The Ineffectiveness of Mammography Interventions in Reaching African-American Women in the U.S. – Kate Laporte

The Centers for Disease Control and Prevention (CDC) reported that breast cancer mortality in the U.S. declined by 2.2 percent per year from 1990 until 2004 (1). This is due primarily to widespread use of mammography and early detection of tumors, which leads to a better prognosis than late-presentation cases (2). However, racial disparities in breast cancer mortality have persisted even as the overall incidence rates have dropped. Incidence rates are lower for African-American women compared to white women, but African-American women have higher rates of mortality from the disease (3). African-American women have also been found to have a higher risk of underutilization of mammography, which is a factor in the increased mortality rates (4). Traditional public health approaches to increasing mammography use have focused on raising awareness about the risks of breast cancer and the benefits of mammography through education efforts. The National Breast and Cervical Cancer Early Detection Program of the CDC describes the purpose of their recruitment program as follows: to increase the number of women in priority populations receiving clinical screening services by raising awareness, addressing barriers, and motivating women to use these screening services (5). Intervention strategies to increase the uptake of mammography are focused on three aspects: educational efforts that increase women’s knowledge about breast cancer and mammography, training programs to help physicians increase uptake of mammography by their patients, and increasing access to mammography, typically through mobile mammography clinics and ensuring that women are informed about insurance coverage for mammograms (6). The interventions have failed to reach that goal, especially among African-American women. Researchers at the University of California at San Francisco included over one million women in a recent study of mammography utilization and found that African-American women had a 1.2 odds ratio of not obtaining a mammogram with comparison to white women (4). This study, published in 2006, found that large, advanced-stage tumors and lymph node–involved tumors were more likely to be diagnosed in African-American women than in white women. However, when rates of mammography screening were accounted for, the differences were attenuated or eliminated. Public health interventions to increase mammography use, based largely upon traditional behavioral change models, have had too narrow a focus to be effective in reaching African-American populations. The following arguments, based on the social context theory, the structural influence model and framing theory illuminate the weaknesses of this approach.
Considering the Social Environment
According to social context theory, there are three dimensions of the social environment that should be taken into consideration when modeling social change (7). These are the following: societal structures or shapers (factors external to individuals such as technology, race and social class), social processes (perceptions, attitudes, values) and social realities (common patterns of social behavior). The public health campaigns to promote mammography and evaluations of such programs have been based upon traditional behavioral models that do not include macro-level processes. They have been focused on changing individual women’s attitudes and beliefs toward their susceptibility to breast cancer and the value of mammography without including the larger societal influences that weigh in on behavior. One recent cross-sectional survey of African American women’s knowledge, attitudes and beliefs concerning breast cancer screening was based on the Health Belief Model (8). The Health Belief Model postulates that people will perform a health behavior if the perceived benefits of the behavior outweigh the perceived barriers (9). The researchers found that the women were aware of the value of the screening process and they identified breast cancer as one of the top health concerns for African-American women. This suggests that public health efforts and fund raisers targeted at increasing awareness had been successful. However, actual mammography utilization was drastically lower than recommended standards; less than half of the women reported having had a mammogram in the past year. The solution recommended by the researchers was increased educational campaigns targeted to African-American women. The broader societal forces that impact African American women were not accounted for in this narrow approach. Other evaluations have similar recommendations. According to social context theory, social realities (common patterns of social behavior) impact individual behavior. The folkways and norms that form common patterns of behavior in African-American communities have been reported to contribute to lower rates of mammography (10). For example, African American women have reported that cultural norms prioritize acute care over preventative health care. There is a tendency for women to neglect preventative care when other concerns are pressing. These others concerns were reported to include neighborhood violence, housing issues and substance abuse. None of these concerns are included as barriers to mammography in the traditional public health approach. Social context theory also emphasizes the affects of societal structures (e.g. race, socioeconomic status) on behavior. Since there is a disproportionate amount of African-American women are living in poverty and in unsafe neighborhoods, these societal structures are important determinants of whether a mammography is obtained. Thus, interventions to increase mammography use in this population must take into account the social context in which health behaviors take place. Another example of the impact of community-level beliefs is the integration of other women’s experiences with breast cancer into the folklore and norms of the community. One study found that the shared experiences of the community were found to impact women’s attitudes and beliefs concerning breast cancer screening (10). Negative experiences with mammography or breast cancer were found to impact how women viewed obtaining a mammogram, regardless of whether the information was correct or if it had happened to someone else. Recommendations to obtain mammograms were disregarded due to the integrated beliefs that it was associated with pain and cancer diagnosis. Traditional educational methods do not address community-level norms and beliefs and fail to capture the impact of these negative experiences on other women’s health behavior.
Communication and the Health Care System
The traditional approach has failed to examine the impact of the experiences of African American women with the health care system upon mammography use. Real or perceived negative experiences with the health care system can create a sense of fatalism regarding cancer (10). However, traditional individual-focused approaches to promoting mammography use have not considered the system-level factors of African American women’s experiences with the health care system. For instance, communication difficulties may play a part in discouraging women to obtain a mammography. One study that used focus groups to elicit the ideas and concerns of African-American women regarding mammography reported women’s fears about cancer that arose from a mistrust of the health care system due to negative encounters with health care providers. The negative encounters were largely concerned with communication, such as inadequate explanation of what a mammography entailed or what would be done with the results (10). Another study documented that African-Americans are less likely than whites to have their physicians discuss treatment plans and preventive health care during clinical encounters. This suggests that racial disparities may exist in the amount of information communicated to African-American women about screening mammograms (11). The structural influence model holds that social determinants (e.g. socioeconomic position) and mediating or moderating conditions (socio-demographics of age, gender, and race/ethnicity and social networks of social capital and resources) impact communication outcomes (12). Communication outcomes include information access, information processing and information utilization. A structural level approach to increasing mammography use would recognize that social determinants and mediating conditions influence communication of patients and providers. Race and poverty, in particular, can play mediating roles in the experiences of African-American women with their providers. Since a disproportionate amount of African-Americans are poor, they will encounter the health care system differently. Poverty has a negative impact on the behavior of health care providers and the availability of health services. Those who provide health care for minorities and people in low income areas, for example, are often less informed about preventive care services and are less likely to be board certified (13). This has not been accounted for in traditional provider training programs that have focused largely on increasing physician recommendation for mammography (6). Training that emphasizes increasing recommendations without regard to the other factors that are impacting communication is most likely ineffective. The structural influence model offers a more comprehensive view than the traditional approach of the interaction of African-American women with the health care system and the impact of that communication on mammogram use.
Framing the Issue
Much has been studied about the disparities in breast cancer mortality between African-American women and white women. The disparities have been documented for greater than thirty years (3). Interventions aimed at increasing mammography use have been focused on individual-level behavior and the problem of mammography utilization among African-American women has been thought of as an education and motivation problem. The social determinants of health have not entered the picture of breast cancer health disparities. Framing theory provides the means to readjust the paradigm concerning mammography use as one of a social and systems problem rather than an individual’s failure. A message can frame population health disparities as being caused by internal factors (within control of the individual), external factors (beyond the control of the individual), or some combination of the two (14). Instead of focusing on under utilization of mammography, the shift to a broader perspective of health disparities would take into consideration the underlying social determinants of health. The social determinants of race and the often correlating factor of income level serve little function as descriptions of study group participants. Their impact on women’s experiences with the health care system and the types of barriers faced by women in their everyday lives to preventative health care are critical factors in understanding why disparities have persisted. Investigation into the social determinants of health can lead to policy change that would address the fundamental underlying factors of disparities. Barriers inherent in the health care system such as communication difficulties could then be addressed on a widespread level. The social norms that discourage preventative health care could be addressed within African-American communities. Finally, agencies and organizations that aim to increase mammography uptake could take into account the real-life society-level concerns that African-American women face and design approaches that consider these concerns.
In conclusion, the traditional, educational, public health approach to mammography uptake has failed. Disparities in mammography utilization and related breast cancer mortality in African-American women in the U.S. have persisted despite millions of dollars of educational and awareness programs. Social science theory elucidates the limitations in the traditional approach. A comprehensive picture of the social context of health behavior and the role of the health care system in promoting mammography use offers new perspectives concerning the underlying determinants of health disparities. The new perspective gained can help frame this health disparity in a way that reflects social responsibility.
A novel approach
Through use of the spatial interaction model, Mobley and colleagues describe a comprehensive approach to factors affecting mammography use (15). The model was applied to aggregate pooled information from several heterogeneous states in the U.S. The aim was to demonstrate that pooled data can provide misleading information regarding predictors of health care utilization. The model includes factors that impact mammography use at several different levels, including fundamental/macro factors, intermediate or community factors, interpersonal factors, and individual factors. It draws from different disciplines to create a more comprehensive picture of what impacts health behavior than individual beliefs and perceived risks (Health Belief Model). Each of the levels, from the outermost (fundamental/macro factors) to the innermost (individual factors) impedes on the next level until, ultimately, the cumulative effects weigh in on individual behavior. The model is described below:
Fundamental/Macro factors:
Distribution of wealth, educational opportunities, and political influence; social and economic policies, institutions, regulations, campaigns, topography, climate, water supply
Intermediate or Community:
Social context – neighborhood, workplace, and housing conditions; public infrastructure and investment; police, enforcement services, crime; health care system
Health care system: proximity and density of facilities, physicians; crowding, scheduling and convenience, personal physician, managed care climate, primary care physician shortage; international medical graduate enclave
Physical environment – community capacity and partnership; land use patterns, transportation systems, buildings, public resources, pollution
Interpersonal:
Stressors, social integration and support, psychosocial factors, behavioral settings, social relationships, living conditions, neighborhoods and communities, neighborhood watchfulness, driver courtesy, social or cultural cohesion, population health behaviors or norms
Individual/Population:
enabling/disabling: personal disability, personal resources, type of health coverage, new address, marital status, employment status
predisposing: age, sex, gender; race or ethnicity, educational attainment
need: beliefs, family history, perceived risk, health status
Accounting for social context
The terms that are highlighted were discussed in previous sections as potential mediating factors in African-American women’s mammography rates that were left unaddressed by the traditional approach. The traditional approach does not consider the social context in which African American women live, including social norms particular to their communities. Population health behaviors or norms are integrated into the interpersonal level in the spatial interaction model. Also, concerns that keep African American women from obtaining mammograms such as neighborhood violence and housing conditions are included at both the intermediate and interpersonal levels. The study based on this model found that factors at the intermediate level did, in fact, affect mammography rates differently across states. In particular, the researchers found that in five of the states, the proportion of the workforce who commuted more than sixty minutes each way to work was negatively associated with mammography use. These findings highlight the need to examine specific social contextual factors that traditionally seem unrelated to health care utilization.
Accounting for system level factors
The model also takes into account the characteristics of the health care system that can promote or inhibit mammography utilization. In particular, the availability of primary care physicians may have an impact on mammography use. Physician shortages tend to occur in poorer areas and this factor may have a disparate affect on African American women, since a disproportionate amount of African American women live in poverty. Crowding, scheduling, convenience and the availability of a personal physician may all play a role in determining whether African American women perceive their experiences with the health care system as positive or negative. These types of variables cannot be quantified at the individual level but require a systems perspective. However, valuable qualitative data from women’s experiences can be obtained through focus groups and open-ended questionnaires that can help illuminate the specific areas of concern. Here, the concerns that surfaced through focus groups are included in the model as mediating factors on mammography use.
Reframing the issue
The spatial interaction model includes race/ethnicity as an individual level factor. While this may seem to be akin to the traditional approach, the model accounts for the impact of race/ethnicity as a determinant of health care utilization through multilevel modeling. The macro-level, intermediate and interpersonal factors that are modeled are the same factors that affect people of different racial/ethnic groups differently. Thus, while including race or ethnicity as an individual risk factor, the spatial interaction model also investigates the higher level processes by which people of various races and ethnicities are affected. The authors reframe the issue of disparate mammography use as one of differences in place-specific resources. The issue of place-specific trends is tightly joined to racial health disparities due to the extremely high degree of racial geographic segregation in the US (16). The health disparities that affect one racial or ethnic group, such as African-American women, are reflective of the place-specific resources and conditions acting upon their lives.
Conclusion
The structural and social forces that drive racial inequalities are being recognized gradually in public health research as the underlying, foundational determinants of health disparities. Mammography utilization is particularly important for African American women, whose mortality rates remain high and frequently present with later stage disease than their white counterparts. Education and individual-level interventions have proven ineffective in reducing disparities over the last thirty years. Specific social contextual factors and broader structural determinants must be addressed if this gap in health care utilization is going to be eliminated.

REFERENCES:
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The Policy Implications of Stigma in Relation to Mental Illness - Tim Washburn

Approximately twenty-six percent of Americans age eighteen and older suffer from a diagnosable mental disorder in any given year. When extrapolated to the census data this means we have approximately fifty seven million people with mental disorders in this country (1). The current treatment of those with mental illness tends to be contrary to public health methods. Public health is defined as the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals (2). Our current health care system tends to medicalize mental illness by treating the symptoms with a reactionary approach rather than a preventative approach. In the words of Michael F. Hogan, Ph.D., Chairman of the New Freedom Commission on Mental Health, “Too often, today's system simply manages symptoms and accepts long-term disability (3).”
The stigma toward mental health in this country lies beneath the framework of mental health care. Stigma is a barrier to care and an influencing factor in public opinion and policy making. This paper criticizes the approach taken to mental health care and examines the role that stigma plays in resource allocation, media influence and the role of public health professionals. Stigma is defined as an attribute, behavior, or reputation that is socially discrediting in a particular way (4). When defined by mental health experts the definition becomes, “the negative effects of a label placed on any group including those who have been diagnosed as having mental health problems (5).” Stigma results in people distancing themselves from the mentally ill by avoiding living, socializing, or working with the identified person. Stigma deprives people of their dignity leading to low self-esteem, isolation, and hopelessness as well as deterring those with mental illness from seeking care to avoid being labeled as mentally ill.
A Segregated History of Mental Health
The field of mental health has been segregated from the rest of healthcare for a number of reasons starting with the work of Rene Descartes in the seventeenth century. Descartes viewed the mind as completely separate from the body. The mind was seen to be the business of organized religion where the body was the concern of physicians. This definition ushered in the separation of mental health and physical health that persists today (6). The separation has been exacerbated by the advances in medical technology in health care that led to the cure of two specific mental illnesses. First, tertiary syphilis is an advanced stage of syphilis that occurs when the bacterium invade the brain and causes neurological deterioration, paralysis, and death. When it was discovered that penicillin would cure this illness the medical field was awarded credibility over the mental health field for the treatment (7). Similarly, pellagra was traced to a nutrient deficiency that was treated with nutritional supplementation of niacin eliminating the patient’s delirium (8). These cases gave credibility to the medical field while leaving the unexplainable mental disorders to the mental health field. We know today that mental health and physical health are inseparable and are essentially one in the same yet the stigma of an inferior field of mental health still exists.
Lack of Resource Allocation for Mental Health Care
The idea of an inferior methodology of treatment for mental illness lends itself to the social theory of Skitka and Tetlock. Their theory explains the decision making process of a policy maker when allocating resources outlined below:
(9)
To summarize, policy makers are given limited resources and typically allocate funds based on the need for the program, the effectiveness of the program and the responsibility of the participants regarding their need for the program (10). If policy makers view mental health services to be inferior and therefore less effective they may be less willing to fund such programs.
Research shows that psychiatric disorders are viewed as more blameworthy than physical health conditions like cancer and heart disease (11). Using Skitka and Tetlock’s model we see that a view of blaming those with mental illness for their condition may lead to a decrease in allocation of funds as well.
Finally, policy makers often make their decisions of resource allocation within healthcare by what population is experiencing the greatest hardship. This is typically on a scale of which group is more likely to die from their condition (12). This process does not lend itself well to mental illness where death is not an easy way to characterize the need. The mental health field may use activities of daily living (ADL’s) and quality-adjusted life years (QALY’s) instead of risk of death for a more accurate picture.
When we apply Skitka and Tetlock’s model to the resource allocation for mental health funds we see three distinct disadvantages inherent in the nature of mental illness and the impact that stigma can have on policymaking and resource allocation.
Eighty five to ninety percent of the mentally ill are unemployed. Since health insurance is linked to employment in this country the majority of the mentally ill are also uninsured. This creates a downward spiral for the mentally ill of being unemployed, therefore not having health insurance, therefore not getting treatment for their mental illness, therefore having further difficulty finding a job due to mental illness and so on.
There is no current return on investment (ROI) analysis of where healthcare dollars should be allocated. The economic cost of untreated mental illness is more than $100 billion each year in the U.S. (13). The majority of the mentally ill can be treated and live productive lives and contribute to society. This realization, follow by a ROI analysis, should lead to a higher funding of mental health services given the reduction of cost to society of untreated mental illness.
Media’s Role in Stigma of the Mentally Ill
Anthropologists use the term enculturation to refer to the process of internalizing the culture of the society. The media plays an important role in depicting the language, beliefs, customs and traditions of a society (14). Over-reporting negative stories about people with mental illness can be misleading and create an implied link between mental illness and violence and further the stigmatization of those with mental illness (15). The idea that “if it bleeds it leads” in news organizations creates a formula of sensationalizing and stigmatizing the mentally ill. The Hollywood portrayal of the mentally ill with such characters as Norman Bates in Psycho and Dr. Hannibal Lecter in The Silence of the Lambs further exacerbates this stigma of the mentally ill being violent.
Studies show that news reports focus on violent behavior and dangerousness regarding people with mental illness but the mentally ill are rarely violent and account for only three to five percent of all violence in the country (16). The news media almost never include statistical facts and context with any story of violence perpetrated by a mentally ill person. The exclusion of people with mental illness speaking on their own behalf in the press leads the watcher to believe that the mentally ill are too disturbed and dysfunctional to communicate.
The role of the media in defining our society is powerful and is currently counterproductive toward the mentally ill, only serving to further the stigma. The media sensationalizes violence from mental illness when it could be used to reshape popular opinion and advocate for funding and programs to help the mentally ill.
Public Health and the Mentally Ill
Unmet mental health need among adolescents is alarmingly high, as more than seventy percent of teens that require mental health care do not receive services. Given that twenty percent of adolescents suffer from a mental health disorder and that unmet need is a critical problem, removal of stigma as a barrier to care should be a priority of the public health community (17). Studies show that the initial mental health intervention experience of teens greatly influences their willingness to use mental health care services in the future (18). The first contact is typically a guidance counselor in a school setting that is more than likely overworked, underpaid, and undertrained to meet the needs of and provide care for a mentally ill teen. The public health community should be focusing their efforts toward ensuring this crucial first point of contact is successful to ensure future use of mental health resources if needed.
Given that stigma is a barrier to seeking care for mental illness the public health community should also make a priority of both reducing that stigma and putting in place a proactive approach to dealing with mental illness. It has been demonstrated that proactive interventions to identify those at risk for mental illness can be effective. A coordinated effort between schools, law enforcement officers, domestic violence specialists, community residents, early childhood educators and care providers, court personnel, child welfare workers, and mental health practitioners can lead to early intervention and improved outcomes in mental health care (19). The current approach of treating mental illness in emergency rooms, or worse yet jails, goes against the principles of public health.
The school dropout rate begins to increase sharply in 9th grade; therefore addressing youth when they are still in school seems to be the best venue for screening. The public health community should be focusing on community based, proactive interventions as a preventative measure to treating mental illness rather than leaving the medical profession to reactively treat the symptoms.
The three critiques summarized in this paper are inextricably linked. We can view the three arguments in a sequence. The media’s influence can have an effect upon the opinions of the public and therefore the opinions of the policy makers. This leads to reduced funding for mental health programs in turn leads to the public health professionals not having the adequate funding to implement mental health programs.
Proposed Intervention
Given the media’s effect on public opinion and the resulting poor resource allocation toward mental health programs, my suggestion is to launch a media campaign to alter public opinion. A media campaign can serve two purposes: media advocacy and enculturation through social diffusion. Media advocacy’s goals are to influence public opinion, policy makers and ultimately policy (20). Social diffusion theory can be utilized in tandem with the media to help shape culture and to reduce stigma.
Media advocacy focuses on changing the behavior of policy makers and not on changing the behaviors of individuals. Its goal is to influence policy makers to vote a certain way and to set the agenda for the issue of concern. Media advocacy is done through advertising campaigns, news media, radio, press releases, opinion pieces, You Tube and any other mass media outlet. The details of the policy agenda will be addressed later in the proposed intervention.
Social diffusion theory explains how media can be used to reduce the stigma that surrounds mental illness by altering the perceptions of the public and influencing the culture of society. Under the social diffusion umbrella, the theories of diffusion of innovation and social marketing theory are highly applicable in regards to a media campaign.
Diffusion of innovation describes how a behavior makes its way into a population and either is or is not accepted. The theory suggests a slow rate of adoption up to a “tipping point,” or the point at which the adoption rate increases in relation to time, followed by a rapid rate of adoption (21). If a media campaign is well crafted and is successful in reaching this tipping point it can have a chance at reducing the stigma surrounding mental illness.
Social marketing theory can help determine the information to communicate in a media campaign and how to package that information. A media campaign is most effective when research is conducted on the target population and the message is tailored accordingly. It may be beneficial to enlist a professional marketing team to assist in the development and implementation of a media campaign if the budget allows.
The “Truth” campaign is an example of how a media campaign can have great results. The “Truth” campaign was an anti-smoking media campaign funded by the State of Florida through its landmark victory against the tobacco industry. It included an earmarked budget of $200 million for a state-run pilot program to fight youth tobacco use. The “Truth” campaign is estimated to have been responsible for a twenty-two percent decline in youth smoking between 1999 and 2002 in the state. The Truth campaign utilized market research in designing their media plan, which resulted in unprecedented results and serves as a great example of an unorthodox yet effective public health strategy (22).
The major news media excludes people with mental illness speaking on their own behalf. The suggestion is to reach out to people that are in the public eye to speak out about their illness. The list of successful and famous people throughout history who are widely believed to have had manic depression or bipolar disorder (as documented by historians, biographers, private letters, etc.) is significant and includes Ludwig van Beethoven, Abraham Lincoln, Albert Einstein, Sigmund Freud and Isaac Newton. A more contemporary list includes Carrie Fisher, Richard Dreyfuss, Jean-Claude Van Damme, Margot Kidder and Linda Hamilton, all of who have spoken publicly about their struggles. "If well-known people in entertainment or politics talk about their experience, it provides people with a knowledge that they're not alone, and that it's an illness that's very treatable," says Mark D. Smaller, Ph.D., a Chicago-based psychotherapist and the director of the Neuro-Psychoanalysis Foundation in New York and London. "The more well known people speak out, the more it facilitates other people getting help (23)."
The final component of the media campaign is to boycott and protest programs and networks that foster the stigma of mental illness. Writing letters to and speaking out against offending programs and networks can be successful. The ABC program “Crumbs” that depicted mental illness in a derogatory light was cancelled after mental health advocates spoke out against it. Shows such as “Intervention” (24) on the A&E network present real life people, not actors, battling mental illness and shows how they can overcome their illness with treatment to lead productive lives. This is real progress we can point to as an example of another unorthodox yet powerful public health intervention that combats the stigma of mental illness.
The next step in the proposed intervention is to secure proper funding for mental health care. The ultimate goal is to pass legislation to make mental health care an entitlement program in the United States. An entitlement program is a government program that provides individuals with personal financial benefits, goods or services to which an indefinite number of potential beneficiaries have a legal right whenever they meet eligibility conditions that are specified by the standing law that authorizes the program (25).
Using our media campaign and social marketing, this goal could be realized. A conceivable way to pass this type of legislation would be to tack it onto Medicare, an existing entitlement program. The Americans with Disabilities Act defines mental illness as a disability (26). If the government can recognize the problem then it may choose to help fix it.
An integral part of the argument to have mental health care as an entitlement program is that it will save money. Most people with mental illness can be treated and live normal, productive lives. As mentioned above, the economic cost of untreated mental illness is more than $100 billion each year in the United States. (27). We would actually save money with an increase in economic productively and a reduction in acute care for untreated mental illness. In these tough economic times any new government program proposal needs to be budget neutral to have a chance of passing into law. This proposal would save the government money in the long term. For evidence of this we can look to the private sector and analyze the implementation of employee assistance programs (EAPs).
EAPs are programs that are typically outsourced or implemented through an organization’s human resources department. These programs offer confidential evaluation, treatment and referrals for a range of personal problems including family and marital issues, mental health, financial and legal problems and substance abuse (28). The results of these programs are noteworthy:
· More than 70% of all Fortune 500 companies have implemented EAPs
· Firestone Tire and Rubber estimated EAP savings of $1.7 million or $2,350 per person involved
· United Airlines reported a return of $16.35 for every dollar invested in EAP costs
· Scoville Manufacturing estimates an annual cost savings of $186,550 credited to their EAP
Undoubtedly a government mental health entitlement program will look very different than an EAP program but the government can use the example as a starting point for a ROI analysis. With a proactive mental health care plan we could potentially save the country millions of dollars. The suggestion is to conduct a comprehensive ROI analysis to support the proposed policy.
The final piece of the proposed intervention is to redesign how the medical establishment treats mental illness. I propose a system more in line with public health practices that focuses on prevention and early detection starting in elementary school. The model exists today in which elementary school children receive mental health evaluation and treatment at school.
Morgan Stanley Children's Hospital of New York conducts a program that serves children aged four to ten, and grades pre-K through five. The program consists of three parts. The first component is an in-school clinic program comprised of comprehensive clinics in five elementary schools. The second part is the Mobile Outreach, Referral and Education (MORE) program comprised of urgent evaluation, short-term treatment, and referral services in another six elementary schools. Finally, a school-based trauma services, prevention and outreach program in all eleven of the schools served. The program operates in collaboration with parents, teachers and school student support staff to give them tools to improve the behavioral and mental health status of their children (29).
This sort of early intervention makes it more likely that the person receiving care will have a positive first experience. This is critical to making the individual willing to reach out for care if he or she needs help in the future. Being exposed to mental health care at an early age will help remove the stigma of mental illness.
In summary, the multifaceted issues regarding mental health care require a multifaceted solution. The proposed approach deals with three major impediments of a coordinated mental health care system in the United States. The media influence on stigma, the policy implications on funding and the resulting approach of medicalized care deserves our utmost attention if we hope to make progress with mental heath care. The proposal of an alternate media campaign, a mental health care entitlement program and a public health approach to mental health care can serve our mentally ill, save money for everyone and enlighten our society.
REFERENCES
1. The National Institute of Mental Health. (n.d.). (National Institutes of Health) Retrieved November 15, 2008, from http://www.nimh.nih.gov/health/statistics/index.shtml
2. Public health. (n.d.). Retrieved November 15, 2008, from Wikipedia: http://en.wikipedia.org/wiki/Public_health
3. President's New Freedom Commission on Mental Health. (2002, December 2). Retrieved November 15, 2008, from Mental Health Commission: http://www.mentalhealthcommission.gov/
4. Stigma (sociological theory). (n.d.). Retrieved November 15th, 2008, from Wikipedia: http://en.wikipedia.org/wiki/Stigma_(sociological_theory)#References
5. Carter, M. (2005). Keep Quiet about It. Community Care , 38-39.
6. U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration , Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, Rockville, MD.
7. (Ibid)
8. (Ibid)
9. Corrigan, P. W., & Watson, A. C. (2003). Factors That Explain How Policy Makers Distribute Resources to Mental Health Services. Psychiatric Services , 54 (4), 501-507.
10. Skitka, L. J., & Tetlock, P. E. (1993). Providing Public Assistance: Cognitive and Motivational Processes Underlying Liberal and Conservative Policy Preferences. Journal of Personality and Social Psychology , 65 (6), 1205-1223.
11. Corrigan, P. W., & Watson, A. C. (2007). The Stigma of Psychiatric Disorders and the Gender, Ethnicity, and Education of the Perceiver. Community Mental Health Journal , 43 (5), 439-458.
12. (Ibid)
13. The National Institute of Mental Health. (n.d.). The National Institute of Mental Health. (National Institutes of Health (NIH), U.S. Department of Health and Human Services) Retrieved November 15th, 2008, from http://www.nimh.nih.gov/
14. DeFleur, M. L., & Ball-Rokeach, S. J. (1989). Theories of Mass Communication (Fifth ed.). White Plains, NY: Longman Inc.
15. Friedman, R. A. (2008, July/August). Media and Madness. The American Prospect , pp. 2-4.
16. (Ibid)
17. Chandra, A., & Minkovitz, C. S. (2007). Factors that Influence Mental Health Stigma Among 8th Grade Adolescents. J Youth Adolescence (36), 763-774.
18. (Ibid)
19. Hyde, M. M. (2008). National Evaluation of the Safe Start Demonstration Project: Implications for Mental Health Practice. Best Practices in Mental Health, 4 (1), 108-122.
20. Edberg, M. (2007). Essentials of Health Behavior, Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, Inc.
21. Wikipedia. (n.d.). Retrieved November 15th, 2008, from Diffusion of innovations: http://en.wikipedia.org/wiki/Diffusion_of_innovations
22. Social Marketing Institute. (n.d.). Retrieved December 10, 2008, from Success Stories: http://www.social-marketing.org/success/cs-floridatruth.html
23. Rustad, M. (2008, September 29th). Living with Bipolar Disorder. Retrieved Dec 7th, 2008, from Revolution Health: http://www.revolutionhealth.com/conditions/mental-behavioral-health/bipolar-disorder/living-with-bipolar-disorder/famous-people-with-mental-illness
24. A&E. (n.d.). Retrieved December 7th, 2008, from Intervention: http://www.aetv.com/intervention/
25. Auburn University. (n.d.). Retrieved December 10th, 2008, from A Glossary of Political Economy Terms: http://www.auburn.edu/~johnspm/gloss/entitlement_program
26. Americans with Disabilities Act. (n.d.). Americans with Disabilities Act. Retrieved December 7th, 2008, from http://www.ada.gov/
27. The National Institute of Mental Health. (n.d.). The National Institute of Mental Health. (National Institutes of Health (NIH), U.S. Department of Health and Human Services) Retrieved November 15th, 2008, from http://www.nimh.nih.gov/
28. Dictionary. (n.d.). Retrieved December 7th, 2008, from Case: http://www.case.edu/med/epidbio/mphp439/Dictionary.htm New York Presbyterian. (n.d.). Elementary School Children Receive Mental Health Evaluation and Treatment at School. Retrieved December 7th, 2008, from New York Presbyterian: http://www.nyp.org/news/hospital/814.html#

Knowledge is Power: Government Funded Abstinence-Only Programs Omit Crucial Information on Sexual Health -Diana Theriault

“Vows of abstinence break more easily than latex condoms (1).” Yet America is still taught to abstain from sex. Education is important. How can anyone make an informed decision when much of the information is not provided? Abstinence-only education is ineffective at preventing many teens from engaging in sex before marriage and only hurts those who do have sex without the knowledge of how to do so safely.
When you think of the word sex, what comes to mind? For many there is a negative connotation that comes along with that word. In America, people don’t talk about sex openly. We keep that part of our lives a secret. It is almost like you have to hide it. Sex should be a topic that everyone is comfortable talking about. This is the first step in having a safe and healthy sexuality. Communication is key in this area. If the only thing we tell the children of America is, “don’t do it,” then what happens if and when they do? Are we just supposed to say, “I told you not to?” No. We should be promoting abstinence, but saying “in the event you do have sex, here is how to protect yourself.” Because when it is all said and done, teenagers are going to have sex whether or not you tell them to.
The data shows that people do have sex before marriage. “The average age of first intercourse is 16.9 for boys and 17.4 for girls (2).” Yet the “average age of first marriage continues to rise. for women the average age is 25.6 and for men it is 27.5 in 2007 (3).” This is a major drawback of these types of programs. We can see that the programs don’t work, that people are still having sex anyway, and many are just ignorant to the way contraception works and how it can protect them. Still, abstinence-only education is valuable right? The following studies show otherwise.
Abstinence-Only Education: More harmful than helpful?
If you think about it, almost everything that we engage in, such as driving a car, jumping on a trampoline, smoking cigarettes, taking prescriptions, swimming in pools and many more, have safety guidelines to abide by. Also in case of an emergency, there are steps to take to prevent any further harm. But why is it that when it comes to sex, we fail to teach those safety guidelines? It’s like throwing someone in the driver’s seat of a car and saying go! If you don’t know how to drive, you don’t know the rules of the road, how to be safe and what to do incase of an emergency, do you really want that person to be behind the wheel? I surely don’t. “In 2005, 37.2 percent of sexually active high school students and 44.6 percent of sexually active twelfth grade students did not use a condom during their last sexual intercourse (4).” Many of them ‘got behind that wheel’ without learning about safety. Unprotected sex can lead to unintended pregnancies and sexually transmitted infections which can lead to other complications. Even more distressing is that, “One-quarter of sexually active adolescents nationwide have an STD, and many STDs are lifelong viral infections with no cure (4).”
A survey from the Kaiser Family Foundation found that young adults want to learn. “They want to know more about how to use condoms, how to recognize the signs of STD and HIV infection, what STD and HIV testing involves, and where they can get tested. They also want more instruction on communicating effectively with partners about sensitive sexual concerns and relationship issues (5).”
Abstinence-only education programs have been funded by the government for many years, however, comprehensive sex education programs have suffered from new restrictions on what can be taught to receive funding. Essentially any program that teaches about contraception has been limited in the funding they can receive under the Bush administration. This allows for more programs that refuse to teach about contraception and safety. If teens want to learn about safety and healthy sexual relationships, shouldn’t we give them guidance?
A study done following over 2000 students from elementary school to middle school and through high school that had abstinence-only education failed to prove that this education is valuable. The study found that there was no difference between those who participated in abstinence-only education versus those who did not. This study confirmed what other studies have already shown. "The most effective programs are those that say abstinence is the best choice but birth control and protection are also worth knowing about (6)." Yet abstinence is still funded heavily by the government. I like the way one woman, Martha Kempner, put it when she said,”Abstinence-only was an experiment and it failed (6)." Failed experiments should not be continued and especially not funded with tax payers dollars.
These programs have not taught our kids properly. Some adolescents even believe they are being safe by using contraception, but they may be using it in correctly. I believe that this proves the point: “One in five young people believe that birth control pills offer protection from STDs and HIV/AIDS. The same amount of people believe that condoms are not effective in preventing the transmission of STDs and HIV/AIDS (5).” If people believe they are protecting themselves or that using condoms won’t protect them from contracting diseases this is a serious misconception. The lack of knowledge about sexual behavior and protection is astounding. I do believe that abstinence is an important thing to teach the young people of America. Children need to develop feelings of self-confidence, independence, and all in all, just grow and mature to make these complicated sexual decisions. But abstinence taught alone leaves people with the knowledge of the dangers of sex but no way to prevent the dangerous consequences.
Not only do these programs fail to educate, but they give out false and misleading information. A report put out by the House of Representatives actually proves that 80% of the curriculum guarantees to contain false, misleading, or distorted information about reproductive health. This false information includes the effectiveness of contraceptives, the risks of abortion, and even scientific errors such as the number of chromosomes that an individual has (7). These things are important. Everyone should know the true facts. How can you make an important judgement like this without having all of the correct information? The same report states that, “youth who pledge abstinence are significantly less likely to make informed choices about precautions when they do have sex (7).”
Community Influence on the Development of Sexuality
Abstinence-only programs teach an ideological view. We set the bar very high when we expect everyone to abstain from sex until marriage. Although this may prevent a few sexual encounters out-of-wedlock, it certainly does not apply to everyone. As kids, we are taught values and morals to live by. As we get older, we discover our own morals and values that we wish to live by. However, when society pushes virginity as the only option, it makes it seem like sex is a bad thing. Therefore, if you have sex, you are bad. This can have social and emotional implications.
Abstinence-only education is an example of the Health Belief Model applied in practice. The Health Belief Model is a theory that suggests that an individual will make a rational decision based on perceived benefits weighed against perceived barriers. It also implies that if a person feels susceptible and that the consequence is severe enough, a person would take action to avoid that behavior (8). Abstinence-only educators believe that if one is taught the severity of consequences and how easily susceptible they are to pregnancy and disease that everyone will abstain. They portray it in such a way that the barriers greatly outweigh the benefits. Even the governments definition of abstinence-only education includes “teaching the social, psychological, and health gains to be realized by abstaining from sexual activity its exclusive purpose (4).” They are trying to prove the benefits of abstinence. These benefits are real, however, we know that decisions are not only based on the individual level alone and so these benefits may not be as important as the beliefs of others for example.
“ ASRH (Adolescent Sexual and Reproductive Health) programming should be approached from an ecological perspective, with the belief that individual behaviors and decisions are not made or practiced in a vacuum, and that social norms and institutions often determine the choices available to most individuals (9).”
There is a large factor of social influence that abstinence only programs come along with. Social norms stereotype men and women as well as heterosexual and homosexuals into different categories. These stereotypes portray “girls as naturally chaste and boys as constantly struggling to control their rampant sexuality and raging hormones (10).” Sexist views put gender roles on men and women. In education like this these stereotypes are taught as facts. The are biological sciences that makes men and women act differently towards sex. This teaches women that if they do express desires and wish to talk about sex, they may be found as promiscuous where men are just generally curious because they have testosterone and it is natural for them to feel these desires (10). This conservative thinking heeds much guilt for women and leaves both sexes uneducated about safety and communication among adolescents. Although gender stereotypes have an enormous impact on teens, stigmas of sexual orientation have an even greater impact. Abstinence-only education programs do not even bring up the subject of homosexuality. This is deliberately left out because programs like these are actually “required by the federal funding guidelines to instruct students that heterosexual marriage is the ‘expected standard’ (10).” Since gay marriage is not recognized nationally in the United States as legal, it is easy to see why the government would leave this discussion out of the program. Because how can you stay abstinent until marriage if you can’t even get married? And we already know that sex out-of-wedlock can be a burden on society so those who do not follow the ‘expected standard’ must also be a burden, right? That is what these programs teach us. It almost allows for discrimination and increases homophobic beliefs which is not right. In society today, everyone should be treated equal regardless of gender, sexual orientation or any other differences we have between us.
As we can see, society and our surrounding communities can greatly influence our views and what we consider social norms. We must adopt a culture open to communication and discussing all sexualities. Teaching teens about contraceptive options, physical differences between men and women, and sexual orientation does not encourage adolescents to go explore what they just learned. We are just providing the facts and allowing them to make an informed decision on their sexuality and bringing about safe options while doing so.
A Violation of Basic Human Rights
Abstinence-only education fails to allow access to basic health information. To educate our children we must provide the full spectrum of options and information. When you hear questions like: “You can’t get pregnant the first time right? Isn’t everyone having sex? Can you get pregnant if you use birth control (11)?,” you know there is much more that teens have to learn before having sex. A person who is in the contemplating stages of having sex should first know their beliefs and feelings about sex. If they feel that they are ready then the next question to ask would be “in what kind of sexual relationship would sexual involvement be comfortable or OK for me (12)?” And when someone is ready to have sexual intercourse they need to be prepared for all of the consequences with that decision including emotional feelings. If kids are not taught the full spectrum of sexual responsibility they can not make informed decisions. Leaving information out or distorting truthful information is harmful to all. Health information should be freely provided and true. By giving out wrong information, these programs are violating our human right to education and information about sexual health.
“Individuals who lack information about sexual and reproductive health care thus also lack the ability to protect themselves from STIs, including HIV/AIDS, and unplanned pregnancy (10).” It is everyone’s right to seek out truthful information. This is why it is not only important for educators to teach the facts, but for parents to divulge all pertinent information as well. Most teens are influenced by many factors when making decisions about health. Parents, peers, and school education are at the top of the list for influencing children on sex. If your peers are taught the same as you, then they are most likely going to base their decisions on the same information you received which does not promote anything but continued misinformation. However, if parents step in, they may be able to influence the child and teach them the right things. Many adults however do not know everything about sex. Even the parent has the right to information and education. That is why it is up to the educators who are supposed to have up to date information on sex and sexual consequences to teach the future of America. Children only learn what they are taught, that is why it is our job to teach, and their right to learn health education.
“Major human rights documents discourage states from limiting access to contraceptives, and other means of maintaining sexual and reproductive health, from censoring, withholding, or intentionally misrepresenting health-related information, including sexual education, as well as from preventing people’s participation in health-related matters, or allowing third parties to do so (10).”
Abstinence-only education violates these rights which has a negative effect mostly on those who do not receive the knowledge. It puts those who do have sex at greater risk for health consequences that they do not even know about, or for that matter, how to prevent negative health effects and unintended pregnancies. Abstinence only education violates the rights of all humans, but has an even greater potential risk in LGBT (lesbian, gay, bi-sexual, and transgendered) individuals and their families by failing to provide “useful and appropriate sexual health information (10).” Men who have sex with men have the highest risk for developing HIV/AIDS (13). These statistics need to be known. Even for those who do not consider themselves gay when they are younger, may realize later in life that they are homosexual or bisexual and should have the facts on both homosexual and heterosexual encounters.
Final Thoughts on Abstinence-Only Education Programs
“The communities should provide access to education about sexual health and responsible sexual behavior that is thorough, wide-ranging, begins early, and continues throughout the lifespan” (14). Such education should give them knowledge about pregnancy, STD's, contraceptives and responsible choices. Abstinence-only education cannot provide this comprehensive education. It should be taught as part of an education program but not as the only program.
A New Perspective
“Comprehensive sex education teaches about abstinence as the best method for avoiding STIs and unintended pregnancy, but also teaches about condoms and contraception to reduce the risk of unintended pregnancy and of infection with STIs, including HIV. It also teaches interpersonal and communication skills and helps young people explore their own values, goals, and options (15).” This type of sex education is important for teenagers to get the full spectrum of knowledge on this topic. Comprehensive sex education have been proven to work (16). Mandates prohibiting educating the youth about the benefits of condoms and contraception make these programs ineligible for federal funding (17). Teens need to learn about all aspects of sexual health to protect them from the dangers of infection and pregnancy. This is something that abstinence-only education cannot provide.
Does Comprehensive Sex Education Provide Benefits?
A concern of many with comprehensive sex education is that it will encourage teenagers to want to have sex at a younger age than they would have had they had abstinence-only education. Research however shows that this is not the case. “Evaluations of comprehensive sex education and HIV/ STI prevention programs show that they do not increase rates of sexual initiation, do not lower the age at which youth initiate sex, and do not increase the frequency of sex or the number of sex partners among sexually active youth (15).” Knowing that these programs do not have an influence on increasing sexual activity of teenagers, we can say that they are not harmful. How though do these programs provide a benefit?
Findings put out by the National Campaign to Prevent Teen and Unplanned Pregnancy, stated that almost all of the comprehensive sex education programs they evaluated had a positive effect on the behavior of teenagers. “In particular, they improved factors such as knowledge about risks and consequences of pregnancy and STD; values and attitudes about having sex and using condoms or contraception; perception of peer norms about sex and contraception; confidence in the ability to say ‘no’ to unwanted sex...communication with parents or other adults about these topics.(18).” Comprehensive sex education is teaching teenagers responsibility, giving them confidence and teaching self-esteem. Not only this but this education is teaching them about risks and prevention. The APA stated, “Based on over 15 years of research, the evidence shows that comprehensive sexuality education programs for youth that encourage abstinence, promote appropriate condom use, and teach sexual communication skills reduce HIV-risk behavior and also delay the onset of sexual intercourse(19).” With all of the evidence shown, it is clear that comprehensive sex education has many benefits and proves to be the superior method to teach teenagers about sexuality.
Influence on Development of Sexuality
Comprehensive education also plays off of the Health Belief Model, although it includes other tools to educate as well. “Rather than trying to deter or frighten young people away from having sex, effective sex education includes work on attitudes and beliefs, coupled with skills development, that enables young people to choose whether or not to have a sexual relationship taking into account the potential risks of any sexual activity (20).” Teenagers need the opportunity to form their own opinions on this subject matter. Have they been taught the consequences of their actions? Have they been taught how to handle such consequences? Do they know where to get support? If one does become pregnant, do they know all the options? Are they emotionally prepared for such consequences? Also, can they communicate with parents and other adults from whom they are educated? There are so many more questions that need to be asked and answered pertaining to sex and the development of sexuality. These questions cannot be answered in an abstinence-only classroom. “Programs designed to prevent pregnancy need to give young women information about pregnancy and opportunities to discuss the topic so that they form opinions. Furthermore, programs should emphasize positive attitudes toward contraception, because effective contraceptive use is shaped by such attitudes and is strongly associated with reduction of pregnancy risk (21).”
Pregnancy is not the only topic discussed in comprehensive sex education. Sexual development, such as physiological, anatomical and emotional changes in puberty are also discussed. For this education to be comprehensive in all aspects it must also include discussions on healthy relationships. “In terms of information about relationships they need to know about what kinds of relationships there are, about love and commitment, marriage and partnership and the law relating to sexual behavior and relationships as well as the range of religious and cultural views on sex and sexuality and sexual diversity (20).” Like I said before, teenagers are going to have sex whether you tell them to or not. Given the tools, teenagers will make the right choice for themselves, and learn about their own sexuality armed with knowledge on how to be safe. The right attitudes and beliefs on sexuality and the known dangers of what sex can be without protection being taught to teenagers is great. Abstinence-only education may be able to provide these things. However, comprehensive sex education goes beyond the concepts in the Health Belief model and brings in the tools needed to develop a healthy sexuality and be safe when engaging in these activities.
Right to Information and a Right to Equality
America has always prided itself on freedom. We are the land of the free. Though many people do not feel this way. Shouldn’t all Americans have the right to decide if and when they want to engage in sexual activity? Abstinence-only education teaches teenagers that this is not a right. One must not engage in such activities until marriage. Well if one doesn’t have that right, than can’t they choose with whom they would like to engage in this activity with? According to abstinence-only education, that too is not a right. By definition marriage is between a man and a woman (22). Which leaves lesbian, gay. bisexual and transgendered teens to believe they do not have the same rights. So if one cannot decide with whom, or when to have sexual encounters, than at least the information on how to be protected and have safe sex is given, right? Wrong again. Contraceptives and other methods of protection are not taught in abstinence-only education programs because teenagers shouldn’t be having sex anyway (23). So when a teenager gets older and maybe does wait until marriage to have sex, do they know how to protect themselves? If never given the information to learn how to fully prepare for sex and the consequences that come with it, physically and emotionally, than no matter how old you get you still are not prepared. Comprehensive sex education prepares you for all of what is to come. You are given the knowledge and information needed to make the right decisions, so when it comes down to it, you can decide if, when and with whom you want to engage in sexual activity with knowing how to stay protected when that decision comes. “State parties must ensure that children have the ability to acquire the knowledge and skills to protect themselves and others as they begin to express their sexuality (23).” These are the rights and freedoms Americans are entitled to.
Culminating Thoughts
Given all of the information about abstinence-only education programs and comprehensive sex education programs, one is clearly able to see the benefits that comprehensive education provides over abstinence-only education. I believe that abstinence is necessary to teach and to instill core values and morals in teenagers. I also believe though that teenagers are rebellious in nature and because they are told not to do something they are more apt to do so. So when educating teens about sex, one should also be taught about contraceptives and how to respect one another’s choices. Whether those choices are to have sex or not, or whom they may choose as a partner, or even how to handle the event of an unintended pregnancy. Developing their own attitudes and beliefs about sexuality is essential. With comprehensive education, one can make an educated decision and learn about sexuality. Comprehensive sex education should be available to all teenagers, it is a right of Americans. Therefore, comprehensive sex education should be funded by the government instead of abstinence-only education. It is important that the children of America have the freedom to make their own choices when it comes to sexuality and they should be guided on how to make the right choices.
REFERENCES
1. Elders, Joycelyn M. “Vows of Abstinence Break More Easily Than Latex Condoms.” Rethinking Schools Online. 2002. Milwaukee, WI. 20 November 2008 <http://www.rethinkingschools.org/sex/elders.shtml>.
2. Guttmacher Instutute. In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men. 2002.
3. U.S.Census Bureau. Estimated Median Age at First Marriage, by Sex: 1890 to the Present. 2007.
4. Trenholm C. et al. Impact of Four Title V Section 510 Abstinence Education Programs. Final Report. Princeton: Mathematica Policy Research; 2007. http://www.mathematica-mpr.com/publications/pdfs/impactabstinence.pdf
5. The Henry J. Kaiser Family Foundation. (2003). National Survey of Adolescents and Young Adults: Sexual Health Knowledge and Experiences. http://www.kff.org/youthhivstds/upload/National-Survey-of-Adolescents-and-Young-Adults.pdf
6. Stepp, Laura Sessions. “Study Casts Doubt on Abstinence-Only Programs.” Washington Post. April 14, 2007. http://www.washingtonpost.com/wp-dyn/content/article/2007/04/13/AR2007041301003.html
7. UNITED STATES HOUSE OF REPRESENTATIVES COMMITTEE ON GOVERNMENT REFORM — MINORITY STAFF SPECIAL INVESTIGATIONS DIVISION. “The Content of Federally Funded Abstinence-Only Education Programs: Prepared for Rep. Henry A. Waxman.” December 2004. http://oversight.house.gov/documents/20041201102153-50247.pdf
8. Rosenstock, I. M. (1974). Historical Origins of the Health Belief Model. Health Education Monographs. Vol. 2, No. 4. 328 – 335.
9. Community Pathways to Improved Adolescent Sexual and Reproductive Health: A Conceptual Framework and Suggested Out come Indicators. December 2007. Washington, DC and New York, NY: Inter-Agency Working Group (IAWG) on the Role of Community Involvement in ASRH. http://www.advocatesforyouth.org/publications/iawg.pdf
10. Kay J.K., Jackson A. Sex, Lies and Stereotypes. How Abstinence-Only Programs Harm Women and Girls. Legal Momentum; 2008
11. “Facts & Stats.” The National Campaign To Prevent Teen Pregnancy. 2002. Washington, D.C. 20 November 2008. <http://www.teenpregnancy.org/resources/teens/facts/default.asp>
12. “Sexual Responsibility.” Olin Health Center. 2002. Michigan State University, MI. <http://www.healthed.msu.edu/fact/sexual_responsibility_1.shtml>
13. Centers for Disease Control and Prevention. “A Glance at HIV/AIDS among Men Who Have Sex with Men.” January 2006.
14. “The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior: At a Glance: Vision for the Future.” U.S. Department of Health & Human Services. July 2004. Washington, D.C. <http://www.surgeongeneral.gov/library/sexualhealth/glancetable.htm>
15. Advocates for Youth. “Sex Education Programs: Definitions & Point-by Point Comparison.” Accessed on December 6, 2008. http://www.advocatesforyouth.org/rrr/definitions.pdf
16. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy, 2001.
17. American Foundation for AIDS Research. Assessing the Efficacy of Abstinence-Only Programs for HIV Prevention among Young People. [Issue Brief, no. 2] Washington, DC: Author, 2005.
18. Kirby D, Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases, Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy, 2007, p. 4, Accessed Dec. 6, 2008. http://www.thenationalcampaign.org/EA2007/EA2007_full.pdf
19. American Psychological Association (APA). (Feb. 2005). “Comprehensive Sex Education is More Effective at Stopping the Spread of HIV Infection.” Accessed December 8, 2008. http://www.apa.org/releases/sexeducation.html
20. Avert: AVERTing HIV and AIDS.“Sex Education that Works.” Accessed on December 8, 2008. http://www.avert.org/sexedu.htm
21. Perspectives on Sexual and Reproductive Health, Vol. 36, No. 6, Findings from Add Health (Nov. - Dec., 2004), pp. 248-257 http://www.jstor.org/stable/1520257 Accessed Dec. 10, 2008
22. "Marriage." Merriam-Webster Online Dictionary. 2008.Merriam-Webster Online. Accessed December 10, 2008 <http://www.merriam-webster.com/dictionary/marriage>
23. Santelli, John S., MD, MPH, Schleifer, Rebecca, JD, MPH, and Lande, Lila J., MPH. “Abstinence and U.S. Abstinence-Only Education Policies: Ethical and Human Rights Concerns.” Accessed on December 10, 2008. http://www.protectchoice.org/downloads/Reproductive%20Justice%20Briefing%20Book.pdf

Connecticut “Make Healthy Fish Choices” Campaign-Amanda DeLoureiro

On October 16, 2008, the Connecticut Department of Public Health and the Connecticut Food Association began publicizing a statewide campaign entitled “Make Healthy Fish Choices” (1). This campaign is geared towards women and children, and its purpose is to educate people about the health benefits and dangers of consuming different varieties of local and store-bought fish (1). This has involved the publication in English and Spanish of take-home cards entitled “Healthy Fish Choices for You and Your Family”, which are being distributed in participating supermarkets and grocery stores statewide (1). The cards contain information specific to pregnant women, nursing women, women of child-bearing age, and young children about the health merits and dangers of eating fish, and suggestions about how often different types of fish should be consumed (2).
Problems of the “Make Health Fish Choices” Campaign
The “Make Healthy Fish Choices” campaign is a clear example of an intervention that follows the Health Belief Model. This model is based on the idea that an individual’s perceptions regarding health behavior are rational, and an intervention can be used to alter the attitudes of the individual (3). This particular health behavior intervention focuses on changing how individuals view their perceived susceptibility, or the degree to which they think they are at risk of getting sick from the toxins found in many fish (4- 37). There are three main problems with this type of an intervention based on the Health Belief Model, in addition to a major problem with how the issue of fish contamination is being framed through this campaign. First, this intervention focuses on individual-level decision-making, and does not take into account the fact that there are environmental factors that can also affect decisions that people make about the consumption of fish (4-38). Secondly, this campaign assumes that everyone in Connecticut will have equal access to the information provided in the guides, which is untrue because of the large segment of the population that is not literate in English or Spanish, and will not understand all of the vocabulary presented in the document (4-38). Thirdly, this intervention assumes that those affected by the campaign will make rational decisions about their consumption of fish, and in doing so discounts the impact of cultural norms on choices regarding fish consumption (4-38). Lastly, this campaign frames the issue of contaminated fish in such a way that it ignores the root cause of this problem, pollution, and instead focuses on what the consumer can do to decrease the health risks associated with consuming this fish. The “Make Healthy Fish Choices” campaign should have done two major things differently: 1) it should have been modeled after a different type of health model that was more community-based, in order to address the influence of outside impacts like culture on behavior, and 2) it should have framed the issue in such a way as to address the root causes of fish contamination in Connecticut.
Individual-level decision-making ignores outside influences on behavior
A major problem with the “Make Healthy Fish Choices” intervention is that it is targeted at the individual, and was not developed to address social and environmental influences on behavior related to health. This campaign involved only a handout that was read by an individual person, instead of a more community-based effort that would address outside influences on diet, such as cultural norms. The focus on the individual person that is used in this campaign, like the example set forth in other interventions based on the ideas of individual-level models like the Health Belief Model and the Theory of Reasoned Action, reflects the value that North American and Western European cultures place on individualism (5). These societies are very focused on the concept that individuals have complete control over their behavior and decision-making, and in doing so tend to overstate the influence of personal behavior on health (5). Most of the original behavioral health models were built on various assumptions, such as 1) the individual is the key decision maker, 2) individuals value good health and will change their behavior in order to attain positive health outcomes, and 3) cognitive predisposition, like beliefs, attitudes, and perceptions, are a major driving force of health behavior (6-5). All of these assumptions are not inherently correct, because they ignore other influences that may impact individual decision-making and make people choose unhealthy habits, like consuming large amounts of contaminated fish. This intervention ignores the extent to which pre-existing beliefs, attitudes, and perceptions regarding fish consumption may counteract the information being put forth in the pamphlet.
In recent decades, researchers have begun to question the validity of relying solely on health behavior models that are based on individual-level decision-making in achieving substantive and sustainable changes to health behavior (6-6). It is thought that many individual-level models, like the Health Belief Model, do not lead to large-scale behavioral change because they are focused on changing the behavior of individuals. More recently developed models have focused on community-based campaigns, through which it is hopeful that norms within an entire community of people will be changed to encourage more healthy behaviors (6-6). Whereas the “Make Healthy Fish Choices” campaign focuses on changing individual perceptions of the health risks involved with fish consumption, community-based initiatives would prioritize changing the perception of an entire population regarding these health risks. Instead of focusing solely on the individual, health behavior campaigns should recognize the impact that factors like community, living and working conditions, and socioeconomic, cultural, and environmental impacts have on decisions people make about their health (5). It is doubtful that this intervention, based on the Health Belief Model, will be adequate to initiate widespread behavioral change in this case because the change for which the campaign is advocating ignores contextual meanings that are entrenched in group qualities, for example cultural practices, skills, and languages (3). Instead, the campaign would have been wise to take into account the outside influences that can significantly impact the choices that people make regarding fish consumption.
Lack of access of information to low literacy populations
Another major problem with this campaign is that the information about healthy consumption of fish is only offered in the form of a written handout. There are two major problems with this document that may inhibit access to the information provided: 1) it is available in only English and Spanish and 2) it makes use of scientific vocabulary. The availability in only two languages is of concern because in Connecticut, 12.9% of the population is foreign born and this number is predicted to rise in the coming decades (7). The large proportion of immigrants contributes greatly to the percentage of the adult population of Connecticut that is not literate in English. In 2001, 16% of Connecticut’s adult population was in the lowest of five literacy levels, which means that this group of people will be unable to understand the information as it is currently being presented (8). This segment of the population will not fully comprehend the suggestions being made, nor are they apt to know the different types of fish that are listed.
Populations with low literacy face various problems properly understanding health risks, including inadequate comprehension of available health education material, social networks that are not well-informed regarding health problems, and inadequate access to health services (9). A previous intervention geared at addressing the health needs of low literacy populations designed a book which promoted understanding through color coding, graphic symbols, simple language, and clear type (9). The “Make Healthy Fish Choices” intervention did not follow this example, and instead presented health-related information using extensive vocabulary, including words like “PCBs” and “omega-3 fatty acids”, in a manner that was not very clear (2). Low levels of literacy in a large proportion of Connecticut’s population, coupled with low understanding of scientific concepts, means that this intervention provides information in a way that many Connecticut residents will not fully comprehend.
Assumes people will make rational decisions without considering cultural practices
Another major problem with the “Make Healthy Fish Choices” campaign is that it assumes that people will make rational decisions without considering other factors that may have a significant impact on fish consumption, such as cultural practices. The Health Belief Model is known to ignore these outside impacts and instead focus on affecting how the individual makes decisions related to health (4). However, there are many groups of immigrants in Connecticut whose diet is composed of a large quantity of fish that may not, even given the information, choose to change their dietary habits. For example, between 2000 and 2006, the Brazilian population of Connecticut grew 82%, from 10,379 to 18,871 (7). Due to its large coastline, vast rivers, and the influence of Portuguese conquistadors who brought their dietary practices to the new world, the diet of many Brazilians includes a large amount of fish (10). Although the diet of this population may be altered due to the influence of living in the United States, diets of particularly the new immigrants cannot be expected to change dramatically with an individual-based intervention like the “Make Healthy Fish Choices” campaign. This intervention provides information that goes against the Brazilian’s cultural norms of consuming large quantities of fish, and yet it is questionable whether this information will be strong enough to change people’s perception of the health risks related to consuming fish. Many immigrant populations, particularly recent immigrants, tend to live in communities that have large populations of others from their country, as well as markets with food from their country. In order to change dietary norms for groups such as this, it would be necessary to create an intervention to address an entire population of people like the recent Brazilian immigrants.
Downstream approach that ignores the cause of the pollution
Another key problem with the “Make Healthy Fish Choices Campaign” is that it focuses on providing information to fish consumers about the dangers of fish consumption, instead of framing the issue in such a way that it places blame on the companies that contribute to the pollution of Connecticut’s fish. In Connecticut, 75% of fish samples taken have mercury levels that exceed the safe limit for women (0.13 ppm), with an average of 0.42 ppm (11). Sampling in Connecticut waters of specific fish species, such as smallmouth bass and certain predator fish, have found that 100% of fish exceed the safe mercury levels for women (11). Much of this mercury comes from businesses along the rivers of Connecticut, such as power plants. In order to reduce mercury pollution in the rivers of Connecticut, the state passed a law in 2003 that limited emissions to 0.6 pounds of mercury per trillion Btu, or 90% efficiency (11). However, the pollutants in Connecticut rivers do not originate solely in the state of Connecticut, as the Connecticut River estuary includes parts of the states of Massachusetts, Vermont, and New Hampshire.
The intervention as it currently stands does not address the underlying causes of pollution of fish from sources like coal fired power plants, and instead focuses on putting the responsibility of healthy fish consumption on the individual consumer. Institutional framing is the way that public health practitioners can social construct risk (12). In this case, the issue should be framed in such a way that people see the corporations from throughout New England that they are polluting their fish and their water as an enemy, so that they become angry with this group and hopefully work to initiate change. The Connecticut Department of Public Health should make use of the frame-alignment process, which involves linking individuals and social movement organizations with the same set of interests, values, and beliefs (12). In framing the issue in this way, the department could help to initiate a movement for change that would ultimately affect all people who consume fish from the waters of Connecticut.
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Alternative intervention
An appropriate alternative intervention will need to address the problems associated with the Health Belief Model, as well as the root cause of water pollution that is resulting in the contamination of fish. The proposed intervention would provide educational programming to people throughout Connecticut, which would teach them about the dangers of consuming certain types and amounts of fish, and also about the causes of water and subsequent fish contamination. The education programs would be advertised in and provided in local libraries, schools, and religious organizations, in order to reach a large segment of the population. The information would need to be provided in such a way that it addresses the needs of individual communities, consequently there would be a need for flexibility so that each presentation of the information would be designed for people of different backgrounds and cultures. The intervention would also provide people with a form to send to their government representatives about the environmental hazards associated with water pollution and its effects on fish. It is hopeful that this would cause a significant change in policy, and encourage the government to properly address the root cause of fish contamination.
This intervention would address the major problems associated with the Health Belief Model that have been previously outlined. Firstly, it is a community-based intervention that is aimed at changing the behavior of a population, not specific individuals. Secondly, the intervention would educate low-literacy groups of people because the information would be provided verbally. Finally, this intervention would address the need for information to be presented in a culturally sensitive manner, by altering the presentation to speak to the cultural dietary norms of each represented population.
It is also hopeful that, by providing information about the causes of water pollution, and by giving people forms to send to their representatives, they will bond together in order to fight major contributors to water pollution. This intervention would be much more successful than the “Make Healthy Fish Choices” campaign because it 1) deals with the problems associated with the Health Belief Model and 2) properly frames the issue in such a way that the root cause of fish contamination is addressed.
Group-level intervention addresses outside influences on behavior
One major problem with the “Make Healthy Fish Choices” intervention is that it focuses on changing the behavior of individual people and ignores the influence of groups on behavior. Some of the more recently developed behavioral theories have emphasized that groups are different than simply a collection of individuals, and that groups of individuals can be affected at the same time (13). One example of how the emphasis in social behavior models has been altered to address the needs of groups is seen in the Social Expectations Theory, which states that people act in mass based on the prevailing social norms (13). Thus, interventions based in the Social Expectations Theory attempt to alter the social norms of an entire group of people (13). For example, an intervention in Finland that made smoking in the workplace illegal was found to be successful at changing social norms, so that non-smoking at work is now seen as normal behavior in this nation (14).
The proposed intervention can be similarly productive because it addresses behavior change at the level of the community instead of at the level of the individual by having members of a population learn about and discuss the causes and implications of fish contamination. It is hopeful that, though discussions in the education programs and follow-up conversations with their peers, citizens of Connecticut will come to see the consumption of reduced amounts of fish as a societal norm.
Provides information to low literacy populations
Another major problem with the “Make Healthy Fish Choices” campaign is that it assumes that people will have equal access to the information provided in the pamphlets, when in reality low literacy populations will be unable to adequately understand the suggestions being put forth. One study of functionally illiterate populations made the suggestion that preexisting health literature should be extensively reviewed by assessing readability and comprehensibility, editing written material, and evaluating the effectiveness of less complex written documents (15). The researchers found changing the educational intervention so that used less complex language and an easy to read format made it more effective in addressing the needs of low literacy readers (15).
The proposed intervention goes even further than the previous example, as it properly addresses the difficulties in comprehension associated with low literacy populations by educating people through verbal presentations. These presentations will be made in different languages depending on the needs of individual populations, and will provide universal access to the information to all people who attend the education sessions.
Considers cultural practices
Another problem with the “Make Healthy Fish Choices” campaign is that it assumes that an individual’s intention to reduce fish consumption, as a result of an educational intervention, will actually result in behavior change. However, this ignores the impact that cultural norms have on diet, such as the example of Brazilian immigrants discussed in a previous section. The proposed intervention addresses the needs of people of very different cultures by encouraging public health professionals to be flexible in how material is presented based on the needs of varying communities. The results of a previous study that looked at the effects of socio-cultural factors on food selection practices suggest that in order to provide information about food in a culturally sensitive manner, public health professionals need to 1) incorporate cultural information into education approaches, and 2) incorporate the entire household in educational programs (16).
The proposed intervention is designed in a way that will be sensitive to the dietary norms of different cultural groups, even recent immigrant populations, by including cultural information in the programming and by encouraging all members of a household to attend. For example, if public health practitioners wanted to address fish consumption in the growing Brazilian population in Hartford, they might teach people how to incorporate other types of meat into recipes that traditionally have fish. In this way, the behavior of a population that has distinct cultural norms regarding food can be changed by encouraging slightly altered behavior that is sensitive to that population.
Addresses cause of pollution
The final strength of the new intervention is that it deals with the issues associated with the consumption of contaminated fish by addressing the root cause of this problem, which is water pollution from industrial waste. It does this by giving participants of the education programs the opportunity to fill out a form to be sent to their governmental representative, which would outline the problem and the changes that would be necessary to reduce fish contamination. This method makes use of framing theory, which states that an issue can be seen from many perspectives and can be viewed as having implications for many considerations (17). Interventions of this kind use framing to reorient how people think about a certain issue (17). Framing theory has been successful in many public health interventions, the most notable being the anti-tobacco Truth campaign. This intervention frames tobacco smoking in such a way that it encourages young smokers to have anti-industry attitudes towards producers of cigarettes (18). A study in 2004 found statistically significant increases in anti-industry attitudes among youth since the Truth campaign was introduced (18).
The proposed intervention is similar to the Truth campaign in that it encourages the general public to speak out against producers of fish pollutants. It frames the issue in such a way that contaminated fish are not simply a food that they should avoid, but also a problem that they can work to prevent.
Conclusion
The “Make Healthy Fish Choices” campaign of informational handouts regarding the benefits and health risks related to fish consumption is not efficient in relaying this information to the general public of Connecticut. This intervention, which is based on the Health Belief Model, is poor because it is based on an individual-level model of decision-making, ignores problems that people may face in accessing the information, and assumes that citizens will make rational decisions about fish consumption once provided with information. Additionally, this intervention ignores the root cause of the need for the campaign, which is water pollution, and instead focuses on changing consumer behaviors.
In order to be a more effective intervention, the Connecticut Department of Public Health needs a campaign that addresses the significant problems associated with the Health Belief Model in a way that encourages Connecticut residents from all backgrounds to want change from corporations polluting local bodies of water. The proposed intervention would address the flaws of the existing campaign by creating a community-based initiative to address the needs of Connecticut’s diverse population in a linguistically and culturally sensitive manner, while also addressing the underlying cause of the fish pollution.
Works Cited
(1) Connecticut Department of Public Health. Connecticut’s Fish Consumption Advisory and the Safe Eating of Fish Caught in Connecticut. 7 Nov 2008. http://www.ct.gov/dph/cwp/view.asp?a=3140&q=387460&dphNav_GID=1828&d phPNavCtr=#47464.
(2) Connecticut Department of Public Health. State Health Department “Reels-In” Fish Eaters. 16 Oct 2008. http://www.ct.gov/dph/cwp/view.asp?A=3294&Q=425142.
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(7) Mejia, Rafael and Canny, Priscilla. Immigration in Connecticut: A Growing Opportunity. Connecticut Voices for Children. Oct 2007.
(8) Gelb, Jennifer. Summary of Connecticut Plan for Adult Education and Family Literacy. OLR Research Report. 16 February, 2001.
http://www.cga.ct.gov/2001/rpt/olr/htm/2001-r-0198.htm.
(9) Berger, David, Moira Inkelas, Sonya Myhre, and Alanna, Mishler. Developing Health Education Materials for Inner-City Low Literacy Parents. Public Health Reports 1994; 109(2): 168-172.
(10) Fish, Warren R. Changing Food Use Patterns in Brazil. Luso-Brazilian Review 1978; 15(1): 69-89.
(11) US Public Research Group Education Fund. Reel Danger: Power Plant Mercury Pollution and the Fish We Eat. Aug 2004.
(12) Zavestoski, Stephen, Kate Agnello, Frank Mignano, and Francine Darroch. Issue Framing and Citizen Apathy Toward Local Environmental Contamination. Sociological Forum 2004; 19(2): 255-283.
(13) Siegel, Michael. SB 721 Class Lecture. 9 October 2008.
(14) Heloma, Antero and Jaakkola, Maritta S. Four-year follow-up of smoke exposure, attitudes and smoking behavior following enactment of Finland’s national smoke- free work-place law. Addiction 2003; 98: 1111-1117.
(15) Horner, Sharon D, Dawn Surratt and Sarah Juliusson. Improving Readability of Patient Education Materials. Journal of Community Health Nursing 2000; 17(1): 15- 23.
(16) Gittelsohn, Joel and Vastine, Amy E. Sociocultural and Household Factors Impacting on the Selection, Allocation and Consumption of Animal Source Foods: Current Knowledge and Application. Constraints on Animal Source Food Consumption 2003; 4036S-4041S.
(17) Chong, Dennis and Druckman, James N. Framing Theory. Annual Review of Political Science 2007; 10: 103-126. (18) Thrasher, JF, J Niederdeppe, MC Farrelly, KC Davis, KM Ribisl, and ML Haviland. The impact of anti-tobacco industry prevention message in tobacco producing regions: evidence from the US truth campaign. Tobacco Control 2004; 13: 283-288.