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

Introduction

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

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

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

“Fat Chance!” Fat chance of losing weight?

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

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

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

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

Are some of the options really safe or feasible?

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

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

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

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

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

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

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

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

Introduction

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

Intervention

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

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

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

Self-efficacy and positive reinforcement

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

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

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

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

Safe environment and non-competitive group activities

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

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

Adressing availability and affordability

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

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

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

Conclusion

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

Conclusion:

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

References:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Promoting a Deficient Tool – Opening Pandora’s Box

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

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

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

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

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

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

Revisiting Individual Models

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

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

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

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

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

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

Could We Get a Little Buy In?

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

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

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

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

Moving Past Shifting the Paradigm

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

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

Stimulating Change

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

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

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

Fostering Healthy Norms

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

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

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

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

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

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

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

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

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

No Substitute for Planning

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

17. Freire P. Pedagogy of the Oppressed. New York: Seabury Press; 1970.
18. Wendell L French; Cecil Bell (1973). Organization development: behavioral science interventions for organization improvement. Englewood Cliffs, N.J.: Prentice-Hall. chapter 8.
19. 
    
20. Berkowitz, A. Fostering Healthy Norms to Prevent Violence and Abuse: The Social Norms Approach. Preventing Sexual Violence and Exploitation: A Sourcebook. Wood and Barnes Publishers, 2007.

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

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

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

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

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

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

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

BMI Report Cards in Schools, Critique of a Current Public Health Intervention – Vibe Andersen

Introduction to a Public Health Problem

Public Health professionals need to focus immediate attention on a rapidly growing public health problem encompassing the United States. The prevalence of obese children ages 6-11 has doubled in the past 20 years from 6.5% in 1980 to 17% in 2006, and has tripled in adolescents ages 12-19 from 5% to 17.6% (1). The increasing numbers of obese and overweight children in the U.S. is due to complex interactions of social/environmental/cultural and political/economic factors, that influences the level of physical activity and eating habits of children in the U.S. (2). At least 61% of obese young people have at least one additional risk factor for heart disease, such as high blood pressure or high cholesterol levels. Children who are overweight or obese are more likely to become obese as adults and are therefore at greater risk of heart disease, type 2 diabetes, stroke and several types of cancer (1,3). Obese children also deal with social and psychological problems such as stigmatization, labeling and poor self-esteem (4). Considering the severe consequences of this growing problem, public health interventions must be considered a crucial necessity.

According to the Centers for Disease Control and Prevention (CDC), a child is defined as being obese when his or her Body Mass Index (BMI) is equal to or greater than the 95th percentile of the age-and-gender-specific BMI charts, and termed overweight or at risk when at or above the 85th percentile (5). In recent years, much attention has been focused on BMI measurements programs by schools as an intervention in the battle against childhood obesity. In 2003, the state of Arkansas initiated and implemented a statewide BMI screening and surveillance program (Act 1220 of 2003) and other states have since followed, (Illinois, Maine, New York, Pennsylvania, Tennessee and West Virginia) (6,7). Under the program, schools inform parents of students they have determined either have or are at risk of developing weight problems, by sending home BMI report cards stating the students BMI. All students receive BMI report cards, not just children in the risk group.

The following will be a criticism of why I believe, that the use of BMI report cards in schools can be considered a flawed intervention in the battle against childhood obesity. I will argue, that this intervention does not provide tools for parents to help boost self efficacy in their children. Another argument will be, that the use of BMI report cards includes a high risk of negative labeling and social marginalization of children. Finally, I will make an argument, that using BMI report cards puts too much focus on weight and not enough emphasis on healthy behavior and living, and on that account risks loosing the focus of promoting a healthy lifestyle in families at risk and most importantly in children.

BMI report cards fails to recognize the importance of self-efficacy

An individual’s decision to engage in a behavior, and his or her persistence to stay with the behavior change, is influenced by the individual’s perception as to whether he or she can be successful. According to Albert Banduras social cognitive theory, the concept of self-efficacy, refers to a persons own belief in that he or she can have control over and success with behavioral change. Children with a sense of high self-efficacy are more likely to engage in behavioral changes and be persistence in sticking to these changes (8,9). A child without a strong sense of self-efficacy will be less likely to attempt behavioural change because of fear of failure. In supporting and boosting self-efficacy you can, according to Banduras, support the child’s beliefs that he or she can succeed in changing their behavior (10).

Giving parents of children with an obesity or weight problem a BMI report card does not provide any tools for the parents in order to help and support their child’s sense of self-efficacy. The BMI report cards provide a number to the parents, that places their child on a scale of being either under, normal or overweight or obese. Some states do also include some information and guidelines for a healthier diet from the American Academy of Pediatrics suggestions for healthy lifestyle, but do not offer counselling or follow-up to the parents (6). Parents are left to make sense of a number on a report card, and just information on healthy lifestyle provided to them by the schools, is not enough to make anyone change behavior and does not boost self-efficacy. Self-efficacy plays a key role, and ways of boosting children’s belief in that they can succeed in changing diet and exercise regime, and in that way influence their BMI, is crucial for the rate of success in any intervention battling obesity. Quite a few parents receiving the BMI report cards for the first time reacted with anger and disregard (11). A qualitative study in the U.K. showed, that parents would like a medical interpretation of whether their child is at healthy weight and also that parents found BMI a difficult concept to understand (12). A more effective way of informing and supporting the families, might be counseling sessions at the schools, which is a more personal setting and may turn out to be a better way of helping the parents find tools to offer to their child.

One could also argue, that without true support within the school environment such as increasing the amount of physical activity scheduled into the school day, and serving a healthier diet in the school cafeteria, the intervention does not have much chance of success (7). Parents and children need to feel that their choice of a healthier lifestyle is being supported in schools where children spend a good part of their week. Schools have a huge responsibility to promote self-efficacy, by providing an environment where modeling from other students and encouragements from teachers and peers is encouraged.

BMI report cards and the risk of negative labeling

By using the term “report card” in the intervention some children could feel as if they are getting graded on the way they look. The risk of children feeling as if they have been officially labeled as “fat” is very high. According to labeling theory, behavior by the individual is influenced by the way the individual is judged by society, and the label he or she thereby gets (13). Labeling theory has roots in sociology and according to social psychologist George Herbert Mead, as an individual you are aware of how you are judged by others from your perception of the role you play in social interactions. There are different rules in different social settings, and varying social and moral norms plays a role in behavior and labeling of individuals (13). The use of BMI report cards focus on the individual, and poses a significant risk of labeling overweight children as being “fat” in the eyes of their peers. Labeling can directly lead to negative behavior in the way that individuals can be seen to accept to the label they are given, in that way enabling the label to work in a self-fulfilling way. The group of children being branded as “fat”, may resign themselves to this being their social role, and may loose any motivation they had to strive for healthier behavior. Some children may start overeating and avoid physical activity because they feel that is what is expected from being “fat” (13,14).

Another negative outcome of BMI report cards could be an increase in taunting and bullying of overweight children, a problem already reported as existing (15). Overweight children are more likely to be teased about their weight and less likely to form friendships than their non-overweight peers (16). Studies conducted on adolescents being teased about their weight showing that they are at high risk for low self-esteem, depression and suicidal attempts (17,18).

Also labeling can have a significant effect on the group of children not characterized as overweight. The fear of being labeled as “fat”, a label this group sees as socially less accepted, can be so severe in this group that unhealthy dieting could become a big problem, resulting in eating disorders and serious body image issues (11,16). So the use of BMI report cards in schools could have negative consequences in both the groups of overweight children and in the group of children being at healthy weight (19).

BMI report cards: too much emphasis on weight not enough emphasis on healthy behavior

The use of BMI report cards risks putting too much emphasis on children’s weight and not enough on healthy behavior and lifestyle. Focusing only on body size, without looking at the big picture, puts the health of children at normal weight at high risk of being neglected. They may have a normal BMI, but eat an unhealthy diet and have sedentary behavior that could lead to health problems later on in life (20). Many problems associated with weight are consequences of poor diet, genetic factors, ethnicity, level of physical activity and spending too much time engaged in sedentary activities, such as watching TV and playing videogames. Parents inactivity and high consumption of energy dense food are also risk factors associated with childhood obesity (12).

The National Health and Nutrition Examination Surveys (NHANES) 1999-2004 found that 23.5% of normal-weight adults were cardiometabolically abnormal, while 51.3% of overweight adults and 31.7% of obese adults were cardiometabolically healthy (17). The long-term health risk might in fact be higher for some of the children defined as normal-weight, and BMI measurement might not be accurate predictor of unhealthy behavior (21). One could argue, that the intervention using BMI report cards does not focus at all on promoting a healthy behavioral change. With BMI report cards, children and parents in the group of “normal” children may be lulled into thinking that they do not need to consider healthier alternatives to change their habits.

BMI is practical, easy to obtain and reliable, but arguments are, that entire states are adopting a policy that has not yet been tested (22). Little is known about the outcome of BMI measurement programs, including effect on weight-related knowledge, attitudes and behavior of children and their families. Kipping et.al.. in a clinical review of obesity in children, argue that as long as we do not have an effective intervention available to follow up on the population that gets a high BMI score, screening school children for weight problems is hard to justify (11,23).

Conclusion

The problem of the increasing numbers of obese and overweight children in the U.S. is, as mentioned in the introduction, a diverse and complex social and environmental problem and it is a collective responsibility that requires individual, family, community, corporate and governmental commitments. Using BMI report cards in schools is one amongst many interventions designed to try to address the growing problem. I would, with my arguments state, that the use of BMI report cards in schools, as an intervention addressing childhood obesity, is flawed in its lack of including important factors, such as self-efficacy, risk of negative labelling of children and lack of emphasis on healthy behavior and living. The effectiveness of this intervention is highly questionable and may actually have directly negative consequences, as the outcome of the intervention has yet to be evaluated. It leaves parents with a number on a report card and no tools to promote self-efficacy, and offers no solution to reverse the course. The significant risk of negative labelling children as being “fat” and in that way directly increasing the risk of further unhealthy behavior in obese and overweight children, as they see the label as their social role, must be seen as another flaw in the intervention. BMI report cards could also promote unhealthy weight behavior in the group of “normal” children, as they fear of being labelled “fat” could lead this group in the direction of eating disorders and serious body image issues. The intervention does not emphasize healthy lifestyle. By this focus on body size (BMI) rather than healthy diet, a positive exercise regime and healthy life style, the intervention overlooks a large group of children who have a normal BMI but might lead a very unhealthy life. BMI levels within the normal range may as a consequence lure families into staying with an unhealthy lifestyle. To date the effect of the BMI screening program on childhood obesity has yet to be scientifically evaluated.

Counter-Proposal to a Current Public Health Intervention

Obesity is a consequence of choices and lifestyle. These lifestyle issues need to be addressed individually and collectively as a society in order to change the path of the rising numbers of overweight and obese children in the U.S. The focus need to be moved away from body size and towards behavior and environmental factors. Instead of using BMI report cards in schools, that indeed focus on body size, I will argue that a focus on healthier lifestyle for all children, no matter what BMI level they are at, is a better approach in order to avoid the flaws pointed out in assignment #3, and also why I find this proposal superior to the original intervention on the specific flaws that I articulated in assignment #3.

Self-efficacy, a key component in behavioral change

Ways of boosting children’s belief in that they can succeed in changing diet and exercise regime is crucial for the rate of success in any intervention battling childhood obesity in the U.S. Children with a sense of high self-efficacy are more likely to engage in behavioral changes, and be persistence in sticking to these changes (8,9). The use of social cognitive theory as part of a frame for an intervention would be a good approach, as a key element in this theory is self-efficacy, social modelling and learning by observing. According to social cognitive theory, children model what they see, and learn from what others do, so if the social norm is healthy lifestyle with healthy food and exercise, there is a good chance that children will model that (10,25). Also studies have shown, that peers and siblings attitude towards eating and food consumption significantly influences children’s behavior (26,27).

Ways of boosting self-efficacy would be to give the children responsibility in their own life and health, make realistic goals for and with the children. In praxis introducing cooking classes in schools, where children get hands on experience in preparing healthy meals, would be one way of boosting the children’s belief in possible behavioral change, and at the same time teach nutrition. Another way of boosting self-efficacy in children, would be focusing more on including or building in physical activity into everyday life for children; walk/bicycle to school, make class projects exploring new ways of exercising daily in a new and fun way. Making the children feel, that they are a part of a group with a common mission. Make children feel they belong and in achieving their goals, boosting their feeling of success.

Changing the social norm is hard and very challenging, families need more practical advise in being able to choose a healthier lifestyle and finding tools to boost self-efficacy (25). Counseling sessions at the school would be a more personal setting than merely a report card sent home. In this way, by giving parents tools to boost children’s self-efficacy through counseling, you move away from the flawed approach by BMI report cards only stating a number. Schools have a huge responsibility in promoting self-efficacy, by providing an environment where modeling from other students and encouragements from teachers and peers is encouraged (7). But not only schools have responsibility, the whole community needs to come together in a multilevel approach where different sections work together to find a solution (home, schools, physicians, state, government).

Reducing the risk of negative labeling

Schools should be a safe and supportive environment for students of all sizes, and implement strategies to promote physical activity and healthy eating. The risk of children feeling as if they have been officially labeled as “fat” is very high by using the term “report cards”, as the BMI report card intervention does. To decrease the risk of negative labeling, you would have to address the way society judge individuals (13). A significant flaw by using BMI report cards in schools, is the risk of self-fulfilling behavior in children with high BMI score. The risk of acceptance and resigning to a social role and the de-motivation this could course for these children, leading to lack of interests in physical activity sometimes combined with overeating (13,14). The question is what type of health related communication, instead of sending home a “report card” from the school to the family, is most likely to bring positive results, and at the same time dismiss the chance of labeling some children. One different approach in schools could be making an assessment of quality of diet, eating habits, physical activity and time spent in sedentary behavior. On top of this you would make an assessment of the child’s body image and relationship with food, and making this assessment part of every child’s school year, the risk of just pointing out some children and hereby risk negative labeling is decreased (7,28).

In addressing the negative effect BMI report cards have on the risk of increasing weight teasing and bullying, schools have a serious responsibility in boosting children’s self-esteem. Working away from a school system with report cards on weight will also be beneficial for the likelihood of overweight and obese children’s risk of teasing and bullying (14,16). The fear of being labeled fat that can lead some children within the normal range of weight to unhealthy dieting and other eating disorders needs to also be addressed (18). Eating and exercise habits are shaped by social and cultural structures and norms, and building an approach that includes these elements would stand a better chance of successfully taking up the battle against childhood obesity (25,93-111).

Emphasis on healthy behavior, environment and lifestyle -not body size

The focus on body size by stating children’s BMI score on report cards puts the health of children of normal weight at risk. BMI report cards focus mainly on overweight and obese children, hereby totally overlooking the risks involved in leading an unhealthy lifestyle but still being within the normal BMI range (17,20,21). A more appropriate approach would focus on positively promoting healthy living, healthy eating habits, exercise for all children, not only for those that, by using BMI report cards, are being labelled obese.

In today’s society and eating environment, good nutrition is something that sadly must be learned. We need to ensure, that the school policies and the whole school environment encourage physical activity, and ensure students meals in pleasant sociable environments as well as providing psychosocial support (23). In my opinion, by making unhealthy food less accessible in schools cafeterias by simply taking it off the menu, not only adding healthier choices, but removing unhealthy choices, you would be able to influence healthier eating behavior. True support within the school environment such as increasing the amount of physical activity scheduled into the school day, and serving a healthier diet in the school cafeteria is needed now (19,23). Parents and children have to feel that their choice of a healthier lifestyle is being supported in schools, where children spend a good part of their childhood hours. Parents need to understand, that they are teachers too, children models what they see, not what they are told and the society needs to build support and awareness for parents (28).

There will always be a political/economic context that will affect what people do, and especially what they can or cannot do (25). The food environment we live in is toxic, the influences of the food industry is massive in the obesity epidemic that is currently a reality in the U.S. (24). One of the problems public health advocates faces in the U.S. is the highly individualistic mentality in the society, and as a result of that, individuals are assumed to have sole responsibility for their choices. The level of individualism is why so many people object to proposals to changes in the food environment, i.e cafeteria lunches, and children’s access to unhealthy food in vending machines, they do not like to be told what they can or cannot eat (24,27). But changes in the food environment are necessary to influence lifestyle changes.

Conclusion

There is very modest effectiveness of programs aimed at individual behavioral change to prevent childhood obesity, which is why a paradigm shift at societal and political/governmental level is needed, in order to see any significant changes towards lifestyle changes. On governmental level politicians needs to realize that changes in the food environment is necessary. Public health workers have to be realistic in their planning of interventions and create a realistic frame for the work. Select from different factors and decide what to focus on in the light of resources, as public health does not have unlimited resources or time, so you have to pick your battles. The battle against childhood obesity is a complicated multi factual battle that will need a multilevel approach. Not only schools have responsibility, but parents, family physicians, community and government all have to contribute. Intervention using BMI report cards in schools is flawed in different ways. An approach focusing on providing tools to help boosting children’s self-efficacy, decrease the risk of negative labeling, and support healthy lifestyle by moving focus away from body size, is in my opinion a superior approach. By the use of social cognitive theory as part of a frame of an approach, you would be able to focus on self-efficacy as a key component, and reduce the risk of leaving parents without tools to support their children. By focusing on a healthier life style for all, you would reduce the risk of labelling some children as fat. By assessing all children, and meet with all families to offer counselling in healthy lifestyle and possible behavioral changes, you would create a possibility not only for overweight children at risk, but all children equally. It is my strong belief that the mindset of thinking convenient, easy, automatic, effortless and free “the American way of life” needs to be challenged and changed if any intervention shall stand any chance in the battle against childhood obesity in the U.S.

References

1. Ogden CL, Carroll MD, Flegal KM. High Body Mass Index for Age Among US Children and Adolescents, 2003-2006. JAMA. 2008;299(20): 2401-2405.

2. Institute Of Medicine of the Nationale Academies. Childhood Obesity in the United States: Facts and Figures. Sep. 2004. http://www.iom.edu/Object.File/Master/22/606/FINALfactsandfigures2.pdf

3. Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The Relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics 1999;103:1175-1182.

4. Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, Robinson TN, Scott BJ, Jeor SS, Williams CL. Overweight in Children and Adolescents: Pathophysiology, Consequences, Prevention and Treatment. Cirkulation 2005;111:1999-2012.

5. Centers for Disease Control and Prevantion. Overweight and Obesity. http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/prevalence.htm

6. Justus MB, Ryan, KW, Rockenbach J, Katterapalli C, Card-Higginson P. Lessons Learned While Implementing a Legislated School Policy: Body Mass Index Assessments Among Arkansas’s Public School Students. Journal of School Health, Dec. 2007, Vol 77, No.10.

7. Levi J, Juliano C, Segal L. F as in Fat: How Obesity Policies are Failing in America 2006. Washington, DC: Trust for Americas Health; 2006.

8. Bandura, A. Principles of Behavior Modification. New York: Holt, Rinehart & Winston; 1969.

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

10. Bandura, A. Self-efficacy in Changing Societies. Cambridge University Press; 1995.

11. Kantor J. At report card time in the U.S., a new topic: weight. The International Herald Tribune, Health and Science January 8 2007. New York Times Media Group

12. Kipping RR, Jago R, Lawlor DA. Obesity in children. Part 1: Epidemiology, measurement, risk factors, and screening. BMJ 2008;337:a1824.

13. Wikipedia. Labeling Theory and George Herbert Mead. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/George_Herbert_Mead

14. Bigler RS, Liben LS. A developmental intergroup theory of social stereotypes and prejudice. Advances in Child Development Behavior. 43:39-84;2006

15. The Center For Consumer Freedom. BMI Report Cards: The “F” is For “Futility”. Feb. 28 2006. http://www.consumerfreedom.com/news_detail.cfm/headline/2980 .

16. Strauss RS, Pollack HA. Social Marginalization of Overweight Children. Arch Pediatr Adolesc Med. 2003:157:746-752.

17. Mitka M. Experts Weigh Pros and Cons on Screening and Treatment for Childhood Obesity JAMA. 2008;300(12) :1401-1402

18. Neumark-Sztainer D, Falkner N, Story M, Perry C, Hannan PJ, Mulert S. Weight-teasing among adolescents: correlations with weight status and disordered eating behaviors. International Journal of Obesity 2002;26:123-131

19. Crawford PB, Woodward-Lopez G, Ikeda JP. Weighing the risk and benefits of BMI reporting in the school setting. Center for Weight and Health 2006.

20. Parson Tj, Power C, Logan S, Summerbell CD. Childhood predictors of adult obesity: a systematic review. Int J Obes Relat Metab Disord 1999;23 (suppl 8):S1-107.

21. Moyer VA, Klein JD, Ockene JK, Teutsch SM, Johnson MS, Allan JD. Childhood Obesity Working Group, US Preventive Task Force. Screening for overweight in child and ado: where is the evidence? A commentary by the childhood obesity working group of the US Preventive Task Force. Pediatrics. 116(1):235-8, July 2005.

22. Agency for Healthcare Research and Quality. Screening and Interventions for Overweight in Children and Adolescents, July 2005. http://www.ahrq.gov/clinic/uspstf/uspsobch.htm

23. Kipping RR, Jago R, Lawlor DA. Obesity in children. Part 2: Prevention and management. BMJ 2008; 337:a1848

24. Brownell, K, Horgen KB. Food Fight: The Inside Story of The Food Industry, America’s Obesity Cricis, and What We Can Do About It. 2004, New York: McGraw-Hill/Contemporary Books.

25. Edberg M. Essentials of Health Behavior, Social and Behavioral Theory in Public Health. 2007 Jones and Bartlett Publishers, Inc. Sudbury, MA.

26. Salvy SJ, Vartanian LR, Coelho JS, Jarvin D, Pliner PP. The role of familiarity on modelling of eating and food consumption in children. Appetite. 50 (2-3); 514-8, 2008 Mar-May.

27. Vartarian LR, Herman CP, Wansink B. Are we aware of the external factors that influence our food intake? Health Psychology 27 issue 5, (533-538) 2008.

28. The Rudd Center for Food Policy and Obesity http://ruddsoundbites.typepad.com/rudd_sound_bites/2008/10/index.html

Abstinence-Only Education: The Failure of a National Forced Belief – Elizabeth Usaj

Introduction

Abstinence-only education (AOE) programs have been on the rise in the United States since 1996, when the federal government created a program called Title V – section 510 of the Social Security Act (1). Title V is a program that was passed as an attachment to a welfare reform law, and allowed for federal funding for AOE programs. President Bush’s 2009 budget designates $204 million for these AOE programs, which is a steep increase from the original $50 million in 1996 (1). To be eligible to receive these federal funds, a program must follow eight explicit characteristics, which require the programs to teach the physical, social, psychological and emotional consequences of early sexual experimentation and the value of sexual abstinence (2). The programs also must not include a discussion of contraception’s as protection against STDs or pregnancies, because the programs make the assumption that sex in a monogamous, married relationship is the expected standard of behavior (2).

Supporters of AOE programs typically believe that teaching abstinence is the only way to prevent unwanted teenage pregnancies and sexually transmitted diseases (STDs), not discussing safe sex practices and proper contraception use. Current statistics regarding teen pregnancy and STDs show that the issues are still of major significance to teenagers and that AOE programs have had little to no effect in reducing the overall rate of occurrence. The Centers for Disease Control and Prevention (CDC) has estimated that approximately 19 million new STD infections occur each year, and that almost half of them are among teens aged 15 to 24 (3). Teenage pregnancy is estimated at 757,000 a year among women aged 15-19 years of age (4). The U.S. has the highest rate of unwanted teenage pregnancies among developed countries (5), despite the hundreds of millions of dollars a year that are thrown at AOE programs aimed at preventing it. The failure of AOE programs can be attributed to the fact that they do not allow for self-efficacy, do not take into account social and environmental factors, and lack adequate understanding of how teenagers react when being told what to do.

Misleading with False Information and Claims of Morality

AOE programs are inherently coercive and provide misinformation and withhold information needed to make informed decisions (6). Information that is provided in 80% of the AOE curricula regarding reproductive health is false and distorted, claiming that “5-10% of women who have legal abortions become sterile” and that “the popular claim that ‘condoms help prevent the spread of STDs’ is not supported by data” (7). Statements such as these are often discussed as the facts in AOE programs and hinder teen’s ability to decide what is fact and what is fiction. Being provided with the wrong information removes a person’s ability to make an informed decision and infringes upon their self-efficacy. The belief that someone can carry out the desired behavior is affected by knowledge of steps necessary to avoid the risk (8). Teens who have information about reproductive health are more likely to use contraception than those without such information (9).

Albert Bandura, creator of the Social Learning Theory, uses the concept of self-efficacy as a main principle to achieve a desired outcome in his theory. Bandura states that self-efficacy is the conviction that one can successfully execute a specific behavior required to produce the desired outcomes (10). AOE programs fail to incorporate this key aspect of decision making into their structure and curriculum, removing a person’s belief that they have control over their own decisions. It has been shown that behavioral beliefs, self-efficacy, and other skills can reduce STD risk-associated sexual behavior among adolescents (11).

“Federal regulations for state abstinence education funding adopt a moral definition of abstinence, requiring that abstinence education teach that a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity” (6). In AOE programs, the word abstinence is often defined in moral terms, using language such as “chaste” or “virgin”, and frames the activity of abstinence as an attitude or a commitment in addition to a behavior (6). Teenagers who have had sex or are contemplating sex may feel ashamed and embarrassed that they are performing immoral or unethical acts, and may try to hide their behaviors. This secrecy can lead them to avoid doctor’s visits that would prevent or treat STDs and pregnancies. The moral definition of abstinence programs is also discriminative against the gay, lesbian, bisexual, transgender and questioning youth because the definition of marriage is limited to heterosexual couples (6). Today, there is currently only one state that recognizes same-sex marriages, which helps to create a stigma around homosexuality as deviant and unnatural behavior (12). These youth may tend to feel isolated, lonely and immoral, increasing their risky behaviors and eliminating their ability to execute healthy behaviors.

Friends and Family Matter

AOE programs are based on the Health Belief Model (HBM) which focuses only on individual level factors and ignores many key aspects of a person’s life that influence decisions. “The HBM explicates the relationship between individual health beliefs associated with a disease or medical condition, and likelihood of engaging in preventive health actions” (13). The model assumes that individual decisions are made in a vacuum and that socioeconomic status, culture, race, social networks, media, and peer pressure do not play into one’s decision. For example, members of racial and ethnic minority groups are more likely to engage in behaviors that lead to early pregnancy, childbearing, and sexually transmitted infections (14). AOE programs are cookie cutter in design and focus on the general population of adolescents, not incorporating the other influential factors into their curriculum.

Peer pressure can play a large role in one’s decision to begin sexual activity. Teenagers with sexually active friends are more likely to engage in sexual activity themselves – they see sex as a “cool” thing to do (15). Even kids who believe, but don’t know for sure, that their peers are having sex, are more likely to engage in sex and feel that it will increase others’ respect for them (16). The same goes for condom usage and contraception methods. Teens who believe their friends do not use condoms are less likely to use them (17).

The relationship with one’s family influences one’s sexual behavior just as much as peer pressure can. Teens born from teenage mothers are more likely to start having sex at an early age and become teen parents themselves (9). Conversely, teens that come from families with two parents that are more educated and have higher incomes are “more likely to engage in positive reproductive behaviors than their peers who lack such backgrounds” (18). The expansion of a visible sexual culture including the increasingly sexually oriented media can also factor into a teens decision as to whether and when to engage in sexual behavior (19). The historical context and current environment of the teen can predict, to some degree, the likelihood that they will engage in risky sexual behaviors. The current AOE programs being designed around the HBM model fail to account for such factors, limiting the impact of the program.

Rational decision-making is another major flaw with the HBM. The model assumes that behaviors are always planned and rational. AOE programs follow this model and ignore the fact that behaviors can be impaired by other risky behaviors such as substance abuse. Teens that are already involved in other risky behaviors such as using alcohol and drugs are more likely to engage in risky sexual behaviors (20). Alcohol and drugs are known substances that blur one’s sense of judgment between right and wrong. Teenagers experimenting with alcohol and drug use could end up having unplanned sexual activity, where there is less of a chance of using protection. AOE programs, by not teaching or discussing information on contraception, do nothing to decrease the chance that these teens, while under the influence of alcohol and drugs, will use protection. 81% of teens want young people to receive more information about both abstinence and contraception (21). Including information regarding contraception options in AOE programs could possibly increase the chance of using them during unplanned and irrational sexual activity.

Don’t Means Do – Rebellious Teens

When a parent asks a teenager to do something, teens usually say no. It is not that they don’t want to help out; it is the mere fact that teens don’t like being told what to do (22). Teens want to figure things out for themselves and have the personal satisfaction of achieving it on their own. This ideology can be applied to AOE programs. Teens want the facts and then to be left to make their own educated decision (22). Smoking, risky sexual behavior and alcohol are all behaviors about which teens want to make their own decisions, and for which the government has set restrictions – in essence telling teens what not to do. Generally the methods used the Florida’s “Truth” campaign can be applied to the AOE programs, as teens generally feel the same way about sex as they do smoking. Research found that for the campaign to be successful the tone of “truth” could not preach and that “truth” needed a message other than “don’t” (22). Research also showed that teens were already well aquatinted with the negative effects of tobacco and despite this knowledge and awareness, teens still saw smoking as rebellious and self-identifying (23). “Using tobacco was a tool of rebellion for the teens, and was all about sending a signal to the world that the user made decisions for themselves” (22). Understanding this attitude, the “truth” campaign turned the focus from telling teens to stop smoking; to telling them it was actually the tobacco companies that were telling them what to do. This idea made the teens want to rebel out against the tobacco companies and the rates of smoking decreased.

The US has created an environment for teenagers to rebel out against the government’s forced beliefs and attitudes regarding sex. Comparing the US teenage pregnancy rates against other developed countries, the US tops the list (5). The situation is the UK, for example, is rather different in that “abstinence education has no support in public policy and receives no funding from government, although there is an expectation that sex educators in schools will emphasize the potential benefits of delaying or abstaining from sexual activity alongside providing information about contraception, sexual health services, sexuality and gender issues” (24). The U.K. government believes that encouraging a delay in the start of sexual activity has its place, but that fundamentally they must recognize the reality that people are able to make their own decisions about their sex lives (25).

Western and Northern European countries are beginning to accept the idea that teens will begin to have sex in their teenage years, certainly before marriage. Rather than trying to force abstinence beliefs upon their citizens, these countries “emphasize through their social institutions the provision of sex education and health care services aimed at equipping young people to avoid the negative consequences of sex” (26). These countries are going against the AOE programs by encouraging and expecting the teens to use contraceptives. This method has been proven effective by studies showing that rates of teenage pregnancy, childbirth and STDs are low in these countries (26).

Conclusion

AOE programs are fundamentally flawed in theory, design and message. Failure to allow for self-efficacy in the programs eliminates teen’s ability to feel that they are capable of postponing sex until they are married. The program curriculum provides false and misleading information. The curriculum also discriminates against the gay, lesbian, transgender and bisexual population by only considering marriage for heterosexuals. The program language also creates a sense that abstinence is the only moral decision for preventing pregnancies and STDs, forcing teens to feel embarrassed or ashamed of their sexual activity.

A teenager does not make a decision to have sex by only thinking about their individual susceptibility and severity. Teens tend to engage in risky sexual activity as a result of peer pressure, family circumstances, media attention, or even under the influence of alcohol and drugs. Their decisions are not always planned and are not always rational. AOE programs fail to account for these factors since the programs are designed off of the HBM. AOE programs also fail to account for the mentality of teenagers when it comes to being told what to do. Teens hate being told what to do and rebel out against this idea by any means that show they are in control. With the amount of money put into sexual education programs, it is only reasonable that they be expected to produce meaningful results. AOE programs have been proven ineffective, so now additional measures must be taken, including teaching safe sex practices and contraception use. These realistic programs, which do not insult the intelligence of their target audience, have been proven far more effective abroad, so it is time we started expanding them in the United States.

A Counter-Proposal to Abstinence Only Education Programs: Re-Framing Sex Education

With the United States ranking highest among industrialized countries in teenage pregnancy and the rates of STDs skyrocketing (3,5), the time for change is now. The current method of sexual education aimed at teens, abstinence only education (AOE), has not accomplished the goal of reducing teenage pregnancies and STDs. AOE education programs are based on the premise that teens should not engage in sexual intercourse until they are married (2), despite the fact that “few Americans remain abstinent until marriage, many do not or cannot marry, and most initiate sexual intercourse and other sexual behaviors as adolescents” (6). In order to create an environment where sexual education can make an impact on the rates of unwanted pregnancies and STDs, the United States needs to re-frame the way we think about sex. This new way to think about sex must address the key limitations of the AOE programs. AOE programs do not allow for self-efficacy, do not take into account social and environmental factors, and lack adequate understanding of how teenagers react when being told what to do.

Proposed Intervention

An intervention that would reduce the number of teenage pregnancies and STD infections would have to take a two-fold approach. The first step would be to re-frame the way the United States thinks about sex in an effort to create a social change. The second step would be to eliminate AOE programs because of their misguided framing of sex, and re-vamp the sexual education curriculum to include information on urging protection, based on social norms and the environment. To begin to re-frame the way the US thinks about sex is a difficult undertaking that may take a considerable investment of time to accomplish. “Frames are fundamentally about the relationship to the world and how people view it,” (27) they are unconscious, develop naturally, come into the public's mind through common use (28), and can be hard to change. The current frame used regarding sex is that sex before marriage is immoral and wrong, and that abstinence is the only way to protect oneself from unwanted pregnancy and STDs. Framing is a powerful tool to use to change peoples behavior. “The essence of social change is changing perceptions, which itself is the territory of framing” (27). People can often be expected to change their behavior solely based on the way something is framed or worded.

The proposed intervention would frame abstinence as being unrealistic and focus on the notion of “be real, be safe.” The frame would acknowledge that teens do engage in sexual activity, but that society doesn’t have to think it’s wrong and immoral. The message would no longer be “don’t have sex before marriage,” but “if a teen chooses to engage in sex, be safe and use protection.” The unconscious frame would no longer be “sex is wrong before marriage,” but “if you I’m going to have sex, I should be safe about it.” This key message would disseminate throughout all aspects of sexual education including the elimination of AOE programs. The basis for sex education for teens would now incorporate curriculum including contraception options, and the method of teaching would be based on the Social Learning Theory, including information on social factors and the environment.

The Social Learning Theory, created by Albert Bandura says that changing a behavior is based on three factors: “A person’s sense of self-efficacy about the behavior, the social/physical environment surrounding individuals, and the interactive process of reciprocal determinism, where a person acts based on individual factors and social/environmental cues, receives a response from that environment, adjusts behavior, and acts again” (29). The proposed programs are designed to incorporate the key message of how social factors and environmental factors can also affect a teen’s relationship with sex and contraception use, factors that AOE programs were lacking.

Knowing The Full Truth

The new intervention method of teaching teens about contraception provides them with the full range of options to prevent pregnancies and STDs. Teens will no longer be provided with false and misleading information regarding contraception, as was occurring under AOE programs (6). Teens will have access the full truth about prevention and will be able to make informed decisions for themselves. It has been shown that teens who do have information about prevention of STDs and pregnancy are more likely to use those contraception methods than those without such information (9). Self-efficacy, the ability to make informed decisions and the belief that one can successfully carry out the desired behavior to prevent STDs and pregnancy (10), will no longer be minimized in the new method of sexual discussions. Studies have also shown that self-efficacy can reduce STD risk-associated sexual behavior among teens (11).

The new frame for sex will no longer consider sex before marriage to be wrong or immoral. Teens that are engaging in sexual activity before marriage will no longer be compelled to hide their behavior or feel ashamed. The frame will encourage teens who choose to engage in sex to use protection. The gay, lesbian, bisexual, transgender and questioning youth will not be discriminated against under the new frame. AOE programs framed the moral standard of sex to be in a monogamous faithful marriage between a man and women (6). With the lack of states that recognize same-sex marriages, the stigma around homosexuality is that it is unnatural and immoral (12). Because the new frame will not place an emphasis on what constitutes a marriage, and will acknowledge that sex happens before marriage, the message will be pure – just be safe. The gay and lesbian population of teens will no longer need to feel isolated or immoral. They can have the confidence that their relationship or sexual activity is deemed normal and the frame of “be real, be safe” applies to them.

Accounting for “The Other” Factors

The new frame and updated sexual education materials will now account for external factors that play a part in teens decision-making process. The cookie cutter design of AOE programs can now be tailored to the specifics of the population in each classroom. Socioeconomic status, culture, race, social networks, media and peer pressure all play into the decision-making process, and information regarding these factors can be incorporated into the curriculum. Education around contraception usage among teens can be discussed and can be turned into the social norm. The knowledge of contraception can also increase use among teens; even when sexual behavior is unplanned or irrational. If teens believe their friends are using condoms, they are more likely to use condoms themselves (17). The old frame allowed teens to see sex as the “cool” thing to do if their friends were doing it (15). With the new frame, the “cool” thing is to use protection if having sex, and the teens will be armed with the appropriate information regarding contraception.

Once sex education classes are modeled around the Social Learning Theory and with the re-framing, factors such as a teen’s family, their history, and even the media will be included in discussions as to why it is good to use protection when having sex. The current media has dramatically expanded the visibility of a sexual culture, which plays into a teen’s decision to become sexually active (19). With the re-framing, acknowledging this fact can be used to the intervention’s advantage. The program could ensure that protection ads are run often, and through popular teen shows, demonstrate that it is “cool” to use protection.

Teen’s family and past history can also influence teen’s behaviors. Teens born from teenage mothers are more likely to start having sex at an early age and become teen parents themselves (9). These teens could have thought that since their mom was a teenage mom, that was normal. Since this lifestyle was all they had known, their environment was supporting that conclusion. Further, existing AOE programs were supporting the conclusion that teenage motherhood is acceptable so long as it is accompanied by a teenage marriage, and it is not too much of a stretch for a pregnant teen to accept the former without the latter. With re-framing the way society views sex, those teens may change their feeling about teenage pregnancy by seeing that the norm is not to be a teenage mom, but to use protection when having sex. Following the Social Learning Theory based curriculum, the media and family history are all part of a teen’s environment and will play into the teens decision making process about when to use protection.

A New View

Under the new proposal, society will no longer be telling teens not to have sex. The framing instead would be, society understands that teens will have sex, just be safe and smart about it - use protection. Teens hate being told what to do - they want to know the facts and then left alone to make their own educated decisions (22). A re-framing message has been proven effective in Florida’s anti-tobacco “Truth” campaign. Research conducted for the campaign found that for the campaign to be successful, the tone of “truth” could not be preachy and that “truth” needed a message other than “don’t” (26). To avoid the “don’t” message, the campaign re-framed the idea that society was telling teens not to smoke, to a frame that the tobacco companies were taking independence away from teens and that it was the tobacco companies that are now trying to tell teens what to do. The methods used in the anti-smoking campaign are applied to sexual behavior in the proposed intervention, as teens generally feel the same way about sex as they do smoking: they want to make up their own minds.

Re-framing sex and providing information regarding contraception is the method that most Western and Northern European countries are using to reduce pregnancies and STDs (24). These countries acknowledge that teens are going to have sex, so they put the emphasis on protection and contraception use. This method has been proven effective in reducing the rates of teenage pregnancy, childbirth, and STDs in these countries (26). The proposed intervention has taken into account what other countries are doing to reduce their rates, further proving that re-framing the idea of sex and providing information on contraception, family history, media and social norms can and will help reduce the rates of the US teen pregnancy and STDs.

Conclusion

AOE programs lack key elements that reduce their chances of achieving their desired goal of lowering the rates of teenage pregnancies and STDs. The proposed intervention accounts for these elements in two key ways: 1) by re-framing the way society views sex among teenagers 2) by basing the sexual education programs around the Social Learning Theory, incorporating teens’ social environments into programs promoting contraception use. Pregnancy and STD exposure are serious risks facing almost all teens. Ignoring the reality that teenagers will, despite all efforts, continue to be sexually active is not doing them any favors. Confronting these mature issues with tactics aimed at juveniles belittles both the issues and the audience. The proposed intervention seeks not only to reframe the way teenagers and Americans in general conceive of teen sexuality, but to empower teenagers with the knowledge to make informed choices and thereby the confidence to make the right decisions.

REFERENCES

1) Hampton T. Abstinence-Only Programs Under Fire. The Journal of the American Medical Association 2008; 299(17):2013-2015.

2) Borawski, Trapl, Lovegreen, Colabianchi, Block. Effectiveness of Abstinence-Only Intervention in Middle School Teens. American Journal of Health Behavior 2005; 29(5):423-434.

3) Centers for Disease Control and Prevention. Trends in Reportable Sexually Transmitted Diseases in the United States, 2006. http://www.cdc.gov.std/stats/trends2006.htm. [Accessed 11/10/08]

4) Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, 2007. Surveillance Summaries. MMWR 2008; 57(No. SS-4).

5) UNICEF. A League Table of Teenage Births in Rich Nations. Innocenti Report Card, July 2001.

6) Santelli, Ott, Lyon, Rogers, Summers. Abstinence-only education policies and programs: A Position Paper of the Society for Adolescent Medicine. Journal of Adolescent Health 2006; 38:83-87.

7) United States House of Representative. The Content of Federally Funded Abstinence-Only Educaiton Programs. Washington, DC: 2004.

8) Bandura, A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall, 1986.

9) Manning, Longmore, Giordand. The Relationship Context of Contraceptive Use and First Intercourse. Family Planning Perspectives 2000; 32(3):104-110.

10) Salazar M. Comparison of Four Behavioral Theories. AAOHN Journal 1991; 39(3):128-135.

11) Jemmott, Jemmott, Fong. Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents: A Randomized Controlled Trial. The Journal of the American Medical Association 1998; 279(19):1529-1536.

12) Kempner M. Toward a Sexually Health America: Abstinence-Only-Until-Marriage Programs that Try to Keep our Youth ‘Scared Chaste.’ New York, NY: Sexuality Information & Education Council of the United States, 2001.

13) Kirscht, J.P., Joseph,J.G. The Health Belief Model: Some Implications for Behavior Change, with Reference to Homosexual Males. Primary Prevention of AIDS: Psychological Approaches. Newbury Park, CA: Sage 1989.

14) Manlove, Terry-Humen, Papillo, Franzetta, Williams, Ryan. Preventing Teenage Pregnancy, Childbearing, and Sexually Transmitted Diseases: What the Research Shows. Washington, DC: 2002.

15) Miller, Norton, Curtis, Hill, Schvaneveldt, Young. The Timing of Sexual Intercourse Among Adolescents: Family, Peer and Other Antecedents. Youth and Society 1997; 29(1):54–83.

16) Kinsman, Romer, Furstenberg, Schwarx. Early Sexual Initiation: The Role of Peer Norms. Pediatrics 1998; 102(5):1185–1192.

17) Whitaker, Miller. Parent-Adolescent Discussions About Sex and Condoms: Impact on Peer Influences of Sexual Risk Behavior. Journal of Adolescent Research 2000; 15(2):251-273.

18) Miller, B.C. Families Matter, A Research Synthsis of Family Influences on Adolescent Pregnancy. Washington, DC: The National Campaign to Prevent Teenage Pregnancy, 1998.

19) DiClemente R. Talk About Sex: The Battles Over Sex Education in the United States. The Journal of the American Medical Association 2003; 290(7):962.

20) Kowaleski-Jones, Mott. Sex, Contraception and Childbearing Among High-Risk Youth: Do Different Factors Influence Males and Females? Family Planning Perspectives 1998; 30(4):163–169.

21) Albert B. With One Voice 2004: America’s Adults and Teens Sound Off about Teen Pregnancy, an Annual National Survey. Washington DC: The National Campaign to Prevent Teen Pregnancy, 2004.

22) Hicks J. The Strategy Behind Florida’s “Truth” Campaign. Tobacco Control 2001; 10:3-5.

23) Social Marketing Institute. Success Stories – Florida “Truth” Campaign. www.social-marketing.org/success/cs-floridatruth.html. [Accessed 11/12/08]

24) DfES. Sex and Relationships Guidance, HMSO: London, 2000.

25) Kaiser Family Foundation. U.K. Rejects U.S. Abstinence Policy for HIV/AIDS Prevention, Supports Generic Antiretroviral Drug Use. http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=24802. [accessed 11/12/08]

26) Cohen S. Delayed Marriage and Abstinence-until-Marriage: On a Collision Course? The Guttmacher Report on Public Policy 2004; 7(2). http://www.guttmacher.org/pubs/tgr/07/2/gr070201.html. [Accessed 11/16/08]

27) American Medical Student Association. Introduction to Framing. http://www.amsa.org/uhc/FramingIntro.pdf. [Accessed 11/29/08]

28) Lakoff G. Simple Framing.

http://www.rockridgeinstitute.org/projects/strategic/simple_framing. [Accessed 11/29/2008]

29) Edberg M. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.