Designing More Effective Dengue Control Programs – Colleen Longacre

Designing More Effective Dengue Control Programs – Colleen Longacre

Dengue is a mosquito-borne infection that causes severe flu-like symptoms and can give rise to a deadly complication called dengue hemorrhagic fever (DHF). Dengue is found in tropical climates worldwide, and DHF is the leading cause of death among children in some Southeast Asian countries (1). The global incidence of dengue has increased dramatically over the past 30 years, making it a major international health priority. Because there is currently no vaccine and no specific treatment for dengue, public health programs have focused primarily on vector control programs that target the mosquitoes that carry the virus. Early control programs were vertical in nature and focused on large-scale chemical spraying of standing water sources. When these efforts alone proved ineffective, public health professionals stressed the importance of community-level campaigns to promote behavior change to promote vector control. However, these community campaigns have been designed primarily using the Health Belief Model and other individual-level models of behavior change. As a result, these campaigns have also failed to inspire community-wide behavior change and decrease the incidence of dengue among the populations at risk.

Components of Current Community Vector Control Programs

Community-level vector control programs are comprised of three elements – insecticide application to potable water supplies, environmental management, and community awareness campaigns. The World Health Organization (WHO) currently approves five insecticides for use in drinkable water. In addition, biological control agents, such as larvae-eating fish, may be introduced into water supplies to kill the mosquito larvae without adversely affecting human health (2). Environmental management consists of clean-up campaigns, installation of water supply systems, solid waste management, and better urban planning (2). Campaigns designed to raise community awareness and participation in vector control efforts are the newest addition to these programs. These campaigns seek to increase control activities at the household level, such as “covering or frequently cleaning water storage vessels, removing discarded food and beverage containers, and disposing of used tires in such a way that they do not collect rainwater” (2).

The Health Belief Model has been widely used in designing these campaigns. The Health Belief Model, one of the most widely used individual behavior change theories in public health, states that health behavior is primarily motivated by four factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (3). This model assumes that an individual rationally weighs the costs and benefits of taking action and then acts (or chooses not to act) according to whether or not the benefits outweigh the costs. Additionally, individuals respond to specific cues to action to initiate behavior change, and will take action only if they feel they have a certain degree of self-efficacy in taking that action (3). Recent dengue control campaigns have attempted to address each of the elements of the Health Belief Model. One organization working in dengue control published a bulletin of targeted messages for NGOs to take back to the communities in which they work. These messages addressed perceived susceptibility and severity (“So, you don’t think that dengue is a real problem? It is here in our community now! Young and old get sick with dengue.”), perceived barriers (“Little time to do clean-up to reduce mosquito breeding sites? No problem! Use the action plan checklist. Use it once a week.”), and perceived benefits (“If everyone spends just a few minutes each week to clean up stagnant water, throw away unneeded containers, or cover them, then it will go a long way to reduce dengue fever.”) (4). The inclusion of these messages in posters and public service announcements is designed to serve as the cue to action.

Although these vector control programs have attempted to engage with communities and have recognized the importance of widespread behavior change on program effectiveness and sustainability, their results to date have been unremarkable (5). Several flaws in the design of these programs are impeding their success in reducing the incidence of dengue throughout much of the world.

The Health Belief Model is an Inadequate Predictor of Individual Behavior

The awareness-raising element of vector control programs assumes that individuals are unaware of their susceptibility to dengue fever and the severity of the disease. However, community-level studies conducted in South America and Southeast Asia have proven that this is not the case. One study in Brazil, for example, found that 95% of the population recognized dengue as a severe illness, and 75% had either a relative who had suffered from dengue in the past or had suffered it themselves (6). In addition, 94% of the population could identify at least one method of vector control (6). However, only 18-31% of the population actually reported employing methods of vector control (6). Similarly, in Cambodia, a study among primary school students found that 73% could identify the cause, symptoms, and consequences of dengue, and 83% could identify at least one method of vector control (7). However, when researchers examined the households of these students, they found that few employed vector control strategies (7).

These findings are at odds with what is predicted by the Health Belief Model. Among these communities heavily affected by dengue, there is apparently widespread awareness of the susceptibility and severity of the disease. There is also seemingly widespread knowledge of the desired action and the benefits of that action. Mass communication campaigns have attempted to reduce the perceived barriers through easy-to-follow checklists and action plans. However, the use of vector control strategies remains low.

The failure of the awareness-raising campaigns to inspire actual behavior change exposes critical shortcomings in the Health Belief Model approach. Most importantly, the Health Belief Model assumes that everyone has equal access to, and an equivalent level of, information to make rational decisions. In developing countries and especially in rural communities, access to information is not uniform. In fact, both the campaigns themselves and the studies conducted to evaluate them may have missed their target completely. In many communities, elderly women are primarily responsible for household tasks such as cooking and cleaning. These women should be the primary targets of any intervention designed to encourage the regular cleaning and covering of water containers and the proper disposal of garbage; however, they are also the least likely to be literate or to be exposed to outside media sources that promote such behaviors. Furthermore, school-aged children and adult members of the household who are exposed to the awareness-raising campaign may feel it is outside their sphere of influence to instruct their mothers or mothers-in-law as to how they should carry out their daily tasks (8). As a result, there is a significant disconnect between those with the information and those with the self-efficacy to enact behavior change that stems from the roles different individuals play within the greater household dynamic. The Health Belief Model fails to take into account these social factors that inform individual decision-making. To develop more effective community vector control programs, public health practitioners should consider alternative behavior change models that address these social issues.

Environmental Management Strategies Fail to Take into Account Maslow’s Hierarchy of Needs

As previously discussed, the environmental management component of vector control programs consists of mass clean-up campaigns, installation of water supply systems, solid waste management, and better urban planning (2). However, the provision of these services requires considerable investment in the overall public health infrastructure of many communities. In order to recoup this investment, cost-recovery mechanisms have been introduced into many communities (2). In rural areas, environmental management often takes the form of the installation of metered community water services, whereby each household pays for the amount of water they extract from a common, certified clean source. In effect, the households are asked to pay for the assurance that they will not contract dengue from their water supply. Mass clean-up campaigns have aimed to eliminate sources of standing water that serve as breeding grounds for mosquitoes. These sources include old tires, wheelbarrows, tin cans, and oil drums that household members may leave around their property (9). Clean-up crews offer to remove these items at no cost to the households.

While these environmental management strategies would be effective in reducing the incidence of dengue, they have been met with extensive resistance from communities. Among some poor communities in Southeast Asia, households resorted to collecting rainwater from roof catchments at no cost, rather than paying for the use of community water supplies. Contrary to its intent, the introduction of community water services has actually increased the incidence of dengue in certain areas (2). Similarly, communities were unwilling to allow clean-up crews to remove tires from their property, because they used these tires during the windy season to anchor the tin roofs of their houses to keep them from blowing away (9).
The response of poor communities to the environmental management strategies is a clear expression of Maslow’s hierarchy of needs. Psychologist Abraham Maslow theorized that all human beings desire to grow and attain their full potential; however, before human beings can pursue any kind of higher-level growth, they must be able to satisfy a set of needs (10). According to this theory, safety of health is a higher-order need than the basic needs of water and housing. Until these basic needs are met, individuals are unlikely to focus on their higher-order needs. Therefore, even if individuals recognize the importance of dengue control, they will value their access to free water and secure housing more highly than they value the implementation of vector control strategies. Public health practitioners must consider alternative strategies of environmental management that either do not disrupt people’s ability to meet their basic needs, or are able to meet them simultaneously.

Some Insecticide Treatment Practices are Not Culturally Acceptable in Communities Where They are Employed

The use of insecticides to treat water supplies has long been the primary means of vector control in dengue campaigns. Households are encouraged to add insecticides to the stored water supplies they use for drinking, cooking, and bathing. These insecticides have been certified by the WHO as safe to ingest, and there are no documented adverse health effects of adding these chemicals to the water supply. However, despite these assurances, many communities disapprove of the use of these insecticides for cultural reasons.

Anthropologist Linda Whiteford studied what she describes as the “indigenous typology of water” in the community of Villa Francisca in the Dominican Republic (8). Because water is a scare commodity in this community, different water from different sources is used for different purposes. Tap water is generally brackish and slightly sour, so people prefer to use this water for cleaning. For drinking and cooking, people relied on so-called “sweet water” purchased from public water sources. The idea of adding chemical agents, which slightly altered the taste of the sweet water, was considered ridiculous. Why would they “unsweeten” the water that they had paid for? Similarly, agricultural communities in Central and South America have been resistant to adding chemicals to their drinking water supplies, in part due to public health campaigns in these regions designed to alert farmers to the dangers of pesticide poisoning. Farmers reported that “[the insecticides] had bad smells, so must be harmful to the health”, because this was how they were taught to identify water that might be contaminated with harmful agricultural pesticides (6). Finally, the use of biological control agents has met with resistance in Southeast Asian countries such as Thailand, where there are strict cultural taboos about bathing with water that contains small fish or other creatures (2). For insecticide treatment programs to be effective, public health practitioners must take into consideration the cultural beliefs and practices of the communities in which they work. They must demonstrate an understanding of current community behaviors before they attempt to induce behavior change.

In the absence of the development of a dengue vaccine, vector control programs remain the most important public health intervention in reducing the incidence of dengue worldwide. By reworking the awareness-raising campaigns so that they target the appropriate audiences, by addressing the effects that changes in public health infrastructure have on the ability of households to meet their basic needs, and by understanding the cultural significance of adding chemicals to water supplies in certain communities, vector control programs will be able to more effectively combat dengue around the world.
Dengue Control Programs Must Engage with Women to Raise Awareness at the Community Level

As previously discussed, there is a significant disconnect between those exposed to current awareness-raising campaigns and those with the self-efficacy to enact the behavior changes necessary to achieve the desired outcome. In order to be more effective, awareness-raising campaigns need to be retooled and redirected. One lesson of the failed campaigns is that it is not the message itself that is the problem. Previous studies have shown that those who were exposed to the message both understood the problem and the necessary course of action to take to fix the problem (6,7). What needs to change is how the message is being disseminated into communities and who is being targeted to receive the message.
Social Networking Theory provides a framework for how this goal might be achieved. Social Network Theory first emerged in the 1950s and has been applied in the diverse fields of sociology, public health, communications, political opinion, mathematics, and systems theory (11). Social Network Theory operates on the assumption that the specific and unique characteristics, beliefs, and attitudes of individuals are not as important as the relationships between and among individuals. The theory posits that it is the nature of those relationships (i.e. family/kin networks, work networks, social groups, etc.) that most influences beliefs and behavior (12). Social networks play an important role in whether individuals adopt specific health behaviors, what information individuals are exposed to concerning their health, and what kinds of social support and coping mechanisms are available to individuals (13).

Researching a community’s social networks would provide public health practitioners with information regarding who the primary targets of their awareness campaigns should be. If they had examined family dynamics in many rural communities, they would have learned that it is the mothers and grandmothers who most need to be exposed to information concerning vector control. Once the targets of the message have been identified, Social Network Theory provides a mechanism for effectively disseminating the message. Public health practitioners identify those women who are central to most of the social groups at play in the community. By engaging with these influential women, public health practitioners will build credibility at the community level for their proposed program. Public health practitioners could host small group discussions with these women, and then encourage them to organize discussions with other members of their social networks. In this manner, the vector control message will eventually trickle out to even the most marginalized members of the social network, and the community will feel a sense of ownership over the message. This sense of ownership increases individuals’ self-efficacy and may encourage more universal behavior change. Moreover, the existing social networks can act as built-in mechanisms of social support – neighbors can check in on each other to ensure that they continue to employ vector control strategies.
Dengue Control Programs Must be Integrated into Broader Development Projects

Environmental management is an important component of dengue control programs; however, it cannot be implemented in a vacuum. More effective environmental management programs would take Maslow’s hierarchy of needs into consideration in their design and implementation. Before public health practitioners decide to install metered community water pumps or organize mass clean-up campaigns, they must first evaluate the ability of communities to cope with these changes. If the average household income in a given community is less than a dollar a day, charging fifty cents for clean water may not be the most effective method of dengue control for that community. If communities cannot afford to pay for clean water, then clean water must be made available to them by another method. Similarly, cleaning crews that offer to remove tires should also be equipped to offer to reinforce roofs by another method. Public health practitioners working on environmental management projects should interface with other organizations doing development work in the communities to ensure that individuals’ basic needs are being met and that they are being provided with alternatives for the behaviors and practices they are being asked to abandon.

Dengue Control Programs Must Utilize Culturally Appropriate Water Treatment Methods

As previously suggested, for insecticide treatment programs to be effective, public health practitioners must take into consideration the cultural beliefs and practices of the communities in which they work. They must demonstrate an understanding of current community behaviors before they attempt to induce behavior change. Cultural theory provides an invaluable tool for addressing these issues. Cultural theory “informs us that we live and behave in subjective worlds of meaning, where behavior and meaning are linked” (14). Decoding the meaning behind behaviors is essential to explaining why individuals are resistant to certain behavior changes. More thorough research is necessary before dengue control programs are introduced into communities. Public health practitioners must be willing to conduct literature reviews of the work of cultural anthropologists in the area, or, alternatively, be willing to employ cultural anthropologists as integral members of their program teams. By incorporating cultural theory, dengue control programs can ensure that insecticides are introduced to communities in ways in which it is more likely to be accepted.

If public health practitioners in Villa Francisca, for example, had been aware of this community’s indigenous typology of water, they could have predicted that simply dispensing insecticides in the community would not induce people to use them. If these practitioners had been familiar with Dr. Whiteford’s research, they could have employed this information in developing their awareness-raising campaigns. They could have reframed the concept of adding insecticides to sweet water as a means of enhancing this water even further by adding a life-saving substance to it, not as a method of unsweetening the water. Similarly, if public health practitioners had known about the cultural taboos in Thailand, they would have invested their resources in procuring chemical insecticides rather than biological control agents for these communities. Ensuring that water treatment methods are culturally appropriate may require more initial research and expenditure of resources during program development; however, dengue control programs that fail to do this run the risk of wasting even more time, effort, and resources on unsuccessful programs.

Dengue is a critical international public health problem that deserves well-designed, well-implemented control programs. Past and current dengue programs have been successful in determining what methods of control are most effective; however, they have been largely unsuccessful in inspiring communities to adopt these methods of control. By utilizing social science theories, such as Social Network Theory, Maslow’s hierarchy of needs, and Cultural Theory, dengue control programs will be able to more effectively target the appropriate audiences, ensure that programs are not disruptive to the overall health and wellbeing of communities, and ensure that water treatment methods are culturally appropriate. The combined effect of these improvements should serve to inspire more widespread behavior change and to begin to reduce the incidence of dengue worldwide.

REFERENCES
1. WHO. “Dengue and dengue hemorrhagic fever.” May 2008. <>.
2. Cattand, Pierre, et al. “Tropical Diseases Lacking Adequate Control Measures: Dengue, Leishmaniasis, and African Trypanosomiasis. Disease Control Priorities in Developing Countries. 2006; 451-466.
3. Rosenstock IM. “Historical Origins of the Health Belief Model.” Health Education Monograph. 1974; 2: 328-335.
4. Lennon, Jeffrey L. “The Use of the Health Belief Model in Dengue Health Education.” Dengue Bulletin. 2005; 29: 217-219.
5. Parks, W. and L. Lloyd. Planning Social Mobilization and Communication for Dengue Fever Prevention and Control: A Step-by-Step Guide. Geneva: World Health Organization. 2004.
6. Augusto, Lia Giraldo da Silva and Solange Laurentino dos Santos. “Control Program of Dengue in Brazil: Critical Reflections.” International Congress on Dengue and Yellow Fever. 2004.
7. Sokrin, Khun, and Lenore Manderson. “Community and School-Based Health Education for Dengue Control in Rural Cambodia: A Process Evaluation.” Neglected Tropical Diseases. 2007; 1: 1-10.
8. Whiteford, Linda M. “The Ethnoecology of Dengue Fever.” Medical Anthropology Quarterly. 1997; 11: 202-223.
9. Correa, Carlos. “Incorporating a New Approach into Dengue Control Programs: Community Participation in Negotiating Behavior Change.” CHANGE Project. AED/USAID. May 2003.
10. Maslow, Abraham. Motivation and Personality. New York: Harper, 1954.
11. Barnes, JA. “Class and communities in a Norwegian island parish.” Human Relations. 1954; 7:39-58.
12. Wasserman, S. and K. Faust. Social Network Analysis. Cambridge: Cambridge University Press; 1994.
13. Pescolido, BA. And JA Levy, eds. Social Networks and Health, 8th ed. Elsevier, Inc: 2002.
14. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007; 121.

Why BMI Report Cards Fail To Curb Childhood Obesity In Schools: Criticisms Centered On Biopsychosocial Theory – Tom Eliopoulos

Introduction

Obesity has been a growing concern in America for over 20 years, as evidenced by the fact that forty-nine states had an obesity prevalence factor of over 20% in 2007 (1). These figures beg the question of what should be done to address this growing trend. Is anyone actually responsible for curbing childhood obesity in America? And if so how far should they go? A conclusion has yet to be reached, but in the mean time a number of people seem to think that middle schools and high schools offer a good forum to address the nation’s problem. A recent approach that schools in over seven are using is Body Mass Index report cards (2, 3). These are special reports sent home regularly or along with a child’s grades that alert them and parents of a child’s seeming health status. This approach is quite flawed when considered in light of the prominent Biopsychosocial model for health and illness set forth throughout the social sciences. This model purports that biological, psychological, and social factors all play a part in determining the outcome of an illness or disease (4). In scrutinizing the flaws of this intervention, I will consider arguments involving each of the three components of this theory.

Biological Misconceptions

From a biological perspective, this approach makes little sense because adolescents have not yet stopped growing, and assessing them by their body mass index is an inappropriate assessment of health status. Further, studies which have explored the variability of body mass index in children have found that this measurement actually suggests that the BMI measure used to assess fatness in children may be under-estimating the true prevalence of the problem (5). This is because the same BMI measure of fat index can reflect a wide range of different values of body fat and fat free mass. In addition, according to Shape Up America! even small errors in measuring height or weight can significantly affect the BMI index, and can easily reflect inaccurate standings as overweight or non-overweight (6). Under this doctrine, then, a perfectly active and in-shape person would be considered to have a high BMI if their height and weight don’t fit properly into the charts.

Continuing with this issue, in 2005 a Fox News special report aired to investigate the use of BMI index as an accurate indicator of health. Their study found that using this index as a reference, nearly 200 of the 426 basketball players in the National Basketball Association (NBA) would be approaching overweight status and a good number would be considered overweight (14). This highlights the fact that BMI does not account for weight due to muscle gains. In fact, this report clearly illustrates the extent to which BMI is inaccurate as a biological indicator of health.

There is also evidence to suggest that onset of puberty can affect weight, and such gains are healthy or normal. In this respect, issuing BMI score reports would not only reflect a flawed strategy but also one that is not even appropriate to apply for many adolescents, especially girls. One study found that even cross-culturally weight gain is a normal derivative effect of puberty for young girls and there is much individual variability based on when these biological developments occur (13).

Psychological Issues

In terms of the psychological approach found in this intervention, there are several reasons why it is flawed. This is the case first in terms of the child’s conception of themselves as overweight individuals. Sending home reports to families that a child has a weight problem sets a tone within their family and educational setting that facilitates harboring negative perceptions about themselves. What is more, is that these reports are sent home even where a child may seem to be approaching a weight spike or a slight weight gain which unduly causes alarm for all parties concerned. A recent study examined this phenomenon in 16,314 individuals and found that the perception that one was overweight in itself presented a significant barrier to engaging in exercise and physical activity in overweight people (7). Further, these reports effectively cause these children to consistently evaluate themselves in terms of their weight status in reference to their community. A study of overweight adolescents found that those who were surrounded by a daily environment with obese people would start to develop inaccurate perceptions of what it is to actually be overweight (8). In other words, they begin their psychological baseline data changes about what obese people actually look like. As a logical extension of this reasoning, standard BMI reports inaccurately labeling children as overweight or on the verge of obesity—when really they are not— will serve a similar function. Where this practice causes children to believe that they have a serious weight problem and improperly incorporate normal-weight peers into their internal reference model for obesity is cause for great alarm.

Additionally, the psychological effect of a child perceiving themselves as overweight or inadequate in some way will inevitably affect their self-esteem in a very negative way. It is quite reasonable to presume that a young child receiving a report from school that they are obese fits these criteria. A study of adolescents showed that they associated weight gain, as defined by BMI, with perceptions of being overweight which in turn resulted in depression and lowered self-esteem (9). Another study surveyed 80 twelve-year-old girls and found that those with higher BMI indexes had significantly lower measures of self-esteem and self-concept as compared to girls with lower BMIs (16). Adolescence is riddled with emotional milestones and awkward developments enough to foster many opportunities for lowered self-esteem and depression, and there is no reason that schools should introduce another variable into the mix by instituting BMI report cards as an attempt at intervention with data so evidencing the practice as psychologically counter-productive in children.

Social Problems

Social factors are grounds for another crucial set of reasons why BMI report cards represent a flawed intervention strategy. One of the biggest obstacles adolescents face in middle and high schools is trying to fit in. This is universal. Part of this challenge emanates from ridicule by peers. Implementing BMI report cards merely provides another way for children to ridicule one another and sets up a forum for further social detriment within the educational setting. One author documents this phenomenon, explaining how bullying and harassment are directly linked to reduced self-esteem in children (10). The article correctly describes how practices, such as this, inevitably lead to a hostile school environment and one in which these overweight children become the product of discrimination. Issuing BMI reports will serve only to strengthen and highlight the differences between adolescents and create dangerous settings in which obesity may no longer be the biggest risk that these children face. Still another study investigated the stigmatization of overweight and non-overweight Mexican children by their mothers and peers, finding that those mothers who were normal weight tended to choose a picture of the non-obese person as the preferred friend for their child over an overweight person in a significant way (15). The results of this study illustrate the extent to which mothers’ negative attitudes towards obesity are projected onto their children and is an important consideration here where BMI is used as the measure for social norms.

Furthermore, such stigmatizations by peers are likely to lead to a preoccupation with being thin and significant social pressures as well (11). By dramatically emphasizing weight status through BMI reports, as opposed to fitness or leading a healthy lifestyle, this strategy puts adolescents at a higher risk for developing eating disorders such as anorexia or bulimia.

Another problem with schools pre-occupying themselves with weight is that it will also serve to propagate a divide among students with respect to SES. By this I would suggest that lower SES families have less money to spend on healthy diets for their children and so are more likely to choose unhealthy option like fast food more often than a student from a higher SES family who can afford meals from Whole Foods. A related study, which examined the association between frequency of family meals and weight status in 4-9 year olds, found that those who ate very few family meals had a significantly greater risk for being overweight during middle childhood (12). These differences are brought to light more readily via this intervention, where these low SES children who consequently must each more such convenience foods are systematically labeled and discriminated against by their peers and school officials because of their weight.

Remarks

An approach conforming to Biopsychosocial theory is by far the most comprehensive method for tackling the growing problem of childhood obesity in our country’s elementary education institutions. The “BMI Report Card” intervention strategy is flawed in a number of important ways that ignore biological underpinnings and psychological implications as they relate to children and their weight or perceived body image and self-esteem. This tactic is most fundamentally flawed in that BMI is not an appropriate measure of fitness or health status in the least, and even neglects consideration of muscle gains in its analyses. Most striking though was the intervention’s complete disregard for the destructive social norms and environment that these institutions were fostering among student-peers by placing such importance on weight—as opposed to fitness or health. Before any future strategy is implemented to address the concern of the rising number of overweight children in American schools, it must make doubly certain that; the biology behind it is correct, the intervention does not cause unnecessary psychological stress, and that it can be achieved in a way that does not exacerbate social injustices and discrimination.

REFERENCES
1. Department of Health and Human Services. U.S. Obesity Trends 1985-2007. Atlanta, Georgia: Centers for Disease Control and Prevention. http://www.cdc.gov
2. ABC News. The Battle of the Bulge at Schools. Drexel Hill, PA; ABC News. http://abcnews.go.com/Nightline/Story?id=2889317&page=1
3. The New York Times. As Obesity Fight Hits Cafeteria, Many Fear a Note from School. New York, NY: NYTimes.com. http://www.nytimes.com/2007/01/08/health/08obesity.html
4. ConneXions. The Biopsychosocial Model of Health and Illness. http://cnx.org/content/m13589/1.2/
5. Wells J. The Contribution of Fat and Fat-free Tissue to Body mass Index in Contemporary Children and the Reference Child. International Journal of Obesity 2002; 10: 1323-1328.
6. Shape Up America!. Childhood Obesity Assessment Calculator. http://www.shapeup.org
7. Atlantis E. Weight status and perception barriers to healthy physical activity and diet behavior. International Journal of Obesity 2008; 32: 343-352.
8. Maximova A. Do you see what I see? Weight status misperception and exposure to obesity among children and adolescents. International Journal of Obesity 2008; 32: 1008-1015.
9. Xiaojia G. Pubertal Transitions, Perceptions of Being Overweight, and Adolescents' Psychological Maladjustment: Gender and Ethnic Differences. Social Psychology Quarterly 2001; 64: 363-375.
10. Meyer J. Obesity Harassment in School: Simply 'Teasing' Our Way to Unfettered Obesity Discrimination and Stripping Away the Right to Education. Law & Inequality 2005; 23: 429-454.
11. Agras S. Childhood Risk Factors for Thin Body Preoccupation and Social Pressure to Be Thin. American Academy of Child and Adolescent Psychiatry 2007; 2: 171-178.
12. Rollins B. Family Meal Frequency and Weight Status in Young Children. Annals of Epidemiology 2007; 9: 745-745.
13. Britton J. Characteristics of pubertal development in a multi-ethnic population of nine-year-old girls. Annals of Epidemiology 2004; 3: 179-179.
14. Fox News. Athlete Study Exposes Flaw of BMI Obesity Measure. FoxNews.com. http://www.foxnews.com/story/0,2933,149807,00.html.
15. Bacardi-Gascón M. Stigmatization of Overweight Mexican Children. Child Psychiatry and Human Development 2007; 2: 99-105.
16. O’Dea J. Self-concept, Self-esteem and Body Weight in Adolescent Females. Journal of Health Psychology.


Campaign For A Healthier Tomorrow: A Better Intervention For Getting America’s Schoolchildren Back In Shape – Tom Eliopoulos


Introduction

The Biosychosocial model, originally posited by psychiatrist George Engel in 1977, presents a comprehensive approach for tacking issues of health and illness by considering the role biological, psychological, and social factors play in the condition (4). Having established that the ‘BMI report card intervention’ offers a flawed approach with regard to this popular social science model, the next step is to suggest a better program for schools to deal with their concern over students’ risk for childhood and adolescent obesity. The following approach addresses some of the flaws of the current intervention and lays out a three-fold plan for encouraging adolescents to start leading healthier lifestyles. By encouraging proper assessment techniques, individuality, and a culture of exercise within school settings this approach offers a comprehensive program to help today’s youth circumvent some of the negative health outcomes associated with obesity and inactivity.

Rethinking Biological Indicators

BMI is already been established as an incomplete assessment for risk of obesity in children and adolescents (5, 6, 13, 14). It cannot account for muscle mass, and is based solely on height and weight measurements. A more accurate indicator for monitoring this problem is waistline measures or waist-to-hip ratio (17). Studies at Harvard and Tufts Universities both issued reports confirming studies that showed that the size of one’s waist was a better predictor of heart disease and diabetes than BMI (18, 19). This is important because obesity is not what schools are worried about—it is the detrimental health effects of this condition like diabetes and cardiovascular strain that are the matters of concern. Thus, as a better way to monitor these health risks, a better intervention would use waistline measurements rather than BMI as its assessment method and my improved approach proposes just that.

Besides these indicators, an essential part of the biology of healthy living involves the food that people consume. Despite school concern over keeping adolescents from becoming overweight— the ‘BMI report card intervention’ did nothing productive to advance the cause, and served only to monitor it. Numerous studies and articles have detailed the significant role that healthier and more frequent eating behaviors play in maintaining a healthy body and self (24). A better intervention would have schools take a more proactive approach to address their concerns, and re-work school menus to include healthier foods or even replace the three-meal system with one where small snacks are served several times throughout the day.
Controlling for Adolescent Self-Deprecation

Another major flaw of the ‘BMI report card intervention’ was that issuing such reports placed weight-status at the forefront of these children’s consciousness, and as such caused psychological stress and feelings of inferiority from quantitatively comparing themselves to their peers (7, 8, 9, 16). A better intervention would address this problem directly by using a system that emphasizes individuality and goal-setting in its approach. Research has shown that where adolescents believe that they can accomplish the goals set before them, such as ones they set for themselves, that they are more likely to actually achieve them (23). Thus an improved approach would enlist adolescents to meet with a nutritionist hired by their school to develop some realistic fitness goals, a timeframe, and a plan for working towards those goals. Such an approach would instead focus adolescents’ attentions upon their own progress and cause them to evaluate themselves based on their own criteria—de-polarizing the importance of peer-to-peer comparisons and associated psychological stresses.

Further, another concern was that labeling a child as overweight could cause them to misinterpret their weight status compared to their community and put them at risk for eating disorders like anorexia. For an improved intervention strategy, I would suggest incorporating the method of bibliotherapy. Bibliotherapy refers to the use of books to help people understand and solve their problems – weight loss in this case (21). In combining these personalized fitness plans with bibliotherapy, this approach offers a superior intervention with regard to psychological matters. Further, studies have shown that where bibliotherapy is introduced into a bold weight loss program, these people experienced enhanced weight loss results (20). Other research has shown that bibliotherapy is particularly useful for developing an individual's self-concept, fostering an individual's honest self-appraisal, and helping an individual plan a constructive course of action to solve their problems (22). This combined approach offers an all around better alternative to the current intervention in a way that is more sensitive to the psychological well-being of adolescents—one where they learn the facts about leading a healthy lifestyle, set realistic goals as individuals, and work towards them at a self-defined pace.

Bridging Social Divides and Championing Stigmatization

A third major flaw of these schools’ method was that broadcasting BMI scores to parents and adolescents creates an environment that enables harmful social stigmatizations involving weight, SES, and even peer associations (10, 11, 12, 15). Therefore, the third component of my improved approach calls for schools to develop an culture where general healthfulness is encouraged, rather than weight loss, and infuse that mentality into the school’s day-to-day operations. This shift in thought will create a world of difference and will be less taxing on children’s self-esteem because health is a long term goal, and not a number that fluctuates daily (27). This can be accomplished by offering a multitude of opportunities for physical activity throughout the day during study halls, lunch breaks, and before and after school. For example, a teacher may lead a fun-run during a free period or yoga during lunchtime as they do in the BU School of Public Health. It is also important that some non-demanding physical opportunities are offered so that anyone, regardless of weight status, could find an activity that they can enjoy as exercise and that speaks to their particular level of fitness. One study involving HIV-positive Latino men addressed this same approach to stigmatization. The study found that community involvement seems to compensate for the associations between stigma and depression (25). In other words, creating a culture where individuals were more involved in an issue, such as health and exercise culture in schools, seems to have the effect of reducing stigmatizations. Another study found that social support and cohesion, attitude, and perceived behavioral control all influenced the extent to which individuals adhered to exercise plans (26). By designing their own fitness plan and setting realistic goals with the school nutritionist, it is likely that adolescents will perceive themselves as having more control over their behavior. However, with faculty and students coming together to create a network of support and excitement around fitness it is much more likely that these children will stick with their individual fitness plans and accomplish their health goals.

Concluding Remarks

This intervention is superior in that it assesses health using a more appropriate technique focusing on fitness, not weight, and allows adolescents to set their own fitness goals and learn the truth about nutrition to avoid stressful peer-to-self comparisons. It is also superior to the ‘BMI Report Card’ intervention because it attempts to foster a supportive school environment where there are physical activities for students at all fitness levels and the faculty partner with students in these fitness efforts. This comprehensive approach, founded on the social science’s popular Biopsychosocial model for health would be a firm step in the right direction. By keeping our children healthy now and teaching them the skills they need to continue living healthy in the future, Americans may have a fighting chance at curbing the obesity epidemic that has swept our nation by storm.

REFERENCES

1. Department of Health and Human Services. U.S. Obesity Trends 1985-2007. Atlanta, Georgia: Centers for Disease Control and Prevention. http://www.cdc.gov
2. ABC News. The Battle of the Bulge at Schools. Drexel Hill, PA; ABC News. http://abcnews.go.com/Nightline/Story?id=2889317&page=1
3. The New York Times. As Obesity Fight Hits Cafeteria, Many Fear a Note from School. New York, NY: NYTimes.com. http://www.nytimes.com/2007/01/08/health/08obesity.html
4. ConneXions. The Biopsychosocial Model of Health and Illness. http://cnx.org/content/m13589/1.2/
5. Wells J. The Contribution of Fat and Fat-free Tissue to Body mass Index in Contemporary Children and the Reference Child. International Journal of Obesity 2002; 10: 1323-1328.
6. Shape Up America!. Childhood Obesity Assessment Calculator. http://www.shapeup.org
7. Atlantis E. Weight status and perception barriers to healthy physical activity and diet behavior. International Journal of Obesity 2008; 32: 343-352.
8. Maximova A. Do you see what I see? Weight status misperception and exposure to obesity among children and adolescents. International Journal of Obesity 2008; 32: 1008-1015.
9. Xiaojia G. Pubertal Transitions, Perceptions of Being Overweight, and Adolescents' Psychological Maladjustment: Gender and Ethnic Differences. Social Psychology Quarterly 2001; 64: 363-375.
10. Meyer J. Obesity Harassment in School: Simply 'Teasing' Our Way to Unfettered Obesity Discrimination and Stripping Away the Right to Education. Law & Inequality 2005; 23: 429-454.
11. Agras S. Childhood Risk Factors for Thin Body Preoccupation and Social Pressure to Be Thin. American Academy of Child and Adolescent Psychiatry 2007; 2: 171-178.
12. Rollins B. Family Meal Frequency and Weight Status in Young Children. Annals of Epidemiology 2007; 9: 745-745.
13. Britton J. Characteristics of pubertal development in a multi-ethnic population of nine-year-old girls. Annals of Epidemiology 2004; 3: 179-179.
14. Fox News. Athlete Study Exposes Flaw of BMI Obesity Measure. FoxNews.com. http://www.foxnews.com/story/0,2933,149807,00.html
15. Bacardi-Gascón M. Stigmatization of Overweight Mexican Children. Child Psychiatry and Human Development 2007; 2: 99-105.
16. O’Dea J. Self-concept, Self-esteem and Body Weight in Adolescent Females. Journal of Health Psychology 2006; 4: 599-611.

17. Barclay L. Waist Girth Predicts Cardiovascular Risk Better than BMI. MedScape Medical News 2002. http://www.medscape.com/viewarticle/441804
18. Waist better than weight as measure of health risk. Harvard Women’s Health Watch 2003; 5: 1.
19. Waist-to-Hip Ratio Predicts Heart Risk Better than BMI. Tufts University Health & Nutrition Letter 2006; 11: 1-2.
20. Klem M. Competition in a minimal-contact weight-loss program. Journal of Consulting and Clinical Psychology 1988; 1: 142-144.
21. Holistic Online. Depression: Bibliotherapy. HolisticOnline.com. http://www.holisticonline.com/remedies/Depression/dep_bibliotherapy.htm
22. Aiex N. Bibliotherapy. ERIC Clearinghouse on Reading, English, and Communication Digest 2003; 83.
23. Lambert M. Positive psychology and the humanistic tradition. Journal of Psychotherapy Integration 2008; 18: 222-232.
24. Neumann K. Reach your Feel Great Weight!. Health 2008; 4: 108-115.
25. Valles J. Confronting Stigma: Community Involvement and Psychological Well-Being Among HIV-Positive Latino Gay Men. Hispanic Journal of Behavioral Sciences 2005; 1: 101-109.
26. Courneya K. Cognitive mediators of the social influence-exercise adherence relationship: A test of the theory of planned behavior. Journal of Behavioral Medicine 1995; 5: 499-515.
27. Tiggemann M. The Effect of Exercise on Body Satisfaction and Self-Esteem as a Function of Gender and Age. Sex Roles 2000; 1-2: 119-127.

Why Teen Pregnancy Interventions Fail- Kari Cheng

Since 1991, the federal government and community organizations such as the National Campaign and Planned Parenthood have made similar efforts to prevent teen pregnancy. The main focus of these efforts is educating teens about contraceptives, promoting abstinence, and providing media messages that help raise teen awareness of the issue. As a result, the teen pregnancy rate has continued on a downward trend for more than a decade (1). However, despite these successful campaigns, teens account for about 80% of the approximately 3 million unplanned pregnancies annually (2). Furthermore, the National Center for Health Statistics reported in 2006 that the 14-year decline in the U.S. teen birth rate has reversed, and both the number of births to teens and the teen birth rate have risen (1). Although the teen birth rate grew only 3% between 2005 and 2006, experts are expressing reasonable concerns that the teen pregnancy rate will continue to increase in the upcoming years (1).

The tools that social organizations utilize (contraceptive education, media messages, and abstinence promotion) fall short of expectations, and this is likely due to the inappropriate application of the Social Cognitive Model in their intervention designs. Repeatedly, the concepts of self-efficacy and reciprocal determinism are under-addressed in many of the teen pregnancy prevention advertisements and education programs.

Social Cognitive Theory (SCT) explains that a behavior is constructed from the intricate interactions of an individual’s internal
world (self-efficacy), environmental influences (external factors), and interactive processes with others (reciprocal determinism) (3-5). Self-efficacy is an individual’s confidence and ability to overcome obstacles in order to pursue the behavior of interest (3-5). The level of self-efficacy can be influenced by factors such as the individual’s past experience in trying to accomplish the desired behavior, social persuasion, stress, and learning experiences (5). The more an individual believes in his or her ability to achieve a desired behavior, the more likely it is that it will be accomplished (3-4). The external environment, which includes both physical and social factors surrounding an individual, is important during the construction of the behavior, according to SCT, because during this process, individuals observe “rewarding” behaviors to learn or “emulate,” and “vicarious learning” takes place (4-5). Finally, a behavior is also heavily influenced by the reactions of the people with whom the individual interacts (3). Therefore, interventions fall short of expectations because organizations overemphasize the external learning factor of the SCT while undermining the importance of self-efficacy and reciprocal determinism.

Teen Pregnancy Interventions Put Too Much Emphasis on “Vicarious Learning”

When people shape their behavior by observing and emulating others in the environment (via positive or negative reinforcements), they are experiencing vicarious learning. Most of the teen pregnancy interventions are attempts to address the behavior as socially “rewarding” or socially “unacceptable.” For example, many abstinence campaigns employ famous and well liked celebrities, like winners of the Miss America pageant and Britney Spears, who take the abstinence pledge to set an example for teens and show them that abstinence is something “rewarding” to do (6). Conversely, abstinence campaigns may also have slogans that imply that sex prior to marriage has serious and unwanted consequences. For example, in 2007, the statewide Washington abstinence campaign slogan was ‘No Sex. No Problems” (7). Similar techniques are also used in contraceptive promotion advertisements. For example, the famous Zazoo commercial that was first aired in 2006 showed a wild, uncontrollable child creating an uproar in a supermarket and a meek, young father who simply did not know what to do about the situation. It ended with the message, “Use the condom” (8). The message was that having sex without contraceptives can bring results that are more than one can handle. A majority of the teen pregnancy interventions are structured in this way, with slogans and images trying to either encourage the good behavior (abstinence) or deter bad behaviors (sex without condoms). However, none of these interventions consider the importance of self-efficacy or reciprocal determinism, which may be especially relevant for interventions involving intimate relationships. Interventions devoid of these key components fail to value obstacles, such as an individual’s finances or power differences between the woman and the significant other that may deter individuals from accomplishing the desired behavior and understanding the consequences of having unprotected sex.

Teen Pregnancy Interventions Fail to Address Social Factors that May Lower Self-Efficacy

Studies have shown that the recent changes in public policies and mixed media messages may have provided additional barriers and kept teens from adhering to the desirable behavior (lowered self-efficacy). For example, starting in 2005, governmental funding for contraceptives or emergency contraceptives for teens has been falling. This decrease may put a higher financial burden on young teens and keep them from adhering to the desirable behavior (1). They may decide to have unprotected sex because they cannot afford condoms or pills on a long-term basis. Furthermore, the advertisements for “emergency contraception pills” may send a mixed message to teens: “If you messed up, it’s okay. You can just take a pill to fix it.” A recent randomized, controlled trial comparing the impact of direct access to emergency contraception through pharmacies and unintended pregnancies found that women are more likely to be negligent in engaging in unprotected sex when they know emergency contraceptives are an option (9). Other under-addressed self-efficacy issues are related to culture and language. One of the factors related to the recent increase in unprotected sex is large immigrant populations (1). While many of the teen pregnancy interventions provide powerful messages on educational Web sites, few are multi-lingual. If an immigrant does not speak English, it may be very difficult for her to comprehend the consequences of engaging in unprotected sex, and she may not be aware of resources for help. This may increase her sense of “helplessness.” She may feel that no one is there to explain available resources in the community, and there may be no counseling services to help with her emotional needs.

Therefore, additional approaches addressing the empowerment of teens and help them to think responsibly or boost their self-confidence are highly desirable if we want to help teens adhere to the desirable behavior (abstain from sex or use contraceptives when engaging in sexual behavior). Unfortunately, there are very few intervention slogans that focus on teen self confidence and empowerment. To make matters worse, many teen pregnancy campaigns target teen fears by sending a message that by acting irresponsibly, they will become social outcasts or undergo extreme stress. A recent UK anti-teen pregnancy campaign displays images of teen mothers who are social outcasts with nowhere to go and no one to help them. In addition, this commercial also shows that these young mothers are “frightened” and simply “helpless” (11). Although this commercial sends a powerful message, it may backfire, since “fear” may not deter teens from irresponsible sexual activities. Commercials like this one are telling teens that they will be “helpless.” Even though resources like Planned Parenthood are available to help teens through difficult situations, they may not bother to try to seek out help, believing the message in campaigns like the one detailed above.


Teen Pregnancy Interventions Failed to Address the Power Relationship

Most of the interventions focus on women and their emotions and the social consequences they will face if they are pregnant. However, very little study has been dedicated to understanding the behaviors of the men that lead to unplanned pregnancy. Statistics shows that 6 in 10 babies fathered by teen boys age 18-19 are unplanned and 52% of babies fathered by men between the ages of 20-24 are unplanned. Furthermore, Latino men between the ages of 15-44 are most likely to have unplanned children. Additionally, about one half of unmarried men under 24 do not use condoms while engaging in sexual activities (10). These statistics simply show that teen pregnancy interventions are ineffective in reaching males. These statistics also suggest that teen pregnancy interventions are only as effective as the number of males who follow the instructions. We must take into account the reciprocal determinism in interactions between the partners and recognize the power differences between men and women in a relationship. Oftentimes, women cave in to the desires of their male partners due to the power differences between them the power difference is especially clear when men are the financial providers, older, or have more social power than the female partner (12-14). Thus, in these inherently imbalanced relationships, most women do not want to offend or disappoint their partners. So far, none of the teen pregnancy interventions address the issue of teaching women to say “no” to unprotected sex or how to counter power differences. Power differentials in a relationship are more visibly portrayed in the anti-domestic violence campaigns, where oftentimes the messages are “say no” or “seek help” (13-14). Ironically, these are the types of messages that should be incorporated in the anti-teen pregnancy interventions. Providing teens with information about the consequences of sexual behaviors (babies, STDs) and the knowledge about where to access contraceptives is simply not enough. These tools need to be integrated successfully in the communications between two people in order for the messages to work.

Currently, most of the teen pregnancy campaigns focus on changing women’s behaviors. However, some messages should appeal to men. This is true because men have the power to convince their female partners to change their behaviors. After all, educating the less powerful side to convince the more powerful party to change a behavior is obviously not as effective as educating the powerful party to accept a behavioral change.

When considering powerful slogans to promote desirable behaviors, all components of SCT are equally important to the success of an intervention and should be addressed in equal proportions. Underweighting the importance of some aspects of the theory may reduce the overall effectiveness of the model. Interventions will not be successful when we fail to see that self-efficacy and power differentials in a relationship are also powerful characteristics that need to be considered in order for our interventions to work. We may have failed because even though we understand that teens change their behaviors by observing and emulating environmental models, we did not boost their confidence to achieve the behaviors (self-efficacy), or we targeted our interventions to the wrong population (should focus on behaviors of teen boys instead of teen girls). The results are, of course, compromised and diminished.

References
1. National Center for Health Statistics: Birth/Natality. http://www.cdc.gov/nchs/births.htm.
2. Proportion of All pregnancies that are Unplanned by Various Socio-Demographics, 2001. TheNationalCampaign.org. Visited: November 18, 2008.
3. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
4. Salazar MK. Comparison of four behavioral models. AAOHN. 1991; 39:128-135.
5. Bandura A. the self system in reciprocal determinism. Am Psychol. 1978; 33: 344-358.
6. How effective are abstinence pledges. News.bbc.co.uk. November 18, 2008.
7. Statewide abstinence campaign tells youth "No Sex. No Problems." http://www.doh.wa.gov/Publicat/2007_news/07-089.htm visited: November 18, 2008.
8. Zazoo condoms. http://www.zazoocondoms.com/
9. Raine TR, Harper CC, Rocca CH. Direct Access to Emergency Contraception Through Pharmacies and Effect on Unintended Pregnancy and STIs: a Randomized Controlled Trial. Jama. 2005; 293(1): 54-62.
10. Martinez GM, Chandra A, Abma JC, Jones J, and Mosher WD. Fertility, Contraception and Fatherhood: Data on Men and Women from Cycle 6 (2002) of the National Survey of Family Growth. National Center for health Statistics. Vital Health Stat; 23 (26).
11. Think about it. Think Contraception. http://www.thinkcontraception.ie/
12. Cleary BS, Keniston A. Havranek EP. Albert RK. Intimate partner violence in women hospitalized on an internal medicine service: prevalence and relationship to responses to the review of systems. Journal of Hospital Medicine. 2008; 3(4):299-307.
13. Antai DE, Antai JB. Attitudes of women toward intimate partner violence: a study of rural women in Nigeria. Rural & Remote Health. 2008; (3):996.


Teen Pregnancy Intervention Revisited: An Intervention That Works

Background
Since 1991, despite the combined efforts of both public and private institutions in lowering teen pregnancy, teen pregnancy still accounts for approximately 80% of the 3 million unplanned pregnancies annually (1). The failure of appropriately applying the principles of social cognitive theory is likely to be responsible for the inefficacies in many of the currently available interventions.

Social cognitive theory (SCT) explains that a behavior is constructed from the interactions of an individual’s internal world (self-efficacy), environmental influences (external factors, both physical and social), and interactive processes with others (reciprocal determinism) (2-4). These three primary components (self-efficacy, external factors, and reciprocal determinism) are often under addressed in teen pregnancy prevention campaigns, rendering them ineffective. The failures of currently available interventions call for a new effective intervention.

New Intervention
Old interventions have failed to account for factors in the following three areas: a) the overemphasis on promoting “vicarious learning” in teen pregnancy intervention campaign messages, b) the under evaluation of the physical environmental barriers to adherence of the targeted behavior, and c) the lack of focus in addressing both an individual’s self-confidence and his or her relationship to intimate partners. This new intervention proposes to increase the effectiveness of such interventions by coupling the fundamental underlying framework (SCT) with other theories in each of the problematic areas. The new intervention will be devised as follows. First, social marketing theory will be used to promote the desirable behavior. The desirable behavior (using condoms or abstinence) will be “dressed” up to encourage adolescents to emulate this behavior afterward, instead of using ineffective and bland campaign messages. Second, this new intervention will incorporate community mobilization theory to “mobilize” the available community resources to crack down on barriers that keep adolescents from adhering to the wanted behavior. The primary target of this focus is to provide adolescents with easy and increased access to the necessary contraceptives or emotional support. Finally, this intervention will use anthropology and social marketing theory to investigate both the individual’s self-efficacy and his or her relationships with partners in “context.” This approach aims to train the available support system (e.g., parents and counselors) to better associate with adolescents and their behavior norms depending on their social environment (social economic status, racial disparities, etc.) and attempt to encourage more males to practice safe sex with their partners.

Hence, this new intervention will be community based (since different communities have different compositions of needs, resources, income brackets, and ethnicities) and will utilize attractive advertisements via TV, radio, posters and pamphlets. In addition, it will mobilize the community to push for increased provisions of low-cost contraceptives and introduce local or mobile STD clinics that provide contraceptives, counseling, and testing services. Such services would involve training more culturally aware counselors from the community to convince male partners to practice safe sex and support adolescent women’s feeling empowered.

The arguments for the design of the intervention are further explained in the following sections:

A. Use social marketing theory in campaign advertisements: tailor the targeted behavior as desirable to the population

As the modern community becomes more diverse and interests are becoming more heterogeneous, implementing campaign slogans and employing “role models” who can uniformly reach all adolescents have become less effective (6,7). In dealing with fragmented adolescent populations, targeting them one community at a time may be a preferred strategy (6). Additionally, bare-bones campaign messages are rarely effective among adolescents; for example, the 2007 statewide Washington abstinence campaign slogan was “No Sex. No Problems,” which did not persuade a substantial number of adolescents to practice abstinence (8). Such slogans do not suggest an “attractive” behavior or target self-efficacy. Thus, applying the social marketing theory in campaign advertisements may seem a more suitable and effective strategy when attempting to sway adolescents. The social marketing theory is a specific approach that utilizes marketing principles to promote and generate changes in social behavior (9).

The theory consists of four components: product, price, place, and promotion (9). “Product” refers to the benefits that are associated with a desired behavior, which can change as the values of the target population change (9, 10, and 11). This means that the “product” or “desirable behavior” can be “dressed-up” and redefined as the adolescent’s definition of “cool” changes. “Price” refers to the physical or social cost or the sacrifice that is exchanged for a promised benefit within the target population (9). For example, an adolescent girl who wants to practice abstinence may have to face the social cost of dealing with pressure from her partner (11). “Place” refers to the issues of access and availability, such as the ways in which a certain behavior or product is distributed to the target population (9). For example, condoms would be placed in all convenience stores for easy accessibility for last-minute use (9). “Promotion” refers to strategies that are used to advertise, promote, and persuade a target population to “buy” or exchange its resources for the product (9). Through these four components, social marketing aims to increase the acceptability of a practice (desired behavior) among adolescents with the help of media to promote a product, idea, or attitude and assumes that the adolescents have unique attitudes and behaviors that are based on their own personal experiences (11). To support the claim that social marketing theory may be helpful in convincing adolescents to use contraceptives, a study has shown that adolescents are not likely to engage in safe sex practices unless they believe that the practice possesses “meaning” (12). Further, in the National Strategy Report, incorporating attractive messages using social marketing theory is highly recommended and proved successful in anti-teen pregnancy campaigns (7). Using social marketing strategy in media campaign messages is also adopted by various social organizations, such as Teen Pregnancy Prevention & Partnership and APAUSE (13, 14).

B. Incorporate community mobilization theory to “mobilize” the available community resources to crack down on barriers that keep adolescents from adhering to the wanted behavior

Since SCT theory failed to address many physical barriers for adolescents, such as having easy access to contraceptives or counseling services, more organized community-based efforts are needed to lower those barriers. Typically, the two primary environmental factors that prevent adolescents from adhering to safe sex practices are financial and local barriers to contraceptives or support. For instance, since 2005, governmental funding for contraceptives for adolescents has been falling (1, 15). This decrease may put a higher financial burden on younger adolescents and keep them from adhering to the desirable behavior (1, 15). Or the barriers can occur from the resources and culture of their communities. Adolescents of some communities may have to travel far to gain access to condoms. Additionally, some communities may not have convenient stores that stay open late, which may also serve as a deterrent for adolescents to practice safe sex. Thus, a community effort should push for late-hour licensing for some of the local convenience stores and encourage more funding for contraceptives or mobile clinics that provide condoms and STD testing services. Community actions involve the collective actions of community groups to increase awareness about the problem (16). Some successful and visible campaigns using such strategies include anti-alcoholism and anti-abortion movements (17, 18). In order to launch a successful community mobilization movement, one should first have a clear understanding of what type of community it is (Is it conservative or liberal? Does it have few or many resources?), choose the most feasible strategy to promote the agenda (e.g., create a budget for mobile clinics, extend stores’ hours, or apply for more funding), and gather information on powerful advocacy groups that can help strengthen the claim (15-18). For example, the Amherst Association for Healthy Adolescent Sexuality (AAHAS) is a grassroots community organization created in response to community concerns about adolescents’ sexual behavior and high pregnancy rates (19). This organization has been successful in promoting safe sex by incorporating local post-bachelor students to serve as community counselors and maintaining good relationships with local community board members. As such, frequent interactions were promoted between local parents and the organization via social meetings to sustain the empathy for “community feelings” and to involve everyone as part of the anti-teen pregnancy work. The AAHAS has been highly successful since its establishment (19).

C. Apply anthropology theory to create a nurturing counseling environment to help adolescents feel more empowered and address power differentials in relationships

Finally, many of the interventions fail to address the self-efficacy and reciprocal determinism components of the SCT. One way to help strengthen the application of this aspect is to combine anthropological and social marketing theories to help public health promoters stay focused on the issue. Cultural anthropology understands and explains health behavior as part of a pattern of living that integrates action with meanings, symbols, and values connected to a larger social structure (20, 21). It sees the behavior in context of the larger social context (20, 21). Therefore, to train and provide counselors from their own communities with sufficient understanding of the community’s background and structure, one can target an individual’s needs more successfully than a counselor that goes by the book. Both self-efficacy and reciprocal determinism target the internal and external influences on an individual. One focuses on an individual’s confidence when engaging in an activity, while the other explains how outside social influences can impact the individual’s behavior. The anthropology approach focuses on the social context that shapes an individual and their behaviors, which would include what structures their internal values and who has the most powerful influence on the individual. For example, if an adolescent is feeling helpless because of his or her race or social economic status, meeting with a counselor from a similar background who has experienced similar ideologies and values and has had a similar neighborhood experience would be much more empowering for that adolescent. Likewise, the anthropology approach can be enhanced by social marketing theory by applying it to the local boys to encourage them to practice safe sex. If an intervention can successfully induce adolescent boys to practice safe sex, adolescent girls will experience less reciprocal determinism (6).

In conclusion, although some components of the SCT may be difficult to apply, we can create interventions that combine other frameworks targeting each shortcoming to better address our public health problem. We should know that an effective strategy comes from a careful assessment of the culture, social, and environmental context of a community and tries to target our population and their behaviors within the context of that community. If we can first understand their cultural context, we can design a program incorporating the necessary frameworks and devise the most effective intervention.


References

1. National Center for Health Statistics: Birth/Natality. http://www.cdc.gov/nchs/births.htm.
2. Proportion of All pregnancies that are Unplanned by Various Socio-Demographics, 2001. TheNationalCampaign.org. Visited: November 18, 2008.
3. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
4. Salazar MK. Comparison of four behavioral models. AAOHN. 1991; 39:128-135.
5. Bandura A. the self system in reciprocal determinism. Am Psychol. 1978; 33: 344-358.
6. A National Strategy to Prevent Teen Pregnancy. US Department of Health Services. http://aspe.hhs.gov/hsp/teenp/ann-rpt00/
7. Kotler P, Roberto EL. Social Marketing strategies for changing Public Behavior. New York: Free Press; 1989
8. Statewide abstinence campaign tells youth "No Sex. No Problems." http://www.doh.wa.gov/Publicat/2007_news/07-089.htm visited: November 18, 2008.
9. Grier S, Bryant CA. Social Marketing in Public Health. Annu. Rev. Public Health. 2005; 26:319-39.
10. Kotler P. Marketing for Non-Profit Organizations. Englewood Cliffs, NJ: Prentice-Hall; 1975.
11. Walsh D, Champman Rudd RE, TW Maloney. Social Marketing for Public Health. Health Affairs. 1993. (summer); 104-119.
12. Koniak-Griffin D. Lesser J. Uman G. Nyamathi A. Teen pregnancy, motherhood, and unprotected sexual activity. Research in Nursing & Health. 26(1):4-19, 2003 Feb.
13. Teen Pregnancy Prevention and Partnership. http://www.teenpregnancy-stl.org/
14. Added Power and Understanding in Sex Education. http://www.apause.com
15. Martinez GM, Chandra A, Abma JC, Jones J, and Mosher WD. Fertility, Contraception and Fatherhood: Data on Men and Women from Cycle 6 (2002) of the National Survey of Family Growth. National Center for health Statistics. Vital Health Stat; 23 (26).
16. Beyer JM, Trice HM. Implementing Change: Alcoholism Policies in Work Organizations. New York: Free Press; 1978
17. Steckler A, Goodman RM, Kogler MC. Mobilizing organizations for health enhancement: theories of organizational change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Research and Practice, 3rd ed. San Francisco, CA: Jossey-Bass; 2002.
18. Fullerton JT, Killian R, Gass PM. Outcomes of a community and home based intervention for safe motherhood and newborn care. Health Care Women Int. 2005; 26(7): 561—567
19. Joffres H, Langille D, Rigby J and Langille DB. Factors Related to Community Mobilization and Continued Involvement in a Community-Based Effort To Enhance Adolescents' Sexual Behaviour. The Qualitative Report. 2002; 7 (2).
20. Hahn, RA. Anthropology in Public Health: Bridging Differences in Culture and Society. New York: Oxford University Press. 1999.
21. Singer M. AIDS and the health crisis of the US urban poor: the perspective of critical medical anthropology. Soc Sci Med. 1994; 39(7) 931-948.

Appendix
Essay 3
Why Teen Pregnancy Interventions Fail

Since 1991, the federal government and community organizations such as the National Campaign and Planned Parenthood have made similar efforts to prevent teen pregnancy. The main focus of these efforts is educating teens about contraceptives, promoting abstinence, and providing media messages that help raise teen awareness of the issue. As a result, the teen pregnancy rate has continued on a downward trend for more than a decade (1). However, despite these successful campaigns, teens account for about 80% of the approximately 3 million unplanned pregnancies annually (2). Furthermore, the National Center for Health Statistics reported in 2006 that the 14-year decline in the U.S. teen birth rate has reversed, and both the number of births to teens and the teen birth rate have risen (1). Although the teen birth rate grew only 3% between 2005 and 2006, experts are expressing reasonable concerns that the teen pregnancy rate will continue to increase in the upcoming years (1).
The tools that social organizations utilize (contraceptive education, media messages, and abstinence promotion) fall short of expectations, and this is likely due to the inappropriate application of the Social Cognitive Model in their intervention designs. Repeatedly, the concepts of self-efficacy and reciprocal determinism are under-addressed in many of the teen pregnancy prevention advertisements and education programs.
Social Cognitive Theory (SCT) explains that a behavior is constructed from the intricate interactions of an individual’s internal world (self-efficacy), environmental influences (external factors), and interactive processes with others (reciprocal determinism) (3-5). Self-efficacy is an individual’s confidence and ability to overcome obstacles in order to pursue the behavior of interest (3-5). The level of self-efficacy can be influenced by factors such as the individual’s past experience in trying to accomplish the desired behavior, social persuasion, stress, and learning experiences (5). The more an individual believes in his or her ability to achieve a desired behavior, the more likely it is that it will be accomplished (3-4). The external environment, which includes both physical and social factors surrounding an individual, is important during the construction of the behavior, according to SCT, because during this process, individuals observe “rewarding” behaviors to learn or “emulate,” and “vicarious learning” takes place (4-5). Finally, a behavior is also heavily influenced by the reactions of the people with whom the individual interacts (3). Therefore, interventions fall short of expectations because organizations overemphasize the external learning factor of the SCT while undermining the importance of self-efficacy and reciprocal determinism.
Teen Pregnancy Interventions Put Too Much Emphasis on “Vicarious Learning”
When people shape their behavior by observing and emulating others in the environment (via positive or negative reinforcements), they are experiencing vicarious learning. Most of the teen pregnancy interventions are attempts to address the behavior as socially “rewarding” or socially “unacceptable.” For example, many abstinence campaigns employ famous and well liked celebrities, like winners of the Miss America pageant and Britney Spears, who take the abstinence pledge to set an example for teens and show them that abstinence is something “rewarding” to do (6). Conversely, abstinence campaigns may also have slogans that imply that sex prior to marriage has serious and unwanted consequences. For example, in 2007, the statewide Washington abstinence campaign slogan was ‘No Sex. No Problems” (7). Similar techniques are also used in contraceptive promotion advertisements. For example, the famous Zazoo commercial that was first aired in 2006 showed a wild, uncontrollable child creating an uproar in a supermarket and a meek, young father who simply did not know what to do about the situation. It ended with the message, “Use the condom” (8). The message was that having sex without contraceptives can bring results that are more than one can handle. A majority of the teen pregnancy interventions are structured in this way, with slogans and images trying to either encourage the good behavior (abstinence) or deter bad behaviors (sex without condoms). However, none of these interventions consider the importance of self-efficacy or reciprocal determinism, which may be especially relevant for interventions involving intimate relationships. Interventions devoid of these key components fail to value obstacles, such as an individual’s finances or power differences between the woman and the significant other that may deter individuals from accomplishing the desired behavior and understanding the consequences of having unprotected sex.
Teen Pregnancy Interventions Fail to Address Social Factors that May Lower Self-Efficacy
Studies have shown that the recent changes in public policies and mixed media messages may have provided additional barriers and kept teens from adhering to the desirable behavior (lowered self-efficacy). For example, starting in 2005, governmental funding for contraceptives or emergency contraceptives for teens has been falling. This decrease may put a higher financial burden on young teens and keep them from adhering to the desirable behavior (1). They may decide to have unprotected sex because they cannot afford condoms or pills on a long-term basis. Furthermore, the advertisements for “emergency contraception pills” may send a mixed message to teens: “If you messed up, it’s okay. You can just take a pill to fix it.” A recent randomized, controlled trial comparing the impact of direct access to emergency contraception through pharmacies and unintended pregnancies found that women are more likely to be negligent in engaging in unprotected sex when they know emergency contraceptives are an option (9). Other under-addressed self-efficacy issues are related to culture and language. One of the factors related to the recent increase in unprotected sex is large immigrant populations (1). While many of the teen pregnancy interventions provide powerful messages on educational Web sites, few are multi-lingual. If an immigrant does not speak English, it may be very difficult for her to comprehend the consequences of engaging in unprotected sex, and she may not be aware of resources for help. This may increase her sense of “helplessness.” She may feel that no one is there to explain available resources in the community, and there may be no counseling services to help with her emotional needs.
Therefore, additional approaches addressing the empowerment of teens and help them to think responsibly or boost their self-confidence are highly desirable if we want to help teens adhere to the desirable behavior (abstain from sex or use contraceptives when engaging in sexual behavior). Unfortunately, there are very few intervention slogans that focus on teen self confidence and empowerment. To make matters worse, many teen pregnancy campaigns target teen fears by sending a message that by acting irresponsibly, they will become social outcasts or undergo extreme stress. A recent UK anti-teen pregnancy campaign displays images of teen mothers who are social outcasts with nowhere to go and no one to help them. In addition, this commercial also shows that these young mothers are “frightened” and simply “helpless” (11). Although this commercial sends a powerful message, it may backfire, since “fear” may not deter teens from irresponsible sexual activities. Commercials like this one are telling teens that they will be “helpless.” Even though resources like Planned Parenthood are available to help teens through difficult situations, they may not bother to try to seek out help, believing the message in campaigns like the one detailed above.


Teen Pregnancy Interventions Failed to Address the Power Relationship
Most of the interventions focus on women and their emotions and the social consequences they will face if they are pregnant. However, very little study has been dedicated to understanding the behaviors of the men that lead to unplanned pregnancy. Statistics shows that 6 in 10 babies fathered by teen boys age 18-19 are unplanned and 52% of babies fathered by men between the ages of 20-24 are unplanned. Furthermore, Latino men between the ages of 15-44 are most likely to have unplanned children. Additionally, about one half of unmarried men under 24 do not use condoms while engaging in sexual activities (10). These statistics simply show that teen pregnancy interventions are ineffective in reaching males. These statistics also suggest that teen pregnancy interventions are only as effective as the number of males who follow the instructions. We must take into account the reciprocal determinism in interactions between the partners and recognize the power differences between men and women in a relationship. Oftentimes, women cave in to the desires of their male partners due to the power differences between them the power difference is especially clear when men are the financial providers, older, or have more social power than the female partner (12-14). Thus, in these inherently imbalanced relationships, most women do not want to offend or disappoint their partners. So far, none of the teen pregnancy interventions address the issue of teaching women to say “no” to unprotected sex or how to counter power differences. Power differentials in a relationship are more visibly portrayed in the anti-domestic violence campaigns, where oftentimes the messages are “say no” or “seek help” (13-14). Ironically, these are the types of messages that should be incorporated in the anti-teen pregnancy interventions. Providing teens with information about the consequences of sexual behaviors (babies, STDs) and the knowledge about where to access contraceptives is simply not enough. These tools need to be integrated successfully in the communications between two people in order for the messages to work.
Currently, most of the teen pregnancy campaigns focus on changing women’s behaviors. However, some messages should appeal to men. This is true because men have the power to convince their female partners to change their behaviors. After all, educating the less powerful side to convince the more powerful party to change a behavior is obviously not as effective as educating the powerful party to accept a behavioral change.
When considering powerful slogans to promote desirable behaviors, all components of SCT are equally important to the success of an intervention and should be addressed in equal proportions. Underweighting the importance of some aspects of the theory may reduce the overall effectiveness of the model. Interventions will not be successful when we fail to see that self-efficacy and power differentials in a relationship are also powerful characteristics that need to be considered in order for our interventions to work. We may have failed because even though we understand that teens change their behaviors by observing and emulating environmental models, we did not boost their confidence to achieve the behaviors (self-efficacy), or we targeted our interventions to the wrong population (should focus on behaviors of teen boys instead of teen girls). The results are, of course, compromised and diminished.

Reference
1. National Center for Health Statistics: Birth/Natality. http://www.cdc.gov/nchs/births.htm.
2. Proportion of All pregnancies that are Unplanned by Various Socio-Demographics, 2001. TheNationalCampaign.org. Visited: November 18, 2008.
3. Bandura A. Social Learning Theory. New York: General Learning Press, 1977.
4. Salazar MK. Comparison of four behavioral models. AAOHN. 1991; 39:128-135.
5. Bandura A. the self system in reciprocal determinism. Am Psychol. 1978; 33: 344-358.
6. How effective are abstinence pledges. News.bbc.co.uk. November 18, 2008.
7. Statewide abstinence campaign tells youth "No Sex. No Problems." http://www.doh.wa.gov/Publicat/2007_news/07-089.htm visited: November 18, 2008.
8. Zazoo condoms. http://www.zazoocondoms.com/
9. Raine TR, Harper CC, Rocca CH. Direct Access to Emergency Contraception Through Pharmacies and Effect on Unintended Pregnancy and STIs: a Randomized Controlled Trial. Jama. 2005; 293(1): 54-62.
10. Martinez GM, Chandra A, Abma JC, Jones J, and Mosher WD. Fertility, Contraception and Fatherhood: Data on Men and Women from Cycle 6 (2002) of the National Survey of Family Growth. National Center for health Statistics. Vital Health Stat; 23 (26).
11. Think about it. Think Contraception. http://www.thinkcontraception.ie/
12. Cleary BS, Keniston A. Havranek EP. Albert RK. Intimate partner violence in women hospitalized on an internal medicine service: prevalence and relationship to responses to the review of systems. Journal of Hospital Medicine. 2008; 3(4):299-307.
13. Antai DE, Antai JB. Attitudes of women toward intimate partner violence: a study of rural women in Nigeria. Rural & Remote Health. 2008; (3):996.

One Finger Points, Three Point Back- Sarah M. Ragsdale

An estimated 6-percent of middle-aged men abuse alcohol – nearly four times greater than women and twice the rates of just one decade prior (37, 38). Due to the social, economic and physical effects of alcohol abuse, the public health community must improve its strategies to reduce the prevalence of alcohol abuse among all populations. Specifically, many criticisms of the public health community’s strategies to reduce alcohol consumption among middle-aged men are presented. The public health community has failed to adequately measure the problem, study the populations at-risk and intervene effectively. Population stigmatization and confusion result from the individualistic approaches to interventions among middle-aged men.


Failure to Measure

The first major limitation of the public health community’s approach to address the problem of alcohol abuse exists in the existing definitive measures of the problem. The problem of alcohol abuse is largely defined in terms of overall consumption and other quantitative measures. Healthy People 2010 “set the national objective for reducing per capita alcohol consumption to no more than 1.96 gallons ethanol, … a decrease of 12.5 percent, or about 3 percent per year from 2006 through 2010” (1). It is problematic to measure alcohol abuse by per-capita consumption or overall deaths by alcohol-related diseases because population-level measures do not allow for the detections of “subtle and complicated relationships,” which can lead to underreporting (2 p. 163); therefore, requiring flawed individual assessments.

Addressing the first point, when alcohol epidemiologists measure alcohol in the aggregate of per-capita consumption or deaths by cirrhosis of the liver, only correlation, not causality, can be inferred. Relying on the “three primary sources” of alcohol data (death certificate data, the Fatal Accident Reporting System, and the National Hospital Discharge Survey) limits understanding of the problem (3). Although defined as objective, data from death certificates present inherent flaws as “sympathetic certifiers” of the cause of death may enter non-alcohol-related codes to protect the individual’s reputation (3). This often leads to underestimates of the problem’s true prevalence in all populations.

Due to the limitations of data collected in terms of overall consumption or deaths, additional individual-level data must be collected to understand possible relationships. Of six national surveillance studies sponsored by the Centers for Disease Control (CDC), all assess only volume consumed in a given time frame (5). This is problematic because, again, alcohol consumption measurements are often in terms difficult for all consumers to relate and self-quantify. Using a graduated frequency scale of mean consumption per day, week or month proves to be less effective than other approaches, which impacts accuracy of reports (6). The primary method for data collection is what the National Institute of Alcohol Abuse and Alcoholism (NIAAA) sadly describes as the “newer and improved” approach of self-reported questionnaires. These flawed assessments further contribute to the failure to definitively measure alcohol abuse. Surveys, in their effort to quantify the problem, are often skewed by limited sample sizes, increased margins of error, failures to properly sample minority populations, underestimate consumption and under-sample heavy drinkers (3). Marks discusses the problem of “inappropriateness in framing the questions” (4, p. 15) as yet another threat to the study of this public health problem.

Failure to Study the Population

Not only has the public health community failed to develop definitive measures of the problem of alcohol abuse, it has failed to study the root causes of the problem among populations, including middle-aged men. This failure results from the reliance on quantitative and biomedical models to study treatment and prevention, virtually ignoring possible qualitative and social science approaches.

According to the NIAAA’s suggestions for improving treatment and prevention in the middle-aged population, new research opportunities should focus on developing new medications for craving control and organ injury prevention (8). They note most research on the topic has “focused on how alcohol damages body tissues,” and they secondarily note “research shows that a variety of factors—both biological and social— influence an individual’s response to therapy” (8). Focusing greater attention on biologic factors over social factors in research presents the missed opportunity to employ the social sciences (8).

The NIAAA discusses the overlook of social science methods in its strategic plan by outlining the need to “identify biological factors and contextual social factors that contribute to the decisional process to change drinking behavior as part of the transitional process from alcohol dependence to recovery” and “increase understanding of the role of social context in promoting positive change in drinking behavior” (9). Although this suggestion is slightly better, it still does not address primary prevention as it incorporates social science techniques in response to relapse alone. The NIAAA also notes “naturalistic, qualitative and longitudinal studies can identify factors influencing natural history and disease course, in order to inform more explanatory studies” (9). The idea of contextualizing risk factors is supported by Link, et al when they advocate for a shift in the assessment of public health problems as “social factors have received far less attention” and suggest “fundamental causes” and “social patterning” of disease (10, p. 80).

According to Marks, “health is a “multivariate construct that lends itself to interdisciplinary approach” (4, p. 10) therefore, understanding alcohol abuse from a social perspective, allows for more effective study of target populations particularly. The NIAAA “recognizes the need to support research that focuses on client populations as well as research on the aggregate population” (11). Doing so, according to the NIAAA, “could provide meaningful insight to guide the development of more effective strategies to change individual behavior to improve health” (11). However, when studying specific populations, alcohol researchers have focused much effort on underage drinking and college student drinking patterns, making the middle-aged population much less of a priority (34). The reasons for this are complex. It appears the public health community views alcohol abuse as a socially and environmentally modifiable “risky behavior” during youth (9); however, when the population ages, it is seen as chronic or genetic - only modifiable by drug treatment and therapy (12). With such frame, focus naturally gravitates toward the development of treatments as opposed to interventions. If alcohol abuse is viewed in the same context as HIV, it is clear that “there is an epidemic beneath the epidemic we know about” (13, p. 69) as the public health community has failed to understand the root social causes of alcohol abuse among middle-aged men.

Failure to Intervene

The public health community’s individualist approach to alcohol abuse among middle-aged men is reflected in the measurement and study of the problem as well as the approaches to intervene. Since “the goal of public health research is to provide a scientific basis for the development of effective strategies to improve health status” (7, p. 1175), it is not surprising public health has over looked alcohol abuse at the social-level resulting in population confusion and stigmatization.

Social-level interventions

The NIAAA discusses in its strategic plan many methods to reduce alcohol abuse among middle-aged men, focusing on drug treatment and individual behavior change (9). The NIAAA advocates for various models including the Transtheoretical Model (Stages of Change), Cognitive-Behavioral Therapy, and Motivational Enhancement (9), but makes no mention of various social theories and approaches. Although many structural-level policies exist to combat underage and college student drinking, few exist that specifically target middle-aged or male populations (34). The same can be said for community-level social interventions. Of the six “effective” prevention programs the NIAAA lists, zero target adult populations (34).

Confusion

Public health professionals have historically plagued the community with mixed messages on many primary prevention fronts resulting in public confusion. Don’t have sex before marriage, but if you do, use a condom. Don’t use drugs, but if you do, recycle your needles. Don’t drink underage, but once you are of age, go for it. Don’t drink and drive, but if you don’t drive, then drink. Alcohol is bad for you, but alcohol is good for you. How is the public to synthesize this information? The CDC defines heavy drinkers as consuming one or more drinks daily (14), while Men’s Health Magazine reports alcohol to be “fine in moderation” (15) and “the recommended safe intake for men is around three units of alcohol a day. That is 21 units per week.” (16). Although Men’s Health is not a peer-review scientific magazine, it is accessible and accepted by many adult men who may internalize it guidelines over the CDC fact sheets. The popular media messages and some scientific data are clearly counter to the messages from public health organizations which often declare alcohol as unsafe in any quantity or frequency.

Public health organizations have received criticism for exaggerations of risks associated with alcohol abuse, leading some to be classified as neo-prohibitionist. The Center on Addiction and Substance Abuse (CASA) was sharply criticized by representatives from the American Beverage Licensees and the Chronicle of Higher Education by its efforts to “paint the most alarming picture possible" (17) resulting in “denounce(ing of) responsible consumption (of alcohol) with half-baked advocacy disguised as real research." (18). The Washington Times criticized Mothers Against Drunk Drivers (MADD) in much of the same way by declaring that MADD's "ongoing push to compel states to adopt ever-lower standards for being legally drunk‚ is becoming a prohibitionist jihad driven by hysteria, not medical reality" (19). Even the American Medical Association (AMA) is not free of criticism as many question the rationale for never rejecting their resolution in support of prohibition in the 1920s (17).

Stigmatization

Stigmatization is a side effect of the public health community’s alarming alcohol messages as well as the individualistic frame of alcohol abuse. Alcohol abusers were “viewed more harshly” by peers than even the heavily stigmatized mentally ill according to one study’s findings (20). Stigmatization is further illustrated by the skewing of death records by “sympathetic certifiers” as mentioned previously. The same study noted that if the individual is viewed as responsible for their alcohol abuse problem, their peers tended to place blame and viewed them as “dangerous” and “feared and avoided them” (20).

This is even more problematic when alcohol abuse is considered with mental illness. The mentally ill are already marginalized, which compounds barriers to treatment of mentally ill alcohol abusers. As noted in tobacco research which concludes “these people are already stigmatized by their underlying psychiatric condition - Adding the further burden of the stigma associated with smoking makes it even harder for them to achieve the wellness that they and their families seek” (21 p. 2286). One study concluded that “those in treatment for alcohol or drug problems are frequently and disproportionately marginalized” (25). Just as was shown in smoking research the “risk of the marginalization of smoking is that it further isolates the group of people with the highest rates of smoking – persons with mental illness, problems with substance abuse, or both” (21). Cohen, et al describe social isolation as a health risk “comparable to the risks associated with cigarette smoking, high blood pressure and obesity and is robust even after controlling for these and other traditional risk factors” (40). Hence, it is no surprise as result that 42-percent of alcohol addicts had “bad opinion of health services” (25) resulting in missed treatment and intervention opportunities.

Conclusion

Public health practitioners can be our own worst enemy when it comes to assessing and preventing public health problems. In the case of alcohol abuse, the public health community has failed to adequately measure and the problem through failed epidemiologic measures and assessment methods. The public health community’s failed intervention and communication strategies have further confused, stigmatized and negatively impacted the screening and treating of alcohol abuse among middle-aged men.

Silver Lining:
Public Health Solutions to a Public Health Failure

In light of the many existing criticisms of the public health community’s strategies to reduce alcohol abuse among middle-aged men, several solutions are possible. In order to address the epidemiological problem of flawed definitive measures of alcohol consumption and abuse, improvements to data collection measures are necessary. Next, techniques from social epidemiology are necessary to address the failure to study the underlying reasons for alcohol abuse. Finally, the failure to develop successful interventions is addressed through approaches from Social Network Theory and Social Marketing Theory, which address the individual-level bias and stigma associated with alcohol abuse in this population.

Failure to Measure - Solutions

In order to address the failure to definitively measure alcohol abuse, the very epidemiologic approaches of assessment require improvement. The first proposal is to improve the way consumption data is collected on individuals. The second is to look at the overall social effects of alcohol abuse.

Since population-level data can lead to the underreporting of alcohol abuse, individual-level assessments are necessary to understand and define the scope of the problem. Strunin addresses many of the problems associated with the public health community’s methods to collect data on alcohol abuse when noting “valid reports of drinking has been controversial in alcohol studies” (30). She points out that many estimates of alcohol abuse “rely on accuracy of self-report data” that can “deny or deliberately deceive reports of behavior” (30); however, much can be done to improve instruments of measurement.

One improvement is to use improved questionnaires to fill in the knowledge gaps of consumption data. Some suggested improvements to questionnaires from the literature range from using diary methods and improving survey questions and their ordering (27, 28, 29). Another improvement that Strunin and others note is the use of beverage-specific measures (6, 30). The most compelling improvement from her work is the use of “multidisciplinary approaches” and “ethnographic interviewing and other qualitative methods in assessing alcohol use” (30). This approach is particularly useful to measure specific populations such as middle-aged men.

By focusing on measures such as volume of ethanol consumed and death by cirrhosis of the liver, the public health community misses other big picture strategies to measure the problem of alcohol abuse. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) lists “social problems resulting from alcohol abuse” as an “area of interest” but underscores that researchers rely on “more objective sources” (3). However, many quantifiable social problems result from alcohol abuse in the middle-aged population including failure of work obligations, legal problems, divorce, marital violence, child abuse and other crimes (26). Although it is difficult to develop measures of association, the failure to examine social effects to measure alcohol abuse among populations is clearly a missed opportunity to assess population-specific alcohol consumption.

Failure to Study - Solutions

With solutions to correct the public health community’s failure to develop definitive measures to effectively assess alcohol abuse, it is important to improve the strategies in studying the root causes of alcohol abuse among middle-aged men. The present methods in studying the individual risk factors for alcohol abuse can be improved by the conceptualization of risk factors in the social epidemiologic approach.

The NIAAA reports many causes of alcohol abuse among middle aged men including a gene influencing consumption (31), depression (32) anxiety (33) and family history (34). These conclusions ignore many social factors, which is not surprising as they result from the heavy reliance on the biomedical model. They also possibly result from the Type III error of epidemiology by “providing the right answer to the wrong question” (7). This error results from the “discrepancy between the questions being asked and the methods used to address the question” (7, p. 1175). The “evident” failure of epidemiologists to recognize many social factors (35. p. 110) results from what Schwartz lists as “value-laden considerations” that “limit the realm of inquiry” (7, 1175). This error, however, can be minimized by replacing this individualistic risk factor epidemiology with social epidemiology.

To combat “biomedical individualism,” social epidemiology studies social determinants as root causes of disease (36, p. 22). Instead of adjusting for social factors in the analysis phase of study design as possible confounders, social factors are the “focus of analysis” (36 p. 22). In order to review possible social risk factors, cultural context would first need to be assessed through both anthropologic and epidemiologic approaches. Then, social networks would be reviewed to map relationships and normative behavior among alcohol abusive individuals to identify a possible “core group” (36). Next, neighborhood effects would be studied to view the interaction of social networks in their cultural and geographic context – paying attention to poverty, marginalization, social isolation, etc. Finally, social capital would be measured. After reviewing social factors, structural risk factors require analysis. Adequate structural analysis would review demographic changes, violence and discrimination, legal structures and policy enforcement (36).

Failure to Intervene – Solutions

Along with the failure to study and definitively measure alcohol abuse, the public health community has failed to develop social-level interventions for alcohol abuse among middle-aged men. Confusion and stigmatization of the population result from this failure. This can be corrected in two ways. The first is to employ social-level techniques including Social Network Theory. The second is to use Marketing Theory to disseminate accurate information to the public, reduce stigmatization of the population, and change social norms.

Social Network Theory

The goal of social epidemiology is to reveal the underlying social networks that influence behavior. Once these are revealed, the Social Network Theory can be applied to develop social-level interventions. The effects of social networks are illustrated in research on smoking cessation. In the predominantly middle-aged population studied, researchers found that smokers quit “in concert” (41). Isolated individuals did not influence decisions to quit smoking, but rather it was social ties to other smokers and non-smokers (41). If results translate to the same population of alcohol abusers then specific social networks can be studied and successfully intervened upon.

Marketing Theory

Ether defines social networks as predictors of the “formation of public opinions” (39); therefore, marketing to specific social networks effectively alters social norms and attitudes. This is important for alcohol abuse among middle-aged men because “social networks can be especially important in the construction of a person’s reputation” (39). As discussed previously, barriers to treatment result from the stigmatization and social isolation of the population so a shift in perception of reputation can reduce stigmatization.

Aside from reducing the stigmatizing effects of alcohol abuse among middle-aged men, marketing theory accomplishes health behavior change because media is “a major source of patterned social expectations about the social organization of specific groups in modern society.” (42). The basic idea is to make a promise to mass media consumers and support that promise with visual images and a consistent message. If applied correctly, this strategy will identify what the population aspires to be and will offer that to them.

Marketing theory views groups differently than a collection of individuals based on group dynamics. DeFleur and Ball-Rokeach note the individual-level treatment interventions such as those suggested by NIAAA offer a “very incomplete picture of the human condition” because human beings act in an “intensely social nature.” (42, p. 219). This allows for the idea that groups of middle-aged men can be affected at the same time through a mass media message. Due to the group focus, it recognizes the many layers of influence on the individual. This addresses the flaw of the NIAAA models as they “fail to account for real-world cognition” (4, p. 8) by falsely assuming an internal locus of control and free choice. They also assume that behavior is “not restrained by political or social factors” (4, p. 8) many of which are portrayed through mass media. People are powerfully influenced by “accumulated exposure to media content” as “indirect influences on culture and society” (42, p. 206).

Conclusion

The failures of the public health community to address alcohol abuse among middle-aged men are clear; however, the solutions are promising. This paper does not suggest tossing out the window current epidemiologic approaches to measuring and studying the problem in this population, but does present clear opportunities to incorporate the social sciences and qualitative approaches. Theories with roots at the social level offer promising solutions to the failed individualist intervention attempts.


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