance of decisional balance and self-efficacy in relation to stages of change for fruit and vegetable intakes by young adults. Am J Health Promot, 16(3), 157-166.
10. Mooney, C (1990).Cost and availability of healthy food choices in a London health district. Journal of Human Nutrition and Dietetics. 3, 111-120.
11. National Cancer Institute, (1992).5-A-DAY FOR BETTER HEALTH. NIH Guide. 21, 34.
12. Population April 1, 2000 & estimate for July 1, 2007: American Fact Finder (U.S. Census Bureau): Table GCT-T1, 2007 Population Estimates for New York State by County, retrieved on November 15, 2008
13. Resnicow, K., McCarty, F., & Baranowski, T. (2003). Are precontemplators less likely to change their dietary behavior? A prospective analysis. Health Educ Res, 18(6), 693-705.
14. Rosenstock, PhD, I.M., Strecher, PhD, MPH, V.J., & Becker, PhD, MPH, M.J. (1988). Social Learning Theory and the Health Belief Model, Health Education & Behavior. 2, 175-183 .
15. Scott, J. (2001, August 17). Economics; Mixed findings on poverity in survey of bronx. New York Times,
16. Shunk, D.H. (1990).Goal Setting and Self-Efficacy During Self-Regulated Learning . Educational Psychologist. 25, 71-86.
17. Sorensen, G., Stoddard, A., & Macario, E. (1998). Social support and readiness to make dietary changes. Health Educ Behav, 25(5), 586-598.
18. Strecher et al, (1986).The Role of Self-Efficacy in Achieving Health Behavior Change. Health Education & Behavior. 13, 73-92.
19. Suris, A. M., Trapp, M. C., DiClemente, C. C., & Cousins, J. (1998). Application of the transtheoretical model of behavior change for obesity in Mexican American women. Addict Behav, 23(5), 655-668.
20. Van-Duyn, M. A., Heimendinger, J., & Russek-Cuhen, E. R. (1998). Use of the transtheoretical model of change to successfully predict fruit and vegetable consumption. Journal of Nutrition Education, 30, 371-380.
21. Willett, W. C. (2001). Diet and cancer: one view at the start of the millennium
Websites:
22. CDC, (2003,July 23). About the national fruits & vegetable program. Retrieved November 15, 2008, from Eat a variety of fruits and vegetables every day Web site: http://www.fruitsandveggiesmatter.gov/health_professionals/about.html
23. CDC, (2008, April 11). Deaths- leading causes. Retrieved November 16, 2008, from National Center for Health Statistics Web site: http://www.cdc.gov/nchs/FASTATS/lcod.htm
24. Saletan, W. (2008, July 31). Food Apartheid: Banning fast food in poor neighborhoods. Slate, Retrieved November 22, 2008, from http://www.slate.com/id/2196397/
25. The Louisiana Public Health Inititative, (2008). Healthier Cajun & Southern Recipes . Retrieved November 22, 2008, from Stay healthy LA Web site: http://stayhealthyla.org/home/issues/view/89/sub/a
26. Thompkins, L. (2005,June 23). Caribbean food: A little history. EZine Articles, Retrieved November 15, 2008, from http://ezinearticles.com/?Caribbean-Food---A-Little-History&id=45781

Tertiary Child Maltreatment Prevention Strategies: Not Only Last but Also Least Effective of the Three Traditional Approaches – Carly Foster

2008-12-18T09:21:00.000-08:00

Introduction
Child maltreatment has been recognized in numerous publications as a global public health problem that needs immediate attention and intervention. Currently, the U.S. Child Abuse Prevention and Treatment Act recognizes four major types of child maltreatment: physical abuse, neglect, sexual abuse, and emotional abuse. In 2006, U.S. state and local Child Protective Services (CPS) cited that more than 900,000 children were victims of abuse in an investigated 3.6 million reports of children being abused or neglected (1). Agencies such as the World Health Organization and the U.S. Centers for Disease Control and Prevention argue that children who have experienced abuse and neglect are at an increased risk of negative health outcomes such as higher rates of alcoholism, drug abuse, depression, smoking, multiple sexual partners, suicide, and chronic disease (2, 3). Organizations agree that these health outcomes are in addition to the immediate physical and emotional effects of maltreatment. Public health prevention programs are absolutely essential to eradicating this global crisis. Unfortunately, many of the current public health prevention programs have originated from treatment programs. Considered to be prevention, the treatment programs are designed to alter the behavior of the abuser and protect the child from future abuse (4).
There are three types of child maltreatment programs currently recognized: primary, secondary, and tertiary prevention. Primary prevention strategies promote dissemination of information regarding positive parenting techniques, child development, risk factors for child maltreatment, and resources across communities and society. Secondary prevention strategies target individuals who are determined to be at “high-risk” for child maltreatment. Those at “high risk” for abuse may have predictive factors for child maltreatment such as history of abuse, drug or alcohol use, young age, and low levels of education. Tertiary prevention, closely related to treatment programs, strive to end further abuse and target the individual abuser. Minimal evidence exists to demonstrate effectiveness of this strategy and most professionals involved with families of abuse stress the importance of primary and secondary strategies if child maltreatment is ever to be eradicated (4).
Prevention of Abuse “After the Fact” May be too Late
Due to the complicated nature of predicting and identifying root causes of abuse, tertiary prevention programs may not address the many factors that may contribute to abuse. Many researchers agree that the perpetration of abuse results from complex interactions among characteristics of parents, children, cultures, and environmental influences (5). In a Developmental Psychology argument, Belsky attributes child maltreatment to three contexts – the developmental, immediate interactional, and environmental contexts of maltreatment. The “developmental context” examines the roles of parent and child characteristics in child maltreatment. When focusing on parent-child interaction and its processes associated with abuse, the “immediate interactional context” is analyzed. Lastly, the “broader context" discusses effects of the community, cultural, and evolutionary processes on child maltreatment (6). The volume of factors contributing to abuse limit prevention programs that target individual perpetrators of abuse. When developing a prevention program for groups of people who have committed child maltreatment, it is extremely difficult to reach the individual level and address specific needs. Next steps would include developing methods to identify the root causes of abuse for each individual perpetrator of child maltreatment in order to effectively prevent the behavior.
In addition to the multiple factors contributing to child maltreatment, tertiary prevention strategies tend to be punitive in nature and do not address social, economic, or psychological factors affecting the perpetrator of abuse. Response to child abuse and neglect involves identification of maltreatment and referral of victims and perpetrators for associated health care, social, and legal services; treatment of medical and psychological effects; and the reporting of abuse and neglect to the appropriate investigatory authorities in order ensure appropriate protection for the child. In addition to the child receiving protective services, the perpetrator may have to undergo such activities as parent support groups, parent education, home visitations, mental health, and other social support and therapeutic services (7). Despite efforts to affect behavior changes and prevent future abuse, studies show that one-third or more of the parents receiving intense support maltreated their children while in treatment. Many researchers suspect that over one-half of the families served are likely to mistreat their children following tertiary prevention strategies (8).
Some argue that the stress of treatment and prevention programs in addition to the existing array of factors may contribute to continued maltreatment of children. In addition, it may be difficult for parents and caregivers to focus on the treatment and prevention program when the root causes of child maltreatment have not been addressed (8). Other researchers argue that parental risk factors for child maltreatment, such as mental health problems and substance abuse may exacerbate the difficulty of establishing a trusting and open dialogue with parents (9).
Tertiary child prevention strategies have been shown to be most effective when the programs were more intense and prolonged, rather than short-term regimes. Generally a program that lasts longer than 4-6 weeks may be considered a ‘longer’ program (10). This data suggests that the success of the intervention, however, may depend on its ability to engage and retain parents for the entire program. The National Center for Injury Prevention and Control reported thirty to eighty percent of families most at risk for child maltreatment actually complete prevention programs. Even though families may attend programs, studies have shown they do not always adopt changes or maintain their skills. Despite the effectiveness of tertiary prevention programs, they have limited impact if they are unable to reach, engage, and retain prospective participants (11).
The last and perhaps most significant reason why prevention programs after the fact may be too late is demonstrated by Geeraert et al. This meta-analysis of 40 child maltreatment prevention programs suggests abusive parenting may become a fixed pattern of parent-child interaction without intervention (12). The reality is child maltreatment may exist for a long period of time before the authorities and child protective services become involved. This study provides important insight into the complex nature of parent-child relationships. Merrill also suggests that there are certain traits according to Personality Theory that predispose individuals for abuse. He suggests that parents may be categorized into four groups based upon psychological traits – chronically aggressive; rigid and compulsive, lacking warmth and reason; those who demonstrate a high degree of passivity and dependence; and extremely frustrated individuals (13). Not only is the treatment and prevention of further abuse more difficult at the tertiary level, but also may be ineffective if child maltreatment patterns are ingrained behaviors or personality traits of the perpetrator.
Control Theory
Control Theory, as defined by Glasser in 1986 states that all behavior is an attempt to satisfy powerful forces within ourselves. He argues that regardless of our circumstances, all people do, think, and feel is always the best attempt at the time to satisfy the forces within them. This behavior may be ineffective or even destructive to oneself or those around them. Individuals have choices, and he notes that people are typically unaware that they choose much of their misery (14). Expanding on this idea, Flowers explains that family violence may be an attempt to maintain power and control over another or others. He also argues that the use of force is always a choice. He even mentions that abusers would not necessarily become “out of control” when dealing with a police officer or member of society, but may become out of control when dealing with family or children (15). Utilizing Control Theory to explain child maltreatment challenges previous arguments that the causation of abuse is due to psychological, social, or environmental factors. This adds an additional layer to the problem and an additional reason why tertiary prevention programs may not be effective in stopping abuse.
If a parent or caregiver is using child maltreatment as a form of control, intervention and treatment may be extremely difficult. Family violence occurs in the absence of social controls that would normally result in positive behavior and punish acts of violence. Unless the abuser regains control in other aspects of their life such as social, economic, and emotional factors, treatment and prevention efforts may not decrease the incidence of child maltreatment. There are also researchers who argue whether social control is designed to keep violence from occurring or to maintain a certain level of family violence. There are still conflicting norms as to whether the use of violence in families is acceptable; many still feel that a certain amount of violence in families is accepted and even mandated.
What about the Child? The Ecological Model and Tertiary Prevention
Arguably, parental involvement is the most influential factor in determining child outcome. Attentive, stimulating, affectionate, and responsive child rearing may lead to optimal child development. Of the many influences associated with abuse, characteristics of parents are considered to be most important because they mitigate the external influences such as the environment. Thus, parents are often the target of interventions designed to prevent the occurrence of child abuse (17).
Though parental traits and behaviors may be an important aspect of child maltreatment, the Ecological Model considers the entire context of the abuse in order to understand and prevent child maltreatment. The four factors affecting child maltreatment include the parent, the family (including the child), the community, and the culture or society. Each of these levels may affect the child differently. Previous arguments have discussed the parent, the community, and the societal factors of abuse, but the purpose of this argument emphasizes the importance of the child. Tertiary prevention factors focused on the parent may not address the special needs or temperament of the child, nor prevention strategies targeted towards the child.
Many studies suggest that characteristics of the child do not increase the likelihood of child maltreatment. On the other hand, studies have shown that children who have special needs such as physical or mental disabilities, difficult temperaments, and mental health problems are more likely neglected. Regardless of whether child characteristics increase the likelihood of child maltreatment, the Ecological Model highlights the interaction between parents and children as considerations for abuse. A parent with high levels of stress interacting with a child with a difficult temperament may increase the probability of child maltreatment. Additionally, child characteristics may indirectly affect the parenting strategies used and the child-parent relationship. If a tertiary prevention strategy does not incorporate child characteristics, the program may be ineffective in preventing child maltreatment (18).
Following reported cases of abuse, parents are often referred to Child Protective Services (CPS) in order to undergo varying levels of therapy and treatment. Children often undergo therapy to address any feelings associated with the abuse and prevent them from being an abuser in a future family setting. What about the child’s role in preventing the abuse? Tertiary prevention programs do not empower children to prevent the abuse and obtain help when they are subjected to abuse. Without consideration for the child, tertiary prevention programs may not be successful in ending future abuse.
Conclusion
Minimal evidence exists to demonstrate effectiveness of tertiary prevention of child maltreatment and future research needs to focus on primary and secondary prevention efforts. Arguments against the tertiary prevention strategies include: the target population has already perpetrated the abuse, the Control Theory suggests an additional factor to address, and the child is left out of most tertiary prevention strategies. In order to fully understand and prevent child maltreatment, multi-faceted and multi-agency approaches need to be researched and validated. It is important for public health professionals to develop strategies based on the most current research.
Prevent Child Maltreatment Before it Starts:
Implement Parent Training Programs for all New Parents

There are three types of child maltreatment programs currently recognized: primary, secondary, and tertiary prevention. Primary prevention strategies promote dissemination of information regarding positive parenting techniques, child development, risk factors for child maltreatment, and resources across communities and society. Secondary prevention strategies target individuals who are determined to be at “high-risk” for child maltreatment. Those at “high risk” for abuse may have predictive factors for child maltreatment such as history of abuse, drug or alcohol use, young age, and low levels of education. Tertiary prevention techniques, closely related to treatment programs, strive to end further abuse and target the individual abuser. Primary prevention of maltreatment in the form of parent training should be implemented for all new parents, regardless of risk factors (4). This achievement would require an overhaul of the pre and post-natal care system, but may benefit children in the long term.
The Approach
Similar to Project 12-ways of the Behavior Analysis & Therapy Program of the Rehabilitation Institute at Southern Illinois University, this intervention would offer a range of services to families. The primary focus of Project 12-ways is to teach children and their parents the skills necessary to get along without abuse and neglect. This initiative emphasizes that family problems may be eased by teaching parents effective child-rearing skills. By incorporating the principles of Project 12-ways into the proposed national public health intervention, all new parents would receive parent training as a part of their pre and post-natal care. If finances were not a barrier to this intervention, home visitation may also be an important aspect of the parent training experience. By sending clinicians, social workers, or case managers to the families’ homes, the program would be able to identify risk factors for child maltreatment and assess the progress the families have made in accordance with the parent training.
Prevent Child Maltreatment Before it Begins
In a meta-analysis of 23 parent training programs, Lundahl et. al reported moderate but significant positive gains in all outcome constructs, such as attitudes linked to abuse and emotional adjustment. This study argues parent training is effective in reducing the risk of physical abuse, emotional abuse, and neglect. Following parent training, parents were more likely to develop child-friendly beliefs and attitudes and understand children’s developmental capabilities, emotions, and intentions. Parent training programs challenged the notion that corporal punishment is an effective long-term discipline strategy. Parent training also served to enhance the emotional well-being and stability of the parent, a major risk factor attributed to child maltreatment. When parents interacted with children following parent training, they were more likely to use warmth and democratic reasoning rather than coercion or force (5).
By conducting parent training for all expecting parents, the program trainers may be able to identify risk factors present in the parents. For instance, they may be able to assess the stress and anxiety levels of the parents, their employment status, and emotional attitudes towards child abuse. Early identification of these indicators is an important reason why primary prevention may be most effective. In tertiary prevention, or treatment, the root causes of child maltreatment have not been addressed, whereas primary prevention would enable parents to address risk factors for child maltreatment prior to the child’s birth or early in the child’s development (8). Similarly, the parental training programs may identify mental health problems and substance abuse, which are thought to contribute to child maltreatment and prevent open dialogue with healthcare providers (9).
In a meta-analysis by Geeraert et al, of 40 child maltreatment prevention programs, he suggests abusive parenting may become a fixed pattern of parent-child interaction without intervention (12). If parental training was practiced, parents and children may be more likely to develop positive interactions and relationships, rather than abusive patterns. Parent education programs improve parenting competence, effectively address risk factors for child maltreatment, and may result in fewer incidents of child maltreatment. Moreover, family visits may be an important factor to ensure that child maltreatment does not become a fixed interaction between parents and children (9). Primary prevention strategies encourage fixed patterns of positive parent-child interaction and may be more effective than tertiary prevention strategies.
Control Theory and Primary Prevention Strategies
If a parent or caregiver is using child maltreatment as a form of control, intervention and treatment may be extremely difficult. Primary prevention strategies may enhance social controls, resulting in positive behavior and reducing acts of violence. Parent training programs may assist parents to gain control in other aspects of their life such as social, economic, and emotional factors. Early identification of risk factors for child maltreatment may intensify the parent training, incorporating anger management and classes on self-control. Primary prevention strategies may also address the concern that many parents still believe that the use of violence in families is acceptable or mandated. Primary prevention and parent education may provide alternate strategies for parenting and an opportunity for parents to learn the long-term effects of child maltreatment (15).
The parent education classes would also require a component of child development and behaviors. This segment may reinforce the argument that, by understanding child development, the parents may have a better sense of what actions constitute “normal” childhood behaviors. This strategy may enable parents to relinquish their need for power if they are aware of the aspects of child development over which they do not have control.
The Ecological Model: When Primary Prevention Strategies Acknowledge the Child
Arguably, parental involvement is the most influential factor in determining child outcome. Primary prevention strategies promote attentive, stimulating, affectionate, and responsive child rearing, which may lead to optimal child development. Of the many influences associated with abuse, characteristics of parents are considered to be most important because they mitigate the external influences such as the environment. Thus, parents are often the target of interventions designed to prevent the occurrence of child abuse (17).
Primary prevention strategies address the special needs or temperament of the child. Studies have shown that children who have special needs such as physical or mental disabilities, difficult temperaments, and mental health problems are more likely neglected (18). The proposed parent training program would incorporate principles from the Triple P – Positive Parenting Program in Australia. The Triple P-Positive Parenting Program is comprised of five levels of intervention, which customizes the program with increasing intensity based on the necessities of the families. Level 1 aims to increase community awareness of available parenting resources and to increase parents' receptivity to participating in the Triple-P Positive Parenting. Levels 2-5 incorporate specific concerns of the child into the education. Level 2 of the program offers targeted interventions for specific concerns such as a child's developmental or behavioral difficulties. Level 3 of the Triple P-Parenting Program targets families with a child who possesses mild to moderate behavioral difficulties. The fourth level of the program offers intensive training in positive parenting skills to parents with children who possess more severe behavioral difficulties. Level 5 of the program is geared towards families with children who exhibit persistent behavioral problems and experience additional external risk factors such as parental depression or martial difficulties. This intensive program is specific to meet the families’ needs and the training includes: parenting skills training; mood and stress management training; and, partner support training (9).
Primary prevention strategies may also empower children to prevent the abuse and obtain help when they are subjected to abuse. Without consideration for the child, prevention programs may not be successful in stopping abuse before it starts. The Self Esteem and Assertiveness and Stress Reduction components in Project 12-ways are a great model for empowering the children. These programs aim to educate children about asserting their feelings and reducing stress, each important life skills.
Conclusion
Although labor intensive and a tremendous financial commitment, primary prevention strategies, such as parent training and home visitation may be the most effective methods to eliminate child maltreatment. Secondary prevention strategies target individuals who are at “high-risk” for child maltreatment, but studies have shown that there may be many false positives and false negatives for individuals at risk for committing child maltreatment. Tertiary prevention strategies are implemented following the abuse and may not be effective in reducing child maltreatment. Thus, a strategy of ending child maltreatment may be to stop it before it starts.
References

1. U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2006 [Washington, DC: U.S. Government Printing Office, 2008] available at: http://www.childwelfare.gov.
2. Prevention of child maltreatment. World Health Organization.
3. Preventing Childhood Maltreatment. Program Activities Guide. U.S. Centers for Disease Control and Prevention.
4. Knudsen D. Child Maltreatment: Emerging Perspectives. Rowman Altamira, 1992
5. Brad W. Lundahl, Janelle Nimer and Bruce Parsons. Preventing Child Abuse: A Meta-Analysis of Parent Training Programs. Research on Social Work Practice 2006; 16; 251
6. Belsky, Jay. Psychological Bulletin. Vol 114(3), Nov 1993, 413-434.
7. Chalk R, King PA, Violence in Families: Assessing Prevention and Treatment Programs. Committee on the Assessment of Family Violence Interventions Board on Children, Youth, and Families. Commission on Behavioral and Social Sciences and Education. National Research Council and Institute of Medicine National Academy Press, Washington, D.C., 1998
8. Cohn AH, Daro D. Is Treatment Too Late: What Ten Years of Evaluative Research Tell Us. Child Abuse Neglect. 1987: 11(3): 433-42.
9. Holzer PJ, Higgins JR, Bromfeld LM, Higgins DJ. The effectiveness of parent education and home visiting child maltreatment prevention programs. Child Abuse Prevention Issues. no.24 Autumn 2006.
10. Kelly, RF (2000). Family preservation and reunification programs in child protection cases: Effectiveness, best practices, and implications for legal representation, judicial practice, and public policy. Family Law Quarterly, 34(3), 359-391.
11. National Center for Injury Prevention and Control. Using Evidence-Based Parenting Programs to Advance CDC Efforts in Child Maltreatment Prevention Research Activities. Atlanta (GA): Centers for Disease Control and Prevention; 2004.
12. Geeraert L, Van den Noortgate W, Grietens H, Onghena P. The Effects of Early Prevention Programs for Families with Young Children at Risk for Physical Child Abuse and Neglect: A Meta-Analysis. Child Maltreatment, Vol. 9, No. 3, 277-291:2004.
13. Merrill EJ. Physical Abuse of Children: An Agency Study, in V De Francis, ed., Protecting the Battered Child (Denver: American Human Association, 1962).
14. Glasser W. (1986). Control Theory -- A New Explanation of How We Control Our Lives. Harper and Row, New York
15. Flowers RB. Domestic Crimes, Family Violence and Child Abuse: A Study of Contemporary American Society. McFarland, 2000.
16. Finkelhor D, Gelles RJ. The Dark Side of Families: Current Family Violence Research. SAGE, 1983.
17. Belsky, J. 1984. "The Determinants of Parenting: A Process Model." Child Development. 55: 83-96.
18. Harrington D, Dubowitz H, Chapter 5 in, Family Violence: Prevention and Treatment. Hampton RL. SAGE, 1999.
19. Project 12-Ways: Behavior Analysis & Therapy Program of the Rehabilitation Institute at Southern Illinois University. http://www.p12ways.siu.edu/

Breast Health Access for Women with Disabilities: Good Intervention or just Good Intention? - Kelsey L. Dicker

2008-12-18T09:18:00.000-08:00

The Breast Health Access for Women with Disabilities (BHAWD) program is one of the only initiatives of its kind in the country. Based in California, BHAWD has an accessible clinic with specially trained providers for nearby residents to take advantage of mammography services as well as training in adaptive self-breast exam techniques (1). Within the realm of the biomedical model, BHAWD should be proud of the quality care the clinic provides to women with disabilities in the Bay Area. Unfortunately, the public health outreach of BHAWD falls short. The 2001 California Health Interview Survey found that women with disabilities were 13% less likely than women without disabilities to adhere to cancer screening guidelines for mammography (2). As a pioneer in this field, BHAWD has made a significant accomplishment by starting an initiative, but has otherwise missed the mark. My critique of BHAWD has three arguments: a) the program focuses on the individual rather than society; b) the program ignores the historical and cultural context of disability; and c) the program does not account for psychological factors.
Society’s impact.
BHAWD focuses its efforts on educating the individual in an effort to promote behavioral change. It does not address societal factors that are ultimately leading to the disproportionate rates of mammography in women with disabilities compared to women without disabilities. According to Ramirez et al (2), “…individual health behaviors may be secondary to structural (health insurance and access to care) and/or clinical factors (doctor’s recommendation) underpinning the differences observed in preventative cancer screening outcomes evaluated.”
Providers’ attitudes and beliefs may have a large influence on why mammography rates are lower in women with disabilities. Often they unwittingly subscribe to the myth that complete exams and screenings are not feasible due to the physical limitations of a woman with a disability. Furthermore, the same are likely to suffer from a lack of training in specific adaptive examination techniques and a lack of focus on disability in medical school (3). Some studies have even gone so far as to say that negative attitudes held by physicians about patients with disabilities may lead to providing substandard care, or worse, withholding care all together (4). A subject in a qualitative study in 2004 (5) recounted a related experience when her provider refused to address her fatigue because he believed it was actually just laziness.
According to Nosek et al (6), 25% of women with disabilities who have never received a mammogram reported their main reason for not adhering to guidelines was that no doctor had ever discussed or recommended mammography with them. In addition to the influence of provider’s personal beliefs on suggesting mammography, there may be other crucial factors beyond his/her control.
For instance, time constraints during visits is one reason noted by primary care physicians for not addressing preventative health behaviors, such as mammograms, with patients with disabilities (7,8). Time constraints are likely shaped by a number of reasons, the first being the primary care shortage across the country. This puts pressure on all providers to see more patients in the same amount of time, leading to an average time per patient 15.7 minutes (including documentation) (9). For patients with disabilities, this means their more complex health issues, including both chronic and acute problems, must be discussed in this smaller window of time (10). Addressing health problems, rather than preventing them, becomes the priority of the visit. Physicians also mentioned underinsurance or low reimbursement rates for preventative health measures as a reason for not engaging in or recommending prevention to patients with disabilities (7,8).
A 1999 article published by Chan et al (11) found that only 13.2% of female Medicare recipients with high levels of functional limitation (defined as 5-6 activities of daily living limitations) had received a mammogram. This percentage dropped to only 5.2% for women living in long-term care facilities. Importantly, this study adjusted for important patient characteristics, such as income, race, and education, and found that increased level of disability was independently linked to decreased rates in mammography. This may be attributed to issues addressed above, or more intangible problems, such as society’s perception of patients with disabilities.
Though it still is important for the individual to take initiative when it comes to personal health, there are obviously much larger forces at play that prohibit women with disabilities from receiving mammography services at the same rate as their peers without disabilities. Even if a woman has a mammogram scheduled, issues beyond her control, such as transportation (6,12) or inaccessible facilities (6,10,12), can prohibit her from receiving the desired care.
Historical & Cultural Context of Disability.
BHAWD ignores the historical and cultural context of disability. We as a country have just begun to accept persons with disabilities as first-class citizens. It has been merely eighteen years since the Americans with Disabilities Act (ADA) passed. Culturally, we are slowly catching up with the policy passed nearly a score ago. The past has certainly shaped where persons with disabilities stand today.
Despite nearly fifty years of international policy work, including the United States, on equal education for persons with disabilities, this work remains largely symbolic. Effective methods of inclusive education practice remain to be seen on anywhere other than a local level. From the beginning of the disability rights movement,
“…people with disabilities have recognized the right to education as key to employment opportunities, quality of life, self-advocacy, empowerment, social justice, and equity in society at large (13).”
With high school graduation rates for individuals with disabilities at just 57%, compared to 75% of those without disabilities (14), it can be seen that these individuals are missing more than just the prom and a few math courses. Individuals with disabilities are less likely to be able to self-advocate, a key in today’s fragmented healthcare system. With forces working against women with disabilities, self-advocating is necessary to receive appropriate care, such as mammograms.
Employment is also a shaping force in the cultural context of women with disabilities. According to a 1998 study, 79% of non-disabled persons of working age were employed, whereas 29% of people with disabilities of working age were employed. Of the 29%, many are employed in marginal jobs, and of the remaining unemployed, many have job searched for years to no avail and give up in discouragement. Also consider that women with disabilities may encounter two counts of employment discrimination, based on both gender and disability (15). Employment is linked to tangible benefits that help individuals to access preventative health care, such as higher income and health insurance. The intangible benefits of employment for persons with disabilities include a greater sense of control over one’s life. For the vast majority of women with disabilities without the benefits of employment, preventative health care measures can fall to the wayside.
The history and cultural implications of eugenics from the early 20th century still resound today, specifically in health care. Block et al (16) discuss how the institutionalization and sterilization of the “feeble-minded” still affect persons with disabilities today. Persons with disabilities were then sterilized because they were thought to have variant sexuality from the rest of society and because eugenists wanted to purge society of their supposed detrimental genes. The pervasive and skewed belief of women with disabilities as aberrant (both on the whole and sexual levels (3)) has shaped how women and their sexual health, including mammography, are still viewed today by society-at-large and healthcare providers.
Psychology of Disability.
Approximately 11% of individuals without a disability living in the United States have moderate to severe depression. In comparison 20-30% of individuals with a disability have depression (17). Also consistent with the increase in depression in individuals with functional limitation is the pervasiveness of anxiety (18). Another compounding factor is that women are twice as likely as men to have depression (18,19). Depression can affect mood, appetite, sleep patterns, and social interactions. It is often a challenge for an individual with depression or related mental health issues to attend scheduled doctor’s appointments. The effect of depression on an individual’s self-efficacy should not be underestimated. BHAWD ignores mental health in their intervention, despite its prevalence in women with disabilities.
In addition to comorbid mental health issues, persons with disabilities may have anxiety over discovering they have another health issue to cope with, such as breast cancer. This anxiety may lead to avoidance of prevention and screening, such as mammograms. Unfortunately the literature on barriers to screening in women with disabilities is scarce and evidence remains largely anecdotal (3).
Self-efficacy is also a determining factor for receiving mammograms and was overlooked by BHAWD. Because of the paucity of literature on self-efficacy and disability, a study examining self-efficacy and pain-related disability can illustrate the effects. Arnstein (20) found that self-efficacy is inversely related to levels of disability, meaning that individuals with more self-efficacy found their situation to be less disabling. Depression also acted as a mediator in the relationship between self-efficacy and disability. It can be implied that women with more self-efficacy will perceive a lower level of disability. It has already been shown in the literature that women with lower levels of disability receive mammograms at a higher rate than their peers with more disability (11).
Looking Forward…
In my research I was able to find many published articles on mammography and women with disabilities, but a majority of them relied on the Health Belief Model or other individual-level models. The individual-level model is exactly what I have critiqued about BHAWD, so this literature needs to be taken with a grain of salt. After working with women with disabilities on a mammography project, it was apparent that forces larger than the individual are essentially choosing for women whether or not they will have a mammogram: insurance company and Medicare denials, a multiplicity of providers and specialists, facilities with inaccessible radiology equipment, etc.
As we move forward into the 21st century, advances must be made in the field of disability, in particular for women. The baby boomers are aging quickly and individuals with disabilities are living longer and longer so disability will become more prevalent in our society. New research techniques, such as qualitative methods, and social science models, such as framing theory and social expectations theory, must be employed if progress is to be made. Most importantly, we must educate our providers en masse, via medical and nursing schools, to erase institutional biases.
And Moving Forward.
These three critiques of BHAWD are meant as a starting point from which to create an improved intervention for increasing access to mammography for women with disabilities. Building upon what I have learned from my research, I propose a report entitled “Educating Tomorrow’s Doctors: Improving Medical School Curriculum to Better Serve Patients with Disabilities.” A curriculum recommendation for American medical schools, this new intervention aims to address the three main weaknesses of BHAWD. Developed based on literature and expert recommendations, this report would advise medical schools to incorporate a focus on individuals with disabilities into their existing curriculum. Saketkoo et al (21) showed a positive change in knowledge, skills and attitudes towards disability issues after a one-time, three-hour workshop for fourth year students. A nationwide recommendation can hopefully amplify the effect seen in this workshop at Tulane.
Go Beyond the Individual.
As discussed, BHAWD focuses on the individual, assuming that changing individual behavior will resolve the issue. To improve upon this, “Educating Tomorrow’s Doctors” goes beyond by moving to a group-level intervention targeting medical students. Evidence illustrates that a large reason for the lower rates of mammography in women with disabilities are provider beliefs and attitudes (3-6).
An individual-level intervention can only hope to change mammography rates at a 1-to-1 ratio, at most, meaning for each person targeted, at most one person will be affected. A group level intervention such as this curriculum recommendation can ripple much farther. For each doctor educated about disability issues, it can be assumed that they will positively affect most, if not all, of their patients with disabilities. A group-level intervention gives a much greater return on the investment.
“Educating Tomorrow’s Doctors” targets the root of the problem. BHAWD could be the best individual behavior change intervention in existence, but with a cause beyond individual behavior, the intervention will only be treating the symptom of a larger issue. By targeting the root of the problem and reaching all future physicians, “Educating Tomorrow’s Doctors” eliminates the need for an individual behavior change intervention. The curriculum recommendations will improve mammography rates among women with disabilities, and beyond, as doctors well versed in disability issues will positively influence the 49.7 million Americans with disabilities (22).
To ensure “Educating Tomorrow’s Doctors” is widely accepted, I will employ Social Expectations Theory and Framing Theory, both group-level theories. First with Social Expectations Theory I will work to receive the endorsement of the Association of American Medical Colleges (AAMC). Second, I will seek to pilot the AAMC-endorsed recommendations at a few prestigious medical schools, such as Harvard or Johns Hopkins. Using top-notch medical schools as an example, the social norm will become incorporating a disability focus into curriculums and other medical schools will hopefully follow suit and adopt the recommendations.
Framing Theory will assist in getting the recommendations adopted, as I will frame including a disability focus as a cornerstone of medical education. By publicizing that 1 in 5 Americans has a disability (22), no longer can learning about disabilities be considered an elective or extra material. Medical schools must incorporate a focus on disability, otherwise they will be leaving future doctors unprepared for the needs of 20% (and rising) of the patient population.
Incorporate all Contexts of Disability.
The societal and historical context plays a large role in how providers today look at and treat women with disabilities. In part, the past systemic medical mistreatment of women with disabilities can only begin to be healed by providing our future doctors with factual information rather than allowing unexplored misconceptions to persist.
“Educating Tomorrow’s Doctors” will encourage examining the clinical and biological aspects of disability in a medical school classroom, in hopes of dispelling many commonly held myths. In the case of mammography, an incorporation of a disability focus into coursework on the reproductive system is necessary to educate that women with disabilities commonly have normal, functioning reproductive systems, including their breasts. Women with disabilities are often viewed as asexual or their disability is also assumed to affect their reproductive system (3). This myth may lead to doctors skipping recommended screening guidelines, such as mammograms, to women with disabilities.
In addition to providing scientific information on disabilities to medical students, the report will recommend incorporating the history of maltreatment of persons with disabilities into a medical ethics seminar or class. This will hopefully bring a two-fold improvement in doctor training, as they will be equipped with both medical facts to appropriately treat patients with disabilities, while understanding the past and root of the problem.
Address Psychological Issues.
As shown, “Educating Tomorrow’s Doctors” aims to enable medical schools to easily add a disability focus to curriculums. Many of the given recommendations are for various adaptations that can be made to existing curriculums, rather than reinventing the wheel. One suggestion is targeted to show providers the individual psychology of disability, in addition to the clinical aspects. Currently some medical schools, such as Mount Sinai School of Medicine, have a longitudinal clinical experience. In this experience, each student is assigned to and follows one patient for two (or more) years. “Educating Tomorrow’s Doctors” would take this excellent program one step further by recommending that each student be paired with a patient with a disability.
By building rapport and being able to focus on a caseload of one, the future physician can witness the psychological and social aspects of living with a disability. Seeing the same patient over a few years can show possibly unveil mental health issues, such as depression or anxiety, and the effect this has on the patient’s ability to seek healthcare services. This comes in addition to participating in the clinical aspects of a complicated case over time. The student should be encouraged to both act as an advocate and a navigator of the health care system throughout their time with the patient with whom they are paired. This will give the student hands-on experience in order to develop his or her own tools for motivating and counseling patients with disabilities.
Longitudinal clinical experience not only builds an intimate clinical understanding of disability over time, but increases one’s sensitivity to disability-specific issues. In the case of mammograms (or any other screening activity), the future physician will have the chance to see complex psychological issues, including the thought that having a disability makes one less susceptible to other health problems. Medical students may even gain a first-hand look at what it might mean to someone with a disability to discover another health burden. This sensitivity to patients with disabilities is a key element, because a doctor well-versed in clinical disability issues will still not connect with a patient if psychological aspects are ignored.
Change that Benefits All.
A colleague of mine recently told me that we are all temporarily able-bodied. This seems especially poignant when examined in the light of our rapidly aging society. With increased life expectancy, one has a greater chance of experiencing some form of disability. Consequently, curriculum reform such as “Educating Tomorrow’s Doctors” would benefit more than just women with disabilities. It will help everyone with a disability, whether temporary or permanent. This will inevitably include our family members, our friends, and possibly someday ourselves. Even if you are lucky enough to go through life without being touched by disability, having a provider who is better able to contextualize clinical care will certainly help us all.
REFERENCES
1. Breast Health Access for Women with Disabilities. Berkeley, CA: Breast Health Access for Women with Disabilities. www.bhawd.org.
2. Ramirez A, Farmer GC, Grant D, Papachristou T. Disability and preventative cancer screening: results from the 2001 California Health Interview Survey. American Journal of Public Health. 2005 Nov;95(11):2057-64.
3. Thierry JM. Observations from the CDC: Increasing breast and cervical cancer screening among women with disabilities. Journal of Women’s Health & Gender-Based Medicine. 2000 Jan-Feb;9(1):9-12.
4. Paris MJ. Attitudes of medical students and health-care professionals toward people with disabilities. Archives of Physical Medicine and Rehabilitation. 1993;74:818-25.
5. Nosek MA, Hughes RB, Howland CA, Young ME, Mullen PD, Shelton ML. The meaning of health for women with physical disabilities. Family & Community Health. 2004 Jan-Mar;27(1):6-21.
6. Nosek MA, Howland C, Rintala DH, Young ME, Chanpong GF. National Study of Women with Disabilities: Final Report. Sexuality and Disability. 2001 Mar;19(1):
5-41.
7. Downs A, Wile N, Krahn G, Turner A. Wellness promotion in persons with disabilities: physicians’ personal behaviors, attitudes, and practices. Rehabilitation Psychology. 2004 Nov;49(4):303-8.
8. Councilman DL. Caring for adults with mental disabilities. Post-Graduate Medicine. 1999 Nov;106(6):181.
9. Shafrin J. Time Allocation in Primary Care Visits. San Diego, CA: Healthcare Economist. http://healthcare-economist.com/2007/09/24/time-allocation-in-primary-care-visits/
10. Iezzoni LI, McCarthy EP, Davis RB, Siebens H. Mobility impairments and the use of screening and preventative services. American Journal of Public Health. 2000 Jun;90(6):955-61.
11. Chan L, Doctor JN, MacLehose RF, Lawson H, Rosenblatt RA, Baldwin LM, Jha A. Do Medicare patients with disabilities receive preventative services? A population-based study. Archives of Physical Medicine and Rehabilitation. 1999 Jun;80(6):642-6.
12. Bachman SS, Verdrani M, Drainoni ML, Tobias C, Maisels L. Provider perceptions of their ability to offer accessible health care for people with disabilities. Journal of Disability Policy Studies. Winter 2006;17(3):130-6.
13. Peters SJ. “Education for All?” A historical analysis of international inclusive education policy and individuals with disabilities. Journal of Disability Policy Studies. Fall 2007;18(2):98-108.
14. National Center for Education Statistics. Student Effort and Educational Process: Elementary/Secondary Persistence and Progress. Washington, DC: US Department of Education Institute of Education Sciences. http://nces.ed.gov/programs/coe/2008/section3/
15. Fleischer DZ, Zames F. Access to Jobs and Health Care (pp 110-131.) In: The Disability Rights Movement: From Charity to Confrontation. Philadelphia, PA: Temple University Press, 2001.
16. Block P, Balcazar FE, Keys CB. Race, poverty and disability: Three strikes and you’re out! Or are you? Social Policy. Fall 2002;33(1):34-38.
17. Rehabilitation Research and Training Center on Aging with a Disability. Depression and People with Disabilities: What the Consumer Needs to Know. Downey, CA: Rancho Los Amigos National Rehabilitation Center. http://www.agingwithdisability.org/factsheets/depfactsht.htm
18. Chevarley FM, Thierry JM, Gill CJ, Ryerson AB, Nosek MA. Health, preventative health care, and health care access among women with disabilities in the 1994-1995 National Health Interview Survey, Supplement on Disability. Women’s Health Issues. 2006 Nov-Dec;16(6):297-312.
19. The National Women’s Health Information Center. Illnesses and Disabilities: Depression. Washington, DC: US Department of Health and Human Services Office on Women’s Health. http://www.womenshealth.gov/wwd/conditions/depression.cfm
20. Arnstein P. The mediation of disability by self efficacy in different samples of pain patients. Disability and Rehabilitation. 2000;22(17):794-801.
21. Saketkoo L, Anderson D, Rice J, Rogan A, Lazarus CJ. Effects of a Disability Awareness and Skills Training Workshop on Senior Medical Students as Assessed with Self Ratings and Performance on a Standardized Patient Case. Teaching and Learning in Medicine. 2004;16(4):345-54.
22. Waldrop J, Stern SM. Disability Status: 2000. Washington, DC: US Census Bureau, 2003.