“Just Say No”: Why One of the Largest Prevention Campaigns was Destined to Fail- John H. Murphy

Anti-drug campaigns have been a prominent part of American culture since the early 1980’s and the introduction of the “War on Drugs”. Most of these initiatives have not done well in regards to curbing adolescent drug use. One of the worst campaigns was the Reagan initiated “Just Say No” initiative. Created in the 1992, the campaign sought to abolish drug use through concept of empowering young people by making them realize they had the power to not do drugs, improve their self-esteem, and thus their lives. Unfortunately, this proved to be quite untrue. This particular initiative failed for a multitude of reasons, with some of the most prominent being that it was based on a flawed model of behavior, actually increased drug use by making it appear prevalent, and because of the fact that drug use and culture are embedded in corporate America.

The “Just Say No” campaign’s failure was, in large part, due to the fact that it was created using an outdated and flawed model for behavior: The Health Belief Model. One of the most important issues with the HBM is the fact that it is based on individual level, rational decision making (1). The very name of the campaign implies that the person confronted with the decision as to whether or not to use drugs, has the ability to make the rational decision to not do so. Obviously, this is untrue, as so many young people engage in drug use. If the healthy, logical decision to not do drugs was so simple, this would not be the case. This issue is also important in regards to the concept of intention leading directly to behavior, which is something else that the HBM assumes. By making this assumption, HBM ignores the fact that many other factors (environmental, social, etc.) can influence the outcome of the intention to do something (1).

The second issue with the HBM is that it fails to acknowledge the role that social factors play in health behavior and decision making (2). These factors, along with environmental, SES, etc cannot be ignored because, for many young people, the desire to not do drugs may pale in comparison to the desire to fit in with their peers, be accepted by larger social groups, or feel supported. Simply, it is often much too intimidating to “just say no.”

The HBM is also flawed in its definition of choice and how people weigh the options. In the HBM, it is assumed that people weigh the pros and cons of a behavior as strictly black and white. That is to say that a behavior that is negative, will be negative for everyone, as was noted in recent litigation against Big Tobacco:

“To me it’s like any other form of pleasure, whether it’s jogging, drinking beer or smoking cigarettes. If it provides a benefit to the person...in the eyes of the beholder, if it makes that person feel better about himself or herself,... There is a benefit, otherwise you would not sell the number of cigarettes that we sell every year...” (3).

Clearly, the benefit of a particular behavior is something that is unique to the individual and assuming that behavior is all or nothing fails to acknowledge this very important aspect of human psychology.

The final problem with the HBM is that it assumes that all human behaviors are in concert. That is to say that the intention to not do drugs will fall in line with all other intentions, such as the desire to do well in school. This was a major issue in the “Just Say No” campaign and many others after it. In multiple advertisements, young people who did not say no were depicted as being losers with no desire to, often, do well in school. This demonstrated the immediate and assumed link between the two. For example, while most people don’t want to be overweight, it does not mean that they don’t want to eat cheeseburgers, as noted in, “health beliefs compete with an individual's other beliefs and attitudes” (4).

The “Just Say No” campaign actually made more kids do drugs. By disseminating advertisements and interventions that showed drug use as prevalent, the campaign was showing teens that drug use was a common behavior, engaged in by many. This, when linked with the desire to be part of a group, which is incredibly strong because it feeds natural instincts: comfort, support, protection, love, etc., may have increased drug use. This was demonstrated in a study published in the Journal of Consulting and Clinical Psychology in 1999. The researchers found that the “Just Say No” and DARE campaigns not only did not decrease teen drug use, but that they actually led to an increase. They concluded that this was to the fact that the campaigns made drugs seem very prevalent and they also showed young people engaging in the illicit behavior. In turn, teens may have seen people their age engaging in an activity shown to be prevalent. Because of the desire to fit in, this combination could have led to increased usage rates (5). Recently, another study, to be published next month in the American Journal of Public Health, came to the same conclusion:

“Our basic hypothesis is that the more kids saw these ads, the more they came to believe that lots of other kids were using marijuana,” Hornik said. “And the more they came to believe that other kids were using marijuana, the more they became more interested in using it themselves” (6).

In the same study, researchers showed that as the number of ads seen per month increased, so did marijuana use. For teens that saw 12 or less ads per month, 82% reported no drug use. This number dropped by 6% with teens who saw over 12 and continued along this path as the number increased (6).

All of this is not to say that saturating the market with the messages that are trying to be conveyed is ill-advised. On the contrary, models, such as the diffusion of innovations theory, demonstrate the importance of doing just that. Otherwise, how else can one hope to reach the target audience with any effectiveness? However, the message that is being conveyed must be relevant to that audience. If it is not, it may have the opposite effect and actually reinforce the negative behavior. The “Just Say No” campaign is not alone in having a so called “boomerang” effect (6). The safe sex initiative of the mid 1980’s and 1990’s that was intended to improve safe sex behavior in MSM had just the same effect. The initiative sought to educate men about the dangers of unprotected sex by reinforcing the highly negative consequences of contracting HIV. This initially worked well because of the high levels of fear regarding the disease in the population. However, as treatment and subsequently life span for those with HIV improved, the effectiveness of the campaign began to crumble. In fact, by the mid 1990’s, increased rates of unsafe sex were being reported in MSM. Researchers believe that this was due to the fact that the fear based tactics of the message was no longer relevant to the intended audience. These men no longer viewed HIV as a death sentence and actually reported having “treatment optimism”. Also, because these men were repeatedly being told “you MUST always have safe sex”, many of them viewed not doing so as an act of rebellion (7). This is very similar to the effect of the “Just Say No” campaign. The message was not relevant, even laughable to many teens, and for some, the act of doing drugs was an act of anti-conformity and rebellion.

Because of these findings, it seems appropriate that in order to combat teen drug use, campaigns should focus on young people who aren’t doing drugs. The “truth” campaign is an example of an initiative that sought to target its intended audience in just this way. The researchers for the “truth” campaign discovered that “youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making.” After discovering this and marketing the “truth” campaign as a brand of rebellion in Florida, tobacco use by teens in the state dropped 7.4% in the first 30 days (8).

The third and some could argue most difficult issue to resolve, reason for the failure of the “Just Say No” campaign is the fact that drug use, especially marijuana, is embedded in corporate America. Corporations make “decisions about the production, pricing, distribution, and promotion of their products and political efforts to create an environment favorable for their business” (9). At its most basic level, it is a “how can we make the most money possible, regardless of the means” mentality. Because of this, young people are perpetually provided positive reinforcement for the use of illegal drugs by corporations and people that they view to be cool or even role models. Hollywood is the perfect example. Shows such as Entourage display people smoking Marijuana on a daily basis and being no worse for the wear. The show also happens to be predominantly viewed by 18-30 year old men, who are also the heaviest users of pot. It is not hard to decide which one, Entourage or a “Just Say No” ad, a young man would rather watch and what their association, negative or positive, would be with marijuana. Clothing is another example. Walk into any Pacific Sunwear and it won’t be hard to find hoodies, hats, and belts emblazoned with pot leaves. These shows and articles of clothing are viewed as much cooler than anti-drug ads, and are also used as a form of rebellion by, again, demonstrating anti-conformity.

The demographic that corporations target is also of importance. Multiple studies have shown that people who have low SES have greater risk for negative health behaviors such as, smoking cigarettes, alcoholism, drug use, and unsafe sex (10,11). These facts are no secret to corporations. For many businesses, these population groups are a prime target for their products. For example, the media outlet BET and clothing store Urban Behavior’s target demographic are African-American men between 18-30 years old. It is not unusual to see many of their products (music videos, shows, hats, shirts) displaying many references to the positive aspects of drug use: you will get women, wealth, friends, etc. Tobacco marketing is a prime example of corporations doing just the same thing. Studies have shown that neighborhoods with low SES have higher tobacco marketing saturation rates because there will be a larger proportion of smokers and possible smokers in those neighborhoods (12).

Recently, large corporations (Merck, Firestone) have been found to have been aware the negative health effects of their products, but continued distribution because of the high profit margins, and even “conducted extensive public relations and lobbying campaigns to try to maximize financial returns” (9). While these specific instances are extreme, they are not unlike the Hollywood executive producing a show glorifying drug use. They know exactly what effect it will have on the viewer, because they have put the time and money into the research. In contrast, the “Just Say No” campaign was based around a single, cheesy catchphrase: just don’t do it. This is no match for the huge influence corporate America has on behavior. Businesses employ hundreds of marketers, advertisers, and psychologists to determine what factors influence the choices of consumers. Corporations then take the wealth of information learned through their research and are able to create products and then market, distribute, and price them in a manner that elicits a strong, positive, and often subconscious reaction from the targeted group (13).

To alleviate the negative impact of corporate practices the glorify drug use, it will be necessary, not to create new, stronger anti-drug campaigns, but rather, provide consumers with adequate knowledge about the negative health impacts of drug use while protecting the young and especially vulnerable groups, increase penalties for disseminating pro-drug products, and increase health and policy spending to level the playing field (9). Otherwise, huge corporations, such as film and TV studios and clothing manufactures will always be able to out spend health campaigns while marketing their product in a manner that creates the perception of coolness by the consumer.

In hindsight, it is not surprising that the “Just Say No” campaign was unable to deter adolescent drug use. The entire campaign was based on a model of behavior that reduces decision making and behavior to an individual cost v. benefit analysis. It also saturated media outlets, schools, etc with a message that showed drug use as something prevalent in young people, which may have actually increased usage rates. The fact that drug culture is something that is so highly embedded in American culture and business also played a significant role in undermining this and many other campaigns. In order to reduce teen drug use, it will be important for initiatives to use the message as a brand that assumes no rational thinking and takes into account the many pressures young people face.

The “Just Say No” campaign was inherently flawed and destined to fail because of its creators unwillingness to accept or unawareness of the fact that adolescent drug use is more than a simple yes or no decision, should be displayed as an act of the minority rather than the majority, and that drug culture is highly rooted in the practices and products of corporate America. In order to reduce teen drug use, it is imperative that each of these issues be incorporated into future campaigns. If the multi-factor causes of drug use are not acknowledged, anti-drug campaigns will continue to have little effect.

One of the greatest flaws of the “Just Say No” campaign was its utilization of an already outdated model of behavior, the Health Belief Model. In order to construct an intervention that would not be inherently flawed, the core issues of the HBM must be addressed. For instance, the HBM assumes health behavior is based on rational, logical decision behavior (1,2). A successful campaign and intervention would have to utilize a model that does not make this assumption, thus enabling it to account for the extreme variation in similar groups of people in regards to health choices. For example, models such as the Diffusion of Innovations Theory make no mention of logic or rational being the basis for decision making. By doing so, such a model would allow campaign creators to construct an intervention that would acknowledge the, in many cases, complete lack of logic that human decision making is based upon.

The second major flaw of the HBM that must be addressed is the lack of inclusion of social factors as playing a major role as determinants of health behavior and decision making. For example, the HBM assumes that intention leads directly to behavior (2). Obviously, this is often untrue when put into the context of a real-life scenario. For example, many heroin addicts intend not to use again, but often they do, and sometimes for lengthy periods of time, all the while intending each hit to be the last. By addressing the importance of environmental, social, economic, and cultural factors in regards to health behavior, an anti-drug campaign would have a much greater chance of addressing the multi-factor causes of drug use. It is crucial that things such as social acceptance, peer pressure, and SES play a major role in the construct of the model being utilized (1,2).

One of the greatest challenges in creating a successful health campaign is the marketing strategy. In the 1980’s and ‘90’s, the “Just Say No” campaign portrayed illicit drug use as being prevalent in adolescent society. In doing so, the initiative normalized drug use and may have even led to increased usage rates (5,6). In order to avoid this phenomenon, an anti-drug campaign must take the opposite approach. Drug use and the desire to avoid using should be marketed as the norm. Teens need to see that the benefits, maturity, acceptance, and happiness that their peers have enjoyed and gained through other activities. Drug use should be shown as an outlier behavior that few teens engage in. By doing so, the campaign would be able to market drug use a socially unacceptable and taboo. This is in direct contrast with the “Just Say No” campaign which, by failing to engage in such a marketing campaign, may have demonstrated that a lack of drug use would be viewed as social suicide in adolescent groups. An example of just such a marketing campaign is the “Truth” initiative in which smoking is portrayed as being the activity of the minority and thus viewed as a negative behavior. By doing this, the campaign was able to show non-smokers as the non-conformist group rebelling against “Big Tobacco” (8). This is an important point. For many young people, adolescent years are difficult and many feel a need to rebel against their parent, society, etc. Often, drugs are the perfect outlet for this angst. A successful anti-drug campaign needs to account for these emotional needs in youth and demonstrate just that: a lack of drug use is a form of rebellion through strong and individual (a.k.a non-conformist) thinking and decision making.

All of this being said, it is still important, just as in the “Just Say No” campaign, that the market (TV, radio, popular culture, etc.) is saturated with the message. The flaw of this tactic with said campaign was not the actual high level of disbursement of the message, but rather the message that was being dispersed. While the “Just Say No” campaign failed, in part, because it normalized drug use, which led to a “boomerang” effect, it is still important to do the same, but with a relevant message normalizing a lack of dug use (6). Just as in the Diffusion of Innovation Theory, it is crucial that the early stages of the campaign are marked by high recognition of the message. Adolescents must encounter large “doses” of the alternate campaign, one in which positive, socially accepted alternatives to drug use are displayed. By doing so, teens will begin to desire the same acceptance, hope, love, and self-efficacy that is being demonstrated by their peers in the campaign.

The third obstacle and, by far, the most difficult to address is the effect that corporate America and their practices has on the youth of this country. As noted previously, organizations and industries, such as Hollywood and clothing manufacturers, spend billions of dollars each year researching the psychological factors that influence consumer’s decisions (9,10,13). By doing so, these organizations are able to create and market items that play into the subconscious desires of their target audience. For example, television shows and movies, such as Entourage and Blow, portray drug culture as a positive in many ways. The individuals highlighted in these pieces are shown to be flashy, wealthy, surrounded by women and, possibly most importantly, happy (9,10,13). When young people are constantly surrounded by messages extolling how drug use will lead friends, wealth, and happiness, it is no surprise that these fictitious messages begin to become reality to them. It is analogous to the idea that the more a person hears or tells a lie, the more it becomes a truth. While seeing such a message at a low rate may not influence behavior or influence choice, when constantly surrounded by the message, even though it may be rationally false, it can become incredibly difficult for it not to begin to shape a persons perception of the path to success.

The first step to changing these practices is through an increase in policy and public health spending. If this nation is to reduce drug use, it is imperative that politicians pass legislation prohibiting the rampant dissemination of the positive aspects of drug culture and allow public health organizations access to adequate levels of funding, so that they may compete with multi-billion dollar corporations. This legislation must also be multi-pronged. Because so many industries utilize drug culture as a means for amassing wealth, it will be necessary to target all. There must be regulations on the content that is permissible for the youth of the country. This is a very thing line to walk because blanket regulation is not possible, nor it should be. One of the hallmarks of this country is held in the First Amendment of the Constitution and the right to free speech. This must never be infringed upon. However, our citizens and politicians can demand that the distribution of such products can no longer go, so completely, unchecked. For example, to purchase clothing with drug references people under the age of 18 should have to have an adults consent to do so. To view certain shows with ratings acknowledging drug use and references, parents must take a more active role and “lock” these programs. In order to achieve the latter, high levels of marketing must be done to make parents aware of particular shows and movies. Simply showing parents in a commercial putting “parental controls” in place on their television is not enough because many parents are unaware of what to block. Because of this, a majority of the content that could be detrimental to their children slips through.

One of the most important keys to the success of a future anti-drug campaign, and any public health campaign, is that our public health organizations must begin to utilize the social and psychological sciences to a much greater degree. Organizations employ sociologists and psychologists to determine the social trends, individual desires, and needs of youth. By doing so, these organizations create products that are appealing to adolescents ¹³. How can public health practitioners hope to achieve similar results without employing the same methods? By including them in the construction of an anti-drug campaign, public health organizations would be able to tap into the same inherent, group level drivers of behavior. The result would be interventions that youth would find appealing and identify with. The “Just Say No” campaign is the perfect example of an initiative that failed to do this and because of this failure, their simple, catch-phrase message quickly became laughable to teens (5).

Finally, incentives must be created to drive corporations to create more health friendly products and services. Currently, organization’s financial gains often come at the expense of the health of lower class citizens. Corporations spend millions of dollars marketing their unhealthy products to groups in low SES areas of the country (10,11). For example, because of the higher rates of smoking and possible smokers in low SES areas, tobacco companies heavily market in those areas and also market products, such as menthol cigarettes, that are consumed at higher rates by those groups (12). In order to push corporations from producing and marketing unhealthy products to consumers, legislation must be passed that creates financial incentives to do so. For example, tax breaks for organizations that use and produce environmentally and health friendly products could be implemented. The situation is analogous to the current energy crisis. Because of the large financial gains of oil, organizations are unwilling to seek out alternative sources of energy, unless there are financial incentives, often tax breaks, to do so. By implementing a similar sense of urgency and benefit for corporations, a shift from an emphasis on health harming products to those that improve population health could be created.

It is unlikely that drug use will ever be completely removed from society, but an increase in use is possible. However, this will only be possible if policy and campaign creators are willing to look at the multi-dimensional factors that lead to drug use. Illicit drug use, especially in youth, can no longer be simply viewed as an activity for social deviants. Drug use occurs in all groups and for a variety of reasons, none of which is rational decision to begin using. Policy and funds, just as with any public health issue, must seek to attack the issue from a multitude of angles. For example, treating homelessness by simply removing people from the streets is not effective. They must also be provided with mental health and drug counseling, sustainable employment, food, etc. Just as with homelessness, drug abusers become as such because of a variety of reasons and need a variety of support outlets to regain sobriety and maintain it.

REFERENCES:

1. Rosenstock, Irwin. Historical Origins of the Health Behavior Model: University of Michigan School of Public Health. Health Education Monographs Vol. 2, No. 4, 1974.

2. Salazar, Mary Kathryn. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal, Vol. 39, No. 3, 1991.

3. Horrigan EA Jr. Liggett Group. Broin v. Philip Morris Companies Inc. : Circuit Court of the Eleventh Judicial Circuit, in and for Dade County, Florida, 1994:114

4. http://msucares.com/health/health/appa1.htm

5. http://www.time.com/time/nation/article/0,8599,99564,00.html

6. http://www.thecontemplation.com/?p=2016

7. Hart, G.J. Williamson, L.M. Increase in HIV Sexual Risk Behavior in homosexual men in Scotland, 1996-2002: Prevention Failure? MRC Social and Public Health Sciences Unit, University of Glasgow, 4 Lilybank Gardens, Glasgow G12 8RZ, UK.

8. Hicks, JJ. The Strategy Behind Florida’s “truth” Campaign. Tobacco Control 2001; 10:3-5.

9. Freudenberg, Nicholas. Galea, Sandro. The Impact of Corporate Practices on Health: Implications for Health Policy. Journal of Public Health Policy. 2008.

10. Lantz, P. Lynch, J. House, J, et al. Socioeconomic Disparities in Health Change in a Longitudinal Study of US Adults: The Role of Health-Risk Behaviors. Social Science Medicine 2001; 53.

11. Lu, Ning. Samuels, Michael. Wilson, Richard. SES Differences in Health: How Much Do Health Behaviors and Health Insurance Coverage Account For? Journal of Health Care for the Poor and Underserved. 15. 2004: 618-630

12. http://tobaccocontrol.bmj.com/cgi/content/full/11/suppl_2/ii71

13. http://www.corporationsandhealth.org/chron.php

Critique of the Partnership for a Drug Free America Television Ad Campaign & A Potential Alternative Intervention - Christian Pulcini

Introduction

Throughout the latter half of the 20^th century and continuing into the 21^st, public health interventions aimed at reducing illicit drug use among youths and adolescents have been fundamentally flawed in their reasoning and strategies behind the interventions. The over-reliance on traditional public health models to help structure interventions, such as the health belief model and theory of reasoned action, have steered public health professionals and organizations concerned with illicit drug use away from their original goals.

Partnership for a Drug-Free America

No example is more prominent and memorable than the Partnership for a Drug Free America’s commercial campaign, which has targeted illicit drug use over the past 30 years. Although the Partnership touts it successes by citing an overall decline in drug use over the past 30 years, it fails to acknowledge that drug use reached its peak in the late-1990s years after its most well-known and widely distributed television advertisement “This is drugs. Now this is your brain on drugs. Any questions?”.[1]

The answer to this advertisement in the context of structuring successful public health intervention is most certainly “yes”. In fact, this advertisement can offer insight into the fundamental questions of why did the Partnership’s early interventions fail? And why will their advertisements aimed at preventing illicit drug use continue to fail to reach the youths and adolescents of the United States if they refuse to alter the structure and foundation behind their interventions? By exploring and questioning the earlier advertisements and mass media campaigns by the Partnership for a Drug-Free America within a more broad social science construct, one can achieve a better sense of the answers to these questions.

The Nature of Drug Use & Missed Social Science Cues by the Partnership for a Drug-Free America

The Partnership for a Drug-Free America has consistently employed more traditional health behavior models in constructing their market-based interventions. More specifically, “This is drugs. This is your brain on drugs. Any questions?” is an excellent example of a health belief model-based intervention. What is interesting about the reasoning behind this intervention is that the Partnership appears to completely ignore the multiple behavioral factors that influence drug use, and also fails to recognize the inadequacy of the health belief model in predicting complex behaviors. By reviewing psychological theory over the past thirty years in parallel with the foundations of the health belief model, one may attain a better understanding of why the Partnership for a Drug-Free America initially produced ineffective advertisements and why they continue to do so today.

When the first mass media campaign was launched by the Partnership for a Drug Free America, psychological theory held (as evidenced by the DSM-IV & ICD-10) that drug use is a largely atheoretical disease which can be classified by a traditional medical model conceptualization.[2] Many argued against this reductionist view of the illness however, as they felt it could not be classified under a single disease and instead involved multiple factors which could not be accurately defined.[3] As early as the mid-1980s, the psychological theory behind drug use began to shift to support the latter opinion and reject the more traditional classification of drug use. Psychologists found that the relationship between behavior and drug use is not easily categorized, and cannot be defined by a set of agreed upon variables.[4] More recently, psychologists have agreed that drug use is a multi-dimensional behavior that can be influenced by various factors including genetics, biology, environment, socio-cultural factors, and the biochemistry of the substance itself. The exact formula that leads an individual to use drugs is largely unknown, and could be any combination of the factors listed above.⁴ Modern psychopathology recognizes that physicians, sociologists, behavior-oriented researchers, and other scientists and social scientists that study drug use all produce different theories and interventions based on their discipline.[5] Therefore, although mainstream psychological theory failed to recognize the complexity of the behavior involved with drug use in the 1970s, it certainly has come to agree with other social sciences that drug use is not a behavior that can necessarily be predicted.

Although the health belief model has several limitations, the one that is most relevant to the psychological theory presented above (in the context of evaluating the Partnership’s intervention campaign) is that the health belief model has repeatedly been shown to be a poor predictor of complex behavior.[6] Why then would the Partnership utilize the health belief model in their marketing campaign to address drug use? Although the answer to this question is difficult to answer without input from the Partnership for a Drug-Free America, it can be postulated that the Partnership has consistently failed to incorporate social science theory into their interventions and consequently has failed to capture their target audience. They instead decided to adopt the health belief model as a common model to predict health behavior, not evaluating the efficacy of the model in predicting complex behaviors. Although the Partnership may not be held accountable for their failure to recognize drug use as a complex behavior when they initially produced their interventions (because mainstream psychological theory had not decided until the mid-1980s drug use was a complex behavior), their failure to adapt to new social science theories and abandon the health belief model in constructing illicit drug use interventions cannot be excused for at least the last 20 years.

Marketing Campaign or Just Another Public Health Intervention?

In addition to the failure of the Partnership for a Drug-Free America to recognize that the health belief model cannot readily predict complex health behaviors, they also failed to incorporate more modern marketing theories in their interventions that are generally a better predictor of behavior. The Partnership claims they that are the pioneers who successfully breached the long-existing gap between public health and mass media, but they do not recognize that their advertisements fall short in addressing the problem of illicit drug use among youths because the foundation which produced their memorable yet ineffective messages was wrongly applied.[7]

This once again leads us back to a discussion of the health belief model and its limitations. The health belief model hypothesizes that behavior is based on individual, rational decisions which are not influenced by social or environmental factors. Besides the fact that these characteristics also support the first argument presented above, they also display that the Partnership was largely unaware of the components of a successful marketing campaign based on marketing theory. Marketing theory, almost in direct opposition to the health belief model, is a homogenous approach which concentrates on influencing the behavior of large portions of a population as opposed to individual idiosyncrasies.[8] The pattern that marketing theory follows to achieve this goal is as follows:

• First, they present to the group of people something they want, need, or desire.
• Second, they offer a promise that their product can fulfill the consumer’s newly discovered demand.
• Third, an image is given that reinforces the goals of the audience.
• Lastly, support must be offered to show how the promise will be delivered.[9]

If the marketing theory model explained above is compared to the Partnership’s health-belief model based intervention “This is drugs. This is your brain on drugs. Any questions?”, the distinctions and argument become much clearer. The first step in the marketing theory, which appeals to a groups wants, needs, and/or desires, is successfully addressed in the intervention. No teenager or adult wants their brain to be fried by drugs. It is unclear whether or not they are attempting to address a rational individual, which would indicate a health-belief model based intervention, or a group of people who are predictably irrational (marketing theory). Either way, it is safe to assume that any individual or group regardless of rationality would not want their brain fried by drugs. In terms of the first portion of the marketing theory, the intervention does appear to be successful. This also appears to be the case with the third component, as the strong, memorable image does reinforce the goal of the audience.

If the 2^nd and 4^th elements of marketing theory are discussed within the context of the intervention, one is able to realize that these are the crucial steps within marketing theory that are missing. In the television advertisement, there is no promise or proof that shows an individuals brain will be fried if they use drugs. Teenagers watching the commercial interventions who are considering using drugs may dismiss the strong imagery based on the lack of a promise, and make the assumption that the claim within the commercial is false. Logically the last component of the marketing theory cannot be addressed if the 2^nd is not produced, which indicates that no support is offered by the Partnership which proves the adverse effects of drug use.

Overall, the “This is drugs. This is your brain on drugs. Any questions?” intervention does incorporate elements of marketing theory. It appears as if the Partnership however, when they attempted to merge mass media and public health, was largely unsuccessful in bridging the gap between public health and mass media because they picked up on parts of marketing theory and put it into a health belief model context. Instead, the Partnership should have fully utilized marketing theory as a better predictor of complex behaviors and dismissed the health belief model entirely. By incorporating marketing theory components into the a health belief model based intervention, the Partnership falls short of its goal and the commercial simply becomes another failed attempt to prevent illicit drug use among youths.

Later Intervention: Change or Just the Same?

It is important to mention that the Partnership, after their initial commercial campaign, decided to modify “This is drugs. This is your brain on drugs. Any questions?” commercial campaign to incorporate other public health based behavior models. It is unknown whether the Partnership viewed the early campaign as a failure and decided to change, or whether they felt they could strengthen their already successful campaign to combat illicit drug use among youths. Regardless, it appears as if the Partnership did strengthen their newest mass media product, but still fell short of obtaining the goal because of their reliance on the traditional health behavior models.

The revamping of the 1980s Partnership for a Drug Free America anti-narcotics commercial in the late 1990s features a woman with a frying pan, who smashes an egg after declaring “this is your brain, now this is your brain after you snort heroin”.[10] She continues to destroy the entire kitchen with the pan stating “And this is what your family goes through, and your friends, etc., etc.”.[11] The intervention attempts to portray the outcome expectancies for the viewer(s), perceived social approval, and to strengthen the feelings of the viewer(s) towards the outcomes. These are all important components of the theory of reasoned action, a model similar to the health belief model which integrates outcome expectancies, perceived social approval, and different attitudes and beliefs towards the behavior.[12]

Although interventions based on the theory of reasoned action have more potential than the health belief model to be successful in predicting behaviors surrounding the use of illicit drugs, the Partnership once again fell short in fully recognizing the nature of the problem. Even more so than the original commercial campaign; this commercial relies on those youths considering illicit drug use to be able to make a rational, planned decision. It also does not provide any explanation of the disconnect between intentions and behavior. In other words, impulse behavior is not accounted for within the theory of reasoned action. For example, the contents of the commercial assume that before using drugs the teenager is going to be in a rational mindset to ask questions such as: what is this drug going to do to my brain? How is it going to effect my family and friends? How am I going to feel about myself if I do the drugs?. Several surveys of teens agree, including ones published by the Partnership for a Drug Free America, that drug use is usually not pre-meditated and the decision to use drugs is based on their immediate availability.[13] Teens in these surveys also overwhelmingly agree that they know any kind of drug use is bad (89%), but what is interesting is that over 18% of students nationally are engaging in illicit drug use (alone) according to the Youth Risk Behavior Survey.[14] It is obvious that the decision to use drugs is often not rational, planned, or intended, but instead is based on the disconnect between intention and behavior, which the theory of reasoned action fails to address.

Even though social sciences have a difficult time agreeing on the exact components of the behavior which encompass drug use, they all agree that the decision to engage in the behavior is often not planned, rational, and intended.[15] The partnership does make a better attempt at addressing illicit drug use among youths in their second campaign, but still falls short in assessing the nature of drug use and consequently fails in constructing a successful intervention.

Conclusion: Flaws that Need to be Addressed

The Partnership for a Drug Free America should be applauded for their persistence in attempting to curb illicit drug use among youths from the latter half of the 20^th century until present. But as what often occurs with public health interventions, persistence with the wrong framework and structure leads to continued failure. The Partnership’s over-reliance on traditional health behavior models, such as the health belief model and theory of reasoned action, and their failure to apply marketing principles to a marketing campaign have led to 30 years of misled advertisements, wasted public dollars, and ineffective efforts. Until the Partnership is able to incorporate modern social science theory into their interventions, their efforts are doomed to continuously fall short in reaching out to the youths of America.

Introduction to an Alternative Intervention

Given the fundamental flaws in the Partnership for a Drug Free America’s commercial intervention, it provides a significant opportunity to suggest an alternate intervention which addresses each of the previously addressed flaws and may serve as a guide for a future successful intervention aimed at preventing the use of illicit drug among teens. By creating a commercial based on marketing theory (instead of the traditional health behavior models) which addresses the limitations of the Partnership’s current campaign, more teens at risk of using drugs will be reached if the proposed intervention is implemented.

The Intervention: “Fate” & Positive Choices

To truly understand the context of the proposed intervention, it is imperative to give a short background of the television advertisement it is based upon. A recent commercial by Nike (entitled “Fate), which shows very brief clips of two notable football players, LaDainian Tomlinson and Troy Polamalu, developing into the excellent players they are today is an solid foundation for a public health intervention.[16] As the original commercial displays how these two players were born to be excellent football players, a public health intervention could also portray the same idea. The commercial shows images of the players as children and adolescents, running to class with books in their arms, running up stairs, etc. to portray that they not only worked hard, but were also destined to do what they have done. Nike’s Vice President states “The beauty of this ad is it reminds us of how much hard work, sacrifice, and yes, fate it takes to make it to the top of the sport of football”.[17] The commercial finishes with a dramatic clash of the two players in an actual game.

A public health intervention aimed at keeping adolescents off drugs could use the marketing theory strategies utilized in the Nike commercial. First, the commercial would begin exactly the same; with two athletes born and excelling from youth to adolescence. At this point, the public health intervention would deviate from the actual commercial. It would show one of the players working hard and the other player experimenting with marijuana around high school age. Both players would still be shown at big name colleges, one displayed as scoring a touchdown and the other player who had experimented with drugs as not living up to his potential. It would show them after the game, one getting high fives with people all around him encouraging him, with the other using some sort of illicit drug(s). The last shot would be the football player who worked hard scoring a touchdown on a NFL team, and the drug user in a secluded room alone using drugs. The final message would be “What fate gives, drugs can take away”, in which the famous successful football player (ideally LaDainian Tomlinson because of his clean record and respect he receives from in and out of the NFL) would deliver the message to keep consistent with the Nike message and to directly influence the youth of the United States.

Although the exact representations in the commercial may be improved upon by marketing experts, the basic idea and message of the commercial could be effective according to marketing theory. This intervention could also be extended to other public health interventions (ex. Teen pregnancy) and sports (ex. Women’s basketball) to potentially influence a wider audience.

A Better Predictor of Complex Behavior: An Intervention with Potential

The first fundamental flaw in the Partnership’s commercial campaign is their use of the health belief model, which has repeatedly been shown to be a poor predictor of complex behavior.[18] The proposed commercial intervention, which is based on marketing theory, more accurately recognizes that behaviors surrounding drug use are often complex and cannot be predicted utilizing traditional health behavior models. In fact, one of the strengths of marketing theory is that it accounts for behavior(s) of individuals being dynamic.[19] The commercial involving two football players does not assume that each individual watching makes independent decisions regarding drug use, but instead it attempts to influence the decisions’ of a group of individuals (causing herd mentality) who are considering and/or exposed to drug use. More specifically, the advertisement forces a group of teens to consider the consequences of drug use, but also reinforces the idea that drug use is not acceptable among a group of individuals (NFL players) who teens often aspire to be.

The proposed campaign could be more successful because it does not attempt to simplify behaviors surrounding of drug use. Instead, it realizes that drug use among teens has multiple contributing factors, and does not attempt to address these multiple factors with a model that does not lend itself to doing so. As a result, the intervention based on marketing theory has the potential to be more successful than the original ad campaign in predicting and/or preventing drug use among a large faction of teens who aspire to be NFL football players.

Applying Marketing Theory to Construct a Successful Intervention

In addition to the failure of the Partnership for a Drug-Free America to recognize that their intervention, based on the health belief model, cannot readily predict complex health behaviors, they also failed to incorporate more modern marketing theories in their interventions (which are generally a better predictor of behavior). The proposed intervention however utilizes marketing theory to construct an intervention which has the potential to reach out to teens and more effectively prevent drug use.

Marketing theory, almost in direct opposition to the health belief model, is a homogenous approach which concentrates on influencing the behavior of large portions of a population as opposed to individual idiosyncrasies.[20] The pattern that marketing theory follows to achieve this goal is as follows:

• First, they present to the group of people something they want, need, or desire.
• Second, they offer a promise that their product can fulfill the consumer’s newly discovered demand.
• Third, an image is given that reinforces the goals of the audience.
• Lastly, support must be offered to show how the promise will be delivered.[21]

In regards to how the proposed intervention relates to marketing theory, the goal of the commercial is to tap into the viewer’s desire to become a professional football player (as researched for the original commercial). The promise of the advertisement is that it is possible for those who are naturally gifted to become NFL players, but not for those who use drugs and do not work hard. Ultimately it draws comparisons to the two individuals’ choices, where the one football player chooses to use his natural talent while the other chooses to throw it all away. The supports are the images of the players growing up and making choices, and the apparent success and failure of each player is how the promise will be fulfilled. It is important to note that the commercial also incorporates the social aspect of using drugs and how using drugs can have adverse consequences on relationships.

Therefore, although the Partnership for a Drug Free America does incorporate some aspects of marketing theory, the new ad campaign has the potential to be more successful because it accurately reflects all components of marketing theory instead of just two of them. Teens will be able to see through the players’ choices that the promise of the consequences of using drugs will be fulfilled, and will consequently make better choices when presented with the opportunity to use illicit drugs.

Rational or Predictably Irrational? A Better Model to Prevent Drug Use Among Teens

The third limitation of the Partnership’s drug ad campaign occurred after they had revamped their original campaign. The “revamping” involved using the health belief model to construct an intervention, with the new commercial implementing components of the theory of reasoned action. Although the theory of reasoned action has more potential than the health belief model to be successful in predicting behaviors surrounding the use of illicit drugs, the Partnership once again fell short in fully recognizing the nature of the problem as the new commercial relies on those youths considering illicit drug use to be able to make rational, planned decisions.

Because the recommended ad campaign is based on marketing theory, it does not assume that a teen is going to be able to make a rational, planned decision when considering drug use. Instead, it postulates that behavior is predictably irrational.[22] The proposed intervention exposes a group of teens to an idea and promise that if they decide to use drugs, then they will not be able to succeed in athletics regardless of inherent ability. This could potentially be a much stronger motivator, as teens would see a promise of something they aspire to be fulfilled in the new intervention, whereas in the original intervention no promise is fulfilled.

These components of the proposed intervention strongly support the need for the Partnership to realize that decisions involving drug use are often not planned and rational, but instead are impulsive and irrational. The proposed intervention targets a group of individuals who aspire to be athletes, as opposed to the Partnership’s campaign which fails to address the aspirations and desires of its viewers. Although the proposed marketing campaign may need several commercials to address the different desires and aspirations of different groups of teens, this model has been shown a much more effective predictor of behavior.

Conclusion

Even though the Partnership for a Drug Free America has consistently failed to incorporate social science theory into their interventions, more specifically marketing theory, there is still hope for the Partnership to construct a potentially successful ad campaign in the future. By implementing the proposed intervention, using the Nike “Fate” commercial as a model, many of the fundamental flaws in the Partnership’s original and revamped campaign would be addressed. As a result, the prevention of teen drug use in the United States through commercial ad campaigns would become a reality, and thousands of teens would be able to fulfill their aspirations and desires by choosing not to use drugs.

References

---

[1] Partnership for a Drug Free America. Case Studies About the Effectiveness of the Partnership’s Media-Based Educational Campaigns. September 2006. Available at http://www.drugfree.org/Portal/DrugIssue/News/campaign_effectiveness. Accessed Thursday, November 13th, 2008.

[2] Parents. The Anti Drug. Rockville, MD. Natinoal Youth Anti-Drug Media Campaign. http://www.theantidrug.com/drug_info/prescription_tips.asp. Accessed November 13th, 2008.

[3] Pattison, E. M., Sobell, M. B., & Sobell, L. C.. Emerging concepts of alcohol dependence, New York: Springer. 1977. p. 58-63.

[4] Shaffer H.J., Neuhaus Jr. C. Testing Hypotheses: An Approach for the Assessment of Addictive Behaviors. 1985. p. 87-103.

[5] Maddux J., Winstead B. Psychopathology: A Foundation for a New Understanding. 2005. p. 308.

[6] Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974;2:Entire Issue.

[7] Partnership for a Drug Free America. Case Studies About the Effectiveness of the Partnership’s Media-Based Educational Campaigns. September 2006. Available at http://www.drugfree.org/Portal/DrugIssue/News/campaign_effectiveness. Accessed Thursday, November 13th, 2008.

[8] Austin EW, Pinkleton BE. Strategic Public Relations Management. Lawrence Earlbaum Associates, Inc., New Jersey. 2001. p. 284.

[9] Siegel M, Siegel LD. Marketing Public Health. 2004. p. 57-58.

[10] Partnership for a Drug Free America. Available at http://www.drugfree.org/Portal/About/NewsReleases/Fried_Egg_Message. Accessed October 2nd, 2008.

[11] Partnership for a Drug Free America. Available at http://www.drugfree.org/Portal/About/NewsReleases/Fried_Egg_Message. Accessed October 2nd, 2008.

[12] Fishbein M, Azjen I. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley; 1975.

[13] Partnership for a Drug Free America. Partnership Attitude Tracking Survey. 2003. Available at http://www.whitehousedrugpolicy.gov/publications/pats/final_rpt.pdf. Accessed on Tuesday, November 20^th, 2008.

[14] Youth Risk Behavior Surveillance – United States 2007. MMWR. June 6^th, 2008. Vol. 57. No. SS-4. Available at http://www.cdc.gov/healthyyouth/yrbs/pdf/yrbss07_mmwr.pdf. Accessed on Tuesday, November 20^th, 2008.

[15] Shaffer H.J., Neuhaus Jr. C. Testing Hypotheses: An Approach for the Assessment of Addictive Behaviors. 1985. p. 87-103.

[16] Nike Corporation. “Fate” Available at http://www.nikebiz.com/media/pr/2008/10/09_Fate.html. Accessed Tuesday, October 22nd, 2008.

[17] IBID.

[18] Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974;2:Entire Issue.

[19] Siegel M, Siegel LD. Marketing Public Health. 2004. p. 57-58, 204.

[20] Austin EW, Pinkleton BE. Strategic Public Relations Management. Lawrence Earlbaum Associates, Inc., New Jersey. 2001. p. 284.

[21] Siegel M, Siegel LD. Marketing Public Health. 2004. p. 57-58.

[22] Ibid.

The Smallstep Campaign against obesity and its Small Effect- Navid Shams

Introduction

In the past 30 years we have witnesses the obesity problem in this country develop into a major epidemic and a predominant issue in public health. Just in the first 20 years, the percentage of obese adults doubled from 15% to 30%. In a similar time period the prevalence of overweight children increased from 5% to 17.4%. [i] Now about 64% of the US population is either overweight of obese. [ii] This striking progression also brings with it direct and indirect costs that are estimated to be as high as $117 billion dollar annually. [iii] These costs are so high due to the fact that being overweight or obese has been shown to increase the risk for a series of diseases, including osteoarthritis, Type 2 diabetes, coronary heart disease, stroke, gallbladder disease, sleep apnea, respiratory problems, and even breast and colon cancer. ⁱ

The steady and significantly increase in the prevalence of obesity as well as the associated costs have pushed the government to act. In November of 2005, the US Department of Health and Human Services in conjunction with the Advertising Council mounted a $1.5 million a year media-based campaign called smallstep. Its goal is to “increase awareness, change behavior and promote healthier lifestyles among the millions of Americans who are currently unhealthy and overweight and at risk for obesity and long-term chronic diseases.” ^xvi A series of professionally produced television, magazine, and radio public service advertisements get people’s attention by using humorous visual images and then refer them to the companion website so they can learn about more than 100 small steps that can lead to a healthier lifestyle. The small steps are thought to be manageable enough to fit into a busy schedule without requiring drastic changes and therefore should promote long-term, sustained weight control and good health.

In conjunction with this campaign, a sub-campaign, smallstep kids, has recently been added to encourage children to eat healthier and be more active. It uses similar media outlets to portray healthy fruits and vegetable as fun foods that can be used as fuel for play. It also utilizes NFL players, LPGA golfers, and Shrek characters to promote the “Play 60” and “Be A Player” concepts that urge children to get out and play everyday.

The smallstep campaign uses a novel approach to obesity problem. It integrates healthier eating and a more activity into the typical American’s life in a reasonable manner. It even incorporates a non-traditional model by using advertising theory. However, it still doesn’t seem to be effective enough to produce positive health outcomes. In the following analysis, I provide an evidenced-based criticism that illuminates why this public health campaign is not succeeding.

Argument 1: Dependence on the HBM does not account for the impact of social networks on behavior change.

The smallstep campaign uses the Health Belief Model (HBM), which is an individual-level, value-expectancy model that posits that people will engage in healthy behavior when they intend to do so because they value the outcome and believe it will result from their behavior. [iv] In their campaign report, the smallstep developers emphasize how the program promotes self-efficacy, a trademark of the HBM. [v] They highlight the idea that having to complete only a few simple and small steps (i.e. take the stairs instead of the escalator, get off the bus a stop early and walk, try smaller sized items when snacking or eating out) will boost confidence in one’s ability to perform the behaviors.

Although this tactic makes the tasks seem more manageable, it is counterproductive to give each step a number. The actual numbers associated with each “step” on the main webpage make it seem like one’s goal should be to complete each one as if it is a task. Also, mentioning that there are over 100 of them makes it seem less manageable and can be intimidating for people, especially those who are already not very hopeful about their ability to eat right and exercise regularly.

Besides not considering the previously explained challenges facing individuals in vulnerable economic situations, the select use of the HBM also doesn’t permit the developers to address the influence of social networks on predicting behavior. Social Networking Theory tells us that the relationships with a person’s peers, teachers, teammates, friends, neighbors, and family are of great importance and can significantly affect a person’s decisions. This effect depends on the nature of the relationship, which involves reciprocity, frequency and complexity of interactions, and the setting. [vi] This theory is especially important to consider because the “network phenomena appear to be relevant to the biologic and behavioral trait of obesity.” [vii] By focusing on individuals, the smallstep campaign neglects research that suggests the obesity tends to “spread” through social ties and develop in clusters.

For instance, being friends with an obese person increases one’s risk of becoming obese by 57% and having a sibling who becomes obese increases it by 40%. [viii] Although the smallstep kids advertisements do promote activity that involves friends and peers, the smallstep adult and teen section doesn’t recognize that an individual’s social network plays a role in determining actions related to health, the health information one is exposed to, and the social support people have available to them. Only one of the exercise related tips even addresses the idea of involving another person in your physical activity: Tip # 44 states “Ask a friend to exercise with you). Most of the activities are very individual-based, such as the use of a step tracker, which includes an online component that promotes setting activity goals and tracking progress using an interactive calendar.

A lack of consideration of Social Network Theory (SNT) is apparent in the discord between the adult/teen and kids sections. The developers should have considered the relationship between parent’s obesity status and its effect on their children. Children are known to adopt parent’s diet and health related behavior due to daily exposure. [ix] Children with 2 obese parents have an 80% chance of becoming obese in their lifetime, while those with one obese parent have a 40% chance and those with no obese parents have only a 7% chance. [x] Considering that part of this is related to the social-norms established by parents, the developers should have taken more steps to link the kids and adult sections of their campaign.

Lastly, a person who has overweight/obese social contacts has a different perception of the acceptability of being overweight/obese. It may even be a social-norm for them. This partially explains why weight gain by same-sex friends and siblings had such a large impact on the risk of the individual becoming obese. ^xvi Approaching the public with more group level smallstep interventions could be more effective at instituting long lasting behavior change.

It is important to link appropriate individual and population-based theories when designing interventions. This produces a richer intervention because, after all, we are all
individuals but we are also enmeshed in social networks. The specific importance of social networks in the obesity problem warrants using a group-based theory like SNT to combat the limitations from HBM. Neglecting this aspect leads to a smallstep campaign that does not have a strong multi-level intervention.

Argument 2: Poor Use of Advertising Theory

The inclusion of the Ad Council in this public health intervention was a good decision because it allows for the use of multiple media outlets (TV, internet, newspapers) that have a large audience. Also, it allowed for the addition of aspects of the intervention that are based on Advertising Theory. This theory involves two essential components: a promise and its support.

The support aspect can be implicit and even laughable, but should include compelling visual images, music, etc. In the case of the smallstep ads, the support has drawn confrontation and is being laughed at instead of being laughable. As Michael Jacobson of the Center for Science in the Public Interest says, it so “namby-pamby [that] I think people will shrug it off.” [xi] This is a criticism of the commercials that show people finding love handles, double chins, and other fatty and unwanted pieces of flesh in public places because they have lost them due to simple exercise (e.g. taking the stairs, walking to the office).

We know that “viewers pay more attention to ads that evoke feelings of personal loss, sadness, anger, disgust or fear [and] tend to remember such ads longer,” ^xvii so it’s unfortunate that the developers didn’t use more vivid, dramatic effects to get their point across. They even admit that research showed the ads to be humorous, instead of evoking any of the above feelings. Even the “lost” fat isn’t particularly disgusting, or as disgusting as it could be. This also applies to the magazine ads that are supposed to look like lost cat type signs, but lack attention-getting colors. These ads are poorly designed and do not evoke the right emotions from the audience, which is critical to their success.

The promise aspect of an advertisement is of critical importance and must be researched thoroughly so as to identify what exactly it is that your target population most aspires to at a core level. Unfortunately, the text that delivers the promise on the print ads is also impossible to read as it is very small, not colorful, and written vertically. In addition, framing theory tells us that the ads would be more effective if they identified core values. Unfortunately, only a couple of them do this reasonably well: “Now runs the risk of being mobbed by female admirers.” Most of them miss the mark: “No longer dependant on wearing vertical stripped shirts.” Also, the use of humor continues in these ads: “fights urge to run on the soccer field and play forward.” So, even if you manage to read the promise, it may not even be effective.

It is surprising to me that the Ad Council didn’t come up with more promising material and leads me to be suspicious of the partnership with the “Coalition for Healthy Children,” which includes Coca Cola, Pepsi, Hershey, and the National Confectioners Association. Their products are serious contributors to obesity, yet there is no mention of them. There could be conflict of interest issues that led to the absence of candy and soft drinks in the advertisements.

The smallstep kids advertisements are also flawed, especially in regards to the “brand name” they developed. The “Play 60” and “Be A Player” show groups of kids having fun and playing easy outdoor games like tag, 4-square, football, kickball, cheerleading. Respectively, they include well known professional football players and LPGA golfers, and Shrek characters that are involved in the kid’s activities. The impressive recruiting the developers did is counteracted by the use of “brand names” that emphasize the wrong idea. Play 60 advertisements specifically tell the kids to play for 60 minutes every day and suggest that this should be their goal. However, research tells us that kids would be more responsive if values like improved appearance or social standing were addressed. [xii] [xiii] The well respected athletes could have been used more effectively in this way.

On the other hand, the Shrek characters, although they are certainly popular are not exactly the most athletic group that could have been used to promote physical activity. However, that is exactly the point: you don’t have to be an athlete to enjoy and benefit from physical activity. This raises issues around the effectiveness of the message delivered by the advertisement and the coordinated online system, which gives health tips based on personal exercise and health statistics. Shrek isn’t focused on physical activity but instead on improving health, which we know is not a core value for children. [xiv] We know that the kids watching these are already displaying sedentary behavior, so the smallstep kids developers need to be sure to dissuade the inactivity while they have the children’s attention. [xv]

Argument 3: Developers Overlook the Sociological Perspective

When designing a public health intervention, it is critical to know the traits of the problem. However, the designers of the smallstep campaign have overlooked the socio-demographic characteristics that are an important part of the obesity problem. In the US, we have seen the prevalence of obesity rise more than twice as fast among minority groups compared with white groups. [xvi] Moreover, we know that black and Latino children are as twice as likely of being overweight compared with white children. [xvii] Among adult women, obesity prevalence varies significantly by ethnic group: 31% among whites, 40% among Mexicans, and 52% among African Americans. In terms of obesity, the concepts of race/ethnicity and SES are interlinked. [xviii] Namely, the highest rates of obesity occur among populations with the highest poverty rates, and poverty disproportionately affects minorities. [xix] Keeping this connection in mind there are a couple of reasons why overlooking socioeconomic status, specifically, is a major flaw of the smallstep campaign.

The idea of a family’s socioeconomic status (SES) is a key factor that influences food options. People from lower SES backgrounds are more likely to become overweight due to limited access to health-related stores and local food shops with available fresh and healthy foods. [xx] So, even if people want to eat the healthy, fresh fruits and vegetables that smallstep suggests, they are not readily available and can be prohibitively expensive. [xxi] A related factor is the lack of reliable transportation. Also, there are there are fewer supermarkets with fresh, affordable produce and many more small independent grocers that provide low cost, high-energy foods in low-income areas. This leads to the purchasing of cheaper meals and snacks that are convenient but offer little nutritional value. [xxii] These are factors that will certainly impede the effectiveness of the “Can your food do that?” aspect of the smallstep kids campaign, which is well designed enough that is can succeed at getting children to want to eat fruits and vegetables. Unfortunately, when it succeeds and the children want those foods, they may not have access to them.

SES can also restrain physical activity. Lower income neighborhoods can have more crime and street violence. This does not allow children to safely use parks and open spaces; children in lower income neighborhoods get less physical activity when compared to children in safer, wealthier neighborhoods. [xxiii] Besides the safety concerns, the built environment itself can impact physical activity. Geographic areas occupied by low SES and minority populations are known to have less availability of physical activity facilities than those occupied by higher SES populations. [xxiv] Studies have shown a correlation between the accessibility to sidewalks, gyms, gardens, and parks and increased physical activity. [xxv] Understandably, areas with more facilities have been associated with lower rates of overweight and obese people. So, although the “Shrek” and “NFL Play 60” ads [xxvi] can get kid’s attention because of the presence of popular football players and movie characters, the fun they have playing in seemingly safe, sizable parks and well equipped and maintained sports facilities is not possible for many of the more vulnerable children. It is especially unrealistic for those in urban areas.

Conclusion

The US Department of Health and Human Services’ smallstep campaign has tackled the complex obesity problem with a media-based approach that certainly has possibilities. It focuses on perceived barriers to individual behavior in a novel and worthwhile manner. However, this epidemic requires multi-level interventions that address the underlying causes of obesity from various dimensions. The individual’s behavior must be viewed in relation to the social network and also social environment. Its failure to do this is common among public health interventions, but is still unforgivable. The use of creative solutions based on Social Network Theory, coupled with a better use of Advertising Theory is warranted.

Counter-Proposal

Introduction

The US Department of Health and Human Services’ smallstep campaign has tackled the complex obesity problem with a media-based approach that certainly has possibilities. It focuses on perceived barriers to individual behavior while integrating healthier eating and a more activity into the typical American’s life. Their approach is novel and worthwhile. However, it still isn’t effective enough to produce positive health outcomes because this epidemic requires multi-level interventions that address the underlying causes of obesity from various dimensions. The individual’s behavior must be viewed in relation to the social network and also social environment. The use of creative solutions based on the sociological perspective and Social Networking Theory, coupled with a better use of Advertising Theory is warranted. In the following proposal, I present an intervention that builds upon the smallstep campaign by capitalizing on its strengths and addressing its weaknesses.

Step I: Accounting for the impact of social networks on behavior change.

A major strength of the smallstep campaign is its unique approach to addressing self-efficacy by providing simple and small steps. This tactic does, in fact, make the tasks seem more manageable and will be effective once the numbering of steps is removed. Because each step is independent (i.e. take the stairs instead of the escalator, try smaller sized items when snacking or eating out) they can be effectively understood and implemented no matter what order they are used in. Not using numbers also adds to their self-efficacy by removing the intimidation brought on by knowing that there are over 100 possible small steps.

Along with the Health Belief Model (HBM), Social Networking Theory (SNT) will be utilized. The new campaign should recognize that obesity tends to “spread” through social ties and develop in clusters. It should promote individual’s involvement in their social networks so that they can give and get support and health information from them. The tips that are given to adults and teenagers should specifically address the inclusion of others. This can be done by referring to general characters in a person’s life. For instance, “Make a pact with a coworker to use the stairs.” We could even modify the step tracker program so that it allows for teams of people to join online and have inter-departmental competitions.

Along with promoting the inclusion of coworkers and friends, the new campaign will consider the parent’s obesity status and its effect on their children. Because the effect is related to the social-norms that are established by parents, it can be used to have a more positive effect on the child as well. We will take more steps to link the kids and adult sections of the campaign so that each group is addressed separately and also as one social unit. For instance, the children could be asked to make a grocery list after using the interactive “Can your food do that?” interface. It could recommend that they discuss it with their parents, which would expose the parents to the campaign and perhaps promote the purchase of those healthy foods. On the other end, suggesting that the parents walk their kids to school or to activities would get the children to view that activity as more normal.

This part of the new campaign links appropriate individual and population-based theories and ultimately results in a richer, multi-level intervention.

Step II: Effective Use of Advertising Theory

The use of multiple media outlets (TV, internet, newspapers) and the inclusion of the Ad Council is another major strength of the campaign. However, just because a larger audience is exposed to an intervention, does not necessarily mean that it will have better results. A better understanding and use of advertising theory will increase the new campaign’s effectiveness.

First, we will adjust the emotions that the images evoke. Instead of laughter, we will aim for disgust, which is known to cause viewers to remember an ad longer. This will be accomplished by using attention-getting colors on the magazine ads and vivid, dramatic effects in the commercials. For instance, in portraying the “lost” love handles, double chins, and other fatty and unwanted pieces of flesh, a “surgeon’s view” of fat will be used in place of the simple looking plastic objects that were used in the previous set of advertisements. Adding this type of drama to the ads will make sure that the “support” that advertisements are using isn’t just being viewed, but noticed and having an impact.

Concurrently, the “promise” aspect of the new advertisements will be enhanced. First, the text that conveys this on the magazine ads will be large, colorful, and horizontal so that it is easy to read. Using framing theory, we will create more effective ads that identify core values (i.e. “having to buy that new bikini” and “leaving work early because you are the captain of the soccer team”).

Lastly, this new campaign will recognize the importance of having a captivating “brand name.” This is especially critical in the aspects that target kids and teens. These groups have been shown to be quite responsive to brand names that address values like improved appearance and social standing. The VERB campaign that the CDC ran until 2006 can be incorporated into this campaign. Using this model, we can successfully increase and maintain physical activity by getting kids to find, take ownership of, and integrate their own verb into their personal lives. In this way, the campaign isn’t focused on improving health, which we know is not a core value for children, but instead on physical activity.

This new brand name, coupled with the well known professional football players, LPGA golfers, and Shrek characters that were part of the previous advertisements will make for an innovative approach that will likely be popular and catchy enough to spread through communities. Along these lines, it can address social networks by having parents, teachers, doctors and coaches also targeted by using advertisements that expose them to the slogan “it’s what you do” and have them utilize it in their interactions with the kids.

By using a provocative brand name with effective, theory based, advertisements in a mass communication medium this new campaign makes some warranted improvements.

Step III: Including the Sociological Perspective

The designers of the smallstep campaign overlooked the socio-demographic characteristics that are an extremely important part of the obesity problem. The new campaign will take into account the interlinked concepts of race/ethnicity and SES and adjust the intervention to specifically target the social and ethnic communities that suffer the most from the epidemic.

Because of the large audience that this intervention reaches and engages, it has the awesome possibility for meaningful health education. The online portion of the campaign can be especially useful to introduce viewers to programs like Women, Infants, and Children (WIC), which are in place to provide food, nutritional counseling, and access to health services for low-income families. Because few families recognize that programs like this exist, having links to their website or even including them among the tips can have lasting effects for those at highest risk. Although there are certainly still challenges, like dependable transportation, these programs can at certainly decrease the number of factors that stand in the parents way.

This type of community health education can be expanded from only addressing access to healthy foods to encouraging local programs that promote the use of safe outdoor space. This campaign can’t change the built environment, but it can identify the local programs and give people information about them in region specific ways via the website. Also, the new campaign will replace the safe, sizable parks and well equipped sports facilities that were in the previous advertisements with settings that are more realistic for those living in low income and urban areas.

Conclusion

The US Department of Health and Human Services’ smallstep campaign is attempting to address an obesity epidemic that is 30 years in the making. The media-based framework of the approach has great utility in promoting long-term, sustained weight control and good health. However, we must recognize that obesity has been a predominant issue in public health for this long because no one theory or intervention is going to address each important dimension. In light of this, the intervention I have presented capitalizes on the strengths and properly addresses the weaknesses of a previous program in hopes of creating a well enhanced program. It involves creative solutions based on the sociological perspective, Social Networking Theory, and Advertising Theory. Even so, it understands that it is dependant on other programs and factors to achieve the positive health outcomes that it seeks.

References

---

[i] CDC National Center for Health Statistics. Health E-Stat. NHANES data on the Prevalence of Overweight Among Children and Adolescents: United States, 2003–2004. 28 Mar. 2008.

[ii] Flegal K, Carroll D, Ogden L, Johnson L. (2002) Prevalence trends in obesity among U.S. adults, 1999-2000. JAMA, 288(14), 1723-1727.

[iii] U.S. Department of Health and Human Service (2001). The surgeon generals call to action to prevent and decrease overweight and obesity. Rockville MD: US Department of Health and Human Service, Office of the Surgeon General.

[iv] Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974;2:Entire Issue.

[v] Ad Coucil/Healthy Lifestyles and Disease Prevention Media Campaign Report. March 2004

[vi] Edberg M. Essentials of Health Behaviors: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

[vii] Moffitt T. Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychology Review. 1993; 100:674-701.

[viii] Christakis NA. Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine. 357(4):370-9, 2007 Jul 26.

[ix] Birch LL, Fisher JO. Development of Eating Behaviors Among Children and Adolescents. Pediatrics 1998; 101:539-49.

[x] Whitaker RC, Wright JA, et al. Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine 1997;337:869.

[xi] Stobbe, M. Critics say ads on obesity lack punch: Call ‘Small Steps’ spot too tame. The Boston Globe. October 23, 2007

[xii] Strauss RS, Rodzilsky D, Burack G, Colin M. Psychosocial correlates of physical activity in health children. Archives of Pediatric and Adolescent Medicine 2001:155:897-902

[xiii] Sothern M, Gordon S. Prevention of obesity in young children. Clinical Pediatrics 2003;42:101.

[xiv] Ward-Begnoche W, Speaker S. Overweight youth: Changing behaviors that are barriers to health. Practical advice for dealing with the family, the child, and socioeconomic environment. Journal of Family Practice 2006; 55(11):957-963.

[xv] Standford Prevention Research Center. Building “Generation Play:” Addressing the crisis of inactivity among America’s children. Stanford, CA. Stanford University School of Medicine, 2007.

[xvi] Ebbeling CB, et al. Childhood obesity: public-health crisis, common sense cure. Lancet. 2002, 360: 473-82.

[xvii] Haas JS, et al. The Association of Race, Socioeconomic Status, and Health Insurance Status With the Prevalence of Overweight Among Children and Adolescents. American Journal of Public Health. 2003; 93: 2105-2110.

[xviii] U.S. Census Bureau. Current Population Survey (CPS). Annual Social and Economic (ASEC) Supplement. Income Distribution Measures, by Definitions of Income: 2006. (INC RD-AEI 1).

[xix] Drewnowski A., Specter SE. Poverty and Obesity: The Role of Energy Density and Energy Costs. American Journal of Clinical Nutrition January 2004; Vol. 79, No. 1, 6-16.

[xx] Stafford, M. et al. Pathways to obesity: Identifying local, modifiable determinants of physical activity and diet. Social Science and Medicine 2007, 65, 1882-1897.

[xxi] Ard, J.D., et al. Informing Cancer Prevention Strategies for African Americans: The Relationship of African American Acculturation to Fruit, Vegetable, and Fat Intake. Journal of Behavioral Medicine, Volume 28, Pages 239-247.

[xxii] Cummins, Steven & Sally Macintyre. Food Environments and Obesity –
Neighborhood or Nation? International Journal of Epidemiology, 2006. 35(1): 100-104

[xxiii] Lumeng, J.C., Appugliese, D., Cabral, H.J., Bradley, R.H., & Zuckerman, B. (2006). Neighborhood safety and overweight status in children. Archives of Pediatric & Adolescent Medicine, 160(1), 25-31.

[xxiv] World Health Organization. Global Strategy On Diet, Physical Activity And Health. 28 Mar. 2008.

[xxv] Duncan MJ, Spence JC, Mummery WK. Perceived environment and physical activity: a meta-analysis of selected environmental characteristics. Int J Behav Nutr Phys Act 2005; 2:11.

[xxvi] U.S. Department of Health and Human Services. Washington, D.C. SmallStep Kids. http://smallstep.gov/kids/flash/index.html