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

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

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

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

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

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

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

REFERENCES:
1. http://www.cdc.gov/cancer/breast/statistics/trends.htm; accessed on 12/01/08.
2. Feig SA. Effect of service screening mammography on population mortality from breast carcinoma. Cancer 2002; 95:451–457.
3. Newman LA. Breast Cancer in African-American Women. The Oncologist 2005; 10:1-14.
4. Smith-Bindman R. et al. Does Utilization of Screening Mammography Explain Racial and Ethnic Differences in Breast Cancer? Ann Intern Med. 2006; 18:541-53.
5. http://www.cdc.gov/cancer/nbccedp/ accessed on 11/24/08.
6. Wong FL. The Manual of Intervention Strategies to Increase Mammography Rates. The Centers for Disease Control and Prevention. 1997. http://www.cdc.gov/cancer/nbccedp/publications/; accessed on 12/02/08.
7. Earle L and Earle T. Social Context Theory. South Pacific Journal of Psychology. 1999; 11(2).
8. Sadler GR et al. Breast cancer knowledge, attitudes, and screening behaviors among African American women: the Black cosmetologists promoting health program. BMC Public Health 2007; 7(57).
9. Rosenstock IM. Historical origins of the health belief model. Health Educ Monogr. 1974;2:328-335.
10. Peek ME, Sayad JV and Markwardt R. Fear, Fatalism and Breast Cancer Screening in Low-Income African-American Women: The Role of Clinicians and the Health Care System. J Gen Intern Med 2008; 23(11):1847–53.
11. Oliver MN, Goodwin MA, Gotler RS, Gregory PM, Stange KC. Time use in clinical encounters: are African-American patients treated differently? J Natl Med Assoc 2001; 93:380–85.
12. Taylor-Clark K, Koh H and Viswanath K. Perceptions of Environmental Health Risks and Communication Barriers among Low-SEP and Racial/Ethnic Minority Communities. Journal of Health Care for the Poor and Underserved 2007; 18:165–183.
13. Gerend MA and Pai M. Social Determinants of Black-White Disparities in Breast
Cancer Mortality: A Review. Cancer Epidemiol Biomarkers Prev 2008;17(11).
14. Niederdeppe J, BU QL, Borah P, Kindig DA and Robert SA. Message Design Strategies to Raise Public Awareness of Social Determinants of Health and Population Health Disparities. The Milbank Quarterly 2008; 86(3):481–513.
15. Mobley, LR, Kuo T-M M, Driscoll D, Clayton L and Anselin L. Heterogeneity in mammography use across the nation: separating evidence of disparities from the disproportionate effects of geography. International Journal of Health Geographics 2008; 7(132).
16. Williams DR and Collins C. Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health. Public Health Reports 2001; 116: 404-416.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

REFERENCES:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Introduction

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

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

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

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

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

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

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

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

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

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

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

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

Argument 2: Poor Use of Advertising Theory

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

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

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

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

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

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

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

Argument 3: Developers Overlook the Sociological Perspective

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

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

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

Conclusion

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

Counter-Proposal

Introduction

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

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

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

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

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

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

Step II: Effective Use of Advertising Theory

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

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

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

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

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

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

Step III: Including the Sociological Perspective

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

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

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

Conclusion

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

References

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